Dizzy is Not a Root Cause Getting the right answer to the wrong question! Learning Objectives. Learning Objectives 9/24/2015

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1 Dizzy is Not a Root Cause Getting the right answer to the wrong question! A FRESH LOOK AT PREVENTING FALLS IN NURSING HOMES Learning Objectives Fall Review: Understand the impact of falls on the nursing home population Identify the multiple physical, cognitive and environmental risk factors that contribute to falls Discuss the essential role that root cause analysis plays in fall prevention Review the critical role of assessment Learning Objectives Understand syncope in its many presentations Recognize the role of pain, discomfort and the desire to move in fall causation Discuss environmental adaptation methods for managing visual & cognitive deficits Learn how to avoid auditory clutter Consider the value of personal alarms and their role in sleep deprivation 1

2 Learning Objectives Understand how to provide gravity assisted seating to promote stability Discuss the value of supplementation and protective gear in fall related injury prevention Learn how to promote appropriate physical exercise for fall avoidance Understand the role of staffing issues related to falls TRUE or FALSE Fall prevention is a nursing function With an appropriate plan, all falls are preventable A fall assessment should be conducted within 30 days of admission Between 50% and 75% of nursing home residents fall annually Approximately 1800 nursing home residents die annually from falls Some Facts Average of 2.6 falls per year for each nursing home resident Fear of falling = depression, feelings of helplessness, social isolation Most falls have multiple causes, requiring multiple approaches Understanding the root cause is the ONLY way to prevent future falls 2

3 CRITICAL ROLE OF ASSESSMENT Critical Role of Assessment Interdisciplinary, multi-factorial approach Before the first fall / at admission Evidence-based fall risk screening tool History review Comprehensive physical exam Functional assessment History Review Consider those risk factors related to prior fall history. Include a comprehensive review of : Cognitive deficits Medication use and recent changes Osteoporosis Incontinence Cardiovascular disease Uncontrolled pain 3

4 Comprehensive Physical Examination Mobility Physical conditions, abilities and limitations must be carefully considered: Joint function Neurologic function Muscle strength Visual acuity Cardiovascular status Foot condition/footwear Functional Assessment Consider the residents ability to perform activities of daily living and gauge their fear of falling All ADLs History of multiple falls Gait/balance issues Fear of falling HAROLD & CONNIE TWO CASE STUDIES (PLEASE SEE HANDOUTS) 4

5 About Harold: Multiple risk factors for falls (the usual suspects!) Primary Parkinson s diagnosis Required assistance walking to and from dining room Eventually staff instituted wheelchair assistance to and from dining room Loss of independence upset him Attempted unassisted ambulation, resulting in a fall. Anatomy of a Root Cause Analysis Why did he try to get up? Social Worker: He s upset about not being able to walk anymore Why can t he walk anymore? Nurse: He s weaker and seems to be getting stiffer Why is he weaker? Dietician: He had a weight loss of over 10% in the last month Why is he stiff? Nurse: He s due to see his physician soon to assess changes in his Parkinson s symptoms Anatomy of an RCA (con t) Is a medication adjustment needed? Physical Therapist: It may not be a medication issue. Immobility can cause stiffness and muscle weakening Why is he losing weight? Dietician: His meal intake has been less than 50% for several weeks Why is he eating less? Nursing Assistant: He has a sore in his mouth and he won t wear his dentures an AHA! moment 5

6 Possible Root Cause? Harold fell because he had an unreported and untreated sore in is mouth??? YES! We can prevent Harold s next fall by treating the root cause o Conduct a comprehensive oral assessment o Treat his oral impairment. o Modify his diet to improve his nutritional status o Schedule a neurologic consultation to assess and treat advancements of his Parkinson's disease symptoms We can also prevent other residents next falls by addressing the underlying process issue Asking the WRONG questions How can we get Harold to stay seated? How can we keep Harold from attempting unassisted ambulation? What can we do to keep Harold off the floor? Why did Harold try to get up? This can be the right question Always the RIGHT question: Why can t Harold stand and walk safely? About Connie Tall & lanky, had been a professional tennis player Developed dementia, became non-verbal and wheelchair bound Always slid foreword asymmetrically in wheelchair, putting right hip at edge of seat Frequently attempted to rise when unattended 6

7 Right Answers, Wrong Question Lap buddy Pommel cushion Wedge cushion Self-releasing seat belt Pelvic seat belt with clasp at back of chair (recommended by occupational therapy) All solutions focused on how to keep her in her chair and prevent her from falling All solutions also increased her pain RCA: Detective Work Staff re-examined their basic assumptions Reviewed her medical history Interviewed her family: multiple tennis injuries to her right hip treated with steroid injections over many years Advocated for further x-ray and MRI studies: revealed right hip avascular necrotic femoral head Previous solutions made her pain worse Connie s Solution Family declined hip replacement due to advanced dementia Staff ordered specialty cushion for offloading pressure to right hip Used a recliner to lessen the hip flexion angle while seated Order for appropriate pain relief medication 7

