Implementing AMDA's Falls & Fall Risk CPG in the Clinical Setting

by Kathleen Frampton, RN, MPH, AMDA's Project Coordinator, Clinical Affairs
and Jacqueline Vance, RNC, AMDA's Director of Clinical Affairs

Most clinicians and regulators would attest to the value of clinical practice guidelines (CPGs) as quality-improvement tools because they serve to delineate best practices and minimize variation in treatment. There is also widespread agreement on the unique challenges guideline implementation pose to the direct care staff. AMDA has attempted to meet the needs and concerns of the clinical community in this area in a variety of ways.

AMDA recently published We Care: Tools for Providers and Staff to Implement Clinical Practice Guidelines, a follow up to its 1998 Guideline Implementation CPG. The new tool kit provides real-world assistance to facility staff by addressing common pitfalls, assessing facility strengths and weaknesses, and presenting concrete ways to overcome obstacles.

To further illustrate CPG implementation in the real world, we interviewed Barbara Resnick, PhD, CR , a member of the AMDA CPG Steering Committee, President of the National Conference of Gerontological Nurse Practitioners, and a member of Caring's Editorial Board. Dr. Resnick participated in the development of the We Care Tool kit, and is lead investigator for an AMDA Foundation study on the feasibility of implementing two AMDA CPGs (Chronic Pain Management and Falls and Fall Risk), and assessing their effectiveness on specific clinical-process and outcomes data in 22 nursing homes in Maryland. Dr. Resnick is also the lead investigator for a related descriptive case study on the implementation of the Falls and Fall Risk CPG in one Maryland nursing home. The study provides a model for implementing this CPG in long-term care.

Starting with the larger, multi-site study, how did you manage to recruit so many nursing homes to participate in the research?

Dr. Resnick We introduced the AMDA CPGs to representatives of 40 facilities in the state of Maryland during a full day continuing education session presented by the Beacon Institute, Mid-Atlantic Lifespan, the Maryland Medical Directors Association, and the Health Facilities Association of Maryland. After the session, representatives of 32 of the facilities volunteered to implement the chronic pain management and/or the falls and falls risk CPGs. A meeting was set with the nursing home administrator and director of nursing of each facility that volunteered to implement a CPG. Following this discussion, a consent form was obtained from the director of nursing.

As it turned out, 23 facilities consented to participate in the study. Of the remaining nine, four declined to participate, two did not respond to follow-up calls or letters, and three expressed interest in participating at a later time.

Of the 23 facilities that consented to participate, 13 implemented the falls CPG, 10 implemented the pain CPG, and eight implemented both CPGs.

What type of study design did you use?

Dr. Resnick We took a combined quantitative and qualitative approach. Specific outcomes were assessed six months prior to implementing the guidelines and six months after implementation. In addition, the director of nursing from each facility was interviewed and asked to describe the facility's experience with implementing the guideline 12 months following implementation.

Quantitative data collection focused on process indicators for the implementation of each CPG, as well as clinical outcomes. Both process and outcome indicators were evaluated at six-month intervals. A total of 10 cases per facility were randomly evaluated for both process and outcomes. In addition, we obtained cumulative outcome indicators, using the Minimum Data Set, from each facility. We also compiled a Process Indicator Score Sheet for each facility.

What were the results of this multi-site study with respect to falls?

Dr. Resnick A recently completed preliminary analysis for facilities that implemented the falls CPG show some positive findings and support for the CPG's effectiveness. Specifically, there was an increase in the average percentage of what we termed "indicators of guideline implementation"--that is, specific tasks and behaviors that demonstrated that the guideline was actually followed in the clinical setting. These indicators included: (1) evidence of a form for fall risk; (2) evidence of an evaluation for fall cause; (3) completion of a risk form; (4) treatment of the fall; and (5) evidence of re-evaluation of the intervention.

Following implementation of the falls CPG, there was an increase in the incidence of the measure of "no falls in the past 30 days" and a decrease in incidence of the measure of actual falls in the past 30 days. There was also an increase in residents who improved in overall function and a decrease in residents who declined functionally.

You mentioned that the director of nursing from each facility was interviewed and asked to describe the facility's experience 12 months following CPG implementation. What did you discover?

Dr. Resnick The directors of nursing identified four themes related to the implementation process: challenges to implementation, process recommendations, benefits to implementation, and future recommendations.

Challenges to the implementation of clinical guidelines included: staff education, helping staff to consistently carry over what they needed to do to appropriately implement the guideline, getting staff "buy in," dealing with turnover and float-pool staff, staff accountability, work load, assessment and documentation issues, and the ongoing maintenance of the program once it was initiated.

During these interviews, these nurses also shared recommendations for processes that would facilitate implementation. They suggested not taking on too much--i.e. implementing one CPG at a time--meeting with and including the staff in the process, helping staff to know the rationale for implementation, properly educating staff, and getting the necessary tools together for implementation (for strategies that help in reaching agreement among staff, or resolving disagreements, see the box at right).

You were also the lead investigator in a descriptive case study at one nursing home in Maryland that now serves as a model for guideline implementation. Can you tell us about this?

