Falls Prevention Mapping the incidence of falls as they occur throughout a nursing home facility can be used to pinpoint

a specific pattern related to location, shift, time of fall, and/or particular day. By using a falls mapping tool, a visual representation on the emerging patterns for falls allows for more expedient and effective dissemination of falls-related data, including prevention measures, to front-line staff.

Using falls mapping in the prevention of resident falls

P
rofessional care staff at Cedarvale Terrace Long-Term Care Home in downtown Toronto have recognized the importance of developing a falls prevention program that works. Analysis of past interventions used at the Cedarvale facility revealed that, while the response by staff to resident falls was prompt and professional, and incident data consistently recorded, the interprofessional communication and analysis of causes of falls was done rather poorly. Staff, therefore, developed a simple colour-coded visual tool that would allow mapping of falls in real time and the recording of essential details including the location of the fall, nursing shift (days, evening, night), and specific action plans incorporating the Plan-Do-Study-Act Quality Improvement Model. (See sidebar on the P-D-S-A model for improvement). The inspiration for this initiative on falls mapping came from the historical approach taken by Dr. John Snow who deciphered the origins of the London cholera outbreaks in the mid-1800s. Snow carefully analyzed the map of London to sort out the data of cholera cases into identifiable clusters and locations and then focusing on any emerging patterns. As a result he correctly identified the major clusters of outbreaks in the city. He successfully identified a particular water pump on Broadwick St. in the Soho district which he suspected of having water contaminated with fecal matter. In 1854, he convinced a local London council to disable the contaminated water pump by removing the handle. Within days, the deadly cholera epidemic in that area came to an end. To prove his point, Snow had mapped the London cholera outbreak. He visually depicted clusters of choleraoutbreak data seen in different parts of London. The mapping technique he used is the basis of the F.A.C.T. Analysis Kaleta Tool, which is described below, and which is now employed at Cedarvale Terrace. Mapping the incidence of falls throughout a nursing home facility can pinpoint a specific pattern relative to exact location, shift, time, and/or particular day. This visual representation on falls allows for expedient and effective dissemination of data to frontline staff. Because nursing staff in LTC homes provide care 24 hours a day, 7 day a week, it is possible to track falls continuously on a monthly basis. The recorded data self-arranges into clusters (colour-coded on the tool) and leads to the interpretation of emerging themes. In the graphic of the Fall Analysis Tool, one can see multiple falls occurring in the early morning hours

By Janusz Kaleta, B.Sc.N., R.P.N., C.P.T.A.

Falls analysis

Falls mapping

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Note missing handle on the waterpump at the Dr. John Snow memorial in Soho.

Canadian Nursing Home

No: 00

Fall Analysis Tool

Day:
M T W T O U E H N E D U

Kaleta, Janusz, 2010

1 2 3 4 5 6 7 8 9 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1

Plan Do Study Act

Month:
Time 07:00 08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 24:00 01:00 02:00 03:00 04:00 05:00 06:00

Nursing Shifts
Study/Actions:
1. Safe footwear 2. Assist with toileting 3. Use assistive devices 4. Safety checks

F S S M T W T F S S M T W T F S S M T W T F S S M T W R A U O U E H R A U O U E H R A U O U E H R A U O U E I T N N E D U I T N N E D U I T N N E D U I T N N E D

Locations legend

Each coloured

dot represents

07:00 - 15:00

a fall in the

corresponding

location, day,

time and shift.

Residents Room

Washroom

Study/Actions:
1. Communicate risk 2. Assist with toileting 3. PM hygiene care 4. Safety checks

15:00 - 23:00

Dining Room

Hallway

Elevator

Main Floor

Study/Actions:
1. Safety walkabouts 2. Lowering beds 3. Early toileting 4. Safety Checks

