Mercy Health Residential Aged Care
FIT for the future
Mercy Health Residential Aged Care
Residential - Metropolitan, 80 + beds
Health and wellbeing, Clinical care / medication management, Safety
About the program
More than half of all people living in residential aged care facilities have at least one fall a year. Injuries from falls are also common, with up to half of these falls causing serious injuries such as fractures, which impact negatively on independence, function, and quality of life.
The introduction of a new falls indicator, together with tools for recording falls data, provided us with robust data which we were able to analyse at both a local home and organisational level. This information was used to further reduce the number of falls. The heightened awareness around falls was also acknowledged to contribute to the reduction in numbers.
The challenge was then to be able to provide this analysis in real time so that homes could address risk factors in a timelier manner and therefore reduce falls even further. We achieved this through an innovative approach to the collection of falls data which has enabled sites to quickly and easily identify trends and patterns in their own data.
While falls may not be able to be eradicated in residential aged care, we have shown that proactive management (including risk assessments and harm minimisation strategies) decreases the risk of falling and the level of injury sustained while robust post-fall investigation decreases the likelihood of recurrence for the individual resident.
The use of our self-designed tools has resulted in a significant reduction in both the number of falls and the number of falls with serious over a two-year period.
What we did
We started with our reporting of data and looked at how other aged care homes in Australia reported falls data. We decided to adopt the Victorian public aged care homes falls indicator as it gave us both an upper (potential problem with care) and lower (potential problem with reporting falls) threshold level. The indicator was implemented at our homes during 2012.
We also developed and implemented a Falls Investigation Tool (FIT) that was to be undertaken each time a resident had a fall. This document gathered data on not just the mechanics of the fall but potential causal factors (medication changes, toileting issues, footwear being worn etc). Data from the individual FIT was then recorded on a Falls Data Sheet (FDS) at each home to enable us to identify trends. The Aged Care Quality Unit worked with the homes to review the data at a home level and to detect trends. An organisation level analysis was also undertaken using 12 months of data. A number of organisation-wide strategies were put in place to reduce the risk of falling. These included implementation of a standard ‘safe shoe’ assessment tool, a resident environment assessment for the resident’s room and the use of stickers on mobility aids and in the resident’s room to alert the staff that the resident was at high or medium risk of falling. Several homes implemented additional local strategies including a review of toileting preferences to reduce the number of falls and the increased use of low-low beds to minimise the impact of falls.
We monitored three aspects of falls: the number of falls per 1000 bed days, the number of falls resulting in severe injury (fracture, head injury, serious laceration), and the number of times a home was in breach of the falls indicator upper threshold. Following implementation of the various strategies, there was a reduction in the numbers in all three categories. It was also recognised that the staff’s heightened awareness of falls contributed to this reduction.
While we were pleased with the outcome, we wanted further improvement. We thought it was important for homes to have access to trended data in real time as this would enable timelier implementation of prevention and/or reduction strategies. We also wanted to increase staff awareness of falls. We retained the tools that had been introduced (FIT and FDS) as staff were happy with their functionality. The Falls Data Sheet was further developed to include graphical depiction of the data entered. This provides our homes with immediate data analysis ability in a number of areas (Table 1 & 2). In addition, the resident’s fall risk (low, medium, high) was added to the Summary of Daily Care Needs, a document used by staff to quickly identify resident needs.
The introduction of Learning Facilitators at every home and embedding of the Mobility and Dexterity Care Module provided the required education for staff in falls prevention and harm minimisation. Significant further reduction in falls was achieved.
Why we did it
We had been collecting data on the falls in our homes for some time. Although the numbers were reported up through the organisation, limited analysis of falls data was occurring at a local level and inconsistent action was being taken, either proactively or reactively, to reduce the number of falls or the severity of the fall.
