1 Determining Effectiveness of Evidence-Based Education and Interventions for Fall Prevention in Long-Term Care Lauren B. Adams-Sanantonio, BSN, RN, DNP student Chelsea L. Richard, BSN, RN, DNP student Michigan State University, College of Nursing Linda J. Keilman, DNP, MSN, RN, GNP-BC, FAANP 2 Table of Contents Abstract ………………………………………………………………………………..………… 5 Introduction ……………………………………………………………………………...………. 6 Background ………………………………………………………………………………..…….. 7 Clinical Question ………………………………………………………………….……….……. 9 Clinical Site Description ……………………………………………………………………….. 10 Residents/Care Setting …………………………………………………………………. 11 Staffing …………………………………………………………………………………. 11 Policy & Processes ……………………………………………………………………... 12 Patterns …………………………………………………………………………………. 13 Strengths, Weaknesses, Opportunities, Threats ………………………………………………... 14 Fishbone …………………………………………………………………………………….….. 15 Summary of Evidence ……………………………………………………………………….…. 16 Identifying Fall Risk Factors …………………………………………………….…….. 16 Physical Activity/Exercise: Single and Multifactorial Interventions ……….………..… 17 Fall Prevention Programs …………………………………………………..…………... 19 Extrinsic Modifications …………………………………………………..…………….. 19 Education ………………………………………………………….…………………… 20 Team-based Approach to Care ………………………………….……………………… 21 Goals, Objectives, and Expected Outcomes …………………………………………………… 22 Methods ………………………………………………………………………………………… 23 Ethical Considerations/Protection of Human Subjects ………………………………… 24 Setting Facilitators, Stakeholders, and Barriers ………………………………………... 24 3 The Intervention and Data Collection Procedure ………………………………………. 24 Timeline ………………………………………………………………………………... 25 Analysis ………………………………………………………………………………………… 25 Conceptual Framework ………………………………………………………………………… 27 Plan ……………………………………………………………………………………...27 Do ……………………………………………………………………………………… 28 Study …………………………………………………………………………………… 28 Act ……………………………………………………………………………………… 28 Sustainability Plan/Next Steps …………………………………………………………………. 28 Nursing Implications …………………………………………………………………………… 29 Cost-Benefit Analysis/Budget …………………………………………………………………. 30 Conclusion ……………………………………………………………………………………... 30 References ……………………………………………………………………………………… 32 Appendix ……………………………………………………………………………………….. 40 Appendix A …………………………………………………………………………….. 40 Appendix B …………………………………………………………………………….. 41 Appendix C …………………………………………………………………………….. 42 Appendix D …………………………………………………………………………….. 43 Appendix E …………………………………………………………………………….. 44 Appendix F …………………………………………………………………………….. 64 Appendix G ……………………………………………………………………………. 66 Appendix H ……………………………………………………………………………. 67 Appendix I …………………………………………………………………………….. 68 4 Appendix J …………………………………………………………………………… 69 Appendix K ………………………………………………………………………….. 70 Appendix L …………………………………………………………………………... 73 Appendix M …………………………………………………………………….……. 74 Appendix N …………………………………………………………………………... 75 5 Abstract Background Falls are a significant concern for older adults as they can result in hospitalization, disability, death, and increased health care costs. Evidence-based interventions and validated screening tools are available to aid in reducing falls among older adults in long-term care. However, falls continue to be a major health concern for older adults in nursing homes. Purpose The purpose of this evidence-based quality improvement project was to impact the knowledge and skills of direct care workers regarding falls in older adults residing in Holt Senior Care and Rehabilitation Center in Holt, Michigan. The main goal of the project was to provide education to direct care workers and to reduce falls and fall-related injuries of the older adult population at the Holt facility. Methods A pre- and post-test design was distributed to direct care workers to assess their knowledge of fall prevention before and after an in-person educational PowerPoint presentation. Educational handouts were also provided to all direct care workers. Scores were analyzed after the education session to determine whether any changes occurred. Implications/Conclusion Primary outcomes were that direct care workers demonstrated improvement in post-knowledge and attitudes scores post-intervention. Secondary outcomes were that Minimal Data Set statistics on falls improved in subsequent quarters of survey assessment at the facility. Keywords: Falls, fall prevention, older adults, education, nursing, long-term care 6 As human life expectancy increases, the global older adult (OA) population continues to grow. In 2022 there were more than 46 million adults aged 65 and older in the United States (US) with a prediction of 90 million by 2050 (Arigoni, 2022). The last of the Baby Boom cohort will reach the age of 65 by 2030 and that event will result in approximately 18 million more OA over 65 in the US (Fry, 2020). Considering the increasing numbers of OA, it is interesting to note that in 2034 there will be more individuals 65 and older in the US than those under 18 years of age (U.S. Census Bureau [USCB], 2021). A visual representation of this demographic change is offered in Figure 1. Figure 1 An Aging Nation: Projected Number of Children and Older Adults Figure from a US government public domain diagram by the U.S. Census Bureau available at https://www.census.gov/library/stories/2018/03/graying-america.html 7 Within this aging population, maintaining independence through mobility and daily functioning becomes an essential part of quality of life (QoL). However, functional independence often becomes hindered due to age-related physiological changes, co-morbidities, polypharmacy, or most notably, falls and injuries related to falls. Falls can lead to disability, death, and increased health care costs and are a leading cause of hospitalization and long-term care (LTC) placement in the US (Hoffman et al., 2017). Falls within the OA population have been an ongoing issue worldwide. Falls occur when an individual unintentionally collapses or descends to the ground with or without injury (Khow & Visvanathan, 2017; Meimandi et al., 2021). Fall prevention interventions and protocols were created to better assess risks associated with falls. Unfortunately, falls continue to be an ongoing issue regardless of the setting. More innovative and proactive strategies need to be implemented to educate OA, their families, direct care workers (DCWs), health care professionals and providers to gain in-depth understanding of fall risk and to provide resources to improve fall prevention and management. For this project, DCWs are those who work directly with residents in LTC. DCWs include registered nurses (RNs), licensed professional nurses (LPNs), certified nursing assistants (CNAs), physical therapists (PTs), occupational therapists (OTs), speech therapists (STs), and activity rehabilitation staff. Background Falls are a leading cause of death among OA globally and in many cases, can be prevented (Centers for Disease Control and Prevention [CDC], 2021). Among OA, one out of five individuals who fall develop a serious injury such as a fracture (National Council on Aging [NCOA], 2022). Fractures in the OA population can lead to more severe complications than they would for a child or younger adult including increased morbidity, mortality, loss of 8 independence, reduced QoL, and increased healthcare expenditures. The risk factors that contribute to falls are categorized as either intrinsic (physical and psychological) or extrinsic (environment). See Appendix A for a definition and list of specific fall risk factors. In addition to the information in Appendix A, acute and chronic diseases such as Alzheimer’s, arthritis, cancer, depression, osteoporosis, Parkinson’s, and stroke are also considered intrinsic risk factors. These intrinsic and extrinsic factors can often be modified through the implementation of evidence-based (EB) interventions and screening measures. Common interventions that are implemented in LTC facilities include call lights, bed alarms, fall risk mats, beds in the lowest position, and frequent and on-going medication reviews. With all the available EB resources and screening tools, why are falls still an issue for OA? It is important to note there are special circumstances and challenges surrounding every fall. One example is there were less falls occurrences during the coronavirus disease (COVID- 19) pandemic at Holt Senior Care and Rehabilitation Center (HSC&RC). During this time, OAs were quarantined in their room to prevent the spread of infection and may have become weaker due to lack of strength activity exercises conducted by the activity department. Following the pandemic, the facility saw a rise in falls among OAs as they were able to move about the facility and might have become more deconditioned due to decrease in activity level during quarantine. In addition, the pandemic led to staffing shortages and travel DCWs who may not have been as familiar with the OAs. Inadequate staffing leads to unsafe care and has been associated with increased falls in multiple healthcare settings (Abusalem et al., 2021). Adequate staffing, proactive prevention efforts, and reinforced education on the importance of fall prevention can help in achieving lower fall rates among OA (Abusalem et al., 2021; Gulka et al., 2020). Anticipated benefits of quality improvement (QI) changes include: 9 • an EB proactive education (knowledge, skills) fall prevention program, and • post-fall assessment interventions, implemented among residents at the facility in Holt, Michigan (MI). The outcomes of the QI project include maintaining function and independence in activities of daily living (ADL) and instrumental activities of daily living (IADL) for as long as possible, increased QoL, a decrease in transitions of care, and a reduction in healthcare costs. See Table 1 for an explanation of ADL and IADL function. Table 1 Functional Ability: ADL and IADL Components FUNCTIONAL ABILITY ADLs IADLs Activities related to personal care More complex set of skills needed to live independently • Ambulating • Doing laundry • Bathing or showering • Food preparation • Dressing • Housekeeping • Eating • Managing finances • Toileting • Managing medications • Transferring (in & out of bed or a • Using the telephone chair) • Using or arranging transportation Clinical Question In OAs residing in LTC, will education of DCWs on innovative, proactive, EB interventions for fall prevention, compared to the current facility standards, decrease the number of falls thus improving QoL and functional status? The QI team collaborated with HSC&RC 10 staff to review data on the number of falls, types of fall-related injuries, ratio of DCWs to residents, and interventions implemented by the facility before and during the COVID-19 pandemic which was declared by the World Health Organization (WHO) on March 11, 2020 (Cucinotta & Vanelli, 2020). It is important interventions are proactive rather than reactive to prevent falls and the complications that can potentially occur with falls. Implementation of collaborative and proactive EB interventions include: • The importance of safe, frequent ambulation to maintain function • An increase in routine ambulation during resident group activities and while performing ADLs • Hourly rounding using the 4 Ps: pain, position, possessions, and personal needs (Centre for Effective Practice, 2016) • Increased strength and balance-related exercises led by activity department staff • Education for DCWs on the pathophysiology of normal aging • Appropriate steps to complete root-cause-analysis and post-fall assessment Clinical Site Description HSC&RC is a for profit short-term rehabilitation and LTC facility in Holt, MI, that is owned and managed by the NexCare Health Systems Corporation. HSC&RC aims to provide personalized care in a hospitable environment that is welcoming to residents and rehab patients while promoting