Oct 01, 2011
By Angela Merrett, RN, BScn, B.A.Sc., Mhs , Patricia Thomas, RN, MScn, M.Ed. , Anne Stephens, RN, BScn, M.Ed., Gnc(c) , Rola Moghabghab, RN(ec), MN, NP-Adult, GNC(C) , Marilyn Gruneir, Msw, Rsw
A collaborative approach to fall prevention
Collaboration among health-care providers has emerged as a key factor in improving client care. The authors describe the Geriatric Emergency Management–Falls Intervention Team (GEM-FIT) project, a nurse-led research initiative to improve fall prevention in older adults through interdisciplinary collaboration. Public health nurses and occupational therapists assessed participants before and after fall-prevention interventions and found modest improvements in participant outcomes and reductions in modifiable risk factors. The project resulted in successful collaboration, interdisciplinary teamwork and improved service delivery to participants. Among the challenges were delayed timelines, complex issues outside the project protocol and communication difficulties. The authors, who served on the project team, make recommendations for health-care professionals interested in initiating similar projects.
More than ever, health-care providers need to communicate with each other to stay informed about the services clients receive. Working in collaboration is essential to the delivery of effective, efficient and timely care (D’Amour, Ferrada-Videla, San Martin Rodriguez, & Beaulieu, 2005; Interprofessional Care Steering Committee, 2007). We all had roles on the Geriatric Emergency Management–Falls Intervention Team (GEM-FIT) project, which was aimed at evaluating an alternative service-delivery pathway to reduce the number and consequences of falls in adults aged 65 and older who presented to an inner-city hospital emergency department. The project was based on the Falls Intervention Team (FIT) study, which had evaluated a best practice, multifactorial fall-prevention program for community-dwelling older adults (Baycrest Centre for Geriatric Care, City of Toronto, & Regional Municipality of York, 2006). Like the earlier study, the GEM-FIT project was multidisciplinary.
Four organizations participated in the project: St. Michael’s Hospital, Toronto Public Health (TPH), Community Occupational Therapy Associates (COTA) Health and the Toronto Central Community Care Access Centre (CCAC). Each assigned management representatives to the project team. In addition, St. Michael’s Hospital provided a site coordinator, who was the clinical nurse specialist for geriatric emergency management, and TPH contributed a site coordinator and three public health nurses. COTA Health supplied three occupational therapists, and CCAC provided two hospital coordinators and funded the occupational therapy visits. A total of 14 staff members made up the team.
The four partner organizations formally recognized their commitment and shared vision through a letter of agreement, which specified a framework, definitions and terms for their respective roles and responsibilities. The letter of agreement was intended to foster a sense of belonging among the group and identify leadership and governance for the project. The two site coordinators were responsible for preparing and coordinating the ethical review applications and letters of support. The team decided to use the existing practices of community service providers.
To facilitate referrals of participating patients, the team first identified the existing service pathways. The hospital medical director distributed an overview document to inform emergency department physicians of the project, and the clinical nurse specialist reviewed the referral process, protocols and documentation with nursing staff.
Sample population. The site coordinator from St. Michael’s Hospital scanned emergency department records to identify older adult patients at risk of falls (e.g., those taking more than five medications; those who had had a recent fall, gait or balance problems, vision or hearing impairment; those who relied on assistive devices). Both site coordinators completed a literature review for multifactorial fall-prevention initiatives involving emergency departments and community health sectors. They also consulted with four emergency department nurses on approaches and triage tools for referring potential patients to the project. Senior managers from each organization were asked to approve components of these activities before the project planning phase continued.
Project design. The team met monthly to plan, develop and implement the project. As in the FIT evaluation study, assessments were performed before and after the interventions (Baycrest Centre for Geriatric Care et al., 2006). Emergency department nurses assessed patients using the Triage Risk Screening Tool, screened them for eligibility and asked whether they would be interested in becoming project participants. Patients who gave informed consent were referred to CCAC. For each referral, an occupational therapist performed the established mobility assessment, and the TPH site coordinator was asked to send a notice of participation letter to the patient’s family doctor.
Each participant was assigned to a public health nurse, who made six home visits to the participant over 12-14 weeks (along with a phone call), and to an occupational therapist, who made a maximum of three home visits (Figure 1). The home visits included one joint visit by the public health nurse and the occupational therapist during the active intervention phase. The post-intervention phase of the protocol consisted of one followup visit (T2) immediately after the intervention phase, a six-month followup visit (T3) and then discharge. The structure of the T2 and T3 visits was identical to the initial assessment visit (T1), and the same data collection tools were used throughout.
