FINAL REPORT: MINISTRY OF HEALTH SERVICES
STEPPING IN: LONG-TERM CARE COLLABORATIVE FALLS PREVENTION PROJECT
ADMINISTRATIVE ORGANIZATION
§
§
Adult Injury
Management Network &
§
Institute on
Health of the Elderly, University of
§
School of
Nutrition & Dietetics at
Principle Investigators
Vicky J. Scott, RN, PhD
Elaine M. Gallagher, RN, PhD
Co-Investigators
Mariana Brussoni, PhD
Jean-Francois Kozak, PhD
Shanthi Johnson, PhD
CORRESPONDING AUTHOR
Dr. Vicky Scott
BC Injury Research and
Prevention Unit and
Office for Injury Prevention
Ministry of Health Services
1515 Blanshard 4-2
V8W 3C8
Ph: 250-952-1520
E-mail: vicky.scott@gov.bc.ca
DATE
3.1 Project Partners 5
3.2 The Need for the project 6
3.2.1
Why the Need for a New Falls Reporting Form and Prevention Protocols 6
4.2 Changes in Goals and Objectives 8
5.1 Timeline of Activities 10
5.2 Unintended Activities or Events 11
8.1 Falls Prevention among Residents
of Long-term Care Facilities 17
8.2 Understanding Injuries from
Falls in Long Term Care 17
8.3 Implications for Prevention 19
8.4 Future Activities and Dissemination 19
9.1 Introduction 19
9.2 Goals of the Project 20
9.2.1
Deliverables 20
9.2.2
Recommendations from Interim Report 23
9.2.3
Upward Amendments 24
9.3 Brief Overview 25
9.4 Description of
Evaluation 25
9.5 Evaluation
Results—What We Did and What We Learned 25
9.5.1
Communications 25
9.5.2
Cross-Site Data Analysis 26
9.5.3
Reliability and Validity of Falls Surveillance Report© 26
9.5.4
9.5.5
Interventions Data Collection 26
9.5.6
Dissemination of Falls Surveillance Report© 27
9.5.7
Advisory Committees 27
9.5.8
Falls Prevention Strategy Advice 27
9.5.9
Ongoing Surveillance Protocols 28
9.5.10
Final Reporting of Data Analysis 28
9.5.11
Final Evaluation 29
9.5.12
Scientific Results Reporting 29
9.5.13
Stakeholders Meeting May 2004 29
9.5.14
CAG Pre-Conference Workshop October 2004 29
9.5.15
Onsite Reporting System 29
9.5.16
Review of CIHI-DAD Epidemiological Data 30
9.6 What Difference We
Made 30
9.6.2
Surveillance Encouraged in Other Places 30
9.6.3
Frontline Clinical Workers Empowered 31
9.6.4
Stakeholders More Invested in Prevention 31
9.7 What Next? 31
9.7.1 Validity
and Reliability 31
9.7.2
Automation 32
9.7.3
Specialization 32
9.7.4 Role of
Provincial Senior Advisor 32
9.7.5
Concluding Assessment 32
10.0 Recommendations 32
10.1 What
we have gained from project that we would like to share 33
10.2 What
we would do differently 33
10.3 Comments
about project experience 33
11.0 References 34
Appendices
A. Interventions Used in Stepping In
1.0 Introduction:
2.0 Project Summary:
3.0 Background
3.1
Project Partners
This
project was a collaborative effort between the following four partners: the
British Columbia Injury Research and Prevention Unit at the Centre for
Community Health & Health Evaluation Research at the Children's &
Women's Health Centre of B.C; the Adult Injury Management Network (AIMNet) at
the University of Victoria; the Institute on Health of the Elderly, University
of Ottawa; and the School of Nutrition & Dietetics at Acadia University,
Nova Scotia. The BC Injury Research and
Prevention Unit took a lead in the data collection and analysis. The BC Injury
Research and Prevention Unit and the
The B.C. Injury Research and
Prevention Unit (BCIRPU) was established in August 1997 as part of a
province-wide partnership between the Centre for Community Health & Health
Evaluation Research, B.C. Ministry of Health Services and BC Children's
Hospital. With unique links to
government, institutions, experts in the field and community leaders, the unit
also plays a key role in coordinating intervention efforts through
environmental modification, legislation and policy recommendations.
BCIRPU has worked
collaboratively with AIMNet on both the Best Practices Guide and the Inventory
of Canadian Programs for the Prevention of Falls & Fall-related Injuries
Among Seniors Living in the Community. In
2001, Dr. Scott was appointed as Senior Advisor Falls Prevention, with BCIRPU
and the Office for Injury Prevention of the Ministry of Health. She is also an Adjunct Faculty member with
the UVic School of Nursing and the Faculty of Medicine, Health Care and
Epidemiology at the
AIMNet
has an established track record in relation to research on falls and
fall-related injury prevention among older people. The program was established with the
financial support of Health
The
persons who developed the project and served as the project leaders were:
·
Vicky Scott, RN,
PhD Principle Investigator / Falls Prevention Advisor, BC Region; Senior
Advisor, Falls Prevention, BC Injury Research & Prevention Unit; Adjunct
Professor, University of Victoria School of Nursing
·
Elaine Gallagher,
RN, PhD, Principle Investigator / Project Leader; Professor,
·
Mariana Brussoni,
PhD, Co-investigator, Associate Director of the BC Injury Research &
Prevention Unit; Clinical Instructor, Department of Pediatrics, Faculty of
Medicine, University of British Columbia
·
Jean Kozak, PhD,
Co-investigator / Falls Prevention Advisor,
·
Shanthi Johnson,
PhD, PDt, Co-investigator / Falls Prevention Advisor, Atlantic Region;
·
Pattie Thomas,
PhD, Project Coordinator
A National Advisory Committee
and Regional Steering Committees were formed to steer the project and assist
with dissemination. These are discussed more fully in Section 5 of the report.
3.2 The Need for the Project
Approximately 30 to 50
percent of all long-term care residents fall each year, and of these, 40
percent fall twice or more each year (Tinetti, 1987; Aronow & Ahn, 1997;
Kiely et al., 1998; Nygaard, 1998).
Approximately 10 percent of these falls result in serious injury,
including up to 5 percent resulting in bone fractures (Butler et al., 1996;
Thapa et al., 1996). The risk of
sustaining a hip fractures is 10.5 times higher for women who are in facilities
than if they were living in the community, and less than 15 percent of facility
residents who sustain a hip fracture regain pre-injury ambulation status
(Folman et al., 1994).
For Canadian seniors, falls
are the most frequent cause of injury-related hospitalization, and account for
78 percent of injury-related deaths (Raina et al., 1997). This is a growing problem, as the number of
falls and fall-related injuries will increase as the proportion of those aged
80 years and over in
3.2.1 Why the
Need for a New Falls Reporting Form and Prevention Protocols
Current practices for
recording falls and fall-related injuries in Canadian LTC facilities was
limited to in-house report forms designed differently by each facility,
critical incident reports and/or by a new national system known as InterRAI
Minimum Data Set 2.0, for charting all resident health problems, including
falls and injuries.
Each of the three current
recording systems has limitations. The in-house report forms tend to be
designed to document information that may be necessary in the result of a legal
action due to a fall or injury, and not for the purposes of preventing future
falls. The data are not examined for trends or patterns and they are not shared
across facilities due to the lack of standardization (Scott, et al., 2001).
The critical incident reports
are limited to the nature of the injury and type of incident, i.e., fall or
other incident causing injury. Once again, they are not designed with the
purpose of gathering information for designing prevention strategies or
understanding trends or patterns of falls.
The InterRAI Minimum Data Set
2.0 (MDS) system has the potential to assist in understanding the problem of
falls in facilities but it is a long way from being introduced in all Canadian
facilities and has a number of limitations with regard to designing and
monitoring prevention strategies. Although the MDS captures whether or not a
person has fallen, it was never designed to function as prevalence or incidence
falls instrument.
As such, the MDS 2.0 has
several inadequacies as a standalone instrument regarding falls. First, the MDS
only reports whether an individual has fallen at any time within the past 30 or
31-180 days. Falls “prevalence” captured by the MDS, therefore, only reports
the number of people who fell within that time period, prevalence of fallers
and not the prevalence, nor incidence, of falls. Moreover, there is no
indication of the number of times a person has actually fallen. Thus, it is not
possible to use the MDS by itself to identify clinically different populations:
those who fall infrequently versus who those who do, each of which requires
different forms of intervention and prevention.
The MDS is also unable to
provide clinically important information regarding the level of injury sustained
by the fall. Nor is it able to identify environmental factors that contribute
to the fall incident. Even more problematic is that falls are not specifically
defined in the MDS support documentation, which is crucial for any falls
prevalence/incidence instrument. Thus,
specific types of falls reported by a facility in the MDS may or may not be
reported across facilities. For example,
one facility may only report injurious falls whereas a second may report any
incident when a resident is found on the floor. Comparisons between these two
facilities would inaccurately reflect a higher prevalence of falls in the
second facility.