QoL and providing high quality care. Additionally, HSC&RC has been recognized for years as a 5-star facility by Medicare after careful review of their staffing, health inspections, and quality measures (Centers for Medicare & Medicaid Services [CMS], 2022). A facility rating of 5-stars overall is evaluated at above average quality and considered the best in 11 the industry; facilities with 1-star have quality below average and considered providing poor quality care (CMS, 2022). Residents/Care Setting Of NexCare’s 18 senior care and rehab centers across the state, HSC&RC is their only facility in Holt, MI. With a population of 25,888, Holt is located within Delhi Charter Township in the state of MI (USCB, 2020). HSC&RC participates in Medicare and Medicaid; they currently have 101 dually certified beds to account for both the rehabilitation and LTC population. On average, in 2019 there were 92 residents living at the facility, 79 residents in 2020, and 80 residents in 2021. During this QI project in 2022, census was 75. Staffing A variety of professionals with diverse skills are employed at this facility to provide optimal care. Leaders of HSC&RC include the facility administrator, medical director, director of nursing, assistant director of nursing, and director of education. The facility externally contracts with professional agencies representing therapists (OT, PT, ST) to provide qualified CMS covered residents with personalized rehabilitation activities/exercise. Spiritual support services are provided through personal contacts with clergy or per resident or family request. Before COVID-19, HSC&RC staffed 16 DCWs for day shift which was from 0630 until 1500. For second shift they staffed 15 DCWs from 1400 until 2300. Night shift was staffed with 9 DCWs from 2230 until 0700. From 2020 through 2022, HSC&RC experienced a decrease in staffing to 9 CNAs for day and second shift, and only 5 CNAs for night shift. During COVID-19 there has been fluctuations of 4 to 5 nurses for day shift and second shift but staffing has stayed consistent with 3 nurses for night shift from 2020 to the present. A comprehensive breakdown of the DCW staff shift patterns can be found in Table 2. 12 Table 2 DCW Staff Shift Patterns SHIFT CNA LPN RN Day 0630 – 1500 11 5 6 Pre-pandemic 2nd 1400 – 2300 10 5 2 Night 2230 - 0700 6 3 1 Day 0630 - 1500 9 4-5 5 Pandemic 2nd 1400 - 2300 9 4-5 2 Night 2230 – 0700 5 3 1 Policy & Processes HSC&RC does not currently utilize any specific fall risk assessment tool. However, they do have a fall reduction program policy that is accessible to anyone in the form of an informational book at each of the four (4) nurses’ stations. The most recent fall reduction policy was originally published in 2008 and revised in 2016. This current policy details the procedures that nursing staff should follow to reduce resident falls. The current Fall Reduction Program (FRP) policy includes an outline for the nursing staff that includes: • Identifying a resident’s fall risk, • Implementing individualized interventions into the care plan, • Determining the need for ongoing assessments/interventions based on Minimum Date Set (MDS) reviews, fall risk history, and interdisciplinary team (IDT) member recommendation, and 13 • Evaluating trends/patterns to establish new facility strategies towards improvement in the FRP. The LTC MDS is a standardized, primary screening and assessment tool of health status done initially on admission to LTC. The MDS provides a baseline comprehensive assessment for all residents in CMS certified facilities. Data is collected quarterly or with any change of condition (Healthy People Data, 2022). The policy also includes steps for the charge nurse to take in the event of a resident fall. The steps include initial incident report/assessment, updating the plan of care with interventions, documenting a physical and neurological exam, and completion of a root cause analysis with the interdisciplinary team (IDT). Notifying the physician and pharmacist through the Request for Medication Regime Review (MRR) form must also be completed. The full FRP policy description can be found in Appendix B. The HSC&RC administrative team provides fall education for all DCWs twice a year via in-service and online module training. Although there is not a formal fall risk assessment tool, the facility does utilize fall prevention items such as fall mats, hipsters, touch pad call lights, silent call alarms, non-slip footwear, low beds, and perimeter mattresses as EB interventions for residents. There is also a section in the EHR to document fall occurrences as electronic occurrence reports. Additionally, as detailed in the NexCare FRP, the unit nurse must document a corresponding fall assessment review, intervention, and root cause analysis within the EHR 24- 48 hours post fall. Patterns Both nurses and CNAs provide direct care to the residents of HSC&RC. However, there are less nurses (LPNs and RNs) staffed despite their increased responsibilities and larger resident 14 ratios. The typical nurse resident ratio based on staffing is 1:25; CNA resident ratio is 1:10. With fluctuations in acuity and staffing due to COVID-19, these numbers can lead to longer call-light response times and preventable resident falls and injuries. During the pandemic, the staff to resident ratio was much more disproportionate due to inadequate staffing as well as utilization of new and unfamiliar agency staff. Staff retention has been an arduous task since the genesis of the pandemic, which has made routine management and resident care for available staff more challenging. Strengths, Weaknesses, Opportunities, Threats To create a QI project that focuses on education and the implementation of new EB interventions for the HSC&RC facility, the team needed to understand and outline HSC&RC’s strengths and weaknesses, as well as potential opportunities and threats that could improve or impede interventions. Strengths, weaknesses, opportunities, and threats (SWOT) are further analyzed in Appendix C. SWOT analyses are tools that can be utilized in various domains, including health care. SWOT analyses in health care help provide insight of potential improvements that can be made to provide higher quality of care and better outcomes for both the facility and the individual (Stonehouse, 2018). Strengths of the facility include a policy on fall risk assessment for all residents, OT/PT/ST on contract every day, and regular activities for residents held by the Activities Department. Although there are regular resident activities, they lack incorporating more exercise-based activities to help with strength and balance. During the pandemic, residents were limited with their activities by being quarantined to their rooms to prevent the spread of the virus. During this time, OT/PT/ST ceased their services because the therapists were contracted employees from an agency rather than hired employees of HSC&RC. The therapists were 15 therefore considered non-essential and were not allowed to enter the facility. Besides the residential and therapy restrictions, other weaknesses became more prevalent due to the pandemic, such as longer call light response times due to short staffing and the increased time needed to don personal protective equipment (PPE). In addition, the fall policy in place for the facility applies to the NexCare System as a whole and is not customized to the residents’ needs at this facility. Potential challenges to the implementation of effective interventions within the facility included short staffing, reluctance of residents to adhere to safe practices, and the use of agency staff who were unfamiliar with the residents and their needs. However, there are many opportunities within the facility for successful implementation of interventions to reduce the number of falls, including motivated and compassionate staff and the facility being highly rated for their care and quality measures. Fishbone The fishbone analysis in Appendix D displays the contributing factors related to falls in LTC facilities. The analysis examines the domains of people, methods for pre- and post-fall interventions, and environment which addresses how the barriers to falls can be overcome. This illustration can help guide interventions to be implemented in practice by DCWs to help with fall prevention. Literature Review The literature review utilized for the QI project was centered around the clinical question, In OAs residing in LTC, would education of DCWs on innovative, proactive EB interventions for fall prevention, compared to the current facility standards, decrease the number of falls thus improving QoL and functional status? The literature review was obtained by using the 16 Cumulative Index of Nursing and Allied Health Literature (CINAHL) and PubMed databases. Search terms and applicable Boolean operators included “elderly” or “older adult” and “fall prevention” and “long-term care.” Additional search terms consisted of “falls” and “safety” and “long-term care.” Also included were the terms “older adults” or “elderly” or “seniors” or “geriatrics” and “falls prevention” or “preventing falls” or “prevent.” Search results were limited to the years 2017-2022, free full text, and English and Spanish language. After removing duplicates and studies inapplicable to answering the clinical question, 27 articles remained. The final selected articles are listed in the literature review in Appendix E. These articles were further evaluated for their applicable EB interventions to help explore the answer to the problem statement. Summary of Evidence Despite finding thousands of articles related to fall prevention, falls remain an ongoing issue in healthcare. As of 2018, the state of MI alone accounts for 28.8% of falls and 54 per 100,000 fall-related deaths in OAs (CDC, 2020). Considering that some of the most vulnerable and frail OAs reside in LTC, it is essential for these facilities to have interventions in place for fall prevention. Currently, HSC&RC’s interventions for falls and fall related injuries include fall mats, touch pad call lights, silent call alarms, low beds, and perimeter mattresses. There is not a current screening tool being used to assess fall risk among the residents; staff gauge fall risk based on the resident’s personal history of falls. Luckily, there are many validated tools and EB interventions for fall prevention that are summarized in the findings below. Identifying Fall Risk Factors Fall prevalence is highest in the first days after admission, therefore, team practices related to assessing the risk of falls should be reinforced by the facility and be assessed using a 17 validated tool or via recognition of residents at risk for falls (Baixinho & Dixe, 2020; Ferguson & Mason, 2020). Early identification of fall risk factors could possibly prevent falls. With a thorough fall-risk assessment, DCWs can identify residents in need of special call lights, assistive devices, motion-activated lights, needing a room near the nurses’ station, or those that need assistance with toileting (Baixinho & Dixe, 2020). During admission, education should also be provided to the residents so they are aware of their new surroundings, which could minimize potential environmental causes of falls (Baixinho & Dixe, 2020). Another essential component of identifying fall risk factors is finding out about the resident’s fall history as well as their fear of falling (FOF). One study found that FOF was reported in 48.8% of those who experienced a fall within the previous year and 46.8% of those who had a fall in the previous month (Chen et al., 2021). DCWs should be aware that the FOF can last for at least one-year post-fall, and it can increase the risk of future falls (Chen et al., 2021). FOF can be assessed via the Falls Efficacy Scale (FES) which has proven to be a valid and