Preventing falls, promoting fitness.

Resident falls are an ongoing concern for many facilities that strive to be "restraint-free," yet maintain a safe environment for residents. The lines of resident freedom and resident safety are not etched in black or white and, consequently, team members must continually grapple with appropriate interventions for "high-risk-for-fall" residents. The specific problems in our facility were as follows: as of December 1996, 29% of our population was restrained, compared with a state norm of 13.4% and a national norm of 18%. We had a total of 204 resident accidents/incidents, or an average of 17 per month (Figure 1). In short, too many residents were restrained and too many residents were falling. Both problems required attention, intervention and correction.

The Plan

Planning our response began with three fundamental objectives. The focus committee involved would:

1. Use a monthly tracking tool to determine any underlying patterns/trends that might contribute to resident falls.

2. Identify those residents who might be candidates for restraint alternatives.

3. Create imaginative and innovative programs designed to promote both independence (restraint-free) and safety (no falls) for the residents.

These objectives were quantified as follows:

1. No more than 10 falls per month.

2. No more than 12 (10%) of the resident population restrained.

3a. Patterns/trends of falls would be analyzed using a monthly accident-/incident-tracking tool (Figure 2).

3b. Once patterns/trends are identified, initiate specific activity groups or interventions.

Implementation

Although resident falls and the number of restrained residents were of concern to all our interdisciplinary team members, it was decided that a smaller committee would focus on this issue. The team decided to select a physical therapist, nursing supervisor, recreation therapist and the director of nursing services (DNS) to pursue this project.

The nursing supervisor was responsible for collecting the monthly data regarding resident falls. Each month, for a period of three months (1/97-3/97), the nursing supervisor would complete the accident-/incident-tracking form and bring it to a meeting with the other members of the focus group. It was during this process that trends were identified and patterns noted. The following were our benchmark data from which all interventions followed:

* Falls occurred most frequently between 10 and 11:30 am (60%) and between 3 and 4:30 pm (30%).

* Ninety percent of the falls occurring between 10 and 11:30 am involved extremely confused residents who were attempting to stand/walk/move from the confines of a wheelchair.

* All the falls occurring between 3 and 4:30 pm involved alert and oriented residents attempting to go beyond their limits (e.g., walk without walker or assistance, bend down to pick up something off the floor).

Inherent to all of the noted falling patterns was a common desire by the residents to move. The confused residents wanted to get up, turn around or just stretch and feel free. The oriented residents wanted to move also, even if the movement was more than their limited capabilities would permit. The team decided to channel the residents' desire for movement into positive and productive activities. The focus team conceived, developed and implemented the following three interventions designed to promote movement and fitness while providing a safe environment: a geriatric conditioning program, a tai chi program and a ballroom dancing program.

Geriatric Conditioning Program

This program was designed for confused residents who were at high risk for falls and/or were candidates for "no restraints."

The program begins at 10:00 am each day and ends at 11:30 am The nurses on each unit decide (on a daily basis) which three or four residents they believe are at high risk for falls. (On some days, residents are agitated or have more energy than other days.) These three or four residents from each unit are invited to the geriatric conditioning program for the day.

Since the morning is extremely busy for the nurses and nursing assistants, it is difficult to continuously supervise the high-risk residents. Accommodating them in a closely supervised area reduces the chance that an accidental fall will occur.

The residents selected for geriatric conditioning spend one and a half hours enjoying themselves while they move to music, with direction and supervision. A physical therapy assistant, a recreation assistant and a nursing assistant lead the exercises. Exercises are varied and include modalities such as upper and lower body strengthening, and ball tossing to improve dynamic sitting balance.

Because the ratio of staff to residents is approximately 1:3 or 1:4, group members receive much individualized attention. Those residents who are agitated or eager to move about have the perfect opportunity to do so, but within safe confines. When the music stops and everyone pauses for a breather, refreshments are served. At the conclusion of the program, the residents are transported back to their units.

