Translating evidence-based falls prevention into clinical practice in nursing facilities:: Results and lessons from a quality improvement collaborative

OBJECTIVES: To describe the changes in process of care before and after an evidence-based fall reduction quality improvement collaborative in nursing facilities. DESIGN: Natural experiment with nonparticipating facilities serving as controls. SETTING: Community nursing homes. PARTICIPANTS: Thirty-six participating and 353 nonparticipating nursing facilities in North Carolina. INTERVENTION: Two in-person learning sessions, monthly teleconferences, and an e-mail discussion list over 9 months. The change package emphasized screening, labeling, and risk-factor reduction. MEASUREMENTS: Compliance was measured using facility self-report and chart abstraction (n=832) before and after the intervention. Fall rates as measured using the Minimum Data Set (MDS) were compared with those of nonparticipating facilities as an exploratory outcome. RESULTS: Self-reported compliance with screening, labeling, and risk-factor reduction approached 100%. Chart abstraction revealed only modest improvements in screening (51% to 68%, P <.05), risk-factor reduction (4% to 7%, P=.30), and medication assessment (2% to 6%, P=.34). There was a significant increase in vitamin D prescriptions (40% to 48%, P=.03) and decrease in sedative-hypnotics (19% to 12%, P=.04) but no change in benzodiazepine, neuroleptic, or calcium use. No significant changes in proportions of fallers or fall rates were observed according to chart abstraction (28.6% to 37.5%, P=.17), MDS (18.2% to 15.4%, P=.56), or self-report (6.1-5.6 falls/1,000 bed days, P=.31). CONCLUSION: Multiple-risk-factor reduction tasks are infrequently implemented, whereas screening tasks appear more easily modifiable in a real-world setting. Substantial differences between self-reported practice and medical record documentation require that additional data sources be used to assess the change-in-care processes resulting from quality improvement programs. Interventions to improve interdisciplinary collaboration need to be developed.