When the Aged Care Quality Unit (ACQU) was formed in mid-2011, falls was one of the first areas to be reviewed in detail. We were concerned about both the number of falls but more importantly about the inability of some homes to recognise accurate causal factors. Several homes simply assumed that the high number of falls was due to their resident mix (for example, had a high proportion of ‘high-care’ residents compared to ‘low-care’) or stated it was because they had ‘repeat fallers’. These assumptions meant no proactive steps were taken to reduce either the number and/or severity of outcome of falls on an individual resident level and no sustained change in practice was ever considered.
We knew from talking to our residents that having a fall can lead to a fear of falling, which in turn can mean that the resident avoids activities of daily living, can become socially isolated, and has a real or perceived lowered quality of life. Given we aspire to give each resident the opportunity to have the best day possible every day, it was evident we needed to improve both our falls rate and our management of falls.
Who worked with us
The Aged Care Quality Unit and the Learning Facilitators worked closely with care staff at the homes to ensure the importance of good falls prevention strategies and harm minimisation strategies were understood. Residents from some of the homes were involved in discussing the psychological impact of falls and their opinions were sought on the use of stickers to identify their fall risk. When the tools were reviewed after the first twelve months, senior clinical care staff were invited to provide their input into both the content of the Falls Investigation Tool as well as the functionality of the Falls Data Sheet. This collaborative approach resulted in a successful uptake of the new tools and processes.
What we learned
As a result of using the Falls Indicator, the Falls Investigation Tool and the Falls Data Sheet, together with targeted education of staff, seven of the eleven homes experienced a reduction in both the number of falls and the number of falls with serious injuries. Three other homes remained static in their number of falls but reduced the number of falls that resulted in injury. The fourth home significantly increased the bed numbers during the period and did not reduce their overall fall numbers. This was not unexpected as it is known that the risk of falling is greatly increased in the first few weeks of moving into an aged care home. They have since reduced their falls numbers.
At a local level homes have been able to identify accurate causal factors and take action. An example of this was where the Falls Data Sheet at one home showed that the majority of their falls were occurring in a two hour time period in the evening. This data enabled the home to target their investigation, looking at the factors that were contributing to this. It was found that a staff member finished their shift just prior to this period meaning there was fewer staff available to assist with toileting after residents had eaten their tea. The home was able to use the data to discuss this with staff and changed the shift to commence one hour later and finish one hour later, providing increased staffing numbers in the time period required. The home’s falls rate decreased immediately after this change was made.
At an organisational level, we achieved a significant reduction in all areas:
- Number of homes that breached the indicator’s upper threshold level on a least one occasion in a twelve month period – reduced from 9 homes to 3 homes over two years.
- Number of months homes breached the upper threshold level of the indicator – reduced by 31% over two years.
- Fall rate per month across all 11 homes – reduced from 279 in 2013 to 245 in 2015, resulting in 408 fewer falls across the homes over two years
- Number of falls with serious injury per month across all 11 homes – reduced from 67 in 2013 to 50 in 2015; meaning there were 204 fewer falls resulting in serious injury
- To ensure the improvements are sustained, the Falls Indicator is reported and discussed at both a local home level (Quality Meeting) and at the Aged Care Quality Committee. Consolidated data is reviewed at both the Aged Care Clinical Governance Committee and Board Quality Committee. The Aged Care Quality Unit regularly reviews the Falls Data Sheet to ensure that trends are being acted upon. The efficacy of the Falls Investigation Tool and the Falls Data Sheet is reviewed on a bi-annual basis to ensure it continues to meet the needs of the homes and provides all the information required to monitor fall trends.
While we continue to monitor and evaluate the ongoing effectiveness of the various tools and processes, we aim to continue to improve these over time. A new Model of Care is currently being embedded at our homes. This model encourages enablement and a degree of risk taking, and therefore we may very well find that our falls rate increases in the short term. We are working on how we incorporate these changes into our current tools to ensure we are capturing accurate causal factors.
Falls will continue to be monitored and data collected from falls analysed to identify potential trends. This data will be used to ensure the causal factors we can influence are well managed and those factors that we cannot control are identified, recognised and accepted, enabling each resident to have the opportunity to have the best day possible, every day.
More information on this program:
Susan Blackbourn, SBlackbourn@mercy.com.au, or phone (03) 8416 7964