About the program
Falls are the most serious frequent accident among older people. Falls in residential aged care settings are three times higher and injury rates up to ten times higher than a community setting. The Medication Advisory Committee (MAC) within our 179-bed aged care facility raised concerns about the number of medication related falls occurring, and considered how best to address this.

Medication review in aged care facilities is routinely managed by doctors and pharmacists using the Residential Medication Review (RMMR) program. Reviews are usually carried out by pharmacists as per the government stipulations (once every two years). While there is provision for RMMRs to be undertaken if a resident has a change in health status or medications (especially if they have a fall, hospitalisation or are newly admitted to the facility) we did not have a procedure in place to capture changes for residents to trigger an RMMR.

The MAC considered the clinical team ideally placed to identify residents who were at risk of medication misadventure (such as fall). In addition, the MAC considered a more interdisciplinary approach was needed to raise awareness of the impact of medicines on falls risk across the entire aged care setting, and encourage a culture of shared care, where falls prevention was everyone’s business. By increasing education and developing a nurse-led prompt for a medication review, this project aimed to increase awareness and responsibility for reducing medication-related falls in our 179 bed facility.

What we did

  • Gathered perspectives of management and stakeholders to determine project objectives and outcomes
  • Collected information on falls of six months from January to July 2015
  • Completed a trend analysis from the information to use as a baseline
  • Examined time frame comparisons to determine if there was a temporal relationship with falls (i.e. if falls occurred more frequently at a particular time of the day/night)
  • Improved falls descriptors in routine data collection to identify the type of falls (i.e. fall from chair on standing or rolls from bed while resting)
  • Involved pharmacists, the clinical team and GPs to develop a collaborative approach to falls
  • Developed a ‘Residential Medications Management Review’ (RMMR) referral form to be used as a nurse led prompt to organise a collaborative medication review
  • Commenced education sessions for clinical staff
  • Conducted daily meetings with the clinical team at handover time so that frequent fallers could be identified by the clinical staff and a referral for RMMR was organised
  • Encouraged staff involvement with a multi-disciplinary approach through regular meetings, to discuss RMMR recommendations and encourage brainstorming to determine multi-factorial solutions to prevent the risk of falls
  • Organised a training programme for care staff
  • Organised a falls awareness week for all staff, residents and relatives
  • Organised a Walk for Falls fun day encouraging participation from staff, residents relatives and the community
  • Monitored falls statistics over the following six months from July to December and evaluate the effectiveness of the programme.

Why we did it
Falls are the most serious frequent accident among older people, with the risk of falls and subsequent injury, morbidity and mortality significantly higher in aged care settings.

Our Medication Advisory Committee (MAC) raised concerns about the number medication related falls occurring in our 179 bed facility. There was particular interest in known risk factors for medication related falls such as polypharmacy, the use of benzodiazepines, hypnotics or psychotropic and postural hypotension. The potential for a mechanism to trigger GP-Pharmacist medication review where facility staff (nurses, carers) or family members were concerned about medications influencing falls risk was also addressed.

Falls information and statistics were collected from the previous six months (January to July 2015) and revealed a concerning increased trend in the occurrence of falls. These falls were further examined to determine if there was a temporal relationship with falls (i.e. if falls occurred more frequently at a particular time of the day/night). The “types” of falls were determined to improve the descriptors in routine data collection (i.e.fall from chair on standing)

The pharmacist members of the MAC considered a more interdisciplinary approach could increase awareness of the impact of medicines on falls risk, as well as provide an opportunity to prompt GPs for a collaborative medication review. Several activities were suggested for this project, with the ultimate aim to reduce the number of falls, and the risk of falls for residents while creating a culture of shared care for falls prevention across the entire facility.

