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Acknowledgments and Funding. Canadian Patient Safety InstituteOntario LTC Association:Krista Robinson-Holt, RN, MN (Co-I)Jennifer LangstonOLTCA Applied Research CommitteeFamily representative: Ms. Krystyna SchmidtParticipating LTC FacilitiesResearch Team:Nina Mafrici, Julie Andrassy, Joanna
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2. Acknowledgments and Funding Canadian Patient Safety Institute
Ontario LTC Association:
Krista Robinson-Holt, RN, MN (Co-I)
Jennifer Langston
OLTCA Applied Research Committee
Family representative: Ms. Krystyna Schmidt
Participating LTC Facilities
Research Team:
Nina Mafrici, Julie Andrassy, Joanna Dionne, Hannah Gao, Xiao Jin Chen, Yannie Aass
Thecla Damianakis, PhD, MSW
3. Background Falls are the most frequently reported adverse incident in LTC settings
Approximately 50% of residents fall each year
Numerous studies have addressed falls in LTC, very few have focused on the processes of identification, implementation, and communication regarding the management of falls
4. Research Questions What fall risk factors are identified by nursing staff and which factors result in associated interventions documented on the fall risk care plan?
What fall prevention strategies are listed in the fall risk care plan and are these interventions correctly implemented into actual practice?
How is care plan information regarding falls communicated and implemented to the health care team?
5. Methodology Descriptive correlational design in 8 randomly selected homes in and around central Ontario (>100 beds)
Range 120-170 avg. monthly census
Data collection:
Monthly incident report review
Medical record review
Quarterly rounds to examine care plan interventions
Focus groups
6. Resident Demographics N= 635
Average age: 82.27years (10.22SD)
Average Length of stay: 28 months
Female: 67%
Risk factors:
Fall history 66% Dizziness 14%
Wandering 26% Anxiolytic 32%
Antidepressants 44% Restraint 6%
7. Falls 1901 Total Reported Falls among the 8 facilities over 1 year period
Average 20 falls per facility/per month
Range 6 - 37
Average 3 falls per faller/per year
Range 1 - 35
8. Care Plan/Medical Record Review Risk Factor
Medical Problems
Mobility Problems
Footcare Problems
Urinary/Bowel Incontinence
Vision Problems
Unsafe Behaviours
Psychological condition
Environmental/external
hazard
Medications Example
Stroke/TIA
Gait dysfunction
Neuropathy
Nocturia
Glaucoma
Combativeness
Depression
Cluttered room
Antidepressant
9. Results: Medical Record Review Risk Factor
Medical Problems
Mobility Problems
Footcare Problems
Urinary/Bowel Incontinence
Vision Problems
Unsafe Behaviours
Psychological Condition
Environmental
Medications
% Identified / % Follow-up
86% / 41%
88% / 73%
11% / 54%
74% / 15%
51% / 14%
43% / 60%
76% / 58%
3% / 21%
67% / 6%
10. Quarterly Environmental Rounds N= 1517 observations
Observations focused on risk factors
Mobility, unsafe behaviours, vision, environment, incontinence, etc.