Finally, while the
information available from the MDS may provide information about the intrinsic
or host factors that may be associated with falls (i.e. mobility, disease
diagnosis, daily routine, medication groups), the MDS does not provide a
meaningful examination of fall incidents themselves.
4.0 Goals of the Project
4.1 Purpose
and Goals
The overall purpose of this
project was to reduce falls and fall-related injuries among residents of
Canadian long-term care facilities through positive, collaborative action by
those who are at risk and those who are responsible for their care and
safety. Using principles of community
development, three phases of activity were undertaken by a collaborative team
of falls prevention experts and residential care providers, under the direction
of a National Advisory Committee. The
objectives of each phase were as follows.
Start-up Phase
The objectives of the start-up phase were to:
a. Secure participation agreement from
three facilities representing Eastern, Central and
b. Establish project Advisory
Committee,
c. Establish onsite interdisciplinary
Falls Prevention Team in each participating facility, with both resident and
family representation,
d. Conduct literature review and
compile resource manual of tested interventions and those showing promise,
e. Hire and train project assistants,
f.
Introduce
and trial common fall reporting protocol in facilities (adapting existing forms
developed by Scott and Kozak).
Implementation Phase
The objectives of the implementation
phase were to:
a. Provide data analysis support
through BC Injury Research & Prevention Unit of findings of fall reports
for each facility,
b. Support each agency in their
undertaking of in-house assessment of fall risk issues based on data from falls
reports and current best practices literature,
c. Support development of
collaborative protocols for prevention to address identified fall risk using
educational, environmental, and engineering approaches,
d. Support agencies to implement falls
prevention strategies based on the developed collaborative protocols,
e. Hold a mid-term workshop at BCIRPU.
Evaluation Phase
The objectives of evaluation phase
were to:
a.
Describe
models of intervention which emerged,
b.
Evaluate
impact, outcomes and cost effectiveness of intervention models,
c.
Develop
sustainability collaborative protocols and disseminate results.
4.2 Changes in Goals and Objectives
While there were no
significant changes to the goals as outlined above, two items not originally
planned added value to meeting those goals. Funding from the national study
supported the involvement of the national sites from
Several new goals, however,
did emerge, thereby prompting the request from the National funders for three
upward amendments to the project, and extending the project by two years. In addition, interest from of other BC sites,
lead to a partnership with the Interior Health Authority that resulted in new
sites receiving support by BCIRPU for the use of the Falls Surveillance Report.
The goal of the first upward amendment was to facilitate dissemination
and uptake of the project results.
We proposed to host a one-day
seminar in
The purpose of the second upward amendment was to enhance
dissemination, evaluation and sustainability of falls prevention activities in
long-term care settings in the target sites and other facilities across
There were two objectives, which were complimentary to
the existing project goals:
Objective 1: To enhance dissemination and sustainability of the
current falls prevention activities through the creation of onsite evaluation
capability. It was proposed that
information technology specialists at BC Injury Research and Prevention Unit
work with the onsite falls prevention collaborative teams to carry this out.
Objective 2:
To enhance dissemination of the findings and subsequent recommendations of the
“Stepping In” project through a pre-conference workshop on “Clinical Practice
Experience of Falls Prevention in Long-term Care Settings” to be held at the 2004
Canadian Association on Gerontology Annual Scientific and Educational Meeting
(ASEM) to be held October 21-23 in Victoria, B.C.
The purpose of the third amendment was to collect, analyze and
synthesize epidemiological data related to falls and fall-related injuries
among seniors who reside in long-term care (LTC) institutional settings across
To accomplish this we
proposed the following two objectives, which would enhance the results of the
existing project goals.
Objective 1:
The project team would retrieve and review data related on fall-related
injuries among person aged 65 years and older in Canadian provinces and
territories through an analysis and synthesis of data from the Canadian
Institute for Health Information (CIHI) Discharge Abstract Database (DAD) from
1998/99 through 2002/03. This data would
focus on institutionalized elderly Canadians aged 65 years and older. This information would be presented in the
form of charts with accompanying interpretations.
Objective 2:
The project team would analyze and interpret the data on falls and fall-related
injuries among residents of the five LTC facilities participating in the
study. This information would be
presented in the form of charts with accompanying interpretations, targeting an
audience of policy makers and practitioners who are responsible for the
provision of services to the elderly in LTC settings. These analyses and interpretations would
allow for a wider dissemination of the findings in a form that would
demonstrate the strength of the findings.
The goal of the BC support for additional sites using the Falls
Surveillance Report included BCIRPU support to 8 extra facilities in the East
Kootenay Region in partnership with the Interior Health Authority.
In addition to the sites in Quesnel, in the Northern
Health Region and in
5.0 Activities
Undertaken During Program
5.1 Timeline of
Activities
Figure
1 outlines the activities undertaken during this project along the project
timeline.
In addition to the activities outlined in Figure 1,
each facility was charged with planning interventions to address needs for
injury prevention as identified during the surveillance phase. Appendix A
presents a summary of these showing a breakdown by facility and by type of
intervention. A wide range of interventions were undertaken, drawing heavily on
published best practices as well as creative initiatives designed by
participants.
5.2 Unintended Activities or Events
A large number of events took
place beyond those listed in the work plan.
The following list was compiled from the Quarterly Reports submitted to
Health
·
On
June 26, Victoria MP David Anderson held a press conference at
·
On
June 27, Elaine Gallagher and Vicky Scott were interviewed by CBC radio as part
of their coverage of Mr. Anderson’s press conference.
·
Several
other LTC facilities besides the three regional facilities will be using the
surveillance instrument and collecting data.
Funding for two other institutions in
·
Each
region is planning to kick-off the surveillance phase with a media event. As of the end of the second quarter, only
·
October
15th kick-off at Sechelt facility had media coverage.
·
In
November, Shanthi Johnson gave a presentation based on this project to
personnel from 6 Long Term care facilities in
·
Progress
was made towards including an Ontario LTC facility as well. St. Patrick’s will also be using the tool and
sharing data with the national project.
This facility has a number of veterans and will be an important addition
to the data.
·
The
addition of 8 facilities being supported by BCIRPU to use the Falls
Surveillance received press coverage in
·
Facilities
from all over
·
Talks
between BCIRPU Senior Advisor on Falls Prevention and the BC licensing office
in the Ministry of Health Services have the promise of incorporating the
surveillance tool into licensing assessments.
Some concerns regarding incident reporting to the licensing office have
been raised and discussions will continue to maximize the benefit to LTC
facilities in reducing falls and related injuries without undue workload for
documentation through a collaborative approach with facilities, licensing and
BCIRPU.
·
At
the end of December, the Sechelt facility coordinator gave a presentation to
the local health authority home health care staff meeting regarding the
long-term care project. The case
managers and OTs in attendance were interested in participating in falls
prevention protocols.
·
The
BC provincial Ministry of Health Services funded BCIRPU to launch a new project
targeting falls prevention among clients of home support services. This pilot study includes 60 community health
workers in three cities in
·
May
13-14 workshop was hosted by BC Provincial projects and the BCIRPU. In addition,
·
·
Shanthi
Johnson was interviewed by The Advertiser regarding the Wolfville project.
·
An
informal scan of BC facilities outlined what alarm systems and monitors was
conducted by the BC falls advisor and shared with the Sechelt facility along
with other facilities involved in the provincial and health authority projects.
·
·
The
informal scan of BC facilities outlining what alarm systems and monitors
conducted by the BCIRPU Falls Advisor was shared with other facilities
throughout BC and across
·
Vicky
Scott from BCIRPU was able to visit Residence Saint Louis in November while she
was in
·
BCIRPU
has developed a falls page on their website http://injuryresearch.bc.ca
highlighting LTC falls prevention activities and literature.
·
New
Minister and Health in
·
Joint
funding between the BC Ministry of Health Services and the regional Public
Health Agency of Canada (PHAC), Western Regional office has been secured to
conduct and environmental scan of falls prevention initiatives in BC. This will include an extensive inventory of
all falls interventions programs in BC along with a qualitative study (in-depth
interviews of key players) at two sites to see the role of social capital in
the development of falls intervention projects.
·
A
CIHR application was not funded for the proposed study of the biomechanics of
falling and carrying a purse, however, there is some indication that a second
submission would be possible.
·
BC
Ambulance services are including falls prevention in their crew review, using
similar information to the Falls Surveillance Report©
·
Vicky
Scott of BCIRPU presented preliminary findings from this project at the International
Conference on Injury Prevention in
·
The
Wolfville facility held an appreciation event with residents and family
members, closing the project officially.
The event was covered by the local newspaper.
·
Jean
Kozak held an educational session at Hillel Lodge in
·
Kozak,
JF, Hubert, C. & Marinescu, L. presented a paper, “Long-term Care
Collaborative Falls Prevention Project” at the
·
BCIRPU
has conducted systematic review on Fall Screening and Assessment Tools,
focusing on the LTC studies only, providing a comprehensive overview of why the
validity and reliability of such tools is important. This report will be available to participants
of the PCW in October.
