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Ehn M, Kristoffersson A. Clinical Sensor-Based Fall Risk Assessment at an Orthopedic Clinic: A Case Study of the Staff's Views on Utility and Effectiveness. SENSORS (BASEL, SWITZERLAND) 2023; 23:1904. [PMID: 36850500 PMCID: PMC9958653 DOI: 10.3390/s23041904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/27/2023] [Accepted: 02/02/2023] [Indexed: 06/18/2023]
Abstract
In-hospital falls are a serious threat to patient security and fall risk assessment (FRA) is important to identify high-risk patients. Although sensor-based FRA (SFRA) can provide objective FRA, its clinical use is very limited and research to identify meaningful SFRA methods is required. This study aimed to investigate whether examples of SFRA methods might be relevant for FRA at an orthopedic clinic. Situations where SFRA might assist FRA were identified in a focus group interview with clinical staff. Thereafter, SFRA methods were identified in a literature review of SFRA methods developed for older adults. These were screened for potential relevance in the previously identified situations. Ten SFRA methods were considered potentially relevant in the identified FRA situations. The ten SFRA methods were presented to staff at the orthopedic clinic, and they provided their views on the SFRA methods by filling out a questionnaire. Clinical staff saw that several SFRA tasks could be clinically relevant and feasible, but also identified time constraints as a major barrier for clinical use of SFRA. The study indicates that SFRA methods developed for community-dwelling older adults may be relevant also for hospital inpatients and that effectiveness and efficiency are important for clinical use of SFRA.
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A Multicenter Cohort Study of Falls Among Patients Admitted to the ICU. Crit Care Med 2022; 50:810-818. [PMID: 34995212 DOI: 10.1097/ccm.0000000000005423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the incidence of falls, risk factors, and adverse outcomes, among patients admitted to the ICU. DESIGN Retrospective cohort study. SETTING Seventeen ICUs in Alberta, Canada. PATIENTS Seventy-three thousand four hundred ninety-five consecutive adult patient admissions between January 1, 2014, and December 31, 2019. MEASUREMENTS AND MAIN RESULTS A mixed-effects negative binomial regression model was used to examine risk factors associated with falls. Linear and logistic regression models were used to evaluate adverse outcomes. Six hundred forty patients experienced 710 falls over 398,223 patient days (incidence rate of 1.78 falls per 1,000 patient days [95% CI, 1.65-1.91]). The daily incidence of falls increased during the ICU stay (e.g., day 1 vs day 7; 0.51 vs 2.43 falls per 1,000 patient days) and varied significantly between ICUs (range, 0.37-4.64 falls per 1,000 patient days). Male sex (incidence rate ratio [IRR], 1.37; 95% CI, 1.15-1.63), previous invasive mechanical ventilation (IRR, 1.82; 95% CI, 1.40-2.38), previous sedative and analgesic medication infusions (IRR, 1.60; 95% CI, 1.15-2.24), delirium (IRR, 3.85; 95% CI, 3.23-4.58), and patient mobilization (IRR, 1.26; 95% CI, 1.21-1.30) were risk factors for falling. Falls were associated with longer ICU (ratio of means [RM], 3.10; 95% CI, 2.86-3.36) and hospital (RM, 2.21; 95% CI, 2.01-2.42) stays, but lower odds of death in the ICU (odds ratio [OR], 0.09; 95% CI, 0.05-0.17) and hospital (OR, 0.21; 95% CI, 0.14-0.30). CONCLUSIONS We observed that among ICU patients, falls occur frequently, vary substantially between ICUs, and are associated with modifiable risk factors, longer ICU and hospital stays, and lower risk of death. Our study suggests that fall prevention strategies should be considered for critically ill patients admitted to ICU.
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Abraham J, Neef R, Meyer G, Möhler R. [Development and feasibility of an intervention to reduce physical restraints in hospitals: A mixed methods study]. Pflege 2021; 35:155-163. [PMID: 34939434 DOI: 10.1024/1012-5302/a000864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Development and feasibility of an intervention to reduce physical restraints in hospitals: A mixed methods study Abstract. Background: Physical restraints (PR) are regularly used in people with dementia or delirium in general hospital settings. There is no clear evidence for the effectiveness of PR, but their use is associated with an increased risk for harm. Therefore, a restraint-free care is recommended. Aim: Development and feasibility test of an intervention to reduce PR in general hospital settings. Methods: Systematic literature reviews and theory-guided modelling of an intervention involving relevant clinical stakeholders and mixed methods study in two wards of a university hospital (geriatric traumatology and neurology). Results: The complex intervention comprises the following components: qualification of multipliers, interprofessional education about PR reduction, regular audit and feedback meetings, and the support regarding the aim of the intervention from nursing and medical leaders. The results of the feasibility test indicate that the intervention is feasible and helpful, but the interprofessional approach was not implemented as planned. An important barrier hampering PR reduction was the high workload. The results on the prevalence of PR could not be interpreted due to a very low number of measures applied. Conclusion: The complex intervention with a multiplier approach for preventing PR use was judged as feasible, but there is a need for further development to strengthen interprofessional cooperation. The feasibility of the intervention should also be tested in other departments.
