4/8/2015

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Home Safe Home… Internal and External Factors of Fall

Prevention

Mike Delaney Assistant Vice President Loss Control, Argent

Kristin West Vice President, The Kemper Company

Objectives

• List physical and medical factors that may contribute to fall in long term care.

• List contributing environmental factors and barriers to falls.

• Create an environment focused on fall prevention for residents, staff, and guests.

• Identify and plan proactive processes for building safety.

According to the CDC, the most common causes

of long term care falls are:

• Muscle weakness and walking or gait problems account for about

24 percent of the falls in nursing homes. • Environmental hazards (wet floors, poor lighting, incorrect bed

height, and improperly fitted or maintained wheelchairs) cause 16 to 27 percent of falls among residents.

• Medications, particularly sedatives and anti-anxiety drugs, can increase the risk of falls and fall-related injuries, especially during the three days following medication changes.

• Other causes of falls include difficulty in moving from one place to another (for example, from the bed to a chair), poor foot care, poorly fitting shoes, and improper or incorrect use of walking aids.

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Challenges of Aging

Risk Factors • Age • Medications • Previous Falls • Depression • Stroke • Dementia • Muscle weakness • Incontinence of Bowel and/or Bladder • Perceptual Impairments

Vision

• How we process what we see

• Changes in the Occipital lobe

• Changes in the vision field

• Medical Conditions

Normal Vision

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Age Related Macular Degeneration

Cataract

Personal Risk Factors of Patient Falls Physical

• Weak or impaired gait

• Decreased mobility of lower limbs

• Poor condition and balance

• Muscle weakness-5x more likely to fall

• Visual Impairment-impaired depth perception 3x greater risk of multiple falls

• Slower reaction time-increased body sway

• Cognitive-ranges up to 4x increase in falling

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Start the Conversation… Prior to Move-in

• Share with family the reality of falls

• Don’t make promises you cannot keep

• Ensure Assessment includes Fall risks AND Fall History

• Ask and Ask again what the family’s expectations are for fall prevention

Prevention – (3) Steps

• Assessment and FOLLOW-UP

• Staff training

• Changing and maintaining the environment- Inside and Out

STEADY U Ohio Promotional Toolkit

• Please use the resources below to help tell others in your community about STEADY U Ohio and this website. We would appreciate it if you would contact us to let us know how you are spreading the word that we can prevent falls, one step at a time!

• STEADY U Ohio Promotional Tip sheet

• STEADY U Ohio Logo

• STEADY U Ohio Poster

• STEADY U Ohio Tri-fold Brochure

• A Matter of Balance Tri-fold Brochure

• STEADY U Ohio Flier

• Facts About Falls in Ohio

• About STEADY U Ohio

• Tip of the Day widget for websites

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Resident Assessment

Residents with high risks for falls include those

who have poor vision, disturbed gait, muscle

weakness, cardiovascular disease, incontinence

and a history of falls. When new residents are

admitted, assess them for risk factors, orient

them to their environment and observe them

closely for the first few weeks to determine if

further prevention planning is needed. When

developing care plans for at-risk residents,

include specific measures to help prevent falls,

including:

Assessment • Teach residents how to call for help if they have fallen, almost fell or

feel like they might fall • Actively encourage residents to wear prescription eyeglasses. • Teach residents how to properly transition from bed to chair to

toilet using stable furniture for support. • Promote exercise to improve strength, balance and coordination. • Assure that residents use canes, walkers and wheelchairs only when

prescribed and that these aids are properly fitted, in good repair and used correctly.

• Monitor the medications your residents take, especially sedatives and tranquilizers, and work with the resident's physician to discontinue any unnecessary medications.

• Note any changes in the residents' physical and mental status, and adjust their care plan, particularly .

Staff Training • Staff Education • Keep falls prevention on the minds of your entire staff through ongoing education

programs. Staff who are sensitive to falls hazards will play a part in noticing, reporting and eliminating them. Engage staff in all departments to develop strategies for falls prevention and monitoring at-risk residents. Often, front-line staff can be your best resource for developing practical interventions tailored to the unique needs of each resident.

• Post a list at each nurses' station of all residents identified as at-risk for falls, along with educational and instructional resources.

• Educate staff on proper lifting techniques and stress that at least two staff be present when lifting a resident, even when using lift aids.

• Stress the importance of following all instructions on lift assistance devices, including the proper use of safety straps.

• Make gait belts available and encourage their use, especially when assisting a resident in cramped spaces such as the toilet or shower.

• Most importantly, staff should know what to do if they see a resident starting to fall. When staff know proper safety techniques, they minimize the risk of causing injury to themselves or residents during a fall.