·
Shanthi
Johnson has been invited to serve on the provincial intersectoral falls
prevention committee set up by the NS Office of Health Promotion. Results from this project have been shared at
with the committee.
·
Jean
Kozak will be giving an invited talk this November: Implementing an
evidence-based falls programmer in nursing homes at the Leadership Forum for
Medical Directors in LTC, November 6,
·
Jean
Kozak will be working with Dr. Pierre Soucie and Camille Hubert on an
internally funded project on developing a falls clinical management protocol
for nurses and physicians.
Work during this period did not
include events not in work plan or spin-off projects. An upward amendment with the objective to
collect, analyze and synthesize epidemiological data related to falls and
fall-related injuries among seniors who reside in long-term care (LTC)
institutional settings across Canada was submitted in December 2004.
·
Shanthi
Johnson will be presenting results from this project with the Nova Scotia
Department of Health - Falls Committee this spring.
·
The
Eastern Region is receiving support from the local district health authority to
explore the possibility of using the surveillance tool in a random controlled
trial study. This will be explored more
fully in the coming months.
·
Nine
sites in the
·
The
Falls Surveillance Report© will
remain under the supervision of BCIRPU and will be available to long-term care
facilities on a cost-recovery basis.
6.0 Participation of the National and
Regional Committees
The
major stakeholders in this project were front line practitioners form Nursing,
Medicine, Physiotherapy, Occupational Therapy and Long-term Care Managers.
Accordingly, a National Advisory Committee and Regional Steering Committees
comprised of professionals and seniors with strong connections to the community
and to local and national seniors’ associations, provided direction for the
project. In addition, members of the
committees included representatives of Continuing Care Agencies, Long-term Care
Facilities, Residential Facility Licensing, National Nursing Associations,
National Dietitians Association and individuals with expertise in falls
prevention in facilities from a variety of health care disciplines including
nursing, dietetics, geriatric medicine, and psychology. Members of the National
Advisory Committee were:
·
Executive
committee (E. Gallagher, V. Scott, J. Kozak, S. Johnson, M. Brussoni & P.
Thomas)
·
Jennette Toews,
Division of Aging and Seniors, Health
·
Dr. Taylor
Alexander, President, CEO, Canadian Association of Community Care
·
Sue Calthrope
(senior), Vancouver, BC, Senior Citizen’s Councilor Volunteer Program for the
Ministry of Health Services; and former member of the Office for Seniors
Committee for the International Year of Older Persons; member of Vancouver
Cross Cultural Seniors’ Society and West Side Seniors’ Action Network
·
Darlene Cook,
Heath Policy Researcher, Canadian Healthcare Association
·
Dr. William
Dalziell, Canadian Geriatrics Society
·
Lorna Guse,
Nursing Policy, Canadian Nurses Association
·
Judy Jenkins,
Regional Executive Director, Dietitians of
·
Darene
Toal-Sullivan, CAOT Director of Professional Practice, Canadian Association of
Occupational Therapists
In addition, a Steering
Committee in each region brought in representation from other facilities in the
region with an interest in conducting similar falls prevention activities in
their institutions as well representatives from regional organizations with a
jurisdiction for safety of LTC residents.
A local working group in each
participating site with representation from residents and their family members,
and facility staff oversaw the implementation of the program. This local working group was facilitated and
guided by an onsite coordinator at each site.
Having an onsite coordinator was a key element to the success of
including residents, their family members and staff not only in the
participation of the local working groups, but in the ongoing efforts that were
needed for surveillance and intervention. Onsite coordinators creatively
encouraged participation, actively organizing onsite efforts to encourage
commitment and involvement by all participants at the site level. In addition,
the onsite coordinators provided the best means of communication with the
executive committee, providing monthly reports and giving immediate feedback to
challenges as they emerged.
The most significant
partnership that took place was that between three Universities, stretching
from one coast of the country to the other. The PI’s met on a regular basis, by
teleconference, e-mail and in person, to plan and carry out this project. Dr.
Scott played a leadership role in communicating and directing all aspects of implementing
the surveillance tool, and provided linkages to the data experts at BCIRPU. She
also supervised all aspects of the onsite data collection and training for the
three BC sites. Dr. Marianna Brussoni, Associate Director of BCIRPU, oversaw
the administrative details and management of the Provincial funding
budget. Dr. Gallagher and Dr. Thomas saw
to the administrative details of managing the National funding budget,
submitting quarterly reports, setting up the meetings and agendas. Dr. Johnson
and Dr. Kozak supervised their respective sites and, as well, Dr. Kozak
organized the data collection for the reliability testing of the
instrument.
|
Table 2 Persons
Attending |
|||
|
Name |
Affiliation |
Name |
Affiliation |
|
Vicky Scott |
BCIRPU, |
Emile Therien |
|
|
Elaine Gallagher |
|
Ethel Archard |
|
|
Jean Kozak |
|
Nancy Edwards |
|
|
Ian Pike |
BCIRPU Director |
Kathleen Holdway |
|
|
Shanthi Johnson |
|
Louis Rodriquez |
|
|
Jennette Toews |
HC |
Faranak Aminzadeh |
|
|
Sylvia Ralphs-Thibodeau |
|
Dr Leslie Dubinsky |
Veterans Affairs |
|
Darene Toal-Sullivan |
CAOT |
Anne Marie Pellerin |
Veterans Affairs |
|
Judy Jenkins |
Dietitians of |
Judi Newnhamn |
Veterans Affairs |
|
Lorna Guse |
Canadian Nurses Association |
Darlene Cook |
Canadian Healthcare Association |
|
Sue Calthrope |
Senior Citizen's Counselor Volunteer Program |
Cathy Bennett |
HC Intradepartmental Injury Prevention Working Group
|
|
Taylor Alexander |
Canadian Association for Community Care |
Cynthia St. Pierre |
HC Intradepartmental Injury Prevention Working Group
|
|
Kathy Belton |
HC Intradepartmental Injury Prevention Working Group |
Morag Mackay |
HC Intradepartmental Injury Prevention Working Group |
|
Carla Wells, RN, MN, GNC (C) |
CGNA |
Daryl Rock |
|
The falls prevention
project at WNH was a collaborative venture with active involvement of all staff
and residents. The Stepping In-Long
Term Care Collaborative Falls Prevention Project officially started
WNH and its staff
proved to be very proactive in its approach to falls prevention. Scatter mats
were eliminated from the rooms. Some changes in the admission policy were
implemented at WNH. For example, the
facility decided that no furniture can be brought to the WNH without prior
assessment by physiotherapist and occupational therapist. The WNH purchased a number of hi-lo beds. The
new Director of Care, Charlene Wiseman, has undertaken the task of continuing
the work accomplished by the project by putting it under the umbrella of an
existing accreditation group that would channel any ideas/concerns regarding
falls to the appropriate parties.
The final meeting of
the onsite committee was held on
8.0 Results
There are a number of results or outcomes of this project, they
include:
A.
Falls Surveillance Tool©
B.
Falls Surveillance User Manual©
C.
CAG Pre-conference Workshop Evaluation and Manual©
D.
Draft Results Paper: Falls
E.
Draft Results Paper: Injuries
The papers are in draft form and are
not for circulation or use at the time of this report. Highlights of the findings concerning falls and injury
are presented below, to illustrate the exciting new knowledge gained from the project.
Readers are encouraged to review the other four documents for a complete understanding of
the project results.
8.1 Falls Prevention among
Residents of Long-term Care Facilities (Scott et al., in review)
The purpose of the Stepping In project was
two-fold: 1) to examine the scope and nature of falls and injury among long-term
care (LTC) residents using a standardized fall surveillance tool and 2) to test
the effectiveness of clinically relevant, evidence-based fall prevention
initiative designed and implemented by a
collaborative team of falls prevention experts and residential care providers,
under the direction of a National and Regional Advisory Committees.
This study employed a prospective design for
tracking falls, fallers and injury among long-term care residents over two
phases of a 16-month study: surveillance (180 days), training between phases
(120 days) and intervention (180 days).
Five facilities from three provinces in
Results showed the rate of fall per 1,000 bed-days were 8.4 and 7.8
during surveillance phase and intervention phase respectively. The rate of fallers (those who fell once or
more) per 1,000 bed-days was 3.1 and 3.4 respectively. The differences were not
statistically significant between the 2 phases. All injurious falls, and a sub
set of severe falls (those requiring medical treatment on the site or
transferred out for medical treatment), decreased significantly during
intervention. A slightly reduction among fall frequency was seen for fallers
with 3 or more falls during the intervention phase. Intervention phase results
also captured information about the resident characteristics at the time of the
fall, location of fall, and activities and environmental factors at the time of
fall. Most fallers had one or more health problems apparent at the time of
fall, and non-narcotic analgesics were most frequently reported medications
taken up to 24 hours prior to the fall for both phases, followed by
anti-hypertensives and antipsychotics. For both phases, the leading type of
injury due to fall were bruises/abrasions, scrapes/cuts and skin tear.
Head/neck was most common body part injured by the fall, followed by
arm/hand/wrist and leg/foot.
