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Pragmatic Innovations in Post-Acute and Long-Term Care Medicine

Feasible new, practical products or approaches intended to improve outcomes or processes in post-acute or long-term care

STOP-FALLING: A Simple Checklist Tool for Fall Prevention in a


Nursing Facility
Supakanya Wongrakpanich MD a, b, *, Katalin Danji MD b, Lewis Lipsitz MD a, b,
Sarah Berry MD, MPH a, b
a
Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
b
Hebrew Senior Life, Institute for Aging Research, Boston, MA

a b s t r a c t

Falls are highly prevalent and lead to major health morbidity and mortality in older adults. We developed a “STOP-FALLING” checklist as a multifactorial
intervention tool kit for a single long-term care facility. The objective of this study was to determine feasibility and adherence of the checklist, and to
determine whether STOP-FALLING reduces total number of falls, frequent fallers, and fall-related injuries.
This is a quality improvement demonstration project comparing the effect on falls 3 months before and 3 months after introducing a STOP-FALLING
checklist. All older adult patients who lived in the long-term care unit of a single facility were included. PTs, geriatricians, and registered nurses
participated in the STOP-FALLING initiative. Staff were surveyed on satisfaction by 8-item questionnaires, which were obtained 3 months after checklist
implementation. Data on the rate of falls, the number of recurrent fallers, the number of minor injuries, and the number of major injuries 3 months prior
and 3 months after the intervention were collected by facility fall log.
A total of 32 patients were screened using the STOP-FALLING checklist. Staff survey revealed a high satisfaction rate with 15 minutes to complete the
checklist. Data at 3 months after initiation of the checklist revealed a reduction in the fall rates (2.80-1.65 falls per person-year), number of frequent fallers
(5.00-2.30/mo after), number of falls without injuries (3.00-1.67/mo), number of minor injuries (4.00-2.67/mo), and number of major injuries (0.33-0/
mo).
We observed excellent staff satisfaction using the STOP-FALLING checklist. Our pilot project suggests that the intervention may decrease fall rates and
other fall-related injuries.
Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Keywords: Falls, multidisciplinary, checklist, prevention, barriers, long-term care

Problem/Significance The registered nurse (RN) and geriatrician were responsible for the
“purple” and “red” sections, respectively.
Falls are a major contributor to morbidity and mortality among All staff participated in at least 1 of 3 training sessions for checklist
nursing home (NH) residents. Implementation of fall prevention in the implementation. Interventions were customized according to each
NH has been challenging. Reasons include lack of knowledge, diffi- patient’s clinical circumstance. Our checklist includes the following:
culty in accessing information, time pressure, lack of involvement of
patients and families, and inadequate staff communication.1e6 A real-  Vitamin D Supplementation with oral vitamin D3 1000 IU per
world initiative that provides education, requires input from multi- day
disciplinary team members, and takes minimal time helps to  Patient and family caregiver education (Teaching) by a physi-
overcome some of the above barriers. cian or RN using Stopping Elderly Accidents, Deaths, and In-
juries (STEADI) patient and family caregiver brochures.7,8 Also,
Innovation all family caregivers received a STEADI brochure at their
mailing address.
We developed a “STOP-FALLING” checklist (Figure 1) and adapted  Orthostatic vital signs measurement9,10
interventions to make our checklist specific to the NH setting. For  Physical therapist evaluation and ongoing treatment10,11
instance, we included family caregiver education because of signifi-  Foot and gait evaluation10,11
cant numbers of participants with dementia. We made this checklist  Hearing Aids and hearing evaluation12
easy to implement by using a color-coding system. For example, the  Medication List and polypharmacy review13 (A medication
physical therapist (PT) was responsible for the “blue” section, which review was conducted by physicians according to the 2015 AGS
included PT evaluation and orthostatic hypotension measurement. Beers Criteria. Medication reduction or withdrawal was
attempted, whenever possible.)
 Low bed14
The authors declare no conflicts of interest.  IN-room safety evaluation11 (All potential environmental haz-
* Address correspondence to Supakanya Wongrakpanich, MD, Department of
ards, including rugs, slippery floors, electrical cords, and chairs
Gerontology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
02215, USA. without handrails, were suggested to be removed or changed.
E-mail address: Supakanya.w@gmail.com (S. Wongrakpanich). Lighting was evaluated and improved, as needed.)

https://doi.org/10.1016/j.jamda.2018.10.002
1525-8610/Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
2 S. Wongrakpanich et al. / JAMDA xxx (2018) 1e3

Review Board. All older adult patients aged >65 years who resided in
the Orchard Cove long-term care nursing facility from October 1 to
December 31, 2017, were included. There were no exclusion criteria. Fall
rates between October and December 2017 were compared with fall
rates 3 months prior to intervention (July 1 to September 30).
At 3 months, staff were asked to complete a satisfactory survey using
an 8-item questionnaire.
A fall with a minor injury was classified as having bruising, he-
matoma, superficial laceration not requiring suture, or acute pain after
a fall. A fall with a major injury was categorized as sustaining a frac-
ture or as skin laceration requiring suture. Overall fall rates per
person-years were calculated. Independent t tests were used to
compare the mean difference for number of falls using SPSS version
21.0.

