[1] 1. Ontario Health Quality Council (OHQC). Long-term care in ontario: A report on quality. Ontario:2009. Available from: http://www.ohqc.ca/pdfs/ohqc_2009_ltc_supplement_e.pdf. Accessed August 16, 2010.

[2] Ireland, S., Lazar, T. B. H. S., Mavrak, C. B. S., Morgan, B. B. S., Pizzacalla, A., Reis, C., et al. (2010). Designing a falls prevention strategy that works. Journal of Nursing Care Quality, 25(3), 198-207.

[3] Logghe, I. H. J., Verhagen, A. P., Rademaker, A. C., Bierma-Zeinstra, S. M. A., Rossum, E., Faber, M. J., et al. The effects of tai chi on fall prevention, fear of falling and balance in older people: A meta-analysis. Preventative Medicine, June 29, 2010. (http://www.sciencedirect.com/science/article/B6WPG-509W727-1/2/d42f3843b8ba03c4249f37111b27db80)

[4] Tzeng, H. (2010). Inpatient falls in adult acute care settings: Influence of patients' mental status. Journal of Advanced Nursing, 66(8), June 29, 2010. (http://dx.doi.org/10.1111/j.1365-2648.2010.05343.x)

This macroscopic analysis of the tracking system brings questions to its efficiency and effectiveness. Several suggestions for the tracking system were given; however, further analyses as to what information would be needed for a more complete picture of the situations reported would be required. This should be initiated by identifying what information is missing, and what information would augment the importance of already-existing information.

With the information obtained, several trends were identified and presented. It is our suggestion to take the trends observed in this pilot project and conduct a full study to determine if the trends observed maintain their significance under more rigorous statistical analyses.

The purpose of this study was to determine where quality improvement actions could be applied to minimize resident falls. We propose the following 5:

I. A system or method that allows earlier patient care response to falls could potentially help understand the cause of the fall. Many reports state that the patient was "found" in a certain position or state with no record of how the fall had occurred. If less time elapses between the incident and report, it would assist in developing more accurate incident reports. An example would be "assistance strips" on the floors of washrooms for patients that have fallen.

I. A self-assessment of both Belmont House and its facilities, as they pertain to fall rates, could assist in the search for underlying causes and potential solutions to most common incidents. [2]

I. Applying successful interventions from parallel facilities. Various other novel and inexpensive interventions are being developed world wide. Ireland et al [2] applied frequent observation of residents. Since many of the falls occur during night hours, more emphasis may be needed during these times. Logghe et al[3], uses Tai Chi as an intervention for fall prevention in seniors. Tzeng [4] also puts emphasis on patients' mental status and fall prevention, recommending targeted surveillance and risk assessment of fall.

I.A patient and/or staff education program. Education programs designed to focus on fall prevention and associated contributing factors. Such as blood pressure and medication regimes. Engaging various members, such as nurses, health care practitioners and non-health care members in a committee may also be an important intervention. A small, diverse committee, specific to fall reports, would analyze each case in detail on a weekly basis to improve quality of service and to identify contributing factors in detail.

I. Reassessing the risk from contributing factors after falls could provide solutions. It could also provide relevant information about specific aspects that could be used in preventing future falls.

Using the current method of primary data collection, information could either be lost due to incomplete forms or ambiguous explanations, making the information extracted invalid or obsolete by the time it was being analyzed. In response, the following suggestions are made (figure 4)

Figure 4: Incident Report Variables

Of all of the incident reports (n=82), the majority of residents experienced a single fall (Figure 2).

Figure 2: Resident Fall Rates

The location of falls also shows a trend where the majority of falls occur in and around resident rooms.

Figure 3: Number of Falls by Location

No trend has been observed with respect to day of the week. More than half the falls (53.7%) occur overnight between 7PM to 7AM.

Falls are one of the leading causes of injury and complications faced by seniors (>65yrs) in long-term care homes in Ontario. The Institute of Clinical Evaluative Sciences has determined that 9 in 100 residents experience a fall severe enough to warrant ambulance transportation to hospital a year.[1]

Belmont House, a home for the aged situated in the heart of Toronto, has one of the highest fall rates in the region. As a result, an analysis of fall incident reports was undertaken by Quality Improvement team 6 of the IHI Open School, University of Toronto chapter, under the supervision of Karen Yatabe, RN.

It is important to note that 'resident' and 'patient' may be used interchangeably.

The progression of the analysis took place in three phases:

(1)Designing the database template (Figure 1)

• Follows chronology of incident report currently in use at the LTC facility

• Incorporates all pertinent information recorded• Organized for ease of data analysis without

compromising data quality• Prior to initiation of data collection, standardized

interpretation of common terminology and definitions were developed

(1)Data collection• Primary data collection occurs in paper incident

reports by Belmont staff at the time of incident or as soon as possible thereafter

• The database was compiled directly from these patient incident reports by members of the research team

• Incident reports between December 2009 - February 2010 were included

• Each patient was assigned an anonymous identifier (under the heading “code” from figure 1)

(1)Data Analysis• Data was sorted and examined for trends based on:

• Patient code• Location of incident(1) Time of fall (hour, day)

Falling Forward: Analyzing Fall Data at Belmont HouseLiu, Franky (Pharmacy)*; Brener, Stacey (MSc. Candidate Health Services Research); Dong, Ken (Pharmacy); Kugathasan, Kapilan (Medicine); Tran, Jimmy

(Radiation Therapy); Yatabe, Karen (Belmont House, RN, BA, M.Ed.)Institute for Healthcare Improvement Quality Improvement Team 6; University of Toronto

Introduction

Methodology

Results

Conclusion

Discussion

References

Code (Last, First initial - Room #)

Date (d/m/y)

Day of week

Time Activities leading to fall / How the were found

Location Severity

Type of Injury Contributing Factors

Intervention Systolic BP

Diastolic BP

Medicine (within 12hrs)

Notes

Interpretation

5 Next StepsIdentify trends and common contributing factors in resident falls at Belmont House LTC home between December 2009 - February 2010.

Objective

The reoccurring falls may be patient-specific; however, the limited data from the reports does not allow further interpretation.

It may be beneficial to further study the rooms and hallways for potential obstructions or contributing factors such as location of commonly-used items or furniture.

The higher rate of falls in the evening may be due to dreariness associated with awakening from sleep, falling off beds and limited lighting. While continence was questioned as a potential contribution factor there is insufficient information in the data collection to objectively infer this suggestion.