25 Years of Patience and Effective Presence edited

Issues involved in incorporating these evidence-based fall prevention interventions into outpatient practice are discussed, as are the trade-offs inherent in managing older patients at risk of falling. While challenges and barriers exist, fall prevention strategies can be incorporated into clinical practice. Mr Y, an year-old retired salesman, lived independently until 3 years ago.

He had a right humeral fracture in and a left hip fracture 3 months later.

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After hip fracture repair and rehabilitation, he moved in with his daughter, a physical therapist. In , Mr Y fractured his right hip in a bar brawl; he used alcohol heavily until a few years ago. He became delirious when taking oxycodone ER, 10 mg every 12 hours. In June , his daughter brought Mr Y to see Dr C, a geriatrician, who noted pruritus, chronic rhinorrhea, and weight loss.

Mr Y scored 28 of 30 on the Folstein Mini-Mental State Examination 1 ; he missed the date and recalled 2 of 3 objects at 5 minutes.

Canadian Patient Safety Institute

He weighed lb. There was tenderness to palpation over the left greater trochanteric region; the hardware from his hip surgery was palpable. The Romberg test result was negative. The most frequently recommended screening test for mobility, this test takes less than 1 minute. Have the patient get up from a chair, walk 10 feet, turn, return to the chair, and sit down.

Any unsafe or ineffective movement suggests balance or gait impairment and increased risk of falling, and the patient should be referred to physical therapy for complete evaluation and treatment. Mr Y was very slow and unsteady getting out of the chair; he had flexed posture and a slow, shuffling gait. A person who fails this quick mobility screen should have a more complete balance or gait evaluation by a physician or a physical or occupational therapist. The POMA involves assessing the quality of transfer, balance, and gait maneuvers used during daily activities and takes about 5 to 10 minutes to complete.

The POMA is not appropriate for very functional patients or patients with a single disabling disease such as Parkinson disease or stroke. While there are several versions of the POMA, one feasible in a busy ambulatory setting includes observing these transfer and balance maneuvers: In addition to determining if the patient is at risk of falling, the POMA can be used to ascertain if there are balance and gait impairments that require intervention eg, cane or walker and to assess for the presence of possible neurological or musculoskeletal disorders.

For example, difficulty getting up without arms suggests proximal muscle weakness; difficulty with gait initiation suggests fronto-subcortical disorders such as Parkinson disease or normal-pressure hydrocephalus; worse performance with eyes closed than open suggests peripheral neuropathy or vestibular problem; wide-based gait that worsens with eyes closed and improves with handheld assist suggests peripheral neuropathy; leg crossing the midline suggests central nervous system disorder such as stroke or normal-pressure hydrocephalus; shorter step with one leg suggests a muscle, joint, or nervous system problem on the opposite side.

A version of the POMA, with scoring, can be found at http: Copies of the assessment with instructions and scoring can also be obtained from the author. Results of urinalysis, complete blood cell count, and routine serum chemistries were normal. A left hip radiograph revealed nonunion and bony collapse. A magnetic resonance imaging scan of the brain revealed multiple infarcts.

In September , an orthopedist injected corticosteroids in the area of the left greater trochanteric bursa.

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He was discharged from PT when he was no longer making progress. He used a 4-wheel walker. Over the next few months, he continued to fall. One fall occurred after he took a cold medication containing diphenhydramine. Another fall occurred in July after he inadvertently took several sublingual nitroglycerin tablets and developed dizziness and headache.

Results of computed tomography of the head were unremarkable. Mr Y was sent home but continued to feel dizzy. Dr C subsequently stopped the lisinopril and reduced the dose of metoprolol. In November he underwent removal of his left hip fixation plate and screws and restarted PT. The dose of vitamin D was increased to IU daily.

June 3rd - June 6th, 2019 (Ottawa, ON)

He had no further falls. Mr Y denied that his falls were a significant problem.

He declined a paid attendant or referral to adult day care but agreed to a personal emergency response system when it was explained that this would give his daughter peace of mind. It was a big worry of my daughter and my doctors. He was on a lot of different medications and was having a lot of pain … a lot of medical issues….