sensitive tool to identify FOF in OAs (Meimandi et al., 2021). If a resident expresses concerns for FOF, DCWs should inquire about potential visual impairment, as visual impairments may prompt further assessment. A study by Kim et al. (2021b) revealed that mild visual impairments may be due to the resident’s perception of inadequate lighting. If this is the FOF source, lighting should be adjusted according to the residents’ preferences. Without adequate fall-risk identification, OAs can fall and consequently may need trauma-related hospitalization for their injuries (Holt & Testerman, 2022). When OAs are hospitalized their QoL declines as well as their functionality, therefore prevention is crucial. Physical Activity/Exercise: Single and Multifactorial Interventions 18 After further reviewing the literature, organized multifactorial interventions with intentional rounding and an exercise component tailored to individual resident needs have been supported and linked to reducing falls and fall related injuries among OAs. Azkia et al. (2021) found in their quasi-experimental study that balance strategy exercises (BSE) (p=0.001) and lower limb-range of motion (ROM) exercises (p=0.001) reduced the risk of falls among LTC residents. More notably, they found the limb-ROM group demonstrated a much higher reduction in Timed Up and Go (TUG) scores than the BSE group after the intervention (p=0.008); lower limb-ROM exercises were shown to be better in reducing the risk of OA falls in LTC (Azkia et al., 2021). The TUG test is a reliable and valid performance-based measure of functional mobility. The OA is asked to get up from an armchair, walk to a marker approximately 10 feet away, turn around, walk back, and sit down again (Kear, 2017). The simplicity of lower limb- ROM exercises can be applied and taught to any DCW and be utilized as part of a fall prevention program in LTC. A systematic review of randomized control trials (RCTs) found that multifactorial interventions including exercise, environmental assessment and modifications, and fall risk assessment helped reduce the rate of falls (risk ratio [RR] 0.87; 95% confidence interval [CI]) (Dautzenberg et al., 2021). A study by Gulka et al. (2020) found that single interventions reduced falls among OAs with exercise being the most effective single intervention (RR 0.79, 95% CI = 0.60-0.81); however, the study suggested that exercise interventions were less effective for individuals with cognitive impairment. Dautzenberg et al. (2021) also found that single exercise interventions were associated with fall reduction when compared to usual care (RR 0.79; 95% CI 0.73–0.86); likewise, Ožić et al. (2020) supported custom exercise interventions due to findings of halted frailty progression. When exercise interventions involve a 19 balance component, fall reduction appears to be most effective (Azkia et al., 2021; Schroberer & Breimaier, 2020; Senderovich et al., 2021). Overall, the commonality among the studies emphasized the importance of OA ambulation to encourage bone strength and balance maintenance. Fall Prevention Programs Patient-centered fall prevention programs, such as A Matter of Balance Program (MOB), and the Fall Tailoring Interventions for Patient Safety (TIPS) Program, were also found to be effective in reducing falls among OAs (Hood & Sharrah, 2022; Tzeng et al., 2021; Valatka, Krizo, & Mallat, 2021). The MOB Program involves the functional reach test and gait speed (measured by the TUG test); it is also EB and promotes physical activity while reducing FOF (Hood & Sharrah, 2022). This program is gaining popularity across the country because of its train-the-trainer philosophy. After paying for certification, any DCW can be a certified trainer for the MOB classes. Similarly, TIPs is a staff-based training program that involves residential engagement including a 3-step fall prevention process, Morse Fall Scale (MFS) risk assessment, as well as interactive case studies (Tzeng et al., 2021). The MFS identifies an individual’s risk factors for falling (Kim et al., 2021a). There is also the Vivifrail multicomponent individualized exercise program targeted towards frail OAs based on their functional abilities. This intervention was highly effective in 4 weeks at increasing functional and strength performance and reversed frailty status in 36% of participants, with 59% achieving high self-autonomy (Courel-Ibáñez et al., 2022). This intervention would likely involve the participation of PT and other members of the IDT to assess residential progress. Extrinsic Modifications 20 In addition to programs focused on increasing strength and balance, a few studies also noted the importance of proper footwear to aid in fall prevention of OAs. Footwear is considered an environmental factor in fall prevention and has been shown to help with maintaining balance and preventing falls when compared to those without proper footwear (Pavana et al., 2020; Prevettoni et al., 2021). Increasing dietary forms of calcium and vitamin D were also identified as extrinsic modifications that can be used to reduce the risk of not only falls, but also fractures. One RCT used dietary supplements of foods rich in calcium as an intervention for OAs in LTC; the outcomes were associated with risk reductions of 33% for all fractures (121 v 203; hazard ratio 0.67, 95% CI 0.48 to 0.93; p=0.02) (Iuliano et al., 2021). Similarly, an RCT by Ling et al. (2021), that used vitamin D alone and vitamin D with calcium supplementation, revealed that combined daily supplementation of vitamin D and calcium showed a 12% reduction in fall risks (RR 0.88, 95% CI 0.80 to 0.97). Increasing dietary regimens and supplementations would require a collaborative approach to properly identify residents with deficiencies, but the outcomes have shown to be somewhat beneficial for OAs in LTC. Additional extrinsic modifications were detailed in a cross-sectional study by Lytras et al. (2022) which revealed 40% of OAs expressed that poor lighting conditions or vision problems contributed to their fall. This study also revealed 60% of falls occurred at night, in the bedroom, or bathroom (Lytras et al., 2022). DCWs should therefore ensure properly lighted and decluttered environments as well as intentional rounding and safety checks to further prevent extrinsic related falls. Education Besides exercise-related strategies, there are many other effective interventions that were identified in reducing fall related injuries including intentional hourly rounding, staff education, 21 and post fall huddles (p=0.005) (Acosta et al., 2022; Zubkoff, 2019). Education became a recurring theme in many of the articles. Educational programs for DCWs are not only cost- effective, but also directly associated with increased knowledge regarding falls and increased recognition of fall-risk residents which can in turn improve fall prevention strategies (Baixinho & Dixe, 2020). Educational interventions are more successful when used with other multifactorial interventions (Gulka et al., 2020; Prevettoni et al., 2021; Tricco et al., 2019). Team-Based Approach to Care The literature findings emphasized the importance of team-based approaches to care. One study linked higher residential fall rates to low levels of teamwork, poor handoff communication, and insufficient organizational education sessions (Abusalem et al., 2021). With these concerns in mind, a quantitative study involving a fall simulation was developed to create a team-based approach to falls. This simulation engaged the entire IDT and emphasized the importance of group post-fall huddles and fall risk assessments (Acosta et al., 2022). Post-fall huddles are brief meetings that occur after falls to determine the root cause of the incident and make changes as needed to prevent future falls. The results of the post-survey findings revealed an overwhelming amount of support for simulation-based learning with greater than 80% of participants expressing the ability to apply skills they learned in future interactions with OAs (Acosta et al., 2022). Another team-based approach was found in a systematic review of 126 RCTs which revealed case management and patient reminders, or combined case management, patient reminders and staff education were both statistically superior compared to usual care in preventing falls in OAs (Tricco et al., 2019). As with any team-based approach to care, clear roles and communication are required among team members to yield high quality outcomes. 22 Medication reviews were also heavily emphasized, and if done properly. this process can prevent avoidable hospitalizations and fall related fractures (Wang et al., 2021; Yu Ming et al., 2021). Medication reviews alone had a positive impact on decreasing the risk of fall-related fractures (RD = -0.02, 95% CI: [-0.04, -0.01], I2 = 0%, p = 0.01) (Yu Ming et al., 2021). However, if medication reviews are utilized in conjunction with multifactorial intervention approaches including caregiver education, exercise, environmental safety assessments, and fall risk assessments, they will be more effective at preventing falls in OAs (Gulka et al., 2020; Prevettoni et al., 2021). In fact, this approach, with the addition of organized patient care, providing adequate feeding and hydration, and the use of appropriate footwear and gait support instruments, showed an impressive reduction of falls in frail OAs of 41.7%, with a fall reduction rate of 78% (Prevettoni et al., 2021). Although there are various EB fall prevention strategies and interventions in circulation, there are no concrete recommendations for standardized interventions for use in LTC. The lack of guidance surrounding this topic contributes to the global fall issues, as well as the evident fall issues seen in HSC&RC. Goals, Objectives, and Expected Outcomes The overall goal of this QI project was to improve fall risk education and fall-related outcomes for the OA residents of HSC&RC. With the implementation of EB interdisciplinary fall risk education and post-fall assessment tools, the objective was to increase DCW’s awareness and knowledge of falls in order to help decrease the number of resident falls. There was an expected outcome of ongoing utilization of the provided tools to improve fall rates as well as the QoL and functional status of HSC&RC’s OAs. These goals were achieved as evidenced by the improvement of post-test scores and the DCW’s willingness to implement the provided fall reduction practices. The long-term expected outcome is for HSC&RC’s DCWs to 23 continue to provide fall risk education and implement a standardized EB fall risk prevention strategy or tool to improve their resident and fall related MDS data for HSC&RC. Methods The methodology of the QI project was constructed in the form of a pre- and post-test questionnaire for HSC&RC DCWs. DCWs were instructed to complete a pre-test questionnaire prior to the fall prevention educational session to assess their baseline knowledge of falls and fall prevention. After the educational session for DCWs on general fall information and pathophysiology of the aging process, a post-test questionnaire was completed to assess whether knowledge of falls increased. The test was constructed via Qualtrics XM, a web-based survey tool, and consisted of ten true/false and multiple-choice questions which can be found in Appendix F. In addition, DCWs would complete hourly rounding in the charting system on the residents using the 4Ps: pain, position, possessions, and personal needs. Resident charts were audited every two weeks for two months to see if the hourly rounding was being completed. These two months were compared with the prior two months to see if this intervention helped prevent falls among residents. Another preventative intervention the team implemented was coordinating with the Activities Department to implement