Falls among older adults Discussion

Falls are a major concern for older adults in all set- tings, causing significant

morbidity and mortality and affect- ing quality of life. In the hospital, falls occur at an estimated rate of 8.9 per 1,000 patient days. About 30% to 50% of these falls cause injury. Falls increase hospital stays and may necessitate a long-term stay.

According to the Centers for Disease Control and Prevention (CDC), 22,900 older people died from fall-related injuries in 2011. Falls also are linked to de- pression, anxiety, and fear of falling. In persons who’ve fallen, the risk of falling again rises signifi- cantly. Obviously, we must put effective measures into place to prevent falls.

The literature on falls prevention is abundant, and many fall-risk assess- ment instruments exit. Clinical practice guidelines on reducing falls recom- mend a multicomponent strategy that addresses functional, physical, psy-

chological, and educational aspects of falling, individualized to each pa- tient. Locating and reviewing these guidelines is easy, but integrating them into practice and individualiz- ing them for each patient can prove challenging.

Efforts to improve falls preven- tion require a systemic approach that involves organizational change. Falls prevention should be part of

an organizational culture of evi- dence-based practice (EBP). EBP entails integration of clinical expert- ise, patient values, and the best re- search evidence into the decision- making process for patient care. An essential component of professional nursing practice, EPB is also a criti- cal component of the Magnet Recognition® and Pathway to Excel- lence® programs of the American Nurses Credentialing Center.

Using an appropriate EBP model Multiple models or frameworks can be used to implement EBP. The Iowa Model of Evidence-Based Practice is a trusted model that’s easy to understand and use. It takes a systematic approach to analyzing a problem and gathering research to identify reasonable actions to ad- dress it, followed by practice changes to reduce recurrence of the problem, with subsequent critique and continued monitoring to sus- tain desired outcomes. This model can be used to develop an interdis- ciplinary plan to reduce falls in clinical settings. Falls among older adults Discussion

After identifying the problem (such as a high number of falls, falls with injuries, or failure to re-

Creating an environment of falls prevention

Evidence-based practice can reduce falls and fall-related

injuries. By Sharon Stahl Wexler, PhD, RN-BC, FNGNA, and Catherine O’Neill D’Amico,

PhD, RN, NEA-BC

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duce falls using current interven- tions), interdisciplinary staff from one or more units can gather the most recent falls-related literature in all fields and evaluate its suggested use in the practice setting. After this literature review and critique, the team develops a set of actions and pilots a project using fall-risk as- sessment and prevention actions identified in the literature that match the units’ populations and settings. After a suitable interval, the interdisciplinary team evaluates desired outcomes of the EBP proj- ect. Based on results, changes to practice are introduced throughout the organization.

Two EBP falls-prevention projects The EBP projects discussed below illustrate how organizations can in- tegrate falls prevention into a cul- ture of EBP.

Community hospital’s med- surg unit A med-surg unit of a suburban community hospital already had an active and effective falls-pre- vention program in place, with fall rates below national bench- marks. But hospital leaders wanted to reduce rates even fur- ther. The EBP project used clini- cal practice guidelines from the American Geriatrics Society and British Geriatrics Society, which recommend a multicomponent strategy addressing functional, physical, and psychological as- pects of falling, tailored to pa- tients’ individual needs.

Clinicians partnered with the patient and engaged the pa- tient’s active participation in the falls prevention program. This multicomponent patient-engage- ment strategy included a safety agreement on admission and a group-walk initiative throughout the hospital stay, aimed at moti- vating patient participation. The

safety agreement addressed pa- tient concerns and fall-risk edu- cation; patients were asked to sign it, further encouraging their active participation. The initia- tive included three 6-meter group walks daily at a self-set pace.

Since program inception, falls on this unit have decreased ap- proximately 25% and patients’ mobility has increased; no fall- related injuries have occurred. About 75% of patients partici- pate in daily walks. Falls among older adults Discussion

Academic medical center’s rehab unit The unit’s interdisciplinary team was concerned about the num- ber of fall-related patient in- juries, but wanted to stay true to the goals of the rehab unit— helping patients regain their prehospitalization functional level and reducing overall func- tional impairment. As part of its EBP, the team analyzed the re- habilitation and geriatric litera- ture for solutions related to falls prevention.

Their work led the team to develop a 1-page educational tool that targeted patients deemed unlikely to ask for help ambulating. These patients and their family members were asked to sign an agreement inviting patients to call for help when they needed to get out of bed, go to the bathroom in a hurry, reach for objects while sitting or lying in bed, or using assistive equipment. In return, staff promised to make rounds every 30 minutes to anticipate patients’ needs and to answer requests for assistance immedi- ately. Staff were empowered to use the agreement to teach pa- tients and families about safety. The staff-patient partnership and

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individualization of care have led to a significant reduction in falls with injuries on this unit.

EBP promotes positive outcomes Outcomes achieved with both projects demonstrate that combin- ing specific actions in an interdis- ciplinary environment can reduce falls and fall-related injuries. Both units continue to work within their organizations to roll their successes forward to other units, following the pattern of the Iowa Model. These initiatives illustrate how an EBP model can improve patient safety and the patient ex- perience. •

Sharon Stahl Wexler is an associate professor at Pace University College of Health Professions, Lienhard School of Nursing, in New York, NY. Catherine O’Neill D’Amico is the director of Education, Research, and Magnet Project at Mt. Sinai Beth Israel’s Beatrice Renfield Division of Nursing Education and Research in New York, NY.

Selected references Association of Rehabilitation Nurses. The Specialty Practice of Rehabilitation Nursing: A Core Curriculum. 6th ed. Glenview, IL: Association of Rehabilitation Nurses; 2015.

Centers for Disease Control and Prevention. Falls among older adults: An overview. Last updated March 19, 2015. www.cdc.gov/Home andRecreationalSafety/Falls/adultfalls.html.

Hill AM, Etherton-Beer C, Haines TP. Tai- lored education for older patients to facilitate engagement in falls prevention strategies af- ter hospital discharge—a pilot randomized controlled trial. PLoS ONE. 2013;8(5):1-11.

Panel on Prevention of Falls in Older Per- sons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for preven- tion of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-57.Falls among older adults Discussion

Titler MG, Kleiber C, Steelman VJ, et al. The Iowa model of evidence-based practice to promote quality care. Crit Care Nurs Clin North Am. 2001;13(4):497-509.

Zavotsky K, Hussey J, Easter K, Incalcaterra E. Fall safety agreement: a new twist on ed- ucation in the hospitalized older adult. Clin Nurse Spec. 2014;28(3):168-72.