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Affiliation(s)
- Jens Abraham
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg
| | - Rüdiger Neef
- Department für Orthopädie, Unfall- und Wiederherstellungschirurgie, Abteilung für Alterstraumatologie, Universitätsklinikum Halle (Saale)
| | - Gabriele Meyer
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg
| | - Ralph Möhler
- Institut für Gesundheits- und Pflegewissenschaft, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg.,Institut für Versorgungsforschung und Gesundheitsökonomie, Centre for Health and Society, Medizinische Fakultät und Universitätsklinik Düsseldorf, Heinrich-Heine-Universität Düsseldorf
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Abdoolakhan S, Ong KT. Can we relax surveillance on more mobile older inpatients with high fall risk? Australas J Ageing 2021; 40:225-226. [PMID: 34132019 DOI: 10.1111/ajag.12918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 12/21/2020] [Accepted: 12/24/2020] [Indexed: 11/26/2022]
Affiliation(s)
| | - Kevin T Ong
- General Medicine Department, Armadale Kelmscott District Memorial Hospital, Mount Nasura, WA, Australia
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Rosbergen ICM, Tonello I, Clark RA, Grimley RS. Does hospital design impact on patient activity levels and time spent alone? Disabil Rehabil 2020; 44:3173-3180. [PMID: 33336598 DOI: 10.1080/09638288.2020.1861117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE The aim of this study was to quantify changes in patients' activity levels, location and people present, within one acute stroke unit (ASU) and one inpatient rehabilitation unit (IRU) with respect to change in hospital design. METHODS A prospective observational study using behavioural mapping. We observed participants from 8 am till 5 pm every 10 minutes across two days and compared participant activity (physical, social and cognitive), location and people present pre and post-transition to new units. Built design, staffing levels and models of care were contrasted. RESULTS We recruited 73 participants (63% stroke): old-ASU (n = 19); new-ASU (n = 15); old-IRU (n = 19); new-IRU (n = 20). Compared to old, new units had more single rooms, larger floor spaces and higher staffing levels. We found no significant change in participants' activity levels between the old and new ASU. Participants in the new IRU showed increased physical activity (43.4% vs. 54.4%, p = 0.02) but social and cognitive activity remained similar. Participants were more alone (ASU 47.4% vs. 66.7%, p = 0.01; IRU 41.7% vs. 58.3%, p < 0.001), and less often with nursing staff (ASU 17.7% vs. 6.7%, p = 0.04; IRU 18.8% vs. 5.7%, p < 0.001) in new units. CONCLUSION Hospital design appears to impact on patients' physical activity. Single rooms may increase isolation and reduce interaction with nursing staff.Implications for rehabilitationDesign of new rehabilitation units needs to consider patients' social engagement with family, friends, other patients and staff in addition to privacy and infection control.A change in built design of rehabilitation units should prompt observation of patients' activity levels and engagement with people and available space to ensure optimal use of new environments.Promotion of communal spaces and activities away from the bedroom to encourage social engagement is recommended for patients recovering in rehabilitation facilities.Less time in contact with nursing staff in rehabilitation environments with predominantly single rooms suggests a review of clinical practice and patient safety is warranted.
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Affiliation(s)
- I C M Rosbergen
- Allied Health Services, Sunshine Coast Hospital and Health Services, Birtinya, Australia.,Sunshine Coast Health Institute, Sunshine Coast Hospital and Health Service, Birtinya, Australia
| | - I Tonello
- Allied Health Services, Sunshine Coast Hospital and Health Services, Birtinya, Australia
| | - R A Clark
- School of Health and Sports Science, University of the Sunshine Coast, Sippy Downs, Australia
| | - R S Grimley
- Medical Service Division, Sunshine Coast Hospital and Health Services, Birtinya, Australia.,Sunshine Coast Clinical School, School of Medicine, Griffith University, Birtinya, Australia
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Abstract
Delirium is an acute confusional state that is common and costly and is associated with significant functional decline and distress. It is the manifestation of acute encephalopathy and is variably called acute brain failure, acute brain dysfunction, or altered mental status. All patients are at risk for delirium, although those with more vulnerabilities (such as advanced age, exposures to other stressors like infection, and certain medications) are at higher risk. The pathophysiologic cause of delirium is not well understood. It is important to recognize patients at risk for and those with delirium and to immediately identify and treat factors contributing to it. There is no single intervention or medication to treat delirium, making it challenging to manage. Therefore, risk mitigation and prompt treatment rely on a sophisticated strategy to address the contributing factors. Delirium may be prevented or attenuated when multimodal strategies are used, thereby improving patient outcomes.
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Affiliation(s)
- Melissa L P Mattison
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (M.L.M.)
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Atay S, Vurur S, Erdugan N. Opinions of Nurses About the Evaluation of Risk of Falling Among Inpatients. Rehabil Nurs 2018; 42:E19-E24. [PMID: 27278821 DOI: 10.1002/rnj.281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patient falls and fall-related injuries are an important problem for patients, relatives, caregivers, and the health system at large. AIMS This study aims to identify opinions of nurses about the risk of falling among patients staying in hospitals. METHOD This study uses a qualitative descriptive design and employs a semistructured interview method to identify the opinions and experiences of nurses about patient falls. This study evaluated the opinions of a total of 12 staff nurses. FINDINGS It was found that nurses consider patients in the postoperative period to be most prone to falls. They think that most falls take place during transfers and that the medical diagnosis of the patient plays a crucial role in fall incidents. The most important problem associated with patient falls was symptoms of traumatic brain injury. According to the participating nurses, the risk of fall for every patient should be evaluated upon admission. Measures that the nurses take against patient falls include raising the bed's side rails and securing the bed brakes. CONCLUSIONS The findings of this research suggest that in-service training programs about the evaluation of the risk of falling should be organized for nurses. Guidelines should be developed for patients with different levels of risk of falling. It is suggested that nurses should be in charge of training patients who are conscious, their relatives, and caregiver personnel. CLINICAL RELEVANCE The training of nurses and caregivers helps to prevent the falls of inpatients.
