Problem proposal

Discuss about the Report for Nursing Assignment of Quality Improvement Project.

Proposal statement- Fall prevention in a hospital setting.

With the aging population, there is increased demand among the older population to remain physically independent as far as possible. There is a need for utilization of novel interventions and technology to assist them in active aging. However, fall is the leading cause of injury-related death among older adults. Besides this, the rate of inpatient hospital admissions for a fall-related injury such fractures bones and joints has increased.  The fall-related injury is also one the most expensive medical condition among adults (Currie, 2008). Therefore seeing these issues, this project has been proposed to address the problem. It will identify factors associated with fall in particular population and recommend cost-efficient and comprehensive measures to prevent fall in a hospital setting.

The purpose of this project is to develop effective strategies to develop functional skills to avoid fall occurrence, assess functional balance and fall efficacy among older people and develop an intervention to prevent falls in adults.

To plan effective fall prevention strategies, identifying risk factors for falls in older people in nursing and hospital is necessary. One literature comprehensively considered risk factors for falls in older hospital inpatients (HI) and nursing home residents (NHR). It identified different risk factors in both settings like medical factors, the effect of medications, socio-demographic mobility, medical factors and many others. In a nursing home, the majority of fall occurred due to walking aid use and different forms of disability. They found decreased risk among female patients. However, this literature did not consider balance and weakness as a risk factor for falls. It concluded that incidence of falls in older people in hospitals and nursing homes has multifactorial etiology. They identified walking aid use, disability and history of falls as strong predictors of fall (Deandrea et al., 2013).

Another literature reviewed the effectiveness of intervention strategies to reduce the incidence of falls in older people of the community. It reported that about 30% of old people above 65 years of age fall every year. The randomized trial of interventions related fall prevention in older people was the selection criteria for the study. Data collection and analysis was done using rate ratio and confidence interval to compare the rate of falls between the control group and intervention group. The risk of falling was analyzed using risk ratio and confidence interval according to a number of people falling in each group. The results showed that several forms of exercise like Tai Chi significantly reduced falls. Vitamin D did not reduce falls but was effective on those people who had a low level of Vitamin D before treatment. Other factors like home safety assessment intervention, pacemakers, withdrawal from psychotic medicines reduced rate of falls, anti-slip shoe device and cognitive behavioral intervention reduced rate of falls. It finally concluded that Group and home-based exercise programs and home safety intervention reduced the rate of fall and risk of falling, but multi-factorial assessment and intervention reduced the rate of falls but not the risk of falling (Gillespie et al., 2012).

Project aim

Fall in elderly often leads to severe consequences like soft tissue injuries, fractures, acute pain, disability and reduced quality of life. This literature mainly investigated fear of falling post stroke in a hospital setting as there is little research on it. It tried to find the proportion of individual with a fear of falling and its effect during the post-stroke period. It was based on a pilot cohort study with 28 adults with acute stroke before discharged from the hospital. It included measures like self-reported fear of fall, stroke-specific quality of life, satisfaction with performance, anxiety, and disorder. The results showed that more than 50% reported anxiety, fear of fall and they had a low level of energy, decreased performance and satisfaction with work. These signs were not found in people without fear of fall. The study concluded that post-stroke fear of fall is associated not just with physical challenges but also with cognitive and emotional challenges in the post-stroke period. It will be necessary to identify and treat this problem in patients to decrease fall of fear and improve health outcome in the post-stroke period (Schmid, 2015).

Fall prevention continues to be a great challenge among health care continuum. For example in the United States, unintentional falls account for the majority of non-fatal injuries among people above 65 years (Currie, 2008).  Females are at more risk of fall than males in this age group. It is leading 41 fall-related death per 10000 people every year (Harvey & Close, 2012). Inpatient fall prevention has been an area of concern for health care since the past 50 years. It is associated with high mortality and morbidity, and it is a great cost for different countries. 20-30% fall injuries lead to reduced mobility and increase the risk of premature death (Ambrose et al., 2013). Fall rate among hospital residents is much higher than community dwellers (Quigley et al., 2014). There is an urgent need to identify predisposing and situational factors leading to falling and implement multi-component interventions for fall prevention and management in older people in a hospital setting. Fall prevention strategies aimed at behavioral change and risk modifications can be effective in reducing the number of falls. Risk factor assessment and screening of selected population will be essential in this regard (Moyer, 2012).

The project aims to provide a solution to the high rate of falls in older people in the community. To prevent falls in a hospital setting, the first step is to identify risk factors leading to falls among older adults.

Literature review

Identification of risk factors related to fall:

Physical stability is a factor that influences fall rate. The ability to maintain stability is dependent on proper functioning of sensory, musculoskeletal components (Hassankhani et al., 2012). Ageing is associated with cumulative impairment whose aggregation lead to fall. For example, a urinary tract infection may result in fall due to impaired stability and decreased the ability to maintain proper balance (Muir et al., 2012). The project plan is to identify both predisposing and situational risk factor related to fall.

