Falls in older adults are a significant global and national health problem. Estimates suggest that 1 in every 3 adults older than 65 years will experience a fall annually.1 Older adults may experience serious sequelae from fall events, such as hip fractures and brain injuries. Even falls that do not result in injury may create anxiety and fear in older adults, leading to reduced physical activity and avoidance of social situations. Falls result from a complex interplay of predisposing factors that can be found in both inpatient and community-based settings. Using strategies to reduce both risk of falls and injuries related to those falls is an emerging area of opportunity for advanced practice nurses (APNs) across many settings.

FALL PREVENTION EFFORTS

Addressing Fall Risks in the Inpatient Setting

Fall prevention is a growing interest for healthcare facilities and is especially challenging when combined with the increasing mean age of the inpatient hospital population. Falls in hospitalized older adults are a leading cause of injuries in inpatient settings and may result in prolonged hospital stays. As many as 1 million older adult patients fall in hospitals each year.2 These falls can be costly, increasing a hospital's operational costs for serious fall-related injury event by more than $13 000 and length of stay for the patient by a mean of 6.72 days in one study.3 Other reports suggest that falls were more common and associated with the highest rates of injury in medical units.4

The need to develop comprehensive fall prevention and injury risk reduction programs offers multiple opportunities for APNs to become involved in efforts to reduce fall events.

Karen Reynolds, DNP, CNS-BC, FGNLA, works closely with the geriatric population in her position at the Sarasota Memorial Healthcare System. She has been employed with the Sarasota Memorial Healthcare System for the past 27 years, beginning as a registered nurse, followed by serving as a clinical instructor. Reynolds completed her Doctor of Nursing Practice degree in 2012, with a focus on gerontology. In 2009, after she earned her certification as a clinical nurse specialist (CNS), she transferred to the Education, Professional Development and Research Department as the geriatric CNS, where she now works alongside other APNs in implementing best practices for the mitigation of fall and injury risk reduction. Her team includes other Bachelor's and Master's-prepared nurses, conducting educational outreach and coordinating research and evidence-based implementation in fall prevention. Reynolds estimates that more than 60% of admissions to the facility in which she is employed are for patients 65 years or older and finds that her work to prevent falls in the older adult population aligns well with both her interests and training as a CNS. She has worked with her colleagues to design and implement a program designed to reduce falls and the risk of injuries from falls for at-risk patients upon admission to the hospital. Reynolds notes, "This is a very collaborative effort-everyone can have a part to play" (K. Reynolds, personal communication, August 26, 2016). Beginning with a review of current evidence, Reynolds worked with a team to implement a risk for injury assessment in congruence with the use of the Morse Fall Scale upon admission of every patient 65 years or older. If the patient's score on the Morse Fall Scale is 45 or greater and has any one of the risk factors for injury, the risk-for-injury protocol is implemented.

Using her skills across multiple spheres of influence, along with her advanced training in working at both the population and systems level, has given Reynolds a unique perspective on the need for interdisciplinary teamwork in addressing the risks for falls and subsequent injuries in her hospital system. For example, full implementation of the fall risk/injury risk reduction protocol has been a slower process than anticipated, despite the efforts of the interprofessional team. An initial test of change revealed the need for additional resources to implement the protocol. With further review and streamlining of the protocol to match the evidence, the protocol was revised.

Fall Prevention Efforts in the Community Setting

Falling is not considered to be a normal part of the aging process, but there are age-related changes that may put older adults at a greater risk. Poor muscle strength, lower extremity weakness, balance abnormalities, reduced visual acuity, postural hypotension, inappropriate footwear, household clutter, and the effects of polypharmacy often combine to increase the risk for the older adult residing in a community setting, resulting in 2 million older adults seeking emergency medical care annually.1

As in the inpatient setting, falls in the community can have serious consequences for older adults, leading to loss of functional ability and independence, increased early admissions to skilled nursing facilities, and increased direct medical costs. Community-based interventions to improve balance and strength may reduce the risks of falls and injuries in the older adult population. Efforts to disseminate fall prevention strategies into the community are increasing.