Results indicate that interventions were successful
in reducing the rate of falls and fall-related injuries. Continued use of the Fall Surveillance Report
is recommended to track trends and patterns over time and to provide the
details needed to implement tailored intervention strategies. However, further examination is needed on the
effectiveness of interventions over a longer period of time, with randomized,
controlled research design.
8.3 Understanding
Injuries from Falls in Long Term Care (Scott et al., in review)
One
of the goals of this project was to conduct a prospective study to examine the
predictors of injurious falls among a convenience sample of long-term care
(LTC) residents as part of a larger study on falls prevention within five
long-term care facilities. Trained staff used a standardized fall risk
surveillance tool to record fall and fall related injury outcomes over
17-months. During this time 1691
resident falls were reported, of which 32% resulted in injury. This rate is greater than the 25% injury rate
found in a study of nursing home residents in Sweden (Sadigh, Reimers,
Andersson, & Laflamme, 2004) but lower than studies that found a 40% injury
rate among fallers with dementia in a LTC setting (van Doorn et al., 2003) and a 54% injury
rate among frail older residents in a LTC setting (Kallin et al., 2002). The 2% fracture rate observed in this sample
is at the low end of the range of 2 to 8% generally observed among this
population (Luukinen et al., 1994; Norse et al., 1998; Rubenstein et al., 1994;
Sadigh, Reimers, Andersson, & Laflamme, 2004). The high rate of fractures among females
found in this study is also consistent with findings from research in similar
settings that distinguishes between male and female residents (Luukinen et al.,
1995).
Bruises/abrasions
were the most common type of fall-related injury and the head and neck were the
most common injury location. Head
injuries are frequently reported as the most common fall-related injury
location among LTC residents (Luukinen et al., 1995; Sadigh et al., 2004) and
may point to an inability among residents to arrest a fall using their extremities
(DeGoede, & Ashton-Miller, 2003).
The fact that females in this study were more likely to injure their
head and hip in a fall compared to males may point to differences in extremity
strength and bone density. This is
supported by evidence indicating that older females tend to have weaker
quadriceps and knee extension strength compared to male counterparts (Janssen,
Samson, Meeuwsen, Duursma, & Verhaar, 2004; Sieri & Beretta,
2004). The greater rates of osteoporosis
among females would also explain increased numbers of hip fractures compared to
males (Dubey, Koval, & Zuckerman, 1999).
Regression
analysis results indicate that resident factors and fall-related incident
factors contribute to either an increase in injurious falls or have a
protective effect on injury. Two
resident factors that were significant risk factors for injury were the use of
a brace/prosthetic and age. However,
wheelchair use was associated with a decreased risk of injury. Although the ability to ambulate was not
found to be a significant predictor of fall injury, residents using a
brace/prosthetic likely have impaired gait and balance which make ambulation
challenging. Lower extremity weakness is
often indicated as a factor in injurious falls and risk has been shown to increase
proportionally with more balance and gait problems (Rubenstein, Josephson &
Robbins, 1994; Rubenstein, Powers & Maclean, 2001; Tinetti, 1987). Increased age is likely a proxy for more
chronic health problems that are known to be associated with increased risk of
fall injury, such as dementia, urinary frequency and mobility impairments
(Myers et al., 1991; Rubenstein, Josephson & Robbins, 1994). The finding that falls among residents who
normally use a wheelchair were found to be protective of injury in this study
is consistent with the lower rate of injurious falls among non-ambulatory
residents compared to ambulatory residents documented elsewhere (Thapa et al.,
1996).
Residents
in this study who used anti-anxiety and/or narcotic analgesics in the twenty-four
hours before the fall were at increased risk of injury. These findings differ from those by Myers et
al. (1991), who report that analgesic and sedative use among institutionalized
persons are associated with falls but not injury, and that hypotensive
medication use was the only medication found to be significantly associated
with fall-related injury. The
contribution of the use of narcotic analgesics to fall-related injuries may be
a combination of the side effects of the medication and the contribution of the
underlying cause of the pain for which the medication is being prescribed.
There
were three environment factors associated with an increased risk of injury:
uneven surface, clothing that is long or obstructive and being pushed by another
resident. As advancing age corresponds
with a decline in response time and lower-extremity weakness (DeGoede &
Ashton-Miller, 2003; Tinetti, 1987), the capacity for older residents to
effectively recover from being pushed, or from tripping over uneven surfaces or
obstructive clothing, is jeopardized.
The contribution of uneven surfaces may also be a factor of the age of
the facilities and lack of regular maintenance.
Two
environment factors found to be associated with a decreased risk of injury that
appear to be counter intuitive are no or low lighting and a new arrangement of
objects. One would expect that a new
arrangement of objects and insufficient lighting would increase the risk of
fall-related injury. However, most falls
with injury occurring under conditions of no or low light would occur at night
(Jensen, Lundin-Olsen, Neyberg, & Gustafson, 2002), and it is possible that
many of these falls involved sliding off the bed, which would result in a
low-impact fall. Less impact from a fall
may also occur if residents take greater care and walk more slowly than normal
due to poor lighting or when they know that there are new arrangements of
objects. However, these are only
speculations and further research on lighting and new arrangement of objects is
warranted.
Due
to the multi-factorial nature of falls and related injuries, effective
interventions are those that are tailored to the individual’s risk profile
(Rubenstein, Josephson, & Robbins, 1994).
This is best accomplished through a fall risk assessment on admission,
with regular updates; on going falls surveillance that details the
circumstances and activity at the time of the fall; and post-fall evaluation to
create tailored prevention plans that utilize a multidisciplinary intervention
approach. Based on the fall injury
risks identified in this study; special attention should be given to assessment
balance and gait problems and use of obstructive clothing among older, ambulatory
residents. Attention should also be
given to facility-wide contribution factors, such as the role of uneven
surfaces, contributors to resident aggression that results in pushing of other
residents and the use of medications that have been shown to increase the risk
of falling with injury. Thus the project has the strong potential to influence
biological, social, behavioural and environmental influences on health.
8.4 Future Activities and Dissemination
A range of future activities has
emerged from the project. One of these is the future uptake of the surveillance
tool and User Guide. This will be coordinated by the BCIRPU and will be
available on a cost-recovery basis. At present, a commitment has been expressed
by the Central Interior health Authority of BC to introduce the tool and
on-site evaluation program at nine sites in the
9.0 Project Evaluation
9.1
Introduction
This
section presents the final evaluation of the Stepping In: Long-Term Care
Collaborative Falls Prevention Project, funded under Health
This
final evaluation report covers the period from June 2002 to March 2005, with an
emphasis on the period since the Interim Evaluation Report, October 2003 to
March 2005, including the intervention phase of data collection, the
development of an onsite reporting system, the collection and analysis of
CIHI-DAD falls injury data, and the dissemination of project results. The
evaluation uses a participatory
approach because the methodology of such an approach fits well with the
project’s purpose of developing a collaborative process for addressing falls
and fall-related injury prevention.
The
evaluation is based upon feedback from
project stakeholders, including
interviews and questionnaires, upon reviews
of project documents, including regular reports, meeting minutes and
email exchanges, and upon participant-observation
field notes, including the notes taken at both face-to-face and
teleconference meetings and the Clinical Experience of Falls Prevention
Pre-Conference Workshop held on October 21, 2004 in Victoria, British Columbia
at the Canadian Association on Gerontology Annual Scientific and Education
Meeting. The results of this evaluation build on the Interim Evaluation Report,
building on the 12 recommendations made in that report as well as the goals of
the four upward amendments approved since that report.
9.2 Goals of the Project
9.2.1 Deliverables
The
major tasks of this project are outlined in Table 3. Outcomes of these
deliverables are also outlined in the table. These tasks reflect the original
project plan as well as the goals that were set during the Interim Evaluation
Process and the subsequent upward amendments. This final report will
concentrate on the tasks delivered during the period of October 2003 and March
2005.