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Affiliation(s)
- Selma Atay
- 1 School of Health Sciences, Çanakkale Onsekiz Mart University, Çanakkale, Turkey2 University Health Application and Research Center, Çanakkale Onsekiz Mart University, Çanakkale, Turkey
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Fehlberg EA, Lucero RJ, Weaver MT, McDaniel AM, Chandler AM, Richey PA, Mion LC, Shorr RI. Impact of the CMS No-Pay Policy on Hospital-Acquired Fall Prevention Related Practice Patterns. Innov Aging 2018; 1. [PMID: 29911187 PMCID: PMC6002153 DOI: 10.1093/geroni/igx036] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background and Objectives In October 2008, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursing hospitals for costs related to patient falls. This study aimed to examine whether the CMS no-pay policy influenced four fall prevention practices: bed alarms, sitters, room changes, and physical restraints. Research Design and Methods Using electronic medical record data collected from four hospitals between 2005 and 2010, this secondary observational analysis examined the associations between the CMS no-pay policy and nursing interventions and medical orders related to fall prevention. Multivariable generalized linear mixed models with logit link function and accommodation for matching was used to assess the associations between the CMS no-pay policy and nursing interventions and medical orders. Results After the CMS policy change, nurses were more likely to perform one or more fall-related interventions (adjusted odds ratio (aOR): 1.667; 95% confidence interval (CI): 1.097–2.534). Of the four prevention practices, the use of bed alarms (aOR: 2.343; 95% CI: 1.409–3.897) increased significantly after the CMS policy change. Discussion and Implications The CMS no-pay policy increased utilization of fall prevention strategies despite little evidence that these measures prevent falls.
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Affiliation(s)
- Elizabeth A Fehlberg
- Division of Research on Healthcare Value, Equity, and the Lifespan, RTI International, Research Triangle Park, North Carolina
| | - Robert J Lucero
- Departments of Biobehavioral Nursing and Family, Community, and Health System Science, University of Florida College of Nursing, Gainesville.,Clinical and Translational Science Institute, University of Florida, Gainesville.,Center for Latin American Studies, University of Florida, Gainesville
| | - Michael T Weaver
- Departments of Biobehavioral Nursing and Family, Community, and Health System Science, University of Florida College of Nursing, Gainesville
| | - Anna M McDaniel
- Departments of Biobehavioral Nursing and Family, Community, and Health System Science, University of Florida College of Nursing, Gainesville
| | | | - Phyllis A Richey
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
| | - Lorraine C Mion
- Center of Excellence in Critical and Complex Care, The Ohio State University College of Nursing, Columbus
| | - Ronald I Shorr
- Clinical and Translational Science Institute, University of Florida, Gainesville.,Geriatric Research Education and Clinical Centers (GRECC), Malcom Randall VAMC, Gainesville, Florida.,Department of Epidemiology, University of Florida, Gainesville
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Abstract
Falls are a constant risk for patients in acute-care hospitals, which can lead to serious consequences. The purpose of this study was to examine hospital fall case studies and to learn the contributing factors for patient falls. This was achieved by conducting a secondary analysis of 11 fall case studies obtained from two previous studies. The fall cases used the Senior Falls Investigative Methodology (SFIM) approach, which provided detailed analysis of the circumstances surrounding the falls. A total of 549 contributing factors were identified in the 11 case studies, where major categories were classified according to the four different layers of defenses using Reason's Swiss Cheese Model of Accident Causation (organizational factors, supervision, preconditions, and unsafe acts). Hospital policies, reduced supervision, disease processes, the environment, and patients transferring without assistance dominated the reasons for increased risk. Additional strategies were recommended for all layers of defense to reduce patient falls.
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Cuttler SJ, Barr-Walker J, Cuttler L. Reducing medical-surgical inpatient falls and injuries with videos, icons and alarms. BMJ Open Qual 2017; 6:e000119. [PMID: 29450285 PMCID: PMC5699144 DOI: 10.1136/bmjoq-2017-000119] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 09/30/2017] [Accepted: 10/03/2017] [Indexed: 11/16/2022] Open
Abstract
Background Inpatient falls and subsequent injuries are among the most common hospital-acquired conditions with few effective prevention methods. Objective To evaluate the effectiveness of patient education videos and fall prevention visual signalling icons when added to bed exit alarms in improving acutely hospitalised medical-surgical inpatient fall and injury rates. Design Performance improvement study with historic control. Setting Four medical-surgical units in one US public acute care hospital. Study participants Adult medical-surgical inpatients units. Interventions A 4 min video was shown to patients by trained volunteers. Icons of individual patient risk factors and interventions were placed at patients’ bedsides. Beds with integrated three-mode sensitivity exit alarms were activated for confused patients at risk of falling. Main outcome measures The main outcome measure is the incident rate per 1000 patient days (PDs) for patient falls, falls with any injury and falls with serious injury. The incident rate ratio (IRR) for each measure compared January 2009–September 2010 (baseline) with the follow-up period of January 2015–December 2015 (intervention). Results Falls decreased 20% from 4.78 to 3.80 per 1000 PDs (IRR 0.80, 95% CI 0.66 to 0.96); falls with any injury decreased 40% from 1.01 to 0.61 per 1000 PDs (IRR 0.60, 95% CI 0.38 to 0.94); and falls with serious injury 85% from 0.159 to 0.023 per 1000 PDs (IRR 0.15, 95% CI 0.01 to 0.85). Icons were not fully implemented. Conclusion The first known significant reduction of falls, falls with injury and falls with serious injury among medical-surgical inpatients was achieved. Patient education and continued use of bed exit alarms were associated with large decreases in injury. Icons require further testing. Multicentre randomised controlled trials are needed to confirm the effectiveness of icons and video interventions and exit alarms.
