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Overview

Created on November 10, 2015

Issue

A fall is defined as an event or unintentional change in position that results in a person coming to rest inadvertently on the ground or floor, or other lower level. 1, 2 Falls and fall-related injuries are among the most serious and common occurrences experienced by older adults. Falls can lead to a loss of independence and deterioration in one’s quality of life.2

Health Quality Ontario reported on its public reporting home care web page that in 2013-2014, 31% of long-stay home care clients had a fall in the 90 days prior to their last assessment, changing little from 30% in 2012-2013.3 In 2012-2013, 36% of home care clients were identified as being at risk of falling.4 In 2013-2014, approximately 55,000 home care clients across Canada were at risk of falling.4 (Figure 1)

However, an increasing proportion of home care clients have complex health issues, multiple chronic conditions, and thus higher care needs. The more complex the needs of a client, the greater the likelihood of having a fall. Community Care Access Centres (CCAC) in Ontario have been working with researchers and other stakeholders to develop falls prevention programs that are targeted toward these higher needs clients.5

In Ontario, in 2012-2013, the rate of fall-related hospitalizations was 12.1 per 1,000 seniors, compared to 16.3 across Canada. Half of the falls resulting in hospitalization in Canada occurred in or around the home. In Ontario, a person stayed in hospital for an average of about 8 days (for any reason), compared to about 11 days for a fall-related hospitalization.6 Those who have fallen before are more likely to fall again. It has been shown that having had a fall or multiple falls is the best predictor of falling again. About 40% of home care clients who have fallen once are at risk of falling again and 65% of clients who have had multiple falls are at high risk for future falls and injuries. Falls may indicate safety hazards in the home, functional decline, vision problems, reactions to medications, delirium, infections, or other conditions. 4

Causes and Consequences of Falls and Injury

There are several factors that can increase the risk of falling, including increasing age, multiple chronic conditions, limited mobility, medications, as well as several factors in the environment such as loose rugs, stairs, slippery surfaces, poor lighting, or exposed electrical cords. Individuals who have five to seven chronic conditions have more than a two and a half times risk of falling and four and a half times risk of sustaining an injury from a fall, compared to those without chronic conditions.7, 8 As noted above, in Ontario, many more home care clients have complex needs, such as multiple chronic conditions. Falls in seniors can result in injury, disability, a reduced quality of life, and in severe cases, death.6 Falls and fall-related injuries are a strong predictor of admission to a long-term care home. In seniors who have experienced two or more falls without injury, the risk of admission to a nursing home is five times higher and those who experienced an injury have a 10 times higher risk of being admitted to a long-term care home.7

Call to Action

In 2012-2013, 84% of home care clients in Ontario were 65 years or older, with the average age of 78. 9 Preventing falls and injuries in frail seniors is imperative, as it will allow seniors to remain at home and maintain their quality of life, reduce hospital admissions and readmissions, and delay entrance into a long-term care home. 10 Data from the Canadian Institute for Health Information show that the percentage of home care clients who require a care plan for falls has increased steadily from 28% in 2007-2008 to 36% in 2012-2013.11 By training and providing support to personal support workers, other home care workers, and family caregivers on increasing safety measures in the home and decreasing the risk of falls, we can ensure that further declines are averted, the quality of life of those being cared for at home improves, and hospital visits are avoided. The tabs on measurement, best practices, and tools and resources will provide direction on how to make these improvements and implement them in the homes of the clients your organization cares for.

Ontario is the first jurisdiction to publicly report on home care quality indicators. Being able to measure and monitor your efforts is one of the first steps in any quality improvement initiative. The tools and information provided in this quality improvement resource will lead you on a path toward providing home care clients with the best possible care.

  1. Morris JN, Berg K, Bjorkgren M, Declercq A, Finne-Soveri H, Fries BE, et al. interRAI Community Health (CHA) Assessment Form and User's Manual. Version 9.1. Canadian Edition.

    Washington, DC: interRAI; 2010.
    Available from: http://ebooks.interrai.org/product/interrai-community-health-cha-assessment-form-users-manual-electronic-edition

  2. Registered Nurses' Association of Ontario. Nursing Best Practice Guideline: Prevention of Falls and Fall Injuries in the Older Adult.

