Opinion

Dementia and Falls Prevention

      Figures from 2013, show that the average cost for hospitalisation of a dementia resident is higher than the general public (Dementia Care in Hospitals, 2013). Aged care usually has high staff turnover, meaning nursing homes are constantly faced with the choice of either relying on agency nurses or employing and training new staff. This takes time, money and resources, and even after they have been trained, there is no guarantee that they will stay on as nurses for longer than three months. Reasons for this turnover are many, they range from injuries, low pay, work stress and lack of challenging or engaging work (Parliament of Australia, 2020). But while staff turnover is dependent on the industry, a high turnover in most cases suggests a problem with the way the industry is run. Engaged employees are generally happier, perform better and stay in the industry longer. Studies show that a high turnover of staff in nursing home inevitably affects the continuity of care and the general operation of the facility (Emmanuel et al., 2020). Having a robust framework that accounts for this high staff turnover and ensures there are no gaps in the way falls are managed. Will In the short term save time and resources and long term it will improve the general quality of life for residents and allow them to be in an environment they are familiar with. 

     At the patient level, studies show that hospitalisation among the elderly comes with a lot of risks (Husaini et al., 2015). There are three main reasons why people with dementia are at higher risk of readmission. Firstly, people with dementia have difficulty following directions, taking medication and performing activities of daily living like toileting (Tible et al., 2017). This inevitably leads to poor health and increases the risk of falls. Secondly, people with dementia find it hard to express their symptoms, especially the ones that cannot communicate (Gale et al., 2018). It then becomes hard to work out if the resident is deteriorating, especially when there are no regular staff to provide the continuity of care. For example, after a fall, minus vomiting and increased drowsiness, all other symptoms associated with concussions can be attributed to behavioural and psychological issues of dementia (CDC Injury Center, 2019). Knowing if a dementia resident is deteriorating, in this case, relies on staff knowing what behaviours are normal for resident and the behaviours that need urgent attention. Studies show that the risk of readmission is dependent on the stage of dementia. Acute readmission is more common in advanced stages of dementia (Pickens et al., 2017). Often when people with dementia are admitted to the hospital, they are more confused, unsettled and are at higher risk of falls. Because the hospital is not an ideal place to manage behavioural issues, dementia patients are often medicated for their safety and the safety of other patients (Nakanishi et al., 2018). Also, people with dementia usually need a rigid routine of sleep to work time, this is essential when managing challenging behaviours which they cannot have at the hospital (Cipriani et al., 2015).  

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, Fraser, Hendriksen, kim &Hunter, 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 learning plan 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 training program is suited for graduate nurses, new staff and assistant nurses. 

Policy Issues

     Currently, no laws are regulating the way nursing homes are staffed per shift. Some nursing homes are not required to have a registered nurse on-site and are run by enrolled nurses or care workers (Parliament House, 2019). There are a few reasons why more and more nursing homes are understaffed. One reason could be the labour cost, the labour cost for a nursing home is higher compared to other health care sectors. This is largely due to the decline in the functional status, meaning most the residents need help with all aspects of their ADLs. Staffing in nursing homes is dependent on the acuity of the resident and not the number of residents in the facility (Health, 2019). Funding from the government is also dependant on how much care is needed for one resident and not the facility. It is not unusual to find one Registered Nurse overseeing 70 residents (Parliament House, 2019). Moreover, funding from the government does not automatically mean that the facility will employ more staff. In the end, what ends up happening is that the nursing home will stretch the staff they already have. 

      Without enough nurses and nursing assistants, nursing homes will be unable to provide a level of care that is personalised to each resident. It also means that subtle changes to the residents’ conditions are missed, which can lead to care becoming reactionary. Understaffed nurses do not have the time and resources to pay attention to the conditions of the patient so when there is a big change in the resident’s functional status they are often sent to hospital (Kiekkas et al., 2019). In this case, the dementia residents that lack the ability to communicate are at higher risk of neglect. Moreover, nursing homes lack the hierarchy of competency and a framework of escalation of critical events. In hospitals, there is a clear framework for the escalation of a deteriorating patient. Nurses know, who is responsible for referrals and advanced care directives are clearly stated and handed over. One way to limit unnecessary hospital transfers is to have clinical nurse managers and registered nurses always respond to emergencies in the wards they are responsible for. Reason being most clinical nurses are in the same ward all the time, they know more about the resident’s condition and are the ones responsible for family conferences and initiating the palliative care pathway.