We had meetings with the doctors, social workers, and therapists. I told him that it would be more of a burden … to be too far away…. Falling can cause lasting discomfort and decreased function, imposing family and societal care burdens. More than one-third of community-living adults older than 65 years fall each year. Falls are major contributors to functional decline and health care utilization. Falling without a serious injury increases the risk of skilled nursing facility placement by 3-fold after accounting for cognitive, psychological, social, functional, and medical factors; a serious fall injury increases the risk fold.

As with other conditions affecting older adults, such as delirium and urinary incontinence, falling is classified as a geriatric syndrome. Defining features of geriatric syndromes include the contribution of multiple factors and the interaction between chronic predisposing diseases and impairments and acute precipitating insults.

Falls that occur during usual daily activities generally result from diseases or impairments affecting 1 or more systems. We conducted 3 systematic reviews, focused on community-living older adults, to identify 1 multiple impairments and conditions predisposing to falls; 2 effective physical therapy and exercise interventions; and 3 effective multifactorial interventions.

The search strategies, search results, and publications resulting from each search are presented in the eAppendix , available at http: The factors identified in the systematic review as contributing independently to risk of falling or experiencing a fall injury in at least 2 of the 33 studies appear in Table 1. The strongest risk factors for falling include previous falls; strength, gait, and balance impairments; and use of specific medications. Of note, falls and fractures share many risk factors. The risk of falling increases with the number of risk factors.

Medications are particularly complex risk factors for falling. Diseases such as depression, heart failure, or hypertension may increase fall risk but so also may the medications used to treat them. Common adverse medication effects such as unsteadiness, impaired alertness, and dizziness are risk factors for falling. Single as well as multifactorial interventions have been investigated in randomized controlled trials. The 1 trial of cardiac pacing in persons with cardioinhibitory carotid sinus hypersensitivity who had fallen was associated with a reduced rate of falling relative risk [RR], 0.

Reducing the number of medications consumed was associated with a reduction in fall risk in 1 trial, although efforts to reduce psychoactive medications were not effective. Exercise is the most widely studied single intervention. Twenty-five trials of either tai chi 6 trials or combinations of strength, gait, balance, and endurance training 19 trials were identified in the systematic review eAppendix.

All of the positive trials included balance training as one component. Only 1 of 5 trials of a single exercise component reduced falls. The frequency and intensity of the exercise programs varied among the effective trials. Evidence supports progressive balance and strength, and perhaps endurance, training for fall prevention, although the optimal frequency and intensity remain to be determined.

Multifactorial trials included those in which investigators carried out the intervention components or directly ensured that the interventions occurred and those in which investigators only offered advice or referral to existing community or health care sources. Among the former group with direct interventions, at least 1 fall-related outcome was better in the intervention group than in the control group in 8 of 11 trials Table 2.

The Patient Who Falls

Other systematic reviews and meta-analyses have drawn conflicting conclusions about the effectiveness of multifactorial interventions. Components included in the clinical trials are listed in the eTable. The preponderance of evidence supports multifactorial interventions as the most effective preventive strategy.

The only study of cognitively impaired community-living older adults individuals presenting to an emergency department after a fall showed no significant difference between the intervention group, which received management of medical problems, modification of psychotropic medications, PT, and home hazard modification, and the control group RR, 0. The eBox lists risk factors for osteoporosis and fractures, recommendations for screening, and evidence for treatment and prevention, in older men.

I know my Dad only tells people what he wants them to know … like why he was falling before he came to live with me; there was alcohol involved and nobody knew that but him and me…. The first clinical issue is deciding who should have risk factors for falling assessed and treated. Evidence suggests that persons older than 65 years who present with a fall, report at least 1 injurious fall or 2 or more noninjurious falls, or report or display unsteady gait or balance Box should undergo fall risk factor assessment and management.

