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The Gravity of Falls
The Gravity of Falls: Evidence-Based Preventative Strategies presented by Home Health Quality Improvement (HHQI) National Campaign Welcome Cynthia Pamon, RN, MBA, MSHCAD, CCM Lead, Million Hearts & Disparities Programs GTL, Home Health Quality Improvement National Campaign Center for Clinical Standards and Quality, Quality Improvement Group Centers for Medicare & Medicaid Services Today’s Agenda • Falls Risk Assessments presentation • Medications & Risk of Fall in the Elderly • Fall Prevention Interventions • Free Falls Prevention Educational Resources • Final Questions • Closing Remarks Questions & Answers • Please send your questions and comments to [email protected] now or at any time • We will address as many as time will allow during today’s live webinar broadcast • You may also contact us at [email protected] at any time if you have questions or comments in the future Today’s Guest Speakers Nancy Kimmons, BS, PT Home Care Therapy Operations Manager, Rehab Affiliates, Division of Main Line Health, Philadelphia, PA Michele James, BSN, MSS, RN-BC Home Care Case Manager, The Home Care Network, Jefferson University Hospitals, Philadelphia, PA Michele B. James RN, BSN, Home Health Nurse The Home Care Network, Main Line Health [email protected] Nancy J. Kimmons BS PT, Therapy Manager Rehab Affiliates, Main Line Health [email protected] Background Opportunity to design and carry out a clinical research project supported by MLHS Falls identified as national safety goal by the Joint Commission on Accreditation of Healthcare Organizations 2010 OASIS requirements for assessing risk of falls with a valid, multi-factorial tool Who are we? The Home Care Network is part of Main Line Health System, based outside Philadelphia Falls Committee activities: trending, developed risk assessments, staff education, electronic falls tracking Falls—what we know Aging population, aging in place, social challenges Impact of falls on society, individuals Costs Need for accurate risk assessment to help to design effective care plans—different disciplines may assess differently What we learned—literature review Little research done in home setting No validated tools available in 2010, when we started our study Simplicity of use versus accuracy Applicability to home setting TUG—”gold standard?” Our Purpose Statement The primary purpose is to determine if the score on the multi-factorial Falls Risk Assessment accurately identifies the risk of falls in a homebound client. In addition, we examined if any individual item had a higher correlation with the incidence of falls. Hypothesis There is a positive relationship between an elevated score of combined factors and incidence of falls occurring in the home. Define the problem: what is a fall? Definition A fall is defined as an event resulting in a person coming to rest unintentionally on the ground or other lower level, and not as a result of a major intrinsic event (e.g. stroke, syncope) or overwhelming hazard; an overwhelming hazard was defined as a hazard that could have resulted in a fall by the youngest, healthiest people (Tinetti, Speechley, Ginter, 1988). Our Process Identifying subjects: 100 fallers, 25 non-fallers Selection criteria: Age 65 to 90, completion of a Falls-Risk Assessment at Start of Care, and the absence of an unavoidable fall Design of data collection tools, refining process Collecting data—method Barriers/speed bumps Event reports on paper—identifying subjects was tedious, reports not complete or accurate in some cases Falls Risk assessment documentation was not always complete; software did not require all elements to be completed. Late request to add comparative group of nonfallers Limitations Variability of clinicians performing assessments—lack of quality control aside from staff education and assumption of competence Inability to ask clinicians for clarification due to timeframe, limited access to records due to software change Data Collection Tool Falls Risk Assessment in /ROC OASIS-C—indicate score Level of consciousness/mental status History of falls Ambulation/Elimination status Vision status Timed Up and Go Gait and Balance Orthostatic changes Medications Predisposing diseases Equipment Issues Total score Score NA Comments Variable Score range Description Level of Consciousness 0-4 Alert to intermittent confusion History of Falls 0-4 Past 3 months Ambulation/Elimination 0-4 Incontinence issues Vision Status 0-4 Range Timed Up and Go 0-5 Based on score (# of seconds) Gait and Balance 0-6 Descriptive Orthostatic