Developing A Policy For Fall Injury Prevention In Older People

The overall purpose of the assessment is to develop a new policy or update an existing policy, from your workplace or the public domain, which impacts on the potential for older people to engage actively and meaningfully in their community. 

An accompanying report is required to support the development to the new or updated policy. 

The report should include: 

• clear statement explaining the background the health policy for review;
• brief overview of the policy and how it impacts on the health of older people;
• consultation with consumers and colleagues to develop the new or updated policy;
• review of the evidence base to inform the content of the new or updated policy;
• review of the evidence base focused on guidance for successfully implementing policy in practice;
• recommendations about how to measure successful implementation of new or updated policy;

Policy template1
NAME OF DOCUMENT
TYPE OF DOCUMENT	Policy
DOCUMENT NUMBER
DATE OF PUBLICATION
RISK RATING
REVIEW DATE Documents are to be reviewed a maximum of three years from date of issue
FORMER REFERENCE(S) Documents that are replaced by this one
EXECUTIVE SPONSOR or EXECUTIVE CLINICAL SPONSOR
AUTHOR Position responsible for the document including email address
KEY TERMS
SUMMARY Brief summary of the contents of the document

NAME OF DOCUMENT	Fall Injury Prevention in Older People Policy
TYPE OF DOCUMENT	Policy
DOCUMENT NUMBER	NA
DATE OF PUBLICATION	1991
RISK RATING	High
REVIEW DATE Documents are to be reviewed a maximum of three years from date of issue	2015
FORMER REFERENCE(S) Documents that are replaced by this one	NA
EXECUTIVE SPONSOR or EXECUTIVE CLINICAL SPONSOR	Public Health Association of Australia
AUTHOR Position responsible for the document including email address	Richard Franklin & Lyndal Bugeja, Co-Convenors, Injury Prevention SIG – [email protected]; [email protected]
KEY TERMS	Falls, prevention, fall injury, elderly patients, fall risk, policy
SUMMARY Brief summary of the contents of the document	The policy outlines the objectives and goals of the Public Health Association of Australia in the prevention of injury related to falls for elderly people in Australia. The document provides various strategies which can be used to reduced, minimized or prevented the risk of falls among the target population, supporting the strategies from evidences from research. The document also outlines the guidelines set by Australian Commission on Safety and Quality in Health Care (ACSQHC) Falls Best Practice Guidelines (2009). Based on these supporting evidences, the document outlines the steps and actions that can be used to reduce or prevent the risks due to falling among the elderly people. The document follows the best policy guidelines of ACSQHC https://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Guidelines-COMM.pdf

Policy Template

A fall can be understood as an incident which causes an individual coming at rest accidentally on the ground, floor or a lower level, according to the definition by the World Health Organization (WHO). The WHO statistics shows that every year 646,000 people die due to injuries caused by falling. Adults who are 65 years or older are at the highest risk of falling, and receiving a fatal injury due to it. Moreover, every year there are 37.3 million incidents of falls, which require medical attention. The WHO recommends that preventative strategies should focus on education, training and developing safe environments as well as on studies on fall and fall prevention and devise effective policies to alleviate the risk of falling (who.int 2018). The risks of falling also increases with age, which is supported by the Canadian Community Health Survey in Canada on people above 65 years of age. The statistics (published by WHO) shows that the risk for fall related injuries increased progressively among the age groups 65-69 (35 cases), 70-74 (46 cases), 75-79 (66 cases) and above 80 (76 cases). The statistics also showed comparatively higher risks of injuries related to falls among women, compared to men (who.int, 2018).

                                                                    

                                                                      Figure 1 Statistics on falls related injury rate:  source (who.int 2018)

The statistics also analysed the location of these falls, showing the most of the falls occur outside home (56%), while the next most significant location is on level surfaces (26%), and indoor locations include shower or bath (6%), stairs (6%), getting out of bed (3%) and chairs or ladders (3%).

                                                                                

                                                                                Figure 2: Locations of injury due to falls. source (who.int 2018) 

Risk Factors for Falls and Fall-Related Injuries

According to the Public Health Association of Australia, there is an increasing trend in the ageing population in Australia. According to their estimates the percentage of population aged 65years and above will reach 19% by 2031 (from 15% as of 2014), with even a greater increase in the population aged 85 years and above. The risk factors that increases the chances of falling and injuries related falling have been identified as: age, gender, balance and gait, strength, vision, vertigo/dizziness, heart diseases, dementia, depression and even due to medications, wrong footwear and the environment at home. PHAA also points out that the risk of falling increases with age (more than 1 in three people of age 65 or older, in community dwelling setup fall every year and between 2010 and 2011, more than 92,150 cases of injuries related to falls have been recorded, which needed hospitalisation. The annual costs incurred due to such injuries amounts to about 600 million dollars (towards hospital expenses). Also, with the improvement in the life expectancies among Indigenous Australians (aboriginals and Torres Strait islanders), it is important to focus on reducing the risks of fall related injuries in the population aged 45 years and older (workingwitholderpeople.edu.au 2018; phaa.net.au 2018).

