Health Opinion

Reducing Hospital Transfers through Falls Prevention

Between 2016-2017, there were 1.6 million emergency department visits among people over the age of 65. The three most common presentations where chest pain, and musculoskeletal issues related to falls ( Falls Resulting in Patient Harm in Hospitals, 2018). Dementia people living in residential aged care facilities are vulnerable, frail and often have many comorbidities that put them at risk of falls (Fernando et al., 2017). For many of these resident’s hospitalisation, carries it with it a lot of risks. (Bail et al., 2015) Found that urinary tract infections, pressure areas, pneumonia and delirium are preventable hospital acquired complications that place a heavy financial burden on the health care system. Studies show that while people with dementia are at higher risk of hospital readmission, many of these hospitalisations are preventable (Ma et al., 2019).

        Between 2016-2017, there were 1.6 million emergency department visits among people over the age of 65. The three most common presentations where chest pain, and musculoskeletal issues related to falls ( Falls Resulting in Patient Harm in Hospitals, 2018). Dementia people living in residential aged care facilities are vulnerable, frail and often have many comorbidities that put them at risk of falls (Fernando et al., 2017). For many of these resident’s hospitalisation, carries it with it a lot of risks. (Bail et al., 2015)  Found that urinary tract infections, pressure areas, pneumonia and delirium are preventable hospital acquired complications that place a heavy financial burden on the health care system. Studies show that while people with dementia are at higher risk of hospital readmission, many of these hospitalisations are preventable (Ma et al., 2019).   Using the change model- Plan- Do-Study- Act (PDSA), this paper will explore some of the way’s hospital transfers can be reduced in people with dementia through various falls prevention and management strategies. The PDSA model is a four-step interactive model for improving a process. The first step is the development of a plan in which the desired outcomes are clearly outlined (Christoff, 2018). The first part of the paper is the suggested framework for hospital admission reduction. This is in the form of a concept map. The paper also has a learning program for falls prevention and management that is suited for new nurses and new employees. The aim is to have no gaps in nursing practice, regardless of the years of experience and how long the nurses have been employed.  Secondly, it will explore some of the underlying reasons why so many elderly people are sent to the hospital, despite all the falls preventions strategies that are in place.  

Learning Principles

      The first learning principle that will be utilised for this training program will be, relevance. For nurses and adults in general, learning should be a problem-centred approach rather than content-based (Yang & Yang, 2013). Studies show that people are motivated to learn when the material they are learning has immediate and long-term implications. Hospital transfers and return from hospital care are usually very time consuming and labour intensive (Albrecht & Karabenick, 2018). For example, minor fractures can cause significant functional decline, pain and distress. Sometimes even minor falls can cause fear of falling in older people, this causes them to reduce their activity and this is when there slowly lose their independence.

     Secondly, transference, this principle deals with how the material learnt can be transferred to the specific facility and residents. Transfer of training can happen when the trainees can incorporate into their practice the knowledge and the skill that they have learnt. Transference, in this case, is most likely to happen when nurses and direct care workers can associate the new information with what they already know and are practicing. Another way is if the new information learnt is similar to the material they already know, and all the educator is doing is building slightly on the existing schema. For example, during the learning process ,Vygotsky believed that there is a zone between what the learner can do without help and those they can achieve with guidance ( ScienceDirect Topics, 2010).  In other ways, if the information is too complicated people tend to not want to learn and if it is too easy, they become bored. The aim of transference, in this case, is to build on the existing policies and procedures and find ways the facility can manage time and resources efficiently (Jackson et al., 2019).

      Thirdly, retention, for nurses to benefit from the learning experience, it is important for them to retain the new knowledge and for them to use the information in their daily practice. People generally retain information when they perceive the information as meaningful.  The amount of retention is related to the degree of original learning. Other studies show that retention of information is affected by the amount and the degree of practice among adults. It is then important that when this information is transferred, the more senior and experienced staff should oversee and help the new nurses and care workers on the policies around falls management and prevention. Another way to help the nurses retain the information is through skills test and refresher courses  (Frank & Kluge, 2019).  

