Reduce the Falls in the Aged Care Facility at Amity, Campbell

Abstract

This report studies the impact of falls on the elderly population, its impact and the policies and guidelines on fall prevention and provides suggestions to reduce the incidence of falls in the Aged Care Facility at Amity, Campbell Town.

The incidence of falls is on the rise world wide, including Australia. Increased expectancy of life and the ageing population has contributed to this rise in incidence of falls in aged individuals. The incidence of falls is the highest in health care facilities, including residential care for the aged. These falls can lead to severe injuries, like hip fractures with severe morbidity consequences to the aged individual, which could even culminate in death.

Falls can be prevented by reducing the impact of the intrinsic and extrinsic factors that are responsible for falls in aged persons. The rising incidence and the possibility of severe consequences for the aged individual as a result of these falls make it relevant to put in place intervention strategies tailored to meet individual requirements to reduce the incidence of falls and its severe consequences.

At the aged care centre at Amity Campbell Town currently there are no such intervention programs to reduce the incidence of falls. It is recommended that a quality improvement program that takes into consideration the risk factors for falls of the aged at the residential centre be put in place, in keeping with the steps outlined to improve the quality of care at the centre. Resistance to the changes that this quality improvement program will bring with is to be expected and steps will have to be taken to ameliorate the impact of this resistance, before the implementation of the program and during the program.

Introduction

Background for the Initiative

Advances in the fields of medical science and its tool of medical technology have led to a dramatic in life expectancy all around the world. This has resulted in an ageing of the world population that is changing the values and attitudes to the elderly in societies worldwide, making an important change in human development and civilization. The elderly are becoming more important socio-economic players, such that there is increased focus on their needs and well-being (Mermet, 2005).

Among the major problems that impact on the well-being of the elderly is the risk of falls. Nearly thirty percent of the population above the age of sixty-five experience a fall every year while living in the communities, with the number of falls in healthcare institutions being higher (Gillespie, 2007).

In health care environments falls are a frequent occurrence, with a majority of these falls occurring among the elderly. Between two to twelve percent of patients admitted to health care facilities experience falls. The extent of falls varies depending on the kinds of units, with units providing health care services to the elderly showing a much higher percentage of falls than other units (Coussement et al, 2008). These falls not only pose a major economic and social problem, they also have an impact on the confidence of the elderly to lead a normal life (Clemson et al, 2004).

Australian Context

In Australia there is growing awareness of falls as a common problem within its elderly community and has become a major concern in residential care facilities for the elderly. In the 1990s in Australia nearly thirty percent of the elderly experienced either a single or multiple falls (Department of Ageing & Health 2004, p.5). In aged care settings this falling rate is even higher, with it being as high as fifty percent over the same twelve month period (Department of Ageing & Health 2004, p.49).

There are an ever increasing number of elderly people in Australia. Statistics from the American Bureau of Statistics, demonstrates that in keeping with trends seen all over the world, there is increase in the number percentage of the elderly population and hence the fall rates are only bound to increase (Australian Bureau of Statistics, ). Falls are a major cause of injuries for the elderly and it should be kept in mind that injuries that result from faults contribute in a large manner to the mortality and morbidity rates in the elderly segment of population (Tideiksaar 2002, p.3-11).

In recent times a significant number of incidences of falls have been reported by nursing staff in Amity at Campbell Town aged care facility. Over the past three months five residents had to be transferred to acute care facilities as a result of hip fractures or rib fractures resulting from falls. In the case of some of the patients in the aged care facility, they the incidence of falls was multiple. Yet, there is no fall prevention appropriate and effective fall prevention program put in place by the facility committee. This has made it necessary to prepare and introduce a quality improvement project at the Amity aged care facility at Campbell Town, so that falls may be prevented.

Aims

This study aims to recommend a quality improvement project for the prevention of falls in the elderly at Amity, Campbell Town

Materials and Methodology

The method chosen for deriving an understanding for the means to prevent falls in the elderly in a health care environment is a literature review. The initial step in the literature review was to scour the local library for books and journals containing material relevant to the topic. Books and journals containing the relevant material were selected for inclusion in the literature review. The next step in the search for relevant material was to use the Internet.