Overall: 66% adherence to care plan interventions
11. Rounds Adherence Mobility (e.g., proper footwear): 64%
Unsafe behaviours (e.g., bed alarm, call bell, bed in lowest position): 57%
Vision (e.g., glasses clean and on while out of bed): 60%
Environmental (e.g., common items within reach): 80%
No Falls Risk Care Plan: n=104
12. Facility Policies Admission policy (n=6 facilities)
Risk level (e.g., high) (n=2)
Staff education (n=3)
Prevention program reviews (n=3)
Medication reviews (n=6)
Interdisciplinary participation/communication (n=3)
Post fall policy (n=8)
Immediate evaluation (n=8)
Contact family member (n=7)
Facility fall committee (n=5)
Explicit QI Program (n=2)
13. Fall Risk Assessment Fall history (n=8)
Secondary diagnosis (n=7)
Ambulatory aid (n=4)
Gait/Balance (n=8)
Mental status (n=6)
Medications (n=7)
Continence (n=6)
Sensory impairment (n=5)
Orthostasis (n=1)
14. Focus Group: Design & Selection 8 focus groups in 4 randomly selected LTC facilities
1 RN/RPN and 1 PSW/HCA group per facility
21 RN’s and RPN’s
21 PSW’s & HCA’s
Purposive sampling
Inclusion criteria
Informed consent
15. Method: Focus Group Demographics Sex:
35 female; 5 male
Ages:
17% 26-35 years
17% 36-45 years
24% 46-55 years
12% > 56 years
30% Preferred not to respond
Type of Position:
11 (27%) Registered Nurses (RNs)
9 (22%) Registered Practical Nurses (RPNs)
21 (51%) Personal Support Workers (PSWs)
16. Method: Data Collection
Semi-Structured Interview Format:
30 min per focus group
Audiotaped; Transcribed
Facilitator and Recorder
Interview Guide:
Falls Risk Identification: Assessing “High Risk” Residents
Post Fall Reporting Procedures
Communication Processes
Falls Quality Improvement and Prevention Strategies
17. Method: Data Analysis Data Analysis:
Open and hierarchical coding
Within and cross-case analysis
Thematic analysis
Observational recordings
Interrater reliability of coding and analysis with research team; triangulation; thick description
18. OVERALL Perceptions Falls monitoring and incident reporting good overall
Good communication: RN’s & PSW’s
Teamwork is important
Staff shortages
Multiple barriers
19. Fall Risk Identification: “High Risk Resident”
Variation in meaning of “High Risk Resident” across locations and sample groups
Some falls considered non-preventable (inevitable) and others preventable
Prioritize: Seriousness of Falls
20. RN’s PSW’s CCAC report
Visual
Physiotherapy
Nurses
Identifiers:
bracelets; bed alarms, signs
Information from families
RN Report(s)
primarily verbal
Visual
Physiotherapy
Identifiers:
bracelets; bed alarms, signs
21. Falls Risk Identification: How do you know which of your residents are at high risk for falling? RN: sometimes we have some information from the previous place, but it’s not always correct and we can’t rely on that, so the best thing is to have our own assessment.
PSW: I believe…we have new metal id bracelets…some of them are colour coded…red, blue, green, blah, blah, blah…but I can’t remember the one that’s “has a history of falls”.
22. Post Fall Reporting Procedures
Limitations Noted:
Lack of communication b/w licensed and non-licensed staff contributes to poor incident reporting
Lack of knowledge of inexperienced staff
23. Post Fall Reporting Procedures: How are you informed that the fall has occurred, and how is this information communicated to other staff members working on the following shift?
RN: I do a report…a written report at the end of the shift, and that report goes down to management….And then we report at the end of the shift to the next shift coming on.
RN: Pretty good here. They (PSW’s) let us know whatever they discover, anything…if there is anything new with the resident….anything unusual…their walking patterns, or if they get drowsy or something…they let us know.
24. Post Fall Reporting Procedures: How is the fall incident communicated to family members? PSW: Whomever is in charge on the floor. Automatically…it doesn’t matter what time of day.
RN: Usually the person whose filling out the report, or the registered staff….always registered staff.
RN: It depends on when they fall too…if it’s late at night they put it on the report for the next shift….the day shift to call the family.
25. Post Fall Reporting Procedures: How are you informed of any changes in the resident’s Care Plan following his/her fall? RN: Well, they (PSW’s) read the care plan.
- F: And how often do they read it?
- RNC: They don’t (with a chuckle)
RN: … you go to the person right away, the person who is taking care of the person, like the PSW whose taking care of them, and you let them know the changes; and it’s in the daily report as well.
26. Post Fall Reporting Procedures: Do you have any concerns when it comes to reporting when a fall occurs on your unit? RN: I’d like them in a more timely manner not three hours after the fall… don’t tell me at like 11 o’clock when I’m trying to close my shift off, that “oh, so-and-so fell at 7 o’clock” and I wasn’t even aware of it to do the incident report.(in a mocking voice): “oh I forgot to tell you three hours ago that the person fell, and they might have hit their head even?!”
PSW: It comes back to the same thing about the knowledge…you go to report it and the nurse…uh…whatever…the nurse will turn around and say: “oh well, you know, you should have done this, you should have done that…you should have known”…But if the knowledge isn’t there, then how would’ve know? So she’s getting upset because a certain person isn’t doing something right, but they weren’t taught the right way, so if they don’t have the knowledge, we’re still going to have falls.