The American Geriatrics Society guideline recommends this screen at least yearly. We went problem by problem and came up with a plan to reduce his risk of falling…. We attacked the muscle weakness by having him go through extensive physical therapy and making sure he has the appropriate assistive devices … [we did] a home safety evaluation…. We started him on calcium and vitamin D …. The multifactorial nature of fall prevention means that care must be coordinated among physicians, nurses, physical therapists, and occupational therapists.

A primary care clinician can coordinate care by assessing and managing the medical components and referring patients to home care or outpatient rehabilitation. Alternatively, interdisciplinary fall teams or clinics are available at many geriatric or rehabilitation centers. Regardless of location or disciplines involved, effective fall prevention requires assessing potential risk factors, managing the risk factors identified, and ensuring that the interventions are completed.

Potential trade-offs must be considered in formulating the assessment and management strategy. Assessment should focus on determining the circumstances of previous falls and on identifying risk factors or factors known to be the target of effective interventions Table 1 and Table 3. The assessments of fall risk listed in Table 3 should be completed in all older patients at risk.

A decreased vitamin D level The examination should include cognitive evaluation, postural blood pressure measurement, cardiac rhythm and rate, muscle strength, joint range of motion, and examination of the feet and proprioception Table 3. A balance and gait screen or evaluation should also be performed Box. The evidence suggests that improving as many of the factors listed in Table 3 as possible is the most effective way to reduce the risk of falling. Medication reduction, physical therapy, and home safety modifications have the strongest evidence of benefit for fall prevention in clinical practice.

I took off a lot of blood pressure medications because he was feeling dizzy and his pressure was low…. We need to make sure that we control the pain, because if you have severe pain … you get deconditioned and you fall. On the other hand, the more medications you take, you run the risk of getting more confused … it increases the risk that … he might fall…. Dizziness or lightheadedness on standing or the use of 4 or more medications should prompt the measurement of postural blood pressure and reduction in the number and dosages of medications. Particular attention should be given to the possible elimination or dose reduction of medications known to increase orthostasis or fall risk Table 3.

The presence of multiple health conditions necessitates a consideration of trade-offs between benefits vs risks of medications, particularly when the treatment of one condition may worsen another. Few data currently exist to guide decision-making for these trade-offs. The clinician must consider which condition presents the greatest threat to the outcome priority of greatest importance to the patient. Dr C articulated well the trade-off between pain management and fall risk for Mr Y.

Because pain is a risk factor for falling, 55 appropriate treatment may reduce fall risk. Pain assessments result in improved detection and treatment. The American Geriatrics Society pain management guideline provides strategies for older adults Resources, available at http: Adding vitamin D, IU and probably without calcium, is indicated in patients such as Mr Y, who are deficient. My doctor and my daughter … decided [an emergency alert necklace] would be good … and it is. When he had the [hip] hardware removed, I requested [physical] therapy again…. Home safety evaluations and modifications, as described in Table 3 , can be self-conducted Resources or performed by a nurse, physical therapist, or occupational therapist.

Patients with reported or observed balance or walking problems should be referred for PT. If homebound, a patient is eligible for treatment by a Medicare-certified home care agency if progress is documented. If not homebound, then the patient must be referred to outpatient rehabilitation, and the therapist must rely on self- or family-report of home safety issues. Available evidence suggests that, for fall prevention, PT should consist of progressive standing balance and strength exercises; transfer practice; gait interventions, including evaluation for an assistive device cane or walker ; and instructions in techniques for arising after a fall.

Referral should be made to therapists skilled in evidence-based progressive balance training for older patients Resources. Endurance training, such as walking, should be added when safe. A challenge is that ongoing exercise is needed to maintain improvements after therapy ends.

In addition to recommending walking, referral to community programs targeting older adults should be considered Area Agencies of Aging may have this information. There is insufficient evidence to determine if PT is beneficial for patients with dementia. Occupational therapy for community-dwelling at-risk older adults focuses on safe ADL functioning; upper-extremity function; activity to lerance; and mobility. For patients with dementia, occupational therapists counsel caregivers about strategies for safe functioning.