Medical databases of Medscape, Medline and PubMed were selected and searched for journal articles on falls in the elderly and the prevention of falls. Search terms used in the search of the databases included “falls in the elderly”, “prevention of falls in the elderly”, prevention of falls in the elderly in health care services” and statistics on falls in the elderly”. Articles found relevant for the literature were included in the literature review. The Google search engine was used to locate and identify health authorities’ policies, recommendations and guidelines in the prevention of falls in the elderly. Such policies, recommendations and guidelines were included in the literature review.

This will be an interpretive/exploratory phenomenological qualitative study in which semi-structured interviews will be employed as qualitative research is “most often associated with naturalistic inquiry” (Polit & Beck, 2004, p.15). Roberts and Taylor 2002, p137 states that “if you are trying to answer a question about the lived experience of a person, a qualitative approach such as phenomenology is more suitable”.

In the context of this research method, to generate a theory from data means “most hypotheses and concepts not only come from the data, but are systematically worked out in relation to the data during the research” (Glaster & Strauss, 1967 cited in Gitlin & Depoy 1994, p.36-37). Researchers in qualitative studies collect primarily qualitative data, which are narrative descriptions gained by interviewing participants, by recording participants’ behaviours in naturalistic settings, or by obtaining narrative records like diaries (Polit & Beck, 2004, p.37). “The goals of interpretive phenomenological research are to enter another’s world and to discover the practical wisdom, possibilities, and understandings found there” (Polit & Beck 2004, p.220-221).

Literature Review

Falls in the Elderly and Risk Factors

Stephen Lord cites the definition of fall in his book as “unintentionally coming to the ground or some lower level and other than as a consequence of sustaining a violent blow, loss of consciousness, sudden onset of paralysis as in stroke or an epileptic seizure”(Lord et al, 2001, p.3). Several studies have found higher incidence of fall among the elderly living in aged care facilities (Australian Council for Safety and Quality in Health Care 2004, p.13). Falls can affect older people in many ways including physical, psychological, medical and social ways Lord 2007, p.26-151. The Australian National Ageing Research Institute 2004, p.50 classifies these factors into two parts, consisting of Intrinsic factors and Extrinsic factors.

According to Lord et al, 2001, p70-82, aged-related changes are one of fall risk factors in the elderly and make up the intrinsic risk factors for falls. Some body functions declined with age, such as impairment in sensory, motor and integration system, vision impairment, vestibular function impairment and loss of muscle strength and power. These impairments of functions influence the ability of the elderly in daily living activities seriously, leading to poor balance, weak legs, faint, dizzy, slip and trip etc and play important role in fall (Lord, 2007).

Additional unique risk factors are associated in patients with medical conditions like spinal cord injury, traumatic brain injury and amputations as a result of the consequential medical condition of the patients (Lin & Lane, 2005). In its list of risk factors for falls in health and care centres, the Australian Council for Safety and Quality in Health Care 2004, p.15, lists age over sixty years as the risk factor that gives a sharp rise in the incidence of falls.

The extrinsic factors that contribute to falls in the elderly significantly relate to the environment of the elderly. Simple issues like the excess height of the bed from the floor contribute to falls in the elderly. Other environmental issues include slippery floors including bathrooms, poor lighting, arrangements of solid objects in the room and kind of footwear used (Lin & Lane, 2005). The Australian Council for Safety and Quality in Health Care 2004, p.15, in its listing of extrinsic risk factors for falls in residential care facilities gives the relocation of the inmates and hazards in the environment of the elderly resident as the main risk factors.

Prevalence of Falls in the Elderly and its Consequences

Among the major problems that impact on the well-being of the elderly is the risk of falls. Nearly thirty percent of the population above the age of sixty-five experience a fall every year while living in the communities, with the number of falls in healthcare institutions being higher (Gillespie, 2007). In health care environments falls are a frequent occurrence, with a majority of these falls occurring among the elderly. Between two to twelve percent of patients admitted to health care facilities experience falls. The extent of falls varies depending on the kinds of units, with units providing health care services to the elderly showing a much higher percentage of falls than other units (Coussement et al, 2008).

In health care environments falls are experienced mainly among the older with minor to severe consequences. The minor consequences account for twenty-eight percent of all falls in the elderly in the form of bruises and minor injuries. The major consequences include severe wounds of the soft tissue, which account for eleven of all falls in the elderly and fractures of the bones, which account for five percent of all falls in the elderly. Hip bone fractures as a result of a fall constitute a major complication for the elderly, with such fractures leading to immobility in twenty percent of those elderly experiencing hip fractures and more importantly in fourteen to thirty-six percent of such patients the cause of death within one year.