The only obstacle involved in implementing this program was determining which residents could participate. Initially, nurses tried to send five or six residents they believed to be at high risk for falls. Once the nurses understood that maintaining a specific staff-to-resident ratio for the group was important if it were to be effective, they selected only three or four residents, as per protocol.

Tai Chi Program

This program is designed primarily for oriented or mildly confused residents who are at risk for falls. It is offered 10:30 to 11:30 am, three times a week. Since the program takes place in the main dining room, where space is plentiful, and because the staff-to-resident ratio does not need to be extremely high, tai chi is offered to everyone who qualifies. Residents who meet the criteria for inclusion are invited to join the program and are escorted to the main dining room.

Tai chi is, of course, a self-defense technique, but it is used here as an exercise for health, fitness and relaxation. Its flowing "forms" consist of slow, coordinated movements that result in one continuous motion. In this setting, the recreation leaders (trained in tai chi) utilize this art form to enhance breathing, flexibility and proper postural awareness. The program encourages movement and strengthening of muscles while creating a mood of relaxation. Soft Chinese flute music adds to the ambience of the exercises.

Two recreation leaders lead the tai chi program, and there is one rehabilitation assistant who assists the residents with their movements. This program was initiated without difficulty, and approximately 20 residents attend it regularly.

Ballroom Dancing Program

This program is designed for alert and oriented residents who are at risk for falling - the kinds of residents who, according to our data, experienced all falls occurring between 3 and 4:30 pm. For this reason, the program is scheduled for that time period.

Ballroom dancing is offered to between eight and ten residents. It takes place in the physical therapy room and is led by the physical therapist, physical therapy assistant and a recreation leader. Each session includes a myriad of traditional ballroom dances, such as the waltz, fox trot and merengue. based on individual abilities and endurance, each resident partners with a leader and dances through a three- to five-minute musical piece. Those residents not actively dancing during a particular number are encouraged to clap their hands and tap their feet to the music's rhythm. Residents alternate between dancing and rest periods, with each involved in about three or four dances per session.

This program is strenuous for residents and demands coordination and dynamic standing balance. It also offers them an opportunity to move about at a time of day when they feel most restless. Ballroom dancing is a fun diversion and promotes a sense of well-being and fitness in a safe environment.

Evaluation

"Preventing Falls, Promoting Fitness" has been a great success. The data obtained before we implemented this program compared with the data obtained after full implementation showed the following related to our three objectives:

Objective: No more than 10 falls per month.

Result: An average of 7 falls per month from April to December 1997, compared with 17 per month from January to December 1996 [ILLUSTRATION FOR FIGURE 3 OMITTED].

Objective: No more than 12 (10%) of the resident population restrained.

Result: An average of 5 (4%) restrained residents at this facility at any given time [ILLUSTRATION FOR FIGURE 4 OMITTED].

Objective: Patterns and trends of falls identified and three specific programs (geriatric conditioning, tai chi and ballroom dancing) developed and implemented as interventions.

Result: Done, with residents receiving all three programs with enthusiasm. Utilizing these programs as interventions to prevent falls and promote restraint reduction for a target population at a target time proved tremendously successful, as disclosed by the following comparative analysis of the trends/patterns of falls before and after we implemented the program: (1) none of the falls are occurring between 10 and 11:30 am, compared with 60% prior to the program; (2) 20% of fails are occurring between 3 and 4:30 pm and involve alert and oriented residents, as compared with 100% prior to the program; and (3) of that 20% of falls between 3 and 4:30 pm, none involved those residents participating in the ballroom dancing intervention.

Conclusion

"Preventing Falls, Promoting Fitness" has been in effect for just over a year. Its success is easily discernible, and this facility is proud of the great strides it has made in reducing restraints and, concurrently, reducing falls. The facility continues to utilize the accident-tracking tool as an ongoing monitoring device to help the staff identify new trends or patterns in resident falls.

This program is simple in design and implementation and can be adapted and replicated easily by any facility striving to decrease resident falls and resident restraints. Most importantly, these interventions are enjoyable for the residents and provide them with a diversion, while promoting movement and fitness for residents who are capable and in need of activity.