The policy suggests that risks of falling as well as the injuries caused by them can be reduced or even prevented through exercise routines that improves balance and strengthens muscles. Activities such as high level balance exercise in group or home setup can be useful to achieve that objective. The policy also outlines few other strategies that can be useful to reduce the risk of falling and injuries due to it:

• Applying occupational therapy interventions for populations at high risk of falling
• A speedier surgery for cataract removal
• Withdrawing the administration of psychoactive medicines
• Assessment of cardiovascular ailments
• Involving a multidisciplinary and intensive assessment for populations at high risk
• Comprehensive geriatric assessment in residential care setup
• Targeted hospital based intervention and education of patients and their care givers.
• Using hip protection for population at high risks (in home care setup)
• In home assessment and modifications to home environment (to reduce fall risks and environmental hazards) for people at high risk of falling

(workingwitholderpeople.edu.au 2018; safetyandquality.gov.au 2018)

The PHAA outlines the following principles on which preventative strategies can be developed:

• An exponential rise in the incidence and expenses related to fall related injuries are likely to occur in absence of a nationally coordinated response, especially due to the ‘baby-boomer’ generation reaching the retirement age. Since the injuries related to falls result in prolonged hospital stays, it results in a high financial burden. Estimations from 2003 showed that without proper interventions and preventative strategies, the healthcare expenses related to fall related injuries can increase by 3 times to reach about 1375 million dollars and 1.17 million bed days each year. Also, the rate of hospital falls also increased by 1.8% from 1999 to 2009, which shows that without proper preventative measures, the rate is likely to increase further.
• Risk of falling also is increased due to a fear of further falling by people to suffered falls earlier, which reduces their confidence towards movement, which further affects their socialization process. Older people who had been hospitalized before due to fall related injuries have increased challenges towards independent living, due to which residential care might be needed for such individuals.
• Even though there is a decreasing trend in the hospitalization rates for hip fractures, it still remains one of the most significant injuries related to falls (17,000 cases each year). The burden is also significant in the context of mortality, morbidity, costs of care and hospitalisation as well as the loss of independent living ability.
• Injuries related to fall is both preventable as is predictable. Also, it is of a high priority to reduce the risks of falling among the older people for health promotion initiatives at national and local (state and territory) levels. Effective strategies need actions which spans a variety of healthcare setups as well as community based and population specific strategies.
• Even with an increasing base of evidence for strategies on fall prevention, more investigation is still required in older to develop more effective strategies for older population suffering from cognitive decline and impairment, to understand the function of physical activity, supporting individuals in residential care setup and for individuals from whom English is a second language as well as individuals living in remote places. Also, prescribing vitamin D can also help to reduce the risks of falling among residents in care setups.
• Additional studies are also needed to understand the efficacy of fall prevention strategies among the indigenous populations, with focus on the cultural and social differences and community orientations among the Torres Strait islander and aboriginal communities in Australia.

The PHAA recommends the following steps which can be undertaken to prevent and minimize the risks due to falls, such as:

1. Developing a nationwide approach to use ACSQHC falls best policy guidelines in order to provide the following advantages to the prevention of fall and fall related injuries among the older population:
   • In a community setup, promotion of the health and wellbeing, removing the fear of falling, improving independence and maintaining the community involvement in care.
   • For healthcare services, a safer healthcare delivery, improving healthcare savings, increasing productivity and reducing aged care and acute service demands
2. Funding the AIHW National Injury Surveillance Unit (NISU) to partake in studies to understand factors related to fall related injuries among older populations
3. Improving the participation and partnerships in order to develop collaborative efforts that spans across different disciplines of healthcare as well as other disciplines and involves communities in order to reduce the risks of falling and fall related injuries among older people.
4. Using evidence base approaches to develop effective strategies that can be used to reduce the risks and also support healthy active living and ageing process and create a low risk population.
5. Understanding the local government’s role in the development and maintenance of safety in the environment, and implementing physical activity routines for older adults, as well as improving accessibility towards those services.
6. Promoting the development of best practice guidelines as well as collaborative strategies to design frameworks that can eliminate the hazards of falling, which can be utilized by architects and designers to understand the needs of elderly people, which can then be used in the design, development and building of buildings and other civil structures or architectures or to upgrade them. This can also help to create an environment that fosters physical activity among the target group and also improve the sense of security to partake in both planned and unplanned activities.

