Preventing Falls in Hospitalized Patients: State of the Science

Falls in older adults hospitalized in tertiary centers in Colombia. Clinical description and complications

OBJECTIVE

The incidence of falls in elderly patients in the hospital environment is three times higher than that in the community. The aim was to determine the characteristics of patients who suffered in-hospital falls and their complications.

METHODS

This was a cross-sectional study with patients older than 64 years of age, admitted between 2018 and 2020 to four clinics in Colombia who presented a fall during their stay. Clinical data, reasons for the fall, complications and use of drugs with a known risk for causing falls and with an anticholinergic load were reviewed.

RESULTS

A total of 249 patients were included. The mean age was 77.5 ± 7.4 years, and there was a predominance of males (63.9%). The patients were hospitalized mainly for community-acquired pneumonia (12.4%) and heart failure (10.4%). Falls occurred most frequently in hospitalization wards (77.1%) and emergency departments (20.9%). Falls were related to standing alone (34.4%) and on the way to the bathroom (28.9%), with 40.6% (n = 102) of falls resulting in trauma, especially to the head (27.7%); the incidence of fractures was low (3.2%). Ninety-two percent of patients had polypharmacy (≥5 drugs), 88.0% received psychotropic drugs, and 37.3% received drugs with an anticholinergic load ≥3 points.

CONCLUSIONS

Hospitalized adults over 65 years of age suffered falls, mainly in hospitalization wards and emergency departments, especially during the process of solitary ambulation. Most had received psychotropic drugs and medications with a high anticholinergic load. These results suggest that it is necessary to improve risk prevention strategies for falls in this population.

Congruency and its related factors between patients' fall risk perception and nurses' fall risk assessment in acute care hospitals

INTRODUCTION

Inpatients need to recognize their fall risk accurately and objectively. Nurses need to assess how patients perceive their fall risk and identify the factors that influence patients' fall risk perception.

PURPOSE

This study aims to explore the congruency between nurses' fall risk assessment and patients' perception of fall risk and identify factors related to the non-congruency of fall risk.

DESIGNS

A descriptive and cross-sectional design was used. The study enrolled 386 patients who were admitted to an acute care hospital. Six nurses assessed the participants' fall risk. Congruency was classified using the Morse Fall Scale for nurses and the Fall Risk Perception Questionnaire for patients.

FINDINGS

The nurses' fall risk assessments and patients' fall risk perceptions were congruent in 57% of the participants. Underestimation of the patient's risk of falling was associated with gender (women), long hospitalization period, department (orthopedics), low fall efficacy, and history of falls before hospitalization. Overestimation of fall risk was associated with age group, gender (men), department, and a high health literacy score. In the multiple logistic regression, the factors related to the underestimation of fall risk were hospitalization period and department, and the factors related to the overestimation of fall risk were health literacy and department.

CONCLUSIONS

Nurses should consider the patient's perception of fall risk and incorporate it into fall prevention interventions.

CLINICAL RELEVANCE

Nurses need to evaluate whether patients perceive the risk of falling consistently. For patients who underestimate or overestimate their fall risk, it may be helpful to consider clinical and fall-related characteristics together when evaluating their perception of fall risk.

'You Just Struggle on Your Own': Exploring Older People and Their Caregivers' Perspectives About Falls Prevention Education in Hospitals

BACKGROUND

Providing older patients with an opportunity to participate in individualised falls preventive education, has been shown to reduce hospital falls. However, few studies have explored older peoples' perspectives of hospital falls prevention education. This study aimed to explore older people and their caregivers' knowledge and awareness about hospital falls prevention, including their reflections on the education they received when hospitalised.

METHODS

A qualitative, exploratory study with focus groups and semistructured interviews was conducted. Participants were a purposively selected sample of community-dwelling older people (65+ years) admitted to a hospital in the past 5 years and caregivers of older people. Data were thematically analysed using deductive and inductive approaches, and a capability-opportunity-motivation-behaviour model was applied to understand key determinants of implementing falls education for hospitalised older people.

RESULTS

Participants' [n = 46 (older people n = 37, age range 60-89 years), caregivers n = 9] feedback identified five themes: distress and disempowerment if the participant did have a hospital fall or nearly fell, anxiety and uncertainty about what behaviour was required while in hospital, insufficient and inconsistent falls prevention education, inadequate communication and underlying attitudes of ageism. Applying a behaviour change model suggested that older people and their caregivers did not develop falls prevention knowledge, awareness or motivation to engage in falls prevention behaviour. Older people were also provided with limited opportunities to engage in falls preventive behaviour while in hospital.