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Design Worse Case

• Visitors and workers

• Impaired

• Disabled

• Weak or sick

• Distraught or distracted

• 24/7

• There’s no silver bullet

Hierarchy of control

• Eliminate the risk (design)

• Don’t count on Administrative controls (training)

• Don’t count on PPE (e.g. footwear)

Where to start

• Look at prior loss data, time, date, location, activity.

• Observe and observe some more

• Understand visual cues and/or distractions

• Design the most efficient routes or process

• Then re-test thru observation

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Nursing Home Assisted Living

• NH/AL challenges

• Bodily fluids

• Transfers while dodging personal items and furnishings

• Bathing/showering

• Cords

• Mats

Extrinsic Risk Factors-Residents • Medications-sedatives, tranquilizers. Those affecting

the central nervous system

• Bathtubs and toilets- equipment without support

• Design of furnishings-chairs and bed heights and ease of use

• Walking surfaces

• Illumination-intensity or glare

• Type of footwear

• Inadequate assistive devices- walkers, wheelchairs, lift devices

Personal Risk Factors of Patient Falls

Physical-cont’d • Foot problems-bunion, toe deformity, confusion

• Body mass index (BMI)- low BMI or weight are associated with low bone mineral density and fall Increase 1

1(Yoshoda, 2006) 1(Yoshoda, 2006) 1(Yoshoda, 2006) 1(Yoshoda, 2006)

1(Yoshoda, 2006)

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What do we know about our workforce/population

What do we know about our workforce

• Getting bigger

• Getting older

• Have balance issues

• One study found 40% of admissions were due to falls1

• Fear of falling results in loss of confidence resulting in self imposed limitations

• Have gait issues

• Don’t /won’t ask for help 1American Geriatrics society ,2001

What do we know about our workforce/population

• Getting older-cont’d • More easily confused

• More easily distracted

• Can’t see as well • By age 40 visual Acuity down by 10%

• By age 60 down by 26%

• More pronounced in low light conditions

• Between 70-79 only 25% has 20/20 vision

• Can’t see as well Cont’d • Insufficient lighting significantly increases underfoot

accidents

• Women at higher risk then men

• Color and depth perception decrease with age

• Glare problematic – Less able to detect contrasts

– Doesn’t adjust as quickly from light to dark

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What do we know about our workforce/population

• One in three adults aged 65 and older fall each year.

• Of those who fall, 20% to 30% suffer moderate to severe injuries that make it hard for them to get around or live independently, and increase their risk of early death.2

What do we know about our workforce/population

• Older adults are hospitalized for fall-related injuries five times more often than they are for injuries from other causes.1

• In 2012, over 2.4 million older adults were treated in emergency departments for falls; more than 722,000 of these patients had to be hospitalized.2

References

1, Sterling DA, O'Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. Journal of Trauma–

Injury, Infection and Critical Care 2001;50(1):116–9.

2. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). Available at:

http://www.cdc.gov/injury/wisqars. Accessed on February 25, 2014.

So What’s the Problem

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Barriers as we see them

• Management attitude

– Not a priority. Everything else is more important

– “It’s winter in the Midwest… what do you expect!”

– Goes unseen until the big loss occurs

– We don’t have the resources

– We don’t trend where they are coming

– We simply don’t spend time on it

Barriers as we see them

• Street parking and employee entry ways.

• Hours of clearing

• Plowing contractor vs. your expectations

– What’s being plowed and when

– The 2” rule and who plows when under

– Final cleanup or follow-up

– Chemical application

Barriers as we see them

Contracted Services-Understand them

• How many clients do they service

• When will they

– Be there and return

– Start

– How often will they return

– Certs of Insurance

– Listed as an additional named insured

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Barriers as we see them

Contracted Services-Understand them

• What will they do

– Plow

– Salt

– Loading and hauling of snow

– In what priority

– Are the willing and capable of applying other types of chemicals

Barriers as we see them

• Design and layout of the lot and entrances

– Catch basins

– Snow pile locations or haul away

– Employee entry points

– Employee smoking areas

– Downspout locations

– Ramps

– Car stops

Barriers as we see them

• Costs

– Parking lots and walks are expensive to fix

– Defects and damage

– Equipment is expensive to buy and maintain and depending on the winter can sit idle.

• We don’t take the time to inspect

• As little as ¼” can result in a trip fall hazard.

• We go out of our way to design in failure

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Designing in Failure

• Ng

Odds and Ends • Dumpsters-height, location, and access

• Off premises operations,

– Meals on wheels,

– Home health,

– Personal care,

– Handyman services, etc.

