Falls and injuries associated to fall are a common and severe problem for older people. About one third of the older population experiences at least one fall each year (WHO 2007). Falling causes distress, pain, injury, loss of confidence, loss of independence and mortality. It not only causes harm to individual but also affects the family members and caretaker of people who fall. Every year, approximately 30% of Australians over 65 years old fall, with 10% of these falls leading to injury (Australian Institute of Health and Welfare 2008). Fall also contribute on the cost of healthcare services.
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It has been estimated that in Australia, the total estimated health cost attributable to falls-related injury will increase almost threefold from A$498.2 million per year in 2001 to A$1375 million per year in 2051. And in hospitals, 886 000 additional bed days per year, or the equivalent of 2500 additional beds, will be permanently allocated to treating falls-related injuries (Australian Government Department of Health and Ageing 2003). Therefore falling has an impact not only in the quality of life and health of an individual who fall but also healthcare costs.
In order to reduce and manage the fall risk in older age people, a practice of risk assessment, fall risk prevention plan along with risk management need to be performed in every residential care and health care settings.
Jacardranda Retirement Valley (JRV) has been facing the problem of increasing incidents of falls during the last 6 months. Currently, they are lacking proper risk assessment tools for fall. Therefore, developing and designing appropriate risk assessment and implementing targeted multifactorial falls prevention strategies that are resourced adequately, monitored and reviewed regularly will help to minimize the problems of JRV in the first hand.
1.1 PURPOSE AND SCOPE
The purpose of designing a system of fall risk assessment and management tool is to provide an overview of how new strategies on fall prevention care processes could be implemented at the age care unit.
The scope of designing the fall risk management system is in minimizing the fall percentage of resident of JRV care center, which ultimately add values in quality service of JVR and resident security and safety.
1.2 PROJECT EXECUTIVE SUMMARY
A form of fall risk assessment for people with age 65 years and over was designed to determine the risk associated with fall in the residential care settings. A large number of articles related to fall risk of old age people was reviewed and base on those research, we determined possible factors associated with fall in elderly people. The Risk factors is divided into intrinsic risk factors (factors that relates to a person’s behavior or condition) and extrinsic factors (factors relates with their environment or their interaction with the environment). The intrinsic risk factors have been focus for our assessment because the assessment is required to be performed at the time of admission to the residential care.
The form was developed using Microsoft Access in which fall risk management form was implemented for risk assessment and management plan as per the risk was also established. A systematic process from brainstorming, to process mapping and data modeling was performed till the formation of management strategies.
1.4 GLOSSARY
JRV
:
Jacaranda Retirement Valley
DOB
:
Date of Birth
WHO
:
World Health Organization
UR No
:
Unit Record Number
ILU
:
Independent living unit
2.1. PROCESS MAPPING
With the advance in technology, we can see growing interest in the development and effective integration of efficient and useable health information management system. However, it is essential that researchers, designers and implementers have a clear understanding of the current care processes in place before they start to develop or implement new electronic systems within health care settings. A critical first step to designing such systems is the development of accurate models depicting existing care pathways and clinical processes and also to introduce new process into the system. Here, use the concept of process mapping to develop a system of assessing fall risk in age care settings and than develop and implement fall risk management plan for the safety of the resident of JRV.
Process mapping is a useful tool to understand existing care pathways and clinical processes. In turn, this can be used in an attempt to anticipate the potential effects of complex technological interventions on work processes.
The flowchart starts with resident filling the registration form. After registration, they will perform self-assessment and then if the risk is high in self-assessment, they will also perform clinical fall risk assessment by the clinicians in the age care clinic. In either of the case clinical risk assessment is performed for the validation and accuracy of the assessment as there are only 320 residents in the age care and these small number of assessment will only take minimum number of time. The risk factors for assessment are history of fall, medication, vision, balance/ gait, mental status, continence, predisposed disease and systolic blood pressure. If there is no risk of fall then they will be in Independent living units (ILU) or high care accommodation area. If there is high risk or any risk then universal fall risk precaution along with tailored responses based on each risk factor identified. Prepare an incident report incorporating fall assessment, changes after implementing prevention plan and enter it into incident report database. However, if risk factors are not identified, implement fall precautions so as not to create a fall risk in future.
