1. National Collaborative for the Prevention of Falls in Long-Term Care
Edmonton General Continuing Care Centre Covenant Health
(Formerly Caritas Health Group)
National Collaborative for the Prevention of Falls in Long-Term Care

2. Background
Covenant Health (Caritas Health Group) is a faith based organization with :
two large acute care sites
150 bed continuing care site under construction (Pineview)
220 bed continuing care site ( Youville Home, in St. Albert)
Edmonton General Continuing Care Centre
(500 Bed Facility)
-478 Continuing Care Bed
- 22 Palliative Care Hospice Beds
- 20 Sub-acute beds

3. Edmonton General Continuing Care Centre
500 bed facility (previously an acute care facility)
- 478 continuing care beds
- 22 palliative care hospice beds
- 20 sub acute beds

4. Aim
To learn and develop a process for creating an awareness of our residents falling to reduce the incidence of falls, particularly major injuries from falls using a multidisciplinary approach.

5. Goal
Reduce the number of major injuries from falls by 50% and the number of falls by 10% by May 2009 on pilot unit.

6. Team Members Jacqui Rapaic RN Practice Development Manager
Joan Oldegbers
HCA
Health Care Aide
Elaine Ferguson PT
Practice Development Supervisor- PT

7. Improvement Objectives
Increase staff, family and resident awareness and implement fall prevention strategies
Fall Risk Assessment for every new admission within hours.
Reduce number of major injury falls by 50% and falls by 10%.
Post fall defining process.

8. Changes Tested
Testing of knowledge re: fall policy and procedure lead to increased need for education
Provide education and retesting lead to increased knowledge
Identification of residents at risk of falling
Interdisciplinary input to identify interventions needed, many in place already; some were added
Accurate recording and communication redundancy ineffective
Selection process of Fall logo intervention increases awareness

9. Results Tested 13 staff from 6 disciplines
18% less than predicted knowledge of 75%

10. Lessons Learned Streamlined reporting process
Effective lines of communications are vital
ID team approach is essential for fall reduction and awareness
Staff enthusiastic with the participation/interactive format
Staff still unsure about what constitutes a restraint and least restraint policy and procedure
Poor understanding of the risk factors involved in a falls risk assessment
Education strategy needs revision to prevent ambiguous results
Staff unaware of definition of a fall
Consistency of staff and team leadership for follow through or fall risk assessment
Regional education sessions required to update, review data with staff and involve in this process

11. Next Steps Test Post Fall Algorithm
Await regional Fall Continuing Care Committee re: possibilities of implementation of Fall Logo
Retest Modified v. Scott tool
Review fall reporting system
Regular Best Practice Fall Committee Meetings (ID)
Test injury prevention products

12. Results Knowledge level up 21% to 78% (3% higher than predicted)
Data accumulation difficult (group vs. individual)
Able to identify specific areas lacking

13. Changes Tested
Did staff knowledge increase having the policy and procedure made available and being asked to read?
Get PDJA cycles

14. Complicating Factors Past Present No unit RCM-Rotating coverage
Unit LPN went off on WCB ▪Regular PT off due to
Pharmacy shortage left limited disability
coverage ▪Inconsistencies & shortage
Improvement team member and of staff
data recorder/submitter off and ▪Coordinating with regional
unavailable group requires a wait
Improvement team key contact time
away for an extended time

15. Expectations Decrease falls and injuries from falls
Continue education to increase knowledge
Develop and test strategies
Identify high risk fallers
Ensure interventions are in place
Re-evaluate on going strategies
Reduce restraints
Regular unit post fall team meetings
Fall Consult Team implementation and expansion