Transcript Document

Kunin-Lunenfeld
Applied Research Unit
Falls in Ontario LTC Settings:
Laura M. Wagner, PhD, RN
Nursing Scientist
Kunin-Lunenfeld Applied Research Unit at Baycrest
Kunin-Lunenfeld
Applied Research Unit
Kunin-Lunenfeld
Applied Research Unit
Acknowledgments and Funding
Canadian Patient Safety Institute
Ontario LTC Association:
Krista Robinson-Holt, RN, MN (Co-I)
Jennifer Langston
OLTCA Applied Research Committee
Family representative: Ms. Krystyna Schmidt
Participating LTC Facilities
Research Team:
Nina Mafrici, Julie Andrassy, Joanna Dionne,
Hannah Gao, Xiao Jin Chen, Yannie Aass
Thecla Damianakis, PhD, MSW
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Applied Research Unit
Background
 Falls are the most frequently reported adverse incident
in LTC settings
 Approximately 50% of residents fall each year
 Numerous studies have addressed falls in LTC, very
few have focused on the processes of identification,
implementation, and communication regarding the
management of falls
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Research Questions
1) What fall risk factors are identified by nursing staff and
which factors result in associated interventions
documented on the fall risk care plan?
2) What fall prevention strategies are listed in the fall risk
care plan and are these interventions correctly
implemented into actual practice?
3) How is care plan information regarding falls
communicated and implemented to the health care team?
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Methodology
 Descriptive correlational design in 8 randomly selected homes in
and around central Ontario (>100 beds)
 Range 120-170 avg. monthly census
 Data collection:
– Monthly incident report review
– Medical record review
– Quarterly rounds to examine care plan interventions
– Focus groups
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Resident Demographics
 N= 635
 Average age: 82.27years (10.22SD)
 Average Length of stay: 28 months
 Female: 67%
 Risk factors:
– Fall history 66%
Dizziness 14%
– Wandering 26%
Anxiolytic 32%
– Antidepressants 44% Restraint
6%
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Falls
• 1901 Total Reported Falls among the 8 facilities over 1
year period
• Average 20 falls per facility/per month
– Range 6 - 37
• Average 3 falls per faller/per year
– Range 1 - 35
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Care Plan/Medical Record Review
•Risk Factor
•Medical Problems
•Mobility Problems
•Footcare Problems
•Urinary/Bowel Incontinence
•Vision Problems
•Unsafe Behaviours
•Psychological condition
•Environmental/external
hazard
•Medications
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•
•
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•
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Example
Stroke/TIA
Gait dysfunction
Neuropathy
Nocturia
Glaucoma
Combativeness
Depression
Cluttered room
•
Antidepressant
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Results: Medical Record Review
•Risk Factor
•Medical Problems
•Mobility Problems
•Footcare Problems
•Urinary/Bowel Incontinence
•Vision Problems
•Unsafe Behaviours
•Psychological Condition
•Environmental
•Medications
•% Identified / % Follow-up
•86% / 41%
•88% / 73%
•11% / 54%
•74% / 15%
•51% / 14%
•43% / 60%
•76% / 58%
•3% / 21%
•67% / 6%
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Quarterly Environmental Rounds
 N= 1517 observations
 Observations focused on risk factors
• Mobility, unsafe behaviours, vision,
environment, incontinence, etc.
 Overall: 66% adherence to care plan
interventions
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Rounds Adherence
 Mobility (e.g., proper footwear): 64%
 Unsafe behaviours (e.g., bed alarm, call bell,
bed in lowest position): 57%
 Vision (e.g., glasses clean and on while out of
bed): 60%
 Environmental (e.g., common items within
reach): 80%
 No Falls Risk Care Plan: n=104
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Facility Policies
•Admission policy (n=6 facilities)
•Risk level (e.g., high) (n=2)
•Staff education (n=3)
•Prevention program reviews (n=3)
•Medication reviews (n=6)
•Interdisciplinary
participation/communication (n=3)
•Post fall policy (n=8)
•Immediate evaluation (n=8)
•Contact family member (n=7)
•Facility fall committee (n=5)
•Explicit QI Program (n=2)
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Fall Risk Assessment
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Fall history (n=8)
Secondary diagnosis (n=7)
Ambulatory aid (n=4)
Gait/Balance (n=8)
Mental status (n=6)
Medications (n=7)
Continence (n=6)
Sensory impairment (n=5)
Orthostasis (n=1)
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Focus Group: Design & Selection
8 focus groups in 4 randomly selected LTC facilities
1 RN/RPN and 1 PSW/HCA group per facility
21 RN’s and RPN’s
21 PSW’s & HCA’s
Purposive sampling
Inclusion criteria
Informed consent
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Method: Focus Group Demographics
Sex:
•
35 female; 5 male
Ages:
•
17% 26-35 years
•
17% 36-45 years
•
24% 46-55 years
•
12% > 56 years
•
30% Preferred not to respond
Type of Position:
•
11 (27%) Registered Nurses (RNs)
•
9 (22%) Registered Practical Nurses
(RPNs)
•
21 (51%) Personal Support Workers
(PSWs)
Time Working in Current Job:
•15% < 1 year
•34% 1 to 5 years
•20% 6 to 10 years
•10% 11 to 15 years
•5% 16 to 20 years
•16% 21 years or >
Highest Level of Education:
•20% High school diploma
•39% Associate degree/diploma in nursing
•32% Some college or university
•9% Preferred not to respond
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Method: Data Collection
Semi-Structured Interview Format:
 30 min per focus group
 Audiotaped; Transcribed
 Facilitator and Recorder
Interview Guide:
 Falls Risk Identification: Assessing “High Risk”
Residents
 Post Fall Reporting Procedures
 Communication Processes
 Falls Quality Improvement and Prevention Strategies
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Method: Data Analysis
Data Analysis:
Open and hierarchical coding
Within and cross-case analysis
Thematic analysis
Observational recordings
Interrater reliability of coding and analysis with
research team; triangulation; thick description
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OVERALL Perceptions
 Falls monitoring and incident reporting good overall
 Good communication: RN’s & PSW’s
 Teamwork is important
 Staff shortages
 Multiple barriers
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Fall Risk Identification:
“High Risk Resident”
 Variation in meaning of “High Risk Resident”
across locations and sample groups
 Some falls considered non-preventable
(inevitable) and others preventable
 Prioritize: Seriousness of Falls
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Assessing “High Risk” Residents
RN’s
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CCAC report
Visual
Physiotherapy
Nurses
Identifiers:
•

