Therapeutic Falls Toolkit

Step 1: Getting Ready

Organizational readiness is not included in this toolkit, but it is recommended as a critical first step. Despite extensive work on safety culture at Toronto Rehab, it was initially challenging to align providers and leaders on discussing falls and risk with patients. Many were comfortable with capable patients making autonomous decisions about risks at home, but practicing higher-risk activities in rehab was more challenging. Everyone comes to work with a different risk tolerance and lived experience about falls. For some, discussing risk with patients and families as a part of recovery was an easy step; for others, it was more challenging, even fearful. This could include fear of patient harm, fear of blame or liability, or fear of how to approach the topic of risk. From the beginning however, patients have reported strong support for this process as a tool to increase independence, autonomy and align rehab with their own goals. It was easier than expected to align diverse groups with different risk profiles. With patients at the centre of the work, it became clear: Practicing higher-risk activities to prepare some patients for community transition is not just advisable; it is essential.

Before you begin, it is recommended that you:

• Understand the ethical and practical concepts of Therapeutic Falls and how they fit into safety culture at your workplace.
• Identify barriers and strengths within your organization as part of your Model for Spread
• Create an advisory or working group consisting of:
  • Operations and practice leaders
  • Frontline providers
  • Patient partners
  • Content experts in falls, ethics, safety and improvement science

Step 2: Adapt

Therapeutic falls is adaptable to different patient populations and care models. Feel free to use and adapt the materials, but please acknowledge the source as follows:

• Toronto Rehabilitation Institute (2024). Therapeutic Falls Implementation Toolkit. 1^st Edition: Toronto.

What changes need to be made to suit your context?

It is suggested that you review each of the toolkit resources to ensure they meet your organization's needs. The Patient and Caregiver Guide has been co-designed with patients, providers and leaders for clarity and content, but some teams may make changes to reflect the priorities of their patient populations.

How will this be documented in the patient record?

A key component of this work is a shared decision-making discussion between patients and providers about home goals and higher-risk activities to achieve them. Documenting this conversation in the health record is critical. The Shared Decision-Making Guide helps guide this discussion and serves as documentation. This guide can be paper or electronic, depending on the health information system.

Develop or refine two key processes

1. Identify patients who are appropriate for Therapeutic Falls
2. To ensure role clarity and consistency, identify the roles and responsibilities for each element of the Therapeutic Falls pathway

Consider

• Who will lead and document the shared decision-making discussion with patients and families using the Shared Decision-Making Guide ? For many, this will be physical therapists (PT) and occupational therapists (OT)
• How will the results of the discussion be communicated to the broader team?
• What is the process if a patient's status deteriorates and they need to quickly come off the Therapeutic Falls pathway? What is the process if a patient falls?
• How does Therapeutic Falls align with your safety event reporting systems?

Step 3: Team Learning

It is strongly encouraged that implementation teams learn from each other in a 60-90-minute facilitated interprofessional workshop. We recognize that not everyone, especially nurses working shifts, can attend for extended periods. Therefore, we suggest two types of workshops: one interactive and longer, and another didactic and shorter. Both cover similar content.

• Interprofessional Workshop: 60–90 minute interprofessional session(s) with breakout groups, and two to three faculty to support co-design and case-based learning
• Spotlight Sessions: 15-minute group sessions that can be repeated over a period of time. This is specifically designed for nurses and can be taught by a nurse educator or clinical champion

As part of these workshops, it is recommended to use a clinical reflection tool to help participants consider their own conceptions of risk and safety as they relate to mobility and falls. Understanding our comfort level, hesitations, and concerns around these concepts may help us to better build on our strengths and consider possible responses (such as asking for support).

Workshop objectives

• Define Therapeutic Falls and review background work
• Consider some of the ethical underpinnings of balancing risk and autonomy
• Review or draft your process map and refine it together
• Understand the specific roles of OT, PT and nursing, as well as the broader interprofessional team
• Consider key metrics for evaluation

Please contact us at therapeuticfalls@uhn.ca to receive a copy of our interactive workshop slides and facilitator guide.

Step 4: Implement

Set a date to pilot! Toronto Rehab uses the Institute for Healthcare Improvement's (IHI) Model for Improvement as the framework to guide and accelerate our improvement work. As part of your tests of change, seek regular input especially from patients and frontline champions. Continue to refine your processes and integrate them into existing structures and processes, such as team huddles, care planning rounds and care conferences.

A note on patient deterioration

Emerging literature suggests that subtle changes to a patient's homeostasis (for example, a new infection or change in specific medications) may be an under-recognized contributor to falls. If a patient is deteriorating, they should not take increased risks. Anyone on the team at any given time can pause Therapeutic Falls. For example, if a person is practicing independent transfers as their Therapeutic Falls activity and develops a fever on Saturday night, their nurse would immediately take them off the pathway and supervise their transfers for the remainder of the weekend, until they can be re-assessed by the team on Monday morning.

Evaluation

Evaluate the impact of your therapeutic falls program using a Quality Improvement (QI) framework. Quality improvement projects should not require Research Ethics Board (REB) approval. Check with your institution's REB or equivalent whether QI projects can obtain an exemption or expedited approval. Here is an example of the evaluation framework used at Toronto Rehab.