Posts

Knollcrest Lodge has significantly reduced the rate of falls in their long-term care home from 16.7% in 2012/13 to 9.9% in 2017/18, but the improvement didn’t happen overnight. Their quality journey began in 2012 and has evolved to include a multi-pronged approach to this complex issue. Their falls prevention program has even expanded to measure its potential impact on emergency department (ED) visits.

Health Quality Ontario had a chance to catch up with Margaret Holst, RN, Quality Lead, and RAI Coordinator at Knollcrest Lodge to find out more.

How did you identify that falls was a quality issue that needed to be addressed?

In 2012, Knollcrest was part of a group of nine homes in Huron Perth county that was selected by Huron Perth Non-Profit Homes and Services for Seniors (HPNHSS) to receive enhanced education and training in quality improvement.

Knollcrest’s Department Managers and RAI MDS Coordinator attended a Quality Education Day offered as part of this initiative. As a result of this education, we identified fall prevention as a high priority area to begin our quality journey. Our falls rate in 2012/13 was 16.7%, which was above the provincial average.

What initial steps did you take to reduce falls in your long-term care home?

When we started our work in 2012, we used the Registered Nurses Association of Ontario’s (RNAO) Gaps Analysis Work Sheet (Preventing Falls and Reducing Injury from Falls, Fourth Edition 2017) to compare our current practice to evidence-based practice.

We identified existing gaps in our workflow, including assessing for risk, comprehensive post fall assessments, documentation, and follow up preventative actions. We also used quality improvement tools such as fishbone diagrams and the 5 whys to determine the root causes of our high falls rate, and Plan-Do-Study-Act (PDSA) cycles to test change ideas.

We set a falls rate target of 8% and implemented the following change ideas:

• Falls Risk Assessment: Within 48 hours of admission and routinely thereafter, a falls risk assessment is completed, and a plan of care with individualized interventions is implemented to address the identified areas of risk.
• 'Falling Star' program: When a resident’s falls risk assessment indicates “high risk,” a logo with a star is placed outside the resident’s room as a cue to notify staff to increase monitoring of the resident. The resident’s fall risk scoring is also taken into consideration by the Physician and Pharmacist with medication changes, quarterly medication reviews and during annual medical physical examinations.
• User-Defined Assessment (UDA) Tool in PointClickCare®: We developed a Post Fall Assessment/Incident Reporting tool with a section for analysis. It is designed to capture specific details and direct front-line staff members to follow a consistent course of action after every fall. The format of the UDA encourages staff to ‘think outside the box’ and to determine what the resident was doing prior to the fall. Were they cold, or hungry? Did they need to be toileted? What could have been done differently? What can be implemented to prevent future falls?
• Fall and injury prevention equipment: We increased the amount and types of equipment available (such as bedside/floor fall mats, bed and chair fall monitor alarms, grippy socks, high/low beds, and hip protectors) and provided education on their appropriate use. Staff felt empowered to promptly implement interventions such as rearranging the room or changing the resident’s plan of care (i.e. to address continence issues).
• Tracking and posting data on our Quality Improvement bulletin board: This was implemented to increase staff ‘buy-in’ and motivate the team to strive for improvement.

After implementing these initiatives, our falls rate was reduced from 16.7% in 2012/13 to 16.4% in 2013/14. We determined that more needed to be done.

What further steps did you take?

Knollcrest’s multidisciplinary team identified gaps within our Nursing Restorative Care Program. We recognized with the current staffing levels and existing workload, some residents were not receiving optimal time and opportunity for functional rehabilitation (strengthening, tolerance, and balance) to maintain or improve safe transfer and ambulation status.

Changes to the program included:

• Creating a well-defined role for a Restorative Care Aide (RCA) to become the champion for the Restorative Program. The RCA’s daily routine includes dressing programs, walking, gym, and group active range of motion exercise programs for strengthening, tolerance and balance work. It also includes 1:1 passive range of motion to prevent contractures, and eating programs at breakfast and lunch for residents who have potential for functional rehabilitation (to become more independent) or experiencing recent losses in functional abilities.
• Completing an assessment upon admission to determine the potential for functional rehabilitation and at least quarterly thereafter. Each resident’s program is reviewed and updated as necessary to address any changes or losses in level of independence. Monthly multidisciplinary meetings to address resident needs in a timely manner has also been of benefit as our resident population’s complexity increases.

