Falls among older adults in acute care settings are a large national problem. When an older adult falls the consequences may be devastating. Fractures may occur, which begin the older adult on a spiral of iatrogenesis, ending in possible death. 

Normal changes of aging surrounding sensory alterations, such as visual and hearing decline, as well as changes in urinary function, contribute to fall risk among older adults. Pathological changes include neuromuscular and cognitive disorders, osteoporosis, strokes, and sensory impairments. Older adults who have fallen previously have a higher risk of experiencing another fall, as well.

Recognizing fall risks on medical units, St. Vincent's Medical Center, a 397-bed acute care hospital serving southwestern Connecticut and Westchester County, NY, piloted a fall prevention program on a med/surg unit called 7 South. St. Vincent's population of older adults is significant, and 7 South is a very busy 32-bed unit with an average daily census of 31.

Fall prevention strategies have been a focus for this unit's team of caring and compassionate caregivers for decades now, but the success of 7 South's newest program aimed at preventing falls may enable others to implement unit strategies in similar med/surg units to prevent falls among an increasing population of chronically ill, older adults.

Educating Nurses in Geriatric Care

A key ingredient to caring for chronically ill older adults and preventing falls is to provide nurses with a background in gerontological care. While great efforts have been made since the 1990s to enhance the gerontological nursing curriculum of undergraduate nursing students, the average age of nurses working in hospitals today is 41.8 years, according to the American Nurses Association. 

In order to begin to meet the nursing care needs of older adults throughout the nation, it is necessary to bring the current best practices in gerontological nursing to the nurses who are currently caring for older adults. 

St. Vincent's did this by first developing an academic-practice partnership with Fairfield University School of Nursing. A total of 16 nurses completed a 30-hour, Web-based nurse education program which included content on common problems of aging and falls. The program was approved by the Connecticut State Nurses Association, an approved provider of contact hours for the American Nurse Credential Center (ANCC). Four nurses on 7 South, the exemplar unit, became certified through the academic-practice partnership.

Implementing Evidence-Based Programs

Improvements are needed in geriatric acute care services nationwide. Such quality improvement initiatives are being developed and disseminated, including the Institute for Healthcare Improvement (IHI) Transforming Care at the Bedside (TCAB), which is supported by the Robert Wood Johnson Foundation.

The TCAB program aims to provide a framework for change on med/surg units and provides specific tools for the delivery of safe and reliable patient-centered care to acute care populations including older adults. The program is focused on vitality, teamwork and value-added care processes. 

St. Vincent's has adopted the TCAB approach to improving care for their rising elderly population and the resources provided by the program have successfully assisted the reduction of falls hospital wide. 

The first evidence-based practice step in preventing falls is to conduct regular fall risk assessments. A fall assessment is conducted on all patients on admission and every shift on 7 South using the Hendrich II Fall Risk Assessment Model (Exhibit A) created by Ann Hendrich, MSN, RN, FAAN, Vice President of Clinical Excellence Operations for Ascension Health in St. Louis.

Each patient is assessed by a nurse once per shift and any change in a patient's condition for the 8 risk factors is noted. If the patient meets the risk factor, the patient receives the corresponding score. If the numbers add up to 5 or greater place the patient at high risk to fall and implement the Ruby Slippers program.

The evidence-based Ruby Slippers  fall prevention program adopted by 7 South was developed by St. Joseph Hospital in Tucson, AZ. St. Joseph's, like St. Vincent's, is a member of Ascension Health, the largest Catholic hospital system in the U.S. Ruby Slippers is a proactive approach to preventing falls and uses strong visual cues to identify patients most at risk of falling.

After adapting the program in 7 South, Ruby Slippers went house-wide at St. Vincent's. 7 South continues to strive for excellence building on this foundation and adding some very innovative procedures and tools with the ultimate goal of always keeping patients safe and the incidence of falls minimal.