more strength and balance related exercises. If a fall were to occur, the team helped the facility to complete a root cause analysis and post-fall assessment. The 5 Why’s root cause analysis was used by DCWs after a fall. The reason for this implementation was to realize the problem and why the problem occurred for a specific resident. Implementing necessary changes can help prevent future falls for the resident. The 5 Why’s are explained in Appendix G. 24 Ethical Considerations/Protection of Human Subjects Ethical considerations were obtained and reviewed prior to sending the QI project to Michigan State University’s Internal Review Board (IRB) for approval. The project was deemed not research. Mandatory educational sessions for DCWs were scheduled between two days and were held in a group setting to facilitate interdisciplinary engagement. Setting Facilitators, Stakeholders, and Barriers Ongoing communication was facilitated between HSC&RC’s nursing administrator and nursing educator to obtain site data and to coordinate implementation of the QI project. The official facility agreement letter is presented in Appendix H. The QI educational intervention was implemented over two consecutive days as to accommodate all DCWs’ shifts. The dates were mutually agreed upon with HSC&RC’s nursing administration. The stakeholders for the project included all DCWs, residents, HSC&RC leaders and professionals. A primary barrier of the project was the limited intervention time and outcome measurement period. Another barrier for HSC&RC regarding fall prevention was related to the shortage of DCWs at the facility. The Intervention and Data Collection Procedure The multimodal intervention included a pre-/post-test knowledge assessment, educational presentation via PowerPoint (PPT) with video, fall prevention handout (see Appendix I), post- fall assessment template, and hourly rounding template. The educational intervention of the QI project utilized a pre-/post-test format, measuring DCWs knowledge and viewpoints pertaining to fall prevention in HSC&RC residents. The survey was written in true/false and multiple- choice answer format. The QI project included implementation of an educational based PPT presentation which included an informational video for the DCWs to view and engage in discussion. The 25 presentation included education on OA pathophysiology and fall related injuries, the definition and importance of falls, a review of a post-fall assessment, as well as several multifactorial interventions. Fall risk assessments, post-fall huddles, routine physical exercise, and purposeful hourly rounding using the 4 Ps were some of the numerous interventions that were discussed. A purposeful hourly rounding template and a post-fall assessment adapted from National Health Services (2015) was also provided to the HSC&RC nursing administration to review for implementation. In addition to the provided tools, the facility also planned to implement the idea of post-fall huddles. All the interventions were implemented to increase the knowledge of fall prevention among staff and improve viewpoints and confidence of preventing falls among the residents. Timeline The data collection process and analysis began in May 2022. Interventions were determined by collaborating with HSC&RC’s nursing administration after reviewing current practices and analyzing potential areas of improvement. The final proposal was submitted in August 2022 to the Michigan State University (MSU) College of Nursing (CON) board for review. After approval from the CON, the proposal was then submitted to the MSU Institutional Review Board for official determination and approval. The project was implemented over two days at HSC&RC. All DCWs were mandated to attend one session over the course of two days in October. The educational sessions took one hour to review the material, and answer DCWs questions. After implementation, data was collected from October 2022 – February 2023 to see if the interventions helped reduce falls among OAs at HSC&RC. The full timeline for the QI project can be found in Appendix J. Analysis 26 HSC&RC provided MDS fall data from the years 2019 to 2023 for further analysis, see Appendix K. The data collected included the number of falls, location of falls, time of falls, predisposing risk factors, and the number of residents sent to the hospital. Based on the reported fall data from Appendix K, less falls occurred during the height of the COVID-19 pandemic. In fact, falls were significantly lower during the pandemic when compared to pre- and post- pandemic, see Appendix L. A major factor that may have contributed to this finding is that during the pandemic residents were quarantined in their rooms, which helped eliminate additional areas of unsupervised ambulation. From 2019-2022, there were 527 falls occurrences and 7 of those falls required hospitalization. The most common location for a fall to occur was in the resident’s room. Many predisposing factors were identified from 2020 through 2022. The most common predisposing physiological factors related to the incidence of falls included gait imbalance, confusion, and incontinence. As noted in Appendix K, some falls were multifactorial in origin. The data also revealed the most common predisposing situational factors associated with falls was linked to the lack of call light usage, falls during transfers, and ambulating without assistance. In addition, reported fall data was collected and analyzed monthly from June 2022 – February 2023, see Appendix M. The data was analyzed to determine the effectiveness and longevity of the QI intervention that was completed in October of 2022. Fall rates drastically decreased the month after the intervention was completed in at HSC&RC but began to steadily rise from December 2022 – February 2023. Data was also compared pre-/post-intervention, including DCW fall knowledge, as well as the number of resident falls at HSC&RC. Fall knowledge of DCWs was assessed during an hour-long educational session in October 2022 using a multiple-choice questionnaire (see 27 Appendix F). Attending an educational session was mandatory for the DCWs. There were 49 participants, but one participant was excluded from the data for entering the presentation 15 minutes late (n=48). The pre-intervention scores averaged 8.645 out of 10 or 86.4% and the post- intervention scores averaged 9.48 out of 10 or 94.8%. Therefore, the knowledge of DCWs increased by approximately 8% following the educational intervention. The p-value was 0.0025, meaning there was a significant relationship between fall knowledge scores and educational sessions for DCWs. The standard deviation for the pre-intervention was 1.49 and the post- intervention standard deviation was 1.08. Conceptual Framework The conceptual framework for the QI project was based on the Plan, Do, Study, and Act (PDSA) method (see Appendix N), which is broken down into four (4) stages (Agency for Healthcare Research and Quality [AHRQ], 2020). This model helps carry out change through continuous process improvement. The PDSA cycle is ongoing, and the interventions should be re-evaluated frequently to see if changes need to be made to create more effective outcomes for the residents and facility. This model highlights the importance of intrinsic and extrinsic factors to provide feedback on ways in which to accomplish the goal. The intrinsic and extrinsic highlights for HSC&RC can be found in the SWOT Analysis in Appendix C. Plan Stage 1 of the PDSA framework is plan (see Appendix N). Three main questions were asked during the planning stage of this project: 1. What is the QI team trying to accomplish? 2. How will the QI team know that a change is an improvement for the facility? 28 3. What changes could the QI team make that would result in an improvement in fall prevention (AHRQ, 2020)? One way that helped with brainstorming for the QI project was developing a SWOT analysis (Box 2) that identified what was being done well at the facility and what could be done better. Do Stage 2 is Do. This is the implementation of the action plan which involves taking notes during observations. For example, it was important for the IDT to make note of how the residents reacted to the change, as well as the reactions by the DCWs. Once unexpected outcomes are recognized and data is gathered, stage 3, Study can begin. Study Study is the third stage. The main purpose of this stage is to determine if the intervention resulted in improvement for the facility (AHRQ, 2020). To determine if the intervention was successful, it was important to identify unintended effects and associated trends. During this stage, identifying what the team learned and acknowledging whether the goal was met or not are also important components. Act The fourth and final stage is when the project is determined if it was successful or not. If a project happens to be a success, this plan should be standardized and used on a regular basis at the facility to help prevent falls (AHRQ, 2020). If not successful at this stage, the intervention should be re-examined and then begin again at stage 1: Plan again for process improvement (Figure 9). Sustainability Plan/Next Steps 29 Falls in the OA population has been an ongoing issue for LTC facilities nationwide, including HSC&RC. Despite HSC&RC’s current FRP and biannual fall education training for DCWs, they continue to have issues with their fall rates. While evaluating the facility’s current processes, it was discovered they lacked a standardized fall risk assessment tool, fall policy, and post-fall protocol. With that knowledge, the QI project’s educational materials and presentation were given to HSC&RC’s nursing administration for their biannual DCW fall prevention education sessions. The post-fall protocol and hourly rounding template was also distributed to administration to use as their official rounding and post-fall protocol. The handouts and PPT presentation will be utilized by the nursing educator for ongoing education of DCWs, and MDS fall data will continue to be monitored by the regional clinical director. Nursing Implications Fall prevention in LTC facilities needs to be a priority to help reduce morbidity and mortality rates among OAs. As discussed, falls also lead to astronomical health care costs. Although there has been numerous research on fall prevention, falls remain a leading cause of death among OAs. It is apparent that not one single intervention will prevent falls, instead a multifactorial intervention is more effective in reducing falls. Also, the interventions should be tailored to each OA. Post-fall huddles are able to identify areas for improvement and ways to prevent a future fall. The post-knowledge assessment on the evidence-based fall prevention PPT presentation showed a significant improvement in knowledge scores compared to the pre-knowledge assessment. Based on the data gathered, it would be more beneficial to have frequent education sessions for DCWs to help with knowledge retention. Fall rates decreased during the month of the QI intervention, but steadily increased in the following months. Based on these findings, 30 long-term recommendations would include having more routine fall prevention education sessions for staff. In doing so, it would ensure that new DCWs have proper knowledge about the fall interventions and fall protocols in place at the facility, while providing a beneficial refresher for tenured DCWs. Cost-Benefit Analysis/Budget Cost was a minimal concern when coordinating and conducting the QI project. Financial burdens were distributed amongst the two project team members, HSC&RC’s nursing administration, and one Michigan State University faculty project advisor. Organizing the educational intervention was not accounted for in the final budget. The direct costs of the printed informational handouts and the knowledge surveys were included. The overall QI project was centered on DCW participation and engagement, thus, there were no major financial burdens for the facility. Conclusion Fall prevention in LTC is a vital part of ensuring the maximum QoL for OAs residing in LTC. However, due to various extrinsic and intrinsic factors, falls and fall-related injuries occur. Currently, HSC&RC does not have a standardized fall prevention tool or post-fall tool in practice. Consequently, falls have been an ongoing issue within this facility. The suspicion that the COVID-19 pandemic contributed to these rates was refuted, with a surprising influx in fall rates noted both pre and post pandemic. Although the pandemic was not a direct contributor to the fall data, inadequate staffing ratios, use of contract workers without adequate training, and lack of multifactorial fall prevention interventions were notable risk factors for the facility. The goal of the QI project was to utilize the implementation of in-person education sessions to actively engage DCW participation, as well as distribute fall prevention handouts, hourly 31 rounding templates, and post-fall protocol resources to help improve their fall data long-term. As seen in the months following the educational sessions and use of new fall prevention materials, DCW’s fall prevention knowledge improved as well as the MDS data. With ongoing fall education of DCWs, and implementation of root-cause analyses via fall prevention and post-fall tools, fall rates could vastly improve. The hope is that with continued efforts, fall MDS measures will eventually be improved, as well as residents’ QoL. 