Thinking strategically about falls prevention. (Business Strategies).

Effective strategies involve "doing the right thing," while simultaneously raising revenues, decreasing costs, improving operations, and service delivery. Post-acute, long-term, and residential-care facilities have an opportunity to accomplish all of this by evaluating and implementing strategies that prevent and/or reduce fall-related injuries.

Fall-related injury is one of the most serious public-health problems confronting the elderly. The Centers for Disease Control and Prevention reports that one in three people age 65 years and older falls each year. As many as 30% of those who fall suffer injuries severe enough to reduce mobility and increase the risk of premature death. What is even more disturbing is that two-thirds of those who fall will do so again within six months.

Falls are costly. Direct costs account for such expenses as hospital and nursing home care, physician and other professional services, rehabilitation, medical equipment, and prescriptions. Direct costs, however, do not account for longterm results, such as chronic disability or diminished quality-of-life issues. The federal government reports that in 1994, direct costs of fall injuries for people 65 years or older were $20.2 billion. By 2020, these same costs are expected to increase by more than 150% to nearly $33 billion.

These costs extend beyond the patient/resident and the payer. Fall-related injuries are also increasing costs for long-term care facilities in the form of increased liability. Liability premiums for facilities have, on average, increased 200 to 600%. In some states, such as Florida, premiums have increased as much as 1,000% with deductibles as high as $100,000 per incident.

Frequently serving as an advisor to risk-management organizations, insurers, and pharmaceutical companies, I ma always surprised to hear that many long-term care facilities don't address this problem as part of their ongoing strategic planning. Most continue to deal with falls based on a plan that was developed years ago and has long been antiquated. Information, education, and new technologies exist today that could reduce fall-related injuries and consequently decrease financial costs to the facility, as well as the physical and emotional costs to residents and their families.

I asked an expert to take a fresh look at an old problem. Steven C. Castle, MD, professor of medicine, UCLA and clinical director of geriatrics, Veterans Administration (VA) Greater Los Angeles Healthcare System, offered his assistance. Internationally recognized for his expertise in geriatric care, program development, healthcare professional training, and research in managing the complexities of aging, Dr. Castle is the recipient of two National Institute on Aging grants studying the effects of disease and chronic illness on immunity. Dr. Castle, based on six years of implementing a falls-prevention clinic, has served as a consultant on a VA-funded clinical initiative to develop and implement comprehensive falls-prevention programs throughout hospitals and long-term care in the VA System in Southern California, Nevada, and Florida. He also has participation a treatment advisory group that addressed falls-prevention standards for the VA National Patient Safety Center in Tampa, Florida.

Hyatt: There is a shortage of geriatric clinicians in the U.S. How did you become interested in the field?

Castle: I became interested in geriatrics when I was an intern. I was put on a committee to look at needs of elders in my hospital and was struck by the huge opportunities that opened for me. I later became fascinated with the challenge of diagnosis and management in complex medical situations and the unique aspects of aging. I am attracted to elders who are aging well, much like the unbridled potential of a baby. Both are rare and valuable.

Hyatt: Could you discuss your recent falls-prevention project?

Castle: I was never satisfied with my approach to diagnosing the causes of falls. I decided to immerse myself in the issue by a very thorough review of the literature, with a focus on medications, and by working with a physiatrist, Dorene Opava-Rutter, MD, to broaden my skills. Based on some preliminary models for a fails-prevention clinic we piloted at the VA Greater Los Angeles, we received VA funding for a clinical initiative to expand and evaluate our assessment-and-intervention model throughout Southern California, Nevada, Florida, and Puerto Rico. While we did not do a randomized trial, we did demonstrate a reduction in falls, especially in those who fell frequently. We feel confident in identifying the causes of falls 90% of the time.

Hyatt: Current research tells us that falls among the elderly are a serious problem at home and in hospital-based facilities, free-standing nursing homes, and assisted living centers. What factors increase the risk of falls among older patients/residents?

