Episode 5 – Dr. Fabio Feldman

Transcript: Full episode 24:19 KIM STEGER – Welcome to Patient Safety Voices, the podcast of the British Columbia Patient Safety & Learning System, where we take a deeper dive into patient safety issues affecting British Columbians. I’m your host, Kim Steger. Thanks for listening. [Sound clip] Welcome to episode five of Patient Safety Voices. This episode, we’ll be exploring fall and injury prevention with local expert Dr. Fabio Feldman. Falls are an ongoing concern in many areas of healthcare. In fact, you may not be aware, but falls continue to be the number one patient safety event reported in PSLS. According to Finding Balance BC, falls are the number one cause of injury-related death among seniors, and the Canadian Patient Safety Institute estimates direct healthcare costs for falls in Canada at about 2 billion dollars each year. That’s billion with a “b”. So, today we’re going to hear from Dr. Feldman about some successful interventions for fall and injury prevention, an exciting new research project he’s embarking on within Fraser Health, and he’ll even share some of his adventures as a student at Simon Fraser University with us. [Sound clip] KIM STEGER – Hi, Dr. Feldman. DR. FELDMAN – Hi. KIM STEGER – How’re you doing today? DR. FELDMAN – I’m doing good today. How’re you? KIM STEGER – Excellent. I understand you recently have a new role within Fraser Health. [01:22] DR. FELDMAN – That’s correct. I’ve been with Fraser Health for almost eleven years now, but I recently got the position of Director for Clinical Quality and Patient Safety. And previously I was the Consulting Manager for Patient Care Quality, Safety, and Injury Prevention. But I started in Fraser Health in 2006, as the Manager for Falls and Injury Prevention and that’s where my background and expertise are. KIM STEGER – Yes, congratulations. DR. FELDMAN – Thank you. KIM STEGER – And are you also still teaching at Simon Fraser University? DR. FELDMAN – I don’t teach courses at Simon Fraser University. I’m an adjunct professor. Simon Fraser University’s where I did my PhD and I still have a strong collaboration with Dr. Stephen Robinovitch. He was my PhD supervisor and we continue to do lots of research related to falls and injury prevention. We co-supervise several PhD and Master’s students. So, I have a strong link with the university and the Injury Prevention and Mobility Lab. I go to Simon Fraser mostly to do invited lectures for different courses. KIM STEGER – So, they know you pretty well over there. DR. FELDMAN – They know me well, I know them well. It’s a great school. KIM STEGER – So you started in kinesiology. What led you to injury prevention? [02:48] DR. FELDMAN – I was in kinesiology doing my undergrad and towards the end I was focusing more on ergonomics and a lot of work-related injuries. That was where my interest was. But then when I started working with Dr. Robinovitch as a co-op student in the Injury Prevention Mobility Lab, I was exposed to issues of falls and especially hip fractures and how devastating those injuries are and how much impact falls have on our elderly population. KIM STEGER – Well, we’re all grateful that you did. DR. FELDMAN – Thanks. KIM STEGER – Because we’ll all be there one day, right? The lucky of us will continue to get older and see our family getting older, and so we really appreciate all the work that you’re doing. DR. FELDMAN – That’s correct. And gravity applies to all of us. KIM STEGER – Yes, that’s right. As much as we sometimes wish it didn’t. DR. FELDMAN – Exactly. KIM STEGER – I’m interested to hear about some of the interventions and programs that are currently in place at Fraser Health that you’ve seen some success with. [03:46] DR. FELDMAN – When I started at Fraser Health, my whole research was on prevention of fall-related injuries. So, like I mentioned, a lot of focus on hip fractures, some focus on head injury. And those are the really devastating injuries that are usually the turning point for an older person. So my focus was not so much on the falls prevention portion, but how do we prevent injury in case of a fall. And the reason I was focused on that, is that from all the research I was involved in and all the research that happened before me, there was very little success in actually preventing falls. So the best interventions that were tried in research resulted in twenty – twenty-five per cent reduction in falls. Some that were very costly were getting to thirty – thirty-five, but the majority of people were still falling and having multiple falls. So, my approach, and Dr. Stephen Robinovitch’s approach, was how do we prevent the injury in case of a fall. So, some of the research that we were looking at the beginning for my PhD research, I was trying to understand how young people fall. Looking at the biomechanics of the fall to see if there’s anything in the reaction responses that would reduce the risk of having a hip fracture. KIM STEGER – And how did you find these young people to research? Were they willing to stand still while somebody came up and pushed them over? DR. FELDMAN – Yeah, well that’s why my PhD was quite fun. It’s not that I had to