PSW: I think, [in] general, the staff in this facility take a lot to prevent falls from happening on the units.
27. Communication Processes
28. Communication Processes At Risk Identification & Post Fall Recording:
Direct and indirect
Verbal and written
Quality of relationship important: non-punitive; trusting; safe
29. Communication Gaps Post-Fall Reporting
Not witnessed; resident gets up on their own
Not reported at the time; but reported afterwards if there are visible signs (e.g., bruising)
“Like if we are washing [the residents]…then we have to look…if we locate anything or see anything, we have to…it gets documented right away” (PSW)
Near-misses: not identified
30. Barriers: Preventing Falls or Implementing Interventions Staff (RN’s and PSW’s) acknowledge multiple factors which contribute to falls
Despite lack of both formal and informal discussion on falls, seen as important
Discrepancy in falls quality improvement actions among units at the facilities
Interventions toward fall quality improvement tend toward retroactive not preventative strategies
Infrequent in-service training
31. What barriers do you face in preventing falls or carrying out specific interventions on your unit? PSW: …I think knowledge…not to say that we don’t have the knowledge, but we could always use more knowledge. Because falls is not something…we talk about all the time unless it happens.
RN: …the PSW has eight or ten residents to look after, and when they are busy with one, of course, anything can happen with another, and they can’t be there every single minute.
PSW: …some of the barrier, I think would be the family members.
PSW: It’s like too long…sometimes they need [a] proper wheelchair…waiting for months…Oh months! How long?!! Six months already and we never get it….
32. Do you have meetings to discuss falls on your unit? PSW: We have one inservice two times a year…if residents are falling.
PSW: So…I’ve never had one (referring to meeting about falls).. And I worked on there for a year, and we’ve never had one.
RN: …inservice, we had one last year, regarding falls and these similar…situations
RN: If there is an increase…in the number of falls [and] if a resident would have fallen…[we] discuss what’s going on, and what we can do.
33. Barriers to Falls Prevention 1. Family Non-Compliance
Resident footwear
2. Lack of Staff
Staff-resident ratio
Limited time to monitor
3. Lack of Resident Stimulation
Lack & Quality of Planned Activities
Resident Boredom
4. Cognitive Impairment
Instability; Aggression
5. Medications
Agitation, Weakness
34. Barriers to Falls Prevention 6. Lack of Education-Staff Training
Infrequent in-service training
7. Restraint Policies
Pose ethical tensions for staff
Self-determination vs. safety
Families lack of understanding
8. Proper Equipment
Delays in getting equipment
9. Environmental Conditions
Physical-on floor obstructions
35. Falls Quality Improvement: What is the most pressing issue that needs to be addressed when it comes to residents falling? RN: Well, staffing issues because…right now…I think there is one lady upstairs and she’s out of the chair six times an hour…and I’ve got two staff members and that’s been taking them away from their normal duties….and they’re getting stressed out.
PSW: …or guilt….because, you know, mom used to be up and down here and there, and you know, umm…they don’t want to have mom restrained…they don’t accept that mom is not as strong anymore…mom is weaker and potential for falls is there. So, they’re major…I find the major concern is the family members and falls
RN: ..when you have to prevent a fall, you have to put every nurse in every room…and this is twenty or thirty rooms…we have nobody. It is very difficult, especially at night.
36. Deliverables Website live in April 2007:
www.fallsinltc.ca
OLTCA, ALTCA, Manitoba LTC Assn (Spring 2007)
LTC magazine article: June 2007
“Communicating with Families about Falls”
37. Key Messages Implications for:
Practice-
Education-
Management-
Research-
Policy-
38. Implications for Policy, Clinical Practice and Research Policy & Administration
39. Implications for Policy, Clinical Practice and Research (cont’d) Clinical Training & Practice
Standardized Assessment Tools
In-service:
Common meanings of ‘high-risk’ resident;
Restraint procedures, including policies (e.g., least restraint)
Dealing with ethical challenges
Standardize knowledge across floors
Communication frameworks which focus on quality of interaction and promote teamwork
Includes families
40. Implications for Policy, Clinical Practice and Research (cont’d)
Future Research
Develop valid and reliable fall risk assessment tools
Point-of-care approaches to improve communication of care plan interventions