Reducing falls takes teamwork: an interdisciplinary approach has been the key to success for this fall prevention program.

Fall prevention is obviously important in terms of long-term care residents' safety and well-being, but how does fall prevention--or the lack thereof--affect a facility's well being? Every long-term careadministrator and staff member should know the answer to that question. Because fall rates are closely scrutinized by government agencies, third-party payers, and consumers--and also are recognized as a measure of quality care--fall prevention is vital to facilities' performance and to public perception about their performance.

Proactively addressing this issue will help ensure that quality care is not only a concept, but a reality--one that regulatory agencies and consumers will note. Furthermore, paying adequate attention to or, conversely, neglecting this important area of quality care can certainly affect the bottom line. Treating injuries that result from falls is an avoidable expense--something no facility wants or needs in these days of limited reimbursement and rising costs. And statistics suggest that treating fall-related injuries will cost significantly more over the next several years. (1)

The Senior Health and Housing Services (SHHS) Division of Mercy Health Partners (MHP) in Cincinnati, consisting of Mercy Franciscan West Park, Mercy Franciscan Terrace, Mercy Franciscan Schroder, and Mercy St. Theresa Center, formed a collaborative oversight team called the Quality and Resident Safety Committee to address the organization's growing concern regarding its facilities' fall rates. The administrators, medical director, and directors of nursing from the four buildings agreed that a committee was needed to focus on reducing each facility's fall rate and thus improving quality of care.

The main objectives of the fall prevention initiative were to encourage an interdisciplinary approach to problem solving, reduce the potential for risk and injury to residents, provide the best prospect for positive survey results, and create an opportunity to improve consumer perception about our facilities. These objectives continue to be the committee's focus.

Understanding that successful implementation would require that the committee be truly interdisciplinary, members included risk management staff, the medical director, the director of nursing and quality nurse representative (for each building), and representatives from dietary and therapy services.

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When the committee was formed, Mercy Franciscan Schroder had the lowest rate of falls of the four buildings. Schroder had already carefully examined its fall rates, using an interdisciplinary approach and the following processes: tracking and trending causes, going restraint-free while investing in appropriate equipment to ensure safety; conducting continuous in-services on transfers and lifts; increasing referrals to restorative and rehabilitation services; and having restorative services act as the gatekeeper of the falls investigation protocol.

When Schroder started looking at its fall prevention in July of 1999, its new DON took an aggressive approach to address the issue, realizing that: (1) residents needed to be active and (2) residents did not have what they needed to remain active. It was decided that Schroder would be a restraint-free environment and that every department--including housekeeping, dietary, and maintenance--would be responsible for keeping the environment restraint-free.

With that focus in mind, every resident who was considered a fall risk was assessed to determine whether the risk arose from extrinsic factors (i.e., environmental set-up) or intrinsic factors (i.e., disease process, weakness, pharmacologic contraindications, etc.). Once the cause of the fall risk was determined, a plan of care was implemented.

For those residents at extrinsic risk, a review of the environment was completed by all departments, and changes were made. For example, a bolster, floor mat, or trapeze would be put in place, or the room would be arranged, according to the resident's need. For those at intrinsic risk, the interdisciplinary team assessed what the cause might be and then made appropriate changes. Those might include a bowel and bladder program to reduce a resident's urgency to get out of bed; a referral to restorative or therapy for strength training or balance assessment; or increasing the resident's participation in activities (including one-on-one activities).

Two critical factors were necessary for the program to succeed: a continual review of the plan of care for each resident approximately every three days until resident falls ceased, with quick changes made to the plan of care as needed, and a commitment from all staff, in every department, that a reduction in falls was not just a theory but was to be a reality.

Because Schroder's comprehensive approach had produced excellent outcomes, the committee chose to mimic that facility's processes. The committee projected a per-bed, per-year goal of 1.5 falls as an internal benchmark for measuring success and adopted the following measures as means of reaching the goal:

* Create a committee committed to using a structured problem-solving methodology, and tools to analyze quality indicator data and identify and implement viable solutions

* Reduce falls by seeking and sharing best practices related to fall prevention across the four facilities and other LTC providers

* Create data charts that allow for trending of performance over time and establish targets based on selected internal or external benchmarks

* Conduct monthly meetings that focus on the performance of each facility against benchmarks, including facility reports on specific related solutions and plans to improve quality

* Introduce related Nursing Home Quality Initiative measures that continue to allow the Quality and Resident Safety Committee to identify other areas that may be positively affected by this approach

* Create an atmosphere where professionals are encouraged to share information and openly discuss and debate current systems, new products, and local and national standards and expectations.