push people, but I did develop an apparatus that allowed me to create what we call real falls in the laboratory. So, we had a system that would perturb the balance of the subject and make them fall. I was using different types of equipment to measure their reaction. There were a lot of similarities of how they were falling and how they were reacting to the fall. KIM STEGER – Interesting. So, people tend to fall the same way. DR. FELDMAN – Young people tend to fall the same way. And one thing that was very clear was that the main area they were trying to protect was the head. And that’s not a surprise, right? Like anyone, when you have a fall, you worry that you’re going to impact the head. KIM STEGER – Right. DR. FELDMAN – But our study was more to understand hip fractures, what are the characteristics of falls or reactions to a perturbation that will reduce the chance of a hip fracture. So, what we learned is that when we caused a sideways perturbation, a sideways fall, and that’s what we did for the study, that young people, they were using their hand to protect the fall. And the hand and the knee were impacting the floor before the hip. So a lot of the energy was not going straight for the hip. In comparison to older people, where what we tend to see is that the hip is the first body party to impact the floor. KIM STEGER – So what kinds of things can we do to protect those hips? [07:18] DR. FELDMAN – One of them is exercise. And exercise is good for almost everything. But the idea with exercise, is how do we either increase reaction time so that the hand will be placed much faster in the right location and be able to absorb some of the energy, but also how upper body exercise can be helpful to stop the momentum of a fall. A lot of people think of exercise just for improving balance and mobility, but the way we were thinking is how exercise can actually prevent or reduce the chance of an injury if you end up having a fall. KIM STEGER – That is interesting because, like you said, I think when most of us are thinking of exercise to increase mobility and prevent falls we’re not thinking about our triceps. DR. FELDMAN – Yes, and that’s a lot of the focus of the translation of research that we did, is making a lot of different groups of physiotherapists and recreational therapists and exercise instructors to understand the importance of upper body strength to prevent injuries from falls. KIM STEGER – So, exercise is the number one. DR. FELDMAN – Exercise is the number one. Again, not only because it can reduce the chance of you having a fall by improving your balance and strength and mobility, but also it’s beneficial for many other things. For your heart, for your lungs, for your muscles, so it’s always good to try to be as active as possible. The other focus that we had is, how do we modify the environment to try to address the issue of reducing the chance for an injury. So we’ve been working for many years on two different types of technologies. One of them is hip protectors and hip protectors are not so much about the environment, it’s more protective equipment. Hip protectors are either garments or undergarments that have padding inserted in the garments to protect the hip region. So in case of a fall and you land on your hip, then you have this extra foam material that will absorb enough energy to prevent or to really reduce the chance of having a hip fracture. KIM STEGER – So where have you seen the most success with hip protectors? [09:51] DR. FELDMAN – The most success we’ve seen so far is in residential care facilities, so, nursing homes. We’re just about to publish a study showing that residents wearing hip protectors have a sixty-three per cent reduction in their chance of having a hip fracture. So, it’s been very successful. But in residential care facilities, they do have the support of the staff to remind them to wear the hip protector, to help them put it on, make sure that they go to the laundry, that they’re clean, that they have more than one pair. So a lot of the issues related to hip protectors are addressed in a residential care facility. KIM STEGER – I really like that idea that it doesn’t prevent people from being mobile, and social, and moving around and walking around in the residential care facility, but still offers them some protection. I think that’s great. DR. FELDMAN – And that was the goal. Like, to give additional options for the staff and for the family and for the resident, that you can live a little bit at risk and you should be getting up and doing some activities and not being afraid to fall, because you do have some extra protection. KIM STEGER – Are there any other interventions that you’ve found to be quite successful? [11:06] DR. FELDMAN – There’s a new intervention that we’re trying. We still don’t know how successful it is, but we’ve been working for the last six years with compliant flooring. So the idea of compliant flooring is that instead of wearing the foam material as part of the garment, the idea is, why not have the whole floor being compliant? So it becomes like a passive intervention as opposed to an active intervention. Once you install, and our idea is to install