Evaluation

The mean age of participants was 92.9 years (range 86-100). De-
mentia was the most common comorbidity. There were 3 deaths
during the follow-up period. None of the deaths were fall-related.
Among all STOP-FALLING interventions, teaching (patient and
family education), medication review, and in-house safety evaluation
were the 3 most common interventions implemented by staff (32/32
patient checklists, or 100%). Low bed application was the least com-
mon intervention implemented (2 of 32; 6.3%).
Among 12 staff who completed the satisfaction survey (Table 1),
11/12 (91.7%) strongly agreed that training sessions for checklist
implementation and fall prevention knowledge were useful. All par-
ticipants either agreed or strongly agreed that the checklist does not
interfere with routine patient care time. Staff participants also agreed
Fig. 1. STOP-FALLING checklist downloadable PDF of this form is available at www. that they feel more confident in their fall prevention skills and are able
sciencedirect.com. to confidently merge the checklist with NH initial assessments.
During the 3 months before the study period, 32 patients experi-
 Glasses and vision evaluation10,11 enced 22 falls. Thirteen falls were injurious (1 major and 12 minor). In
The objectives of our quality improvement project were to 1) the 3 months following checklist implementation, 32 patients expe-
determine the feasibility and adherence with a checklist intervention rienced 13 falls (8 injurious, 0 major). At 3 months after initiation of
and 2) determine whether the checklist reduces total number of falls, the checklist compared with 3 months prior, there was a reduction in
fallers, recurrent falls, minor and major injuries from falls, and fall rates. fall rates (2.80-1.65 falls per person-year), number of frequent fallers
[5.00-2.30/mo; P < .001, 95% confidence interval (CI) 1.78-3.56],
Implementation number of falls without injuries (3.00-1.67/mo; P < .001, 95% CI 0.69-
1.97), number of minor injuries (4.00-2.67/mo; P ¼ .015, 95% CI 0.14-
We conducted a study with a protocol consistent with a quality 2.52), and number of major injuries (0.33-0.00/mo; P < .001, 95% CI
improvement project, as determined by Hebrew Senior Life Institutional 0.13-0.53) (Figure 2).

Table 1
Staff Satisfaction Survey After Completion of the STOP-FALLING Project

Strongly Agree, n (%) Agree, n (%) Disagree, n (%) Strongly Disagree, n (%) No Opinion, n (%)

I found an introduction to fall prevention and STOP- 11 (91.7) 1 (8.3) 0 (0) 0 (0) 0 (0)
FALLING presentation in October was useful.
Completing STOP-FALLING checklist does not interfere 3 (25) 9 (75) 0 (0) 0 (0) 0 (0)
with the time I take care of my nursing home
residents.
STOP-FALLING checklist is clear, easy to understand, 8 (66.7) 4 (0.3) 0 (0) 0 (0) 0 (0)
and easy to complete.
I feel more confident that fall number could be reduced 7 (58.3) 5 (41.7) 0 (0) 0 (0) 0 (0)
by multifactorial interventions.
I feel more confident in my fall prevention and 7 (58.3) 5 (41.7) 0 (0) 0 (0) 0 (0)
management skills.
I feel more confident to MERGE this checklist to the 6 (50) 5 (41.7) 0 (0) 0 (0) 1 (8.3)
initial assessment for nursing home resident.
<5 min 5-10 min 10-15 min 15-20 min >20 min
On average, how long does it take for you to complete 1 2 (16.7) 4 (0.3) 6 (50) 0 (0) 0 (0)
STOP-FALLING checklist in a part that you are
responsible for?
Very Satisfied, n (%) Satisfied, n (%) Neither, n (%) Dissatisfied, n (%) Very Dissatisfied, n (%)
How satisfied were you with STOP-FALLING project 7 (58.3) 5 (41.7) 0 (0) 0 (0) 0 (0)
overall?
S. Wongrakpanich et al. / JAMDA xxx (2018) 1e3 3

Fig. 2. Fall statistics pree and posteSTOP-FALLING checklist.

Comment cost-effectiveness studies of multifactorial fall prevention programs in


long-term care facility should be considered.
We developed an innovative, real-world checklist aimed to prevent
falls in a long-term care setting with the hope to overcome some Supplementary Data
implementation barriers in actual practice.
It is well established in literature that multifactorial interventions Supplementary data related to this article can be found online at
for fall prevention are infrequently implemented in a nursing home https://doi.org/10.1016/j.jamda.2018.10.002.
setting.1 Campbell et al1 classified the most common reasons for low
implementation rates for multifactorial fall and fracture programs into References
5 categories: misconception that advanced age would not benefit from
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resources, the requirement for ongoing participation, and lack of an fall and fracture prevention. Age Ageing 2006;35:ii60eii64.
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making sure that the intervention was not overly time-consuming, 7. STEADI Stopping Elderly Accidents DI. Family Caregivers: Protect Your Loved
and (7) using the mnemonic “STOP-FALLING.” The satisfactory sur- Ones From Falling. Available at: https://www.cdc.gov/steadi/pdf/STEADI-
vey after project completion highlights that this STOP-FALLING CaregiverBrochure.pdf. Accessed November 25, 2018.
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After the completion of the STOP-FALLING initiative, all fall sta- 508.pdf. Accessed November 25, 2018.
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The STOP-FALLING initiative appears promising as a practical medication use in older adults. J Am Geriatr Soc 2015;63:2227e2246.
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in the long-term care setting. Our checklist overcomes many of the hospitals: are low-low beds a critical success factor? J Adv Nurs 2013;69:112e121.
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implementation barriers commonly experienced in the NH. Future dential care facilities: A systematic review of barriers and facilitators. Int J Nurs
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The pragmatic innovation described in this article may need to be modified for use by others; in addition, strong evidence does not yet exist
regarding efficacy or effectiveness. Therefore, successful implementation and outcomes cannot be assured. When necessary, administrative and
legal review conducted with due diligence may be appropriate before implementing a pragmatic innovation.

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