Changes 0-4 0 to >20 mm decrease Medications 0-4 Number of high-risk Predisposing Diseases 0-4 Number of specified conditions Equipment Issues 0-3 Presence, appropriate use Total Score Legend 0 1-4 5-9 10 and > No risk Low risk Moderate risk High risk Disciplinary involvement Co-ordination/Referrals Nursing or ST: PT ordered at referral or added by SN if high Falls Risk is identified. PT or ST: SN referral ordered if score in combined Ambulation/elimination and Medication sections is 4 or above. Fall risk noted on home health aide POC Yes No NA Results Fallers and non-fallers had mean scores indicating high falls risk Fallers’ scores were significantly higher than non-fallers Mean scores Fallers N Mean Score p-value 100 14.61 Non-Fallers 25 12.52 Difference 2.09 0.035 Variable Coefficient p-value Level of Consciousness 0.99793 <0.0001 History of Falls 0.98060 <0.0001 Ambulation/Elimination 1.00226 <0.0001 Vision Status 1.00686 <0.0001 Timed Up and Go 1.00834 <0.0001 Gait and Balance 1.01757 <0.0001 Orthostatic Changes 1.02372 <0.0001 Medications 0.99891 <0.0001 Predisposing Diseases 1.01709 <0.0001 Equipment Issues 1.02726 <0.0001 Results, continued Single variables most highly correlated: History of falls Gait and balance, Level of consciousness Ambulation/ elimination However…..none of these are as strongly predictive on their own as the combination of all factors! What do those numbers mean? The multi-factorial FRA we used was accurate at predicting the likelihood of falls. Some factors were more predictive than others, all were significant, but no one was significantly predictive alone TUG was not significantly predictive on its own in our results. What’s next? Looking at differences between people with high risk who fall and those who do not. Assessing interventions which may be effective in preventing falls in people at high risk What is the effect of caregivers on falls? Conclusions Did we validate this tool? We believe it is a useful and accurate tool, but would welcome other studies of this type to validate our results MAHC-10—too sensitive? Useful balance/mobility-focused tools: Berg, DGI, Falls Efficacy, ABC, Functional Reach, Gait Velocity tests References For further detail, see article: “Validating a Multifactorial Falls Risk Assessment,” authored by the presenters and published in Home Healthcare Nurse, January 2014 Response to public comments on revised OASIS C instrument for home health quality measures & data analysis. (2009). Retrieved on July 1, 2013, from http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessmentInstruments/HomeHealthQualityInits/downloads/hhqires ponsestopubliccomments.pdf Questions & Answers • Please send your questions and comments to [email protected] now or at any time • We will address as many as time will allow during today’s live webinar broadcast • You may also contact us at [email protected] at any time if you have questions or comments in the future Today’s Guest Speakers Chuck Lally, RPh Pharmacist, University Hospitals Home Care Services, Cleveland, OH Joanne M. Wile Avenmarg, OTR/L, MS Director of Clinical Operations, University Hospitals Home Care Services, Cleveland OH Be the Difference. The Gravity of Falls Evidence-Based Preventative Strategies April 29, 2014 Medications and Risk of Fall in the Elderly Chuck Lally, RPh Pharmacist Medications and Risk of Fall in the Elderly • Introduction – The Beers Criteria (Beers List) (2012) • Published by Dr. Mark Beers in 1991. It is currently compiled by a panel of experts in geriatric care and the American Geriatric Society. • Hip fractures considered preventable ADR. • Deals with more than just fall risk, 3 classes: • Ineffective, or safer alternative available. • Need to be avoided due to specific conditions. • Medications that need to be used with caution. • Currently considered “Gold Standard” by many practicing clinicians. Medications and Risk of Fall in the Elderly • Pennsylvania Patient Safety Advisory (2008) by Pennsylvania Patient Safety Authority. – – – – – Anxiolytics/ hypnotics Antidepressants…particularly in elderly Neuroleptics Opiod analgesics/ antagonists Insulin/ oral hypoglycemics • British Columbia Falls and Injury Prevention Coalition (2011) – Drugs and the Risk of Falling: Guidance Document by Barbara Cadario. – Focuses on multiple drug classes, including eye drops and alcohol use and the mechanisms involved. Medications and Risk of Fall in the Elderly • Increased Risk of Falling from Medications – Lorazepam (Ativan) • Avoid use for agitation due to increased risk of syncope, cognitive impairment. • Half life from 1 