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Physical & Occupational Therapy in Geriatrics, 37(4), 234–246. https://doi-org.proxy1.cl.msu.edu/10.1080/02703181.2019.1636923 40 Appendix A Box 1 Risk factors for falls Intrinsic Fall Risk Factors Extrinsic Fall Risk Factors • Agitation • Environment (clutter, inadequate lighting, • Changes in gait & balance (effects of normal glare, uneven or wet floor, raised thresholds, aging: reduced arm swing, decreased step missing tiles or linoleum, scatter rugs, worn length, slowed reaction time, slower carpeting, unstable or lightweight furniture, movements) furniture without arms, insecure toilet seat or • Confusion handrail, unstable wheels) • Cognitive impairment • Contractures • Equipment (inappropriate type & height of • Decreased strength cane or walker; missing wheelchair [WC] • Disorientation parts or incorrect WC fit, inadequate WC • Dizziness seating, broken parts, walker without wheels) • Drug interactions • Hard-to-reach personal items (lack of an • Fainting assistive-reacher) • Frailty • Hearing (effects of normal aging: decreased • Lack of assistive equipment in the bathroom sensitivity) (low toilet seat, lack of handrail support) • Imbalance • Impaired judgment • Personal safety (unsafe shoes or slippers, • Incontinence (bowel or urine) untied shoelaces, clothing with zippers and • Loss of joint mobility buttons or hard-to-manage) • Lower extremity weakness • Orthostatic hypotension • Physical restraints (increase the likelihood of • Paralysis serious injury) • Sedation • Tremors • Polypharmacy • Urologic (effects of normal aging: feelings of urgent need to urinate, frequent urination) • Side effects of medications (antidepressants, • Visual impairment (effects of normal aging: sedatives/hypnotics, antipsychotics) decrease in acuity, contrast sensitivity, peripheral vision, night vision; increase Agency for Healthcare Research and Quality (HRQ), increased sensitivity to glare) 2017; Lytras et al., 2022 • Weakness & overall fatigue 41 Appendix B Figure 2 NexCare’s Falls Reduction Program 42 Appendix C Box 2 SWOT Analysis of Fall Prevention in LTC Facility Internal External Strengths Opportunities • Policy for pre-assessment of falls in place • Highly rated facility • Policy for post-falls currently in place • Motivated, compassionate staff • Interventions to prevent falls currently in place • Providing current staff with fall education • Activities Department engages residents on a could help improve understanding of falls regular basis & help with the implementation of • PT/OT/ST on staff proactive interventions to decrease the number of falls within the facility Weaknesses Threats • Policies regarding falls are generalized for • Short staffing NexCare System • Agency staff new to the facility & residents • Longer response times for call lights • Resistant resident behaviors to using • Lack of staff training/education related to falls ambulation devices or seeking assistance • No official post-fall assessment tool in place when needed for HSC&RC • No official fall prevention interventions in place specifically for HSC&RC staff • Limited residential exercise-related activities • No screening tool being used to assess for fall risk, based on patient’s history of falls 43 Appendix D Figure 3 Fishbone Diagram 44 Appendix E Table 3 Literature Review Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments Abusalem, S., Polivka, IV Cross-sectional survey used CMSs’ Nursing High falls rates were Strengths: This study B., Coty, M. B., data from 13 dimensions of Home data sets were due to lower level of highlighted the Crawford, T. N., Furman, culture of safety from five used for the 5 LTCFs teamwork, handoffs, background/practical C. D., & Alaradi, M. long term care facilities for four previous and education. experience of RNs (2021). The relationship (LTCFs) in Louisville, quarters in February Fall risks increased as versus LPNs is a between culture of safety Kentucky. 2015. the number of critical factor that and rate of adverse events Nursing staff, administration, residents per facility contributes to in long-term care management, and The AHRQ’s Nursing increased (rate ratio increased risk of facilities. Journal of rehabilitation staff support Home Survey on [RR] = 1.02; 95% falls in LTC. Patient Safety, 17(4), were surveyed, N=252. Patient/Resident confidence interval 299–304. Safety Culture [CI] = 1.01–1.02) and Data revealed the https://doi.org/10.1097/P Secondary data related to falls assessed the LTCFs’ as the number of LPN importance of TS.0000000000000587 from the selected facilities Cronbach’s α values hours per resident relationships during quarters 1-3 in 2014 as well as their safety increased (RR = 37.7, between person- were obtained by CMS in culture. 95% CI = 18.5– centered culture of Search terms: February 2015. 76.50). safety measurement, Falls AND safety AND quality long-term care Increased culture of improvement, and safety scores were workforce issues. associated with decreased fall risks, Limitations: The extended stay UTIs, study did not contain and short stay ulcers. information about families, visitors, or A higher number of residents. RNs and LPN staffed Generalizability was per resident/day, limited because data 45 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments decreased the rate of was only obtained in falls. Louisville, KY. Only data from five urban LTCFs were used. Acosta, D. J., Rinfret, A. VI From July-December 2019, Patient simulation Quantitative study Participants supported Strengths: R., Plant, J., & Hsu, A. T. 27 simulations were of a resident using mixed-methods simulation-based reinforced the (2022). Using patient conducted in 13 different falling (falling to evaluate learning. importance of simulation to promote nursing home units in simulation participants' > 80% of participants interdisciplinary best practices in fall Ontario, Canada. program) experiences using the stated they would team approach to prevention and post-fall N=94, but only 69 of 94 falling simulation utilize the learning. post fall huddles and assessment in nursing participants responded for the program in an fall risk assessments. homes. Journal of post-simulation survey. interprofessional High value was Nursing Care Quality, setting. Survey placed on post-fall A prior audit also 37(2), 117–122. captured data from huddles and fall risk helped identify staff https://doi- open-ended responses assessments. responses to falls in org.proxy1.cl.msu.edu/10. and applied Analysis the nursing home. 1097/NCQ.00000000000 of Likert. 69 survey responses 00599 were gathered, and Limitations: Internal audits were 98.5% had a good quantitative audits Simulation based learning also conducted (20.6%) or very good limit the details found differences in (77.9%) opinion of needed to enhance Search terms: practice regarding the simulation. fall interventions. older adults or elderly or staff's response to a seniors or geriatrics resident fall and how they identified AND falls prevention or contributing factors preventing falls or prevent related to the fall. The simulation-based education activity included a pre-brief, fall simulation, and a debrief. 46 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments Azkia, Z., Setiyani, R., & III N= 30 OAs Assessing Quasi-experimental Major improvements OAs in LTC could Kusumawardani, L. H. whether Balance study that used a pre- were noted in TUG benefit from exercise (2021). Balance strategy Sample included two LTC Strategy Exercise post design and no scores pre/post related interventions, exercise versus lower facilities in Central Java (BSE) or Lower control group. intervention, BSE such as BSE and limb-ROM exercise for Province, Indonesia from Limb-Range of (p=0.001) and Lower Lower Limb-ROM reducing the risk of falls January-March 2019. Motion (ROM) Cluster randomization Limb-ROM groups to decrease their among older people. exercises have strategies assigned (p=0.001). risk, but Lower Nurse Media Journal of better fall OAs into either BSE Limb-ROM was Nursing, 11(1), 114–123. reduction or Lower-Limb ROM OAs that participated preferred. https://doi- outcomes for groups. in Lower Limb-ROM org.proxy1.cl.msu.edu/10. OAs. had an even larger Limitations: the 14710/nmjn.v11i1.33229 Interventions were decrease in TUG interventions were in implemented three scores compared to groups, so the days per week over a the BSE group overseeing three-week period, in (p=0.008). researchers were 30 minute intervals. unable to see if every resident did Timed Up and Go the interventions (TUG) test measured properly. fall risk. Small sample size Data analysis was was used because of performed using various recruitment paired t-test, barriers during the Wilcoxon and Mann- COVID-19. Also, Whitney U-test. two treatment groups were used. Baixinho, C. L., & Dixe, III Sample was comprised of Evaluating the Data included Fall risks due to Highlighted the M. (2020). Practices of only female caregivers from Scale for pretests, altered gait and usefulness of the caregivers when six different nursing homes, Practices of reformulation, balance had higher validated scale in the evaluating the risk of falls with an average age of Identification of application, and significance when first days after in the admission of older 47.02±10.3, and a work Fall Risk Factors validation. admission. 47 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments adults to nursing homes. history of 12.1±8.35 years during admission compared to Dementia & caring for OAs in LTC process for OAs 21 indicators cognition. Limitations: the Neuropsychologia, 14(4), facilities. in LTC. analyzed using the 5- selected sample did 379–386. point Likert scale Response rate was not allow https://doi.org/10.1590/19 Methodological study & with 5 options per 65.52% which generalized results. 