Wendy dribbles and Peter falls:

managing incontinence and falls

across the continuum

Mary Ann Hamelin, RN, MScN, GNC(c), CNS

Leanne Verscheure, RN, MEd, GNC(c), CNS

Geriatric Institute June 26, 2014

Wendy Dribbles and Peter Falls

• Peter is down cast about his fall

• Wendy fells badly for her accident

• Young Michael says – “well look on the

bright side – at least it wasn’t Tinkerbell –

you’d need an umbrella!”

Agenda

• Urinary incontinence

– Overview

– Assessment

– Management – inpatient and community

• Falls

– Overview

– Assessment

– Intervention and strategies – inpatient and

community

Urinary incontinence- why? • Factors:

– Anatomical - Cultural

– Physiological - Environmental

– Functional

– Psychological

• Continence requires

– Intact lower urinary tract function

– Cognitive and functional ability

– Motivation to maintain continence

– Environment that enables continence

Urinary incontinence- why? • Age associated factors:

– Decreased bladder elasticity and innervation

• decreased bladder capacity and urine flow rate

• increased post void residual and involuntary bladder

contractions

• reduced voided volume

– Benign prostatic hyperplasia in men (BPH)

• urinary urgency, hesitancy, & frequency

– Menopausal loss of estrogen in women → atrophic vaginitis

Despite age associated changes, urinary

incontinence is NOT a normal part of aging.

Types of Urinary incontinence

• Transient (acute) vs Established (chronic)

• Established – Stress

– Urge

– Mixed

– Overflow

– Functional

Assessment of UI

• Determine type

• Factors associated – Anatomical, Cultural, Physiological, Environmental,

Functional, Psychological

• Medication review

• Testing

• Catheters

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Drug Class Adverse Effects

Diuretics Polyuria, frequency, urgency

Anticholinergics Mental status changes

Urinary retention, stool impaction

Psychotropics Anticholinergic effects

Immobility, sedation, delirium

Alpha adrenergic agonists Urinary retention

Alpha adrenergic blockers Urethral relaxation

Calcium channel blockers Urinary retention

Medication Review

Testing for UI • Physical exam

– Abdominal exam (suprapubic distention)

– Genital exam (discharge, atrophic vaginitis)

– Rectal exam (constipation, fecal impaction)

– Skin (fungal rashes, perineal irritation)

• Testing

– Urinalysis

– Culture and sensitivity (to treat or no to treat?)

– PVR (>100cc is abnormal)

– Bladder scanner (ultrasound)

– urodynamics

Inpatient Strategies • Treat underlying causes of transient UI

• Established UI management

– Environmental (equipment)

– Dietary

– Toileting programs (purposeful rounding,

scheduling, prompting, bladder training)

– Pelvic floor exercises

– Consults – OT/PT

• Minimize risk for complications

In/Outpatient Strategies

• Pharmacologic options

– Anticholinergics – urge incontinence and overactive

bladder

– Alpha-adrenergic blockers - frequency and urgency

– Pseudoephedrine – stress incontinence

– Topical estrogen – stress and urge incontinence in

women

• Surgical consultation

• Other techniques

Falls

Falls Prevention

Definition of a fall

• An event by which a person comes to rest

inadvertently on the ground or lower

level

– Witnessed or not

– Injury or not

– Intrinsic or extrinsic factors or both

Complications from falls is the leading

cause of death from injury in both men and

women >65 years old

Defying Gravity • Evidence that fall prevention programs are effective

when they are multifactorial in design and target individual risk factors

• Mixed results for hospital based fall prevention programs

• Need for further development and testing of approaches • Physical restraints do not reduce patient falls and are

associated with soft tissue damage, injuries, fractures, delirium, and death

• Fall prevention is challenging in older hospitalized adults

Focus on risk reduction and don’t get discouraged!