Predisposing risk factors- It is related to an intrinsic characteristic of individual that impairs stability. For example impairment of sensory, hearing and vestibular system that impairs orientation of the person in space. Hearing defects may affect stability while a defect in the vestibular system may impair the spatial orientation at rest (Grundstrom et al., 2012). Diseases of the Central Nervous system such as dementia and Parkinson disease also affect mobility in older adults. Adult people also suffer from impairment of musco-skeletal systems like bones, joints, and tendon (Ambrose et al., 2013). Certain medications like an anti-depressant, sedative, and cardiovascular agents also increase the risk of failure (Butler et al., 2015).

Situation risk factor- Slippery floors and poor lighting may be the reason for fall in a hospital setting. In non-ambulatory patients fall may occur during transfer or due to improperly fitted equipment. Hospital environment around the patient may also be a factor for fall. The majority of fall-related cases is due to tripping, misuse of furniture, devices, and equipment. Many falls occur in the bathroom due to wet flooring or slippery tiles (Landers et al., 2016).

The plan is to assess a specific area and implement effective measures for fall prevention in adults. The assessment of risk in the specific population will be done by the use of risk assessment tools. The three different assessment tool that will be employed are the Activity-specific Balance Confidence Scale (ABC), the Multi-directional Reach Test (MDRT) and 8-foot Up and Go (UG) test to track the balance of individuals. The ABC scale will determine patients fall efficacy. It will be done in the form of questionnaires that enquires patients about their confidence level regarding doing any activity (such as walking around the house, sweeping the floor, walking down the ramp, stepping on and off an escalator while holding to the railing and many others. The score will be calculated taking the average of individual’s total response to questions. It will help in getting a variety of response (Halvarsson et al., 2013).

Current state

The 8-Foot Up and Go test will involve incorporating functional task among older patients like sitting to standing, or stand to sit. It will help to assess dynamic balance and agility of older patients (Barry et al., 2014). The MDRT test will evaluate the extent to which patients can reach backward, forward, right or left outside their base of support. Understanding postural stability required for different direction will be useful in the assessment of individual postural control (Hassankhani et al., 2012). This test will help in the determination of the different level of intervention strategies needed for a selected population.

Intervention strategies:

The intervention strategy is aimed at reducing the risk of fall in selected population. The fall prevention program will include:

• Training older adults to do certain exercise to improve balance.
• Teaching them safety-related skills and behavior.
• Minimizing environmental hazard present in hospital setting.
• Monitoring and adjusting old patient medications to reduce the rate of fall.
• Education to make people aware of fall hazards and practice safe behavior to prevent fall.
• Modification in single risk factor or multifactorial interventions to reduce fall-related injuries (El-Khoury et al., 2013).

Exercise and physical activity: The fall prevention program is to increase physical activity among the older population to improve strength, balance, and orientation in open space (El-Khoury et al., 2013). Several exercises will be taught to older patients such as Tai Chi, other mobility, and flexibility related exercise such as muscle strengthening, balance training and many others to improve balance in older adults (Tousignant et al., 2013). In the case of a patient with major functional limitation, an individualized, specific activity program is planned.

Environmental modifications- Patients surrounding is also a contributing factor in fall. Railing or slippery tiles, wheelchair, furniture, etc. may increase the risk of fall in the home or hospital setting (Miake-Lye et al., 2013). Assessment and modification of environmental risk factor will be to reduce fall in old people.

Medication withdrawal- Older adults often has to take multiple medicines like sedatives, psychotropic medications, anti-depressants. These medications are associated with a feeling of dizziness, and it increases the chance of fall in the patient (Tinetti et al., 2014). Therefore it is proposed to manage medication of older adults and help the patients in withdrawing away from such medicines.

Applying hip protectors: Majority of injury-related fall has caused a hip fracture in adults. This occurs when people fall directly on the hip. To reduce hip injury among old patients, the plan is to encourage the use of hip protectors among adults to prevent falls Hip protectors have foam pads fitted in them to reduce the impact of fall. This is beneficial in shunting energy away from the point of impact and reducing the impact on proximal femur (Choi et al., 2015). The aim of using hip protector is not to mitigate the risk of fall but lessen the impact of fall (Santesso et al., 2014).

Establishing measures for project

Safe flooring: Developing safe flooring in a hospital setting is one of the major aspects of reducing fall-related injuries. It is proposed to have flooring that has better grip and is slip-free. It is proposed to use energy-absorbing flooring material in the hospital to prevent fall among hospital and nursing home residents (Drahota et al., 2013).

Individual assessment- The project offers an individual level assessment to determine particular prevention strategy convenient for that people. Screening of individual older adults will lead to targeted intervention for deficit areas (Gillespie, 2014).

Hospital authority has the responsibility to communicate all staff regarding identifying a patient who is at increased risk of fall. Secondly, they need to ensure essential bed railing and mobility equipment are properly fitted to reduce falls (Moyer, 2012). It is also planned to educate the family members regarding the risk of fall injury and ways to prevent at the time of admission and discharge. Fall prevention literacy will be provided to each staff in health care organizations (Quigley et al., 2014). It will also be necessary to communicate risk and associated interventions related to specific patients at the time of each shift change.