23:00 - 07:00

Outside

Lounge

Recreation

Prayer room

between 05:00 to 06:00 in residents rooms (red) and washrooms (yellow). With this information, appropriate falls prevention interventions can be implemented by the night shift. Front-line staff also relate much better to a visual representation of the collected data rather than verbally reported numbers alone. The visual representation of every fall is charted in relation to date of the fall, time of the fall, the location [i.e., room, washroom, lounge area, recreation room, etc.], and the specific shift [day, evening or night]. Staff now have access to a greater understanding of the specific patterns and probable risk factors for the occurrence of falls. For example, note the increased incidence of falls on the weekends. All the locations are colour-coded in order to provide a means to identify

potential risk factors for falls and to develop appropriate interventions. Based on the location of the identified risk factors, suitable interventions can be developed by the nursing teams, such as walkarounds by staff, early toileting of residents, frequent safety checks, etc. Providing a visual guidance to front-line staff, such as a colour mark on the wall indicating the position a particular bed should be lowered every evening was also found to be a simple and effective way to ensure residents safety. The Falls Prevention Team also recognized that, at night, residents frequently experience reduced vision acuity, slowed adaptation to darkness, and reduced depth perception and colour contrast sensitivity. (See following

Interventions

page on photo-luninescence).

As a model for improvement, the Plan-Do-Study-Act is a simple tool for making or accelerating change. The P-D-S-A cycle has been successfully employed by hundreds of health care organizations - including nursing homes - to improve many health care processes and ensure the saftey of clients. Although originally designed to be used in the business environment, the P-D-S-A model is a repetitive (or iterative) four-step process or cycle that starts off small to test the potential effects on changes that have been made. This can lead to larger and more targeted change(s). With the right health care personnel selected for the team (i.e., a Falls Prevention Team), and the objective established (i.e., reduction in the incidents of resident falls), the variety of possible actions to reduce the number of falls suffered by residents is then discussed in detail by team members. The team has to initially determine what it is they want to accomplish with the change(s) it intends to address - the objective (i.e., reduction of falls). The first step involves planning a test or observation (i.e., assistive devices such as using visual guides). This step also includes a plan for collecting relevant data from various sources (i.e., falls mapping, staff interviews, incident reports, etc.). The second step is to try out or do a test on a small scale and see if the change/ innovation leads to an improvement (i.e., a reduction in resident falls). The third step involves setting aside time to study or analyze the results of the test, (i.e., a test to determine the efficacy of strategically placed visual guides to reduce falls as determined, for example, from the mapping procedure). The fourth step is the refinement, or action stage; that is, the team takes what has been learned from the test and refines or improves on it. After testing the change on a small scale, including duplicating the test and learning from each test, and refining the change or changes introduced, the team now has the option to implement the changes to other parts of the facility.
For more information on P-D-S-A, see: <www.innovations.ahrq.gov/content.aspx?id=2398>.

The P-D-S-A quality improvement process

OHQC - Ontario Health Quality Council, Residents First - Advancing Quality in Ontario Long-Term Care Homes. Road Map to Falls Prevention - May, 2010. See: <http://www. residentsfirst.ca/documents/qiroadmaps/rf_ preventingfalls_d6_may11pdf>. RNAO - Registered Nurses Association of Ontario, Prevention of Falls and Fall Injuries in the Older Adult. RNAO, 2005. Available at: <www.rnao.org/Page. asp?PageID=924&ContentID=810>. Retrieved on May 15, 2011. RNAO, Falls Prevention: Building the Foundations for Patient Safety, Self-Learning Package. RNAO Nursing Best Practice Guideline Program, 2007. See: <www.rnao.org/Page.asp?P ageID=924&ContentID=1707>. Ontario Injury Prevention Resource Centre, Falls Across the Lifespan; Evidence-based Practice Synthesis Document, November, 2008. <www.oninjuryresources.ca/downloads/misc/ FallsReview-D8.pdf>. Lynons, R., John, A. et al., Modification of the home environment for the reduction of injuries; Cochrane Collaboration, 2006. CNA - Canadian Nurses Association, Backgrounder: The Built Environment, Injury Prevention and Nursing: A Summary of the Issues; 2005. Wagner, L., Rust, T., Safety in Long-Term Care Settings: Broadening the Patient Safety Agenda to Include Long-Term Care Services; Cdn. Patient Safety Institute; 2008. S e e : < w w w. p a t i e n t s a f e t y i n s t i t u t e . c a / English/research/commissionedResearch/ SafetyinLongTermCareSettings/Documents/ Reports/LTC%20paper%20-%20Safety%20 in%20LTC%20Settings%20-%202008.pdf>. Zimmerman, R., Ip, I., et al., An evaluation of patient safety leadership - walkarounds; Healthcare Quarterly; Volume 11; Special Issue; P. 16-20; 2008.