Intrinsic Factors • Intrinsic – those factors or conditions that occur

within the person

– Underlying medical illness or presence of chronic disease

– Physical status and age related changes

• Use of high risk medications – Psychotropic agents – Benzodiazepines – Sedatives and hypnotics – Antidepressants – Neuroleptics (antipsychotics) – Anti-arrhythmics – Digoxin – Diuretics

Medications contributing to falls Drug How it can increase falls Drugs that treat mental illness Blurred vision, confusion, dizziness, inability to

sleep, low blood pressure from standing

Drugs that treat anxiety Difficulty moving, confusion, low blood

pressure from standing, dizziness, fainting

Drugs that treat depression Blurred vision, dizziness, drowsiness

Powerful pain medications Low blood pressure, dizziness, drowsiness, lack

of coordination Sleep medication Dizziness, blurred vision, drowsiness

Seizure medication Confusion, dizziness, drowsiness, blurred

vision

Blood pressure medication Syncope (described as fainting), dizziness,

drowsiness, muscle weakness, low blood

pressure

Intrinsic factors

• Medical workup – Dizziness, syncope, poor balance, unsteadiness

– Mental confusion, delirium, dementia

– Generalized weakness, fatigue

– Arrhythmias

– Seizure

– Gait ataxia

– Dyspnea

– Lower extremity weakness, numbness, joint pain

– Unilateral weakness from TIA or CVA

Extrinsic Factors • Environmental considerations

– Floor surfaces – slippery, wet, glare, uneven,

cracked – Unsafe equipment - unsteady IV poles, unlocked

beds or stretchers, faulty or collapsing items – Cluttered pathways – Inadequate lighting or glare – Unsafe bathrooms – lack of support rails or bars, lack

of nonskid floor surfaces and mats – Unsafe footwear - loose fitting, no tread, barefoot,

higher heels – Physical restraints

Assessment for Falls

• History

• Previous falls

• Injury as a result of fall

• History of long lie

• Intrinsic vs extrinsic factors

• Morse fall risk

Defying Gravity Fall Risk Assessment and Prevention Strategies on 10 North

Implications Fall incidence can be limited through careful

assessment and evidence-based prevention

strategies. Fall prevention aligns with the

organizational aim for excellence in patient care

and safety, ultimately seeking to improve patient

outcomes and promote a positive overall

experience in hospital. Fall incidence is a nursing

sensitive indicator and one which will be closely

monitored on our journey to Magnet accreditation.

NEXT STEPS: Moving forward, the ACE Unit’s goal is

zero falls. The unit also welcomes information

sharing on its fall prevention approach with GIM and

other in-patient units.

Acknowledgements

We would like to thank Barb Allen, NUA, ACE Unit and all ACE

Unit staff for their support and continued commitment to

patient safety.

Thank you also to our ward clerks, volunteers, and

interprofessional team.

References

Adams, J. & Kaplow, R. (2013). A sitter-reduction program in an acute health care system. Nursing

Economics, 31(2):83-89. Retrieved from

http://www.medscape.com/viewarticle/806798

Canadian Institute for Health Information (CIHI). (2010). Analysis in brief: falls among seniors: atlantic

canada. Retrieved from

https://secure.cihi.ca/estore/productbrowse.htm?locale=en#F

Morse, J. M. (2009). Preventing patient falls: establishing a fall intervention program (2nd Ed.). New York,

NY: Springer Publishing Company, LLC.

Registered Nurses’ Associated of Ontario. (2011). Nursing best practice guideline: prevention of falls and

fall injury in the older adult. Retrieved from

http://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries-older-adult

World Health Organization. (2008). Global report on falls prevention in older age. Retrieved from

http://www.who.int/ageing/publications/Falls_prevention7March.pdf

Introduction

Falls are the number one cause (54.4%) of admissions to hospital in Canada for injuries (RNAO, 2011). Specifically, in seniors, falls were the cause of 84.8% of all injury admissions (RNAO, 2011). Falls, however, do not just happen in the community. 30-50% of individuals who are moved to unfamiliar environments like hospitals, nursing homes or long term care facilities experience a fall (WHO, 2008). Furthermore, 7% of seniors hospitalized due to a fall, who incurred a hip fracture, died (RNAO, 2011). Fall prevention for inpatients at Mount Sinai Hospital is imperative not only to promote safety and prevent injury, but also to decrease the amount of time an individual needs to be in hospital. The 10 North Acute Care for Elders (ACE) Unit cares for patients over 65 years of age, a population shown to be at a high risk of falls.