Dr. Resnick Yes, this particular case study also demonstrated an improvement in patient outcomes after implementing the falls CPG. Over the 12 months post implementation in a nursing home, a total of 237 falls occurred, with 52 individuals falling. This represented a decrease in the number of monthly falls from an average of 31 in the six months prior to implementation to 14 falls in the first month of implementation, and fewer than 31 falls in each of the remaining months over the first year. In addition, there was improvement in the facility report card quality indicators. This experience demonstrated the value of the falls CPG as a guide to development and implementation of a falls prevention program for long-term care facilities.

What made the implementation process effective?

Dr. Resnick We followed the falls CPG and incorporated its framework for falls risk assessment, evaluation, and management. We then developed four forms to help staff in the implementation process. These forms provided a simple and efficient way in which to evaluate the resident with regard to falls risk assessment, evaluating the fall once it has occurred, and guiding providers in establishing the cause of the fall and in developing an appropriate plan of care.

A four-step approach was then used to implement the CPG. We defined the steps in this way:

Step 1: Staff education and encouragement.
Step 2: Recognition and problem identification.
Step 3: Assessment of falls and evaluation of causes.
Step 4: Seeing and setting examples.

The most exciting part of the process was that a year after implementation, the CPG became routine care (see box below).

In this study, you were able to look very closely at the types of falls and some relevant factors. What did you find?

Dr. Resnick The study provided us with descriptions of the falls that occurred. The most common extrinsic causes of falls included inappropriate footwear (18%) and use of full bed rails (7%). Only a few falls were due to environmental risks such as glare, clutter, or wet slippery floors.

We also discovered that the majority of the falls occurred in the residents' room (48%), with most falls occurring when the individual was walking or transferring (50%). Most of the falls occurred in the noon to midnight time frame.

The study also considered trends indicative of potential intrinsic causes of falls. We found that standing balance impairments (70%) and impaired judgment (60%) were the most commonly reported intrinsic factors related to falls. Also, approximately 5% of falls were associated with anti-anxiety medications, 9% were associated with use of anti-psychotic drugs, and 1% of falls were associated with alcohol use.

What were the specific clinical outcomes of the falls that were monitored in this case study?

Dr. Resnick In the majority of falls (51%) there were no known negative outcomes. Only two fractures (1% of all falls) occurred following the implementation of the falls CPG, and only 11 (5%) individuals had subsequent musculoskeletal pain or suffered a skin laceration. Approximately 23 (14%) individuals had either a hematoma or skin tear as a result of the fall.

What was the impact of the implementation of the falls CPG on the facility report card?

Dr. Resnick With the exception of weight loss, there was a decline in all of the MDS quality indicators monitored following implementation. The percentage of residents who needed help with activities of daily living decreased from 35% to 28%; those with infection decreased from 18% to 6%; the percentage with pain decreased from 10% to 6%; those with pressure sores decreased from 13% to 4%; and the percentage restrained decreased from 7% to 5%.

However, the percentage of residents with weight loss actually increased from 6% to 9%. We know that there are numerous reasons for weight loss, including acute and chronic illness, oral care problems, and medication side effects. Any of these variables may have contributed to the findings.

What were the "lessons learned" from this case study, and what advice would you give to facility staff who are ready to implement the CPG?

Dr. Resnick Information collected using the sample forms developed from the CPG allowed staff to consider the trends within the facility. Moreover, the forms helped staff to evaluate each fall individually and implement appropriate interventions.

We monitored the implementation process and found it was a "win-win" for both the nursing and quality assurance/education staff, because critical points in the guideline correlated with the facility's educational objectives (see box at right).

If there was a knowledge deficit in terms of assessment of a fall, a nurse practitioner would work with the staff person directly to improve assessment skills. Some of the nursing staff needed a review of the appropriate way to evaluate orthostatic blood pressures, or conduct comprehensive musculoskeletal evaluations following the fall. These reviews were done on the nursing unit to avoid time taken away from patient care.

Also, cumulative evaluation of the falls resulted in several changes throughout the facility. Examples include providing residents with nonskid socks to wear when walking, increasing awareness of bed-rail usage as potentially facilitating a fall, and checking with residents in their rooms.

Also, we stressed having staff help with transfers and walking to the bathroom, and we supported increasing evening supervision. The facility also tried new ways to incorporate afternoon naps into daily activities for some residents to decrease late afternoon and evening falls.

Prior to implementation of the CPG, the facility averaged approximately 31 falls per month. Incidence of falls decreased consistently following implementation of the guidelines. There was, however, a slight increase for two consecutive months (April and May). At that point, an interdisciplinary falls team was developed to meet weekly to review each fall and assure that the appropriate intervention was implemented.

What areas would you like to track or study in the future?

Dr. Resnick Areas of future study might include the longer range impact of implementation of the falls CPG, as well as the cost of falls and cost benefit of CPG implementation. The cost analysis should also consider costs to residents, such as such as fear of falling again and quality-of-life issues. Fear of falling leads to a decreased willingness to perform activities such as bathing, dressing, and walking. This is an area that definitely needs to be studied.

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