bracelets; bed alarms,
signs
Information from
families
PSW’s
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RN Report(s)
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primarily verbal
Visual
Physiotherapy
Identifiers:
•
bracelets; bed alarms,
signs
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Falls Risk Identification:
How do you know which of your residents are at
high risk for falling?
 RN: sometimes we have some information from
the previous place, but it’s not always correct and
we can’t rely on that, so the best thing is to have
our own assessment.
 PSW: I believe…we have new metal id
bracelets…some of them are colour coded…red,
blue, green, blah, blah, blah…but I can’t
remember the one that’s “has a history of falls”.
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Post Fall Reporting Procedures
Limitations Noted:
 Lack of communication b/w licensed and nonlicensed staff contributes to poor incident
reporting
 Lack of knowledge of inexperienced staff
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Post Fall Reporting Procedures:
How are you informed that the fall has occurred, and
how is this information communicated to other staff
members working on the following shift?
 RN: I do a report…a written report at the end of the shift,
and that report goes down to management….And then we
report at the end of the shift to the next shift coming on.
 RN: Pretty good here. They (PSW’s) let us know whatever
they discover, anything…if there is anything new with the
resident….anything unusual…their walking patterns, or if
they get drowsy or something…they let us know.
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Post Fall Reporting Procedures:
How is the fall incident communicated to
family members?
 PSW: Whomever is in charge on the floor. Automatically…it
doesn’t matter what time of day.
 RN: Usually the person whose filling out the report, or the
registered staff….always registered staff.
 RN: It depends on when they fall too…if it’s late at night
they put it on the report for the next shift….the day shift to
call the family.
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Post Fall Reporting Procedures:
How are you informed of any changes in the
resident’s Care Plan following his/her fall?
 RN: Well, they (PSW’s) read the care plan.
- F: And how often do they read it?
- RNC: They don’t (with a chuckle)
 RN: … you go to the person right away, the person who is
taking care of the person, like the PSW whose taking care
of them, and you let them know the changes; and it’s in the
daily report as well.
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Applied Research Unit
Post Fall Reporting Procedures:
Do you have any concerns when it comes to
reporting when a fall occurs on your unit?
 RN: I’d like them in a more timely manner not three hours after the fall…
don’t tell me at like 11 o’clock when I’m trying to close my shift off, that
“oh, so-and-so fell at 7 o’clock” and I wasn’t even aware of it to do the
incident report.(in a mocking voice): “oh I forgot to tell you three hours ago
that the person fell, and they might have hit their head even?!”
 PSW: It comes back to the same thing about the knowledge…you go to
report it and the nurse…uh…whatever…the nurse will turn around and
say: “oh well, you know, you should have done this, you should have
done that…you should have known”…But if the knowledge isn’t there,
then how would’ve know? So she’s getting upset because a certain
person isn’t doing something right, but they weren’t taught the right way,
so if they don’t have the knowledge, we’re still going to have falls.
 PSW: I think, [in] general, the staff in this facility take a lot to prevent falls
from happening on the units.
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Communication Processes
Registered Staff
Health CareInterdisciplinary
Professionals
Personal Support
Workers
Administrators
Directors of Care
Families
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Communication Processes
At Risk Identification & Post Fall Recording:
Direct and indirect
Verbal and written
Quality of relationship important: non-punitive;
trusting; safe
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Communication Gaps
Post-Fall Reporting
 Not witnessed; resident gets up on their own
 Not reported at the time; but reported afterwards if there
are visible signs (e.g., bruising)
“Like if we are washing [the residents]…then we have to
look…if we locate anything or see anything, we have to…it
gets documented right away” (PSW)
Near-misses: not identified
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Barriers: Preventing Falls or
Implementing Interventions