dose of 12-14 hours, but dosed every 8 hours often in elderly. • Beers Criteria rating: Strong Recommendation; High Quality of Evidence. – Glyburide (Diabeta) • Avoid use due to increased risk of hypoglycemia in elderly. Hypoglycemia can increase risk of fall. • Beers Criteria rating: Strong Recommendation; High Quality of Evidence • Alcohol – Not rated by Beers Criteria and PA-PSRS report, listed by BC Falls and Injury Prevention Coalition. Medications and Risk of Fall in the Elderly • Increased Risk of Injury from Medication – Warfarin (Coumadin) – Increased risk of bleeding after a fall. Intracranial bleeds possible after fall. – Patients often have change in diet when leaving hospital or SNF and that can change vitamin K levels. – Monitoring frequency might change with transition to home. – Not rated by Beers Criteria and PA-PSRS report, listed by BC Falls and Injury Prevention Coalition. – Aspirin (Greater than 325mg per day) – Increase risk of bleeding after a fall. – Beers Criteria rating: Strong Recommendation; Moderate Quality of Evidence Medications and Risk of Fall in the Elderly • Increased Risk of Injury from Medication – Pioglitazone (Actos) – Double the risk of risk of fracture upon falling. (5.1% of patients) – Bone loss has been seen in older studies of this class. – Seen primarily in female patients with diabetes. – Beers Criteria rating: Strong Recommendation; High Quality of Evidence Medications and Risk of Fall in the Elderly • Ways to Reduce Fall Risk – Fall Assessment • Standardized form at most Home Care organizations. • Usually done early in patient care process. – Medication Reconciliation – Contacting Pharmacy Service for further information. • PPSA recommends medication review by pharmacists. – Contacting Prescribers Medications and Risk of Fall in the Elderly • Conclusion & Questions Fall Prevention Interventions Joanne M. Wile Avenmarg, OTR/L, M.S. Director, Clinical Operations Fall Prevention Interventions • Patient / Caregiver Centered – Home Care Coordinating Council Quality Committee Developed a “Falls Tool Kit” • All tools cannot be used with all patients • Home-Care Safety For People Receiving Care In The Home; A Self-Care Handbook in admit packet – Clinicians review sections at each visit » Highlight » Have patient / caregiver write in book Fall Prevention Interventions Fall Prevention Interventions • Patient / Caregiver Centered • Review of incident reports – – – – Many falls occur when patient is getting out of bed “There is no prosthetic for bad judgement” Issue reachers to patients as needed Developed two tools » Step-by-step process for getting out of bed » Fall prevention: Patient Agreement Fall Prevention Interventions Fall Prevention Interventions Fall Prevention Interventions • Patient / Caregiver Centered • Rehab admissions – focused review of medications by an RN – Able to discuss » Purpose » When to take » Side effects – Electronically document discussion in case note to Case Manager Fall Prevention Interventions • Clinician / Education Centered – – – – TUG & FRT vignettes with associated competencies Journal Club PDCA on interventions Incident Committee • Number of falls • Severity rating for falls • Observed vs non observed Fall Prevention Interventions Questions? Questions & Answers • Please send your questions and comments to [email protected] now or at any time • We will address as many as time will allow during today’s live webinar broadcast • You may also contact us at [email protected] at any time if you have questions or comments in the future HHQI Resources • Fall Prevention BPIP – Leadership information – Focus on fall Prevention – Checklist for agency leaders – Tools and resources – Organizational culture – Physician perspective – Discipline tracks CHAMP Resources • Simple Steps to Prevent Falls – – – – • Home Fall Prevention Checklist for Older Adults (CDC) English Chinese Korean Spanish – English – Chinese – Spanish • CHAMP Geriatric Falls Prevention Toolkit • My Falls Free Plan CHAMP website: www.champ-program.org VNAA Blueprint for Excellence VNAA Blueprint for Excellence website: vnaablueprint.org Connect with HHQI Facebook www.facebook.com/MyHHQI Twitter www.twitter.com/HHQI LinkedIn http://tinyurl.com/lece9t9 MyHHQI Blog http://hhqi.wordpress.com Discussion Forum under Network tab on HHQI website LiveChats under Network tab on HHQI website THANK YOU! This material was prepared by the West Virginia Medical Institute, the Quality Improvement Organization supporting the Home Health Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication Number: 10SOW-WV-HH-MMD-042814.
