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Service Delivery Innovation Profile

Interdisciplinary Team Identifies and Addresses Risk Factors for Falls Among Nursing Home Residents, Leading to Fewer Falls and Less Use of Restraints


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Snapshot

Summary

Ethica Health and Retirement Communities developed a falls management program, the cornerstone of which is an interdisciplinary "falls team" at each nursing home that regularly assesses residents for their risk of falling and develops intervention plans for those found at high risk. The team also documents and investigates every fall and takes steps to reduce the chance of recurrence. The program led to a slight decline in falls and a large reduction in use of restraints.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of fall rates and use of restraints between Ethica facilities implementing the program in a yearlong pilot test and similar facilities not implementing it; this evidence is supplemented with overall pre- and post-implementation comparisons after the institution-wide rollout.
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Developing Organizations

Emory University; Ethica Health and Retirement Communities
Ethica Health and Retirement Communities is located in Gray, GA. Emory University is located in Atlanta.end do

Date First Implemented

2004
Septemberbegin pp

Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Disabled (physically); Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

Falls are a common, often preventable problem at nursing homes, with major consequences for residents, facilities, and staff:
  • A common occurrence with negative consequences: As many as three out of four nursing home residents fall each year. Many patients fall more than once (the average is 2.6 falls per person per year). Up to 6 percent of nursing home falls cause fractures, 10 to 20 cause serious injuries, and approximately 1,800 nursing home residents die each year from falls. Falls also result in severe pain, high medical costs, fear of falling, less participation in activities, and reduced quality of life.1 Protecting residents from falls is the most commonly reported reason for physical restraint use.2
  • Negative impact on nursing homes and their staff: Falls lead to added staff time due to increased care and paperwork requirements. Falls also increase the risk of litigation, leading to higher overall costs due to the expenses associated with lawsuits.2
  • Often preventable: Many falls are preventable. Preventable causes include poor foot care, excessive medication, poorly fitting shoes, improper or incorrect use of walking aids, and hazards (e.g., wet floors, poor lighting, incorrect bed height, and improperly fitted or maintained wheelchairs).1

What They Did

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Description of the Innovative Activity

The cornerstone of the falls management program is an interdisciplinary team that regularly assesses the risk of falls, develops intervention plans for high-risk residents, and investigates the root causes of falls so the facility can implement corrective actions to prevent their recurrence. Key program elements include:
  • Interdisciplinary falls teams: Each nursing home has a falls team that includes the facility's nursing director, a nurse, a physical or occupational therapist, two to four certified nursing assistants, and a maintenance worker. The nurse serves as the team leader and the program's clinical champion.
  • Intake assessments: The team uses standardized forms to assess all new residents on admission for their risk for falling, based on factors such as medications, gait, mobility, vision, orthostatic hypotension, and behavior. Residents who score high, as well as all current residents who have fallen within the previous 12 weeks, enter the falls management program. The team reassesses residents whose scores indicate a low risk of falling on a quarterly basis.
  • Development and ongoing monitoring of intervention plans: The team develops a "fall intervention plan" for all falls management program participants designed to reduce the risk of falling and the severity of injury for falls that do occur. Common interventions include use of hip protectors, concave mattresses (to cut the risk of rolling out of bed), floor mats in the resident's room, sneakers, and alarms placed throughout the room so the resident can call for help if he or she falls. A team member reviews each high-risk resident's intervention plan weekly to check whether the recommended interventions are being followed. Residents who go without falling for 3 months leave the falls management program and are subsequently assessed for risk on a quarterly basis.
  • Fall investigation: Whenever a resident falls, the team conducts a comprehensive investigation that includes collecting basic information about the fall (e.g., the shift, time, location, and day of the week), a determination of the probable cause, and information on injuries. The investigation begins immediately, with on-duty team members responding to the scene of the fall and documenting the circumstances. The full team meets later to complete the investigation, which includes an evaluation of whether medical (e.g., hypotension, medication), environmental (e.g., furniture or mislaid objects, spilled liquids), and/or other factors caused or contributed to the fall and how to eliminate or prevent these factors in the future. If the resident is currently in the falls management program, the team checks whether existing measures from the resident's intervention plan were being used.
  • Communication with physicians: When a resident is injured by a fall, the nursing home informs the resident's primary care physician by phone or fax.
  • Monthly cross-facility team conference calls: Ethica divides its facilities into four geographical regions. Each month, the falls team nurse and the nursing director have a conference call with their counterparts at other nursing homes in the region and a registered nurse from Ethica's corporate headquarters. During these calls, the falls team nurses present overall data on falls and use of restraints, discuss interventions, and review special cases (e.g., residents who fell multiple times and/or suffered serious injuries). After these calls, the nurses have a conference call with Ethica's vice president of clinical services.
  • 24-hour support hotline: Ethica maintains a 24-hour telephone hotline staffed by a nurse or a therapist that nursing home employees can call if they need help with a difficult case.
  • Elimination of side rails to reduce entrapment risk: Beginning in July 2007, Ethica eliminated side rails on patient beds to reduce entrapment risk. To eliminate side rail use without increasing fall/injury risk, Ethica purchased new beds (either low beds, electric beds, and/or concave mattresses, as mentioned above) and equipped all beds with assist bars (“grab bars”) positioned at the top of the bed so that patients can shift in bed independently without using side rails for positioning. Families who insist on side rail use despite written and verbal education about entrapment risk must sign a "refusal of care" form; fewer than 75 beds of the approximately 5,500 beds in the Ethica system still have side rails.