Each facility reports falls to the MIDAS system, a database tool used to track, graph, trend, and compare the data to a monthly 1.5-falls-per-bed rate. The table shows the percent change in the number of falls at each facility between 2001 and 2002, after the fall prevention initiative had been in place for one year. The results are shared with the Quality and Resident Safety Committee, where an open exchange of product methodology, theory, and problem solving is conducted; best practices are identified; and policy changes are implemented.

After each monthly committee meeting, informing the facility of the results becomes the next step. The Quality and Resident Safety Committee takes a Bottom-Top-Bottom approach to disseminating the information. In other words, the process begins with frontline staff reporting the incidence of falls to the Facility Quality Nurse. The Quality Nurse collects the information and reports it to Risk Management to be included in the MIDAS program. The Quality Nurse also shares the information with the interdisciplinary Facility Quality Assurance Team on a quarterly basis. The monthly report is shared in the monthly Quality and Resident Safety Meeting. Best practices, policy changes, or education derived from the monthly meeting is taken back to each facility by the facility's representative. The monthly results and graphs are shared with the Executive Management Team for SHHS and the Board of Directors for MHP and the Southwest Ohio Board of Trustees Quality Committee.

Mercy Franciscan Terrace, Mercy Franciscan West Park, and Mercy Saint Theresa Center have shared the success of Mercy Franciscan Schroder, showing steady, impressive improvement in their rates of resident falls. Not only have all the improvements been maintained, but fall rates continue to decline.

Because other quality measures are directly related to the number of falls in a facility and to the public's perception of quality care, the Quality and Resident Safety Committee continues to meet on a monthly basis. In addition to continuing to monitor fall rates, the committee has initiated projects that measure the number of:

* UTIs

* Skin tears

* Patients receiving antipsychotic drugs

* Infections

* People with weight loss

* People with pressure sores

* People who walk as well or better on 14-Day ARD

With the staggering statistic that 75% of all long-term care residents will sustain a fall with injury or death (2) and the increasing scrutiny from state surveyors and consumers measuring quality of care, it is increasingly important for long-term care facilities to become proactive if they are going to stay competitive with local and national standards. Creating a Quality Team such as ours gives a facility a great opportunity to influence outcomes positively regarding such an important issue.

Ultimately, the results of the Quality Team's efforts clinically impact the care we can give to our residents, through decreased pain and suffering, increased quality of life, increased mobility, decreased incidence of pressure sores, decreased depression, decreased compromised nutritional state, and overall increase in maximum independence, with more confidence and less fear.

Table. Comparison of falls with and without injury between 2001 and 2002
(percent change).

Facility                    Falls with injury  Falls without injury

Mercy St. Theresa Center      -42.4%               -33.5%
Mercy Franciscan Terrace      -21.7%               -26.6%
Mercy Franciscan West Park    -18.5%                -8.6%
Mercy Franciscan Schroder*     +7.8%                +3.0%

* Mercy Franciscan Schroder had a low baseline fall rate at the start of
this initiative.

References

1. National Center for Injury Prevention and Control. The cost of fall injuries among older adults. www.cdc.gov/ncipc/factsheets/fallcost.htm (May 12, 2003).

2. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Annals of Internal Medicine 1994;121:442-51.

Ronda Christopher, MEd, OTR/L, LNHA, is manager of Regional Therapy Services for Mercy Health Partners' Senior Health and Housing Services Division, Cincinnati. She has seven years' experience in long-term care and has participated in several steering committees to address policies and procedures in long-term care clinical delivery. She is an active member of the committee highlighted in this article. For more information, call [phone] or visit www.ehealthconnection.com/regions/cincinnati. To comment on this article, e-mail [e-mail]. For reprints, call [phone].

BY RONDA CHRISTOPHER, MED, OTR/L, LNHA