Decreasing Falls in Nursing Home Patients

According to The Joint Commission, hundreds of thousands of patients fall in hospitals and Nursing Homes each year. Many patients in long-term care are there in the first place because of injuries sustained in a fall or because they have fallen repeatedly. Falls are one of the major reasons for patient’s to be re-admitted back to an acute care facility, which ultimately will have a significant negative effect on reimbursements for long-term care facilities starting in 2019. Decreasing falls in the elderly patient population requires a well-defined strategy, training and consistent use of basic safety techniques.

The Cost of Patient Falls

Individuals who suffer a fall may suffer serious injury, such as a fractured hip or wrist or a head injury. Lacerations can occur if the patient comes in contact with the edge of a bed or knocks a glass flower vase to the floor. Skin shearing may occur due to the fragility of an elderly patient’s epidermis. The Joint Commission notes that one study found a fall with an injury increased in-patient facility length of stay by an average of 6.3 days. Further, the average cost of a fall in which an injury is incurred is $14,000. The American Health Lawyers Association reports that recent settlements for injuries incurred by long term care patients ranged from $205,000 to $620,000. In addition, there is the cost to the patient in terms of pain and disability, the stress on the family, and the guilt and remorse suffered by the nurses responsible for safeguarding the patient.

Elderly Patients Are at Higher Risk

The elderly are more at risk of falls. They are more likely to have balance problems or need assistive devices to walk around. Muscle strength, flexibility and coordination may be problematic for an elderly person. Elderly people are statistically more likely to be on multiple medications, which may have such side effects as lower blood pressure or dizziness. Diuretics may mean an increased frequency of bathroom visits and some medications can cause diarrhea. In the acute care hospital, the elderly are more susceptible to confusion, whether from medications such as narcotics or from being in unfamiliar surroundings. In long-term care facilities, it is often the elderly patient who can no longer live independently – whether from physical disability or mental impairments such as dementia – who needs long-term care in the first place.

Best Practices for Reducing Falls

In 2009, the National Guidelines Clearinghouse published a number of best practice recommendations for fall prevention in long term care. These include:

  • Develop a specific program aimed at reducing falls. This should take into account the patient population, the environment of the long term care facility, and the numbers, skills and experience of the caregivers. If your facility does not have such a program, volunteer to start one.
  • Assess fall risks on admission and after a fall. If a patient does fall, determine the most likely reason for the fall to have occurred. Make changes to prevent a fall from happening again.
  • Develop exercise programs for long term care patients, particularly strength training. Tai chi can also help with balance and coordination problems.
  • Conduct medication reviews – patients who are taking certain medications, such as benzodiazepines, antidepressants, selective serotonin reuptake inhibitors (SSRIs) or multiple medications should be considered at high risk for falls.
  • Educate patients who are at increased risk and who are mentally competent. This can include safe transfer techniques, basic fall prevention such as not getting up abruptly from a sitting position or the use of assistive devices.
  • Conduct regular environmental assessments and modification – reduce clutter, ensure lighting is adequate and clean up spills promptly.

The Top Two

Of all the possible strategies a nurse can use to prevent patient falls, the top two are probably a careful and thorough patient assessment at regular intervals and the consistent use of basic safety techniques. The first helps ensure that patients who are developing balance problems, worsening dementia, medication side effects or confusion from hypoxia will be identified as early as possible. Each time you walk down the hall, make it a practice to glance in the patient rooms on each side. You will be surprised how much information you can glean in a three-second snapshot. Always practice the basics: put up side rails, lower the bed, engage wheel locks and make sure patients can reach call lights, water or other items on the bedside table. Use bed alarms and use them at a short interval, such as two or three seconds.

Protecting elderly patients from falls in long-term care requires unceasing vigilance on the part of nurses and CNAs. Reducing falls can prevent a readmission to an acute care hospital or an extension of what was planned to be a temporary stay in long term care. Regular training on fall prevention and always practicing what you learned in a training will help keep your patients safe.

Sources

http://rnao.ca/sites/rnao-ca/files/Falls_Prevention_-_Building_the_Foundations_for_Patient_Safety._A_Self_Learning_Package.pdf
https://www.managedhealthcareconnect.com/article/strategies-for-reducing-falls-long-term-care
https://scholarworks.bellarmine.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1008&context=tdc
https://www.beckershospitalreview.com/quality/5-proven-strategies-to-prevent-patient-falls.html
https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html
http://rn-journal.com/journal-of-nursing/preventing-falls-in-the-elderly-long-term-care-facilities

Chris Caulfield (RN, NP-C), is the Co-founder and Chief Nursing Officer of Intelycare which the fastest growing Per-Diem Nurse Staffing organization in the US. IntelyCare is a technological enhanced platform that was founded in 2016 and now has over over 3,000 IntelyPros (RN, LPN, and CNA employees) serving over 150 healthcare facilities throughout the northeastern US.

