Clinical Governance And Fall Prevention In Geriatric Ward

Write the Summary of proposed interventions:

Clinical governance refers to a framework by which UK National Health Services (NHS) authorities are accountable for the improvement of the quality of the health care services they are providing. It is one of the key agenda of the UK central government for ensuring the quality care in health care sectors (Swift and Iliffe, 2014). In Australia, clinical governance is also a major issue and it depicts a relationship between the patients and the health care provider. Along with this, state or territory health department, the governing body are also involved. According to the standards of National safety and Quality Health Service Standards( NSQHS), the main components of the clinical governance are (Spigelman and Rendalls., 2015) -

• Governance, leadership and culture
• Clinical performance and effectiveness
• Patient safety and quality improvement system
• Partnering with consumers

• Safe environment for delivery of care.

In this project, the patient safety and quality improvement system and safe environment for delivering care are mostly important, as the project is associated with the prevention of fall in geriatric ward. The risk of fall and fall related injury is very common in the geriatric ward of hospitals. To reduce the risk of fall and fall related injury, nurses should take relevant role in maintaining the safety of patients and safe medical environment and those are key components of clinical governance. For the nurses, it is very important to have proper knowledge of those components. Unless, they are unable to give proper care to the patients.

The enhancement of Australian aged population has increased the risk of fall, fall related injury, and every year the older age population is growing in numbers. Since 2017, about 3.8 million people of Australians having the age of 65 and over which covers about 15 % of total population of Australia. It is predicted that, the growing older age population will reach to 8.8 million by 2057 (Australian Institute of Health and Welfare, 2018).  With rising older population, the case of fall related injury in Australia is also increased. According to a report of Australian Government named ‘Trends in hospitalization injury due to falls in older people’ stated the trend of fall related injury cases of older age population in the time of 2002-03 to 2014-15. According to that report, almost 111,222 patients with the age of 65 or over has been hospitalized due to fall in 2014-15 and it is about 3% of total hospitalization case of adult population (age 65 or over). In this case scenario, it is seen that women were more prone to fall injury than the men. The rate of women fall related injury was 3519 per 100,000 and the rate of men fall injury was 2412 per 100,000 population. The age related injury hospitalization has been increased over the period of time 2002-03 to 2014-15. The rate of increase hospitalization is 3% for the men and it was 2% for the women. The fall related injury in 2014-15 is commonly associated with the head injury (24%) and hip and thigh injury (24%).  Although the rate of head injury was higher in older the population of Australia. The hip fracture was the most common injuries and it is almost 73%. Almost two folds increased the rate of head injury over the time of 2001-03 to 2014-15. In 2002-03 the head injury cases was about 319 and 336 per 100,000 population for men and women respectively. However, in 2014-15 the numbers increased to 706 and 731 for men and women respectively. The most frequent cause of fall injury in Australia was fall on a level from stumbling, slipping and tripping (34%). The percentage was about 15% in case of falling from the household objects as chairs ladder, stairs, beds. Almost, 85% of the fall injury cases in 2014-15 was occurred in home or in residential care unit. The rate of falling in the home was about 1814 per 100,000 population and the rate was 10,090 per 100,000 in case of residential aged care (Australian Institute of Health and Welfare, 2018). Although, there was 17 % case scenario, in which place of occurrence was not specified (Voula ,Shannon and Janneke, 2015). The fall related injury also affect the family member and as well as other care giver of the patients. The Australian Commission on safety and Quality in Health Care had introduced various measures to prevent such fall related injuries. It can be said that, with proper implementation of various plans, the problem of fall related injury could be solved in some extent.

Evidence that the issue / problem is worth solving

The stakeholders play a crucial role in preventing the fall in the geriatric unit of the hospital. In this case, the primary stakeholders are the older age patients, the family and other care giver of the patients, nurses and other health care provider and as well as the health care management team. The nurses are the primary factor in the implementation of interventions of fall reducing measures as they are directly involved in providing the care. The main of this of this project is to reduce the rate of fall related in injury in older age people. To implement the interventions, patient education is very much required and the nurses can play crucial role in educating the people and promote the person cantered care to raise the involvement of patients in this awareness programme 

(Chamberlain-Salaun , Mills and Usher., 2013).

CPI Tool refers to the methodology that supplies a framework for the health care providers for improving the quality of services they are currently providing. There are many tools for improving the quality of services. A PDSA tool is very much effective for this project. The Plan-Do-Study-Act (PDSA) cycle is a crucial part of the health care unit for improving the quality of the services. The main steps of PDSA cycles are (Toussaint and Berry, 2013)-
1)Step 1 is the planning of the observation or the test.
2)Step 2 is the implementation of the tests on a small scale range
3)Step 3 is the study of data that is analysing the data and the study result.
4)Step 4 is the act that is implementation of changes detected by the test.
The main purpose of using this tool in this case is to build up a relationship between the changing process and related outcomes. The PDSA tool helps in finding the project goal, the outcomes of the changes, and the method of attaining those changes in the health sector. In the first step, planning is required for the problems, which are already reported. In this step, innovative ideas are important to address the reported problems. In 2nd step, the suggested changes are implemented and the consequences are recorded. However, if there is any unwanted situations, that also must be recorded. In the next step, the existing literature related to the topic should be reviewed and relation should be established with the test result to support the result of the test. Moreover, the similarity of the project interventions with the literature studies will strongly increase the reliability of the test interventions. In the last step, the small-scale test result are applied to the large scale if the small-scale test results are able to meet the aim of the project. In this project, the PDSA is used to assess the patient experience and based on that interventions are planned to reduce the risk of fall injury  