Bibliography

Janusz Kaleta, B.Sc.N., R.P.N., C.P.T.A., is a staff educator at Cedarvale Terrace Long Term Care Home in Toronto. Author contact: <jkaleta@cedarvaleterrace.ca>. The author acknowledges the input of the multi-disciplinary team at Cedarvale Ter-race, as well as residents and families, front-line nursing staff, the medical team, rehabilitation/physiotherapy, administration, housekeeping and dietary departments.

About the author

Page 6

Canadian Nursing Home

To prevent falls by residents due to visual challenges - especially at night - the Falls Prevention Team at Cedarvale Terrace partnered with Gloway Solutions, a safety products company that produces night-time navigation systems suitable for institutional settings. The products, which are photo-luminescent, require about 30 minutes of natural or artificial light to charge. The stored energy emits light in the dark for over eight hours, which is ideal for visual guidance to residents looking for assistive devices, call bells, glasses, etc. Even holding bars can be illuminated in order to safely self toilet. (See page 8) As illustrated adjacent, the use of photo-luminescent products has been found to be an effective way of enhancing night-time navigation for more independent and mobile residents. This is especially important when a resident experiences a sudden voiding urge at night due to physiological impairment, i.e., poor sphincter control or earlystage incontinence. Too often, residents will rush to the washroom without turning the lights on or looking for assistive devices, a scenario that significantly increases the risk for falls; photo-luninescence significantly reduces this risk.

Falls safety products in residents washroom

(Above) Safety bar daytime.

(Below) At night with photo-luminescence.

Photo-luminescence

(Above) Sink during daytime. (Below) Glowing edges of sink at night.

Volume 22, Number 3, September/October, 2011

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The Falls Prevention Team at Cedarvale Terrace strives to reduce the number of falls and fall related injuries by early identification of risk factors and provision of suitable interventions based on evidence - while reducing the use of restraints. Cedarvale Terrace Falls Prevention Program is focused on interprofessional collaboration with a focus on the unique needs of residents and families. Reduction in transfers to hospital emergency units as a result of falls and fall related critical injuries have been set as a priority. The following additional P-D-S-A [Plane Do Study Act] initiatives with the focus on falls reduction have been conducted: Falls Prevention Brochure For New Residents and Families As a part of improved communication and preventative approach to risk for falls, the Team developed a brochure as a part of the Admission Package to all new families of residents. The aim of the brochure is to share with them a knowledge of the risk factors for falls and apprize them of the need for items the resident should have: non-slip footwear, eyeglasses, assistive devices, and belts. Safety Champions - Last year, the Team recruited Safety Champions from front-line staff to share their expertise of falls prevention with new employees. All Champions volunteered to act in this project and received Safety Champions pins. In was also arranged for residents at risk to have Low Profile BedSide Mats to prevent critical injuries.

Team goals in falls prevention at Cedarvale Terrace Long-Term Care Home

The Team also provided, for residents at risk, a number of falls prevention items such as: Alarms with non-removable clips Head protective soft helmets Geri Hip Protectors Assistive devices via Physiotherapy Prevention of injuries related to use of anticoagulant therapy One of the primary goals of the Team was to reduce the number of fall-related critical injuries such as head trauma and hemorrhage. All residents on anticoagulant therapy, such as Coumadin, have been identified and appropriate interventions were added to their Care Plans. INR levels are monitored as per physician order to ensure therapeutic range. This was completed last year. Safety Cards - The Team designed Safety Cards intended to prompt all front-line care staff to be proactive and aware of three questions when interacting with residents, or before leaving their room. The three questions focus on: need to void/use washroom, pain, and any other need such as having some items close by: remote control, book, or phone. The card will also list Universal Falls Precautions as an easy- tofollow resource guide for front line staff. The RNAOs Nursing Best Practice Guidelines recommends use of Universal Fall Prevention Interventions for all patients (RNAO, 2007).