Purpose

The 10 North staff sought to increase patient safety on the unit through fall prevention.

Goal The ACE staff sought to reduce the number of falls that occur

while patients are on the unit.

Methods

ACE nursing staff applied evidence-based assessment protocols, collaborated with interprofessional resources, and implemented

thoughtful and evidence-based fall prevention interventions.

Risk Factors for Falls

The Move from 17S to 10N While the ACE team has worked hard to assess risk and prevent falls, the unit also moved from 17 South to 10 North and this move

has positively influenced fall prevention. The open concept layout of the unit is such that patients, in general, are at closer proximity to the nursing station. Nurses have better sight lines to patient rooms and shorter distances to travel the farthest rooms on the unit. The new unit has 24-hour floor lights to guide patients to bathroom at

night and increased number of railings in bathrooms/ shower room.

Nursing Interventions

Sitters as the Last Resort

The use of sitters or security is not a routine part of the Ace Unit’s fall prevention strategies. In fact, the literature has shown that use of sitters neither reduce the number of fall incidents nor the severity of an injury from a fall (Adams & Kaplow, 2013). On the ACE unit there has been a reduction in the incidents of falls concurrently with a decrease in the

overall use of sitters and security as constant observers. While a PSW or Security are utilized at times, the use of such personnel is considered only a part of a broader fall

prevention strategy when there is a need to gain additional information to further inform the fall prevention plan. It is recognized that the use of a sitter or security cannot be the

only strategy to prevent falls, but their use on a limited basis, as a part of a broader fall prevention strategy, may

assist in fine tuning that plan.

Most importantly = constant care providers do not guarantee fall prevention

Authored by Alexia Cumal, RN, BScN, Carli Grieve, RN, BScN, and Mary Ann Hamelin, RN, MScN, GNC(c), CNS 10 North Unit Council

With Contributions From the ACE/10N Team

Having patient sit in front of nursing station

Advocate for discontinuing lines and drains

Witnessed and unwitnessed Fall Care Plans

Review meds that may contribute to falls

Pocket talkers for the hearing impaired

Move patient closer to nursing station

Prompt voiding every 2hrs

Q 1 hour monitoring

Fall alarm beds

Mobility

Involve interprofessional

team & volunteers Non-slip socks Fall alarm mats Call bell access

Use of mobility aids

It Takes a Village

The introduction of fall

beds on the unit require a

nurse to respond quickly

when the patient gets up

and the alarm sounds.

Current unit culture on 10N

is such that each fall bed

alarm is everyone’s

responsibility.

The ‘High Risk for Falls’

signs indicate that a patient

requires more frequent

checks. This too is

approached and maintained

through teamwork.

Results

Note: Data is based on Safety Reports Cognitive Impairment

Previous stroke

Previous falls

Confusion/Delirium

Acute Illness

Auditory/Visual Deficits

FALL :

An event that results in a

person coming to rest

inadvertently on the

ground or floor or other

lower level (RNAO, 2011)

Morse Fall

Risk Scale

(RNAO, 2011)

(RNAO, 2011)

(RNAO, 2011) and (Morse, 2009)

Fall Care Plan

Developed by the ACE unit

staff, the fall prevention care

plan is added to the Kardex as

a communication tool on the

measures taken to prevent

falls for individual patients.

Physical Barriers

Proximity to Bathroom

Insufficient Lighting

Need to Toilet

Availability of Call Bell

Availability of Assistive Aids

Morse Falls Risk Assessment

Preventative measures

Home Strategies

• Home safety assessment

– De-clutter

– Furniture placement

– Lighting

– Railings and renovations

– Equipment

Assistive devices/Home

adaptations

Home Adaptations

Outpatient management

• Referrals to programs

– Falls Prevention Clinic

– Day programs

– Exercise programs

• Medications

– Calcium

– Vitamin D

Day Programs

Thank you

• Questions?