CONCLUSION

Older people in our study received sporadic education about falls prevention during their hospital admissions which did not raise their awareness and knowledge about the risk of falls or their capability to engage in safe falls preventive behaviour. Conflicting messages may result in older people feeling confused and anxious about staying safe in hospital.

Remote Patient Monitoring Improves Patient Falls and Reduces Harm

BACKGROUND

Minimizing patient falls and fall-related injuries within organizational constraints is a high priority for nurse leaders. The Centers for Medicare & Medicaid Services do not reimburse hospitals for fall-related expenditures. In-person sitters are used to prevent falls but are resource intensive and costly. Remote patient monitoring (RPM) may offer alternatives to in-person sitters to reduce fall-related harm.

PURPOSE

The efficacy of RPM to reduce patient falls and fall-related injuries was explored.

METHODS

Electronic health record data were extracted from a 13-hospital integrated health care system. Incidence rate ratios were used to analyze the impact of RPM technology on falls and fall-related injuries.

RESULTS

When used in conjunction with standard fall precautions, RPM reduced falls 33.7% and fall-related injuries 47.4%. Fall-related expenditures decreased $304 400 with a combined estimated savings systemwide of $2 089 600 annually.

CONCLUSIONS

RPM technology minimized falls and associated harm and improved patient safety, positively impacting hospital expenditures.

Relationship Between Unit Characteristics and Fall Incidence: A Cross-Sectional Survey Using Administrative Data in Japan

BACKGROUND

Falls are the most frequent accident experienced by inpatients in hospitals. As falls affect patient outcomes, high fall risk factors should be studied to prevent falls and improve patient safety. However, the relationship between hospital unit characteristics and fall risk has never been assessed.

PURPOSE

This study was designed to identify the unit characteristics significantly related to fall risk.

METHODS

A cross-sectional study was conducted on the medical records of patients hospitalized in a Japanese academic hospital between 2018 and 2019. This study quantified unit activities and utilized Diagnosis Procedure Combination data to examine unit characteristics related to falls based on unit day.

RESULTS

Data on 16,307 patients were included in the analysis, and 355 unit days were certified as fall events. Based on patient condition and medical treatment, the results identified antineoplastic injections, radiation therapy, aseptic treatment room, and functional status of partly assisted transfers, meals, and oral care as unit characteristics associated with increased fall events. Decreased nursing time per patient at night (odds ratio [OR] = 0.75, p = .04) and higher numbers of partially assisted transfer patients were also identified as unit characteristics associated with higher fall incidence rates (OR = 5.56, p = .01).

CONCLUSIONS

The results of this study are expected to assist nurses to predict falls based on unit characteristics; reducing nursing time in the units was found to be a factor associated with higher fall risk. Nurse managers must understand the unit-related fall risk factors, appropriately assign nurse staffing numbers, and demonstrate nursing leadership to prevent falls in their units.

Screening for Risk of Fall-Related Inpatient Trauma in a US Acute Care Setting

Introduction Falls during hospitalization are a leading cause of preventable trauma-related injuries. Factors associated with fall risk include an unfamiliar environment, changes in health status, and efficacy based on the home environment. Assessing fall efficacy with an individualized prevention plan can decrease falls. The primary aim of this study was to estimate the effect of implementing a fall efficacy screening and intervention on reducing patient falls. Methods The study utilized a quasi-experimental, cross-sectional design with a convenience sample of patients admitted to an in-patient adult medical unit within a community hospital over a twelve-month period. Sampling times included pre-implementation, immediately post-implementation, and a second post-implementation phase. The intervention consisted of an admission fall efficacy screening tool and an individualized educational initiative. Statistical analysis included descriptive statistics of central tendency and dispersion, along with inferential statistics using independent sample t-tests, chi-square tests, correlations, and binary logistic regression. Results Among the study participants (n=2,074), the total sample had an average age of 67.7 (+/- 17.4) years and had mean scores of 13.3 (6.9) on the Short Falls Efficacy Scale-International and 51.8 (20.3) on the Morse Fall Scale. Fifty-two percent of the study population were female; 16.2% of the patients were diagnosed with cerebrovascular accident (CVA) or CVA-like symptoms. Fall rates decreased with a rate of change of -4.15% after efficacy screening and intervention. Males demonstrated higher efficacy in avoiding falls compared to females (t(828) = 3.369, p <0.001). Patients with a CVA diagnosis demonstrated higher efficacy scores compared to non-CVA patients (t(2071) = -3.348, p <0.001). FES risk groups (OR of 5.632, 95% CI (2.171-7.892)) and age over 65 (OR 1.21, 95% CI (1.006-1.442)) were significant predictors of a fall when patients with a primary CVA diagnosis were omitted from the sample (p= 0.022 and 0.046 respectively). Conclusion The findings suggest that efficacy screening may be associated with decreased falls for acute care non-CVA inpatient populations over 65 years of age. Further research into the predictive utility of fall efficacy screening in acute care CVA and non-CVA hospitalized patient populations aged 65 years and above is recommended.

