falls and their prevention in residential aged care
TRANSCRIPT
Falls and their prevention in Residential Aged Care:
Problems, Practices and Progress
Jacqueline Francis-Coad WA Health Research Travel Fellow 2016 Gerontological Physiotherapist Lecturer, School of Physiotherapy UNDA, IHR
Progress
Practices
Problems
Falls in RAC
Problems
1 in 2 older people in residential aged care fall annually
25-30% sustain a physical injury eg hip #
Falls rates reported range 3-13 falls per 1000 bed days
Cause - complex involving combinations of risk factors:
Intrinsic
Extrinsic
Morley et al (2012), Oliver et al (2007), Onder et al (2012), Rapp et al (2012)
Falls in RAC
Problems
Consequences:
Resident: function & QoL
Staff: burden of care
Organisation: complaints, litigation
Health care system: Cost of fall per person AUD $1887 (2008 base year)
Haines et al (2013), Morley et al (2012), Oliver et al (2007), Rapp et al (2012)
How to prevent falls in RAC?
Staff
• 1185
Environment
• 13 sites
Resident
• 779 beds
Vitamin D supplementation ✓
Multifactorial interventions ✓
Cameron et al (2012), Haines et al (2009), Oliver et al (2007), Ranmuthugala et al (2011), Vlaeyen et al (2015)
CoP?
Medication review ✓
Practices
CoP concept
Member:
Site Care Manager
• RAC connections
• PCA
• RN
• Allied Health
Member:
Site Allied Health
• RAC connections
• PCA
• RN
• Care Manager
Member:
Site Nurse
• RAC connections
• PCA
• Allied Health
• Care Manager
CoP Facilitator (Lead role)
N=2o
Practices
Purpose of the research
Phase 1
• To describe the development and evaluate the establishment of a web-based CoP
Phase 2
• To evaluate if a CoP could conduct a falls prevention activity audit and identify gaps in falls prevention practice
Phase 3
• To evaluate the impact of a CoP on translating falls prevention evidence into practice
• To investigate the impact of CoP action on falls rates and injurious falls rates
Progress
Qualitative Surveys / Interviews
RAC & CoP documents (staff & residents)
Quantitative Surveys (staff)
Falls rates / Injurious falls rates (residents)
Content analysis Descriptive statistics Inferential statistics
Merging of qualitative and quantitative data Realist approach
Complete understanding of CoP impact on falls outcomes
Mixed methods data collection across 3 phases
Adapted from Creswell & Plano Clark (2007)
Phase 1: Development and establishment of a web based CoP
Gained organisational support
Dedicated leadership role
Infrastructure: organisational intranet
Access to computers
Shared purpose, committed and enthusiastic
Met face to face initially
Progress
(Ranmuthugala et al, 2011)
Phase 1: Key Results
Seven (35%) CoP members posted a social profile
Eighteen (90%) CoP members communicated by posting asynchronously during the pilot (6 weeks)
None met the goal of posting a weekly comment
Feasible to operate a web-based CoP if staff are given training and management support time for participation
Barriers Facilitators Getting to know and
recognise other CoP members by text was challenging and slowed building rapport, “you don’t know them and what site they are from”
Add member photographs to posts on discussion board, “Identification photo's for each member so they know who they are communicating with”
Not all CoP members able to attend face to face training, “I have no idea how to blog or what it is. I never use social media”
Easy to follow electronic training document (Welcome Pack) produced, “use screen shot steps on how to access the intranet, navigate our webpage and post on discussion board”
CoP members have multiple demands on their time, requiring attention away from computer. Resulted in forgetting to go to intranet webpage, “You come in, quickly check emails then you have to get on with your work (clinical) so you put it off”
Members receive email reminder alert when new activity on intranet webpage, drawing attention to access webpage, “It’s there (email inbox) right in front of you on the screen when you log on”
Progress
Phase 2: Measuring falls prevention activity
Design
• Cross sectional survey (audit tool)
Participants & setting
• CoP members
• RAC sites
Data collection & procedure
• CoP members conduct audit in conjunction with relevant site staff
• CoP facilitator collects audit tools, codes and delivers to researchers for analysis
Data analysis
• Quantitative questionnaire responses: descriptive statistics
• Qualitative questionnaire responses: content analysis
Progress
Falls prevention audit tool http://www.mednwh.unimelb.edu.au/resource-package/contents/scoping-existing-practice.html
Falls risk assessment
Falls and falls injury prevention
interventions
Falls and falls incident monitoring
processes
Environmental Audits
Organisational support for falls/falls
injury prevention activity
Falls and falls injury prevention staff
training
Falls and falls injury prevention
information for residents
Monitoring falls/falls injury prevention
activities
Other falls/falls injury prevention
activities
Phase 2: Key Results
Audit domain Compliance measure Recommendation/standard Findings
