The use of stable, secure footwear may increase these residents’ stability during ambulation. The use of quality improvement tools, such as the Plan-Do-Study-Act (PDSA) cycle, can assist facilities with this task.9 The PDSA tests a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the results (Study), and determining what modifications should be made (Act). According to a 2011 report from the Mayo Clinic, surveys indicate that old shoes and old habits can contribute to falls in older adults.28 Elderly individuals are less likely to fall in their homes if they wear athletic shoes as opposed to going barefoot or wearing socks or slippers, and they are less likely to fall outside of the home if they opt for supportive shoes, such as lace-up or strap-on shoes with a snug fit, rather than wearing slip-on shoes. Prog Cardiovasc Dis. Until we have better evidence to support coupling these supplements, we recommend that LTC facilities consider each of these supplements separately, deciding for each individual resident whether the benefits of calcium supplementation outweigh the potential risks.25. As these data show, fall prevention is essential; however, this endeavor is challenging, as there is a lack of compelling evidence that any one intervention will reliably decrease the incidence of falls. Willy BA; Centers for Medicare & Medicaid Services Ninth Scope of Work. They’re prevented by engaging the patient and family in the … Epidemiology of syncope/collapse in younger and older Western patient populations. 2010;340:c880. Accessed December 17, 2013. Loftus S. Fall prevention strategies for people living with Parkinson’s. %PDF-1.5 %���� 31. Currently, the evidence favors the continued use of vitamin D for falls prevention in these individuals, particularly because the costs of supplementation are low and there is little risk of toxicity.25, In contrast, calcium poses some risks, particularly for persons who do not need it. Although the AGS/BGS guidelines do not make recommendations for or against hip protectors, the Veterans Administration Safety Center has adopted their use as best practice in their centers. Arguments for the use of noise-producing alarms are based on the perceived needs of the staff, not the actual needs of the elderly person. In this article, we review how to assess falls risk and discuss some key risk factors for falls and potential interventions to mitigate these risks. Some common medical causes include carotid stenosis, orthostatic hypotension (also known as postural hypotension), postural orthostatic tachycardia syndrome, and diabetes. April 24, 2012. Falls and instability in the elderly. Harwood RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T. Falls and health status in elderly woman following first eye cataract surgery: a randomized controlled trial. endstream endobj startxref This is especially essential when a resident appears agitated or distressed or actually communicates experiencing pain. Ruth would often attempt to rise from her chair when she was unsupervised, which resulted in her falling to the floor. In addition, good evidence suggests that the benefits of vitamin D on fall prevention are distinct from its positive effects on bone health.7 Subsequently, the new consensus statement from the AGS recommends that healthcare providers review older patients’ vitamin D intake from all sources, including diet, sunlight exposure, and supplements, and work to achieve a total vitamin D input of 4000 international units daily (IU/day).23 The statement indicates that this will enable 90% of patients to achieve recommended vitamin D levels and minimize their risks of falls and fall-related injuries. Accessed September 20, 2013. Falls are common in nursing facilities. 33. Staff response to an alarm sounding seldom results in the prevention of a fall.18 At best, it can shorten the “rescue time.” The purpose of an alarm is to notify those in the immediate surroundings of imminent danger, such as a fire or tornado. Clustering care is a vital part of every shift, not only for the patient, but for you as the … Patel S, Ogunremi L, Chinappen U. J Am Geriatric Soc. For example, a pilot program that encouraged patients with a high risk of falling and bleeding to wear protective headgear while hospitalized and after discharge reported that many patients embraced the idea when they fully understood the importance of wearing the helmet, with some even adding artistic flourishes to their helmets.31 More importantly, there were no cases of head bleeding among the patients who embraced the helmets and consistently wore them. 2011;342:d3447. Although it has become routine in LTC facilities to include orthostatic hypotension assessments during the resident’s initial intake process and after each fall incident, they are often administered by nursing assistants, who may be unaware of the resident’s recent changes in medication or history of heart arrhythmias; however, even when the assessments are administered by licensed practical nurses or other members of the care team, results may not be accurate due to measurements being taken at incorrect time intervals. 