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Canadian Nursing Home

Residents who are starting on a diuretic, and those who are already on a diuretic and are switched to a higher dose, have an acute increase in their fall risk, says a study from the American Geriatrics Society Annual Scientific Meeting held in Baltimore this past Spring. The study results showed that the risk for falls in residents increases more than two-fold within one day of their In the days after they start taking nonSSRI (non-selective serotonin reuptake inhibitor) antidepressants, such as bupropion or venlafaxine, residents are at significantly greater risk for falls, according to a new study presented at the Alzheimers Disease International Conference in Paris this past summer. Researchers found the increased risk for falls also applies to those who had a dosage increase of their current prescription.

Diuretics increase risk of falls in nursing home residents

receiving a new prescription for a diuretic or an increase in the dosage. The increased risk was especially pronounced with loop diuretics which are used in cases of impaired kidney function, i.e., hypertension, edema. It was recommended that increased surveillance for all residents take place for the first two days following a change in diuretic in order to reduce falls. Our results identify the days following a new prescription or increased dose of a nonSSRI antidepressant as a window of time associated with a particularly high risk of falling among residents, said study author Dr. Sarah Berry of the Institute for Aging Research of Hebrew SeniorLife in Boston. Newer drugs, including serotonin-norepinephrine reuptake inhibitors, may also be associated with risk of falls, it was noted.

Researchers have evaluated a broad range of interventions to prevent falls with a wide range of outcomes.

The unintended consequences of falls prevention programs

Certain antidepressants linked to nursing home falls

Falls may be an indication of early Alzheimers symptoms

Falls are more common among individuals with the earliest signs of Alzheimers, and are twice as likely to fall as healthy people, researchers said during a presentation at the Alzheimers Disease International Conference held in Paris in mid-July.

Older adults with Alzheimers may also be at higher risk for falls because of balance and gait disorders and problems with visual and spatial perception caused by the disease. Understanding the traditional hallmarks of Alzheimers, including cognitive impair-

Gait and balance

ment and memory loss, are important; however, the results of this study illustrate the significance of understanding that, in some people, changes in gait and balance may appear before cognitive impairment, a spokesperson said. Also pointed out was the growing evidence suggesting that silent biological changes may be occurring in the brain a decade or more before the outward symptoms of Alzheimers are observed. According to this study, a fall by an older adult, who otherwise has a low risk of falling, may signal a need for an evaluation for Alzheimers.

Volume 22, Number 3, September/October, 2011

Among seniors, foot problems are associated with falling, a major risk factor for fracture. In a randomized controlled trial, Australian investigators compared the effectiveness of a multi-faceted podiatry intervention, versus routine podiatric care in preventing falls in 305 community-dwelling elders with a mean age of 74. All had chronic foot pain, were receiving podiatric care, and were at elevated risk for falls. Both control and intervention groups continued with the podiatric care they were currently receiving. The intervention group,

Multi-faceted podiatry interventions can prevent falls

A recently published, randomized study from Australia illustrates an overlooked issue about falls intervention outcomes. In Australia, 1206 hospitalized older patients were assigned to one of three fall-prevention programs: one-on-one counseling by a physical therapist using written/video materials; materials alone; and a usual-care control group Falls were reduced 50% in the one-onone counseling group compared with the materials-only and usual-care groups. However, only among cognitively intact patients did the intervention show a positive outcome. Unexpectedly, falls among the cognitively impaired were more common in the intervention group. The study has two main messages, according to the researchers. First, fallprevention programs are labor-intensive. Second, prevention programs can have unintended consequences among certain patient populations. In one study, cognitively impaired patients had more falls after intervention, perhaps because they were encouraged to walk. Concludes the authors: Different fallprevention interventions may be required in different populations.
Source: Journal Watch General Medicine, April 12, 2011.

Overlooked issues

however, received a multi-faceted treatment regimen consisting of prefabricated full-length foot orthotics, the provision of appropriate footwear, an indepth foot and ankle exercise program, and education in fall prevention. The control group received podiatric care only. At one-year follow-up, the number of falls was significantly lower in the intervention group than in the control group. The intervention group experienced one fracture; the control group had seven fractures.
Journal Watch General Medicine, 07/21, 2011.

Ones age should be tranquil, as childhood should be playful. Hard work at either extremity of life seems out of men labor under it;

place. At midday the sun may burn, and but the morning and evening should
Thomas Arnold (1800s British Educator and Historian on Age and Aging.

be alike, calm and cheerful.

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