those in residential care facilities as well, where you have lots of seniors at risk for falls, that once the intervention, the flooring, is installed, there’s nothing else you do. There’s no additional workload for staff, or reminders for the resident. If they end up having a fall, the flooring works as a protective piece of equipment. So, we work developing the floor with a company and we identified a one-inch floor called SmartCells, and we’ve been doing research with that flooring and we’ve found that the floor reduced impact to the hip by close to thirty-five per cent. So this is almost as much as a hip protector. The other benefit of the flooring as opposed to the hip protector is that the flooring protects all the body parts. The hip protector only protects your hip, but the flooring protects your head, and your hip, and your wrists. Any area that is going to impact the floor will actually receive less energy and will be a reduced chance of having an injury. It’s a great intervention and it does not rely on compliance and that’s the area that we’re doing more research now in care facilities to see if that’s a good intervention to implement in different care facilities across Fraser Health. KIM STEGER – I’m wondering about other areas that aren’t residential care. I know some of these areas can be a little bit…I don’t know if they’re more challenging or if it requires a different sort of intervention to have some success in, say, acute care or ambulatory care. Wondering your thoughts on that. [13:10] DR. FELDMAN – We’ve been doing falls and injury prevention for many years. I started as the Manager of Falls Prevention and we had a team here in Fraser Health focused on that and we had lots of initiatives in hospitals proving education to staff about prevention of falls and injuries and the whole awareness about how to support the patients on their acute care journey. One of them is hourly rounding. So we were working with the staff so every hour they’d go back to check on the patient if they need anything, if they have any pain, pain or discomfort, if they need to go to the toilet, and tell them, “Well, I’m going to be back in a hour, but if you need anything you can call me before.” And that process, with trust between the patient and the staff, that they would wait if they needed to get up and they’ll be supported before they get out of the bed. And also creating activities in the hospital to keep them more mobile and to improve their balance. A lot of those initiatives that we implemented in Fraser Health were quite successful. We reduced our rate of fall-related injuries by over forty per cent since I started. And we continue working on that process, it’s a continued awareness and dedication of staff to understand what are the causes and circumstances of falls so they can be able to provide the best care. KIM STEGER – That’s a very good result. I think a lot of organizations would be quite pleased to have a forty per cent reduction. [15:14] DR. FELDMAN – One of the great things to happen, that really supported our work, was the Patient Safety Learning System. So in order to really raise awareness and make people focus on a specific area, is by showing them, that we do have a problem and what is the data related to that. What are we starting and how do we show that we’re making improvements. So in the beginning we didn’t have very good reporting. The falls template for reporting falls in PSLS was just started and a lot of improvements were needed. We worked together with BCPSLS Central Office to make those improvements. But then we started working very closely with staff, providing education that they should report every fall and the reason why they should be reporting and how the data was going to be used for quality improvement and for trying to reduce the number of falls and injuries in Fraser Health. With time, instead of seeing a reduction in falls, we saw an increase in falls reporting because as people were more aware of the importance of reporting, it’s not that we were actually having more falls, it’s just that the staff were reporting more of the falls. And that gave us enough data to understand what are the pockets of work that needed to be done, where to focus, how we share the data that can reach all levels of the organization, and then over time to show the success of the interventions that we’re supporting. KIM STEGER – I understand you share your falls reports and your results quite widely among your staff? DR. FELDMAN – If you don’t use the system, people are going to stop reporting. Right? If they don’t see the data back again, if they don’t see the point of reporting, then they’re not going to use their time to do it. KIM STEGER – What’s coming down the pike in terms of new research or new ideas for injury prevention? [17:22] DR. FELDMAN – What I’m currently working on is a project called telesitter. The idea here is to use technology, just like we have security companies that have technology to monitor your home. We want to use that technology to monitor our patients. So instead of having nurses or care aides providing sitters or providing one-to-one care, mainly sitting in the room