Four validated scales were used for all assessments: Berg Balance Scale (Berg, Wood-Dauphinee, Williams, & Gayton, 1989), Timed Up and Go (Podsiadlo & Richardson, 1991), Activities-specific Balance Confidence (Myers, Fletcher, Myers, & Sherk, 1998), and Reintegration to Normal Living Index–Postal (Daneski, Coshall, Tilling, & Wolfe, 2003). In addition, nurses and occupational therapists completed a Falls Assessment and Intervention Record (FAIR), which outlined multifactorial strategies and measured modifiable risk factors before and after the interventions (Baycrest Centre for Geriatric Care et al., 2006). The FAIR helped the team assess whether these strategies resulted in a change in the number of modifiable risk factors (i.e., postural hypotension, use of sedatives, use of five or more medications, urinary and foot problems, environmental hazards, balance impairment, gait disorder, transfer deficit and fear of falling). During the active intervention phase, the nurse and occupational therapist completed a FAIR at every visit, including the joint visit. As interventions occurred, the FAIR was faxed to the other professionals to keep them informed of the participant’s care. Finally, the nurse and occupational therapist taught participants the Home Support Exercise Program developed by the Canadian Centre for Activity and Aging (Jones & Frederick, 2003). Participants were given a calendar diary and asked to record the number of exercises performed on any given day.
Data analysis. The criteria for evaluating outcomes and processes included demographic statistics and number of falls reported before and after the interventions. Modifiable risk factors were analyzed, along with the outcome measures at T1, T2 and T3.
Project monitoring and adaptation. The team met monthly to assess the referral rates and discuss other issues. TPH facilitated regular meetings with the public health nurses to review the project implementation. Monitoring became less frequent once the intervention protocol was completed for all participants.
During the implementation phase, some patients who lived outside the project catchment area were identified as likely to benefit from an intervention. As a result, the team expanded the service area and extended the referral timeline to allow these patients to participate in the project.
Outcomes for participants. The GEM-FIT project had 22 referrals in an eight-month period. The five participants who completed the entire project from T1 to T3 reported a reduced number of falls (Table 1 [JPG, 337.4 KB]). Outcome measures also improved between the T1 and T2 visits. However, scores fell close to baseline at the T3 visit, which occurred six months after the T2 visit (Table 2 [JPG, 855.2 KB]).
At the T2 assessment, the participants had increased their speed by an average of 4.8 seconds on the Timed Up and Go scale. Their average scores on the other scales were also improved — by 3.6 points on the Berg Balance Scale, 1.4 points on the Reintegration to Normal Living–Postal scale, and 1.6 points on the Activities-specific Balance Confidence scale. These results from the active intervention phase of the project suggest improvements in balance and gait, satisfaction with social participation, and confidence.
Exercise adherence was defined as having performed at least one of the home support exercises three times per week. Adherence was high during the intervention phase (100%), but during the post-intervention followup phase, only two of the remaining five participants returned calendar diaries, and data could not be calculated for the group as a whole.
Perspectives of team members. A feedback session with the public health nurses and occupational therapists revealed some common themes. One was the need to help participants obtain assistive devices; another was the improvement observed in participants’ strength levels after teaching them exercises. Improved collaboration was also highlighted — the nurses and occupational therapists felt they were learning from each other, resulting in better service. The nurses reported that they felt supported by each other through their frequent meetings, which allowed them to solve problems related to care. The FAIR was identified as a good tool for documentation and communication between the different care providers. The team observed that some participants had complex issues, which resulted in early discharge from the project or additional visits outside the protocol. Finally, the team strongly recommended replacing the manual documentation system with the electronic database that was used in the original FIT project, saying that it may have improved communication, allowed access to more complete and timely documentation and resulted in less duplication of work.
Project strengths. The positive outcomes noted at the T2 assessment helped motivate some participants to continue to practise the Home Support Exercise Program. (The importance of practising the exercises regularly was re-emphasized with participants who were more frail.) Some participants stated informally that the equipment they received as a result of the intervention program (e.g., bath transfer seats, bed rails, transfer poles, sofa seats) and the proper adjustment of their existing mobility aids had enhanced their mobility and possibly reduced their risk of falling.
The nurses and occupational therapists were enthusiastic about the benefits of teamwork in doing joint home visits and said they appreciated each other’s work. Each group indicated that they had learned from the other and felt that their own work was validated. The observed benefits to the participants and the opinions elicited through the team’s feedback session corroborate the findings of the original FIT evaluation study (Baycrest Centre for Geriatric Care et al., 2006) and demonstrate transferability of the initiative.
Team members reflected on the positive effects of their collaboration on the participants. By identifying patients in the emergency department who would benefit from targeted interventions with existing resources, such as the occupational therapy rehabilitation service, the team was able to deliver timely and efficient service. Performing comprehensive assessments and having the opportunity to coordinate care in consultation with team members further improved service delivery. During the feedback session, one occupational therapist commented that if not for the project, participants might have “slipped through the cracks” of the health-care system.
Project challenges. Maintaining a project timeline helped the partners establish their commitment to the project. However, the project planning process took longer than expected, and implementation was delayed for nearly 18 months. Reasons for the delay included lengthy ethical reviews, revision of the application, partners’ reviews of the changes, and resubmission. In addition, extensive legal input was required to establish the content, roles and responsibilities outlined in the letter of agreement.