Vitamin D supplementation Mean (SD) proportion residents supplemented vitamin D 41.5% (23.7)
Improve provision of adequate vitamin D supplementation (>800 units/day) for all RAC sites
No CoP members (n = 20) were aware of the Level I evidence regarding effectiveness of vitamin D supplementation in reducing falls rates
Fall definition documented 2 (15.4%) sites RAC facilities should adopt a consistent fall definition and process to ensure consistent uptake by all staff
Site definitions not standardised or clinically explained therefore subject to interpretation; impacts reliability of falls reporting
Falls prevention policy 0 (0%) sites Multifactorial approach using standard falls prevention interventions should be routine care for all residents
Falls management policy (post fall) in place across all sites but multifactorial falls prevention not addressed
Falls risk assessment 12 (92.3%) sites All older persons admitted to RAC receive falls risk assessment, identified risk factors addressed with appropriate intervention
Falls risk assessment tool only covered 4/14 recognised falls risk factors with no clear alignment process to falls prevention strategies in resident care plan
Staff Education 6 (46.2%) sites Falls prevention training provided for all RAC staff. Training should be interactive, experiential, risk factor focussed and explanatory of staff role.
No mandatory falls prevention training. Sites providing annual tutorial at staff meeting had non- standardised content, less than 50% of staff attended
Progress
Falls reporting http://www.health.wa.gov.au/educat
ion/FallsPrevention/player.html
WA Falls Prevention Health Network
Led by Dr Nick Waldron
(Geriatrician)
Phase 3.1: translation of falls prevention evidence to practice
Fall definition, policy and
Risk Ax/Mx plan
Promotion of Vitamin D
supplementation
Care staff survey Resident survey
to inform education program
Adoption of falls prevention
activities in daily practice
Progress
Phase 3.1: Evaluation overview
Member Site Organisation
Quantitative /
qualitative
survey
questionnaire at
entry into CoP
and at 24
months of
operation
CoP meeting
minutes, emails
and electronic
discussion board
transcripts
Social network
analysis
(member
connectivity /
information
sharing)
Quantitative /
qualitative falls
prevention
activity audit
Pre and post
CoP intervention
(proportion of
residents at
facility
supplemented
with Vitamin D)
CoP member
facility activity
reports
Quantitative /
qualitative
survey
questionnaire of
care staff and
residents
Survey of care
managers
Policy and
procedure
documents
relevant to falls
prevention and
stakeholder
meeting minutes
audits
Semi-structured
interviews with
stakeholder
management
representatives
CoP impact at member level
CoP impact at site level
CoP impact at organisational level
Adapted from Ranmuthugala (unpublished), 2014
What worked for whom, how and under what conditions?
Progress
Phase 3.1: Key Results Member level
“It was lovely to have a place
where I could ask questions”
“I gave feedback at staff meetings,
clinical meetings and shift
handovers”
“It was great to get to know
more staff”
11 Topics
Progress
Significant improvement in pre/post falls prevention knowledge p<.001
Phase 3.1: Key Results Site level
Progress
Fall Prevention Policy √ Fall definition √ Fall Risk Ax / Mx plan √
Phase 3.1: Key Results Site level Care staff pilot survey
Remove Hazards Select safe footwear
Call bell in reach Physical restraint
Less than 21% thought the
residents they cared for were at high risk of
falls
Survey then rolled out
across 8 sites (n=147)
Hang, Francis-Coad, Burro, Nobre & Hill (2016)
Progress
Resident survey
6 sites participated
40 face to face questionnaires completed
Education preference for safety/wellbeing approach and reminders in the form of a poster for their room
Progress
Phase 3.1: Example of cCMO’s
Member level Site level Organisation level
Members who demonstrated higher levels of falls prevention knowledge and awareness (psychological capability) and felt strongly that they needed to action fall prevention strategies enough (reflective motivation), better engaged with other site staff to enable implementation of falls prevention strategies
Falls prevention strategies were best implemented and adopted by frontline staff when the required strategies were prompted in novel ways and staff were made accountable for enactment by care managers, by being required to document completion of strategies during their shift
Receiving regular reports on the CoP’s falls prevention actions created a stronger feedback loop from frontline care to general management and assisted in focussing dedicated and more timely attention on falls prevention
Progress
Phase 3.2: Timeline of falls measurement
Six monthly measurement periods
CoP activity at RAC
site level
CoP activity at RAC
organisational level
1 (Jan 2013 - Jun 2013) Pre CoP establishment Pre CoP establishment
2 (Jul 2013 – Dec 2013) Establishment of the CoP. Testing
feasibility of operating a CoP using
ICT
3 (Jan 2014 - Jun 2014) CoP preparation and conduction of
falls prevention clinical audit across
all sites.