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Affiliation(s)
- Sasha J Cuttler
- Collaborative Alliance for Nursing Outcomes Coordinator, San Francisco General Hospital, San Francisco, California, USA.,Physiological Nursing, University of California San Francisco, San Francisco, California, USA
| | - Jill Barr-Walker
- ZSFG Library, University of California, San Francisco, California, USA
| | - Lauren Cuttler
- Department of Nursing, City College of San Francisco, San Francisco, California, USA
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Marques P, Queirós C, Apóstolo J, Cardoso D. Effectiveness of bedrails in preventing falls among hospitalized older adults: a systematic review. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2017; 15:2527-2554. [PMID: 29035965 DOI: 10.11124/jbisrir-2017-003362] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Falls are a major problem today affecting adults of any age, but the elderly are a population that is more susceptible to falls. Falls are the leading cause of injury or death among older adults. Hospitalized older people are particularly vulnerable to falls. Falls cause direct injuries (minor injuries, severe wounds of the soft tissues and bone fractures) to patients and increased length of stay. The prevention of falls is commonly considered an indicator of the quality of care. Therefore, health institutions and professionals treat the identification and implementation of strategies to prevent or minimize their effects as a high priority. Fall prevention interventions involving physical restraints are still common and considered a primary preventative measure, despite controversy in their use. One of the most frequently used restraint interventions is bedrails. The question of the effectiveness of bedrails in preventing falls cuts across all societies and cultures and has with significant implications for the clinical practice of nurses. OBJECTIVES The objective of this review was to identify the effectiveness of the use of bedrails in preventing falls among hospitalized older adults when compared with no use of bedrails or any type of physical restraints. INCLUSION CRITERIA TYPES OF PARTICIPANTS The current review considered studies that included hospitalized adults (female and male), 65 years and over with any clinical condition in a non-intensive care unit (ICU). TYPES OF INTERVENTION(S) The current review considered studies that evaluated the use of bedrails as a restraint to prevent falls among older adults in non-ICUs compared to no use of bedrails or any type of physical restraints, for example, bedrails versus no bedrails, and bedrails versus no wrist or ankle ties. TYPES OF STUDIES The current review considered any randomized controlled trials (RCTs). In the absence of RCTs, other research designs such as non-RCTs, before and after studies, cohort studies, case-control studies, descriptive studies, case series/reports and expert-opinion were considered. OUTCOMES The current review considered studies that included primary outcomes (number of patients who fell or the number of falls per patient) and secondary outcomes (number of head trauma, bone fractures or soft tissue injuries). SEARCH STRATEGY The search strategy aimed to find both published and unpublished articles. A three-step search strategy was utilized in 13 databases. Articles published in Portuguese, English and Spanish beginning from 1980 were considered for inclusion. METHODOLOGICAL QUALITY Assessment of methodological quality was not conducted as no articles were identified that met the inclusion criteria. DATA EXTRACTION AND DATA SYNTHESIS Data extraction and synthesis was not performed, because no articles were included in this systematic review. RESULTS The search identified a total of 875 potentially relevant articles. Sixteen articles were identified through the reference lists of all identified articles. One hundred and thirteen full-text papers were assessed by two independent reviewers to determine eligibility. However, 11 articles were not found (despite all the efforts), and 102 articles did not meet the inclusion criteria. CONCLUSION There is no scientific evidence comparing the use of bedrails in preventing falls among hospitalized older adults to no use of bedrails or any type of physical restraints.
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Affiliation(s)
- Paulo Marques
- 1Center for Health Technology and Services Research (CINTESIS), Escola Superior de Enfermagem do Porto, Porto, Portugal 2Centro Hospitalar do Porto, Escola Superior de Enfermagem do Porto, ICBAS - UP, Porto, Portugal 3Health Sciences Research Unit: Nursing, Nursing School of Coimbra, Coimbra, Portugal 4Portugal Centre for Evidence Based Practice: a Joanna Briggs Institute Centre of Excellence, Coimbra, Portugal
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Chang YW, Chang YH, Pan YL, Kao TW, Kao S. Validation and reliability of Falls Risk for Hospitalized Older People (FRHOP): Taiwan version. Medicine (Baltimore) 2017; 96:e7693. [PMID: 28767601 PMCID: PMC5626155 DOI: 10.1097/md.0000000000007693] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A comprehensive fall risk assessment can provide information for effective prevention and intervention measures and reduce falls among hospitalized elderly people. The purpose of this study was to develop a Chinese version of an inpatient fall risk assessment tool and evaluate its validity and reliability.This study employed the Falls Risk for Hospitalised Older People (FRHOP) assessment to construct a FRHOP-Taiwan Version (Tw-FRHOP) through forward, synthesized, and backward translation. A face validation was conducted by 5 clinical nurses and a content validation was conducted by 5 specialists using the content validity index (CVI) to validate the proposed model. Thirty hospitalized older adults in an internal care unit were selected for an interrater reliability assessment, conducted separately by specialists in 4 disciplines (i.e., nurses, physicians, occupational therapists, and physiotherapists) by using Cohen kappa statistic and intraclass correlation coefficients (ICCs). Specifically, the assessment rating developed in the Tw-FRHOP was compared with the Morse Fall Scale (MFS), St. Thomas Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY), and the Hendrich II Fall Risk Model (HIIFRM) for criterion validation.According to the analysis results, the CVI was 0.94, and the indexes of criterion-related validity for the FRHOP-Taiwan Version, MFS, STRATIFY, and HIIFRM were 0.49, 0.63, and 0.54 (all P < .001), respectively. In addition, after interrater reliability testing was conducted, the results indicated that the index of response consistency in each discipline was 86.7% to 100%, and the values of Cohen kappa were 0.651 to 1.000. The ICCs of the discipline-related subscale were 0.97 to 1.00.The Tw-FRHOP is a multidisciplinary comprehensive fall risk assessment that can serve as a satisfactorily valid and reliable reference tool for medical personnel with full professional training, as well as inpatient fall prevention interventions for multidisciplinary teams in hospitals.