|
TABLE 3: Deliverables Summary for 'Stepping In”: Long-term Care Collaborative Falls
Prevention Project ( |
|||
|
|
|
Task To Be Completed |
Completion of Task |
|
Surveillance Tool Process |
1 |
Surveillance Tool developed
and refined |
Tool was completed for |
|
2 |
Guidelines developed and
refined |
Guidelines were established
with ongoing refinement at individual facilities. |
|
|
3 |
Facility staff trained in
use of tool |
Training sessions were
provided at all facilities. |
|
|
4 |
Data collected |
Data collection was
constrained by challenges outlined in report – however, data was collected
and was yielding usable reports. |
|
|
5 |
Data used to refine tool |
Changes were made to
surveillance tool after review of surveillance phase data and feedback from
the mid-term workshop. |
|
|
6 |
Data collected during
intervention phase |
Data collection went more
smoothly in the intervention phase with less challenges and setbacks. 180
days of data was collected at all sites. |
|
|
7 |
Intervention data collected
during intervention phase |
A method of recording
interventions was developed by the executive committee. All sites recorded
interventions in a timely and thorough manner. Interventions were analyzed
and incorporated into the final report. |
|
|
8 |
Final data analysis and
reliability and validity tests used to refine tool |
A revision of the tool was
completed in light of the final data analysis and the reliability and
validity tests. |
|
|
9 |
Onsite reporting system
created |
One of the nationally
funded facilities and one of the provincially funded facilities served as
test sites for the reporting system. A preliminary system was developed and
put into place in October 2004. |
|
|
10 |
Onsite reporting system
tested |
Feedback from the
preliminary system was given and used to further develop the onside reporting
system. |
|
|
11 |
Onsite reporting system
refined with accompanying manual |
The system was refined and
completed with manual in February 2005. |
|
|
12 |
Retrieve and review data
related on fall-related injuries among person aged 65 years and older from
the Canadian Institute for Health Information (CIHI) Discharge Abstract
Database (DAD) from 1998/99 through 2002/03 |
Retrieval of data was
delayed due to problems at CIHI. Data analysis was planned for early April,
with a draft to be submitted by late April and a final report to be submitted
by the end of May 2005. |
|
|
Collaborative Process |
1 |
Support organization in
place |
Onsite coordinators were
hired, regional and national advisory committees were recruited with meetings
conducted. The establishment of Falls teams has been more challenging at some
sites than others, resulting in alternative methods to obtain stakeholder
input. |
|
2 |
Horizontal collaboration
established and maintained |
Good communication has been
established at each of the three levels of the project. |
|
|
3 |
Vertical collaboration
established and maintained |
Some challenges were
outlined in the Interim Report, but overall communication between levels was
established and continued throughout the project. |
|
|
4 |
Continuous collaboration
was maintained throughout the intervention phase |
Communication levels
continued to remain high with regular reporting from onsite coordinators and
regular reports to advisory committees on both regional and national levels.
E-mail and teleconferences continued to be the primary and effective means of
communication. In addition, onsite visits were made by falls advisors to
provide needed support to local staff in creating interventions. |
|
|
5 |
Ongoing surveillance of
falls at the facility level should be sustainable after the project. |
Each of the facilities
involved in the project found a way to sustain surveillance after the project
is complete though they each found different ways of doing so. |
|
|
Dissemination Process |
1 |
Data analyzed and results
provided as requested to facilities for use in strategy development |
Preliminary data was
presented at midterm workshop. Delays in data collection experienced in the
Surveillance Phase were resolved successfully with lessons learned and
applied to the Intervention Phase. |
|
2 |
Literature Review provided
to facilities to assist in strategy development |
Literature Review was
provided to facilities, organized at the Interim Workshop and throughout the
Intervention Phase for maximum use in strategy preparation. |
|
|
3 |
Preliminary results of
project to be presented to key stakeholders in meeting in |
Meeting was |
|
|
4 |
Conduct a pre-conference workshop
at the annual meeting of the Canadian Association on Gerontology (CAG). |
The Pre-Conference Workshop
was held on |
|
|
5 |
Conduct a regular session
at the annual meeting of Canadian Association on Gerontology (CAG) presenting
project data. |
As session called “Falls in
Long term Care. Report on the Stepping In Falls prevention Project.” was
conducted on |
|
|
6 |
Publish report(s) based
upon project data in peer-reviewed journals |
Reports are being written
and will be submitted for publication in 2005. |
|
|
7 |
Provide a report to Health |
An interim report was
submitted in January 2005. A final report regarding the upward amendment will
be provided with the final project report. |
|
|
8 |
Provide a comprehensive
final report on the results of the project to Health |
Final report will be
completed and submitted in March 2005. |
|
9.2.2
Recommendations from Interim Report
Based
upon the interim evaluation, the following were recommendations and
expectations for the Intervention Phase of data collection and the
dissemination of project results. These recommendations will be addressed as
specific goals of the project and evaluated for what we did and what we
learned.
1. Continue to rely upon
e-mail and teleconference communications to ensure that all stakeholders in
this project are kept informed.
2. Gain
a clear understanding of the ways in which data collection at the sites has
differed in order to interpret data at the end of the intervention phase. This
includes differences in collection of data, interpreting guidelines,
interpreting changes on forms, the timing of collection, facility
characteristics, settings, the coordinator’s relationships to facilities,
disciplinary backgrounds of coordinators and communication efforts at all
levels. These factors should especially be kept in mind when interpreting
cross-site data analysis.
3. Test the reliability and
validity of the surveillance tool with test results and the implications of the
test results being addressed in the Final Report.
4. Continue collecting
surveillance data during intervention phase so that comparisons can be made and
changes in falls rates can be observed after each intervention.
5. Collect intervention data
so that the timing and type of intervention will be available to interpret
changes in falls incidences.
6. Clarify how the
surveillance form should be disseminated at the end of the project. If funding
is insufficient to provide a user-friendly version that can be implemented
without oversight, then consideration should be given to seeking such funds as
a follow-up project to the current one.
7. Seek
to use fully national and regional advisory committees during the intervention
phase, especially in regards to workable prevention strategies and
dissemination of results of the study.
8. Provide
falls prevention strategy advice as requested to assist with effective interventions
during this phase.
9. Establish
protocols that allow for surveillance to be ongoing at the sites involved in
this study.
10. Make
a final report of data analysis that addresses facility data, cross-site
findings and recommendations for changes in the surveillance tool.
11. Make
a final evaluation that addresses impacts of the project and lessons learned
from the project to be included in the Final Report.
12. Write
scientific papers to be published in academic, peer-reviewed journals and
presented at conferences and workshops.
9.2.3 Upward Amendments
In
addition to the 12 goals outlined above, four goals from three upward
amendments were approved to further the development of the Falls Surveillance
Report© and the dissemination of
project results:
1.
A face-to-face meeting was to be held with
major stakeholders in long-term care for the purpose of disseminating
preliminary project results and receiving feedback regarding the Falls
Surveillance Report©.
2.
A pre-conference workshop at the 2004 Canadian
Association on Gerontology’s Annual Scientific and Educational Meeting was to
be organized to reach out to practitioners at long-term care facilities.
3.
An onsite reporting system was to be developed
to allow for ongoing use of the Falls Surveillance Report©
without the assistance of offsite data analysis services. The express goal of
this system is to encourage ongoing surveillance and intervention at long-term
care facilities to encourage effective improvement in falls and fall-injury
prevention strategies.
4.
Using the Canadian Institutes of Health
Information (CIHI) Discharge Abstract Database (DAD)
in comparison with the data collected from the five facilities in this project,
epidemiological data related to falls and fall-related injuries among seniors
who reside in long-term care (LTC) institutional settings across Canada were to
be collected, analyzed and synthesized.
The four goals of these
upward amendments will be addressed as specific goals of the project and
evaluated for what we did and what we learned.
9.3 Brief Overview
All of the 12
recommendations and all four upward amendment goals were addressed successfully
by the end of the project. This evaluation will outline how each of these
recommendations were met, what positive outcomes were achieved and what lessons
were learned. Because detailed descriptions of the project exist both in the
Interim Evaluation Report (June 2002 to September 2003), in the Phase Three
Upward Amendments Report (February 2005) and in the Final Project Report, this
evaluation will assume knowledge of the organizational structure of the
project, the final revised timeline of the project and the purpose of the
project.
9.4 Description of Evaluation
The final evaluation is
based upon feedback from project stakeholders, including focus groups,
interviews and questionnaires, upon reviews of project documents, including
regular reports, meeting minutes and e-mail exchanges, and upon
participant-observation field notes, including notes taken at face-to-face
meetings and teleconferences. This final evaluation continued to utilize the
principles of the participatory approach as outlined in the Guide to Project
Evaluation published by Health
The first part of the
evaluation will address what we did and what we learned from the tasks outlined
in the twelve recommendations the goals of the four upward amendments. The
second part of the evaluation will consider what impact this project has had by
looking at the difference we made. Finally, the last part of the evaluation
will consider possibilities of what can be built upon the successes and lessons
learned from this project.
9.5
Evaluation Results—What We Did and What We Learned
9.5.1 Communications
E-mail
and teleconference communication continued among all levels of the project
stakeholders. This communication helped ensure that the collaborative
“bottom-up” nature of the project stayed focused. All site coordinators
reported that the regional falls advisors provided support needed to
successfully complete the intervention phase and to further the goals of their
respective sites in addressing falls and falls-injury prevention beyond the
life of this project. The fact that each of the sites chose different
post-project approaches to continuing their surveillance and intervention efforts
supports the wisdom of the collaborative, community-based approach taken by
this project (see paragraph 5.9 below for further details).
9.5.2 Cross-Site Data Analysis
Intervention
phase data collection included specific descriptions of intervention strategies
and methodologies taken at sites. (See 5.5 below for a full description of this
process.) In addition to providing useful monitoring of these efforts, this
qualitative data provided a clearer understanding of the processes used by each
site to address what was learned both from the data collected during the
surveillance phase and from the educational support provided to site personnel
by falls advisors and site coordinators. These data also assisted researchers
in understanding the differences among sites and allowed for a fuller, richer
interpretation of data in final reports presented to sites, at conferences, in
published reports and the final project report. This type of data collection
was an important piece of ensuring the success of the collaborative approach as
an important component in using data collected to its highest advantage.