80-57642020dn14- literature review. question. represented good 040008 properties (α=0.913) How the instrument N=152. Reliability was tested to determine fall risks was administered, its to determine the during the admission type, and duration of Cronbach's alpha process of OAs. use could have led to coefficient. socially desirable Caregivers that had responses. more education and training had better outcomes as well. Chen, W. C., Li, Y. T., IV Sample included the United Regression Chi-Squared tests 48.8% of OAs that Results are Tung, T. H., Chen, C., & States’ National Health and analyses were analyzed bivariate had a fall in the past applicable to any Tsai, C. Y. (2021). The Aging Trends Study’s used to identify correlations. 12 months had a FOF OA with history of relationship between (NHATS) data on 5559 OAs causes of fear of and 46.8% had a falls within the past falling and fear of falling in 2017. falling via Model 1 was centered recent fall in the past year. among community- NHATS on demographics and 30 days. Caregivers should dwelling elderly. n=5559. responses. Model 2 note that FOF can Medicine, 100(26), encompassed medical In Model 1, FOF was continue 12 months e26492. conditions, linked to history of post-falling. https://doi.org/10.1097/M depression and falls within the last 30 D.0000000000026492 memory impairments, days (OR = 2.29, Limitations: No data as well as ability to 95% CI: 1.78–2.95) was provided for Search terms: elderly OR perform ADLs. or during the previous environmental older adult year (OR = 2.60, 95% factors that Statistical Package CI: 2.16–3.14). contribute to FOF. AND fall prevention for Social Sciences Additional factors: Data did not AND long-term care was used to determine advanced age, high explicitly link falling significance. ADL/IADL scores, and FOF. 48 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments female sex, and Data did not include chronic conditions. OAs in hospitals or nursing homes. Model 2 showed how the correlation of age, Survey had only one gender, chronic question to assess disease, and fall outcomes. history as contributing factors to NHATS data is FOF. susceptible to error and bias. Courel-Ibáñez, J., II Multicenter RCT conducted Vivifrail- functional capacity After 4 weeks, Vivifrail training had Buendía-Romero, Á., in Spain. Sample included 24 multicomponent and strength were Vivifrail significantly ongoing positive Pallarés, J. G., García- institutionalized OAs (87.1 ± exercise program assessed pre and post helped improve impacts on those Conesa, S., Martínez- 7.1 years, 58.3% women) for OAs. intervention. function and strength involved. The Cava, A., & Izquierdo, M. with history of sarcopenia. performance (effect studied duration and (2022). Impact of tailored Group 1: Long Initial screening: X- size = 0.32-1.44, P < frequency were multicomponent exercise Training-Short ray, to determine .044) without hand recommended to for preventing weakness Detraining group bone mineral density grip strength. safeguard OAs from and falls on nursing home consisting of 24 as well as Mini further functional residents' functional weeks of Nutritional Training for 24 weeks deterioration caused capacity. Journal of the Vivifrail training Assessment (MNA). yielded 10% -20% by sedentary American Medical then 6 weeks of additional lifestyle. Directors Association, detraining Disability was effectiveness (P < 23(1), 98–104.e3. assessed using .036). Limitations: Did not https://doi.org/10.1016/j.j Group 2: Short Barthel index evaluate 8–12-week amda.2021.05.037 Training-Long and IADLs were 36% of OAs had intervention and Detraining group assessed using reversal in frailty, detraining groups. consisting of 4 Lawton index. with 59% reporting Did not evaluate 4 weeks of training high self-autonomy. week Vivifrail then 14 weeks of FOF was assessed training with 14- detraining. with the Falls Detraining led to a week detraining in Efficacy Scale 10% -25% decline in OAs with or without International. strength and augmenting protein.. 49 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments Cognitive impairment functional capacity was assessed with despite training for 24 Folstein's Mini weeks (effects size = Mental State 0.24-0.92, P < .039). Examination. Screening of sarcopenia was done with the SARC-F scale. Functional capacity was assessed using 5- sit-to-stand test, balance test, and TUG test. Isometric handgrip strength was measured with a digital dynamometer. Sit-to-stand speed was measured using a transducer. Dautzenberg, L., I Systematic review & network Comparison of Review of RCTs and 192 studies concluded Limitations: Beglinger, S., Tsokani, S., meta-analysis of 220 RCTs. single, multiple, quasi-RCTs from that single Majority of studies Zevgiti, S., Raijmann, R. n = 104,638. and multifactorial various databases interventions had risk for bias due C. M. A., Rodondi, N., fall prevention until February 27, compared to standard to blinding or Scholten, R. J. P. M., 128 of the studies (58.2%), interventions in 2019, to evaluate fall care practices led to incomplete Rutjes, A. W. S., Di had an average age of 75- OAs. prevention decreased falls: outcomes. Nisio, M., Emmelot, V. 84 years. interventions for exercise (risk ratio M., Tricco, A. C., Straus, OAs. [RR] 0.83; 95% Authors could not S. E., Thomas, S., 11 studies (5.0%) had an confidence interval distinguish between Bretagne, L., Knol, W., average age of ≥85 years. A post hoc analysis [CI] 0.77–0.89) and different Mavridis, D., & Koek, H. was completed in QI techniques intervention dosages, L. (2021). Interventions 2020 to include two including education treatment duration, 50 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments for preventing falls and RCTs published post of OAs (RR 0.90; or lengths of follow- fall related fractures in data collection. 95% CI 0.83–0.98). up durations. community-dwelling older adults: A systematic Pairwise meta- Exercise alone Software had limited review and network meta- analysis and network decreased falls (RR ability to draw analysis. Journal of the meta-analysis were 0.79; 95% CI 0.73– indirect American Geriatrics completed. 0.86). comparisons. Society, 69(10), 2973– 2984. https://doi- Multifactorial org.proxy1.cl.msu.edu/10. interventions 1111/jgs.17375 including exercise, use of assistive technology, environmental modifications, QIs, and falls risk assessments were all linked to decreased fall rates (RR 0.87; 95% CI 0.80–0.95). Ferguson, C., & Mason, VI 2,720 patients that had multi- A survey was Qualitative and Data was collected Fall risk assessments L. (2020). Inpatient falls day stays from acute and used to evaluate quantitative data was from 2,720 patients. were not conducted prevention: state-wide subacute floors from hospitals verbal used. for every patient. survey to identify in Washington. instructions Verbal recall of fall variability in Western provided to Prior admissions, prevention was A criteria review is Australian hospitals. patients, as well diagnoses, and socio- recalled by 60% of needed to determine Australian Journal of A 17 day fall survey as determining economic status was responsive patients. if changes need to be Advanced Nursing, 38(1), consisting of 20 hospitals that completion of gathered by the made to improve 53–59. https://doi- had ~40 acute/ subacute beds falls risk Australian Bureau of 82% of patients had a standard practice. org.proxy1.cl.msu.edu/10. and if they provided care for screening, and Statistics and hospital completed falls risk 37464/2020.381.296 public patients. appropriate accessibility. screening. cognitive testing. 51 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments Multiple regression 37% had proper analysis was cognitive testing. completed as well as odds ratios to OAs and short stay compare outcomes patients did not have against the reference proper fall risk hospital. screening. Gulka, H. J., Patel, V., I n = 30,057. Single, multiple, Systematic review & Fall prevention Limitations: Arora, T., McArthur, C., or multifactorial meta-analysis to interventions Variability between & Iaboni, A. (2020). Participants resided in fall prevention evaluate fall decreased fall studies detailing Efficacy and nursing homes (NH) that interventions prevention numbers (RR) = 0.73, OAs’ cognitive generalizability of falls provided 24-hour monitoring, were used. interventions was 95% CI= 0.60-0.88], status led to prevention interventions and care for OAs over the age completed using fallers (RR = 0.80, estimates without in nursing homes: A of 65. several databases 95% CI = 0.72-0.89), prevalence for systematic review and from September 2013 and repeat fallers (RR dementia. meta-analysis. Journal of to April 11, 2019. = 0.70, 95% CI = the American Medical 0.60-0.81). Studies were Directors Association, 36 RCTs or cluster Single interventions completed in 12 21(8), 1024–1035.e4. RCTs that were 6- drastically decreased different countries so https://doi.org/10.1016/j.j months in duration, falls as well (RR = there is variability in amda.2019.11.012 had an intervention 0.78, 95% CI = 0.69- care and resources. and follow-up, and 0.89) and repeat monitored of falls for fallers (RR = 0.60, the duration of 95% CI = 0.52-0.70), intervention or post- while multifactorial intervention with z interventions scores, p-values, and decreased falls (RR = CIs. 0.69, 95% CI = 0.39- 0.97) and multifactorial interventions reduced number of falls (RR = 52 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments 0.65, 95% CI = 0.45- 0.94). Exercise decreased falls by 36% and repeat falls by 41%. Education of staff was also shown to be effective. Holt, M. F., & VI IRB-approved rural trauma None Trauma registry Advanced age and Limitations: small Testerman, G. M. (2022). registry reviewed OAs review of 327 fall use of anticoagulants sample size. Midlevel providers admitted with fall-related injuries at a rural led to longer visits focusing on geriatrics injuries from 2018 through trauma facility 1 year and increased improve care and 2020. pre and post trauma mortality (both P < outcomes of fall-related N=327 patients. to assess the role of .05). Mortality rates injuries among the demographics, (P = .01) and OAs’ elderly. American chronic disease, and functional level of Surgeon, 88(3), 360–363. medication impact on independence on https://doi- outcomes. T-test and discharge improved org.proxy1.cl.msu.edu/10. regression analysis when hospital length 1177/0003134821105082 were used. of stay decreased 1 (both with P < .05). Hood, J., & Sharrah, M. III N=120 OAs. A Matter of Functional Reach test Average functional Study supported use L. (2022). Functional Average age of 78; mostly Balance program and TUG test were reach improved by of MOB to improve reach and gait speed Caucasian (116/120; 96.7%). was implemented utilized for 0.6 inches (SD = physical outcomes. improvement in a matter to evaluate measurement. 2.21, p = .002; d = of balance participants. functional reach 0.2). Limitations: limited Journal of Trauma and gait speed of Home visits were Falls decreased in the diversity across all Nursing, 29(1), 5–11. OAs. conducted, and initial three months demographics which https://doi- participants were (p=0.002). 53 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments org.proxy1.cl.msu.edu/10. tracked for 6 months. Median gait speed limited 1097/jtn.0000000000000 Comparisons of the was reduced by 1.25 generalizability. 