Programs by Setting: Long-Term Care
Hi Everyone! Welcome to May, as we prepare to celebrate Nurses Week, May 6th – 12th.
I give thanks every day to be a nurse — a rehabilitation nurse. I have enjoyed a thirst for knowledge, a quest to contribute to nursing’s body of knowledge, and a commitment to integrate evidence into practice. We all know that not all published research is good science; thus, we rely on resources whose mission is to take sound, graded evidence and translate that evidence into practice. One such agency that I have relied on is AHRQ: the Agency for Healthcare Research and Quality. Their mission is to “produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used.” (AHRQ About Our Work, available here). I have been fortunate in my career to work with extraordinary colleagues across the country to develop, validate and roll out AHRQ falls toolkits, focusing on hospitals. I have spent much time promoting toolkits for preventing falls in hospitals, and focused toolkits and implementation guides such as “Use of Floor Mats at the Bedside”, “Hip Protector Toolkit”, and “Population-based Approach to Protection from Serious Injuries”.
Recently I was visiting the AHRQ site to search for updated resources toolkits and came across AHRQ’s Quality and Patient Safety Programs by Setting: Long Term Care, available here. As I perused these safety programs, of which there are 11 programs, I wondered how widely these programs have been incorporated into long term care (LTC) organizations’ quality, safety and clinical practices, especially related to falls and patient safety.
Of course, my attention was drawn to two of the 11 quality and patient safety programs: Fall Management and Patient Safety. As I reviewed them, I thought about their application beyond LTC, but to rehab hospitals and inpatient rehabilitation units, specialty hospitals, such as orthopedic hospitals, and more. I’m delighted to share just highlights of each of these programs, with hopes that your interest will be sparked to delve into these with your colleagues, to discover some resources that may be helpful to your practices and patients.
Program 3. Falls Management Program (FMP): A Quality Improvement Initiative for Nursing Facilities (AHRQ, 2017), available here. This program, downloaded as a manual with six chapters, was created by interdisciplinary team members convened to conduct a quality improvement initiative for nursing facilities. Their goal of this initiative was to provide “individualized, person-centered care and improve their fall care processes and outcomes through educational and quality improvement tools”. To move Fall Management Programs in long term care to proactive reduction of fall risk and reduction of injuries, components of the program address strategies to change from a culture of blame to one of no-blame – an open and transparent culture. AHRQ also calls upon LTC organizations to embrace a culture of teamwork, advocating for a Falls Nurse Coordinator, who is responsible for program implementation and serving as the program champion. The roles and responsibilities of the other program members is described with very helpful guidance to plan and run meetings, with evaluation towards agenda and goals. I hope you will review the contents of this program.
So much information is provided in the first chapter of this six chapter program. In creating a culture of safety, they have a culture safety checklist and recommend a Falls Nurse Coordinator as a clinical champion, with responsibilities for full implementation of the program, coordinating fall responses, and ensuring education and training of staff, families, and residents. When forming or enhancing an FMP, one of the most important steps is to conduct a program self-assessment. They have such a tool. Their tool is very detailed to enable LTC facilities to identify what process of care for fall prevention are in place and what areas need improvement, divided into seven program areas:
- Culture
- Organizational commitment and team skills
- Data collection and analysis
- Staff training and information for primary care providers, families, and residents
- Environmental and equipment safety
- Care plan development
- Monitoring implementation and resident response.
This FMP has two primary approaches: immediate response to falls, and long-term management:
Immediate Response. Long-term care organizations have extensive experience with responding to falls, as residents have a higher fall rate than other settings of care and are more vulnerable and at greater risk for injury. This AHRQ management program does confirm that post fall management relies on an immediate response. Chapter 2, Fall Response: careful evaluation, an investigation, that produces an immediate intervention within an expected timeframe — within 24 hours of the fall. All efforts are to identify risk and prevent recurrent falls, measure through quality indicators that are markers of program improvement specific to the residents, administrative and staff members, discussed in Chapter 3: Data Collection and Analysis Using TRIPS.
Long Term Management. Chapter 4 addresses FMP components — timeframes for assessing fall risk from screening on admission to changes in residents’ conditions. For those residents who are high fall risk, comprehensive assessment is to be conducted and an individualized care plan is developed within 1-7 days. In congruence with nursing processes, the plan is implemented and staff monitor resident responses and modify the plan of care accordingly over 1-6 months.
I hope also that you will review this information in Chapter 5, Information and Training for Staff, Primary Care Providers, and Residents and their Families. This chapter contains a full compendium of then educational materials designed to train front-line personnel in nursing homes and other long term care settings. An Instructor Guide contains all the teaching materials, modules with slides, pre- and post-tests, and Student Workbooks for each module. This program is even further developed as the 4th among 11 patient safety program, specific for LTC settings, as I discuss in the next section.
I was delighted to find in this FMP, Chapter 6: Environment and Equipment Safety, available here. I am asked frequently for environmental assessment tools, and this chapter contains information on ways family members can help reduce risk in the environment (i.e., reducing clutter, providing well-fitted shoes, always calling staff to help with transfers if unsure how to assist their loved one to out of the bed or to the bathroom); nursing and engineering inspection lists completed by nursing assistants with completed samples; engineer cane/walker inspection for lose or missing bolts, rubber tips, and rolling casters on walkers; and, lastly, an engineer wheelchair inspection of the general cleaning and lubrication, frame, armrests, seat and back upholstery, brakes, foot- and leg-rests, and wheel/caster cheeks. This resource is the first environmental safety checklist that included canes, walkers and wheelchairs integrity, which I was delighted to find. As a rehabilitation nurse, I made a toolkit for such equipment, because I tightened loose bolts, and adjusted leg and foot rests. It was easier to fix equipment than to lose unit-based equipment to engineering for repair. I so hope you will find this information helpful to you.
Program 4. Improving Patient Safety in Long Term Care Facilities (2018), available here
In Improving Patient Safety in Long Term Care Facilities, this is a fully-developed training curriculum for front-line personnel in nursing homes and other long term care facilities. This program includes a complete step-by-step instructor’s training guide for all three modules:
- Detecting Change in a Resident’s Condition
- Communicating Change in a Resident’s Condition
- Fall Prevention and Management.
Instructor’s materials include suggested slides, pre- and post-tests with all the answers, and even separate student workbooks for each module. Of interest, staff strategies to reduce fall risk (Slide 12b) includes hip protectors, alarms and sensors, and floor mats. What incredible resources!
I am so glad that I found this resource for LTC, and this opportunity to share a glimpse the AHRQ Patient Safety Programs of LTC setting with you.
Thank you for reading my message. I welcome your comments. Again, if you have used any of these programs, I would love to hear back from you.
All my best, Pat
Pat Quigley
References
AHRQ’s Quality & Patient Safety Programs by Setting: Long-Term Care. Content last reviewed September 2021. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/patient-safety/settings/long-term-care/index.html
Improving Patient Safety in Long-term Care Facilities. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/patient-safety/settings/long-term-care/resources/facilities/ltc/instructor.html
The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities. Content last reviewed December 2017. Agency for Healthcare Research and Quality. Rockville, MD.
https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx.html
Dr. Patricia Quigley is a Nurse Consultant, Nurse Scientist, Former Associate Director and VISN 8 Patient Safety Center of Inquiry. She is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation, and her contributions to patient safety, nursing and rehabilitation are evident at a national level, with emphasis on clinical practice innovations designed to promote elders’ independence and safety. She is nationally known for her program of research in patient safety, particularly in fall prevention. The falls program research agenda continues to drive research efforts across health services and rehabilitation researchers.