Evidenced Based Paper RUNNING HEAD: EVIDENCED BASED PAPER

Evidenced Based Practice Paper Akeeka Davis Gwynedd-Mercy College Nursing 323 Professional Issues in Nursing Dean Andrea Hollingsworth February 13, 2012

Evidenced Based Paper Abstract The goal of healthcare is to promote and foster a restructured system that delivers primary health care in acute and community base settings. The research presented will place emphasis on interventions that have been implemented to reduce the risk of falls in the elderly population. The research will further show that one single intervention is not effective in reducing falls in the elderly population. A multi-factorial approach that integrates numerous interventions has shown to be beneficial in reducing falls in the elderly population. This is in part due to many different health issues that are related to the natural aging process. Additionally, diseases that occur from a degradation of the pathological process contribute to falls as well. Nursing Interventions set in place to reduce falls will place emphasis on many aspects of health practices introduced but not limited to include, proper implementation of bed alarms, placement of low beds, proper placement of fall patients in close proximity to the nursing stations, proper lighting at night in patient rooms and bathrooms for toileting purposes. The multi-factorial approach allows us as nurses to adopt the ideology that there is more than one way to prevent falls.

Evidenced Based Paper Description of Clinical Nursing Practice

A nursing intervention is defined as a single nursing action - treatment, procedure or activity - designed to achieve an outcome to a diagnosis, nursing or medical, for which the nurse is accountable (Saba, 2007). This paper will examine the efficacy of current nursing practices in regard to fall prevention in the elderly population. The research reviewed placed a clear focus on detailed assessments that specifically targets older adults. This allows the nurse to be prepared when he or she treats this specific population.

Nursing interventions for older adults in, in-patient settings should be directed towards improving or maintaining the older adults health needs and concerns. Falls are a safety concern for many older adults. Falls may lead to fear of additional falls,

withdrawal from usual activities and loss of independence. Most notably, health related issues include impaired vision; cardiovascular conditions such as postural hypertension or syncope; conditions affecting mobility such as arthritis, muscle weakness, foot problems; conditions affecting balance; alterations in bladder function such as frequency or incontinence; cognitive impairment, and adverse medication reactions. (Taylor, Lillis, LeMone, Lynn & LeBon, 2009)

Environmental hazards in hospital settings include, but are not limited to poor lighting, slippery or wet floors and faulty hospital equipment. An example of faulty equipment is faulty bed alarms and inoperable call bells. Nursing interventions are to be directed toward the management of health-related conditions as well as the reduction of environmental assessment.

Evidenced Based Paper Review of the literature

Research has shown that through implementation and a detailed focused assessment of the elderly adult, specific interventions can be set in place for nurses to include in their plan of care to prevent falls in the elderly. Fulmer ( 2007), focused on six marker conditions that can help guide the nurse in an assessment of the hospitalized older patient. The marker conditions focused on conditions such as sleep problems, problems with eating and feeding, incontinence, confusion, evidence of falls, and skin breakdown. The Pneumonic SPICES serves as an easy guide for nurses to follow and this is how it is presented:

*Sl eep disorders

* Pr oblems with eating and feeding

* In continence

* Co nfusion

* Ev idence of falls

* Sk in breakdown (Fulmer, 2007)