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Affiliation(s)
- Yaw-Wen Chang
- Division of Geriatric Medicine, Tri-Service General Hospital
- Graduate Institute of Medical Science
| | | | | | - Tung-Wei Kao
- Department of Family Medicine, Tri-Service General Hospital
| | - Senyeong Kao
- School of Public Health
- Graduate Institute of Life Science, National Defense Medical Center, Taipei, Taiwan
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Möhler R, Nürnberger C, Abraham J, Köpke S, Meyer G. Interventions for preventing and reducing the use of physical restraints of older people in general hospital settings. Hippokratia 2016. [DOI: 10.1002/14651858.cd012476] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Ralph Möhler
- Faculty of Medicine and Medical Center, University of Freiburg; Cochrane Germany, Institute for Medical Biometry and Statistics; Breisacher Str. 153 Freiburg Germany 79110
- Martin Luther University Halle-Wittenberg; Institute of Health and Nursing Sciences; Magdeburger Strasse 8 Halle (Saale) Germany 06097
| | - Cäcilia Nürnberger
- Martin Luther University Halle-Wittenberg; Institute of Health and Nursing Sciences; Magdeburger Strasse 8 Halle (Saale) Germany 06097
| | - Jens Abraham
- Martin Luther University Halle-Wittenberg; Institute of Health and Nursing Sciences; Magdeburger Strasse 8 Halle (Saale) Germany 06097
| | - Sascha Köpke
- University of Lübeck; Nursing Research Group, Institute of Social Medicine and Epidemiology; Ratzeburger Allee 160 Lübeck Germany D-23538
| | - Gabriele Meyer
- Martin Luther University Halle-Wittenberg; Institute of Health and Nursing Sciences; Magdeburger Strasse 8 Halle (Saale) Germany 06097
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14
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Australian and New Zealand Society for Geriatric Medicine Position Statement Abstract: Physical restraint use in older people. Australas J Ageing 2016; 35:225. [PMID: 26810105 DOI: 10.1111/ajag.12224] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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von Renteln-Kruse W, Neumann L, Klugmann B, Liebetrau A, Golgert S, Dapp U, Frilling B. Geriatric patients with cognitive impairment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 112:103-12. [PMID: 25780869 DOI: 10.3238/arztebl.2015.0103] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 10/21/2014] [Accepted: 10/21/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hospitals are now faced with increasing numbers of cognitively impaired patients aged 80 and older who are at increased risk of treatment complications. This study concerns the outcomes when such patients are treated in a specialized ward for cognitive geriatric medicine. METHODS Observation of a cohort of 2084 patients from 2009 to 2014, supplemented by a sample of 380 patients from the hospital cohort of the Longitudinal Urban Cohort Ageing Study (LUCAS) for the years 2010 and 2011. RESULTS Geriatric inpatients with cognitive impairment tend to be multimorbid. Half of the patients studied (1031 of 2084 patients) were admitted to the hospital on an emergency basis. Complications arising on the ward that necessitated transfer elsewhere arose in 2.6% (51 of 2084 patients). Moreover, analysis of the sample of 380 patients from the LUCAS cohort revealed that the treatments they underwent during hospitalization were associated with an improvement of their functional state: their mean overall score on the Barthel index rose from 39.8 ± 24.3 (median, 35) on admission to 52.7 ± 27.0 (median, 55) on discharge. The percentage of patients being treated with 5 or more drugs fell from 98.2% (373/380) on admission to 79.3% (314/362) on discharge. The percentage receiving potentially inappropriate medications (PIM), as defined by the PRISCUS list, fell from 45% to 13.3%, while the percentage of drug orders and prescriptions involving PIM fell from 7.8 % (327/4181) to 2.0% (53/2600). 70% of the patients were discharged to the same living situation where they had been before admission. CONCLUSION In this study, structured geriatric treatment in a cohort of older acutely ill patients with cognitive impairment was associated with improvement of functions that are relevant to everyday life, as well as with a reduction of polypharmacy. Controlled studies are needed to confirm the observed benefit.