Prior to founding IntelyCare, Chris’ past Healthcare experience includes Long Term Care Nursing, Nursing Informatics, Labor Relations, Case Management, and a Urgent Care Nurse Practitioner.

Why Taking Breaks Is So Important For Nurses

The Problem with Taking Breaks

Nursing is a giving profession and we nurses tend to give a lot, but not all of that giving is by choice. In a conventional job, taking breaks is part of a normal shift. With nurses, there are patients who must receive care. However, providing that care is not always black and white. Patient safety is the top concern and that is sometimes difficult to pull off when so many cogs affect how the wheel turns. For example, a Long Term Care nurse might have twenty patients and two are about to be sent out to appointments, while at the same time you’re expecting two incoming admissions. Not knowing when these patients will arrive makes giving nurses breaks less predictable. Outside factors can make it impossible to stick to a routine schedule that is commonplace in many other industries. When nurses do not receive breaks they become fatigued and that leads to a decrease in patient safety.

There are many studies across many industries that point to the dangers of fatigue on the job. Long-haul truck drivers are a perfect example. If they are too tired to drive they not only risk their own lives but those of other drivers on a road. It is the same with nurses, though the mechanism of injury is different and the outcome varies. A wrong med here, loss of compassion there, lack of infection control, critical medications are given late… the list of possibilities is unfortunately endless. The results show up in data such as increased re-admissions, job turn over, elevated frequencies of call-ins, poor inter-professional relationships, etc.

It seems so easy to fix – just allow nurses to take breaks and eat lunch. Simple, right? The problem is that nursing is not that “cut and dry.” Nursing comes with a high degree of unpredictability and requires around-the-clock constant care. Many times, that care does not fit neatly into a timetable or regimen. Patients always come first. That said, there are definitely ways to manage nurses’ fatigue and even improve your overall quality of care. So, what can be done?

The Road to Caring with Exhaustion

One solution is to ensure your facility is set up with a reliable On-Demand per-diem staffing partner in order to give your internal nurses their own break and reduce the mandatory overtime that’s become commonplace among inpatient health-care facilities. The statistics show that tired nurses have a negative impact on the care they provide, but rarely do we look at their financial impact at their facilities. Tired nurses make mistakes that lead to lawsuits, workers compensation claims, hiring expenses, training, recruitment, etc. Too many patient injuries or too many re-admissions can cause hospitals to lose the faith to discharge their patients back to these LTC facilities. Ensuring that nurses take breaks is important and worth the investment, especially if it leads to decreased readmission frequencies.

Another important fix is to educate nurses so that they understand the impact of caring for themselves at home. There are additional studies that point to the lack of sleep as part of the honest of fatigue. Educating people on how to relax at home and at work is important. Finally, building and maintaining your own internal per-diem pool, as well as a trusted outside per-diem nursing partner who specializes in last minute fill ins, can be very effective tools to help cover short-staff issues. Focusing on these issues will help your facility to improve improve patient care, decrease readmission frequencies, and improve the relationship between nurses as well as the hospital and its community, all while saving you more money in the long run.

Keep your nurses fresh. Well rested nurses do their best work. It takes a lot of energy to care for other people, but we can’t forget to care for ourselves, too.

Deeper Reading and Sources

[1] Association of Sleep and Fatigue With Decision Regret Among Critical Care Nurses 

[2] The Effects of Fatigue and Sleepiness on Nurse Performance and Patient Safety

Chris Caulfield (RN, NP-C), is the Co-founder and Chief Nursing Officer of Intelycare which the fastest growing Per-Diem Nurse Staffing organization in the US. IntelyCare is a technological enhanced platform that was founded in 2016 and now has over over 3,000 IntelyPros (RN, LPN, and CNA employees) serving over 150 healthcare facilities throughout the northeastern US.

Prior to founding IntelyCare, Chris’ past Healthcare experience includes Long Term Care Nursing, Nursing Informatics, Labor Relations, Case Management, and a Urgent Care Nurse Practitioner.

Top 8 Issues with Short Staffing

Top 8 Issues with Short Staffing

As healthcare systems accommodate the retirement of baby boomer nurses and work to do more with less to make ends meet, many organizations find themselves short staffed. And while the best nurses will do whatever it takes to care for their patients, operating without enough help is bound to lead to serious problems.

Here, we share the top eight consequences of short staffing in healthcare.

#1 – Patient mortality increases.

As overworked nurses become tired and rushed, the risk of medical errors with the potential to harm a patient increases. Keeping nurses fresh and ready to provide the best care will lead to significantly better patient outcomes.

