It is commonly recognized that effective fall prevention requires a multifaceted approach for the successful risk mitigation and prevention of avoidable falls. Yet some still struggle to rally, educate and involve every member of the interdisciplinary team. The execution of hands-on care must be carefully aligned with the individual care plans and, of course, supported with accurate documentation.
Even though, this is widely known, some healthcare providers find that educating junior nurses and caregiving staff about the importance of whole-team collaboration and precise implementation of a fall prevention program is an ongoing struggle. This can potentially compromise the healthcare provider's ability to offer quality continuity of care. What with staffing pressures, ever-stretched profit margins and increasing acuity in the SNF population, providers surely have enough on their plates without these additional challenges. We're here to help though.
This article outlines some of the key processes that bedside nursing staff need to be aware of and routinely implement to support your facility's goal of never having a resident suffer a fall or injury from the same cause twice. Fall expert Dr Patricia Quigley shares some of her tips and strategies for effective fall prevention with a focus on the role of the clinical team.
"We can't prevent all falls but we can go after reducing preventable falls." - Patricia Quigley
Dr Pat invites clinical staff to see themselves as the sharp end of the system of care because all that goes into supporting and facilitating the healthcare industry is no use on its own merit.
“We are focusing on your interaction with the patient, understanding that you work in a very complex system of care: your work processes, resources that you have, the environment that you work in but we want to get to the sharp end and that is your interaction with the patient." - Dr Patricia Quigley
The carers at the point of care are where the system meets the needs of the patient and without them, the systems, the planning, the resources and the energy go nowhere. As clinical caregivers at the point of care, you are the one conductive connector between the vastness of the system of care and the patient.
Dr Pat advises that clinical caregivers need to be capable of assessing for a risk of falls and risk of injury as well as just screening for fall risk. A screening tool could tell you whether there is a risk of that person falling, but an assessment will tell you why that person fell in the past or why they are at risk and help you work out what to do about it to help prevent reoccurring falls and injuries.
"When they come into our care we screen [...] for example, fall history. But just screening through someone's fall history is not enough and that's why we have to go from asking someone if they have a history of falls to actually doing an assessment.
"If you have someone that comes into your care and they are someone who has been admitted because of a fall, you should know why they fell. You should know how many falls they've had. What are the circumstances of the fall?" - Patricia Quigley
Caregivers are advised to look beyond the yes/no answer to the question "is this person a fall risk?" to assess the causes of their risk which will in turn feed your assessment of appropriate interventions and their ongoing individualized plan of care for that person.
When you are screening for fall risk, it's important to consider whether the following elements and medical conditions are an issue for this person which could increase their risk of falling.
"When you think about those risk factors, what I also want you to see is that for all settings of care, there are risk factors that are modifiable and those that are not. [...] We know that age is a risk factor for a fall-related injury. We have more risk factors that we live with but age in and of itself is not a risk factor. It's the changes that we have."
Nurses and caregiving staff are at the sharp end of delivering care, as we've mentioned, and Dr Pat advises of the importance of every member of the interdisciplinary team to know the specific risk factors of every resident in their care.
"Whatever role you have; if you're a nursing assistant, or an LPN, or nurses, or therapists, all that are taking care of residents, you should know what those individual risk factors are, not just that they're a high fall risk."
So, yes it's important to be aware of every risk factor for falls for the seniors in our care for effective fall prevention, but what else do nursing staff need to know about falls?
While all falls can result in injury, not all falls are the same. According to Dr Pat, a fall could be placed in one of three categories:
But what are the differences and why does it matter?
"The accidental falls are falls that happen because of an unsafe environment and it's our responsibility when someone comes into our care [...] you try to make that environment as home-like as possible but you also have to create that environment so that it really fits the needs of your residents and it's as safe as possible.
"If someone falls in your care because of the risk factors that are inherent to their person (impaired vision, their weakness, their balance problems) that's going to be the anticipated physiological fall. Those are the two types of falls that you're going to do everything that you can to prevent.
"The third type of fall is the unanticipated physiological fall and that's a fall that happens because someone has a sudden heart attack or a stroke or a seizure. They have a sudden medical event and they go down. That's the kind of fall you can't prevent."
It's important to be able to distinguish between these types of falls so you know where to focus your efforts on preventing future falls through thorough care planning.
To help make third shift a little bit better, here are some quick tips from Dr Pat regarding reducing the environmental risk factors for falls that could present potential fall hazards during the night:
Assess and individualize resident bed height for transfers - "Bed height should be individualized for every one of the residents you're taking care of. Bed height should be adjusted so that the hip is at a 90-degree angle."
Utilize technology - "Look at technology that's available to you. To be able to use sensor technology, surveillance technology, motion sensors, silent sensor technology. Many of these technologies, they don't have to alarm at the bedside."
Limit fluids after 8 pm - "We want to reduce the number of incidences of people trying to get up without you and people having Nocturia so certainly you want to be able to limit those fluids after 8 pm."
Create a safe bed exit side - "Helping to make sure that if someone does get up without you, that they're getting up towards their stronger side so you have that safe exit side."
Optimize the room for a clear and obvious pathway to the toilet or utilize bedside commodes - "I've had some places put glow-in-the-dark footsteps so people can see when they get up during the night what the pathway is to get to the bathroom."
Assess and individualize toilet/commode height - "The commode has to be height adjusted. Even though we talk about height-adjusting a bed which is easier, not always are the bedside commodes actually height-adjusted to the individual."
Schedule toileting around 1 am - "We know that because some of the research that's been done on Nocturia in long-term care, that that's the time when the residents have been laying down and they have better filtration through their kidneys and they start sensing that they need to get up."
Optimize the bathroom for safety - "We should make sure that we have proper armrests and grab bars and grab bars should be etched so that if someone is holding on to them and they have wet hands, that their hands aren't going to slide so they've got better grip. [...] "All of the bathrooms absolutely should have the grab bars on both sides of the toilet, not just one side and they should be close to the toilet.
The trouble with fall prevention advice is that often it's contradictory and therefore caregivers are left feeling confused as to best practice. Use bedside commodes but also adjust toilet height and show them the path to the bathroom. It conflicts but for a good reason. It's because all the advice, tips and hacks in the world can't ever replace a truly individualized care plan. What is a risk mitigation measure for one resident may exacerbate risk for another.
Therefore, while it's important to understand and learn about new ideas for fall prevention, it's important to always use your clinical judgment too and involve the interdisciplinary team to decide on the best course of action to help prevent avoidable falls and injuries on a case-by-case basis. Like Dr Pat says, don't just screen for the presence of risk: Assess it.
For more in-depth training on fall prevention for clinical and nursing staff in long-term care and SNF settings, you can access the full virtual training session Fall and injury prevention: Let's get clinical with Dr Patrica Quigley, on demand now.
{{widget-webinar}}