Key Stakeholders

In this project, firstly, the fall rate in the geriatric unit is examined and the causative factors of the fall injury is assessed. In this project, the assessment group was the older population in the age group of 65 or above. Exercise intervention can be good choice for reducing the risk of fall injury. In a study, it is seen that exercise intervention for a time of 12 months with a frequency of 3-exercise session per week showed effective result in fall prevention. Multifactorial intervention is another effective way in which the initial geriatric assessment is performed and that comprises of any number of the following components like vision, gait, balance, cardiovascular health, cognition, medication, psychological health. The pre and post assessment tests are conducted by physical tests. Administration of vitamin D also showed improvement in fall related injuries (Janelle et al., 2018).  Fabienne et al.(2013) showed that fall prevention exercise programmes for the elderly has reduced the rate of fall and as well as also is responsible for lowering the fall injury. The reduction rate is 37% for all type of injurious fall, 43% for the severe injuries due to fall and lastly the 61% fall is responsible for fracture. In a study by Hill et al. (2013) showed that, educational management is an effective way of preventing fall in the elderly people in the hospital. In this project, initially, the nurses knowledge about fall prevention will be assessed and there role in patient education related to fall prevention is also examined. After that, the nurses would participate in a discussion of fall prevention strategies of the hospital. Next, intervention plan will be made up from the information that has come out from the discussion. In that study, data was collected from the 48 participants who were at the age group of 65 or above. Among them, 23 people reported about fall and 18 case was from the control group and five from the experimental group. The fall rate in the intervention group was 5.4 falls/ 1000 patient and in the control group, it was 18.7/ 1000 patients. This showed that, patient education could reduce the fall rate in elderly. 

Although, the interventions of this project were evidence-based, there are several hindrances to implement those interventions. The health care providers ( HCP) faces various problems like denial that is the elderly people disagreed to accept that they had fall due to the balance, muscle weakness and gait balance and along with this they were also not ready to accept their certain behaviour that can cause fall of them. In some cases, the health care providers had not enough knowledge to assess the fall and they are unable to understand the value of exercise in fall management. In some cases, the hearing problems for the older age people. As a result, they were underdiagnosed by the HCP. The vision problem was also another major barrier for implementing the interventions. The lack of communication between the HCPs causes lack in exchanging information and as a result, there was no proper discussion about the case study of the older people. As a result, the injured people are not sent to the other specialists like physiotherapists, occupational therapists and this ultimately results in hamper of treatment. The lack of follow up treatment in fall injury is another major hindrances and discontinuity in treatment ultimately hampers the medication procedures. Lack of proper education in managing the fall injury is another big problem in implementing the interventions (Loganathan et al., 2015). The negligence from the patient’s end is also a major hindrance in implementing the interventions. Lack of proper funding for the interventions is also decreases the chances of implementation (Gleeson et al., 2014).

CPI Tool

The information collected from this project would be analysed by the various statistical tools. The questionnaires to assess the condition of the fall injury of the elder people would be validated by the Cronbach alpha test to examine the reliability of the questionnaire. To assess the environment of the health care sector, checklist would be used and the checklist should be assessed by reliability test tool. The pre intervention data was collected and stored for future analysis. After that, proposed intervention are implemented and changes were again recorded for comparing with the previous 

result. The comparison of the pre and after data analysis would ultimately enhance the reliability of the project. In this project, it would be recorded that the implementation of the interventions will enhance the patient safety and reduce the fall related injury in the elderly population.

References

Australian Institute of Health and Welfare(2018).Trends in hospitalised injury due to falls in older people 2002–03 to 2014–15. Injury Research and Statistics Series Number 111.

Chamberlain-Salaun, J., Mills, J. and Usher, K., 2013. Terminology used to describe health care teams: an integrative review of the literature. Journal of multidisciplinary healthcare, 6, p.65.

El-Khoury, F., Cassou, B., Charles, M.A. and Dargent-Molina, P., 2013. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMj, 347, p.f6234.

Gleeson, M, Sherrington, C and Keay, L 2014,’ Improving Balance and Mobility in people over 50 years of age with vision impairments: can the Alexander technique help? A study protocol for the visibility randomised controlled trial’, Pubmed, vol 20.

Hill, A.M., Etherton-Beer, C. and Haines, T.P., 2013. Tailored education for older patients to facilitate engagement in falls prevention strategies after hospital discharge—a pilot randomized controlled trial. PloS one, 8(5), p.e63450.

Janelle M., Guirguis-B., Yvonne L. M., Leslie A. P., Erin L. C and Tracy L.B.,2018. Interventions to Prevent Falls in Older Adults Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2018;319(16):1705-1716. US Preventive Services Task Force

Loganathan, A., Ng, C.J., Tan, M.P. and Low, W.Y., 2015. Barriers faced by healthcare professionals when managing falls in older people in Kuala Lumpur, Malaysia: a qualitative study. BMJ open, 5(11), p.e008460.

Spencer, R. and Campbell, S.M., 2014. Tools for primary care patient safety: a narrative review. BMC family practice, 15(1), p.166.

Spigelman, A.D. and Rendalls, S., 2015. Clinical governance in Australia. Clinical Governance: an International Journal, 20(2), pp.56-73.

Swift, C.G. and Iliffe, S., 2014. Assessment and prevention of falls in older people–concise guidance. Clinical medicine, 14(6), pp.658-662.

Toussaint, J.S. and Berry, L.L., 2013, January. The promise of Lean in health care. In Mayo clinic proceedings (Vol. 88, No. 1, pp. 74-82). Elsevier.

Voula S., Shannon G. and Janneke B-G., 2015.Fall-related injury profile for Victorians aged 65 years and older. Victorian Injury Surveillance Unit (VISU). (Edition No. 80).