#2 – Patient satisfaction decreases.

As patients wait longer for a response to their call lights and get less face-to-face time with staff, their perception of the care they are receiving becomes more negative than positive. Making sure your nurses are able to respond to all patients in a timely fashion is important to ensure patients are happiest with your facility’s care.

#3 – Team dynamics are strained.

Even something like a simple bathroom break can be long enough to cause petty arguments. When you need every minute of you can get from your nurses, this can be quite the disruption. In addition, coworkers who worked harmoniously can grow apart in the face of short staffing.

#4 – Nurses get burned out.

Nursing is an incredibly challenging career prone to burnout in the first place. When caregivers and clinical professionals don’t have the support and resources they need, the burnout process can be accelerated. Unfortunately, this means facilities can be put in the precarious position of consistent hiring.  

#5 – Call-outs happen more regularly.

Working short-staffed is physically, mentally, and emotionally straining on the nurses on duty. It increases their risk of getting sick or even simply too fatigued after a long work week. Nurses need time to recharge their batteries, too, but unfortunately sometimes that’s the reason for calling out. To compound the issue, if your floor is already short on staff, call-outs only worsen the issue. This causes an even lower quality of patient care as there simply aren’t enough nurses to go around! Plus, those who are working are asked to do even more, which leads to further fatigue for them.

#6 – The risk of abuse & neglect increases.

This immense physical and mental strain can break down the patience and resolve that most nurses demonstrate every day. Unfortunately, that means it’s easier for your staff to lose their temper with a patient, physician, or coworker. While many skilled living facilities choose to cut staff to save money, they neglect value the risk associated with more outbursts and lesser care. 

#7 – Turnover goes through the roof.

When an organization is short staffed for a week or even a month or two, nurses generally hang in there and push through. The high-quality nurses are usually team players. They’re willing to “buckle down” in times of need. But what happens when short staffing drags on for months and months?  Unfortunately, many nurses begin to look elsewhere for jobs that are less demanding and ultimately, less stressful.

#8 – Costs actually go up.

Besides the overtime you need to pay your existing nurses to cover the short-staffed floors and the call-outs, you might need to deal with an increase in medical claims from your sick & stressed employees. In general, more call-outs and greater turnover can lead to a lower quality of care (more errors), and a definite increase in expensesWorking short staffed actually increases costs and negatively impacts patient care in the long run.

Chris Caulfield RN,MSN
Chief Nursing Officer | IntelyCare

Chris Caulfield (RN, NP-C), is the Co-founder and Chief Nursing Officer of Intelycare which the fastest growing Per-Diem Nurse Staffing organization in the US. IntelyCare is a technological enhanced platform that was founded in 2016 and now has over over 3,000 IntelyPros (RN, LPN, and CNA employees) serving over 150 healthcare facilities throughout the northeastern US.

Prior to founding IntelyCare, Chris’ past Healthcare experience includes Long Term Care Nursing, Nursing Informatics, Labor Relations, Case Management, and a Urgent Care Nurse Practitioner.

Nurse Staffing Ratios in Long Term Care Facilities

Nurse staffing is often a hot button for skilled nursing facilities. The need to balance costs with care occurs on a daily basis. For the nursing administrator, the ability to make a case for staffing increases often rests on the ability to provide solid rationales for the increased personnel costs.

CMS Findings on Staffing

The Centers for Medicare and Medicaid Services (CMS) issued a comprehensive report in that focused on nurse staffing in nursing facilities, including skilled nursing facilities and other long term care facilities. At that time, 97 percent of facilities did not have sufficient nursing staff to meet one or more federal staffing requirements or to prevent avoidable harm to residents. In addition, 91 percent didn’t have sufficient nursing staff to meet five important process requirements – dressing/grooming, exercise, feeding assistance, changing wet clothing and repositioning, and toileting. The Center for Medicare Advocacy (CMA) notes, “The report found insufficient numbers of professional nurses as well as insufficient numbers of aides. Although resident acuity has increased in the decade since the CMS report was issued, staffing has not significantly changed, in terms of either absolute numbers of nursing staff or the professional qualifications of staff.”

Further, CMA notes that reduction of unnecessary hospital readmission is one of the goals of health care reform. Recent data from the Centers for Disease Control and Prevention indicates that eight percent of nursing home residents in the US had an emergency department visit in the previous 90 days. Eighteen percent of that number had two or more visits.

Forty percent of those visits were found to be preventable. Falls – previously found to be directly linked to staffing ratios – were the most common reason for nursing home residents to be admitted to the emergency room.