Inpatients' experiences of falls: A qualitative meta-synthesis

OBJECTIVES

Identify and synthesize published qualitative research reporting inpatient experiences of a fall to determine novel insights and understandings of this longstanding complex problem.

RESEARCH DESIGN

Qualitative meta-synthesis.

METHODS

Online databases were searched to systematically identify published research reporting inpatient experiences of a fall. The included studies were inductively analysed and interpreted then reported as a meta-synthesis.

DATA SOURCES

Databases Ovid MEDLINE, Embase, Ovid Emcare, CINAHL Complete, Scopus and ProQuest Dissertations and Theses Global were searched on 3rd August, 2023.

RESULTS

From 10 included publications, four new themes of inpatients' experiences of a fall were constructed. Themes one, two and three related to antecedents of patient falls, and theme four related to consequences. Theme one, 'My foot didn't come with me: Physiological and anatomical changes', encompassed patients' experiences of medical conditions, medication, and anatomical changes. These aspects contributed to alterations in balance and strength, and misconceptions of capability in activities of daily (inpatient) living. Theme two, 'I was in a hurry: Help-seeking', encompassed patients' experiences striving for independence while balancing power and control, minimizing their own needs over care of others', and unavailability of support. Theme three, 'I couldn't find the call light: Environment and equipment', encompassed patients' experiences of not being able to reach or use equipment, and environment changes. Theme four, 'It was my fault too: Blame and confidence', encompassed patients' expressions of blame after their fall, blame directed at both themselves and/or others, and impacts on confidence and fear in mobilizing.

CONCLUSIONS

Inpatient falls are embedded in a complexity of individual, relational, and environmental factors, yet there are potential ways forward both informed and led by the patient's voice. Strength-based approaches to address the tenuous balance between independence and support may be one opportunity to explore as a next step in complementing the existing multifaceted interventions.

IMPACT

Inpatient falls are a complex and costly health safety and quality problem. Despite global initiatives in the prevention of inpatient falls, they remain intractable. This meta-synthesis provides an in-depth exploration of extant qualitative data on patients' experiences of falls in hospitals. Four themes were constructed expressing the inpatients' experiences: physiological and anatomical changes, help-seeking, environment and equipment, and blame and confidence. Novel considerations for future investigation are offered, drawing from self-determination theory and positive psychological interventions.

IMPLICATIONS FOR PATIENT CARE

This meta-synthesis elicits new considerations for future interventions based on people's experiences of their fall in hospital, offering healthcare professionals novel directions in fall prevention.

REPORTING METHOD

The review was reported according to the Enhancing transparency in reporting the synthesis of qualitative research statement (ENTREQ; Tong et al., 2012).

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

REGISTRATION

PROSPERO CRD42023445279.

Risk-adjusted trend in national inpatient fall rates observed from 2011 to 2019 in acute care hospitals in Switzerland: a repeated multicentre cross-sectional study

OBJECTIVES

This study aimed to investigate whether a significant trend regarding inpatient falls in Swiss acute care hospitals between 2011 and 2019 could be confirmed on a national level, and whether the trend persists after risk adjustment for patient-related fall risk factors.

DESIGN

A secondary data analysis was conducted based on annual multicentre cross-sectional studies carried out between 2011 and 2019.

SETTING

All Swiss acute care hospitals were obliged to participate in the surveys. Except for emergency departments, outpatient wards and recovery rooms, all wards were included.

PARTICIPANTS

All inpatients aged 18 or older who had given their informed consent and whose data were complete and available were included.

OUTCOME MEASURE

Whether a patient had fallen in the hospital was retrospectively determined on the survey day by asking patients the following question: Have you fallen in this institution in the last 30 days?

RESULTS

Based on data from 110 892 patients from 222 Swiss hospitals, a national inpatient fall rate of 3.7% was determined over the 9 survey years. A significant linear decreasing trend (p=0.004) was observed using the Cochran-Armitage trend test. After adjusting for patient-related fall risk factors in a two-level random intercept logistic regression model, a significant non-linear decreasing trend was found at the national level.