Figure-1 shows the complete process of Fall Risk Management in Jacaranda Retirement valley (JRV) from risk assessment to risk identification, analysis and implementation of management plan with proper documentation in system design document.
Resident Registration
Self-Assess of Fall Risk Factors
History of fall
Vision status
Gait/Balance
Weakness
Medications
Predisposing diseases
Clinical Assess of Fall Risk Factors
History of fall
Mental status
Vision status
Gait/Balance
Systolic blood pressure
Medications
Predisposing diseases
Annual Review
Annual Review
Risk of Fall
NO
ILU/HDU
YES
Fall Risk Management
Incident Report
Incident Database
Figure 1: PROCESS MAPPING DIAGRAM
2.2 DATA MODELING
Self-Fall Risk Assessment
UR No
History of fall_Q1
Vision_Q2
Continence_Q3
Weakness_Q4
Medication_Q5
Medication_Q6
Disorder_Q7
Predisposed disease_Q8
Mental_Q9
Total Score
Resident Information
UR_No
Family Name
Given_Name
DOB
Sex
Clinical Fall Risk Assessment
UR No
Mental status_Q2
Vision_Q3
Toiletting_Q4
Medication_Q6
Medication_Q7
Predisposed disease_Q8
Balance_Q9
Total Score
Clinician name
Clinician Designation
Management plan
Figure: ER DIAGRAM
There are three number of table formed in the Microsoft Access for the development of self-risk assessment and clinical assessment form. Each table have come UR No as a primary key, which will link one another in the database formation. Table 1 is Resident Information as an entry and its attributes are UR No, given name, family name, Date of Birth (DOB) and sex of the resident. Table 2 is self-risk assessment table, in which as all the attributes used to create self-assessment form. A total of 10 attributes are used to create this form. Attributes like UR No, History of fall_Q1, Vision_Q2, Continence_Q3, Weakness_Q, Medication_Q5, Medication_Q6, Disorder_Q7, Predisposed disease_Q8, Total Score are used. Likewise clinical assessment is also performed to create validation in the risk assessment of the resident plus further assessment in the clinical settings. The attributes used in clinical assessment are as follows: UR No, Past Hhistory_Q1, Mental status_Q2, Vision_Q3, Toiletting_Q4, Systolic Pressure_Q5, Medication_Q6, Medication_Q7, Predisposed disease_Q8, Balance_Q9, Total Score, Clinician name, Clinician Designation.
Risks factors used in the Fall Risk Assessment Form for JRV.
Fall History: A past history of falls is linked with increased risk. An old person who is prone to fall more than 3 times in his past history is more likely to fall in future.
Age: There is positive correlation with fall and increasing age. Hence, taking age of the resident is very most important.
Medicines: ‘benzodiazepine use in older people is associated with an increase of as much as 44% in the risk of hip fracture and night falls’ (Ray, Thapa & Gideon 2000). There is a significant increased risk of falling with use of medications such as psychotropic, class 1a anti-arrhythmic medications, digoxin, diuretics, and sedatives.
Predisposing disease: According to a research article, circulatory disease, chronic obstructive pulmonary disease, depression and arthritis are each associated with an increased risk of 32% (Lawlor 2003). The prevalence of falling increases with rising chronic disease burden. Old people with mental illness and incontinence also has fall risk.
Balance and gait: With the increase in age after 30, there will be gradual decline in the strength and muscle power, which will decrease our physical functioning. Also some abnormalities or deficit in gait and balance is also associated with fall risk.
Mental status: Mental status is clearly associated with increased risk. As per FROP-Com, 80% increased risk of falling if cognitive impaired.
Continence: It is the ability of a person to control oneself. According to FROP-Com, 50% increased risk of falling if incontinence therefore referral to occupational therapist is required.
Visual impairments: Older people will have low vision with age. An increase in eye disorder, degeneration occurs like glaucoma and macular degeneration, which contribute to risk of falls. Some old people are legally blind and some need glasses for clear vision. (Euro.who.int 2019)
Foot problems: bunions, toe deformities, ulcers, deformed nails and general pain in walking increase balance difficulties and risk of falls. Footwear is also important. (Euro.who.int 2019)
Resident who will score more than 10 points will be marked as at high risk and based on the risk factory he/she will be provided with the appropriate management plans for individual or we can also create a fall risk management plan for JRV as a whole.