Since 2015, CMS has been collecting and reporting data on all-cause 30-day readmission rates for long-term care facilities across the US. Beginning in fiscal year 2019, long term care facilities will receive incentive payments based (Skilled Nursing Facilities Prospective Payment System (SNF PPS)) which are tied to the quality of the care and the re-admission rate to acute care facilities.

To find out more information on how using appropriate staffing levels can increase Long Term Care Facility reimbursements, check out “How Staffing Makes a Difference”

References:

http://www.medicareadvocacy.org/more-nurses-in-nursing-homes-will-mean-fewer-patients-headed-to-hospitals/

http://www.medicareadvocacy.org/preventable-emergency-department-visits-by-nursing-home-residents/

https://www.cdc.gov/nchs/data/databriefs/db33.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Other-VBPs/SNF-VBP.html

 

 

Chris Caulfield (RN, NP-C), is the Co-founder and Chief Nursing Officer of Intelycare which the fastest growing Per-Diem Nurse Staffing organization in the US. IntelyCare is a technological enhanced platform that was founded in 2016 and now has over over 3,000 IntelyPros (RN, LPN, and CNA employees) serving over 150 healthcare facilities throughout the northeastern US.

Prior to founding IntelyCare, Chris’ past Healthcare experience includes Long Term Care Nursing, Nursing Informatics, Labor Relations, Case Management, and a Urgent Care Nurse Practitioner.

How Nurse Staffing Makes A Difference

Appropriate Nurse Staffing levels can make a significant increase in facility payment reimbursement, especially with the Skilled Nursing Facilities Prospective Payment System (SNF PPS) slated to launch in early 2019. All of the measures currently in use by CMS are positively affected by increased Nurse staffing ratios. They include such measures as the percent of residents with new or worsened pressure ulcers, administration of seasonal flu vaccine, falls, drug regimen review, care planning and mobility for patients on ventilator support.

In a document prepared for the American Nurses Association (Nursing World, 2015), Avalere Health LLC, notes, “Nurse staffing systems are often antiquated and inflexible. Greater benefit can be derived from staffing models that consider the number of nurses and/or the nurse-to-patient ratios and can be adjusted to account for unit and shift level factors. Factors that influence nurse staffing needs include: patient complexity, acuity, or stability; number of admissions, discharges, and transfers; professional nursing and other staff skill level and expertise; physical space and layout of the nursing unit; and availability of or proximity to technological support or other resources.”

According to the ANA, appropriate nurse staffing can:
• Reduce medical and medication errors
• Decrease patient mortality, hospitable admissions and length of stay
• Decrease patient falls, pressure ulcers, infections and other complications related to hospitalization
• Decrease patient care costs by reducing unplanned hospital admissions
• Promote better nurse safety, retention and job satisfaction.

In acute care hospitals, McHugh et. al. (Health Affairs, 2013) reported data indicates that those hospitals that use higher levels of RN staffing to ensure manageable workload have lower readmission rates. When staffing is inadequate, care processes such as discharge preparation, care coordination and patient education are hampered due to inadequate time and resources. Nurses are less able to monitor for complications, especially those subtle signs in the early stages of a problem such as an infection, which may result in readmission.

One study by Cimiotti et.al. (American Journal of Infection Control, 2012) found that healthcare-associated urinary tract and surgical site infections were higher in those hospitals in which nurses cared for more patients. Data from this study showed that when a nurse’s workload was increased by a single patient above the average, both urinary tract and surgical site infections increased.

Making the case for better nurse staffing requires good data on the benefits in quality and costs. Unnecessary hospital readmissions are more expensive to the health care system, but they also result in lost revenue for the skilled nursing facility. In addition to the loss of direct revenue, there is a high potential for lost revenue from incentive payments.

Is your facility able to saff up or down based on your frequent fluctuations in acuity or seasonality of your Nurse’s vacation requests? IntelyCare’s On-Demand Staffing platform has some great options for facilities needing the flexibility to adjust their Nurse staffing in as little as 4 hours prior to shift start.

References:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/LTCH-Quality-Reporting/LTCH-Quality-Reporting-Measures-Information.html
http://www.nursingworld.org/DocumentVault/NursingPractice/Executive-Summary.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4315496/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509207/

Chris Caulfield (RN, NP-C), is the Co-founder and Chief Nursing Officer of Intelycare which the fastest growing Per-Diem Nurse Staffing organization in the US. IntelyCare is a technological enhanced platform that was founded in 2016 and now has over over 3,000 IntelyPros (RN, LPN, and CNA employees) serving over 150 healthcare facilities throughout the northeastern US.

Prior to founding IntelyCare, Chris’ past Healthcare experience includes Long Term Care Nursing, Nursing Informatics, Labor Relations, Case Management, and a Urgent Care Nurse Practitioner.