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Affiliation(s)
- Wolfgang von Renteln-Kruse
- Albertinen-Haus, Geriatrics Centre, Scientific Department at the University of Hamburg, Hamburg, Germany, Albertinen-Haus, Geriatrics Centre, Scientific Department at the University of Hamburg, Research Department, Hamburg Germany, Albertinen-Hospital, Department of Medical Controlling, Hamburg, Germany
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Lim SC, Mamun K, Lim JKH. Comparison between elderly inpatient fallers with and without dementia. Singapore Med J 2015; 55:67-71. [PMID: 24570314 DOI: 10.11622/smedj.2014017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION This study aimed to examine the various factors associated with inpatient falls among patients with and without dementia in a hospital setting. METHODS This was a retrospective one-year study using data collected from Singapore General Hospital's electronic reporting system for inpatient falls. RESULTS In the study period, 298 patients aged ≥ 65 years fell during their hospital stay. The majority of the patients (n = 248) did not have dementia. In our study, fallers with dementia were more likely to use ambulatory aids, be visually impaired and have urinary incontinence. More patients with dementia than those without had a history of previous falls, and were placed on fall precaution with restricted freedom of movement, which at times, included restraints. However, the difference between patients who were put on restraints and those who were allowed to move freely was not statistically significant. The majority of falls in both groups occurred at the bedside. We found that fallers without dementia were more likely to fall during the morning shift, whereas fallers with dementia were more likely to fall during the night shift. Fallers with dementia were more likely to be confused at the time of the fall. CONCLUSION In our study, we found that fallers with dementia were more likely to have visual impairment, have urinary incontinence, use walking aids, and to be confused and physically restrained at the time of the fall. The fallers without dementia in our study may have undiagnosed dementia.
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Affiliation(s)
- Si Ching Lim
- Department of Geriatric Medicine, Changi General Hospital, 2 Simei Street 3, Singapore 529889.
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Van Gaal BG, Schoonhoven L, Mintjes-de Groot JA, Defloor T, Habets H, Voss A, van Achterberg T, Koopmans RT. Concurrent Incidence of Adverse Events in Hospitals and Nursing Homes. J Nurs Scholarsh 2013; 46:187-98. [DOI: 10.1111/jnu.12063] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Betsie G.I. Van Gaal
- Senior researcher, Scientific Institute for Quality of Healthcare; Radboud university medical center; Nijmegen the Netherlands
| | - Lisette Schoonhoven
- Senior Research Fellow Nursing Science, Scientific Institute for Quality of Healthcare, Radboud university medical center, Nijmegen, the Netherlands and Faculty of Health Sciences; University of Southampton; Southampton UK
| | - Joke A.J. Mintjes-de Groot
- Emeritus Professor Critical Care, Faculty of Health and Social Studies; HAN University of Applied Sciences; Nijmegen the Netherlands
| | - Tom Defloor
- Was Professor of Nursing Science, Department of Public Health, Faculty of Medicine and Health Science; Ghent University; Gent Belgium
| | - Herbert Habets
- Geriatric Clinical Nurse Specialist, Orbis Medical Centre, Sittard-Geleen, Senior Lecturer; Zuyd University of Applied Sciences; Heerlen The Netherlands
| | - Andreas Voss
- Professor of Clinical Microbiology and Infection Control, Department of Medical Microbiology, Radboud university medical center, Nijmegen, the Netherlands and Consultant Clinical Microbiologist; Canisius-Wilhelmina Hospital; Nijmegen the Netherlands
| | - Theo van Achterberg
- Professor of Nursing Science, Scientific Institute for Quality of Healthcare, Radboud university medical center; Nijmegen, the Netherlands and Center for Health Services and Nursing Research; KU Leuven Leuven Belgium
| | - Raymond T.C.M. Koopmans
- Professor of Elderly Care Medicine, Department of Primary and Community Care, Centre for Family Medicine, Geriatric Care and Public Health; Radboud university medical center; Nijmegen the Netherlands
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Neumann L, Hoffmann VS, Golgert S, Hasford J, Von Renteln-Kruse W. In-hospital fall-risk screening in 4,735 geriatric patients from the LUCAS project. J Nutr Health Aging 2013; 17:264-9. [PMID: 23459980 DOI: 10.1007/s12603-012-0390-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES In-hospital falls in older patients are frequent, but the identification of patients at risk of falling is challenging. Aim of this study was to improve the identification of high-risk patients. Therefore, a simplified screening-tool was developed, validated, and compared to the STRATIFY predictive accuracy. DESIGN Retrospective analysis of 4,735 patients; evaluation of predictive accuracy of STRATIFY and its single risk factors, as well as age, gender and psychotropic medication; splitting the dataset into a learning and a validation sample for modelling fall-risk screening and independent, temporal validation. SETTING Geriatric clinic at an academic teaching hospital in Hamburg, Germany. PARTICIPANTS 4,735 hospitalised patients ≥65 years. MEASUREMENTS Sensitivity, specificity, positive and negative predictive value, Odds Ratios, Youden-Index and the rates of falls and fallers were calculated. RESULTS There were 10.7% fallers, and the fall rate was 7.9/1,000 hospital days. In the learning sample, mental alteration (OR 2.9), fall history (OR 2.1), and insecure mobility (Barthel-Index items 'transfer' + 'walking' score = 5, 10 or 15) (OR 2.3) had the most strongest association to falls. The LUCAS Fall-Risk Screening uses these risk factors, and patients with ≥2 risk factors contributed to the high-risk group (30.9%). In the validation sample, STRATIFY SENS was 56.8, SPEC 59.6, PPV 13.5 and NPV 92.6 vs. LUCAS Fall-Risk Screening was SENS 46.0, SPEC 71.1, PPV 14.9 and NPV 92.3. CONCLUSIONS Both the STRATIFY and the LUCAS Fall-Risk Screening showed comparable results in defining a high-risk group. Impaired mobility and cognitive status were closely associated to falls. The results do underscore the importance of functional status as essential fall-risk factor in older hospitalised patients.