Context of the Innovation

Ethica Health and Retirement Communities is a nonprofit management and clinical consultation organization providing support to 49 nursing homes in Georgia. Ethica's leaders chose to develop this program because falls represent one of the most important health concerns for its residents and facility staff. To that end, Ethica's leadership invited researchers from Emory University to design and implement the program. After an 18-month test period at 19 nursing homes, Ethica's leaders chose to expand the program to all of its nursing homes. While developing strategies to reduce fall risk, and in response to the U.S. Food and Drug Administration's examination of bedside rail entrapment risk, Ethica also examined its use of bedside rails throughout its nursing homes.

Did It Work?

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Results

A comparison of fall rates and use of restraints in 19 Ethica nursing homes that implemented the falls management program with other nursing homes that did not implement the program suggests the program slightly reduced falls and significantly reduced use of restraints. Further evaluation after a broad rollout of the program suggests additional progress on both measures.
  • Slightly fewer falls, significantly lower use of restraints in pilot test: Between September 2004 and September 2005, falls rates in the 19 Ethica nursing homes using the falls management program fell by 5 percent (from 17.3 falls per 100 residents per month to 16.4), whereas restraint use fell by 30 percent (from 7 percent of all residents to 4.9 percent). By contrast, fall rates rose by 26 percent in Ethica facilities that had not implemented the program during that time. The success of the pilot program led to an institution-wide rollout.
  • Continued improvement over time: Falls and use of restraints have continued to decline markedly since the pilot test ended and the program was implemented at all Ethica facilities. Before the falls management program was implemented in September 2004, approximately 20 percent of all Ethica nursing home residents fell each month, whereas about 8 percent used restraints. By September 2007, 17 percent of residents fell each month, and only about 2 percent used restraints.
  • No increase in fall/injury rates as a result of side rail elimination: After a slight increase in falls during the first quarter after side rail elimination, fall rates returned to previous levels; injury rates did not increase at all as a result of side rail elimination. 

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of fall rates and use of restraints between Ethica facilities implementing the program in a yearlong pilot test and similar facilities not implementing it; this evidence is supplemented with overall pre- and post-implementation comparisons after the institution-wide rollout.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Initial meetings: The Emory research team held several introductory workshops for Ethica's corporate officials and clinical leaders from its facilities to discuss how the program would work. Topics included ways to develop a culture of safety, the role of administrative leadership, communication strategies, team function, and use of data.
  • Team formation and self-assessment: Each facility formed an interdisciplinary falls team that included the director of nursing, a nurse, a physical or occupational therapist, two to four certified nursing assistants, and a member of the maintenance staff. Each team completed a facility-specific self-assessment to identify weaknesses in falls management, prioritize areas of focus, and review existing documentation procedures.
  • Training: Falls teams attended two full-day workshops covering core program components. A team from Emory that included two advanced practice nurses, a geriatric nurse practitioner, and a nurse educator experienced in long-term care conducted the workshops. In addition to covering the program's elements, the workshops focused on developing team problem-solving skills, devising new interventions for residents who fall repeatedly, reducing reliance on physical restraints, and managing behavior in difficult cases. In addition, each falls team received a 69-page manual detailing the program, a companion notebook for living space inspections, a videotape on falls management techniques, laminated brochures for unit staff that summarize the program and outline basic strategies for reducing falls, all necessary forms, a case history with examples of interventions, and a list of resources. As new employees are hired, they also receive training in falls management.
  • Assessment and mitigation of bed side rail entrapment risk: Beginning in mid-2008, teams conducted an individual assessment of each patient's use of bedside rails to determine how the side rails could be eliminated and what equipment would be necessary to ensure safety for each patient. The Ethica board made funding available for the purchase of new (lower) beds, concave mattresses, grab bars, and any other equipment necessary so that side rails could be eliminated without increasing fall risk. Staff were trained to provide patient/family education about side rail entrapment risk and to assess patient needs and provide care without reliance on side rails.