After performing clinical assessment, management plan is to be performed.
2.3 Screen Capture of electronic Forms
Self-Fall Risk Assessment Form
Clinical Fall Risk Assessment
3.1 INPUTS
3.2 OUTPUTS
Self-Risk Assessment
Clinical Risk Assessment
Table
field Name
Data type
Descriptions
Field Size
Index
Validation Rule
validation text
validation implementation
Explanation and Comments
Resident Information
UR_No
AutoNumber
Unit record number
long integer
We want data to be automatically allocate the next number
Family name
short text
255
Given name
short text
255
DOB
Date/time
Date of Birth
short date
12/12/19
Sex
short text
Biological Sex
255
F’ Or ‘M’
Please insert F for female or M for male
the validation text comes up when user uses something else.
Self Risk Assessment
UR_No
Auto Number
Unit record number
long integer
History of fall_Q1
Yes/No
Have you fallen more than two times in past 3 months?
Vision_Q2
Yes/No
How often do you remember things? If you do then give 1 point.
long integer
Continence_Q3
Yes/No
DO you have vision impair or cannot see clearly.
long integer
Weakness_Q4
Yes/No
Do you require assistance to do your toileting?
long integer
Medication_Q5
Yes/No
Do you have problem in standing or /and walking, difficulty in turning?
long integer
Medication_Q6
Yes/No
Do you often feel dizzy and weak?
long integer
Disorder_Q7
Yes/No
Do you take medicines, which make you feel sleepy?
long integer
Predisposed disease_Q8
Yes/No
Did you had any predisposed disease in the past?
long integer
Mental_Q9
Yes/No
Do you feel lovst most of the time?
long integer
Name of relatives/caretaker
short text
225
Relation with resident
short text
225
Total Score
Calculated
Sum (B8:B16))
long integer
Clinical risk assessment
UR No
Auto Number
Unit record number
long integer
Past Hhistory_Q1
yes/No
3 or more falls in past 3 months
long integer
Mental status_Q2
yes/No
Mental status of patient seems confusing
long integer
Vision_Q3
yes/No
Poor vision with or without glasses
long integer
Toiletting_Q4
yes/No
Require assistance during toileting
long integer
Systolic Pressure_Q5
yes/No
Drop more than 20 mm Hg between lying and standing
long integer
Medication_Q6
yes/No
Takes psychotropics medicines
long integer
Medication_Q7
yes/No
Takes 3-4 of these medicine currently or /and within last 7 days
long integer
Predisposed disease_Q8
yes/No
Have past history of pre disposed disease.
long integer
Balance_Q9
yes/No
Problem in standing, walking or turning
long integer
`
Total Score
Calculated
sum from Q1 to Q9
long integer
Clinician name
short text
long integer
Clinician Designation
short text
long integer
date of assessment
date /time
gerenal date
Bibliography
DoHA (Australian Government Department of Health and Ageing) 2003, ‘ Projected Costs of Fall Related Injury to Older Persons Due to Demographic Change in Australia’, Department of Health and Ageing, Australian Government, Canberra.
Euro.who.int. 2004, What are he main risk factor for falls amongst older people and what are the most effective interventions to prevent these falls?’, viewed 13 May 2019, http://www.euro.who.int/__data/assets/pdf_file/0018/74700/E82552.pdf
Ray W., Thapa P. & Gideon, P. 2000, ‘Benzodiazepines and the Risk of Falls in Nursing Home Residents’, Journal of the American Geriatrics Society, vol. 48, no.6, pp.682-685.
World Health Organization 2007, WHO global report on falls prevention in older age Geneva, Switzerland, World Health Organization, Switzerland.
Worldcat.org. 2019, A picture of osteoarthritis in Australia (Book, 2008) [WorldCat.org]. [online] viewed 13 May 2019, https://www.worldcat.org/title/picture-of-osteoarthritis-in-australia/oclc/244630242.
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