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Affiliation(s)
- L Neumann
- Albertinen-Haus Geriatrics Centre, University of Hamburg, Hamburg, Germany
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19
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Tolson D, Morley JE. Physical Restraints: Abusive and Harmful. J Am Med Dir Assoc 2012; 13:311-3. [DOI: 10.1016/j.jamda.2012.02.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 02/16/2012] [Indexed: 11/16/2022]
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Impact of place on people and process: the integration of research on the built environment in the planning and design of critical care areas. Crit Care Nurs Q 2012; 34:268-81. [PMID: 21921712 DOI: 10.1097/cnq.0b013e31822c3831] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
What is the role of the built environment in healing? What aspects of the built environment promote healing, staff efficiency, and patient safety? How can we know if these assertions hold true? Can scientific research help us validate these assumptions? These questions are important to explore, especially for our most vulnerable patients-those in critical care settings. This article explores the historical influences on health care design, reveals how the current health care transformation movement has accelerated the incorporation of elements of the built environment into patient safety and quality improvement effort, discusses how healing environments are constructed, and examines how the literature of health care and health care design organizations have incorporated the impact of the built environment on patient, family, and staff outcomes and satisfaction. Finally, a case study of applying "design hypotheses" and a scientific method to the design of an intensive care unit setting is offered. This article will help critical care nurses understand the role the built environment has in creating optimal healing environments.
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Sze TW, Leng CY, Lin SKS. The effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes: a systematic review. ACTA ACUST UNITED AC 2012; 10:307-351. [PMID: 27819940 DOI: 10.11124/jbisrir-2012-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Physical restraint was introduced as the primary measure to maintain patient safety in preventing falls. However, physical restraints may lead to complications such as functional loss, immobility, delirium, pressure sore, and even falls or injuries. Despite all these negative effects and many alternatives that are available, physical restraint is still commonly used in hospitals and nursing homes. Hence, it is crucial to understand the effectiveness of physical restraints in protecting adult patients from falling. OBJECTIVE The overall objective was to examine the effectiveness of physical restraints in reducing falls among adults in acute care hospitals and nursing homes. INCLUSION CRITERIA This review considered quantitative designs, including randomised controlled trials, quasi-experimental studies, cohort studies, case control studies and case series/reports.The participants of this review were male and female adult patients aged 18 years or over who are on authorized physical restraints in acute care hospitals and nursing homes.This review focused on studies that investigated physical restraint as an intervention for reducing falls among adults in acute care hospitals and nursing homes.The outcomes of interest were the number of individuals receiving restraints who fall, or the rate or number of falls in acute hospitals and nursing homes. SEARCH STRATEGY A three-step search strategy was utilised in this review. An initial limited search of MEDLINE and CINAHL was undertaken, followed by a second search using all identified keywords and index terms across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies. All searches were limited to English Language studies and there was no limit in the timeframe. ASSESSMENT OF METHODOLOGICAL QUALITY The quality of the included studies was subjected to assessment by two independent reviewers using the standardised critical appraisal tools from the Joanna-Briggs Institute from the JBI-MAStARI (Joanna Briggs Institute-Meta-Analysis of Statistics Assessment and Review Instrument). DATA EXTRACTION Data was extracted from included papers using the standardised extraction tool from the JBI MASTARI. DATA SYNTHESIS Due to the heterogeneous nature of the study methods, the findings of this review are presented in a narrative summary. RESULTS Nine studies were included in the review. The majority of the findings showed that physical restraints were not associated with the reduction in falls and decreased restraint use did not contribute to more falls. CONCLUSION From the overall results, physical restraints are not effective in reducing falls or injuries among adults in acute care hospitals and nursing homes.National standards and application guides for physical restraints are recommended. The use of physical restraints should be assessed by trained staff based on individualised need and consideration of patient's autonomy and integrity. The awareness of appropriate physical restraint usage should be enhanced among the healthcare professionals.Large multicentre research to determine the risk and benefit ratio of physical restraints and to examine the effectiveness of alternative measures, different number of bedrails, intermittent restraint use and restraint reduction programs are needed respectively.
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Affiliation(s)
- Tang Wing Sze
- 1. Tang Wing Sze. Singapore National University Hospital (NUH) Centre for Evidence Based Nursing. 2. Dr Chow Yeow Leng. Singapore National University Hospital (NUH) Centre for Evidence Based Nursing. Telephone: +65-94526773. Facsimile: +65-67767135. 3. Dr Serena Koh Siew Lin. Singapore National University Hospital (NUH) Centre for Evidence Based Nursing. Telephone: +65-91133702. Facsimile: +65-63258374.
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The effect of a restraint reduction program on physical restraint rates in rehabilitation settings in Hong Kong. Rehabil Res Pract 2011; 2011:284604. [PMID: 22110972 PMCID: PMC3195393 DOI: 10.1155/2011/284604] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Revised: 07/04/2011] [Accepted: 07/05/2011] [Indexed: 11/18/2022] Open
Abstract
Background. In view of the adverse effects of using restraints, studies examining the use of restraint reduction programs (RRPs) are needed. Objectives. To investigate the effect of an RRP on the reduction of physical restraint rates in rehabilitation hospitals. Methods. A prospective quasi-experimental clinical trial was conducted. Demographic data, medical and health-related information on recruited patients from two rehabilitation hospitals, as well as facility data on restraint rates were collected. Results. The increase in the restraint rate in the control site was 4.3 times greater than that in the intervention site. Changes in the restraint mode, from continuous to intermittent, and the type of restraint used were found between the pre- and postintervention periods in both the control site and the intervention site. Discussion. Compared with that in the control site, the RRP in the intervention site helped arrest any increase in the restraint rate although it had no effect on physical restraint reduction. The shift of restraint mode from continuous to intermittent in the intervention site was one of the positive outcomes of the RRP.
