Multidisciplinary Approach to Fall ~ THE CASE OF MS. KELLY
by Barbara Riley-Baker, BA, MA, CMC, C.P.G.
At Mease Countryside Hospital, the rehabilitation program’s social worker calls in the multidisciplinary discharge planning team to review the case of Ms. Kelly.
Ms. Kelly is an 80 year-old female African American. She is a recent widow who lives alone in a single family home. Her medical history includes; diabetes, low blood pressure, and osteoarthritis. Twice, within the past month, Ms. K. has been brought to the hospital’s emergency room for fall related injuries that occurred in her home. The most recent and serious fall resulted in a fractured hip and surgery. Ms. Kelly is about to begin the hospital’s physical therapy program.
It is obvious Ms. Kelly’s first discharge was not successful. She returned to hospital for a second time in one month with a far more serious injury. A multidisciplinary team approach will search for the etiology of Ms. Kelly’s falls and take preventative measures to reduce the probability of another injury and a return to hospital.
Mease Countryside Hospital’s multidisciplinary teams are based on the qualitative methodology approach of Janice M. Morse from the University of Alberta. Ms. Morse has stated, “…falls are (now) considered an event that may be predicted …and prevented.” Falls are no longer thought of as unavoidable accidents or as a normal result of illness. The multidisciplinary discharge planning team consists of its chairperson, the rehabilitation social worker, the hospital pharmacist, the medical director for the falls team, the director of the gait and balance program, and the deputy director of the patient safety center.
The team will assess for any active or latent errors in Ms. Kelly’s care as well a complete assessment of Ms. Kelly’s physical condition, limitations and abilities. The team concluded if Ms. Kelly were sent home without interventions in place, it would not be long before she would return to hospital and then to a long-term care facility and would probably never go home again.
Ms. Kelly’s home will also be assessed for patient safety. Using the Root Cause Analysis approach, the team hopes to improve patient outcomes and reduce expenditures. Ms. Kelly’s evaluation will take into account normal aging changes, intrinsic risk factors (physical conditions), extrinsic risk factors (polypharmacy, polymedicine, restraints, environmental risk factors), and current medical conditions acute and chronic, (diagnosed and undiagnosed).
The falls assessment includes; vital signs, visual acuity, depth perception, Mental Status Examination, neurological exam including proprioception and cerebellar function, fall history, medication review, physical examination, functional assessment and environmental review. Depression screening will also be conducted due to the recent loss of Ms. Kelly’s husband, possible fear of falling again, and any independence concerns.
Root Cause Analysis
The multidisciplinary team uses Root Cause Analysis to discover the cause of Ms. Kelly’s falls. What predicated the falls? Were the falls due to her physical conditions or environmental factors or both? When did the falls happen, the same time of day, in the same room of the house, what was Ms. K. doing at the time of the fall. Was she wearing sensible shoes or shoes with unsafe bottoms? Is Ms. K. taking her medications as prescribed? Has the assessment discovered other health conditions that have not been addressed? The assessment data is analyzed.
Depression was an additional diagnosis revealed by the team. Ms. Kelly was started on an antidepressant. Her lab work was completed and other medications were reviewed and adjustments were made, bringing her low blood pressure into a more-normal range. The team also discovered Ms. Kelly had not had a vision exam in years. There had been definite changes in her eyes due to her diabetes. These changes were addressed including new eyeglasses.
The team recognized the need for immediate education. Ms Kelly attended diabetes education classes while in the hospital rehabilitation program. Classes included meal planning, monitoring blood sugar levels, exercise tips, and social support. The hospital-based support group was culturally diverse and Ms. K. soon made new friends. She received safety training on changes in posture, e.g. safely rising from a seated position.
Ms. Kelly also attended arthritis classes. She learned about osteoarthritis in particular and discovered she was not alone in her suffering. There is no cure for osteoarthritis, but the condition is treatable with medication, exercise, rest, weight control, alternative therapies, coping skills, and surgery. Ms. K. received information about her all chronic conditions and was taught active coping skills and positive reappraisal.