9.5.3 Reliability and Validity of Falls
Surveillance Report©
Both
the reliability and the validity of the tool were supported during the
intervention phase through acceptable research practices. These tests (reported
in the final project report and in research presentations and publications)
were useful as a means to ensure the quality of the data collected during the
project. In addition, the feedback provided helped improve the surveillance
tool. In future potential developments of the Falls Surveillance Report©,
it would make sense to include more powerful reliability tests of the tool that
might be made possible in a larger, randomized, controlled study. The tests
conducted during this project were quite encouraging regarding both reliability
and validity of the instrument and the data collected by the instrument, giving
greater confidence to the results reported. However, the nature of the project
limited that confidence because more powerful tools were not possible in this
kind of a study.
9.5.4
A
full 180 days of Intervention Phase surveillance data was collected at each
site. This data provided both cross-phase and cross-site comparisons. Future
studies should consider longer periods of pre/post intervention surveillance to
allow for differences in falls rates over a year. The possibility of designing
a controlled study with some form of randomized design has been raised by the
researchers as a way to strengthen the integrity of the Falls Surveillance
Report© and to provide better
data. During the surveillance-only phase of this project, it was difficult for
staff to refrain from creating specific interventions as they became aware of
contributing factors. It would be inaccurate to assert that the
surveillance-only phase and the intervention phase were distinct data
collection periods in which the former was pure observation and the latter were
the only time interventions were created and used. There are also significant
ethical issues involved in establishing a pure “no-intervention” policy. A
tension exists between scientific research processes and the goal of providing
quality care to residents of long-term care facilities. Future research in this
area will do well to duplicate the collaborative, community-based approach
taken in this project to account for staff interventions and for the ethic
dilemmas faced in any controlled research approach to surveillance and intervention.
9.5.5 Intervention Phase Data Collection
As
mentioned in 5.2, intervention data was collected during the final phase of
surveillance data collection. See Table 2 below for the format used to record
these interventions. Though not provided for explicitly in the original project
design, the intervention data provided qualitative information to better
understand what steps were taken at each site to address issues raised from the
data collected during the surveillance phase as well as ongoing issues
identified during the intervention phase. The collection of intervention data
also provided ongoing and fairly immediate feedback that allowed regional falls
prevention advisors to identify areas of concern that needed attention. This
made better use of their time and knowledge and supported the collaborative and
“bottom-up nature of the project. It should be noted that this additional data
collection added relatively little cost to the project as it was
well-integrated into the existing organization and reporting system of the
project, yet it clearly added a great deal of value to the success of the
project, the ability to better understand the lessons learned from the project,
the ongoing feedback needed in a collaborative organization the ability to better
interpret the results of the project. Such an addition to the project design
was possible because of the flexibility and responsiveness of a community-based
approach taken in this project.
9.5.6 Dissemination of Falls Surveillance Report©
A
great deal of discussion has been held among the principal investigators and
the stakeholders regarding the disposition of the Falls Surveillance Report©
after this project. Dissemination of the tool and the results of this project
have been and will be accomplished in several ways. The addition of the upward
amendments made it possible to create awareness of the results and the tool
among all levels of stakeholders and to provide an avenue for long-term care
facilities to use the tool onsite without the need of additional data analysis
support. However, a mechanism for how new onsite facilities would be able to
obtain the tool and begin using it remained a matter of concern as the
executive committee anticipated the end of the project. As the project closes,
the plan is for the final tool with onsite reporting capabilities to be made
available province-wide through the British Columbia Injury Research and
Prevention Unit (BCIRPU) on a cost recovery basis to licensed LTC facilities. More funding will be needed to help determine the
long-term utility of the onsite reporting, but no immediate plans have been
made to apply for this funding. More testing of the tool is needed before
national distribution can be considered.
9.5.7 Advisory Committees
Use
of advisory committees has been an integral part of the project. Through
teleconferences, e-mailing, phone conversations and face-to-face meetings,
project advisors have had the surveillance tool and the dissemination of
results. In addition, project advisory committee members have shared the vision
and results of this project with their constituents, thus increasing the impact
of the project. One lesson learned regarding the use of these committees was
that teleconferences would be more useful if written progress reports were
provided and reviewed prior to the meetings. Because so many sites were
involved and the work at these sites were complex and detailed, reports
presented during meetings tended to too long, leaving little time for
discussion at the end before many committee members had to leave the
teleconference due to other obligations. To the credit of the executive
committee, this issue was addressed directly, allowing for better and more
productive use of advisory committees as the project progressed.
9.5.8 Falls Prevention Strategy Advice
9.5.9 Ongoing Surveillance Protocols
All
five sites have established some ongoing method to continue addressing the
factors that contribute to falls and fall-related injuries as well as ongoing
methods of developing effective interventions to address identified issues.
There have been significant differences in these methods.
Wolfville Nursing Home,
Wolfville, NS continues to use the Falls Surveillance
Report© as a hard copy report
with regular reviews to aid in strategy planning for preventative
interventions. They are not continuing electronic collection of data or
analysis.
Residence St. Louis,
Ottawa, ON continues to keep track of falls with a
comprehensive tool, but they use a tool that is compatible with existing
electronic reporting system rather than the Falls Surveillance Report. They
credit the project with improving awareness at the site of falls and falls
injury and influencing the reporting system.
Shorncliff Lodge, Sechelt,
BC is a test site for the onsite reporting system for
the improved Falls Surveillance Report©.
They continue to collect data and analyze to improve intervention strategies
designed to reduce falls and falls injuries. They have been successful in pilot
testing the Access program for the automated reporting of falls using the Falls
Surveillance Report© and are seeing a
downward trend in falls. A summary report on the reduction of falls and fall
injuries over the time of testing the automated reporting system is available
in Appendix B. This site is showing a
downward trend in falls.
Green Home, Cranbrook, BC
is a test site for the onsite reporting system for the improved Falls
Surveillance Report©. They continue to
collect data and analyze to improve intervention strategies designed to reduce
falls and falls injuries. They have expanded the use of the Falls Surveillance
Report© to seven other sites in
the
Dunrovin Park Lodge,
Quesnel, BC has reported many benefits from the use of the
Falls Surveillance Report© and from participation
in the project. They use a similar falls surveillance tool but one that is
newly mandated by their health region. Their staff reported being disappointed
about the change as the Falls Surveillance Report©
was more comprehensive and better tailored to falls prevention planning. The
project on-site coordinator continues to apply the principles of collaboration
in falls prevention planning for this site.
9.5.10 Final Reporting of Data Analysis
Several
dissemination opportunities were available to give reports on the data analysis
made for this project. To streamline efforts and ensure that comprehensive
reporting was accomplished, the executive committee divided up the work among
four categories: context of settings, analysis of outcomes, analysis of
interventions, and the establishment of the validity and reliability of tool.
These four categories were used in parallel in the stakeholders’ meeting in
9.5.11 Final Evaluation
This
report meets the goal of providing a final evaluation of the project. The use
of a more extensive interim evaluation in lieu of a singular final evaluation
allowed for the ability to make adjustments during the final phases of this
project. The executive committee was successful in responding to challenges
identified during the interim process and this contributed to the successful
outcome of the project.
9.5.12 Scientific Results Reporting
As
discussed in 6.0, a streamlining of reporting was devised and carried out. Four
papers are being written based upon the four categories and will be submitted
to appropriate peer-reviewed journals. This will be an important contribution
resulting from this project because of the success this project had in reducing
falls and fall-related injuries.
9.5.13 Stakeholders Meeting May 2004
Fourteen
people attended the May 21 meeting in
9.5.14 CAG Pre-Conference Workshop October 2004
A
summary of the evaluation of this workshop is included with this report as an
attachment. Fifty-one people attended the October 23 meeting, most of who were
front-line clinical workers in long-term care facilities. The full day workshop
was broken into four sections. The first morning section involved presentations
on the design, implementation and results of the project. The second and final
morning session was a presentation by Dr. Steve Castles of UCLA who provided an
informative presentation on many aspects of falls prevention for elderly
residents of facilities. After lunch, interventions for falls prevention were
discussed. Representatives from two of the three federally-funded facilities
who traveled to
Thirty-seven
of those attending provided written feedback in the form of a questionnaire.
The response to the workshop was decidedly positive with most questions have 80
to 95 percent of the respondents answering “excellent” or “good” on all
questions. All of the participants reported that the written materials provided
were “excellent” or “good,” with a number of participants making additional
comments regarding the quality of the materials provided. Participants reported
that the workshop was useful in helping them think about falls, fall-related
injuries, tracking incidences and creating prevention strategies. The only
negative comments were that the case studies were too long and repetitive and
that there was not enough time to get all the information desired.