Evidenced Based Paper Dykes, Carrol, Hurley, Lipsitz, Benoit, & Middleton, (2010) focused on prevention of falls in acute care hospitals. This was a nurse-led study that utilized a toolkit that focused on the assessment of the older adult. A study was conducted to utilize their proposed plan with a control group and an intervention group. The focus was placed on integration of patient and family care. A complete plan of care for healthcare professionals was implemented to highlight presenting symptoms that correlate with falls. Over-head bed icons were placed at each bed that detailed the patients fall risk. Interventions to mitigate risk factors associated with the elderly hospitalized patient involved the fall prevention tool kit (FPTK). The fall prevention tool kit software tailored fall prevention interventions to address patients specific determinants of a fall risk. What was most compelling about this article is that Dykes, Carrol, Hurley, Lipsitz, Benoit, & Middleton (2010) added the communication regimen. Dykes, Carrol, Hurley, Lipsitz, Benoit, & Middleton (2010) research placed a focus on enhancing the degree of communication and the results of the assessment to all healthcare team members that treated the patient. Communication is the focal point of best practices within the nursing community. Moreover, without seamless effective communication among healthcare members, the treatment modality in regards to the patient will be severely compromised. Moreover, mistakes will be made that could affect the life and well-being of a patient and life-threatening illnesses can ensue if preventative measures are not set in place Leveille, Jones, Kilay, Haudsdorff, Guralnik, & Bean (2009), focused on the effects of exercise on falls in elderly adults. A multi-factorial plan of care was presented to minimize fall prevention in the elderly population. Interventions were set in place to

Evidenced Based Paper assist the elderly with doing specific exercises that focused on balance. Behavioral components were implemented but not limited to medication changes, educational functional activity as well nutrition supplements to enhance protein consumption in the elderly. The conclusion of all three articles revealed that the interventions and practices presented did indeed reduce fall rates in the elderly population.

Gerontological nursing offers creative approaches for maximizing the potential for older adults. With comprehensive assessment information regarding the older adults strengths resources, and limitations, the nurse and the older adult together along with the family will identify needs and problems and select interventions that maintain the older adults physical abilities. Proper implementation of nursing interventions creates a safe in-patient setting that will reduce falls.

Evidenced Based Paper Comparison of Selected Nursing Practice with Current Research

In 2005, the Joint Commission introduced a national patient safety goal requiring all hospitals to reduce the risk of patient harm resulting from falls and to implement a falls-reduction program. In 2010, this requirement was upgraded to a standard.

The Northeast Health System, (NHS) in Beverly Massachusetts developed a risk assessment tool, which is used to assess patients at admission and at each shift change. The assessment is based on the Morse Scale, and is recorded in an electronic log, along with the appropriate risk-reduction strategies and interventions associated with each patients risk level. Nurse managers receive daily reports of at-risk patients and place them on units where falls are closely monitored. The team revises the falls report to include more information on the factors that contribute to falls. Additionally, an update to the administrative database allows better unit-specific information for trending and the ability to develop intervention ns that are appropriate to the patient population. Finally, the team established definitions for both fall and injury that could be used facility-wide. (Dick, 2002)

The team worked with plant operations to examine potential environmental fall factors and performed checks on beds, wheelchairs, walkers, handrail placement,

bathroom call bells, etc. The falls prevention program coincided with the purchase of many new beds that were equipped with bed alarms. (Dick, 2002)

A multi-pronged approach including administrative, direct care, environmental, and equipment initiatives included identifying patients with a high risk fall score by placing a

Evidenced Based Paper gold star on the unit, then regularly toileting those patients, ensuring they had adequate lighting at night and appropriately placing patients near the nursing station, and equipping those patients beds and chairs with alarms. (Dick, 2002)

To achieve this, NHS created a falls committee and a clinical educator was assigned to provide ongoing falls education to staff and physicians. The committee conducts falls rounds during which they provide direct education regarding current fall assessments. In addition, the educator is available to nursing units to conduct a falls prevention consult and recommend interventions.

NHS developed an assessment and reporting flow sheet for nurses and physicians to provide standardized monitoring, treatment, and physician/family notification after a fall. The flow sheet outlines very concise responsibilities and steps for staff to follow after a patient experiences a fall.

Most notably, the comparison of the research against the current protocol discusses the importance of a multi-factorial approach, meaning that there is no one single nursing intervention that can solely prevent falls. Using a wide range of interventions has proven to be more effective than single interventions. Current research has proven that the multi-factorial approach reduces falls in the elderly population. The Morse Fall Scale was utilized by (Dykes, Carrol, Hurley, Lipsitz, Benoit, & Middleton, 2010) and the Northeast Health System Fall-Reduction program, and so the research and the current protocol show a correlation in that aspect of care as well. The

Evidenced Based Paper Northeast Healthcare System was able to connect the multi-factorial approach in more detail than the current research.