     Secondly, there are no clear guidelines from the government on the use of psychotropics in dementia. Recent changes to the safety and quality standards demanding that nurses only use psychotropics as last resort make care even more complicated considering how understaffed nursing homes are (Janus et al., 2017). Studies show that the use of these medications which have been known to increase the likelihood of falls are normally a case of striking a balance between other resident safety, their own safety, and the safety of the staff (Harrison et al., 2020). Overuse of psychotropics is considered as chemical restraint, moreover, evidence shows that their effectiveness in managing behavioural issues in dementia to be substandard (Spek et al., 2018). In short, aged care has too many competing interests. There is a high unrealistic expectation from the families, regulatory agencies wanting a certain level of care to warrantee funding, the government wanting to cut cost and nurses trying to advocate for the patient’s rights. All this without the funding and proper staffing levels to meet these requirements. 

Support Structures 

      For this project to be successful, it needs support from facility managers, clinical nurses and the families. As the population ages so will the number of falls increase in the future. The government, in this case, should consider investing in ways nursing homes can reduce hospitalisations related to falls. This, in the long run, will save time, money and resources, resources that can better be spent elsewhere. The tools required are an overhead projector, a meeting room, handouts on falls management, fall preventions and behavioural management. The training session will be in form of case studies and discussions. Discussions are ideal in this case as they promote team collaboration and allows for nurses to learn from each other. 

Tools and Resources

    The sessions will begin with the simple PowerPoint presentation on falls and the impact they have on the health care system and the role nurses have in preventing falls. The whole group will discuss the case study on the PowerPoint initially. This is a way of working out the levels of knowledge within the group. After the presentation which will take about 10- 15 minutes, the group will be split into two, each with a different case study to discuss. The use of case studies is ideal in that they help learners read between the lines and develop critical thinking skills. The nurses will be expected to point out the issues within the case study and the potential issues, and the best way to manage the patient to optimise the quality of life. The nurses will also learn the assessment required post-fall, symptoms of concussions and the importance of full neurological observations, especially in the first 73 hours after a fall. A quiz will be given at the end of the session of which answers can be discussed. 

Potential Outcomes 

The first potential outcome of this project is a reduction in the number of hospitalisations due to falls. Ott, 2018, found that education on falls and the risk factors that contribute to falls within the elderly population reduced the number of falls. Other studies show that most falls are not only predictable but also avertable (Ayton et al., 2017). Reduction of falls needing hospitalisation will mean residents stay in the environment they are familiar with, reduce the chances of recurrent falls, save resources and maintain or improve the quality of life. That is why educating residents and nursing staff on some of the fall’s reduction strategies is the first step in reducing the number of falls among the elderly. Recent studies demonstrate that most patients are unprepared to manage their physical limitation after discharge from the hospital. This, in turn, contributes to the labour cost experienced post-hospital discharge (Naseri et al., 2018). 

    The final potential outcome of this project is that nurses and direct care workers will know the current best practice guidelines for managing falls once they have happened. Also, the nurses will learn what to look for when a resident is deteriorating gradually and the referrals appropriate. The aim here is to manage the symptoms as much as possible at the facility and only send to the hospital if the quality of life is affected and the facility do not have resources and experience to manage the patient. The nurses will learn the symptoms of concussion and hip fractures. The nurses here will also have learnt all the assessment required after a fall has happened. By the end of the session, they will have learnt how to fill in a FRAT, frequency of neurological observation and instances it is appropriate to send the resident to the hospital. If successful, the yearly education can be done over the internet, this is specifically suited for the more experienced nurses. To mitigate the confusion and gaps in information, a flow chart for escalation and management of falls will be placed in every nurse’s station. 

References

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