In Sarasota, Reynolds hopes to implement primary prevention efforts in community-dwelling older adults who are at risk for falls. She has been appointed to a 3-year term on the Sarasota County Commission Senior Advisory Board and was elected to the Friendship Centers Board. Reynolds participates in in-house and collaborates with community-based marketing and education efforts on fall risk reduction and modifications in the home environment. Friendship Centers offers many classes in primary prevention, balance, and exercise to mitigate falls for community-dwelling older adults. Sarasota Memorial has offered classes to teach older adults home-based strategies to prevent falls. The classes are so popular that attendance is standing-room only with a waiting list. These classes are offered through a social media platform from the facility's marketing department for wider viewing.

Other areas of the country are involved in fall prevention efforts. Amy Hunter, DNP, MSN, FNP-BC, a Nurse Practitioner, has been in practice at the Center for Elder Care in Huntsville, Alabama, since earning her certification as a family nurse practitioner in 2013. Hunter completed the requirements for her Doctor of Nursing Practice degree in 2015, focusing her scholarly project on the use of exercise and strength training to improve gait and balance in community-dwelling older adults. In her practice, Hunter continues her efforts to implement a screening protocol for patients new to the practice for fall history, assess for fall risks, and continue the assessments at each office visit. A complete medication reconciliation is conducted at each patient visit as older adults frequently see multiple healthcare providers or have visits to the emergency department, which results in the addition of medications.

Patients in Hunter's practice are encouraged to attend Balance for Life classes, which are offered at no charge to patients by the Center for Aging (a community outreach of the Center for Elder Care). The classes are conducted in local churches 2 to 3 times weekly, teaching patients a stratified approach to improving balance and strength. Hunter sees improvements in confidence and strength for patients who attend the classes.

REDUCING INJURIES IN FALL EVENTS

The need to move beyond facility-based efforts at fall prevention into injury risk reduction has been recognized by the Joint Commission. Reports to the Joint Commission Sentinel Event database reveal that the most common contributing factors for patients who experience falls with injuries are inadequate assessment of risk, failure of communication or adherence to safety practices, inadequate staff training, problematic physical environments, and lack of leadership in injury risk reduction efforts.5 Patricia A. Quigley, PhD, MPH, ARNP, CRRN, FAAN, FAANP, recognized the need for focused efforts upon injury risk reduction early in her career.

During her career as a nurse, Quigley developed a deep interest in rehabilitation nursing, finding gratification in helping adults with disabilities and chronic diseases to be independent, safe, and satisfied. While working with patients in the rehabilitation setting, Quigley sensed the impression among staff and patients that falls were often considered inevitable, and "[horizontal ellipsis]I did not accept that" (P. Quigley, personal communication, September 9, 2016). She developed an interest in the reduction of injury risk associated with falls, examining falls that were preventable and how patients could be prevented from injury. Quigley developed a unique perspective, preferring that someone fall while in her care and subsequently learn strategies to deal with the fall events, rather than allowing someone to be discharged to home, fall, and perhaps not be rescued for several hours.

Quigley managed an interprofessional falls clinic for 17 years and worked with the Institute of Healthcare Improvement to publish a toolkit in 2008, which was revised in a second edition in 2012. After retiring from the James A. Haley Veterans Hospital in Tampa, Florida, in 2016, Quigley was able to pursue her interests in a population-based strategy to reduce the risk of injuries experienced in fall events, building upon her experiences in injury risk reduction that have been in place in Veterans Administration facilities since 2010. She now consults with many healthcare facilities across the United States on efforts to reduce risks of injuries experienced in fall events, encouraging healthcare organizations to assess all older patients for risks of and a history of falls.

CONCLUSIONS

Fall prevention and injury risk reduction efforts represent areas of patient care in which APNs are poised to make significant contributions, in both the inpatient and community-based settings. If this is your passion, consider stepping beyond work in your organization to join the larger discussion on the need for fall prevention and injury risk reduction efforts. Advanced practice nurses possess the clinical training and systems thinking to improve care for vulnerable older adult patients. Encourages Quigley, "Bring people together, shape research agenda, and be a part of policy decision making" (P. Quigley, personal communication, September 9, 2016). Working together to reduce falls and risk of injury in fall events for our older adult patients will take a coordinated effort among many settings and disciplines. Consider using your skills to join this important challenge.

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