He does everything the least safe, worst way possible! Persons at risk for falling face trade-offs between safety and functional independence. To reduce fall risk, they may have to avoid desired activities or rely on help. Conversely, patients may have to accept risk of serious injury if they wish to continue performing activities beyond their balance capability. If there is any question, the clinician must ascertain whether the individual has the capacity to make informed decisions, either by interviewing the patient and family or by referring the patient to a psychiatrist or geriatrician.

As was evident with Mr Y and his daughter, the family may prioritize safety while the patient values independence and mobility. The Improvement Resource includes a summary of evidence-informed practices that reduce the likelihood of harm, and suggested measures for outcomes and processes. For example, evidence-informed practices for Delirium include developing a standardized protocol for preventing or managing delirium, including identifying and treating underlying causes; implementing non-drug strategies such as early mobility; implementing environmental strategies such as visible daylight; and reassessing sedation daily.

For Medication events the evidence includes conducting an organizational Medication Safety Self-Assessment; implementing medication reconciliation and high-alert medication safety processes; and improving core processes for ordering, dispensing and administering medications. Also included in the resource are patient stories, success stories, standards and required organizational practices associated with each clinical group.

The Improvement Resource is a dynamic tool that the Canadian Patient Safety Institute will continue to update as new tools and approaches are developed and more evidence-informed practices emerge. The hospital harm project aims to provide health system leaders with better information on patient safety and support patient safety improvement efforts. Armed with evidence-informed practices compiled through continued research efforts and united through collaboration, clinicians, hospital staff and patients can all play a role in improving safety in Canadian hospitals.

For more information, visit www. The Collaborative aids in knowledge exchange and provides advice and recommendations to the Atlantic Deputy Ministers of Health for the purpose of advancing quality improvement and patient safety across Atlantic Canada. The focus and purpose of the AHQPSC is to help us to advance patient safety knowledge and initiatives across our jurisdictions -- to build capacity, foster relationships and share information, knowledge and expertise.

The Collaborative was created by the Ministries of Health from the four Atlantic Provinces in , to help us learn from each other. The Steering Committee is comprised of 13 members, with three representatives from each of the four Atlantic Provinces two come from the health system and one from the provincial Health Ministry , and a local member of Patients for Patient Safety Canada that sits as the patient and family representative. What are some of the key initiatives that the Collaborative has undertaken? One of the four Atlantic provinces hosts the Conference every second year, with support for planning coming from all members of the Collaborative.

With CPSI at the table, we add national and international perspectives on the advancement and improvement of safety and patient care. The ALE is an opportunity to talk about what is happening in each province and to recognize and celebrate patient safety initiatives across Atlantic Canada.

The next ALE will take place in St. John's, Newfoundland on October , This will be our fifth conference and we welcome everyone interested to come and learn more about our work. The Collaborative has made an investment in patient safety and quality training. By investing in these types of training, we have been able to advance the skill level of a large group of people within each of our respective provinces. This would not have been achievable as individual jurisdictions. In terms of resource materials, the Collaborative was involved in the development of a patient engagement framework in partnership with the Canadian Patient Safety Institute and Health Quality Ontario.

Earlier this year, the Collaborative assisted with revising the guide. This extensive resource is based on evidence and leading practices and aims to help patients and families, patient partners, providers, and leaders work together more effectively to improve patient safety. One of our current priorities is supporting a month virtual collaborative around patient engagement in patient safety and quality improvement. In the past, our collaboratives have taken an in-person format, so this is an opportunity to try something new.

The virtual collaborative was launched in September with 17 teams from the four Atlantic Provinces participating. Over the next year, teams will receive coaching on how to improve patient engagement, learn new strategies, and work together as a larger community to ensure we are at the top of our game in terms of patient engagement. What makes the Collaborative unique and innovative? The Atlantic Provinces have taken a multi-provincial approach in building relationships and seeking opportunities to collaborate on patient safety initiatives.