CONCLUSIONS

A significant decrease in fall rates in Swiss hospitals, indicating an improvement in the quality of care provided, could be confirmed both descriptively and after risk adjustment. However, the non-linear trend, that is, an initial decrease in inpatient falls that flattens out over time, also indicates a possible future increase in fall rates. Monitoring of falls in hospitals should be maintained at the national level. Risk adjustment accounts for the observed increase in patient-related fall risk factors in hospitals, thus promoting a fairer comparison of the quality of care provided over time.

Psychometric Properties of the Fall Risk Perception Questionnaire-Short Version for Inpatients in Acute Care Hospitals

PURPOSE

Patients' perception of fall risk is a promising new indicator for fall prevention. Therefore, a fall risk perception questionnaire that can be used rapidly and repeatedly in acute care settings is required. This study aimed to develop a short version of the fall risk perception questionnaire (Short-FRPQ) for inpatients.

METHODS

For the psychometric measurements, 246 inpatients were recruited from an acute care hospital. The construct (using confirmatory factor analysis and discriminant validity of each item), convergent, and known-group validities were tested to determine the validity of the Short-FRPQ. McDonald's omega coefficient was used to examine the internal consistency of reliability.

RESULTS

In the confirmatory factor analysis, the fit indices of the Short-FRPQ, comprising 14 items and three factors, appeared to be satisfactory. The Short-FRPQ had a significantly positive correlation with the original scale, the Korean Falls Efficacy Scale-International, and the Morse Fall Scale. The risk of falls group, assessed using the Morse Fall Scale, had a higher score on the Short-FRPQ. McDonald's omega coefficient was .90.

CONCLUSION

The Short-FRPQ presents good reliability and validity. As patient participation is essential in fall interventions, evaluating the fall risk perception of inpatients quickly and repeatedly using scales of acceptable validity and reliability is necessary.

Enhancing knowledge, attitude, and perceptions towards fall prevention among older adults: a pharmacist-led intervention in a primary healthcare clinic, Gemas, Malaysia

BACKGROUND

Falls and fall-related injuries are very common among older adults, and the risk of falls increases with the aging process. The lack of awareness of falls and fall-related injuries among older adults can contribute to an increasing risk of falls. Hence, a study was carried out to improve the knowledge, attitude, and perception of falls and fractures among older adults in a primary care setting in Gemas, a rural area of the Selangor state of Malaysia.

METHOD

A structured educational intervention was provided to older adults who visited the primary care setting in Gemas and provided written informed consent to participate in the study. A total of 310 older adult patients was included in the study using a convenience sampling technique.

RESULTS

Before the intervention, 74.84% of the respondents (n = 232) agreed that falls and related fractures are the leading causes of hospital admission among older adults. In post-intervention, the number of respondents who agreed with this statement increased to 257 (82.91%). At baseline, 28 respondents (9.03%) had poor knowledge, 160 respondents (51.61%) had average knowledge levels, and 122 respondents (39.35%) had good knowledge. In post-intervention, respondents with poor and average knowledge reduced to 1.93% (n = 6) and 29.35% (n = 91) respectively. A majority of respondents' knowledge levels improved significantly after the intervention (n = 213; 68.71%). About eight respondents (2.58%) had a negative perception of falls. In post-intervention, the percentage reduced to 0.65% as only two respondents had a negative perception. A total of 32 types of fall-risk-increasing drugs (FRIDs) have been prescribed to the respondents. A strong correlation (r = 0.89) between pre- and post-intervention knowledge was shown among the respondents. Paired t-test analysis showed a statistically significant difference.

CONCLUSION

The pharmacist-led educational intervention significantly improved the knowledge, attitude, and perception of falls among older adults. More structured and periodical intervention programmes are warranted to reduce the risk of falls and fractures among older adults.

Risk factors for falls in older adults with diabetes mellitus: systematic review and meta-analysis

AIM

To identify risk factors for falls in older adults with Type 2 Diabetes Mellitus (T2DM).

METHODS

The eligible studies identified factors associated with the risk of falls in older adults with T2DM. We searched PubMed, Cinahl, Web of Science, Scopus, and the Cochrane Library databases. The review has been updated and the last review date was November 30, 2023 (CRD42020193461).

RESULTS

Twelve studies met the inclusion criteria, and eight studies were included in the meta-analysis. These studies included a total of 40,778 older adults with T2DM, aged 60 to 101 years. The risk of developing the outcome falls in older adults with T2DM is 63% higher compared to the risk in older adults without T2DM (HR 1.63; 95% CI [1.30 - 2.05]). The overall chance of falling in older adults with T2DM is 59% higher than that of non-diabetic older adults (OR 1.59; 95% CI [1.36 -1.87]), and in older adults with T2DM who take insulin the chance of falling is 162% higher (OR 2.62; 95% CI [1.87 - 3.65]). No results on diabetic polyneuropathy were found in the studies.

