Program helps prevent falls in frail elderly
Fall coordinators assess four problem areas
Nearly half of the estimated 1.7 million nursing home residents in the United States fall each year. More than 10% of those sustain a serious fall-related injury. A fall prevention program developed by researchers at Vanderbilt Univer-sity in Nashville, TN, successfully reduced falls among frail nursing home residents by 19% results good enough to prompt Beverly Enter-prises in Fort Smith, AR, one of the country’s largest nursing home chains, to implement the program in 36 of its facilities in 1998.
"If the results are as good as we hope, Beverly will move on to the next stage and roll out the program to all or most of our other facilities," says Vivian Tellis-Nayak, PhD, director of research in the department of quality management at Beverly Enterprises.
100 falls a year
Studies indicate that a typical 120-bed nursing home facility has about 20 high-risk residents who fall a combined 100 times a year resulting in an average of 11 emergency room visits, and three hospitalizations, Tellis-Nayak says.
"If the Vanderbilt program succeeds as it has in the past, we will prevent 35 of those estimated 100 falls, five of the 11 emergency room visits, and about 1.5 of the three hospitalizations for a savings of about $14,000," he says, adding that it also will reduce Beverly’s liability exposure and increase the chain’s attractiveness to managed care organizations and families. "Of course, we also will improve quality of life for our residents."
The original falls prevention study included seven pairs of nursing homes in Tennessee with one facility in each pair randomly selected for intervention. The 14 facilities had a total of 482 residents, 261 in control facilities and 221 in intervention facilities, who qualified for the study because they had a high risk of falls and a potential safety problem that could be solved by the intervention.
Vanderbilt assessment teams conducted structured individual assessment of each at-risk resident. The teams made recommendations to nursing home staff and encouraged them to implement individual recommendations and improve overall facility safety, says Wayne A. Ray, PhD, professor of preventive medicine at Vanderbilt University School of Medicine.
Vanderbilt monitored the program through telephone calls to the facility falls coordinator weekly for the first month and with on-site visits at one, three, and six months.
The four areas of study
Ray says careful review of the literature shows that most falls are caused by four problem areas: environmental and personal safety, wheelchairs, psychotropic drugs, and transferring and ambulation. In the original falls prevention study, a team from Vanderbilt went into the selected nursing homes to assess residents for each of the four areas. As the falls program is rolled out at the 36 Beverly facilities and other nursing homes nationwide, Vanderbilt will train nursing home staff to assess residents.
Examples of issues addressed in each of the four areas include the following:
1. Environmental and personal safety.
Potential hazards include the resident’s bed, floor surfaces, clutter, inadequate lighting, and unsafe footwear. The resident’s room and bathroom are assessed for potential hazards. Adjoining common areas also are assessed. Safety recommendations might include adding functional wheel locks for beds, providing more adequate lighting, modifying flooring, and adding bathroom equipment such as raised toilet seats.
2. Wheelchairs.
Every wheelchair used by a resident is assessed for maintenance, safety features, arm and leg rests, seat and back, forward motion protection, resident posture, and propelling/reaching. Facilities are urged to institute a regular wheelchair maintenance program.
3. Psychotropic drugs.
A geropsychiatric nurse and a psychiatrist work together to identify treatment alternatives for residents currently treated with psychotropic drugs. When appropriate, the psychiatrist sends letters to the residents’ attending physicians to suggest drug regimen changes and appropriate psychosocial interventions or additional psychiatric evaluation.
4. Transferring and ambulation.
All study residents are observed transferring from bed, chair, and toilet. Safety is assessed in terms of equipment height and stability, transfer process, and staff assistance. Ambulatory residents are observed rising from and lowering to bed, chair, and toilet, and walking.
In addition to individual evaluation of at-risk residents, Ray says the original falls prevention study team conducted several facilitywide interventions that should benefit any falls prevention effort. Team physicians met with the attending physicians to solicit their support and acceptance of medication changes.
A positive return
In addition, a team nurse conducted three 45-minute inservices and distributed a brochure that summarized the content of the inservices, which covered the following areas:
• general discussion of the causes and consequences of falls in the frail elderly;
• safety suggestions for each of the four problem areas;
• review and refinement of the resident treatment plans.
"There are two main problems to overcome when you work with nursing homes," Ray says. "First, there is often a general lack of organization. Many of our study team recommendations never were carried out due to a certain lack of a capacity for organization. Second, there is just a simple lack of resources, both financial and in terms of staff time and effort. If you need to spend $50 to modify a bed, and you have 10 beds to modify, that’s $500, and that may be more than the nursing home can spend."
However, Ray hopes his study and the outcomes the falls prevention program achieves at Beverly will provide case managers and nursing home directors with evidence that prevention efforts create a positive return.
"Falls are not inevitable in the frail elderly. They can be prevented. The changes we are recommending are not rocket science," he says. "Any facility can make these improvements. We have to find a way to instill an optimism in the nursing home staff that if they implement these changes, they can prevent falls and serious injuries."
(Editor’s note: See also Ray WA, Taylor JA, Meador KG, et al. A randomized trial of a consultation service to reduce falls in nursing homes. JAMA 1997; 278:557-562.)
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