Who worked with us
This project was a great example of a whole of facility effort to reduce the risk of falls. Stakeholders included:

  • Medication Advisory Committee –Services Manager, Community Pharmacy pharmacists, independent review pharmacists, GPs, Nurses
  • Management
  • Nurses
  • Allied health
  • Team leaders
  • Carers
  • Cleaners
  • Residents
  • Residents family members
  • Community

What we learned
This project was a resounding success, not only raising awareness of the causes of falls and the potential to prevent these by every staff member within our facility, but also in impressively reducing the incidence of falls.

Falls reduced from an average of 36 per month at the beginning of the project to 19 at the end of the year. This impressive result has been possible thanks to our team of allied health, clinical and care staff as well as the cleaners and kitchen staff in their vigilance to ensure the safety of the residents.

Finally, the residents celebrated the project, ensuring this was a truly resident-centred across-facility initiative which resulted in improved collaborative care for residents at risk of falls.

Timely access to medication review for residents at risk of falls
All residents now have a timely Residential Medication Management Review (RMMR) conducted by our team of doctors and reviewing pharmacists early on in their admission to our facility. The newly developed nurse-led prompt for an RMMR has been very effective, not only for new residents, but also for any residents who have been unwell, have had a fall (considered to be potentially due to medication) or have had a hospital stay where their medication management has changed.

This has resulted in an approximately three-fold increase in the number of medication reviews being conducted at our facility. (40 RMMRs for 10 months in 2014, versus 118 RMMRs for the same period in 2015.) This increase in RMMRs has been primarily due to the nurse initiated referral form embraced by the clinical staff and the doctors alike. We consider the provision of timely, targeted medication reviews to have directly impacted on a reduction in resident falls. Falls during 2016 have continued to remain under 20 per month, strongly suggestive that these positive outcomes are sustainable. Antipsychotic use has decreased and sedatives (particularly temazepam) have been reduced to PRN whenever possible.

Education workshops on medication risk embraced clinical team
Education workshops held by our pharmacists throughout the year, raised awareness and educated the clinical staff on the impact medications can have on falls.

Extending falls education from clinical staff to all facility staff
Clinical staff engaged the entire facility staff to improve awareness of how falls occur and how every member of staff can be actively involved in falls prevention. Staff on each floor including occupational therapists, physiotherapists and therapy staff, care staff, cleaners and kitchen staff all participated in decorating the whiteboards with ideas. Teams worked on questions including;

  • What is a fall?
  • What can cause a fall?
  • What are the consequences of falls?
  • How can we prevent a fall?

By the end of the day the boards were very colourful and full of good ideas and information! Informative games where care staff were blindfolded and asked to complete certain tasks helped provide awareness of the impact of poor eyesight on daily living for the residents. This added fun and laughter to an educational experience.

The Finale – Adding fun to falls prevention with facility staff and residents
At the conclusion of our project in December 2015, the entire facility (staff and residents) participated in a Christmas inspired “Lapathon All for Falls Walk”. The walk proved to be a huge success with lots of jolliment and laughter! Teams of all ages and areas were engaged, with a wonderful show by residents and their relatives. As teams pushed residents (and staff!) around the course, there was acknowledgement and encouragement from passers-by with toots and waves! $1,243.50 was collected in fundraising and a new hoist was able to be purchased as suggested by our physiotherapist. The “QUICKMOVE” hoist now assists residents to get their strength back so that they can walk again.

Our facility will continue to map our progress in terms of falls, both type and timing, number of nurse-initiated RMMRs and tracking drug use of sedatives and antipsychotics.

Sustainability
Falls during 2016 have continued to remain under 20 per month which proves that the project has had a sustainable outcome. Through collaboration between healthcare professionals, facility staff and residents, activities focussed on falls prevention produced a sustained reduction in the rate of falls in our facility. Engaging nurses to prompt for medication review for residents at high risk has resulted in a sustained reduction in falls. Continued education and fun-filled activities should ensure both reproducibility and sustainability for this resident-centred across-facility falls prevention initiative.

More information on this program:
Carole Balchand, caroleb@rslwvh.com, or phone 0420 958 633