Outpatient Fall Reduction

1. Outpatient Fall Reduction Leininger Group Members • Cara Nuss • Raechel Little • Tanya Robb, RN, BSN, CCRN • Tiffany Lemanski, RN, BSN, CMSRN

2. INTRODUCTION • Falls and related injuries continue to be an unsolved problem in inpatient and outpatient care areas as well as in the community at large. • Approximately 32% of community-dwelling individuals over the age of 65 fall each year. Americans over the age of 65 currently represent 12% of the population, which equates to approximately 35 million people. Unintentional injury is the fifth leading cause of deathin the general population in the United States, and falls are the second most common cause of unintentional injury across ages. • According to a study by Hausdorff, et. al, in the community setting, fall-related injuries are the most common cause of death in the persons over the age of 65, resulting in 38.4 fall-related deathsper 100,000 individuals 65 years or older (Currie, 2006).

3. PICO Question • Does initiating a fall risk assessment tools or education of staff (I) in outpatient care settings with adults (P) reduce the number of falls (O) than in outpatient care areas where no fall risk assessment or education is performed (C)? • With each of us having nursing experience, we have utilized multiple fall risk assessment tools and interventions in inpatient care settings. This topic sparked our interest because we wanted to know what interventions are being utilized with outpatient, high-risk populations to prevent falls.

4. Literature Review Research today shows that falls are the leading cause of injury related deaths, and the numbers are increasing, according to the National Center for Health Statistics Research data has shown us that the more risk factors that are apparent in patients, the higher the chance of injury from a fall.  If we assess our patients and understand the risk factors to watch for, we can utilize appropriate resources to intervene early.

5. Summarization of findings • Did the literature Review Answer our PICO question • Holistic programs had more success than specific tools for reducing outpatient falls • The main components of a successful fall prevention program are reduction of medical risk factors, exercise, training and motivation. • Training medical staff about successful fall prevention programs helps to reduce falls, however there is resistance among some providers.

6. Summary Continued • General Findings • Most of the successful fall prevention programs were time consuming and required professional involvement (OT, PT, RN) and required patient’s to perform excersises e at home. • Most of the successful fall intervention programs were administered in group settings with individualized follow ups and risk assessments. • Fall and Balance Clinics are effective for helping to reduce outpatient falls, however these sites are a new concept and not widely used in the Primary Care Setting. • There is currently no assessment tool in practice for outpatient hospital area’s such as the ER and Urgent Care Clinics. • There is no specific tool or program that is considered “standard practice” for reducing fall in the outpatient population.

7. Level of Research The Average Level of Research Evidence based on 15 studies….3 • Three articles were level 1, and included two meta-analysis and one historical systematic review. • Two articles were lever 2, Randomized Controlled Clinical Trials. • Four Articles were level 3, and included non-randomized controlled trials • Two articles were level 4, and included cohort studies • Two Articles were level 5, and included descriptive analysis.

8. Internal Validity Selection—Some of the studies selected specific participants who were at higher risk for falls, reducing randomization. History- The historical analysis of falls went back to over 12 years. Many changes over the years may have skewed data Testing- Many of the studies were dependant upon self reporting and diary keeping from subjects. Subjects may have misreported information.

9. External Validity Replication- Many of the level 2 and 3 studies were not replicated to ensure findings. Homogeneity– Trial to educate medical professionals was performed only in the Hartford area, which reduced the ability to generalize the the findings. Interactions between relationships and people—Many of the studies used professional people as trainers in the interventions. How did the personalities and teaching strategies effect the interventions. If performed by different people would the intervention still have the same effect?

10. Fall Risk Factors Category Table of Risk Factors Educating patients, families, and healthcare professionals about the major risk factors and implementing a fall risk assessment tool, will not only assess for possible risks now, but also prevent injury and death in the future. *Biological: exp., advanced age, previous fall, muscle weakness, or poor balance *Behavioral: exp., multiple medications including psychoactive components, risk taking behavior, and alcohol use. *Environmental: exp., lack of stair handrails, slippery surfaces, dim lighting, or tripping on objects. *Social-economical: exp., low income, lack of education, living alone and lack of social support

11. Did you know that research has shown us that the more risk factors you have, the higher the chance of injury from a fall. Using a risk assessment tool, with a numerical value system, could help healthcare providers, determine at what risk a patient might be from a fall.

12. If we as healthcare providers, assess our patients for fall risk, we can utilize appropriate resources and intervene, before its too late. One way to utilize resources appropriately is to have social work organize a to have an occupational therapist to do an assessment at home, to determine if the home is safe, and free of injury risks of falling for the patient. This resource could be determined based on a risk assessment score that is done when the patient is seen in the outpatient setting.

13. Use in nursing practice Educate, educate, educate! Patients and families should be educated in and out of the hospital. People are at risk for falls in any setting and may have exacerbating circumstances that put them at an increased risk. Studies show people want understand their risk want their provider to discuss this issue Clinical staff need to be educated as well Implementing fall risk identification and prevention programs may decrease falls in out patient settings Importance placed on fall prevention can translate into change in practice

14. Use in nursing practice, cont. Assess a persons fall risk at any point Pre-op At an routine appointment with the primary care provider In a home health setting At an out patient procedure or test (dialysis, infusion room, etc) Put a program in place and use it!

15. Future research needed • More quantitative primary research examining effectiveness of fall prevention programs in out patient settings-not just in the community • Research of particular tools used in out patient settings • are the tools for acute care appropriate for other settings? • Do primary care providers find it necessary to discuss falls with their patients? • Do nurses in out patient care settings consider the potential for falls among various populations?

16. References AHC (2008). Make sure your policies and procedures are in place to prevent fatal patient falls. Same Day Surgery. 32(5): 49-52. NLM UID: 7810150 Seifert K (2010). We’re not falling for that! Preventing falls in the ambulatory setting. AAACN Viewpoint, 32 (2): 1, 8-11 CINAHL AN: 2010606084