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Abstract
Falls are a widespread concern in hospitals settings, with whole hospital rates of between 3 and 5 falls per 1000 bed-days representing around a million inpatient falls occurring in the United States each year. Between 1% and 3% of falls in hospitals result in fracture, but even minor injuries can cause distress and delay rehabilitation. Risk factors most consistently found in the inpatient population include a history of falling, muscle weakness, agitation and confusion, urinary incontinence or frequency, sedative medication, and postural hypotension. Based on systematic reviews, recent research, and clinical and ethical considerations, the most appropriate approach to fall prevention in the hospital environment includes multifactorial interventions with multiprofessional input. There is also some evidence that delirium avoidance programs, reducing sedative and hypnotic medication, in-depth patient education, and sustained exercise programs may reduce falls as single interventions. There is no convincing evidence that hip protectors, movement alarms, or low-low beds reduce falls or injury in the hospital setting. International approaches to developing and maintaining a fall prevention program suggest that commitment of management and a range of clinical and support staff is crucial to success.
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Frequencies of falls in Swiss hospitals: Concordance between nurses’ estimates and fall incident reports. Int J Nurs Stud 2009; 46:164-71. [DOI: 10.1016/j.ijnurstu.2008.09.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2008] [Revised: 09/11/2008] [Accepted: 09/12/2008] [Indexed: 11/17/2022]
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O'Keeffe S. The effect of bedrails on falls and injury. Age Ageing 2009; 38:129; author reply 129-30. [PMID: 19029101 DOI: 10.1093/ageing/afn246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Healey F, Oliver D. Reply. Age Ageing 2008. [DOI: 10.1093/ageing/afn247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Healey F, Oliver D, Milne A, Connelly JB. The effect of bedrails on falls and injury: a systematic review of clinical studies. Age Ageing 2008; 37:368-78. [PMID: 18495686 DOI: 10.1093/ageing/afn112] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND around one-fourth of all falls in healthcare settings are falls from bed. The role of bedrails in falls prevention is controversial, with a prevailing orthodoxy that bedrails are harmful and ineffective. OBJECTIVE to summarise and critically evaluate evidence on the effect of bedrails on falls and injury DESIGN systematic literature review using the principles of QuoRoM guidance. SETTING AND SUBJECTS adult healthcare settings REVIEW METHODS using the keyword, bedrail, and synonyms, databases were searched from 1980 to June 2007 for direct injury from bedrails or where falls, injury from falls, or any other effects were related to bedrail use. RESULTS 472 papers were located; 24 met the criteria. Three bedrail reduction studies identified significant increases in falls or multiple falls, and one found that despite a significant decrease in falls in the discontinue-bedrails group, this group remained significantly more likely to fall than the continue-bedrails group; one case-control study found patients who had their bedrails raised significantly less likely to fall; one retrospective survey identified a significantly lower rate of injury and head injury in falls with bedrails up. Twelve papers described direct injury from bedrails. DISCUSSION it is difficult to perform conventional clinical trials of an intervention already embedded in practice, and all included studies had methodological limitations. However, this review concludes that serious direct injury from bedrails is usually related to use of outmoded designs and incorrect assembly rather than being inherent, and bedrails do not appear to increase the risk of falls or injury from falls.
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Affiliation(s)
- Frances Healey
- National Patient Safety Agency, 4-8 Maple Street, London W1 T 5HD, UK.
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Ulrich RS, Zimring C, Zhu X, DuBose J, Seo HB, Choi YS, Quan X, Joseph A. A Review of the Research Literature on Evidence-Based Healthcare Design. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2008; 1:61-125. [DOI: 10.1177/193758670800100306] [Citation(s) in RCA: 683] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: This report surveys and evaluates the scientific research on evidence-based healthcare design and extracts its implications for designing better and safer hospitals. Background: It builds on a literature review conducted by researchers in 2004. Methods: Research teams conducted a new and more exhaustive search for rigorous empirical studies that link the design of hospital physical environments with healthcare outcomes. The review followed a two-step process, including an extensive search for existing literature and a screening of each identified study for the relevance and quality of evidence. Results: This review found a growing body of rigorous studies to guide healthcare design, especially with respect to reducing the frequency of hospital-acquired infections. Results are organized according to three general types of outcomes: patient safety, other patient outcomes, and staff outcomes. The findings further support the importance of improving outcomes for a range of design characteristics or interventions, including single-bed rooms rather than multibed rooms, effective ventilation systems, a good acoustic environment, nature distractions and daylight, appropriate lighting, better ergonomic design, acuity-adaptable rooms, and improved floor layouts and work settings. Directions for future research are also identified. Conclusions: The state of knowledge of evidence-based healthcare design has grown rapidly in recent years. The evidence indicates that well-designed physical settings play an important role in making hospitals safer and more healing for patients, and better places for staff to work.
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Amador LF, Loera JA. Preventing Postoperative Falls in the Older Adult. J Am Coll Surg 2007; 204:447-53. [PMID: 17324780 DOI: 10.1016/j.jamcollsurg.2006.12.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Revised: 11/27/2006] [Accepted: 12/04/2006] [Indexed: 11/24/2022]
Affiliation(s)
- Luis F Amador
- Department of Internal Medicine Geriatrics Division, University of Texas Medical Branch at Galveston, Galveston, TX 77555-0460, USA
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