9.5.15 Onsite Reporting System
Shorncliff
Lodge, Sechelt, BC (federally funded) and Green Home, Cranbrook, BC
(provincially funded) are test sites for an onsite automated reporting system
using Access software for the reporting of falls by way of the Falls
Surveillance Report© . The
A
test is being run comparing data from the Sechelt site with the onsite
reporting system against the previous data collected from the site that was
analyzed through the central database to ensure accuracy of the new system. By
all indications, the system will be useful to the sites in furthering their
abilities to address system-wide factors contributing to falls and fall-related
injuries at their site. All the facilities using the system have reported
satisfaction with the ease of both data entry and report generation. The Falls Surveillance Report©
and the Access software reporting system will be under the watch of the British
Columbia Injuries Research and Prevention Unit (BCIRPU) and will be available
to other facilities on a cost-recovery basis.
9.5.16 Review of CIHI-DAD Epidemiological Data
Due
to problems at CIHI, the review of the DAD data in comparison with project data
has been unavoidably delayed. At the
time of this evaluation, an extension has been granted by the Public Health
Agency of Canada to allow for this delay.
The data is expected to be released from CIHI by mid-April, and a final
report submitted to HC by the end of May 2005.
9.6 What Difference We Made
By
far the most important contribution made by this project is that falls and
fall-related injuries were reduced across all sites. The Falls Surveillance
Report© was successfully used to
identify and measure system-wide factors contributing to incidences of falls
and fall-related injuries and to guide effective interventions that were
carried out and subsequently tracked. For many of the sites involved in this
project, paying attention to falls and fall-related injuries increased
awareness of how complex these factors can become and helped staff become more
conscious of these factors at the facility. Stakeholders at the facilities such
as residents, family members, volunteers and others concerned with the welfare
of residents also became aware of factors contributing to falls and
fall-related injuries.
9.6.2
Surveillance Encouraged in Other Places
This
project gained considerable attention beyond the five sites involved. In
Because
of the encouraging results of this study, all principal investigators involved
in this project have had the opportunity to present information regarding the
factors and effective intervention strategies for prevention of falls and
fall-related injuries at Canadian and international conferences. These
principal investigators have increased their interaction with scholars in
9.6.3
Frontline Clinical Workers Empowered
The
collaborative and bottom-up nature of this project was also successful. This
had the effect of empowering frontline clinical workers at the sites
participating in this project as well as among the fifty-one participants at
the pre-conference workshop in October 2004. The attention paid to these
clinical workers is an important contribution made by this project because it
involved a rarely recognized component of making a difference in institutional
settings – that is, the importance of supporting those people who have to
implement surveillance and intervention efforts. By recognizing the important
contribution made by frontline clinical workers in prevention efforts and by
using a community-based model to accomplish this recognition, this project can
serve as a model for future efforts of similar bottom-up, collaborative
projects.
9.6.4
Stakeholders More Invested in Prevention
Finally,
this project has contributed to a growing awareness among a wide variety of
stakeholders in
9.7 What Next?
9.7.1
Validity and Reliability
Developing
any kind of ongoing reporting tool to be used in clinical settings requires
extensive testing and retesting of that tool to ensure that what is being
measure is valid and reliable. The complex nature of factors contributing to
falls and falls-prevention among seniors makes such testing and retesting more challenging.
In addition, clinical settings dedicated to health care for individuals carry
the privilege and burden of providing ongoing care in an ethical and effective
manner.
This
project was a good first step towards developing an effective surveillance
tool, but some questions remain unanswered because of the length and design of
this project. A more comprehensive and longer study would further ensure the
validity and reliability of the tool and would account for seasonal variations
in falls and falls-injuries incidences (something that has been documented in
other places). A closer approximation to a randomized experimental design with
control sites would also ensure the validity and reliability of the tool,
though as noted in other places in this report, the achievement of a pure
experimental model would be mitigated by the complexity of the contributing
factors and the ethical demands of clinical care.
9.7.2
Automation
Another
challenge is that facilities are at various stages of computerization. Most
frontline clinical workers are not qualified or compensated for knowledge of
computers and electronically generated reporting systems. This is changing, but
differences in rural settings versus urban settings can be seen, as well as
between larger and smaller facilities. As facilities become more automated,
integration into existing reporting systems will be necessary. Future efforts
should be made to partner with existing reporting systems, including privately
designed systems so that the tool can be integrated into systems used by larger
facilities. This could provide additional funding as well, including private
sector partnerships.
9.7.3
Specialization
There
is recognition on the part of the principal investigators and stakeholders in
this project that a comprehensive reporting system might not be useful as an
ongoing tool because of the demands placed upon staff to implement and maintain
it, especially in smaller facilities where automated reporting is not in use.
Future efforts might examine what kinds of ongoing systems might be developed
while using the Falls Surveillance Report©
as a diagnostic tool to bring ongoing attention to falls and fall-related
injuries prevention, and using it as a potential treatment plan where
system-wide rises in falls and fall-related injuries occur. This attention to
specialization and developing variations for the reporting system would be
quite valuable considering the wide variety of situations possible in long-term
care facilities as demonstrated in this project among the five sites.
9.7.4
Role of Provincial Senior Advisor
Finally,
in
9.7.5
Concluding Assessment
Falls
and fall-related injuries remain an important issue facing those concerned with
the health and well-being of Canadian seniors. This project was a complex,
multi-site, national project involving many participants and several years’
commitment. It has considerable value for a relatively small budget. The work
done in this project has contributed to the improvement of the lives of
Canadian seniors and represents a solid base upon which future efforts can be
built.
10.0 Recommendations
10.1 What we have gained from project that we would like to share
This
project has demonstrated that evidence-based, system-wide intervention
strategies can be effective in reducing falls in long term care
facilities. Effective and comprehensive
surveillance designed to provide that evidence is a key factor in creating such
intervention strategies.
This
project has also demonstrated the importance of using a community approach when
implementing such comprehensive surveillance and intervention. The bottom-up approach taken proved to be
effective because the commitment on the part of front-line workers required to
collect accurate surveillance information is considerable. By involving front-line workers from the
beginning and providing the support they needed to understand the importance as
well as the results of their efforts, ensured their commitment. A top-down approach would not be as effective
because it depends upon commitment to the process at all levels in the long term
care facility organizational structure.
This
project has demonstrated the importance of support from stakeholders both
inside and outside the facility. By
connecting facilities with each other and with organizations concerned with the
wellbeing of seniors, it has been a part of building and enhancing an important
network of people committed to reducing falls and fall-related injuries.
10.2 What we would do
differently
Surveillance
was not conducted over a consecutive two-year period allowing for seasonal
comparisons of surveillance and intervention periods. This prevented the examination of time as
part of the analysis. Since falls have
been observed to be seasonal in nature by some studies, the question of falls
and falls-injuries reduction by season is an important question to address. The
project would have been improved by ensuring full years data for comparison
between the surveillance only and the intervention periods.
The
lack of a control group limited the generalizability of the results from this
project. The ideal would be to have
random, controlled experimental groups with at least one site being monitored
for falls, not using the Falls Surveillance Reportã
for surveillance; at least one site being monitored for falls using the Falls
Surveillance Reportã but no intervention other than normal practice;
and at least one site being monitored for falls using the Falls Surveillance
Reportã
and implementing evidence-based intervention.
This ideal would be challenging to deliver in real world in some care
delivery situations because of the ethical considerations and the changing
dynamic in of the provision of care.
It
is important to point out that these two design changes would have added
considerable costs to the project.
Budgetary considerations, not methodological flaws, determined the model
chosen for this project. Given these
budgetary restraints, this project’s methodology maximized the value of the
project and provided considerable advancement in our understanding of effective
intervention in long-term care facilities.
10.3 Comments about project
experience
The
community-based approach taken in this project is a model than can be used
effectively in evaluation and expansion of a number of treatment
situations. While many health
considerations lend themselves well to experimental and laboratory approaches,
complex phenomena such as the multifaceted and complex factors contributing to
falls and fall-related injuries require a balancing of scientific, clinical and
organizational considerations. This
project stands as an excellent example of what can be accomplished in
improvement of treatment when that balance is pursued.
11.0 References
Aronow, W., & Ahn, C.
(1997). Association of postprandial
hypotension with
incidence of falls,
syncope, coronary events, stroke, and total mortality at 29-month follow-up in
499 older nursing home residents. Journal of the American Geriatrics Society,
45, 1051-3.
DeGoede,
K.M.,& Ashton-Miller, J.A.
(2003). Biomechanical
stimulations of forward fall arrests: effects of upper extremity arrest
strategy, gender and aging-related declines in muscle strength. Journal of Biomechanics, 36(3):
413-420.
Dubey,
A., Koval, K.J., & Zuckerman, J.D.
(1999). Hip fracture
epidemiology: A review. The American
Journal of Orthopedics, September: 497-506.
Folman, Y., Gepstein,
R., Assaraf, A., &
Hill, K., Smith, R., Murray, K., Sims, J., Gough, J.,
Darzins, & Vrantsidis, F. (2000). An analysis of research on preventing falls
and falls injury in older people: Community, residential aged care and acute
care settings. Report to the
Commonwealth Department of Health and Aged Care Injury Prevention Section by
National Ageing Research institute.