In 2015, a Quality Lead role was created to organize and move Knollcrest’s Quality Improvement planning forward. The Home’s Falls Prevention Program remained in the spotlight as a priority focus.

We continued to change our processes based on small change ideas, evaluating and evolving our Falls Prevention Program, using PDSA cycles as our main ‘go to’ tool. Some additional changes include using a 'post fall huddle tool' with staff at the scene of the fall, and initiating orthostatic blood pressures to be completed after a fall for those residents who are ambulatory. As a result, orthostatic and postural hypotension have been identified as a contributing factor to falls for several residents. Interventions have been put into place to address these risks.

After two years of implementing these additional initiatives, our falls rate decreased from 16.4% in 2013/14 to 12.4% 2015/16.

Where are you today with your fall prevention efforts?

Our falls rate has consistently decreased since 2012/2013. We have been successful in maintaining a rate of 9.9% since 2017/18 compared to the 16.4% provincial rate (Data source: Health Quality Ontario - System Performance).

What has been your biggest undertaking?

Over the past six years, we have completed over 1200 Post Fall Assessment/Incident Reports. And today, after 30+ versions of this tool (UDA), we continue to evolve to perfect the process.

After years of work with falls prevention as a priority focus in our strategic quality improvement plan, we have witnessed a culture change in staff approach to falls. The team has become more proactive in recognizing high risk scenarios for fall prevention and empowered to implement injury prevention strategies.

What impact has your work on fall prevention had on your emergency department (ED) rates?

In 2018, we began to look at our avoidable ED visits rate. We decided there may be benefit to increasing the efficiency in tracking and analyzing ED visits and hospital admissions. We successfully implemented PointClickCare’s® functionality for Hospital Tracking to collect data on the Home’s ED visits. We are able to track ED visits by day of the week, reason for transfer and by visit outcome (i.e. ED visit only or hospital admission).

From October, 2018 to September, 2019, 16 residents had ED visits for a variety of reasons. 44% of these ED visits were the result of falls (see below). Further analysis of this data may indicate a relationship between the rate of falls and the number of ED visits.

In 2019/20, our rate for potentially avoidable ED visits is well below the provincial average. We will continue with use of the Hospital Tracking Portal in PointClickCare® to track and analyze root causes of ED visits and hospital admissions.

What advice to you have for other long-term care homes who want to tackle fall prevention?

Falls are difficult to prevent among residents in long term care. Our Quality Improvement has been a journey. Our advice would be to:

• Ensure you have a quality lead who has insight into the workflow and roles of the multidisciplinary team. Start with small, measurable goals and complete ongoing Plan-Do-Study-Act (PDSA) cycles.
• Involve all members of the team (including the resident/family members/community) in your improvement plan. Understand and use the strengths of all team members to maximize their skills in quality improvement.
• Seek out input and feedback to create ‘buy-in’, empowering and engaging everyone in the process of change.
• Use tools such as the PointClickCare® Hospital Tracking portal and the Post Fall Assessment/Incident Report UDA. Quality improvement is contingent on good data and analysing the numbers, looking for patterns and trends. Data has been instrumental in our success.
• Use best practices such as RNAO’s fall prevention toolkit.
• Network with other Homes to troubleshoot and learn together. "Unity is strength. . . when there is teamwork and collaboration, wonderful things can be achieved." --Mattie Stepanek.

Do you work in long term care?

Visit Quorum’s Indicators & Change Ideas page for more information on potentially avoidable emergency department visits.

You may also be interested in our quality improvement stories featuring the work of long-term care homes across Ontario.

Read more posts in the fall prevention series on Quorum.

How do you prevent falls in primary care? Share your advice and lessons learned by clicking on “ADD A COMMENT” below.