The PHAA outlines the following actions which has been resolved to reduce and prevent the risks of falling and fall related Injuries. These actions can be applied by the board and branches of healthcare organizations supported by advice from Injury Prevention Special Interest Group, and include the following actions:

1. Supporting strategies to prevent injuries due to falling as a national health priority, which aims to reduce the risks of falling, reduce injuries related to falling and its adverse effects on elderly people using updated policy information which includes a strategy for policy implementation.
2. Developing lobbies to increase funding in order to support health interventions, capacity development to improve access to interventions based on evidences on fall prevention.
3. Supporting a systematic and multifaceted method of investment which can be used to reduce the injuries related to falls, using evidence based strategies in order to foster independent living for elderly people and also reduce future expenses and demands for healthcare services.
4. Supporting strategies that foster collaboration between educators, researchers and policy makers in order to develop research based on available evidence and the unmet needs, and also to translate evidences based of literature into professional practice and to prevent or reduce the risk of fall and fall related injury
5. Developing lobbies for resourcing in order to implement and fund the guidelines.

Certain changes to the PHAA guidelines can also be suggested, which can help in the implementation of the strategies to reduce the risks of falling and fall related injuries among elderly people.

The Falls Policy for Older Western Australians outlines several important aspects in the fall prevention strategy, such as the risk factors (intrinsic and extrinsic) which increases the risks of falling and factors which increases the costs of care due to injuries related to falls (Hendrie et al., 2004; health.wa.gov.au 2018). The policy outlines their objectives as:

• Focus on the quality of life and independence for individuals 65 years and older
• Set up principles based on best practices to be adopted by hospitals, residential care facilities and also in home or community care setup
• Design methods to develop awareness of falls and improve intervention strategies
• Reduce duplication by improved coordination of services
• Improving networks and partnerships between the stakeholders
• Strengthen and support collaboration between the healthcare partnerships and networks

Preventative Strategies and Actions

The policy is moreover based upon 4 key principles, which can be implemented in the recommended policy updates to the PHAA strategies. These principles include:

• Promoting independence among the selected population, helping them to achieve positive and healthy living as much as possible so that they are able to continue residing in the community
• Preventing risks and reducing the risks of falling
• Education and interventions to reduce risks of falling and injuries caused due to it
• Ensure continuous improvement in the provision of services across the various target healthcare setups.

(Hendrie et al., 2004; health.wa.gov.au 2018)

The policy outlines the following target settings which can be focused on in the implementation strategies such as: hospitals, residential care, home and community based care, and the various interfaces with the hospital and health services. These interfaces have been identified as: primary care, emergency department, falls clinics, day hospitals and outpatient clinics. The strategies on fall prevention and risk mitigation can be implemented in these settings.

The Falls Policy for Older Western Australians differentiates the strategies addressing the risks of falling and fall related injuries into three categories: Prevention Strategies, Education Strategies and Intervention Strategies, which can be incorporated into the PHAA guidelines:

• Multidisciplinary and multifactorial approach:
  • Increasing awareness of the staff, patients and their caregivers about risk factors of falling and fall related injuries
  • Individual assessments of fall risk which can include neurological, visual and cardiovascular assessments
  • Developing and implementing clinical pathways and plans for the prevention of falls
  • Review of the environment, medications and footwear
  • Involving exercise routines for the target population to improve balance, strength and mobility
  • Management of continence
  • Review and management of the patient’s dietary status and diagnosis of osteoporosis
  • Supporting and facilitating the use of hip protection for high risk individuals
• Protocols for referrals to other services for prevention strategies already in progress:

• Self training and education
• Education of patient/caregiver and family
• Posters and information packages

• Multidisciplinary, multifactor individual strategies of interventions:
  • Developing and implementing intervention plan and clinical pathways
  • Reducing the individual risk factors for falling
  • Review of environment, medication and footwear
  • Exercise routines that are tailored to meet individual needs to improve balance, strength and mobility
  • Continence management
  • Review of diet and risks of osteoporosis
  • Supporting the use of hip protection
• Coordinating discharge plans
• Protocols for referrals and transfers for continued intervention approaches

Prevention Strategies:

• Multidisciplinary and multifactor approach:
  • Increasing awareness of the staff, residents as well as their families towards the risk factors
  • Risk assessments done individually including review of visual and cardiovascular status
  • Developing and implementing fall prevention plan and clinical pathways
  • Review and modification of the environment, footwear and medications
  • Exercise routines to develop strength, balance and mobility
  • Continence management
  • Review of diet status and signs of osteoporosis
  • Ensuring minimal usage of restraints
  • Supporting and fostering the usage of hip protection in high risk individuals
• Referral and transfer protocols to other services for ongoing strategies