CONCLUSION

Older adults with T2DM present a higher risk of falls compared to non-diabetics. Among the included older adults with T2DM, the most important factor associated with a higher risk of falls was insulin use.

TRIAL REGISTRATION

Registered in the International Prospective Register of Systematic Reviews (CRD42020193461).

Design and Implementation of an Inpatient Fall Risk Management Information System

BACKGROUND

Falls had been identified as one of the nursing-sensitive indicators for nursing care in hospitals. With technological progress, health information systems make it possible for health care professionals to manage patient care better. However, there is a dearth of research on health information systems used to manage inpatient falls.

OBJECTIVE

This study aimed to design and implement a novel hospital-based fall risk management information system (FRMIS) to prevent inpatient falls and improve nursing quality.

METHODS

This implementation was conducted at a large academic medical center in central China. We established a nurse-led multidisciplinary fall prevention team in January 2016. The hospital's fall risk management problems were summarized by interviewing fall-related stakeholders, observing fall prevention workflow and post-fall care process, and investigating patients' satisfaction. The FRMIS was developed using an iterative design process, involving collaboration among health care professionals, software developers, and system architects. We used process indicators and outcome indicators to evaluate the implementation effect.

RESULTS

The FRMIS includes a fall risk assessment platform, a fall risk warning platform, a fall preventive strategies platform, fall incident reporting, and a tracking improvement platform. Since the implementation of the FRMIS, the inpatient fall rate was significantly lower than that before implementation (P<.05). In addition, the percentage of major fall-related injuries was significantly lower than that before implementation. The implementation rate of fall-related process indicators and the reporting rate of high risk of falls were significantly different before and after system implementation (P<.05).

CONCLUSIONS

The FRMIS provides support to nursing staff in preventing falls among hospitalized patients while facilitating process control for nursing managers.

Investigating Racial and Ethnic Disparities in Maternal Care at the System Level Using Patient Safety Incident Reports

BACKGROUND

Maternal mortality in the United States is high, and women and birthing people of color experience higher rates of mortality and severe maternal morbidity (SMM). More than half of maternal deaths and cases of SMM are considered preventable. The research presented here investigated systems issues contributing to adverse outcomes and racial/ethnic disparities in maternal care using patient safety incident reports.

METHODS

The authors reviewed incidents reported in the labor and delivery unit (L&D) and the antepartum and postpartum unit (A&P) of a large academic hospital in 2019 and 2020. Deliveries associated with a reported incident were described by race/ethnicity, age group, method of delivery, and several other process variables. Differences across racial/ethnic group were statistically evaluated.

RESULTS

Almost two thirds (64.8%) of the 528 reports analyzed were reported in L&D, and 35.2% were reported in A&P. Non-Hispanic white (NHW) patients accounted for 43.9% of reported incidents, non-Hispanic Black (NHB) patients accounted for 43.2%, Hispanic patients accounted for 8.9%, and patients categorized as "other" accounted for 4.0%. NHB patients were disproportionally represented in the incident reports, as they accounted for only 36.5% of the underlying birthing population. The odds ratio (OR) demonstrated a higher risk of a reported adverse incident for NHB patients; however, adjustment for cesarean section attenuated the association (OR 1.25, 95% confidence interval 1.01-1.54).

CONCLUSION

Greater integration of patient safety and health equity efforts in hospitals are needed to promptly identify and alleviate racial and ethnic disparities in maternal health outcomes. Although additional systems analysis is necessary, the authors offer recommendations to support safer, more equitable maternal care.

Effectiveness of interprofessional education for medical and nursing professionals and students on interprofessional educational outcomes: A systematic review

AIM AND BACKGROUND

Patient safety is a global health priority as unsafe care is a principal cause of death and disability. Ineffective interprofessional communication and collaboration among nursing and medical professionals and students contribute to unsafe practices. Interprofessional education provides opportunities to strengthen nurse-physician collaboration and enhance patient care. However, there is inconclusive evidence regarding interprofessional education effectiveness. This review aims to systematically evaluate interprofessional education effectiveness for nursing and medical professionals and students on interprofessional educational outcomes (interprofessional attitudes, perceptions, skills, knowledge, behaviours, and organisational and patient outcomes).

DESIGN AND METHODS

PubMed, Cochrane Library, Embase, Scopus, CINAHL, ERIC, PsycInfo, Web of Science were last searched on 13 January 2022. This review included published and unpublished randomised controlled trials, quasi-experimental and mixed-method studies in English examining interprofessional education outcomes among nursing and medical professionals and students. Two reviewers independently appraised studies using the Joanna Briggs Institute Critical Appraisal Tools and extracted data using a modified Joanna Briggs Institute data extraction form. Narrative synthesis was conducted instead of meta-analysis since majority of the included studies had quasi-experimental design, and various interventions and outcomes. Certainty of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluations tool.