Solutions

• Design out the problem(s)

• Assign accountability

• Develop a plan

– Employee parking during snow emergencies

– Determine designated parking and employee points of entry

– Have a plowing plan

– Have appropriate salt/chemicals on site

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Cost and Availability • Sodium Chloride (Road Salt) is typically the cheapest

and easiest to find of the deicers.

• It is widely used and overused.

• Sodium Chloride is only effective at pavement temperatures above 15 degrees.

• It does not work well at colder temperatures, it is often over applied in attempts to get it to work better.

• lower than 15 degrees, switch to a different deicer.

Sidewalk Tips

• Always remove snow prior to applying deicers. If you plow first, refreezing diminishes and slush build-up is minimized.

• Sidewalks are often over-salted.

• Sidewalks are the area of highest area of tracking water and sand into a building. Extra salt and sand contribute to slippery entryways inside the building.

Chemical Lowest Melting

Temp. Eutectic

Temp. Optimal Concentration

NaCl (Sodium Chloride) —Delivered as solid rock salt, also can be made into a brine. The basis of most deicing materials. Very corrosive. Inexpensive. Very available. Rarely has a corrosion inhibitor added.

15º F -6º F 23%

MgCl2 (Magnesium Chloride)—Delivered as a liquid. Often used to wet NaCl crystals to increase adherence to surface and reduce melting points. Corrosive. Higher cost. Often has a corrosion inhibitor added.

-10º F -28º F 27 to 30%

CaCl2 (Calcium Chloride)—Delivered as flakes, pellets, or liquid. Powerful deicer but extremely corrosive. Sometimes used incorrectly to open storm drains. Higher cost. Often has a corrosion inhibitor added.

-20º F -60º F 30%

CMA (Calcium Magnesium Acetate)—Delivered as a powder, crystals, pellets, or liquid. Liquid CMA is used mainly on automated bridge deicing systems. Noncorrosive, biodegradable. Sometimes added to sodium chloride as a corrosion inhibiter. Alternative for areas where chloride use must be limited. Often higher cost.

20º F -18º F 32%

KAc (Potassium Acetate)—Delivered as a liquid. Often used on automated bridge deicing systems and airports. Use for anti-icing, deicing, and pre-wetting. Non-corrosive, biodegradable. Alternative for areas where chloride use must be limited. Higher cost.

-15º F -76º F 50%

Blends— Both chlorides and acetates exist in blends. Talk to your supplier and determine the lowest practical melting temperature, the optimal concentration and the basic components in the blend. Most blends are centered on rock salt since it is cheap.

Winter Sand/Abrasives—Winter sand has some salt mixed in it to keep it from freezing. Abrasives should be used for cold temperatures when deicers are not effective. They provide temporary traction but only work when they are on top of the ice.

Never melts—provides

traction only

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Salt Pavement Temp 1 Lb of Salt (NaCL) Melts Melt Times

300 F 46.3 lbs of ice 5 min

250 F 14.4 lbs of ice 10 min

200 F 8.6 lbs of ice 20min

150 F 6.3 lbs of ice 1 hour

100 F 4.9 lbs of ice Dry salt will blow away

•Use pavement temperatures. Most weather stations

measure temp 30’ above ground.

•Anti icing requires 25% of the material of deicing at 10% of

the cost.

Sidewalks Tips

• Use drop spreaders, not rotary spreaders.

• If using a rotary spreader, adjust opening to limit dispersion of deicers to the sidewalk and/or install shields to restrict the spread pattern. Concentrate the salt on the sidewalk. Minimizes your application rate.

Sidewalk Tips

• Look for opportunities to close extra entrances during the winter to reduce the need to use chemicals on all sidewalks and steps.

• Many slip and fall incidents occur within ten feet of the curb lines.

• Focus on aggressive mechanical removal of snow. The less snow, the less deicer required. This will lend to a safer walking surface.

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Sidewalk Tips

• Salt only needs to melt 1/16 inch to prevent the bond between the pavement and the ice.

• Pre-salt. Save money by applying salt before the ice bonds so you don’t need to melt through it.

Solutions

• Start now it’s not to early

• Assign responsibility and accountability

• Identify the barriers and develop a plan

• Budget

• Have you designed in failure

• Put the sidewalks where the paths are

Solutions

• Ensure you have the resources

– Equipment

– Salt

– Staff

– footwear

• Evaluate and re-evaluate

• Make it a priority

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Walking Traction Aids

Questions

Mike DeLaney

mdelaney@wbmi.com