Jensen, J., Nyberg, L., Gustafson, Y., & Lundin-Olsson, L. (2003). Fall and injury prevention in residential care-Effects in residents with higher and lower levels of cognition. JAGS, 51: 627-635.
Kallin, K., Lundin-Olsson, L., Jensen, J., Nyberg, L., & Gustafson, Y. (2002). Predisposing and precipitating factors for falls among older people in residential care. Public Health, 116: 263-271.
Luukinen, H., Koski, K., Honkanen, R., &
Kivelä, S.L. (1995). Incidence of injury-causing falls among older
adults by place of residence: A population-based study. JAGS,
43(8): 871-876.
Myers, A. H., Baker, S.P.,
Van Natta, M. L., Abbey, H., & Robinson, E.G. (1991).
Risk factors associated with falls and injuries among elderly institutionalized
persons. American
Journal of Epidemiology, 133: 1179-90.
Nygaard,
H. (1998). Falls and psychotropic drug
consumption in long-term care residents: Is there an
obvious association? Gerontology, 44,
46-50.
Rubenstein,
L.Z., Josephson, K.R., & Robbins, A.S. (1994). Falls in the nursing home. Annals of Internal Medicine, 121(6):
442-451.
Rubenstein,
L. Z., Robbins, A. S., Josephson, K. R., Schulman, B. L., & Osterweil, D.
(1990). The value of assessing falls in an elderly population: A randomized
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Sadigh, S., Reimers, A., Andersson, R., & Laflamme, L.
(2004). Falls and fall-related injuries
among the elderly: A survey of residential-care facilities in a
Scott,
V. J., Dukeshire, S., Gallagher, E. M., & Scanlan, A. (2001a). Best
Practices for the Prevention of Falls Among Seniors Living in the Community. A report to the
Federal/Provincial/Territorial Ministries Responsible for Seniors Fall
Prevention Initiative.
Scott,
V. J., Dukeshire, S., Gallagher, E. M., & Scanlan, A. (2001b). An
Inventory of Canadian Programs for the Prevention of Falls & Fall-related
Injuries Among Seniors Living in the Community. A report to the Federal/Provincial/Territorial
Ministries Responsible for Seniors Fall Prevention Initiative.
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V.J., Gallagher, E.M., Hay, V., & Bhatia, H. (2001).
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Long Term Residential Care: Surveillance Pilot Project. Final Report.
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Johnson, S., & Pearce, M. (in review). Risk Factors for
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875-82.
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F., & Maby, J. (1993). Falls prevention: The efficacy of a bed alarm system
in an acute-care setting. Mount Sinai Journal of Medicine, 60(6),
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van
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Appendix A
Interventions Used in Stepping In
|
Appendix A Interventions Used in Stepping In:
Preventing Falls and Injuries in Long Term Care |
||||
|
Environmental
Initiatives Initiative |
Settings |
Targets |
Personnel |
Cost |
|
Adjust bed height |
|
All residents |
OT, RN |
No added cost |
|
Assess/re-arrange
furniture to reduce clutter, remove scatter mats |
Wolfville |
All residents All residents |
OT, RN, PSW Nursing, housekeeping |
No Cost No added cost |
|
Use non-glare floor
wax |
Wolfville |
All residents All residents |
Janitors, PSW Housekeeping |
No added cost No added cost |
|
Color bands across
doors to reduce wandering |
Wolfville |
Dementia residents |
Nursing, Housekeeping |
No added cost |
|
Install secure doors
to all exits |
Wolfville |
All confused mobile
residents |
Management |
Cost assessment being
carried out |
|
Conduct environmental
scan of building Safety scan of patient
rooms |
Wolfville Sechelt Sechelt |
All residents All residents All residents |
LTC Committee RN, Onsite coordinator |
No added cost No added cost |
|
Renovations of
flooring. Removed carpet and installed linoleum |
Sechelt |
First floor lounge and
dining areas |
Outside contract |
Facility |
|
-
- adhesive
strips in front of sinks -
- brakes on
wheels of kitchen carts -
- secure TV's
to stands -
- raise height
of lounge chairs -
- direction
signs for elevators -
- put handicap
spot in parking lot -
- put rough
surface over smooth concrete on sidewalk - fill cracks in walkways - install hook and eye bolt on storage room door - enlarge door handles |
Sechelt |
All residents |
Maintenance |
Facility |
|
- installed a bed pole - portable ceiling lift & track installed in one room |
Quesnel |
Selected rooms for high risk residents |
Maintenance |
Within existing facility budget |
|
Individual risk
assessments in resident bedroom/bathroom.
Assigning an ‘eyes and ears team’ to designated area to assess
environmental risks |
|
Residents |
Residents
/ Staff Family
/ Eyes and Ears Team |
No added costs |
|
Assistive Device Initiatives Initiative |
Settings |
Targets |
Personnel |
Cost |
|
Check of ambulatory
aids: routine and after a fall |
|
All residents with
aids |
PT, OT |
No added cost |
|
Use of helmets |
|
Frequent fallers
(dementia unit) |
OT, RN, PSW |
Family purchase |
|
Hip Protectors |
Sechelt |
Frequent fallers |
OT, RN, PSW |
Family purchase - Approx. $200 for 2-3 pairs for each resident |
|
Anti-slippery socks |
Wolfville |
Frequent fallers All |
OT, RN, PSW All Staff |
Family Purchase |
|
In-service education on use of lifts |
Sechelt |
All staff |
All staff |
No added cost |
|
Hip
protectors for Maple House unit |
Quesnel |
Ambulatory
residents with osteoporosis, high risk for falls for whom other fall
interventions are not working |
Physio and Nursing |
$60
per protector. To purchase 6 pairs
every 6 months until need is fulfilled.
Through physio/ nursing budgets |
|
Hip
protectors |
|
At
risk residents |
Physio and Nursing |
Health
Authority to cover cost |
|
Statnurs Motion Sensor
Alarm System |
|
At
risk residents |
All staff |
Facility |
|
Non-slip
socks |
Quesnel |
Any
resident who gets up at night unsafely and wears socks to bed |
Care aids |
Families
asked to purchase. Several pairs
purchased through physio budget. $6 to 12 / pair of socks |
|
Falls
mats by bedside |
Quesnel |
Residents who prefer sleeping on the floor |
Care aides / Nursing |
$150 per mat - purchased by nursing budget |
|
Restraint Reduction and Monitoring Initiative |
Settings |
Targets |
Personnel |
Cost |
|
Segufix Prev-2000 Positioning belt |
|
Frequent fallers |
OT, RN, PSW |
$20 |
|
Call bells: put in
bathrooms with yellow cord |
|
All residents |
OT, Nursing staff |
Under $5 |
|
Personal alarm
attached to clothes |
|
Frequent fallers |
OT, RN, PSW |
Approx $10 |
|
Tabs alarm on
bed/chair |
|
Frequent fallers |
OT, Nursing |
$300-$500 Purchased by family |
|
Motion detector |
|
Frequent fallers |
OT, Nursing |
Purchased by family |
|
Encourage frequent
family visits, use of sitter |
|
Frequent fallers |
Family, Sitters |
No cost |
|
Mechanical lifts |
|
Non-ambulatory |
RN, PSW |
Approx $2000 |
|
Assess safety of beds |
Wolfville |
Mobile confused residents |
Management, RN, LPN, PCW |
Assessing cost of new bed options |
|
Survey for staff, family and residents re:
opinions on restraints, surveillance tools, hip protectors, ideas about fall
prevention |
Quesnel |
All staff, family and residents |
Falls coordinator |
No added cost |
|
Identified
clarification needs of Restraint Policy for all staff, residents, families,
and other HCT members |
|
Facility manager |
Falls team |
No added cost |
|
Assessment and Individualized Care Planning Initiatives Initiative |
Settings |
Targets |
Personnel |
Cost |
|
Fall risk education
and supervision |
|
All frequent fallers |
OT, RN, PSW |
No added cost |
|
Bathroom scheduling |
|
All frequent fallers |
OT, RN, PSW |
No added cost |
|
Snoezelen relaxation
training |
|
All frequent fallers |
OT, RN, PSW |
Approx $200 |
|
Fall risk assessment
on admission, condition change or after a fall Orange dots to
identify high faller risk residents. Also used TUG |
Wolfville Sechelt |
All residents All residents who fall SCU residents, on
admission, residents who fall or experience health decline |
OT, RN Nursing, OT, Physio Nursing, Care aides |
No added cost No added cost. If AD
needed, resident pays all or part. No added cost |
|
Falls Prevention Resident Safety Checklist
– part of Fall Risk Assessment Policy - documentation of the fall prevention
strategies for each resident on a Resident Safety Checklist Board located in
the residents’ rooms |
Sechelt |
All residents on the 1st
floor |
LTCAs, RN, Administrative Assistant, Project On-site Coordinator |
Approximately $200 for 64 laminated cards
with 64 dry ink pens and mounting tape. |
|
Safety plan checklist placed in bathroom of
residents who are at high risk of falls |
Quesnel |
All residents who are at high risk for
falling |
||