625 pre- and post- seconds. intervention were Convenience measured using the Median TUG speed sampling was used, one-tailed paired t was 11.9 seconds pre- eliminating a control test. intervention and10.65 group. seconds post- Comparisons of OAs intervention. Also, OAs who improved versus volunteered for the OAs that did not was A -10.5% mean study. measured using two- change in TUG scores tailed independent- was noted from pre- samples t tests and to post intervention. two-tailed Pearson's χ2. Huey-Ming Tzeng, VI Sample site was a The Fall TIPS 3- Qualitative data was Average fall rates and High staff turnover Jansen, L. S., government funded NH with step program was gathered from the fall related injuries created difficulties in Okpalauwaekwe, U., 15-beds on a subacute care used to evaluate focus group per 1000 resident completing the study Khasnabish, S., Andreas, unit. its efficacy for discussions and one- days decreased post- results. B., & Dykes, P. C. fall prevention. on-one interviews intervention. (2021). Adopting the fall with OAs and their Limitations: small tailoring interventions for Staff members families. Data was sample size, narrow patient safety (TIPS) were trained on entered into a Word focus on fall rates, program to engage older engaging patients file, for thorough and limited statistics. adults in fall prevention in in their care, content analysis. a nursing home. Journal conducting a of Nursing Care Quality, proper fall risk Quantitative data was 36(4), 327–332. assessment using placed in the https://doi- and followed Statistical Package org.proxy1.cl.msu.edu/10. interactive case for the Social 1097/NCQ.00000000000 studies. Sciences file for 00547 descriptive analyses. 54 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments Iuliano, S., Poon, S., II N=7195 OAs in LTC Results were Analysis of data came Limitations: Poor Robbins, J., Bui, M., facilities were expressed using a from 27 facilities that follow up; <50% of Wang, X., De Groot, L., Sample was composed of supplemented hazard ratio with 95% participated as the OAs had long-term Van Loan, M., Zadeh, A. permanent residents in 60 with 562mg of CI. intervention group follow-up sessions. G., Nguyen, T., & LTC facilities in Australia calcium found in and 29 facilities that Seeman, E. (2021). Effect (4920 (68%) female; mean various dairy “Coxme” package represented the 716 participants of dietary sources of age 86.0). products as well helped estimate control group. consented to being calcium and protein on as 12g of protein. parameters and Fine- analyzed for causes hip fractures and falls in Daily intake of Gray sub-distribution 324 fractures (135 hip of secondary older adults in residential calcium increased estimated mortality fractures), 4302 falls, osteoporosis, rather care: cluster randomised to 1142 (353) mg risk analysis. and 1974 deaths than the entire controlled trial. BMJ and protein occurred during the sample size. (Clinical research ed.), increased to 69 All analytical tools study. 375, n2364. (15) g. used R Statistical Intervention only https://doi.org/10.1136/b Environment. Supplementation was used whole dairy mj.n2364 Control group: linked to RR of 33% products; therefore, were facilities for fractures (121 v benefits of other that kept using 203; hazard ratio dairy products their standard 0.67, 95% confidence cannot be menus which interval 0.48 to 0.93; generalized. included 700 P=0.02), 46% for hip (247) mg of daily fractures (42 v 93; calcium and 58 0.54, 0.35 to 0.83; (14) g of daily P=0.005), and 11% protein. for falls (1879 v 2423; 0.89, 0.78 to 0.98; P=0.04). 55 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments There was a significant RR at five months for hip fractures and falls (P=0.02) as well as at 3-months (P=0.004). Mortality remained the same (900 v 1074; hazard ratio 1.01, 0.43 to 3.08). Kim, D., Chang, C., & VI Sample included 57 OA Evaluate lighting Independent t tests T test showed Small sample size. Margrett, J. (2021). residents living independently and OAs’ were used to noticeable changes in Understanding older in the Midwest perception of differentiate between overall FOF when adults' perception and lighting. FOF and lighting comparing the visual usage of indoor lighting satisfaction. impairment group to in independent senior OAs without living. HERD, 14(3), Paired-sample t tests impairment (t = 2.81, 215–228. helped identify df = 1, p = .007), for https://doi.org/10.1177/19 differences in normal the visually impaired 37586720988616 light levels and OAs (M = 3.31, SD = maximum lighting. 1.33) voicing more concerns (M = 2.32, T tests were also used SD = 1.31). to identify differences in FOF in OAs with visual impairments (n = 32) and OAs without impairments (n = 25). 56 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments Ling, Y., Xu, F., Xia, X., V 31 studies including 57, 867 Vitamin D Systematic review of Meta-analysis showed Limitations: Bias Dai, D., Xiong, A., Sun, OA participants. Supplementation using multiple that vitamin D as may have been R., Qiu, L., & Xie, Z. vs. Vitamin D databases from monotherapy did not introduced in data (2021). Vitamin D 17, 623 falls were added in with calcium inception through decrease fall risks obtained differently supplementation reduces the meta-analysis. supplementation September 2020 [RR] 1.00, 95% for falls in different the risk of fall in the along with a meta- confidence intervals studies. vitamin D deficient 21 RCTs on vitamin D analysis using [CI] 0.95 to 1.05) elderly: An updated meta- supplementation as PROSPERO were when compared to no Studies used analysis. Clinical monotherapy and 10 RCTs on used to determine the treatment in 21 of the different methods to Nutrition, 40(11), 5531– vitamin D plus calcium were interventions’ RCTs. measure 25(OH)D 5537. https://doi- also a part of the meta- efficacy on falls in levels in OAs. org.proxy1.cl.msu.edu/10. analysis. OAs. The other 10 RCTs 1016/j.clnu.2021.09.031 using vitamin D with I2 test assessed calcium showed 12% statistical decrease in fall risks heterogeneity. (RR 0.88, 95% CI 0.80 to 0.97). A qualitative visual estimate using funnel plot, Begg's test, and Egger's tests helped to identify potential bias. Lytras, D., Sykaras, E., IV N= 150 OA fallers. To identify Cross-sectional study Majority of the falls Study took place Iakovidis, P., Kasimis, K., intrinsic and happened at home, during the COVID- Myrogiannis, I., & 15 selected Open Care extrinsic fall risk notably in the 19 pandemic so Kottaras, A. (2022). Centers for the Elderly in 5 factors in OAs. bedroom and there were long Recording of falls in different cities throughout bathroom. closures in the elderly fallers in Northern Central Macedonia, Greece. country. Greece and evaluation of >60% occurred at aging health-related night factors and environmental safety associated with 57 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments falls: A cross-sectional ~40% of OAs study. Occupational reported improper Therapy International, lighting or visual 2022 (1), 1–11. impairments as https://doi- contributing factors. org.proxy1.cl.msu.edu/10. 1155/2022/9292673 Decreased functional performance in the FICSIT-4 test and TUG test, with noted increases in scores for provided questionnaires and abbreviated FES-1 showed a direct correlation with higher falls. Meimandi, M., Fadavi- IV 100 OA residents (aged 60- Comparison of Cross-sectional study FES is a better at Only OAs that Ghaffari, M., Taghizadeh, 87) of two nursing homes in falls efficacy observed the identifying FOF in could walk 10 G., Azad, A., & Tehran, Iran (males: N = 63 scale- correlation between OAs when compared meters and stand for Lajevardi, L. (2021). Falls and female N=37) were international FES-I, FES, and SIQ to SIQ. 90 seconds were efficacy scale and single analyzed from July to (FES-I), Falls questionnaires in included; therefore, item question: Screening December 2017. efficacy scale determining FOF. data is nor accuracy for older adults (FES), and Single generalizable to less residing in nursing item question Area Under the Curve functional OAs. homes. Clinical (SIQ) in measured efficiency gerontologist, 44(5), 544– identifying FOF. of FES and SIQ by Also, participants of 551. using their FOF this study had no https://doi.org/10.1080/07 score. cognitive 317115.2020.1858467 impairments. A logistic regression analysis measured FOF using FES-I scores as an outcome 58 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments along with FES and SIQ scores. Ožić, S., Vasiljev, V., III 410 OAs aged 75 to 95. Study used 2 Frailty was measured There was a drastic Small sample size. Ivković, V., Bilajac, L., & interventions: (1) using Tilburg Frailty increase in frailty Rukavina, T. (2020). determining fall Indicator (TFI) noted in the control Interventions aimed at risks in OAs and survey and ADL- group after a year (r = loneliness and fall eliminating them, related −0.11), but the prevention reduce frailty and (2) twice questionnaires. intervention group’s in elderly urban weekly exercise. frailty did not (both P population. Medicine, > .05). 99(8), 1–8. https://doi- org.proxy1.cl.msu.edu/10. 1097/MD.000000000001 9145 Pavana, Smrithi A., n= 80 recruited OAs. To measure the Scores from the two Asymptotic Z-value Limitations: small Pruthviraj. R., & impact of tests were analyzed was 7.852 with P sample size and Ngilyang Mica. (2020). Functional reach test =40 footwear in including mean and value of p<0.001 unequal distribution Effect of footwear on OAs relation to standard deviation. revealing that OAs of genders. balance and fall risk of balance and fall with proper footwear elderly individuals in Berg balance test = 40 OAs risk in OAs. Whitney test was were better equipped selected old age homes. used for further to remain balance Indian Journal of analysis. compared to OAs Physiotherapy & with improper Occupational Therapy, footwear. 14(3), 164–170. https://doi- 59 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments org.proxy1.cl.msu.edu/10. 37506/ijpot.v14i3.9688 Prevettoni, M. A., III N=108 frail OAs residing in Multifactorial Quasi-experimental Pre-intervention: Criteria of frailty can Guenzelovich, T., Buenos Aires, Argentina aged intervention: study. 33.3% fell within the be subjective. Zozaya, M. E., Giardini, ≥65 years. organization of Data was collected past 30 days (95% CI G., Hornstein, L., patient care, through an in-depth 25.2-42.7); post- Schapira, M., Giber, Mean age of 85.2 years, with caregiver interview and intervention was F., Quintar, E., & Perman, women accounting for 79.6%. education, validated 13.9%. G. (2021). Decreased falls medication questionnaires, which through Severe/total dependence of reconciliation, were recorded in the Pre-intervention fall multifactorial intervention the sample was 56.8% and risk detection, EHR. Data was rates were 50/100 in frail older adults. increased fall risk made of interventions for compared using the OAs (SD 87); post- Journal of the Faculty of 79.6% of the total sample. adequate feeding McNemar test. intervention it was Medical Sciences of and hydration, 11/100 OAs (SD 34), Cordoba, 78(2), 166–170. Dementia accounted for environmental p <0.001. https://doi.org/10.31053/1 29.6%, 30.5% were safety, counseling 853.0605.v78.n2.27832 institutionalized, and 82.4% on appropriate Findings revealed a had polypharmacy. footwear and notable reduction of assistive devices, OAs falls of 41.7%, and strengthening and fall rate decrease exercises. of 78% using the multifactorial approach. Schoberer, D., & I Systematic literature & meta- Review of Data was analyzed Exercises centered Frailty was likely Breimaier, H. E. (2020). analysis of RCTS. exercise from 2007-2018 to around balance or underreported in Meta‐analysis and interventions that identify exercise- utilizing technical some studies. GRADE profiles of can be used for related interventions devices helped exercise interventions for fall prevention. to decrease falls for decrease falls in OAs, falls prevention in long‐ OAs residing in LTC. especially when the term care facilities. interventions were Journal of Advanced utilized >6 months in 60 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments Nursing, 76(1), 121–134. duration. These https://doi- interventions had the org.proxy1.cl.msu.edu/10. opposite effect on 1111/jan.14238 frail OAs. Senderovich, H., Bayeva, I Systematic review & meta- Exercises Multiple databases Balance exercise Sample included N., Montagnese, B., & analysis included 19 RCT were used between training improved cognitively impaired Yendamuri, A. (2021). studies comprised of OAs 1990-2018 to identify balance and falls by OAs; therefore, it Managing fall prevention OAs in high-risk the 19 RCTs month 6 and 12 of the cannot be through exercise in older communities/nursing homes. involving exercise- study. generalized. adults afflicted by related fall prevention cognitive and strength strategies for OAs. Balance improved (p impairment. Dementia < 0.0001) as well as and geriatric cognitive gait by the 12th month disorders, 50(6), 507– of the study (p < 518. 