Ms. Kelly’s adult children, a son and daughter who live nearby, were invited to attend the same educational classes in the evening. The family support members were apprised of fall statistics and the need for interventions. Falls are the leading cause of injury deaths, nonfatal injuries and hospital admissions for trauma for older adults.
Near the end of Ms. Kelly’s in-hospital therapy program the physical therapist, and her daughter visited her home with her for a safety evaluation and the root cause of her falls. Combined with Ms. Kelly’s personal fall history, as well as an environmental review, recommendations were made. The home revealed safety issues that needed to be addressed prior to discharge.
Using the SPLATT test; symptoms, previous falls, location, activity, time, and trauma, the team deduced the cause of Ms. Kelly’s falls. Both of her falls happened in the bedroom. The falls occurred when she was getting out of bed in the morning. Ms. K. informed the team that she had had other falls and near falls but without injury. The home contained a number of fall risks throw rugs, clutter, and in several places, power cords on the floor. The lighting in the home was insufficient including the home needed more nightlights. In the bathroom, a nonskid bathmat was needed, along with grab bars, shower chair, handheld showerhead, and a raised toilet seat with handrails.
The team concluded that a combination of conditions and factors were behind Ms. K’s falls; orthostatic hypotension, vision changes, probable abnormal blood sugar levels, morning joint stiffness, and poor balance caused her to become dizzy and unable catch herself resulting in falls. The home inspection also revealed Ms. Kelly was not taking her medications as directed. Staff compared the date on the pill bottle to the number of pills remaining; taking into consideration the date Ms. K. entered the hospital. Some medications were taken too often and some not often enough.
With Ms. Kelly’s permission, the team’s findings were shared with her adult children and her primary care physician. Her children addressed all suggested home safety modifications and stocked the refrigerator with healthy choices for their mother’s homecoming.
Ms. Kelly’s discharge plan included two pair of hip protectors to reduce future fractures, diabetic Meals on Wheels for nutrition, Home Health therapies; physical and occupational, balance and gait training, strengthening exercises, and safety training for walker and cane to enhance independence in Ms. K’s environment. Ms. K’s medications will now be prepared monthly in bubble packs and delivered by her local pharmacy. Each adult child will visit Ms. Kelly at least once a week and monitor her safety and medications. Ms. K has expressed a desire to continue educational training and support group attendance at the hospital. Her name will be added to the hospital’s outreach monthly mailings. The adult children have offered to provide transportation and may even partake of the training. Any changes in Ms. K’s status will be reported to the team.
Ms. K will also receive a safety monitoring system, such as Live Line, and training in its use. Her name will be added to hospital’s volunteer call list. Ms. K will be called every morning to monitor her health and safety. Any negative reports will be sent to the team and addressed as soon as possible.
Ms. Kelly is competent and values her independence. The interventions put in place by the hospital social worker, the multidisciplinary discharge planning team, Ms. K’s adult children, Home Health, communication network and Ms. K. herself will address her needs upon discharge.
Ms. Kelly and her children have also received education in advanced directives. The family will consult with an elder law attorney to prepare these legal documents as soon as Ms. K. is able. Should she no longer be able to live alone, her daughter has agreed to care for her mother in her home. Ms. K. has agreed but hopes that that move will not be necessary.
A team member will make monthly home visits to Ms. Kelly to assess her progress as well as the program. The team’s motto is, “an ounce of prevention is worth a pound of cure.”
References:
Bulat, Tatjana, (2005). Fall Prevention in the Elderly. Lecture.
Goins, Lora. (2005). Getting to the Heart of Diabetes. Lecture.
Hart-Hughes, Stephanie. (2005). Fall Prevention in the Elderly. Lecture.
McIlvance, Jessica, (2005). Coping With Arthritis in Diverse Elders. Lecture.
National Center for Injury Prevention and Control. 2005. 19 June 2005 http://www.cdc.gov/ncipc/factsheets/falls.htm
Rutledge, Michelle. (2005). Fall Prevention in the Elderly. Lecture.