Castle: There are several obvious risk factors for falls including age, history of previous falls, weakness of legs, and poor balance. It is important to recognize readily preventable causes of falls, especially a change in condition, such as from infections or worsening of underlying disease. Anyone with agitation or delirium is 20 times more likely to fall than someone who is calm and alert. Medications are important to consider, especially the use of sedatives or sleepers, or overuse of antihypertensives and some medications that are strongly anticholinergic, such as some cold medications, bladder relaxants, and psychotropics.

One big lesson I learned from our clinical initiative was counterintuitive. We found that there were several individuals with inadequately treated conditions, especially hypertension and heart failure, that were contributing to poor performance. Sometimes more appropriate drugs are needed. Simple reduction of medications may not be the answer.

There are certain medical conditions that increase the difficulty of preventing falls. The combination of gait/balance impairment with cognitive impairment is problematic, especially in Lewy Body Dementia, which tends to have some parkinsonian features, fluctuation in cognitive impairment and hallucinations. Another problematic area surfaces when someone with a rapidly declining condition, such as cancer, is having difficulty accepting or recognizing his or her decline. I have seen some very traumatic falls in these cases, usually in or on the way to the bathroom.

Hyatt: When you walk through a facility, what are the red flags that you look for?

Castle: A big red flag appears when people are tied to beds with rails up. This is not likely to prevent someone from getting out of bed, but it is likely to lead to injury. I think another aspect is the respect that staff show to impaired individuals; many of these residents feel lonely and depressed and have low self-esteem, and the last thing they need is to be blamed for a fall. Attention should be focused instead on modifying their risks and preventing further falls. Still another aspect can be reliance upon "boilerplate" falls precautions; while a fundamental plan to prevent falls is necessary, of course, falls assessment and risk reduction have to be individualized to the resident.

Hyatt: What lessons have you learned that can help reduce the risks of falls?

Castle: I've learned a great deal from the nurse manager in our long-term care facility, Lily Lara, as well as other experts on falls, and from personal experience. Here are ten lessons I've learned:

1. Falls assessment and prevention needs to start as soon as the resident is admitted.

2. When a fall occurs, the staff focus and approach should be how to prevent the next fall, as well as to discover what caused the last.

3. Talking to residents reinforces the importance of safety. Make hourly safety checks to help the resident understand the importance of calling for help and to be careful not to fall.

4. Lead by example--modeling and training of staff is crucial to sustained efforts. Demonstrate how to efficiently perform a safety check of the area, and incorporate the time into the staff schedule. If a resident needs something quickly, the person making the rounds provides immediate help. If it will take time, the person calls the nurse assigned to the resident.

5. Staff need to be trained and monitored in their ability to repeat cues for safe transfers, and how to use gait belts, when appropriate.

6. Medications may contribute to falls. It is difficult to predict how medications may interact and when their peak effect occurs. When reviewing high-risk medications (psychotropics, hypertensive/heart, hypoglycemics, diuretics, opiolds, anticholinergics, anticonvulsants, anticoagulants),assess how effective they are for the target indications, and what is the likelihood of their contributing to a fall. The assessment should include the possibility of discontinuation, dose changes, alternatives tried, or no change, and why.

7. Improved vision and lighting can help residents avoid obstacles.

8. If residents need warm feet in bed, use slippers with soft soles/treads rather than socks.

9. Hip protectors and alarms are essential in confused or demented residents who show no insight into their impaired balance.

10. Getting residents to accept the use of assistive devices can be a great challenge. Create behavior modification strategies, perhaps using peers or a group process, to help residents accept limitations.

I want to express my appreciation to Dr. Castle for his generosity of time and wisdom. Information and education, along with today's new technologies, could reduce fall-related injuries and thereby decrease financial costs to the facility, and the physical and emotional costs to residents and their families. It is the right thing to do and it's just good business.

Laura Hyatt, MBA, is president of Hyatt Associates, Los Angeles, California, To comment an this article, please send e-mail to [e-mail]