    Toronto: RNAO, 2011.
    Available from: http://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries-older-adult

  3. Health Quality Ontario. Public Reporting.

    Home care-Falls. 2014.
    Available from: http://www.hqontario.ca/Public-Reporting/Home-Care

  4. Accreditation Canada, Canadian Institute for Health Information, and Canadian Patient Safety Institute.

    Preventing Falls: From Evidence to Imrpovement in Canadian Health Care. Ottawa, ON: CIHI; 2014.
    Available from: Available from: https://secure.cihi.ca/free_products/FallsJointReportAugust6_2014_CPHI_EN_web.pdf

  5. Community Care Access Centre. How we care. 2012-2013 CCAC Quality Report.

    Toronto: CCAC, 2013.
    Available from: http://oaccac.com/Quality/Documents1/2012-2013-CCAC-Quality-Report-EN.pdf

  6. Scott V, Wagar L, Elliot S. Falls and related injuries among older Canadians: Fall -related hospitalizations and prevention initiatives. Prepared on behalf of the Public Health Agency of Canada, Division of Aging and Seniors.

    Victoria, BC: Victoria Scott Consulting, 2011.
    Available from: http://www.hiphealth.ca/media/research_cemfia_phac_epi_and_inventor_20100610.pdf

  7. Health Quality Ontario. Aging in the community: summary of evidence-based analsyses.

    Ontario Health Technology Assessment Series. 2008;8(1).
    Available from: http://www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/aging-in-the-community

  8. Safer Healthcare Now! Reducing falls and injuries from falls. Getting started kit. Registered Nurses Association.

    Canadian Patient Safety Institute, 2013.
    Available from: http://www.patientsafetyinstitute.ca/en/toolsresources/pages/falls-resources-getting-started-kit.aspx

  9. Canadian Institute for Health Information. Home Care Reporting System. Quick Stats.

    Ottawa: CIHI, 2007-08, 2008-09, 2010-11, 2011-12, 2012-13.
    Available from: http://www.cihi.ca/CIHI-ext-portal/internet/EN/TabbedContent/types+of+care/community+care/home+care/cihi021338#_Metadata

  10. Health Council of Canada. Seniors in need, caregivers in distress: What are the home care priorities for seniors in Canada?

    Toronto: Health Council of Canada, 2012.
    Available from: http://www.healthcouncilcanada.ca/rpt_det.php?id=348

Best Practices

Created on November 10, 2015

“Insanity is doing things the way we’ve always done them and expecting different results”
Albert Einstein

Evidence-informed best practices are based on quality evidence and should be implemented into practice to optimize outcomes. Listed below you will find best practices graded according to the level of evidence. To view a description of the levels of evidence, click here.

Change ideas are specific and practical changes informed by experience and research that focus on improving specific aspects of a system, process or behaviour. To learn more about change ideas see the QI: Getting Started tab.

A 2008 HQO analysis of falls and fall-related injuries in community-dwelling seniors examined the existing literature to identify interventions that may be effective in reducing the probability of a senior falling and/or sustaining a fall-related injury. Eleven interventions were identified in the literature, of which seven had some level of evidence to support their use in preventing falls and fall-related injuries.1 These interventions have been shown to be cost effective.2 For more details on the evidence found for each of these interventions, read the Aging in the Community: Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors report.

Listed below are best practices to reduce and prevent falls and related injuries. These are based on literature reviews of evidence for each practice. To help you move from best evidence to best practice, click on the + button next to each best practice to find implementation details, as well as change ideas that you can test using a PDSA approach.

Best practices need to be tailored to client characteristics. The Registered Nurses’ Association of Ontario has created an Implementation Toolkit to guide this process.


Notes

i Assessments don’t necessarily lead directly to lower incidence of falls.

ii Systematic reviews and other high levels of evidence show that polypharmacy and psychotropic medications increase risk of falls, but there is no clear evidence to support withdrawal of medications.

iii Primary research shows an association between cognitive impairment and falls, suggesting the need for cognitive assessment.

iv Randomized Clinical Trial studies supporting client education were mostly conducted in hospitals; Expert opinion supports client education in home and community care.