CoP official launch and
commencement of operation
4 (Jul 2014 – Dec 2014) Differences in falls reporting across
sites identified. Interventions
planned as priority implementation
(post audit)
Clarifying what constitutes a fall,
definition implemented. New falls
policy and risk assessment discussed
with stakeholder groups. CoP
educational newsletter implemented
5 (Jan 2015 - Jun 2015) Vitamin D supplementation promoted,
care staff and residents surveyed re
falls prevention education needs
New falls prevention policy and risk
assessment (with aligned
management plan) iteratively
drafted.
6 (Jul 2015 – Dec 2015) Revised risk assessment (with aligned
management plan) piloted. Staff and
resident falls prevention poster
checklist developed.
New injurious falls classification
reporting implemented Aug 2015.
New falls prevention policy made
available online
Progress
Phase 3.2 Key Results: Falls
1o763 falls and 137 fractures across all 13 sites during 3 years (control and intervention periods)
1432 (47.5%) residents fell during the study period
66.8% had 2 or more falls (range 2-193)
Progress
Phase 3.2: Key Results
Comparison of falls outcomes pre and post
operationalisation of the CoP
Rate Outcome Coefficient , (95%
CI), p value
Falls rates, Pre
CoP/post CoP,
falls/1000 bed
days
10.1 / 10.9 0.7, (-33.4, 34.9),
0.97
Fracture rates,
Pre CoP/ post
CoP, falls/ 1000
bed days
0.2 / 0.1 -0.3, (-1.1, 0.4), 0.42
Longer term follow up required
Confounding by:
changes to falls reporting
changes in bed type to short stay transition care services
Fracture rates trended downwards but not powered to show significant difference
Progress
Note. All analysis adjusted for age and presence of cognitive impairment, comparing periods 1&2 with 4,5 & 6
Conclusion The CoP was able to impact falls
prevention at membership, site and
organisational levels
The CoP remains operational and is
ideally positioned to continue to
lead evidence-based falls prevention
practice change as determined by its
membership
Come and visit…
Thank you Any Questions?
Francis-Coad, J., Etherton-Beer, C., Bulsara, C., Nobre, D., & Hill, A-M. (2015). Investigating the impact of a falls prevention community of practice in a residential aged-care setting: A mixed methods study protocol. Journal of Advanced Nursing, 71(12), 2977-2986. doi:10.1111/jan.12725 Francis-Coad, J., Etherton-Beer, C., Bulsara, C., Nobre, D., & Hill, A.-M. (2016). Using a community of practice to evaluate falls prevention activity in a residential aged care organisation: A clinical audit. Australian Health Review. Advance online publication. doi:10.1071/AH15189 Francis-Coad, J., Etherton-Beer, C., Bulsara, C., Nobre, D., & Hill, A-M. (Advanced online publication). Can a web-based community of practice be established and operated to lead falls prevention activity in residential care? Geriatric Nursing Hang, J., Francis-Coad, J., Burro, B., & Hill, A-M. (Advanced online publication). Assessing knowledge, motivation and perceptions about falls prevention among care staff in a residential aged care setting. Geriatric Nursing Francis-Coad, J., Etherton-Beer, C., Naseri, C., & Hill, A-M. (in press) The effect of complex falls prevention interventions on falls in residential aged care settings: A systematic review protocol.
Acknowledgements: Funded by The Collaborative Research Network (CRN) Supervisors A/Prof A-M Hill & Prof C Etherton-Beer