• Education and training of staff
• Education of residents, their families or caregivers
• Posters and information packages
• Increasing awareness of the communities towards fall prevention strategies and intervention services available

• Multifactor approach for intervention and assessments
  • Develop and implement intervention strategies and clinical pathways
  • Reducing individual risks for falling
  • Review and modification of medication, environment and footwear
  • Exercise routines tailored to individual needs to improve balance, strength and mobility
  • Continence management
  • Review of dietary status and signs of osteoporosis
  • Minimal restraint use
  • Supporting the use of hip protection
• Referral and transfer protocols to other services to support ongoing strategies of intervention

• Encourage and support to healthy lifestyle choices and improving attendance of exercise programs for elderly people
• Improving the awareness of the clients to the risk factors, which can include:
  • Medication, environment and footwear
  • Visual reviews and modifications
  • Continence management
  • Review of dietary status and signs of osteoporosis
  • Assessment of deteriorating health
• Client review done regularly with primary care provider, and include cardiovascular and visual review

Education Strategy:

• Education of the client, family and caregiver
• Review of brochures and posters of information on falls prevention strategies
• Developing community awareness on fall prevention strategy and intervention services.

Intervention Strategies:

• Multifactor approach:
  • Reducing individual risk factors
  • Review and modification of medication, environment and footwear
  • Exercise routines tailored to individual needs to improve balance, strength and mobility
  • Continence management
  • Review and management of diet and signs of osteoporosis
  • Support the use of hip protection
• Reviews done with primary care providers regularly and involve cardiovascular and visual reviews.

For interface settings, the same strategies for prevention, education and intervention can be utilized, as outlined above.

Setting	Implementation Plan
Hospital	Developing fall risk assessment tool
	Developing fall care pathway
	Developing education package
	Deliver education
Interface and Community	Adding falls identification tag to EDIS database
	Automatic sharing of falls information to GP
	RMO education and referrals to fall clinics
	Fallscreen analysis
Community	Fallscreen analysis
	Implementation of education
Residential Care	incident reporting systems developed

The ACHS standards can be utilized for the evaluation and quality improvement strategies. The standards evaluate the outcomes based on 5 groups: LA- Little Achievement, SA- Some Achievement, MA- Moderate Achievement, WA- Extensive Achievement and OA- Outstanding achievement (fallsnetwork.neura.edu.au 2018).

The Falls Policy for Older Western Australians also identifies The Statewide Falls Policy Group Executive Committee in the evaluation and monitoring of clinical practices annually utilizing formative, impacts and outcomes as well as economic analysis in collaboration with Injury Research Centre. This can also be implemented for the suggested methods for monitoring the performance of the preventative strategies.

1. ACSQHC falls best policy guidelines
2. AIHW National Injury Surveillance Unit reports
3. Clinical pathways and plans for the prevention of falls
4. Review of diet
5. Review of signs of osteoporosis
6. Risk assessment tool
7. Education package
8. Fall identification tag added to EDIS database
9. Fallscreen analysis

References:

Hendrie, D., Hall, S.E., Arena, G. and Legge, M., 2004. Health system costs of falls of older adults in Western Australia. Australian Health Review, 28(3), pp.363-373.

who.int., 2018. A Global Report on Falls Prevention Epidemiology of Falls., retrieved on 17 May, 2018.,

workingwitholderpeople.edu.au., 2018.  Public Health Association of Australia: Policy-at-a-glance – Fall Injury Prevention in Older People Policy., Retrieved on 17 May, 2018, from: https://www.workingwitholderpeople.edu.au/documents/fall-injury-prevention.pdf

safetyandquality.gov.au., 2018. Preventing Falls and Harm From Falls in Older People, retrieved on 17 May, 2018., from: https://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Guidelines-COMM.pdf

phaa.net.au., 2018. Public Health Association of Australia: Policy-at-a-glance – Fall Injury Prevention in Older People Policy. Retrieved on 17 May, 2018, from: https://www.phaa.net.au/documents/item/878

health.wa.gov.au., 2018. The Falls prevention policy for older western Australians. Retrieved on 17 May, 2018 from:

fallsnetwork.neura.edu.au., 2018. Falls Prevention in Older People: Falls Prevention in Older People: Policy and Practice.

who.int., 2018. Falls., retrieved on 17 May, 2018., from: https://www.who.int/en/news-room/fact-sheets/detail/falls