Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations.
The presented research offers an introduction to the use of root-cause analyses in the Veterans Health Administration for identification of falls in veterans with dementia who were referred to or receiving OT. Results identify specific areas for improvement that may be immediately implemented by OTin all health care systems. Such improvements to care may drastically improve patient safety and decrease fall risk in older adults with dementia.
Primary Author and Speaker: Elizabeth Rhodus
Contributing Authors: Elizabeth Lancaster, Mary Duke, and Andrew Harris
PURPOSE: Falls in persons with dementia are associated with increased mortality. Robust fall prevention programs including rehabilitation are implemented throughout healthcare, yet, falls are still frequent in this population. Investigation into causes of falls in persons with dementia provides opportunity for improved prevention, therapeutic intervention, and patient-centered care options. The purpose of this study was to identify root causes of falls in veterans with dementia who were referred to or receiving occupational therapy services.
DESIGN: This study utilized retrospective review of root cause analyses (RCA) of falls in veterans with dementia within the National Center on Patient Safety database for the Veteran Health Administration. The RCA database was searched from 2000-2019 for falls with adverse events in veterans with dementia and referred to or receiving occupational therapy services.
METHOD: Frequency analysis of demographic information, hip fracture status, mortality results for cases, and involvement in OT services was conducted. Qualitative categorical analysis of determined causes was used.
RESULTS: Eighty RCA's were included in analysis. Mean age of veterans included was 80 years; 96% were male; 76% resulted in hip fracture; and 20% died as a result of the fall. Approximately 36% (n = 29) of veterans received referrals to OT following a fall, and 44% (n = 35) fell immediately after referral to OT services, 8% (n = 10) fell while on established OT care plans, and 4% (n = 3) fell after deemed inappropriate for OT services. Most common root causes include inappropriate or lack of equipment (21%), need for falls/rehabilitation assessment (20%), compliance/training to fall protocol of all staff (19%), and behavior/medical status (17%).
CONCLUSION: Falls in veterans with dementia lead to orthopedic fracture and increased risk of mortality. This review identified root causes of falls in veterans with dementia with implication to OT involvement. Based on results, initiatives to improve compliance and training of fall programs once initiated may significantly reduce falls in this population. Earlier identification of rehab referral may also improve access to services and use of proper equipment to help decrease frequency of falls. These results provide insight into areas of need for future falls prevention program planning within the VHA and all healthcare systems serving adults with dementia.
IMPACT STATEMENT: Occupational therapy services provide interventions related to all areas of root causes identified in this study. Results support implementation of specific service provision improvements that can begin immediately with impact in improving patient safety for older adults with dementia.
References
Soncrant, C., Nelly, J., Bulat, T., & Mills, P. (2019). Recommendations for fall-related injury prevention: A 1-year review of fall-related root cause analyses in the Veteran Health Administration. Journal of Nursing Care Quality, p. 1-6. https://doi.org/10.1097/NCQ.0000000000000408
Elliott, S., Leland, N. (2018). Occupational therapy fall prevention interventions for community-dwelling older adults: A systematic review. Am J Occup Ther, 72(4):7204190040. https://doi.org/10.5014/ajot.2018.030494