  1. Health Quality Ontario. Aging in the community: summary of evidence-based analyses.

    Ontario Health Technology Assessment Series. 2008; 8(1).
    Available from: http://www.hqontario.ca/evidence/publications-and-ohtac-recommendations/ontario-health-technology-assessment-series/aging-in-the-community

  2. Gillespie LD, Robertson, MC, Gillespie, WJ, Sherrington, C, Gates, S, Clemson, LM, Lamb, SE. Interventions for preventing falls in older people living in the community.

    Cochrane Systematic Review. 2012 September.
    Summary available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014335/

  3. Registered Nurses' Association of Ontario. Nursing Best Practice Guideline: Prevention of Falls and Fall Injuries in the Older Adult.

    Toronto: RNAO, 2011.
    Available from: http://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries-older-adult

  4. Shubert TE. Evidence-based exercise prescription for balance and falls prevention: a current review of the literature.

    Journal of Geriatric Physical Therapy 2011;34(3):100-8.
    Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/22267151

  5. Hurst, R. (2008). Practice alert for falls prevention.

    Saint Elizabeth.

  6. Health Canada (2006). It's your health. Seniors and aging - preventing falls in and around your home.
    Available from: http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/life-vie/fp-pc-eng.php

  7. Cameron ID, Murray GR, Gillespie LD, Robertson MC, Hill KD, Cumming RG, et al. Interventions for preventing falls in older people in care facilities and hospitals.

    The Cochrane Collaboration. 2012.
    Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005465.pub3/abstract

  8. Hegeman J, van den Bemt BJ, Duysens J, van Bimbeek J. NSAIDs and the risk of accidental falls in the elderly: a systematic review.

    Drug Safety. 2009;32(6):489-98.
    Abstract available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0028563/

  9. Hartikainen S, Lonnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review.

    Journal of Gerontology. 2007;62(10):1172-81.
    Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/17921433

  10. Bloch F, Thibaud M, Dugue B, Breque C, Rigaud AS, Kemoun G. Psychotropic drugs and falls in the elderly people: updated literature review and meta-analysis (Structured abstract).

    Journal of Aging and Health. 2011;23(2):329-46.
    Abstract available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0032439/

  11. Balzer K, Bremer M, Schramm S, Luhmann D, Raspe H. Falls prevention for the elderly.

    German Medical Science Health Technology Assessment. 2012;8.
    Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3334922/

Measurement

Created on November 10, 2015

How will we know if a change is an improvement? Measurement is one of the critical steps in a quality improvement (QI) initiative that assesses the impact of your tests of change. Quality indicators are used to measure how well something is performing. There are three types of quality indicators used to measure your QI efforts: outcome (indicators that capture clinical outcomes and or system performance), process (indicators that track the processes that measure whether the system is working as planned), and balancing indicators (indicators that ensure that changing one part of the system does not cause new problems in other parts of the system).

Type of Indicator Indicator of Quality Improvement How to Calculate:

numerator
__________

denominator
Targets/ Benchmarks How is This Indicator Used?
Outcome Percentage of adult long-stay home care clients who record a fall on their follow-up RAI-HC assessment The number of home care patients who fell in the last 90 days
The number of home care patients not totally dependent on bed mobility on assessment1
Targets: As low as possible (set by individual homes)

Provincial benchmarks:
not available
Quality improvement

QIP indicator

Publicly reported by HQO
1. Excludes patients whose most recent assessment is within 60 days of when referral was first received or was completed in the hospital setting. For indicators requiring a reassessment, excludes patients whose previous assessment was completed in the hospital setting.

Tools & Resources

Created on November 10, 2015

Tools

Safer Healthcare Now! provides a comprehensive resource to help providers reduce falls and injuries in home care, as well as in hospitals and long-term care homes. Safer Healthcare Now!’s Reducing falls and injuries from falls: Getting started kit provides definitions, tools, measures, and implementation and measurement guidelines to facilitate reduction of falls and injuries among your clients. This kit also provides some indicators and specifies how to collect data. You may choose to submit your data to Safer Healthcare Now! to evaluate your initiatives and compare your performance to other home care providers.

Below you will find additional tools for reducing falls and quality improvement.

Tools for Falls Prevention and Home Optimization
QI Tools

 

Resources

Resources for falls prevention and home optimization
QI Resources