Resources Used and Skills Needed

  • Staffing: Falls team members and other staff participate in the falls management program as part of their regular jobs, and, thus, no new staff were hired for the falls management program. The nurse who leads the falls team at a typical 100-bed facility typically spends roughly 8 to 12 hours a week on falls management program-related work.
  • Costs: Many teams purchased new supplies, such as concave mattresses for $500 each and floor mats for $120 each, for a total cost of approximately $7,500 per facility. When a facility could not afford new mattresses, pool noodles or long pillows on the side of the beds were substituted.
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Funding Sources

Agency for Healthcare Research and Quality; Ethica Health and Retirement Communities
A grant from the Agency for Healthcare Research and Quality funded Emory's involvement in the falls management program. Ethica's internal operating budget covered additional expenses.end fs

Tools and Other Resources

The Food and Drug Administration guidance on reducing hospital bed entrapment risk are available at: U.S. Food and Drug Administration. Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment — Guidance for Industry and FDA Staff. March 10, 2006. Available at: www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm072662.htm

Adoption Considerations

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Getting Started with This Innovation

  • Seek buy-in at all levels: Nursing home employees may be skeptical when a new falls initiative is introduced, considering it a "flavor-of-the-month" program likely to be abandoned quickly. To overcome this skepticism, senior management needs to show its commitment to the program. Regular facility visits from senior corporate officials to discuss falls and the program's importance can help overcome employee skepticism.
  • Create a positive atmosphere: To encourage accurate documentation and effective followup, program leaders should emphasize that employees will not be punished for reporting falls. Leaders also should make it clear that, although not all falls can be prevented, effective teamwork can minimize both the number and severity of falls.
  • Roll out gradually: Ethica found that gradually introducing the falls management program to more nursing homes was more effective than implementing it in all facilities at once. This approach reduced the potential for overwhelming senior management with questions and problems from individual facilities, and it also made it easier to tweak the program over time.
  • Expect and address resistance to side rail elimination: Nurses have been trained to rely on side rails to mitigate patient fall risk. Training about entrapment risk is critical to prompting a culture change. Similarly, families may be adamant about the use of side rails. Families should be provided with verbal education and published literature about entrapment risk; Ethica staff showed families pictures of entrapment taken from the U.S. Food and Drug Administration guidance.

Sustaining This Innovation

  • Emphasize ongoing training: Because nursing homes tend to have high employee turnover, it is vital that all new employees receive training as part of their orientation in falls management.

More Information

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Contact the Innovator

Pam O'Rourke
Vice President of Resource Management
Ethica Health and Retirement Communities
1005 Boulder Drive
Gray, GA 31032
(478) 621-2212
E-mail: porourke@ethicahealth.org

Holly Brown

Clinical Practice Director
Ethica Health and Retirement Communities
1005 Boulder Drive
Gray, GA 31032
(478) 621-2212
E-mail: hbrown@ethicahealth.org

Pam Clayton
Ethica Health and Retirement Communities
1005 Boulder Drive
Gray, GA 31032
(478) 621-2212
E-mail: PClayton@ethicahealth.org

Innovator Disclosures

Ms. O'Rourke, Ms. Brown, and Ms. Clayton have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Rask K, Parmelle PA, Taylor JA, et al. Implementation and evaluation of a nursing home fall management program. J Am Geriatr Soc. 2007;55(3):342-9. [PubMed]

Footnotes

1 Falls in Nursing Homes. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/HomeandRecreationalSafety/Falls/nursing.html
2 Rask K, Parmelle PA, Taylor JA, et al. Implementation and evaluation of a nursing home fall management program. J Am Geriatr Soc. 2007;55(3):342-9. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 28, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 08, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: April 09, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.