RESULTS

This review included 15 studies involving 1185 participants. Improvements were reported in each interprofessional educational outcome after interprofessional education. High-fidelity simulation with multiple scenarios, standardised communication tools, didactic and active learning methods, theoretical frameworks, debriefing sessions and provider training enhanced interprofessional education effectiveness.

CONCLUSIONS

Effectiveness of interprofessional education for nursing and medical professionals and students was demonstrated since improvements were observed for each interprofessional educational outcome. This systematic review addressed literature gaps, demonstrated effectiveness of interprofessional education in clinical practice and academic curricula and provided evidence-based insights that future research can consider to enhance global patient safety standards for optimal patient outcomes and quality of healthcare. Caution is advised in interpreting findings due to 'very low' evidence certainty and limited studies. More high-quality randomised controlled trials with longitudinal designs are needed.

Characteristics, Outcomes, and Its Associated Factors Among Patients Hospitalized With Mild Traumatic Brain Injuries

OBJECTIVE

The aim of the study is to investigate the characteristics and hospital outcomes of patients with mild traumatic brain injuries.

DESIGN

A total of 1940 patients with mild traumatic brain injuries from seven community hospitals between 2017 and 2019 were identified using International Classification of Disease codes and an documented initial Glasgow Coma Scale score of 13-15. A stepwise logistic regression was used to identify demographics and clinical characteristics associated with in-hospital mortality and home discharge.

RESULTS

The median age was 69 yrs old with 66.6% associated with falls at admission. Subdural hemorrhage was the most common brain lesion and more common in the group with falls. Increased age, male sex, epidural hemorrhage, presence of hemiplegia, paraplegia, renal disease, cancer, hospital-acquired sepsis, anemia, and use of direct vasodilator were associated with increased odds of in-hospital mortality. Increased age, medical coverage by Medicare, cerebral edema, lower initial Glasgow Coma Scale, length of stay, comorbidity of acute myocardiac infarction, and use of thiamine and opioids were associated with decreased likelihood of discharge to home.

CONCLUSIONS

Recognizing characteristics of hospitalized patients with mild traumatic brain injuries and their association with increased in-hospital mortality and nonhome discharge can be useful for improving care of this vulnerable population.

Alarm with care-a de-implementation strategy to reduce fall prevention alarm use in US hospitals: a study protocol for a hybrid 2 effectiveness-implementation trial

BACKGROUND

Fall prevention alarms are commonly used among US hospitals as a fall prevention strategy despite limited evidence of effectiveness. Further, fall prevention alarms are harmful to healthcare staff (e.g., alarm fatigue) and patients (e.g., sleep disturbance, mobility restriction). There is a need for research to develop and test strategies for reducing use of fall prevention alarms in US hospitals.

METHODS

To address this gap, we propose testing the effectiveness and implementation of Alarm with Care, a de-implementation strategy to reduce fall prevention alarm use using a stepped-wedge randomized controlled trial among 30 adult medical or medical surgical units from nonfederal US acute care hospitals. Guided by the Choosing Wisely De-Implementation Framework, we will (1) identify barriers to fall prevention alarm de-implementation and develop tailored de-implementation strategies for each unit and (2) compare the implementation and effectiveness of high- versus low-intensity coaching to support site-specific de-implementation of fall prevention alarms. We will evaluate effectiveness and implementation outcomes and examine the effect of multi-level (e.g., hospital, unit, and patient) factors on effectiveness and implementation. Rate of fall prevention alarm use is the primary outcome. Balancing measures will include fall rates and fall-related injuries. Implementation outcomes will include feasibility, acceptability, appropriateness, and fidelity.

DISCUSSION

Findings from this line of research could be used to support scale-up of fall prevention alarm de-implementation in other healthcare settings. Further, research generated from this proposal will advance the field of de-implementation science by determining the extent to which low-intensity coaching is an effective and feasible de-implementation strategy.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT06089239 . Date of registration: October 17, 2023.

Experience of patients with restraints in acute care hospitals and the view of their relatives: A qualitative study

AIM

To describe the experiences of patients and relatives with any form of restraints in somatic acute care hospitals.

DESIGN

Qualitative explorative design.

METHODS

Qualitative research methods were used. Participants were recruited through clinical nursing specialists in participating departments of a university hospital between June and August 2020. Individual interviews were conducted and analysed using content analysis.

