A fall is defined as “an unexpected event in which the participant comes to rest on the ground, floor, or lower level, not as a result of a major intrinsic event” (Currie, 2008, p.3). Falls are the top cause of injuries sustained by older adults. In nursing homes, it is estimated that between 100 and 200 falls occur each year with about 25% of cases needing medical treatment such as for wounds and fractures (Gallagher, 2011). Falls are largely preventable and create an unnecessary increase in the cost of health care.
Moreover, value-based purchasing entitles nursing homes to incentives based on the quality of care provided and improvements thereof, one performance criteria being the rate of falls (CMS, 2013). In addition, quality measures are made available to the public through Nursing Home Compare and consumers increasingly use this information to make long-term care decisions. Thus, there is a necessity to improve current systems and processes using evidence-based practices to prevent patient falls and achieve better patient outcomes.
The control chart for fall incidence, shown below, further supports the need for improvement. The number of falls based on facility incident reports was recorded per month for 2013. The monthly incidence ranged from two to nine with an average of 5.4. The total number of falls reported was 65. Considering that no patient should suffer a preventable fall, the numbers highlight the need for change in the process of delivering care.
Chart 1. Monthly Incidence of Patient Falls for 2013
Falls are related to intrinsic or patient-related factors including poor gait and balance, vision problems, orthostatic hypotension, muscle weakness, medications, urinary incontinence, and cognitive decline (Michael et al., 2010; Cameron et al., 2012). Co-morbidities such as arthritis, stroke, and diabetes mellitus also contribute to the risk for falls. Extrinsic factors relate to the environment such as patient’s footwear and clothing, bed height, lighting, restraint use, and staff training (Gallagher, 2011).
The focus of the change project is to alter the modifiable patient risk factors by implementing a geriatric care evidence-based protocol. As the type and degree of risk differ among patients, fall prevention interventions will be individualized (Currie, 2008). Hence, a comprehensive risk assessment upon admission and continuing assessment for changes will be instituted using standardized tools. Multidisciplinary prevention planning will be implemented because risk factors are within the scope of different disciplines.
The control chart data for 2013 will serve as baseline performance measure. Similar data will be collected for 12 months following implementation. Comparison will be done with baseline to establish the impact of the change project and determine its effectiveness in improving patient fall incidence. It will help in making decisions about continued adoption or modification of the protocol.
Gray-Micelli & Quigley (2012) integrated best practices in fall risk prevention into a protocol after evaluating available evidence in systematic reviews and meta-analyses. There is strong evidence for a comprehensive assessment using intrinsic and extrinsic risk factors as parameters especially high-risk medication use, restraint use, and urinary incontinence. Routine environmental assessment is also suggested. There is also evidence supporting the taking of the patient’s fall history, medication review, and functional assessment in addition to a physical exam (Gray-Micelli & Quigley, 2012).
Following assessment, research supports the need for nurses to document and communicate fall risk factors to the care team as well as initiate the development of a fall prevention plan (Gray-Micelli & Quigley, 2012). The plan may incorporate strategies such as increasing patient mobility, medication adjustments, increasing surveillance, ensuring proper footwear and clothing, and promoting environmental safety. In addition, restraints have been associated with falls. As such, its use must be avoided as much as possible.
Human Resource Implications
System improvements are necessary to guarantee improvements in the process of patient fall prevention and reduce fall incidence. A learning needs assessment will be conducted to determine deficiencies in staff knowledge and skills about patient fall etiology and risk factors, assessment, prevention planning, implementation, and evaluation as detailed in the protocol. In-service education content will be based on identified gaps. The nurse educator will facilitate and monitor completion of the course while the nurse manager will monitor for compliance.
Change will cause difficulties for the staff. As such, support will be given such as direct supervision and decision-making tools. The staff will also be provided opportunities to air concerns and feedback to allow their participation in perfecting the protocol in the context of the facility. At the same time, adherence to the protocol requires adequate personnel. The staffing committee will elicit input from direct care nurses before deciding on and implementing a better nurse-to-patient ratio. Toward this end, recruitment and retention policies will be reviewed to address job satisfaction and turnover issues.
Cameron, I.D., Gillespie, L.D., Robertson, M.C., Murray, G.R., Hill, K.D., Cumming, R.G., & Kerse, N. (2012). Interventions for preventing falls in older people in care facilities and hospitals (review). Cochrane Database of Systematic Reviews 2012, Issue 12, Art. No.: CD005465. doi: 10.1002/14651858.CD005465.pub3.
Centers for Medicare and Medicaid Services (2012). Nursing home quality initiative. Retrieved from http://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment- Instruments/NursingHomeQualityInits/index.html?redirect=/NursingHomeQualityInit
Currie, L. (2008). Patient safety and quality: An evidence-based handbook for nurses. R.G. Hughes (Ed.). Rockville, MD: Agency for Healthcare Research and Quality.
Gallagher, L.G. (2011). The high cost of poor care: Financial case for prevention in American nursing homes. Retrieved from http://www.theconsumervoice.org/sites/default/files/advocate/action-center/The-High- Cost-of-Poor-Care.pdf
Gray-Micelli, D., & Quigley, P.A. (2012). Fall prevention: Evidence-based nursing protocols for best practice. Retrieved from http://www.guideline.gov/content.aspx?id=43933
Michael, Y.L., Lin, J.S., Whitlock, E.P., Gold, R., Fu, R., O’Connor, E.A., Lutz, K.W. (2010). Interventions to prevent falls in older adults: An updated systematic review. Rockville, MD: Agency for Healthcare Research and Quality.