2014;23(1-2):13-23. If they self-propel the chair with their feet, it may be necessary to start with a lower wheelchair frame in which the seat is closer to the ground to ensure that when the front of the seat is raised, their feet can still remain flat on the floor.21, Considering Vitamin D and Calcium Supplementation. Therefore, reducing the risk of falls and fall-related injuries in long-term care (LTC) facilities requires a comprehensive approach that focuses on identifying the myriad conditions that predispose to falls and addressing each resident’s identified risk factors6; this needs to start on each resident’s first day of admission. Poor oral health, for example, can lead to nutrition and hydration deficits that in turn may cause weakness, cognitive changes, and poor healing of infections, among other issues. Staff members become accustomed to these residents being independently safe during position changes, but these individuals are at higher risk for falls during this time period. Falls: Fall Prevention Intervention Care Plan 1. The integration of active lifestyle concepts into the daily routine of all residents, such as limiting the use of wheelchairs when they are used only to save time and to reduce the effort of the caregiver, enhances the residents’ quality of life and mobility skills. These same principles apply in the LTC setting. Published May 29, 2012. 32. In this article, the authors provide two case scenarios that demonstrate why individual risks need to be carefully explored. The Falls Management Program (FMP) is an interdisciplinary quality improvement initiative. The Centers for Disease Control and Prevention website provides a helpful instruction and documentation tool for measuring blood pressure with position changes as part of their falls prevention package, the STEADI (Stopping Elderly Accidents, Deaths & Injuries) Tool Kit for Health Care Providers, which can be ordered online. Using split shifts or management on the floor during high fall incident times identified through analysis of facility trends has also been effective in many facilities. Cappuzzo KA. 2005;89(1):53-59. Monitor Residents’ Medications and Overall Health: Monitoring residents’ medications — especially those that increase fall risk — is an essential part of any fall prevention strategy. Betty Willy, PT, MA, CWS; bettywilly2001@yahoo.com, Christine M. Osterberg, RN, BSN; christine.osterberg@pathwayhealth.com. 10. This step helps prevent injury and cardiopulmonary decompensation from performing the wrong type of exercise or becoming overexerted. Patients with dementia and other cognitive impairments may be prone to wandering, which can also increase the risk of falls. In persons with dementia, alarms from unknown sources result in defensive responses, such as agitated behaviors, calling out, physical aggression, physical attempts to escape the stimulation, or shutting down and withdrawing from the stimulation.19 And yet, as an industry, we continue to use “personal alarms” as an intervention to help keep our residents safe. Patient falls not only increase patient length of stay and healthcare costs but may also trigger lawsuits resulting in settlements of millions of dollars due to patient injury.1 As of 2008, the Centers for Medicare and Medicaid Services no longer reimburse any hospital-acquired conditions that lengthen hospital stay.2 Hospitals now absorb the extra medical costs of patient injuries sustained in falls, which are considered preventable or “never” events.3 Since 2009, The Joint Commission (TJC) sentinel event database receiv… Population Health Learning Network is a trademark of HMP. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Yet good evidence suggests that vitamin D supplementation in older adults can improve the uptake of calcium to reduce osteoporosis and prevent sarcopenia (loss of muscle mass),22 both of which can contribute to falls. 9. If these measures do not alleviate the pain, pharmacologic measures can be considered, starting with mild analgesics. Using gravity to enhance the safety of their seating eliminates this problem,21 and this can be achieved as follows: •     Placing the seat low enough to enable the person’s feet to be flat on the floor. 23. Selection of residents for this intervention could be based on a history of unresolved fall risk, presence of moderate to severe osteoporosis, and level of compliance with regard to such devices. 11. In addition, strong lighting without glare, nightlights, and lighted pathways to the toilet are good common practices in many facilities. Accessed September 20, 2013. Fall Interventions to help public health practitioners use the best scientific evidence to effectively address the problem of falls. Children fall as they grow, develop coordination and new skills.and are often unaware of their limitations. The interventions will be compared, but not limited, to control conditions where there are no falls prevention interventions, where usual care is provided or where the intervention group receives falls prevention in addition to usual care or another falls prevention … Toileting needs o Ask the resident every one to two hours if he/she needs to use the bathroom. Talk presented at: 2012 Transforming Fall Management Practices Conference; May 2012; Clearwater, FL. Cameron ID, Gillespie LD, Robertson MC, et al. RELATED CONTENT To address issues of pain and boredom, which can lead to depression, several steps can be taken. Fall prevention: out with the old shoes, old habits. This team first completed a thorough assessment of both the existing policies and practices of nursing staff related to reducing falls and better understanding the conditions possibly leading to the recent increase in falls… About 1 in 3 of those who fall will fall two or more tim… Quigley P, Neily J, Watson M, Wright M, Strobel K. Measuring fall program outcomes. _��"Pp�� �t@�-��Pb��؁�ɷ��(ɶl9u�-0hQ��x��x�Şq�9��Lp�%J3���h�LŖy�l���,Vx8H*t�u�yτ�2N�C��IL2)4u)&���f�*��a��T�Lz��S�ZTb���v�QqP(8S6��@v!a�B�BS��5��4'�eZJ�qL2J����h������ӧ�d��k�{��4_����}��Of=s�1�FC�����F;ɴ���~�h},d�~ܔOy���������|q�M�+j? Not only can ill-fitting or worn-out shoes contribute to falls, but they can also increase the likelihood of developing painful