This makes us unique in Canada. We come together to identify priorities and pool our resources to produce results that can be utilized across Atlantic Canada. We aren't aware of any other jurisdiction that has seen this type of cross-province success in their partnerships. What makes the Collaborative successful is that we have been able to go explore areas that may not have been given the same amount of thought if we had all been working independently. We have been able to tackle priorities together; we may be at different places along the road, but we are able to work on priorities that are important to all of us.

This strong collaboration facilitates the sharing of ideas and learning across all of Atlantic Canada, which has proved to be effective, efficient, and also ensures standardization across the jurisdiction. In terms of value and how we do our work, we have representation from all four provincial Health Ministries sitting at the table, along with the delivery arm of the system, to have conversations and establish priorities.

We sit at the table together, share information and develop an approach to take us along the patient safety journey. What learnings or takeaways has the Collaborative provided for you? Debbie For me personally, gaining an in-depth understanding of both patient safety and quality improvement has been very beneficial.

Being part of the Collaborative has also offered a different level of thinking and learning around how to engage patients and the value of having the patient and client at the table. Colin In healthcare, or otherwise, it is important that we have alignment within more than one province. We have been able to identify some truly remarkable things to focus on, targeted our resources to develop them together, and put them into use across the four Atlantic Provinces.

We don't often see such success in working across provincial boundaries. This was an eye-opener for me. We have seen progress and we all continue to have a commitment to the work we are doing together across the Atlantic Provinces. Is the Collaborative a model that others could replicate? At the end of the day, it is about finding the common ground, something that all parties are interested in advancing together.

We have been able to tap into the expertise and knowledge of CPSI, which is very helpful. We are not big provinces, and at times it is a bit of a lonely space to be in. You can't always look at other jurisdictions and feel like you are talking to someone who is similar to you, which is an advantage that we are grateful to have at the Collaborative table.

The fact that we have a pan-Canadian partner who has the knowledge and processes to support and bring people together is a huge advantage. We have had great success in our partnership with the Canadian Patient Safety Institute. When people are coming together on their own it can be a bumpy road, but if you leverage a partner to help you identify opportunities, it certainly makes the journey easier.

Where can our readers go to learn more? We are happy to lend our expertise nationally! Contact us at Colin. As the Vice President of Quality and System Performance with the Nova Scotia Health Authority, Colin is responsible for leading the development and implementation of strategic plans, goals and objectives to support the delivery of provincially integrated health programs and services; and ensuring there are structures, systems and processes in place to enable the Nova Scotia Health Authority to achieve the best outcomes in health care program and service with a focus on quality, performance and patient safety.

Debbie Molloy is a human resources professional with 20 years of experience in the healthcare, energy and hospitality industries. She has worked in both the public and private sectors and brings a broad understanding of the challenges and opportunities facing health care in today's environment. Her career path has allowed her to develop expertise in the areas of organizational effectiveness, talent management and employee relations.

Beyond human resources she has also a solid background in quality improvement and patient safety. With the holidays coming up and the weather getting colder, it makes sense to share warm thoughts of family and home in the last month of the year. I believe that we had a great deal of success in spreading the word that Not All Meds Get Along and encouraging conversations about medication safety between patients and their healthcare providers.

Our successes during Canadian Patient Safety Week are a vital part of all the exceptional work we have accomplished in the past month.

I am delighted with the progress of these two projects, since they both lend support to our mission of inspiring and advancing a culture committed to sustained improvement for safer healthcare. With over 80 residents from Nova Scotia and the Maritimes in attendance, patients, caregivers, academics, students and providers had their voices heard on pharmacare. Several speakers mentioned the importance of medication safety and the need for improved information for patients, medication reconciliation, polypharmacy and the value of a national surveillance system.

CPSI has already provided a submission to the Council and we will be forwarding a synopsis of this event to Health Canada. In less than five minutes, you can help ensure clear labels for products that can pose a risk for Canadians and help us achieve our goal of patient safety… right now! Super Early Bird Deadline: Executive Training Program https: This course will help you to improve team collaboration, clinical outcomes and patient safety at your organization. It looks like your browser does not have JavaScript enabled.

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