and watching the patient to make sure that they’re okay, that they’re not pulling their tubes, or they’re not trying to get out of bed. The idea of this project is to have a centralized location within the hospital where we have a telesitter and then have portable cameras that can be brought to the room and this one telesitter can actually monitor between six and twelve patients at once. The advantage of that is not only the cost savings of having one person monitoring up to twelve, but also the benefits of being able to monitor someone twenty-four hours a day, talking to the patient directly through the camera system. It has a two-way voice. Or talking directly to a nurse, to say “This is what’s happening in the room, you should go there” and provides whatever is needed. Or being able to monitor the patient even in the middle of the night when it’s very dark. The camera has infrared lights so they can see. And, it’s not only for falls prevention. A lot of the research on telesitter has shown huge reductions in falls and injuries with patients that are being monitored using that system. It can also have benefits on preventing pressure injuries and patients trying to pull tubes or for patients in mental health units, so has lots of benefit by being able to monitor some of the patients that are at high risk. KIM STEGER – I’ve never heard of anything like that before. DR. FELDMAN – Yeah, I’ve been working on this project for a year and a half, but similar systems have been in the U.S. for six-seven years, over a hundred and fifty hospitals already using it. But we’re going to be, once we start the pilot in the next two months, we’re going to be the first one in Canada trying to start the technology. KIM STEGER – That’s exciting. Where’s the pilot going to be taking place? [20:05] DR. FELDMAN – The plan is to do the pilot at Langley Memorial Hospital and we’re going to start the pilot with six cameras, so we’re going to be able to monitor six patients at a time. And it will be not only the ones that need one-to-one supervision, that we’re going replace by the system, but we’re going to be monitoring other patients that maybe are just at risk for falls, but are not requiring one-to-one, so we have that capability of providing more monitoring at a lower cost than what we’re currently doing. And on top of that, there are a lot of benefits for the nursing staff, for all the staff on the unit. It might reduce their workload because they don’t have to keep checking on the patient constantly. They don’t have to be responding to alarms or call bells all the time. Every time they are called, it’s a true alarm because there’s someone monitoring and they know what’s going on. And so, it might increase confidence of the staff that they’re going to be able to provide more care to the patients that really need it. KIM STEGER – So, we’ve talked about a lot of different interventions. We’ve talked about things that people can do themselves in terms of exercise, being mobile, strength-training, being open to some of these interventions like hip protectors, other interventions that sort of take the decision out of people’s hands, like compliant flooring, telemonitoring. Is there any sort of one thing that you would want listeners to take away from today in terms of fall and injury prevention for themselves and their families? [21:16] DR. FELDMAN – Yeah, I think I can end the same way I started with being active. It doesn’t have to be, we don’t have to call it an exercise program, but being active is one of the most important things. So, try to work to keep your balance, or improve your balance, and your strength, and mobility. What I present to seniors when I go to rec centres and senior centres, is that there’s a fine line between being careful and being fearful of falls. We want people to be careful but continuing to do their activities instead of being fearful and trying to prevent doing activities because they’re going to fall. Because a lot of research shows that if you have fear of falls, you actually have a higher risk of having a fall. Right? Because if you don’t use it, you lose it. And then when you’re going to try to do something, or get up, or get out of bed, you’re going to end up having a fall at one point. So, being active is the most important thing and as you get older, don’t be afraid of technology or use of aids. There’s a lot of issues that we find, of people don’t want to use a walker or a cane because of the stigma. But they have to understand that the angle here is independence, right? Being independent. And some of the technologies or the aids are there to support people to remain independent as opposed to end up having a fall, and then completely losing their independence. KIM STEGER – Thank you so much. There’s so much great information. DR. FELDMAN – No problem. [Sound clip] KIM STEGER – We hope you enjoyed our interview with Dr. Fabio Feldman from Fraser Health. For more podcasts and blog stories highlighting what’s new in patient safety, please visit our award-winning website at www.bcpslscentral.ca. Thanks, again, for listening to Patient Safety Voices, the podcast of the BC Patient Safety & Learning System.