The quality improvement project related to fall prevention in the hospital setting has been comprehensively planned after analysis of all the risk factors leading to falls in the elderly population. The literature review provided direction and support to the project to determine areas of improvement that can be implemented in health care setting. The plan is an attempt to reduce the risk and number of fall among older adults. Proper identification of risk factors and using assessment tools to identify gaps leads to the planning of effective intervention and prioritizing fall prevention in the specific population. Proper knowledge literacy related to fall prevention among health professionals and medical staff is also essential to reduce cases of injury related fall in adults.

References

Ambrose, A. F., Paul, G., & Hausdorff, J. M. (2013). Risk factors for falls among older adults: a review of the literature. Maturitas, 75(1), 51-61.

Barry, E., Galvin, R., Keogh, C., Horgan, F., & Fahey, T. (2014). Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC geriatrics, 14(1), 1.

Butler, A. A., Lord, S. R., Taylor, J. L., & Fitzpatrick, R. C. (2015). Ability versus hazard: risk-taking and falls in older people. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 70(5), 628-634.

Project plan

Choi, W. J., Cripton, P. A., & Robinovitch, S. N. (2015). Effects of hip abductor muscle forces and knee boundary conditions on femoral neck stresses during simulated falls. Osteoporosis International, 26(1), 291-301.

Currie, L. (2008). Fall and Injury Prevention. Agency For Healthcare Research And Quality (US). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK2653/

Deandrea, S., Bravi, F., Turati, F., Lucenteforte, E., La Vecchia, C., & Negri, E. (2013). Risk factors for falls in older people in nursing homes and hospitals. A systematic review and meta-analysis. Archives of gerontology and geriatrics, 56(3), 407-415.

Drahota, A. K., Ward, D., Udell, J. E., Soilemezi, D., Ogollah, R., Higgins, B., … & Severs, M. (2013). Pilot cluster randomised controlled trial of flooring to reduce injuries from falls in wards for older people. Age and ageing, 42(5), 633-640.

El-Khoury, F., Cassou, B., Charles, M. A., & Dargent-Molina, P. (2013). The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials.

Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M., & Lamb, S. E. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev, 9(11).

Grundstrom, A. C., Guse, C. E., & Layde, P. M. (2012). Risk factors for falls and fall-related injuries in adults 85 years of age and older. Archives of gerontology and geriatrics, 54(3), 421-428.

Halvarsson, A., Franzén, E., & Ståhle, A. (2013). Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporosis international,24(6), 1853-1858.

Harvey, L. A., & Close, J. C. (2012). Traumatic brain injury in older adults: characteristics, causes and consequences. Injury, 43(11), 1821-1826.

Hassankhani, H., Kakhki, A. D., Jafarabadi, M. A., & Malek, M. (2012). Elders Fall Risk Predictors.

Landers, M. R., Oscar, S., Sasaoka, J., & Vaughn, K. (2016). Balance confidence and fear of falling avoidance behavior are most predictive of falling in older adults: prospective analysis. Physical therapy, 96(4), 433-442.

Miake-Lye, I. M., Hempel, S., Ganz, D. A., & Shekelle, P. G. (2013). Inpatient fall prevention programs as a patient safety strategy: a systematic review. Annals of internal medicine, 158(5_Part_2), 390-396.

Moyer, V. A. (2012). Prevention of falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 157(3), 197-204.

Muir, S. W., Gopaul, K., & Odasso, M. M. M. (2012). The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age and ageing, 41(3), 299-308.

Quigley, P. A., Barnett, S. D., Bulat, T., & Friedman, Y. (2014). Reducing falls and fall-related injuries in mental health: A 1-year multihospital falls collaborative. Journal of nursing care quality, 29(1), 51-59.

Santesso, N., Carrascoâ€ÂLabra, A., & Brignardelloâ€ÂPetersen, R. (2014). Hip protectors for preventing hip fractures in older people. The Cochrane Library.

Schmid, A. A., Acuff, M., Doster, K., Gwaltney-Duiser, A., Whitaker, A., Damush, T., … & Hendrie, H. (2015). Poststroke fear of falling in the hospital setting. Topics in stroke rehabilitation.

Tinetti, M. E., Han, L., Lee, D. S., McAvay, G. J., Peduzzi, P., Gross, C. P., … & Lin, H. (2014). Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA internal medicine,174(4), 588-595.

Tinetti, M. E., Han, L., Lee, D. S., McAvay, G. J., Peduzzi, P., Gross, C. P., … & Lin, H. (2014). Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA internal medicine,174(4), 588-595.

Tousignant, M., Corriveau, H., Roy, P. M., Desrosiers, J., Dubuc, N., & Hébert, R. (2013). Efficacy of supervised Tai Chi exercises versus conventional physical therapy exercises in fall prevention for frail older adults: a randomized controlled trial. Disability and rehabilitation, 35(17), 1429-1435.