RESULTS

Four interviews with patients and five interviews with relatives were conducted with a mean duration of 25 min. The following three topics emerged in the analysis as important: What was perceived as restraints, Assessing the experiences of restraint use on a continuum, and Lack of information about restrictive measures. Patients and relatives defined restraint very broadly and assessed the experiences of restraint on a continuum from positive to negative, with a more critical view from patients. Relatives clearly seemed to approve of the use of restraints in acute care hospitals because it provided them with a sense of security. In general, there seemed to be a lack of information about the use of restraint and its effects on patients and relatives alike.

CONCLUSION

The involvement of patients and relatives in the decision-making process about restraint use seems to be low. Healthcare professionals need to be better educated to be able to pass on adequate information and to involve patients and their relatives adequately in all processes of restraint use. However, when relatives are involved in decision-making as proxies for patients, it is important to consider that patients' and relatives' opinions on restraints may differ.

PATIENT OR PUBLIC CONTRIBUTION

Patients and relatives agreed to participate in the study and shared their experiences with us.

Nurses' perspectives on inpatient falls in a large academic hospital in South Africa

BACKGROUND

Falls risk assessment tools, including the Morse Falls Scale, have been used for years, and yet falls remain key adverse events in hospitals. Nurses are key role players in falls prevention and can champion patient safety.

OBJECTIVES

The aim of the study was to explore ward nurses' attitudes, knowledge and practices regarding the use of falls risk assessment tools, institutional falls policy and falls prevention.

METHODS

A survey design was used. All permanent ward nurses were eligible to participate, and a convenience sample was used.

RESULTS

Nurses endorsed the Morse Falls Scale, recommended by institutional policy, as effective in reducing falls and indicated that incident reporting measured progress on monitoring fall events. Falls prevention training was scanty; however, nurses were keen for further education of falls.

CONCLUSION

Effective falls risk management needs to extend beyond promulgating policy and actively address nursing and patient education.Contribution: This study adds to the sparse literature regarding nursing practice and falls prevention in a developing country. Recommendations for change have been made.

Inpatient Falls and Orthopaedic Injuries in Elderly Patients: A Retrospective Cohort Analysis From a Falls Register

Background Hospital inpatient falls have been a major area of concern in the healthcare setting. This poses a multifaceted challenge to healthcare systems, as elderly patients are at increased risk of harm and significant morbidity secondary to inpatient falls. In addition, hospital admission increases the risk of falls in acutely unwell elderly patients. There remains little consensus on best practices in reducing inpatient falls. With this, lies the risk to life or quality of life to this cohort of patients. Moreover, it is not evident whether orthopaedic injuries sustained by elderly patients in hospital and their management, including rehabilitation, has evolved with time. Methodology This was a retrospective cohort analysis of all inpatient falls over a three-year period in a single UK District General Hospital. A total of 101,183 acute admissions were analysed. All falls were identified and categorised into harm categories according to National Patient Safety Alerts. Patients sustaining moderate harm or more were assessed to determine injuries sustained, patient-associated factors, factors surrounding the fall, management incurred, length of stay, and financial burden incurred. Results A total of 101,183 admissions were analysed revealing a total of 2,453 in-patient falls. The rate of inpatient falls was 2.42%. Of these, 49 (1.98%) patients sustained moderate harm or more. Patient-related factors included age and comorbidities; 82% of patients were above the age of 75, and 78% of patients had three or more medical comorbidities. Fall-related factors leading to moderate harm or more included time of fall and ward. Most falls occurred out of hours (80%) and in acute medical wards (69%). The average length of stay following fall was 2.4 weeks per patient and a combined 110 weeks in the three-year period. In non-deceased patients, increased dependency and reduced mobility at discharge were noted. The total hospital annual financial burden due to moderate harm or more following an inpatient fall was approximately £123,490.00. Length of stay was the major contributor to this (£90,090.00 annually). Conclusions Inpatient falls remain a considerable patient safety issue, with orthopaedic injuries playing a central role in harm to patients following these falls. These also pose considerable service and financial costs to healthcare organisations. Further work is needed to identify best practices in in-hospital fall prevention and streamlining post-fall management and rehabilitation.