    Finally, reinforcement, reinforcement is about helping the nurses and direct care workers retain and apply the knowledge and the skills they have learnt. In this case, it involves actively encouraging the nurses to use the skills in there day to day practice. Positive reinforcement is about offering the nurses incentives that reward good behaviours and promote good practice (Mayer et al., 2020). For example, efficient use of resources would mean more money can be freed to hire more staff. Negative reinforcement is about taking steps to limit poor practice. For example, harm caused by bad practice and negligence can lead to lawsuits and loss of income.

Learning Objectives

         At the end of this learning program, nurses will have gained knowledge on the factors that contribute to falls.  The training sessions will cover the role UTI and psychotropics have in incidents of falls among dementia residents.  Due to the decline in physical fitness, many adults become less and less active as they get older. Studies show that the risk of major falls related to injuries, such as hip fractures and mortality is higher among people with dementia (Fernando et al., 2017). Several reasons could account for this. People with dementia are more likely to have problems with their mobility, balance and muscle weakness, can have issues with their memory and finding a way around (Wheatley et al., 2019). This often contributes to behavioural issues which in turn places the resident at a higher risk of falls and hospital readmission.

     Secondly, at the end of the training session, the nurses and direct care workers will have learnt on the best practice guidelines of post-fall management and ongoing care.  Under this objective, nurses will learn the importance of neurological observation, the frequency and the duration. Nurses will also have learnt the principles of head and hip injury management and instances when it is appropriate to escalate for a hospital transfer (Fall Response, 2020).

       Thirdly, at the end of the training session, the nurses will have demonstrated that they know how to fill the falls risk assessment tool (FRAT) post every fall. The FRAT score is a 4 item falls risk screening tool for sub-acute and residential care. It has three parts, the first part is the risk status, part two has the risk factor checklist and part three is the action plan.  The strongest predictors of falls are usually a history of falls, this is because an individual’s reason for falling the first time is likely to happen again. Filling this form accurately helps the facility have a good picture of the reasons for the falls, this, in turn, helps the facility explore strategies to minimise falls (Cattelani et al., 2015). 

       At the end of this training session the nurses will have also learnt some of the falls preventions strategies that are specifically used in dementia residents. Nurses here will learn the importance of simple tasks like having a toileting schedule for dementia residents and the effect it has on behavioural management (Meyer et al., 2019). This is especially important for residents that cannot communicate. The staff will learn the importance of good behavioural management strategies in the reduction of falls. Other strategies that can be explored include; the use of hip protectors for residents that are at higher risk of falls and the use of alarm mats or censor beams when residents go to sleep. Nurses will also learn the importance of monthly review of pain and behaviours and the regular review of the effectiveness of medications such as psychotropics (Janus et al., 2017).

         Finally, nurses will learn the ongoing management of the patient’s post-fall, especially in the first three days. Important to learn, in this case, are the symptoms of concussion and hip injuries. Suspected concussion and hip injuries should always be sent to the hospital. For example, increased confusion, headaches, increased drowsiness, repeated vomiting, excruciating pain and limb shortening can all be reasons for sending the patient to the hospital for further investigation (Peters & Gardner, 2018). These symptoms are not always apparent every time after a fall, hence the three days full neurological observation. And if the resident does not have these symptoms, education will also explore what other professionals the resident would benefit from seeing. For example, a review from the physiotherapist is always warranted to work out if the resident needs a mobility aid or having the existing aid adjusted. Other aspects to consider post falls is a medication review by the doctor. 

     These learning objectives will be achieved through feedback from nurses and families. Nurses will also be assessed by using simple quizzes on falls and falls prevention. Another way to work out if the training has been successful and the nurses are incorporating the information into their practice is through monthly review of all falls in the facility. Success will not solely be based on the reduction of falls in the facility, but also, of the falls that happened in a month, how many needed to be hospitalised.

        The education session will be presented in form of case studies and group discussions. Case studies and group discussions are ideal because they promote team collaboration and enhance group participation (Heale & Twycross, 2018). Discussions and use of case studies also helps the presenter know the levels of knowledge within the group. The nurses will be given a case study and then in small groups to discuss the different patients in the case studies. And then after 10-15 minutes, the group will then discuss the patient and the strategies for prevention and post fall management. This allows the nurses to learn from each other, and for new nurses to learn from the older nurses (Florence, 2020).  