bunions, corns, and blisters.28 The exception to this would be individuals with a festinating gait pattern, such as ambulatory residents with Parkinson’s disease. It also includes a comprehensive physical examination that evaluates mobility, joint function, cognitive/neurologic function, muscle strength, visual acuity, cardiovascular status, and feet/footwear, as well as a functional assessment that considers a patient’s ability to perform activities of daily living and gauges his or her fear of falling (eg, via the Falls Efficacy Scale). •     Allowing the resident to sit for a period while the gait belt is applied before he or she rises to a standing position. In addition, the interventions initiated to address fall risk factors must be monitored to determine their impact on the safety culture of the facility and the individual resident’s safety and then modified until effective sustainable programs are in place. This article provided a review of many—but not all—factors contributing to falls in LTC facilities, along with suggested interventions to reduce injuries. 16. Fall prevention in nursing homes presents multiple challenges. When an individual is first placed into a nursing home, the facility … Accessed December 30, 2013. In addition, in Ruth’s case, the staff sought ways to keep her in her wheelchair, rather than determining why she was trying to get out of it in the first place. And, in fact, the fall patterns reported in Guildermann’s study20 indicate that this is true; they found that no residents fell between 7:00 am and 10:00 am in facilities that had turned off all personal alarms during the night. Once a comprehensive fall risk assessment is completed, the team must plan care interventions to reverse or address each risk identified on the falls assessment instrument. 29. J Am Geriatr Soc. Any modification to how these drugs are used should be communicated to the nursing assistants, who are charged with assisting residents to rise safely from the supine or sitting positions. 22. Online J Issues Nurs. After she figured out how to remove the lap buddy, the team tried using an antithrust cushion and pelvic seat belt with the clasp in the back of her chair, as recommended by the occupational therapist. Br J Ophthalmol. Accessed December 17, 2013. BMJ. Staff members resorted first to using a lap buddy, a cushion that is placed into the wheelchair and across the lap of the individual to prevent him or her from trying to stand unassisted while providing upper body support and posture assistance. In a webinar for Stratis Health from April 2012, Sue Ann Guildermann presented the unpublished results of a grant in which 16 nursing homes participated in a noise-reduction program in an attempt to reduce falls.20 The results strongly indicated that noise in the environment was the primary contributor to falls. Using wheelchairs with the back reclined puts residents at risk of sliding to the floor. Oliver D. Falls risk assessment tools in hospitals: mermaid or manatee? Living alone Path… A thorough multifactorial risk assessment is essential, as many potential falls may be related to medication and/or cardiac conditions. Interventions for fall risk prevention in nursing homes According to recent studies, an elderly person will be treated for injuries from a fall every 13 seconds. 17. 4. Collaborate or Punish: Is There a Middle Ground to Be Found in the Survey Process? u��P;��o\��0р�B�ӳy �=�n����~v��\�ؽ-�Qb�. 2005;26(3):203-219. Life observation tells us that we as humans have a physiologic need to move. Vasovagal syncope, one of the most common types of syncope, occurs when a person faints in response to a sudden drop in heart rate and blood pressure. In addition, for patients who have experienced multiple falls or report gait and/or balance problems, focusing on a tool that specifically assesses gait and balance, such as the Tinetti Assessment Tool, is helpful.7. Fall Prevention; Dementia Management; Safety; Nursing Interventions and Rationales 1. Approximately 30% of patients 65 years and older who have experienced syncope will not be aware that they have fainted, but will instead report that they have fallen.10 Therefore, the prevalence and incidence figures for syncope in older adults are confounded by an overlap with presentations classified as falls11; however, population-based studies indicate that approximately 40% of adults have experienced syncope, with women being more likely to report a syncopal event.12 The cause of syncope can be multifactorial or a single cardinal event. 30. 2007;12(2):8. Providing staff training on fall reduction; Implementing interventions to reduce falls based on the patient’s or resident’s assessed risk; Educating the patient/resident and their family members on fall reduction strategies; Periodically evaluating the effectiveness of all fall-reduction … www.uspreventiveservicestaskforce.org/uspstf12/vitamind/vitdfact.pdf. Quality Improvement Organizations, Stratis Health. Idaho Department of Health and Welfare Website. Socks with grip… Key words: Falls, falls prevention, fractures, root cause analysis, wheelchair use. Finally, while most nursing homes provide wheelchairs that are wide enough for morbidly obese residents, many do not recognize the need for chairs that are deep enough to accommodate tall individuals as they lean forward. J Am Geriatr Soc. Hip protectors. Documenting these discussions and tracking falls data enable trends to be identified that will contribute valuable information as to when, where, and how each fall occured. 