The key facts of the research and the current protocol at the Northeast Healthcare System addressed the use of fall scales to guide nursing care, new equipment such as low beds, alarms and placards were implemented to reduce falls. Communication and teaching was also addressed and encouraged between healthcare providers, patients and families. Tremendous strides are being made in fall-reduction programs but its work is yet to be completed.

Evidenced Based Paper Recommendation for Incorporating Research into your Practice

Collaborative projects to reduce patient falls, including safety walk-rounds, medication reviews and environmental changes should be implemented. The multi-factorial approach is key to the success of reduction of falls. A single nursing intervention to reduce falls in the elderly in acute patient settings is not effective; research has proven that it takes several interventions to reduce falls in the elderly.

Teams from different disciplines, including physiotherapy, occupational therapy, nursing and medicine, work together towards common goals, sharing lessons learned and testing new ideas to reduce falls in the elderly. Implementation of a fall scale is important and upon completion of the assessment the data should be entered into the data base for all assigned health care providers to view.

Upon discharge from the hospital referrals should be made if needed to nutritionists and exercise programs for the elderly. These referrals will encourage patients to engage in activities to reduce their risk of falls, and in time strengthen bone and muscle mass which will help with gait and balance techniques.

Safety rounds of high risk patients should be implemented to ensure that proper lighting and toileting procedures are set in place for at-risk fall patients. Placards should be posted on the outside doors, with accompanying bracelets. Beds should be kept in the lowest position at all times when the patient is un-assisted. Proper bed/chair -alarms should be set in place to alarm if patient begins to ambulate un-accompanied. Nursing notes should accurately documented and updated as necessary. Maintenance of falls equipment should be checked at

Evidenced Based Paper every shift to ensure devices are working at maximum capacity. A review of the data should be compiled and a report should be prepared quarterly by the falls review board and improvements should be made based on the data presented via the summative report of findings. Nurses should teach, advocate for and educate the families about the importance of detecting at-risk fall episodes and the prevention of falls. Nurses should stay current with Evidenced-Based Practices as well as Best Practice nursing literature that substantiate and prove that interventions proposed reduce falls in patients. Nurses should establish health programs that promote older adults wellness and work hard to recommend and promote preventative measures. Health promotion recommendations for older adults include good nutrition, exercise, and smoking cessation measures to reduce the risk of falls, and measures to reduce adverse medication reactions. Acute care settings place older adults at risk for delirium, dehydration, malnutrition, nosocomial infections, urinary incontinence and falls. Restorative nursing interventions, whether accomplished in the older adults home or in long-term care institutions, stabilize chronic conditions, promote health, and promote independence and activities of daily living.

Evidenced Based Paper References Dick, D. (2002, December 01). Fall prevention program yields quick results. Retrieved from www.premierinc.com/../falls/../S-11-case-hty-ne-falls-text-final-02-23-04.doc Dykes, P. C., Carrol, D. L., Hurley, A., Lipsitz, S., Benoit, A., .., , & Middleton, B. (2010). Fall prevention in acute care hospitals. American Medical Association, 304(17), 1912-1918. Fulmer, T. (2007). How to try this; fulmer spices. American Journal Of Nursing, 107(10), 40-49. Leveille, S. G., Jones, R. N., Kilay, D. K., Haudsdorff, J. M., Guralnik, J. M., .., , & Bean, J. F. (2009). Chronic musculoskeletal pain. American Medical Association, 302(20), 22142241. Saba, V. (2007). Clinical care classification system. Retrieved from http://www.sabacare.com/Interventions/ Taylor, C., Lillis, C., LeMone, P., Lynn, P., & LeBon, M. (2009). Taylor fundamentals of nursing. (6th ed., pp. 841-851). Philadelphia, Pa.: Lipincott, Williams & Wilkins.