Needs Analysis

        A training needs analysis identifies gaps within the knowledge, skills and attituded that people in the organisation have (Holloway et al., 2018). Aged care homes usually have a high turnover of staff, this means that aged care homes tend to spend more time and money educating new staff on their policies and procedures (Roche et al., 2015). The training program is suited for newly graduated nurses and newly employed staff.  Regular staff usually know the resident, they know the ones that are high falls risk and those on medication that can cause bleeding.  The key achievement upon completion of this training program is to have uniformity in practice among staff regardless of their levels of competency and how long they have been at the facility. The second achievement of the paper is to hopefully reduce hospital transfers and the functional decline that often happens post return from hospital. The training package will be given to every newly employed nurse as part of the orientation training package and a flow chart will be put in the orientation pack of agency nurses. For experienced nurses, to promote retention, the training package will form part of the yearly mandatory education competency refresher courses.

Training Tools

           The training tools required for this learning program is a meeting room, educational hand outs and overhead projector which will be supplied by the facility. The handouts will be on, falls prevention and post-fall management. All these educational handouts can be downloaded from PubMed or NCBI for free. The only cost here is for paper and ink. Most facilities have meeting room fitted with projectors; the job of the presenter then is to have a PowerPoint with visual representations. During the teaching process, the aim is to teach new information to the new staff and for old more experienced nurses the aim is to consolidate the existing knowledge so that there is uniformity in the practice. The training sessions will last for an hour and can be done at the end of the shift. For experienced nurses, the incentive for attending the education session is that this can be used as part of the hours for continuous improvement needed by nurses for registration. For new nurses this training will be mandatory upon employment. Post fall management procedure flow chart will be put in every nursing station for everyone to read.

Evaluation of Training

       Evaluation of the effectiveness of training will be done monthly by reviewing the facilities falls register and hospital transfers. Success, in this case, will be based on the reduction in the number of falls over the month and the number of falls needing hospital admissions. The aim is to have an 80% reduction in hospital admission within six months of implementation. The training program will form part of the yearly educational competency for all nurses in the facility or whenever there is a sudden increase in the critical incidents in the facility. If successful, subsequent training does not have to be face to face, a yearly refresher on falls prevention can be over the internet. A training app most facilities use is Bridge. A training program can be done on Bridge together with a quiz. Upon completion, the participants will have to get a certificate to hand in into management.

      The effects of falls on dementia patients are massive, the general assumption among families is that a hospital is always a safe place for the resident. But too often when dementia patients are sent to the hospital, they tend to be more confused upon readmission to the care home (Tible et al., 2017). This is because dementia patients usually need a rigid routine of sleep to work time and when to have meals, which is important when managing challenging behaviours (Cipriani et al., 2015). Depending on the nature of the injury, it also means that more resources are allocated to one patient for rehabilitation. Studies show that hospitalisation is often harmful to people with dementia and results in higher costs to the health care system. Figures from 2013 estimates that the average cost for hospitalising a dementia patient was higher than the general public (Dementia Care in Hospitals, 2013). That is why a comprehensive dementia care program may reduce the number of admissions to the hospital and the wider implementations of falls management strategies would allow for the resident to stay in the facilities in the environment they are familiar with.

       In addition, making sure that there are no gaps in practice among nurses regardless of how long they have been in the facility is also important during the accreditation process. To continue to receive subsidies from the government, Australian nursing homes are required to be accredited (Aged Care Quality and Safety Commission, 2020).  Accreditation involves the periodic full audit of the facility to assess compliance with the quality standards. The commission monitors the quality of care and services within the facility and they also manage noncompliance in aged care standards ( Aged Care Quality and Safety Commission, 2020). The accreditation process judges the care home based on the eight safety and quality standards, and this report is then released online. Sub-optimal care or non-compliance would mean loss of funding from the government and an eventual loss of business as more and more people opt not use the nursing home.  

      In conclusion, this paper has explored some of the reasons for the high rates in hospitalisation in dementia patients living in nursing homes. A PDSA model was used to come up with a possible framework for reducing unnecessary hospitalisation of residents from aged care homes. Thirdly, the paper looked at how this can be achieved through a training session. The training is suited for newly graduated nurses and new staff. The framework for reduction aims to account for the high turnover of staff in aged care, the aim is to have no gaps among nurses in falls prevention and management.

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