The complex issues participants encountered during the intervention protocol were greater than anticipated. New medical diagnoses, eviction threats, bedbug infestations and other life events were often perceived by participants as larger priorities than their continued involvement with the project. These developments made it difficult for the team to adhere to the protocol.
Finally, the paper documentation system made communication among team members difficult. Forms had to be faxed between organizations to facilitate the next stage in the protocol. Faxes were sometimes unclear, and forms were not always conducive to faxing. Written documentation was often difficult to read.
A formal letter of agreement is recommended as a way of increasing organizational accountability to the agreed upon service. This document outlines roles, responsibilities and scope of work to be provided by all involved, including front-line staff and management. Partners can clearly see the vision and goal for the initiative, where they fit into the project and which clinical settings are involved. The letter of agreement also enhances trust and provides a communication tool that can help with decision-making.
In initiatives such as GEM-FIT, careful consideration must be given to timelines, which can have a significant impact on the resources needed for implementation. Timelines may need to become more flexible when multiple organizations are involved.
Good communication among organizations is essential to delivering timely service. The team recommends adoption of an electronic system that allows real-time documentation and lets multiple service providers at different sites access the same record.
The GEM-FIT project benefited a select number of older adults discharged from the emergency department, who succeeded in maintaining or slightly improving their functional capacity between the T1 and T2 assessments. Although this collaborative project required significant time, cost, resources and commitment, the care taken in designing the initiative strengthened the partnership commitment and made the project a success overall.
The emergency room experience of a frail senior can be intimidating, exhausting and confusing. But geriatric emergency management (GEM) nurses are seeking to change that.
Frail elderly patients entering an emergency department are directed to a GEM nurse, who spends up to several hours assessing the patient — a lifetime in emergency department time, says Kerri Fisher, education coordinator at the Regional Geriatric Program of Toronto.
“GEM nurses make the experience of a frail elderly person that much better when they go to the emergency room. It’s better than just being put in a chair, which is what happens in a normal triage process and which can take a long time. The experience of these elderly patients is that much better, and they get the services they might not get if they were in the normal stream. The GEM nurse looks at their physical condition, their cognition levels, their level of functioning, their social interactions — all aspects that could affect why they’re in the emergency department, not just the initial reason they came in. It’s a comprehensive assessment,” says Fisher.
One of the first programs to use the GEM acronym began back in the late 1990s at Toronto’s Sunnybrook Hospital, says Fisher. In 2004, after a pilot program proved successful, the hospital’s GEM program was launched and an initial group of eight nurses were hired. Today, there are 90 GEM nurses in hospitals and health centres in Ontario.
In Quebec, geriatric emergency initiatives are interprofessional and focused at the research hospital setting, says Dr. David Ryan, director of education at Toronto’s Regional Geriatric Program. British Columbia’s provincial geriatric emergency nursing program is now defunct, whereas Alberta has researchers who are working in this area, but no formal program.
The authors acknowledge Toronto Central CCAC for facilitating referrals to COTA Health and providing occupational therapy services for the project. They thank the other members of the GEM-FIT project team for their contributions in preparing this article.
Baycrest Centre for Geriatric Care, City of Toronto, & Regional Municipality of York. (2006). Falls Intervention Team (FIT) pilot project final report: An evaluation of a best practice model of a seniors’ pilot program. Richmond Hill, ON: Authors.
Berg, K., Wood-Dauphinee, S., Williams, J. I., & Gayton, D. (1989). Measuring balance in the elderly: Preliminary development of an instrument. Physiotherapy Canada, 41(6), 304-311. Retrieved from http://utpjournals.metapress.com/index/t30n37061661184r.pdf
D’Amour, D., Ferrada-Videla, M., San Martin Rodriguez, L., & Beaulieu, M.-D. (2005). The conceptual basis for interprofessional collaboration: Core concepts and theoretical frameworks. Journal of Interprofessional Care, 19(Suppl. 1), 116-131. doi:10.1080/13561820500082529
Daneski, K., Coshall, C., Tilling, K., & Wolfe, C. (2003). Reliability and validity of a postal version of the Reintegration to Normal Living Index, modified for use with stroke patients. Clinical Rehabilitation, 17(8), 835-839. doi:10.1191/0269215503cr686oa
Interprofessional Care Steering Committee. (2007). Interprofessional care: A blueprint for action in Ontario. Toronto: HealthForceOntario. Retrieved from http://www.healthforceontario.ca/upload/en/whatishfo/ipc%20blueprint%20final.pdf
Jones, G. R., & Frederick, J. A. (2003). The Canadian Centre for Activity and Aging’s Home Support Exercise Program. Geriatrics and Aging, 6(7), 48-49.
Myers, A. M., Fletcher, P. C., Myers, A. H., & Sherk, W. (1998). Discriminative and evaluative properties of the Activities-specific Balance Confidence (ABC) Scale. Journal of Gerontology: Medical Sciences, 53A(4), M287-M294. doi:10.1093/gerona/53A.4.M287
Podsiadlo, D., & Richardson, S. (1991). The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39(2), 142-148.