8 Why RCA Failures Occur We ask the wrong questions Staffing issues Time constraints Superficial reviews Investigation does not begin at the time of the event with staff on shift Good RCA requires practice SYNCOPE IN FALL CAUSATION Syncope Facts 30% of 65 and older experience syncope Self-reporting only the fall, not the fainting Multi-factorial or a single cardiac event Carotid stenosis Orthostatic hypotension (vasovagal) Postural orthostatic tachycardia syndrome Diabetes 8

9 Orthostatic Hypotension Often recorded incorrectly: Must allow resident to spend 5 minutes in supine position before recording BP Must record standing BP immediately upon standing---no time to apply gait belt Must repeat standing BP within 1 minute and 5 minutes of rising Online tool: Syncope & Medications Extra monitoring in first 72 hours for addition of, or change in: Diuretics Calcium antagonists Angiotensin-converting enzyme inhibitors Nitrates Antipsychotics Antihistamines Central nervous system agents Narcotics PAIN, DISCOMFORT & THE DESIRE TO MOVE 9

10 Pain, Discomfort & the Desire to Move Why do residents fall from their wheelchairs? We look for UTI, need to toilet, behavioral problems ( he won t wait for help ) Chronic pain and falls are related Move away from painful stimuli, and towards comfort Boredom creates need to move Pain and boredom create depression and falls Alleviating Pain and Boredom Regular evaluation for pain or discomfort Respond to agitation and distress with assessment Focus on non-pharmacologic interventions first Not to hot or to cold Control noise and bright lights Provide appropriate social activities Cushioning and assistive devices Food and drink Meet needs as above > mild analgesics>narcotics VISUAL & ENVIRONMENTAL FACTORS 10

11 Visual & Environmental Factors No evidence vision correction impacts falls (except for 1 st cataract surgery) Environmental adaptations make a difference. Contrasting colors for: doorways, phones, water jugs, wheelchair arm pads, toilet seats, call lights Strong lighting without glare, nightlights, lighted pathway to toilet Visual & Environmental Factors Carefully consider impact of design choices More homelike design Light to medium floor colors with no patterns A variety of seating areas in long halls Medium firm cushions on seating Sound absorbing materials to absorb background noise (carpet, drapes, sound absorbing panels) AUDITORY CLUTTER 11

12 Avoiding Auditory Clutter Personal alarms do not prevent falls They can only shorten rescue time Lifelong conditioning says that an alarm sounding means it is time to flee! Alarms never mean everything is OK; sit down Demented residents respond to alarms with behaviors or withdrawal Avoiding Auditory Clutter (cont) Personal alarms: particularly damaging at night Sleep deprivation: can be a major contributor to falls Loud staff conversations during sleeping hours: not home-like In one study, there were no falls on 11-7 shift for a protracted period of time when personal alarms were eliminated GAVITY ASSISTED SEATING 12

13 Gravity Assisted Seating Prevent falls with proper wheelchair proportions and adjustments Seat low enough for feet flat on floor Deep enough seat o No more than 2 fingers between back of knee and front of chair seat o Nipple line behind seat edge hen leaning forward Keep 90 degree angle at hip, but lower the back of seat Gravity Assisted Seating For posture of kyphosis, make sure seat conforms to the kyphosis and eyes are forward, not down Person s center of gravity must remain over the wheelbase Wide wheelchairs Tall wheelchairs Footrests & risk SUPPLEMENTATION AS PREVENTION 13

14 Supplementation? Vitamin D for both injury prevention and fall prevention Consider all sources: (sunlight, diet & supplementation) Cost is low, little risk of toxicity Consider Calcium separately, due to risks Calcium causes constipation, contributing to falls Data is not compelling for paired supplementation USE OF PROTECTIVE GEAR Protective Gear The footwear problem Old shoes, old habits Lace up and strap on v. slip on Festinating gait: avoid non-slip sole Identify poor footwear proactively, not post fall Admission and quarterly foot evaluation 14

15 Protective Gear Helmets for the anticoagulated? Numerous compliance issues Hip protectors; they do work? History of unresolved fall risk Presence of moderate to severe osteoporosis Resident compliance, discomfort EFFECTIVE EXERCISE Skeleton v. Muscle Skeleton Shape Protection of vital organs Support Movement Blood cell production and storage Muscle Strength Movement Abdominal protection and support Smooth / Sphincter functions 15

16 Promoting Exercise Little evidence to support formal group exercise programs Exercise program should be individualized by PT and performed by restorative nursing to prevent injury, decompensation Limit use of wheelchairs for staff convenience Active walk-to-dine programs STAFF AS PREVENTION Addressing Staffing Issues Falls linked to nurse staffing patterns Consistent staff assignments Charting near frequent faller s rooms Frequent rounds Extra staff during high risk times of day (just after meals and near sundown) Unwitnessed, in resident room, on

17 Conclusion Fall prevention requires an organized, consistent approach Complete reporting of fall details and investigation in real-time Tracking, trending and pattern identification Careful Root Cause Analysis Asking the right questions Maintaining a pro-active approach QUESTIONS? 17