Other costs to the elderly from falls are longer duration of stay in hospitals increasing the health care costs of the elderly. In some cases such falls could have legal consequences, with the health care institution liable for legal action. An elderly individual, who has experienced a fall at some time, is liable to lose confidence in their abilities, leading to decrease in their mobility, increased dependence for care and social costs. The incidence and consequences of falls in health care institutions make it necessary to for hospitals and elderly care facilities to undertake programmes to prevent these undesirable events for the elderly (Gillespie, 2007).

Approaches for Prevention of Falls in the Elderly

The most effective strategy for the prevention of falls in hospitals and residential aged care facilities is a step by step process involving four components. The first component is the implementation of the standard fall-prevention strategies. The second component is identifying the risk for falls in the case of each elderly patient or resident. The third component is developing and implementing the right interventions for each patient or resident, so that falls are prevented to the maximum possible.

The final component is preventing injuries or reducing the possibility of severe injuries, should a fall occur. All four components are an essential part of any fall prevention strategy and have to be implemented together, as they do not work in isolation to provide success to a fall prevention strategy for the elderly in hospitals and residential aged care facilities Australian Council for Safety and Quality in Health Care 2004, p.16).

According to Seculi et al 2004, p.188, “Although it is necessary to advance on the knowledge of the risk factors and interventions addressed to prevent and reduce the occurrence of falls in the elderly people, a multi-factorial and inter-sectorial approach seems the most adequate”. This multi-factorial and inter-sectorial approach has several elements included in it. The first element is the education and health promotion programs.

The objective of the education and health promotion programs is to create and increase the awareness of the older people and their health service providers about the risk factors involved in falls, how they can be identified and the suitable strategies that need to be put in place to prevent such falls. This is founded based on an increase in awareness bringing about the necessary behaviour modification to reduce the possibility of falls (Department of Ageing & Health 2004, p.10-41).

The second element is the exercise program. There are different models in the delivery of exercise programs, like individual programs or group programs. Furthermore there are several types of exercises that include balance exercises, strength training, flexibility exercises and fitness training. The type of exercise and the modality of delivery is essential decided specific to each elderly person (Department of Ageing & Health 2004, p.10-41).

The next element is the assessment of environmental hazards. Environmental hazards constitute any object or situation that increases the risk of falls. Such environmental hazards may be classified as those encountered in the living environment, like homes or residential care facilities and those present in public places. Commonly experienced living environment hazards include cords on the floor, loose mats, slippery bathrooms, poor lighting and poorly discernible steps. Environmental hazards commonly encountered in public places include uneven footpaths, slippery floors in supermarkets and poorly lit walking areas (Department of Ageing & Health 2004, p.10-41).

The third element is the clinical assessment of the individual. The clinical assessment consists of evaluating the older people for risk factors that are likely to cause falls to them. Such an evaluation may be carried by a medical practitioner or any of the other health care professionals like nurses or suitably trained personnel. The intervention program suitable to prevent falls in each older person is decided as an outcome of this exercise of clinical assessment. Within the clinical assessment several components are consisting of a comprehensive medical assessment that includes assessment of sensory impairments, occurrence of dizziness, reduced peripheral sensation, motor impairments and the evaluation of medications used by the individual and the possibility of their contribution to risk for falls (Department of Ageing & Health 2004, p.10-41).

The final element consists of the choice of interventional devices to reduce falls or reduce the impact of falls. The interventional devices include suitable footwear and walking aids, personal alarm devices for immediate medical attention and hip protector garments. Included in this final element are the nutritional strategies to maintain and improve strength of the bones, like supplementation of the diet with vitamin D and calcium (Department of Ageing & Health 2004, p.10-41).

Lin & Lane, 2005, however warn that prevention of falls in the elderly is not easily accomplished and success or progress is not achieved overnight. It is the commitment and the adherence to planned actions in addressing the intrinsic and extrinsic factors to minimize falls and their devastating consequences that contribute to the progress of prevention of falls among older persons in the long run (Lin & Lane, 2005).