Staff (RN’s and PSW’s) acknowledge multiple factors which
contribute to falls

Despite lack of both formal and informal discussion on falls,
seen as important

Discrepancy in falls quality improvement actions among units
at the facilities

Interventions toward fall quality improvement tend toward
retroactive not preventative strategies

Infrequent in-service training
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What barriers do you face in preventing falls or
carrying out specific interventions on your unit?
 PSW: …I think knowledge…not to say that we don’t have the knowledge,
but we could always use more knowledge. Because falls is not
something…we talk about all the time unless it happens.
 RN: …the PSW has eight or ten residents to look after, and when they
are busy with one, of course, anything can happen with another, and they
can’t be there every single minute.
 PSW: …some of the barrier, I think would be the family members.
 PSW: It’s like too long…sometimes they need [a] proper
wheelchair…waiting for months…Oh months! How long?!! Six months
already and we never get it….
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Do you have meetings to
discuss falls on your unit?
 PSW: We have one inservice two times a year…if residents are
falling.
PSW: So…I’ve never had one (referring to meeting about falls)..
And I worked on there for a year, and we’ve never had one.
RN: …inservice, we had one last year, regarding falls and these
similar…situations
RN: If there is an increase…in the number of falls [and] if a resident
would have fallen…[we] discuss what’s going on, and what we
can do.
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Applied Research Unit
Barriers to Falls Prevention
1. Family Non-Compliance
Resident footwear
2. Lack of Staff
Staff-resident ratio
Limited time to monitor
3. Lack of Resident Stimulation
Lack & Quality of Planned Activities
Resident Boredom
4. Cognitive Impairment
Instability; Aggression
5. Medications
Agitation, Weakness
Resident Falls
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Applied Research Unit
Barriers to Falls Prevention
6. Lack of Education-Staff Training
Infrequent in-service training
7. Restraint Policies
Pose ethical tensions for staff
Self-determination vs. safety
Families lack of understanding
8. Proper Equipment
Delays in getting equipment
9. Environmental Conditions
Physical-on floor obstructions
Resident Falls
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Applied Research Unit
Falls Quality Improvement:
What is the most pressing issue that needs to be
addressed when it comes to residents falling?
 RN: Well, staffing issues because…right now…I think there is one lady
upstairs and she’s out of the chair six times an hour…and I’ve got two
staff members and that’s been taking them away from their normal
duties….and they’re getting stressed out.
 PSW: …or guilt….because, you know, mom used to be up and down
here and there, and you know, umm…they don’t want to have mom
restrained…they don’t accept that mom is not as strong
anymore…mom is weaker and potential for falls is there. So, they’re
major…I find the major concern is the family members and falls
 RN: ..when you have to prevent a fall, you have to put every nurse in
every room…and this is twenty or thirty rooms…we have nobody. It is
very difficult, especially at night.
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Applied Research Unit
Deliverables
 Website live in April 2007:
• www.fallsinltc.ca
 OLTCA, ALTCA, Manitoba LTC Assn (Spring 2007)
 LTC magazine article: June 2007
• “Communicating with Families about Falls”
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Key Messages
Implications for:
PracticeEducationManagementResearchPolicy-
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Applied Research Unit
Implications for Policy, Clinical
Practice and Research
Policy & Administration
Need for more staff
Increase in-service training
Focus on prevention not only incident reporting
Encourage non-punitive reporting
Ensure quality programming which facilitates resident N
stimulation and activities; decreases boredom
Establish an interdisciplinary approach with families to
provide education and facilitate understanding of care
procedures
Environmental impact: “geriatricproof” to minimize impact
of falls; provide frequent audits
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Implications for Policy, Clinical
Practice and Research (cont’d)
Clinical Training & Practice
 Standardized Assessment Tools
 In-service:
• Common meanings of ‘high-risk’ resident;
• Restraint procedures, including policies (e.g., least
restraint)
• Dealing with ethical challenges
• Standardize knowledge across floors
 Communication frameworks which focus on quality of
interaction and promote teamwork
Includes families
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Applied Research Unit
Implications for Policy, Clinical
Practice and Research (cont’d)
Future Research
 Develop valid and reliable fall risk assessment tools
 Point-of-care approaches to improve communication of
care plan interventions