Push for an improved fall prevention program brings better patient health
Florida agency cuts falls from 12% to 4%
You can cut your patients’ risk of falling by 75% as an Inverness, FL, home care agency did by following a program that includes comprehensive fall risk assessment, patient education, and thorough outcomes tracking.
"We began tracking patient falls in 1994 after noticing the number of patients admitted to the hospital or ER [emergency room] due to falls," says Jan Powers, RN, director of Citrus Memorial Home Health Agency, a hospital-based agency in Inverness.
The agency had routinely tracked patients admitted to the hospital or ER, but needed a standard for tracking admissions caused by falls.
First, the agency reviewed literature on fall risk and prevention in the elderly, looking for benchmark data. The quality improvement (QI) department divided the information between the risky activities that a home care agency could prevent and those it couldn’t.
"The literature told us how falls happen," Powers says. "We tried to see what area we could work on and to understand what areas of fall prevention we’ll never have any control over."
For example, a home care agency cannot make a patient use a walker or cane when the agency’s staff are not present.
Still, there are many ways home care aides and nurses can help patients prevent falls, so the QI staff selected a goal of limiting hospital readmission and ER visits due to falls to 10% of the agency’s patient census during a particular month.
When the percentage of patients returning to the hospital due to falls rises above 10%, it triggers a chart review process in which the quality manager assesses the cause of the problem, says Lisa Place, RN, quality improvement supervisor.
Since the agency’s program began, the percentage of readmission and ER visits due to falls has dropped from 12% in the worst month to 4% in a recent month.
Here’s how Citrus Memorial Home Health Agency achieved those results:
1. The QI staff created an outline for a fall prevention program.
The QI staff conducted research into the stages of fall prevention and how to identify risk factors. Then they incorporated their findings in a two-page outline that also includes admission procedures, ongoing procedures, and documentation requirements. (See fall prevention program outline, p. 83.)
The outline covers the areas the agency planned to teach staff, such as how the nurse determines when to refer a patient to the fall prevention program and how to teach the patient and family about fall prevention. The QI staff passed the program out to all staff and covered it at a staff meeting.
The staff also helped with the outline and program revisions. For example, the first version made no mention of a risk factor involving patients on multiple medications. The staff pointed out that this was a problem, and that is now listed on the outline.
2. Give staff patient education material.
The QI staff wrote a one-page fall prevention guidelines sheet for patients to sign. The tool serves as a way to educate patients and their caregivers about how to make their homes safer, wearing safer clothing and shoes, using adaptive equipment, and taking safety precautions when in motion. (See Fall Prevention Guidelines, inserted in this issue.)
The staff put the tool in patient education folders so nurses can easily pull it out and hand to patients.
"On the first visit, nurses present guidelines to patients and say, We’re here to help you prevent any unnecessary injuries, and your cooperation is essential,’" Powers says.
Then nurses discuss the safety precautions listed on the guidelines; after the patient signs the guidelines, the nurse also signs.
3. Show staff how to conduct thorough and accurate risk assessments.
At first, the agency QI staff left the risk assessments to the nurses’ discretion. If a nurse felt a patient was at risk for falls, then the nurse could conduct a risk assessment. A high score on the assessment tool would put the patient into the fall prevention program. The tool consisted of 25 fall risk items, nine mobility safety assessment items, and additional space for nurses to comment. (See fall risk assessment tool, inserted in this issue.)
While it seemed that everything was working well under this system, the hospital readmission percentage climbed to over 10% — the control limit — the QI staff knew it had to make a change in the process.
"We changed our risk assessment procedure to automatically putting everyone on it rather than just leaving it up to the nurse to decide," Powers says.
The agency gave nurses a new assessment form that included a small section on fall risk. The fall risk items were condensed to 15 items, and if the nurse checked more than two of these, he or she was instructed to initiate the fall prevention program. (See assessment tool, inserted in this issue.)
Read the instructions
4. Educate aides on how to use home care equipment.
The aide care plan lists all of the different devices that may be used in a patient’s home. It’s up to nurses and supervisors to make sure aides know how to use them and how to make safety precautions in the home.
For example, the one-page home health aide care plan lists 12 different pieces of equipment, six safety precautions, and 13 limitations that may result in patients being at a greater risk for falls.
The agency makes sure aides are taught how to use the equipment and how to handle the safety precautions that are checked on each care plan. The plan also has a place for checking activities that require the aide to help the patient. Plus there may be special instructions written on the plan. (See Home Health Aide Care Plan, inserted in this issue.)
"The plan tells aides how much assistance they need to give, whether they need to have the caregiver help them, and whether they will be transferring the patient from the bed to the chair, etc.," Powers explains.
5. Continue evaluating program’s outcomes.
When the agency’s fall statistics climbed above 10% in 1997, the agency conducted an in-depth survey by reviewing charts of all patients who had falls.
"The QI department looked at whether the patient was put on the fall prevention program or whether anything was left out that should could have prevented the fall," Place says.
The chart reviewers asked these questions:
• Was the patient identified at admission as at risk for a fall?
• Was the patient given the fall prevention guidelines?
• Was the fall caused by something the agency could have prevented?
• Was the fall caused by patient noncompliance?
Depending on the answers, the QI staff recommended changes. For instance, if the patient exhibited noncompliance, the nurse was told to reinforce patient education on fall prevention.
That was also when the QI staff decided to switch to having fall risk assessments done on each patient.
Soon, the percentage fell and remained stable below 10%, and the agency stopped the automatic chart audits. It will initiate them again only if the number of falls rises above 10%, Place says.
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