Quality Improvement Project

Recommended Plan of Action

The recommended plan of action for the quality improvement project to reduce the incidence of falls at Amity, Campbell Town has been developed based on the insight on risk factors for the elderly and the fall prevention strategies in older persons. The recommended plan of action consists of the following elements:

1. Set up database for every resident, collect data, incidence of fall, any injuries following fall, summarize monthly at multidisciplinary meeting.
2. Have a care and intervention plan for each resident, which included the residents level mobility level, with a red dot to indicate residents with a high risk for falls. Work out the most suitable method for transference or assistance and highlight in the handover book.
3. Physiotherapist to review residents regularly and assess patients, which will include even the level of beds and chairs that they use. Colour tags are to be used to indicate level of mobility and risk of patient, like red tag on bed to indicate that the bed level is maintained at the lowest level.
4. Change the currently used incident form to make it more individual resident focused in the form of an individual fall incident report, divided into two sections – one for the care staff and the other for the RN. RN is to identify the risk factor involved in the fall incident, review the medications and evaluate whether a physician or physiotherapist needs to be called in to provide a review.
5. CN/RN to assess the room of the resident for environmental hazards and make necessary alterations in discussions with the relatives to reduce the presence of any environmental risk factors and its contribution to the fall in the concerned elderly resident.
6. Education and training of the resident and the concerned staff to bring about behaviour modification in the resident through greater awareness and improved efficiency in the staff.
7. Failure of these steps to reduce the incidence of falls in the resident will require the CN/RN to assess the individual and use protection devices like hip protector, sensor alarm and foam mattress on the floor. In case the evaluation by CN/RN finds that physical or chemical restraint is necessary, the restraint or safety order is to be signed and the physical or chemical restraint used.

Obstacles to the Quality Improvement Project

At the aged care facility Amity, Campbell Town there has been no fall prevention program for older persons in place. The quality improvement program recommended is a change in the functioning of the care providers at this aged care facility. Change brings with it resistance to the change, as health care staff may not be conducive to the alterations in their functioning that the quality improvement program requires.

Institutions and organizations within the health care set up have essentially a bureaucratic set up which is very resistant to change. This resistance occurs both at the individual level as well at the organizational level (Ashford et al, 1999). This resistance at individual level as well at the organizational level is expected to be the obstacles for the quality improvement program suggested to reduce falls in the elderly residents of this aged care facility.

Overcoming the Obstacles to the Quality Improvement Program

Landaeta et al, 2008, suggests that resistance to change in the health care sector does have its unique features and hence it is necessary to identify and understand the sources of resistance and address them through all the integral parts of the change process, before the initiating the change, during the change and after the efforts for change, if resistance to change is to be effectively faced and dealt with. Keeping this advice in mind overcoming the resistance to the changes brought about by the quality improvement program will be dealt with it by initially clearly communicating the need for the changes with the management and administration at Amity, Campbell town and getting their cooperation.

Subsequently all the individuals involved in the care of the aged residents will be informed clearly on the objective of the quality improvement program, the changes in functioning required and the benefits that would be derived the staff and the residents through these changes. Individuals that demonstrate greater resistance to change will be met with and convinced of the need for change and in this manner their cooperation sought. The extent of the success of this coordinated activity will be monitored regularly to evaluate the success in its implementation, alterations required for maintaining progress and change leadership requirements

Conclusion

Falls in the elderly occur frequently because of the frailty and medical conditions that come due to ageing processes, as well as the hazards in the environment that pose a risk for falls in older individuals. The health care environment particularly those facilities that deal with older persons have a higher incidence of falls. Reducing the incidence of falls in residentially facilities for the aged makes it necessary to put in place fall prevention programs that cover the intrinsic as well as extrinsic risk factors through intervention strategies. At the Amity Campbell aged care facility a quality improvement program to reduce the incidence in falls is recommended.

Obstacles to this change are expected both at the organizational and individual level. These obstacles are expected to be overcome by understanding these sources of resistance and overcoming the resistance through communication and convincing activities. The success of the resistance to change overcoming activities as well as the quality improving program will be monitored regularly.

Literary References

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Australian Council for Safety and Quality in Health Care. 2004, ‘Guidelines for the improved safety and quality of care for older people’, Queensland Health. Web.

Clemson, L. Cumming, R. G., Kendig, H., Swann, M., Heard, R & Taylor, K. 2004, ‘The Effectiveness of a Community-Based Program for Reducing the Incidence of Falls in the Elderly: A Randomized Trial’, Journal of the American Geriatrics Society, vol.52, no.9, pp.1487-1494.

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