Benchmark study identifies frequency, causes of falls

Medication changes, pain cause more falls

Although home health agencies have focused on falls in the home for many years, their importance was brought into the spotlight when the Joint Commission on Accreditation of Healthcare Organizations included that category in the 2005 National Safety Patient Goals.

With an average fall rate of 5.1% for a total of 7,622 patients assessed during the first year of the Patient Fall Reduction Benchmarking Project and an average of 8.1% of patients who fell requiring emergent care for hip fracture, the importance of reducing falls in home care is apparent, says Janice Roush, project coordinator for the Missouri Alliance for Home Care in Jefferson City, one of the participants in the study.

Mary Calys, MSPT, rehabilitation supervisor for North Kansas City (MO) Hospital Home Health, agrees with that assessment. "Home health agencies have always tracked patient falls and collected a lot of data, but we never had any benchmarks to which we could compare our own agency."

To address that need, the Missouri Alliance for Home Care put together a group of agency representatives who began meeting in June 2003 to identify existing research related to falls in the home and pertinent risk factors, Calys says.

"There are now 29 agencies that participate in our falls reduction project," Roush notes. The agencies, which represent 10 states, collect and submit data on patient falls quarterly, she notes.

The data are compiled into an overall report for all agencies and also are split into reports that show agencies how they rank according to type of agency such as freestanding or hospital-based, Roush explains. The cost for participation in the project is $300 per year and includes data collection forms, questionnaires, and telephone support.

As with any benchmark study, it was critical to make sure the data were collected in the same manner in all agencies, Calys continues. "We spent time defining falls, defining witnessed and unwitnessed falls, and making sure our forms were clear and easy to understand," she says.

Defining a fall as "an unintended change in position that results in coming to rest on the ground or lower level" was essential to ensure accurate collection of data, Calys explains.

"A patient might tell a nurse that he or she had a near miss, but didn't fall," she says. The near miss might mean that the patient fell but landed on a bed or a chair, Calys adds. "Even if the patient didn't land on the floor, it is a fall because the patient would have landed on the floor if the bed wasn't there."

Another difference in the data collection for this project is that witnessed and unwitnessed falls are counted, Roush explains.

"We discovered that agencies were documenting falls witnessed by nurses or other home care staff members such as physical therapists, but not documenting falls that the patient or the family caregiver might mention," she says.

"Excluding the unwitnessed falls from the data does not give an accurate picture of falls risks because the majority of falls are not witnessed by the health care provider," Roush notes.

Nurses and therapists ask patients and their family members if they have fallen since the last visit, Calys points out. The falls reported to the nurse are listed as unwitnessed and included in the overall report, she says.

"The average percentage of unwitnessed falls for 2004, the first year of collected data, was 92%." This demonstrates the importance of documenting all falls, including unwitnessed falls, Calys adds.

Patient and family education is important to make sure falls are reported to nurses, she says. While patients may be reluctant to report falls because they are afraid that a fall means that they cannot stay in their home, a nurse can reassure patients that a fall doesn't mean admission to a nursing home, Calys notes.

"We explain that we want to know about all falls so that we can take steps to keep the patient in the home. We also emphasize the fact that patients who have fallen once are at increased risk to fall again," she says.

It is important that patients and their families understand the risk factors for falls, Calys says. (For a list of risk factors, see article.)

"We also make sure our employees know the risk factors so that they will be able to identify them when they are in the home," she adds.

They don't educate home care nurses only but also make sure all therapists and aides attend educational sessions related to falls, Calys notes. "Any agency employee in the home is responsible for identifying risk factors."

Participants in the benchmarking project have started looking at trends associated with falls to see what programs agencies can put into place to reduce the risk, Roush says.

"We have added questions to our reporting form that ask nurses to document patient medications at the time of the fall," she adds.

The questions ask how many medications the patient is taking, how many pain medications are taken, and if there was a change in any medication prior to the fall.

They've learned that a change in medication is an important risk factor for a fall, Calys explains. "Not only are the number and type of medications taken by the patient important, but if there is a change in the dose or if an additional medication is added, it can affect the patient's balance for up to two weeks," she says.

Nurses at North Kansas now call a patient on the day of a doctor visit to ask if there were any medication changes, Calys says.

"If there is, the nurse will explain that the patient's body may need a week or so to adjust to the new medication so the patient will be at higher risk to fall," she explains.

"The nurse will advise the patient or the family caregiver to be more aware of the risk." If there is any indication that the patient is unsure of the proper way to take the medication, or seems to be experiencing side effects, the nurse will schedule a visit, Calys adds.

Her agency also is looking at options to pain medications. "The popular way to treat pain is to pop a pill," she admits. "Unfortunately, when an elderly patient is on four or more medications and at least one is a narcotic for pain, you have a higher risk for dizziness, balance problems, and confusion."

They are investigating other pain treatments such as ultrasound, electrical stimulation, and massage, she adds. Review of the data collected for the falls prevention project did provide one surprise, Calys notes.

"As a physical therapist, I always focus on a thorough assessment of the patient's environment to remove any potential causes of falls," she says. "The data from the agencies show that environmental factors are a very low risk factor for falls."

One reason for the low risk may be the years of focus on the environmental factors and education of patients and families by home care nurses and therapists, Calys explains.

"I believe these data show that we've done a good job addressing one risk factor for falls," she adds. "Now we need to identify and focus attention on other factors."