0.0001) specifically https://doi.org/10.1159/00 in OAs with cognitive 0521140 impairments. Tricco, A. C., Thomas, S. I Systematic review and Modifying the Multiple databases Team changes were Two investigators M., Veroniki, A. A., network meta-analysis of 126 structure of the were used to significant in screened studies. Hamid, J. S., Cogo, E., RCTs involving 84,307 OAs. primary health determine the most decreasing fall related Strifler, L., Khan, P. A., care team. efficacious fall injuries compared to Sibley, K. M., Robson, prevention standard care (odds R., MacDonald, H., Riva, approaches. ratio [OR] 0.57 [0.33 J. J., Thavorn, K., Wilson, to 0.99]; absolute risk C., Holroyd-Leduc, J., Two investigators difference [ARD] - Kerr, G. D., Feldman, F., analyzed available 0.11 [95% CI, -0.18 Majumdar, S. R., Jaglal, data and appraised to -0.002]). S. B., Hui, W., & Straus, risk of bias S. E. (2019). Quality independently. Data from 61 RCTs improvement strategies to including 40,128 OAs prevent falls in older supported case 61 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments adults: A systematic management, patient review and network meta- reminders, and staff analysis. Age and ageing, education (OR 0.18 48(3), 337–346. [0.07 to 0.47]; ARD - https://doi.org/10.1093/ag 0.27 [95% CI, -0.33 eing/afy219 to -0.15]) as successful interventions compared to usual care. Valatka, R., Krizo, J., & VI N=40 A Matter of Single group pre/post 29 participants (73%) Small sample size Mallat, A. (2021). A Balance program test questionnaires finished the pre-/post- with OA volunteers. survey-based assessment 40 OAs attending the Matter were distributed survey. of “Matter of Balance” of Balance Program between amongst OA participant fall-related March 2019- March 2020. attendees of the Of OAs that experience. Journal of program to assess experienced falls Trauma Nursing, 28(5), their opinions of the before the course, 304–309. https://doi- program as well as 75% noted a decrease org.proxy1.cl.msu.edu/10. how it impacted their in falls. 1097/jtn.0000000000000 fall history, and 602 personal habits. 71% of those who initially reported Wilcoxon test was FOF, reported a used for data reduction in FOF comparison. after the course. Wang, K. N., Tan, E. C. IV 383 OAs across 6 different Medication A 2 year prospective 77.5% of OAs were Took place in K., Ilomäki, J., Gilmartin- Australian nursing home/LTC review cohort study. female, with average Australia, cannot be Thomas, J. F. M., facilities. age of 87.5 (standard generalized to other Sluggett, J. K., Cooper, deviation = 6.2). countries. T., Robson, L., & Bell, J. S. (2021). What is the The average total of best definition of medications per OA 62 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments polypharmacy for was 10.0 (standard predicting falls, deviation = 4.1). hospitalizations, and mortality in long-term Mean rates of all- care facilities? Journal of cause hospitalizations the American Medical = 2.6 per 1000 Directors Association, resident-days, fall- 22(2), 470–471. related https://doi- hospitalizations = 0.4, org.proxy1.cl.msu.edu/10. and falls per resident 1016/j.jamda.2020.10.040 4.7. Mortality rate was 38.4% or n=147. Cut points for all hospitalizations were 11.5 medications while fall-related hospitalization, had 9.5 regular medications. Yu Ming, Zecevic, A. A., I Fourteen RCTs Medication Two reviewers Using medication Only two reviewers Hunter, S. W., Wenxin reviews analyzed RCTs found reviews as a single conducted the Miao, & Tirona, R. G. in PubMed, intervention helped search. (2021). Medication EMBASE, Scopus, prevent fall-related review in preventing older and CINAHL. injuries in OAs (Risk adults’ fall-related injury: Difference [RD] = - A systematic review & Meta-analyses was 0.06, 95% CI: [-0.11, meta-analysis. Canadian used for data -0.00], I2 = 61%, p = Geriatrics Journal, 24(3), similarities. .04). 237–250. https://doi- 63 Citation & Search Terms Design, Level Sample Team Based Measurement: Findings Strengths/Limitation of Evidence Intervention Variables & s & Purpose Instruments org.proxy1.cl.msu.edu/10. Additionally, 5770/cgj.24.478 medication reviews helped decrease fall- related fractures (RD = -0.02, 95% CI: [- 0.04, -0.01], I2 = 0%, p = .01). Zubkoff, L., Neily, J., III 27 state veteran homes. Post-fall huddles, Data was gathered for Fall related injury Participants Delanko, V., Young-Xu, education of staff 6 months to account rates decreased from volunteered, so Y., Boar, S., Bulat, T., & members, and for outcomes pre-, 7.4 (pre-) to 6.6 intra, selection bias is Mills, P. D. (2019). How utilization of intra-, and post- (p = 0.009) and 5.6 possible. to prevent falls and fall- intentional intervention post-intervention (p = related injuries: A virtual rounding. using a Poisson 0.005). breakthrough series regression model. Minor injury rate collaborative in long term decreased from 6.4 care. Physical & throughout the Occupational Therapy in intervention to 5.8 (p Geriatrics, 37(4), 234– = 0.000) post- 246. https://doi- intervention. org.proxy1.cl.msu.edu/10. 1080/02703181.2019.163 There was no 6923 statistically significant decrease in total fall rates or major injury rates. 64 Appendix F Pre/Post-Intervention Knowledge Assessment Correct answers marked with * Q1 Which of the following are risk factors for falls in the older adult? A) Fear of falling B) Confusion/cognitive impairment C) Poor coordination/balance D) All of the above * Q2 What are interventions that can help decrease falls in older adults? A) Assisting with frequent ambulation and exercise to maintain function * B) Ignore call lights C) Assisting with toileting only in the morning D) Keeping all personal belongings away from the bedside Q3 True or false. If a resident has a fall, they are at a lower risk of having another fall. A) True B) False * Q4 True or false. Fall risk assessments should only be done after a resident falls. A) True B) False * Q5 True or false. Pain medications, mental health medications, and seizure medications can cause a resident to fall. A) True * B) False Q6 Do you know where Holt's fall policy is located? A) No B) Yes * 65 Q7 Where do the majority of falls take place at this facility? A) In the resident's bathroom B) In the dining room C) In the resident's bedroom * D) In the hallway Q8 What is the definition of a fall? A) When someone loses consciousness and comes to rest on the ground B) When someone suddenly and involuntarily comes to rest on the ground with or without loss of consciousness * C) When someone loses balance and almost hits the ground D) When someone voluntarily comes to rest on the ground Q9 True or false. As the body ages, muscles become stiffer and bones become more brittle, which increases the risk of fall related injuries. A) True * B) False Q10 Which of the following is one of the first steps that should be taken in the event of a residential fall? A) Leave the resident and call nursing administration B) Call 911 immediately C) Assess the resident * D) Help the resident off the ground 66 Appendix G Figure 4 5 Whys Figure adapted from the State of Michigan. (n.d.) 5-Whys Guide & Template. https://www.michigan.gov/- media/Project/Websites/mde/Year/2020/04/02/5_Whys_Worksheet.pdf?rev=1b003b15440b4394 acc0936df7970f4d 67 Appendix H Figure 5 Facility Agreement Letter 68 Appendix I Figure 6 Fall Prevention Han 69 Appendix J Table 4 Timeline of QI Project Using GANNT Format Project Task 5/22 6/22 7/22 8/22 9/22 10/22 11/22 12/22 1/23 2/23 3/23 4/23 Communication with community partner Advisor Meeting Problem Statement Development Project Proposal Draft 1-2 (problem statement) Project Proposal Draft 3-4 (Literature Review, Gap Analysis) Project Proposal 5-6 (Fishbone Analysis, Conceptual Framework, Outcome Measures/methods) Project Proposal 7-8 (GANNT, Budget, Conclusions) IRB Application Intervention development Education and survey implementation Data Analysis Finalization of Proposal Proposal Defense/Dissemination 70 Appendix K Table 5 Fall Data Report by Year CATEGORY DATES 2019 2020 2021 2022 # of fall incidents 173 39 47 268 # of residents sent to hospital 3 1 1 2 Location of fall Resident’s room 121 28 28 204 Resident's 14 3 9 27 bathroom Hallway 15 7 3 11 Outside 2 0 0 2 Dining Room 5 0 3 7 While on LOA 3 0 0 3 Nursing station 8 0 1 3 Lounge 1 0 0 0 Activity room 1 0 0 0 Shower 1 1 0 3 Reception/ 1 0 1 3 Lobby Therapy Room 0 0 2 0 Transport 0 0 0 1 vehicle Common 0 0 0 2 bathroom Therapy 0 0 0 1 Unknown 1 0 0 1 Predisposing Poor lighting NA* 1 NA* 18 environmental Rugs/carpeting NA* 0 NA* 3 factors ** Furniture NA* 0 NA* 6 Noise NA* 0 NA* 3 Crowding NA* 0 NA* 5 Clutter NA* 0 NA* 6 Wet floor NA* 0 NA* 2 Other NA* 5 NA* 53 None listed NA* 33 NA* 190 Gait imbalance NA* 15 NA* 161 71 Recent illness NA* 2 NA* 12 Impaired NA* 23 NA* 105 memory Confused NA* 17 NA* 100 Recent change in NA* 1 NA* 5 cognition Recent change in NA* 2 NA* 9 medication/ new medications Weakness/ NA* 3 NA* 31 Predisposing fainted physiological factors ** Fluctuating NA* 0 NA* 7 blood sugar Fluctuating NA* 0 NA* 7 blood pressure Oxygenation NA* 0 NA* 2 changes Drowsy NA* 1 NA* 12 Incontinent NA* 2 NA* 56 Current UTI NA* 0 NA* 5 Other NA* 0 NA* 24 None listed NA* 5 NA* 31 Predisposing During transfer NA* 8 NA* 36 situation Call light not NA* 23 NA* 148 factors ** used Footwear not in NA* 1 NA* 19 place Using cane NA* 1 NA* 2 Using walker NA* 2 NA* 17 Ambulating NA* 11 NA* 110 without assistance Wanderer NA* 2 NA* 9 Active Exit NA* 1 NA* 3 Seeker Admitted within NA* 1 NA* 10 last 72 hours Recent room NA* 1 NA* 19 change Staff alerting NA* 0 NA* 8 devices not in use 72 Gait belt not NA* 0 NA* 9 used Other NA* 3 NA* 41 None listed NA* 4 NA* 28 *NA = Not Available ** Each fall could have had more than 1 predisposing factors 73 Appendix L Figure 7 Number of Fall Incidents 2019 - 2023 74 Appendix M Figure 8 Monthly Data Comparison, Four Months Pre- and Post- Intervention Reported Falls, June 2022 – February 2023 June 2022 July 2022 August 2022 Sept. 2022 Oct. 2022 Nov. 2022 Dec. 2022 Jan. 2023 Feb. 2023 23 24 24 22 31 6 18 22 29 Key: Green = pre-intervention Orange = intervention Blue = post-intervention 75 Appendix N Figure 9 PDSA Cycle Act: What changes are we going to make based on our Plan: What is the team trying to accomplish? o Fall prevention education, reduction in falls and findings? fall-related injuries • Implement post-fall assessment validated tool o Increase QoL in residents • Reinforce education to DCWs biannually • How will the team know that a change is an improvement for the facility? o Pre-/post- fall knowledge assessment of DCWs o Evaluation of MDS measures • What changes could the team make? o DCW fall education, post-fall assessment implementation, hourly rounding Study: What were the results? Do: When and how did we do it? • From data gathered from HSC&RC, more falls • HSC&RC OA fall data was gathered from 2019-present occurred during 2019 and 2022 thus far • HSC&RC fall prevention protocols were evaluated • Goal of intervention was met → reduction in falls • Extensive literature was reviewed for current evidence- and improvement in DCWs fall knowledge based fall prevention interventions o Exercise as a single and multifactorial intervention o Fall prevention programs o Education o Hourly rounding o Post-fall huddles o Identify and modify fall risk factors