Janet K Sluggett1,2, Samanta Lalic3, Sarah M Hosking3,4, Jenni Ilomӓki3,5, Terry Shortt6, Jennifer McLoughlin6, Solomon Yu4,7,8, Tina Cooper6, Leonie Robson6, Eleanor Van Dyk9, Renuka Visvanathan4,7,8, J Simon Bell3,10,4,5. 1. Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia. janet.sluggett@monash.edu. 2. NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, NSW, Australia. janet.sluggett@monash.edu. 3. Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia. 4. Centre of Research Excellence in Frailty and Healthy Ageing, National Health and Medical Research Council of Australia, Adelaide, SA, Australia. 5. Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia. 6. Resthaven Incorporated, Adelaide, SA, Australia. 7. Adelaide Geriatrics Training and Research with Aged Care (G-TRAC) Centre, School of Medicine, The University of Adelaide, Adelaide, SA, Australia. 8. Aged and Extended Care Services, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia. 9. Pharmacy Department, Alfred Health, Melbourne, VIC, Australia. 10. NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, NSW, Australia.
Abstract
BACKGROUND: Fall-related hospitalisations from residential aged care services (RACS) are distressing for residents and costly to the healthcare system. Strategies to limit hospitalisations include preventing injurious falls and avoiding hospital transfers when falls occur. AIMS: To undertake a root cause analysis (RCA) of fall-related hospitalisations from RACS and identify opportunities for fall prevention and hospital avoidance. METHODS: An aggregated RCA of 47 consecutive fall-related hospitalisations for 40 residents over a 12-month period at six South Australian RACS was undertaken. Comprehensive data were extracted from RACS records including nursing progress notes, medical records, medication charts, hospital summaries and incident reports by a nurse clinical auditor and clinical pharmacist. Root cause identification was performed by the research team. A multidisciplinary expert panel recommended strategies for falls prevention and hospital avoidance. RESULTS: Overall, 55.3% of fall-related hospitalisations were among residents with a history of falls. Among all fall-related hospitalisations, at least one high falls risk medication was administered regularly prior to hospitalisation. Potential root causes of falling included medication initiations and dose changes. Root causes for hospital transfers included need for timely access to subsidised medical services or radiology. Strategies identified for avoiding hospitalisations included pharmacy-generated alerts when medications associated with an increased risk of falls are initiated or changed, multidisciplinary audit and feedback of falls risk medication use and access to subsidised mobile imaging services. CONCLUSIONS: This aggregate RCA identified a range of strategies to address resident and system-level factors to minimise fall-related hospitalisations.
BACKGROUND: Fall-related hospitalisations from residential aged care services (RACS) are distressing for residents and costly to the healthcare system. Strategies to limit hospitalisations include preventing injurious falls and avoiding hospital transfers when falls occur. AIMS: To undertake a root cause analysis (RCA) of fall-related hospitalisations from RACS and identify opportunities for fall prevention and hospital avoidance. METHODS: An aggregated RCA of 47 consecutive fall-related hospitalisations for 40 residents over a 12-month period at six South Australian RACS was undertaken. Comprehensive data were extracted from RACS records including nursing progress notes, medical records, medication charts, hospital summaries and incident reports by a nurse clinical auditor and clinical pharmacist. Root cause identification was performed by the research team. A multidisciplinary expert panel recommended strategies for falls prevention and hospital avoidance. RESULTS: Overall, 55.3% of fall-related hospitalisations were among residents with a history of falls. Among all fall-related hospitalisations, at least one high falls risk medication was administered regularly prior to hospitalisation. Potential root causes of falling included medication initiations and dose changes. Root causes for hospital transfers included need for timely access to subsidised medical services or radiology. Strategies identified for avoiding hospitalisations included pharmacy-generated alerts when medications associated with an increased risk of falls are initiated or changed, multidisciplinary audit and feedback of falls risk medication use and access to subsidised mobile imaging services. CONCLUSIONS: This aggregate RCA identified a range of strategies to address resident and system-level factors to minimise fall-related hospitalisations.
Authors: Janet K Sluggett; Gillian E Caughey; Tracy Air; Max Moldovan; Catherine Lang; Grant Martin; Stephen R Carter; Shane Jackson; Andrew C Stafford; Steve L Wesselingh; Maria C Inacio Journal: Age Ageing Date: 2022-07-01 Impact factor: 12.782
Authors: Janet K Sluggett; Ria E Hopkins; Esa Yh Chen; Jenni Ilomäki; Megan Corlis; Jan Van Emden; Michelle Hogan; Tessa Caporale; Choon Ean Ooi; Sarah N Hilmer; J Simon Bell Journal: J Clin Med Date: 2020-04-08 Impact factor: 4.241
Authors: Maria C Inacio; Robert N Jorissen; Steve Wesselingh; Janet K Sluggett; Craig Whitehead; John Maddison; John Forward; Alice Bourke; Gillian Harvey; Maria Crotty Journal: BMJ Open Date: 2021-11-17 Impact factor: 3.006
Authors: Janet K Sluggett; Samanta Lalic; Sarah M Hosking; Brett Ritchie; Jennifer McLoughlin; Terry Shortt; Leonie Robson; Tina Cooper; Kelly A Cairns; Jenni Ilomäki; Renuka Visvanathan; J Simon Bell Journal: Int J Environ Res Public Health Date: 2020-05-08 Impact factor: 3.390
Authors: Maria C Inacio; Max Moldovan; Craig Whitehead; Janet K Sluggett; Maria Crotty; Megan Corlis; Renuka Visvanathan; Steve Wesselingh; Gillian E Caughey Journal: BMC Geriatr Date: 2021-12-07 Impact factor: 3.921