2012;12:CD005465. Acceptability and compliance with hip protectors in community-dwelling women at high risk of hip fracture. These interventions can be delivered alone or in combination with or without intervention … 2007;11(5):564-571. Standing and walking should be maintained to the tolerance of each resident. Although many of these risk factors are well reported in the literature, they may be overlooked, particularly as facilities struggle with staffing issues and time constraints, leading to more superficial reviews when conducting fall risk assessments and root cause analyses. Eur J Pain. In addition, to prevent skin breakdown and provide proper support to residents with orthopedic foot deformities from diabetic peripheral neuropathies, a consultation with an orthopedist for custom-molded diabetic shoes may be warranted. Cochrane Database Syst Rev. www.cdc.gov. Leistikow IP, Kalkman CJ, de Bruijn H. Why patient safety is such a tough nut to crack. Accessed September 20, 2013. 8. Reducing wandering through improved waiting room design. 2014;22(1):23-32. As they become teenagers, they seem to have a hunger for stimulation, such as loud cacophony in their music and dance, and a need to multitask using electronic media. 120 0 obj <>stream For example, falls have been linked to nurse staffing patterns.36 The consistent assignment of staff to the same residents allows for staff to have an intimate knowledge of their charges, enabling them to anticipate the residents’ unsafe errors in judgment or high-risk behaviors, to be present in the area of risk, and to have the greatest ability to intervene before a fall occurs.37 Caregivers can be much more effective in their vigilance if they are not moved to different units with each schedule change. Bakker R. Environmental design. 2. BMJ. Such reviews are essential in developing sustainable and efficacious fall prevention programs and in promoting a culture of safety. First and foremost, residents should be regularly evaluated for pain or discomfort, even if they are unable to properly express their pain. The interventions we review were based on a combination of research findings reported in the medical literature and in the American Geriatrics Society/British Geriatrics Society (AGS/BGS) Clinical Practice Guideline for Prevention of Falls in Older Persons.7 Despite best efforts to prevent falls, we recognize that they will still occur; however, to promote a culture of safety in the nursing home and optimize the efficacy and sustainability of fall prevention programs, thorough root cause analysis is essential when any falls occur. Disclosures: The authors report no relevant financial relationships. Implementation guide: goal 2: improving consistent assignment of nursing home staff. Mountain Pacific Quality Health 2010. White race 3. Subsequent radiographs and magnetic resonance imaging scans revealed an avascular necrotic femoral head as the cause of her right hip pain with weight bearing in a flexed position in the wheelchair. 2013;21(8):36-37. Although it remains unclear exactly which factors contribute to poor compliance among the LTC population, a study that assessed the acceptability and compliance with hip protectors in community-dwelling women at high risk of hip fractures found that many who discontinued wearing them attributed this to discomfort, dislike of how the hip protectors made them look, and disagreement about their fracture risk.33 It is likely that many of these same issues may lead to lack of compliance among LTC residents; however, new designs to high-impact pads may change this. In 2007, an Australian study found that participants with enough pain to cause moderate to severe interference with their ability to perform activities of daily living were more likely to report any falls or multiple falls in the 12-month study period compared with participants reporting no pain.13 The association was stronger for multiple falls than for any single fall. Finally, including all facility staff in making rounds and observing for risks can be helpful, as can adopting a practice of checking on residents regardless of call light use, as these practices further support an environment of heightened safety awareness. STARS Website. __________________________________________________________________________________________________________________________. The team interpreted Ruth’s body language of sliding to the front of the chair as a dementia-related behavioral problem instead of a symptom of pain, and their initial interventions led her to experience even more pain. 2012;60(2):230-237. How to improve. Rader J, Frank B, Brady C. Rethinking the use of position change alarms. The family opted against a total hip replacement due to her advanced dementia, and the problem was addressed by using a specialty cushion to offload the pressure under her hip, a recliner chair to decrease the hip flexion angle while sitting, and appropriate pain medication. Therefore one could conclude that all children are at some risk of falling. As their neurologic system grows and matures, their tolerance improves and they develop the ability to self-soothe. It is widely acknowledged that children are at risk of falls in the community and with many education programs supporting prevention, it is important that this education is reflected in the hospital environment. Interventions for preventing falls in older people in care facilities and hospitals. Consult Pharm. Such interventions could include provision of a comfortable environment that is not too hot or cold and that reduces overstimulation from noise and bright lights; engaging the resident in appropriate social activities to prevent boredom; using appropriate cushioning and assistive devices; and ensuring proper nutrition.
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