Fall Prevention in Elderly Adults

EBP project with Implementation Plan and Evaluation Plan
Picot Question: Among the geriatric population (P), how effective are discrete nursing interventions (I) as against a complex fall prevention initiative (C) for reducing inpatient falls (O) over a one-year period (T)?
Falls among the elderly are one of the leading causes of incapacity and injury. For facilities which have a substantive amount of elderly patients, creating a plan to reduce falls is a critical component of protecting patients while still ensuring the maximum degree of autonomy.
Fall Prevention Program
Fall prevention begins with assessment. All patients must be assessed for their fall risk using an evidence-based testing scale. According to Phelan (et al. 2016), risks associated with falls include poor muscle strength, gait imbalances, poor vision, and medication regimes. After an initial assessment, all patients should be evaluated for a potential personal fall reduction strategy as well as integrated into the unit’s overall fall reduction strategy. For example, in one study of at-risk patients “only 21% of these had their prescription dose-reduced or discontinued or documentation of continued need for the medication after their fall,” despite the fact that an “intervention to decrease or stop the medication” decreased falls “in 49% of cases; another study that examined psychopharmacy found a [reduction] rate of 28% regarding the use of medication” (Phelan et al., 2016, par. 34). While reducing medications which contribute to falls through sedation may not be possible in the case of all patients, the possibility should be explored, given the risks of falls and also the risks of over-medication of elderly patients in general.
Muscle tone and balance can also be addressed through the use of physical and occupational therapy. While the responsiveness of the patient may vary based upon age, physical condition, and mental deterioration, incorporating yoga and other forms of movement therapy specifically designed to improve muscle tone and to diminish the risk of falls may be useful. Finally, a redesign of the unit itself may facilitate protecting patients. Data analysis itself may be beneficial on a unit-by-unit basis “Control charts can be used to analyze fall rates overall; type of fall; repeat falls; fall injury and level of severity; number of days between preventable falls; and serious injury” (Quigley & White, 2013, par. 20). The use of bright colors to mark steps, guard rails, and specifically assigning staff members to high-risk patients to ensure that they carefully supervise yet encourage appropriate movement are all components of an effective fall prevention program.
Staff Meeting
As can be seen by the above-mentioned suggestions, getting staff members on board for a proposed change is critical. Nursing staff will provide the initial evaluation of patients and must also engage in ongoing evaluation of patients, to see if patients are improving or deteriorating and may need additional assistance. For example, if a patient must be prescribed a more sedating medication than usual, nursing staff must make a note that the patient may require additional supervision to prevent likely falls. Nursing staff must also be responsible for educational efforts of other staff members. Nurses should periodically review patients’ medications to ensure that patients are not being prescribed overly sedating substances and are being put at needless risk for a catastrophic fall.
Nursing assistants also have a vital role to play. They may be on the front lines of taking precautions in assisting the movements of high risk patients and ensuring that patients are not at risk for falls during the acts of daily life. Nursing assistants should be routinely briefed in how to improve the ways in which they interact with patients and assist them with fall prevention; they should also be charged with observing independently mobile patients and asked to report any problems which may be arising or any failures to adhere to proper safety protocols in the physical layout of the unit.
Physical and occupational therapists likewise have a very important role to play in fall prevention. The role of physical therapists are to assist with the rehabilitation of patients from falls. Occupational therapists, in contrast, provide solutions for patients regarding the acts of daily life. “Occupational therapy practitioners work with the client and caregivers to review the home [and unit] environment for hazards and evaluate the individual for limitations that contribute to falls” but also offer strategies to cope with those limitations, such as using a shower chair to enable the patient to wash him or herself independently or rails to use the toilet independently (“Occupational Therapy and the Prevention of Falls,” 2018, par.3). Yoga for limited mobility, weight training, and cardiovascular activities as well as strength-specific training can be incorporated into physical therapy. Finally, given the important role of cognitive functioning, activities such as arts and crafts can assist with fine motor skills; meditation may be useful in encouraging mindfulness and stress relief.
Family Members: Fall Prevention
Given that many patients at high risk for falls will eventually be rereleased for some duration back into a home-based setting, it is essential that family members are likewise briefed about fall prevention. Reconfiguring the home may be necessary, particularly if the elderly individual is moving back to a home with adult children that has not previously accommodated someone in need of eldercare. Having regular visits from home nurses can help the family with professional assessment, to ensure that the family has not overlooked changes in the patient’s vision and balance.


Primary Care Physicians
Screening for vision and hearing, balance, and identifying physical issues that can lead to fall risk is critical. Physicians are ultimately responsible for prescribing medications and identifying the recommended regime of occupational and physical therapy. Physicians may also be needed to facilitate between any conflicts between different therapeutic modalities. For example, physical therapists may recommend and exercise program for a patient but the physician may feel that certain activities (such as deep squatting) may not be advised because of the patient’s past orthopedic issues. Ultimately fall prevention requires the efforts of an interdisciplinary approach.
Staff Training
Simulations of day-to-day activities and requirements associated with assisting patients that are at high risk for falls; ensuring that staff is physically fit and capable of dealing with patient; and conducting a full inventory of the facility for high-risk areas is critical. Budgeting for guard rails and other physical modifications to the environment may be needed.
Pilot Testing
To ensure that the new fall prevention strategy is effective, a group of patients should be assessed before and after the implementation. Variables such as age, physical fitness, and mental capacity should all be controlled and patients should have relatively similar characteristics for the pilot study. A control group of high-risk patients from a similar facility which has not undertaken a fall prevention program can be used as a source of comparison to validate the results. Data-collection is critical whenever a new program is implemented and is necessary to periodically justify the measures used with evidence-based research.


References
Melnyk, B. & Fineout-Overholt, E. (2014). Evidence-based practice in nursing & healthcare
(3rd ed.). Wolters Kluwer Health / Lippincott Williams & Wilkins-LWW.
Phelan, E. A., Aerts, S., Dowler, D., Eckstrom, E., & Casey, C. M. (2016). Adoption of
evidence-based fall prevention practices in primary care for older adults with a history of
falls. Frontiers in Public Health, 4, 190. Retrieved from:
http://doi.org/10.3389/fpubh.2016.00190
Occupational therapy and the prevention of falls. (2018). AOTA. Retrieved from:
https://www.aota.org/About-Occupational-Therapy/Professionals/PA/Facts/Fall- Prevention.aspx
Quigley, P. &White, S. (2013). Hospital-based fall program measurement and improvement in
high reliability organizations. OJIN: The Online Journal of Issues in Nursing, 18 (2).
Retrieved from: https://www.aota.org/About-Occupational- Therapy/Professionals/PA/Facts/Fall-Prevention.aspx