Nurses' Experience Implementing an Automated Video Monitoring System to Decrease the Risk of Patient Falls during a Global Pandemic

Healthcare is a complex sociotechnical system where information systems (IS) and information technology (IT) intersect to solve problems experienced by patients and providers alike. One example of IS/IT in hospitals is the Ocuvera automated video monitoring system (AVMS), which has been implemented in more than 30 hospitals. The purpose of this study was to evaluate nurses' attitudes toward AVMS implementation over time as they received the training program developed for this intervention. Consistent with the job demands-resources (JDR) model, we found that perceptions of AVMS usefulness increased over time and were positively associated with perceptions of social influence and behavioral control. These results were consistent with our finding that there was a significant decrease in the risk of unassisted falls from the bed from baseline to intervention. Leaders in hospital systems and healthcare organizations may want to consider implementing an AVMS as researchers continue to test, verify, and demonstrate the effectiveness of these interventions for improving patient well-being.

Using Quality Indicator Codes to Identify Patients' Fall Risk in Inpatient Rehabilitation Facilities

OBJECTIVE

To discover if quality indicator (QI) codes are associated with patient falls in inpatient rehabilitation facilities (IRFs).

DESIGN

This retrospective cohort study explored differences between patients who fell and those who did not fall. We analyzed potential associations between QI codes and falls using univariable and multivariable logistic regression models.

SETTING

We collected data from electronic medical records at 4 IRFs.

PARTICIPANTS

In 2020, our 4 data collection sites admitted and discharged a total of 1742 patients older than 14 years . We only excluded patients (N=43) from statistical analysis if they were discharged before admission data had been assigned.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Using a data extraction report, we collected age, sex, race and ethnicity, diagnosis, falls, and QI codes for communication, self-care, and mobility performance. Staff documented communication codes on a 1-4 scale and self-care and mobility codes on a 1-6 scale, with higher codes representing greater independence.

RESULTS

Ninety-seven patients (5.71%) fell in the 4 IRFs over a 12-month period. The group who fell had lower QI codes for communication, self-care, and mobility. When adjusting for bed mobility, transfer, and stair-climbing ability, low performance with understanding, walking 10 feet, and toileting were significantly associated with falls. Patients with admission QI codes below 4 for understanding had 78% higher odds of falling. If they were assigned admission QI codes below 3 for walking 10 feet or toileting, they had 2 times greater odds of falling. We did not find a significant association between falls and patients' diagnosis, age, sex, or race and ethnicity in our sample.

CONCLUSIONS

Communication, self-care, and mobility QI codes appear to be significantly associated with falls. Future research should explore how to use these required codes to better identify patients likely to fall in IRFs.

A Geriatric Approach to Percutaneous Coronary Interventions in Older Adults, Part II: A JACC: Advances Expert Panel

We review a comprehensive risk assessment approach for percutaneous coronary interventions in older adults and highlight the relevance of geriatric syndromes within that broader perspective to optimize patient-centered outcomes in interventional cardiology practice. Reflecting the influence of geriatric principles in older adults undergoing percutaneous coronary interventions, we propose a "geriatric" heart team to incorporate the expertise of geriatric specialists in addition to the traditional heart team members, facilitate uptake of the geriatric risk assessment into the preprocedural risk assessment, and address ways to mitigate these geriatric risks. We also address goals of care in older adults, highlighting common priorities that can impact shared decision making among older patients, as well as frequently encountered pharmacotherapeutic considerations in the older adult population. Finally, we clarify gaps in current knowledge and describe crucial areas for future investigation.

Falls risk perception measures in hospital: a COSMIN systematic review

Falls prevention in hospital continues to be a research priority because of the poor health outcomes and financial burdens that can arise. Recently updated World Guidelines for Falls Prevention and Management strongly recommend evaluating patients' concerns about falling as part of a multifactorial assessment. The aim of this systematic review was to evaluate the quality of falls risk perception measures for adults in a hospital setting. This review was conducted using the Consensus-based Standards for the selection of health Measurement Instruments guidelines and provides a comprehensive summary of these instruments, including psychometric properties, feasibility and clinical recommendations for their use. The review followed a prospectively registered protocol, in which a total of ten databases were searched between the years 2002 and 2022. Studies were included if the instruments measured falls risk perception and/or other psychological falls constructs, if they were conducted in a hospital setting and if the target population contained hospital inpatients. A total of 18 studies met the inclusion criteria, encompassing 20 falls risk perception measures. These falls risk perception instruments were grouped into five falls-related constructs: Balance Confidence, Falls Efficacy/Concern, Fear of Falling, Self-Awareness and Behaviour/Intention. Two of the patient reported outcome measures (PROMs) received Class A recommendations (Falls Risk Perception Questionnaire and the Spinal Cord Injury-Falls Concern Scale); however, this rating is only applicable for the populations/context described in the studies. Thirteen PROMs received Class B recommendations, solidifying the need for further validation studies of these PROMs.

Nurses' experiences of using falls alarms in subacute care: A qualitative study

Bed and chair alarms have been included in many multifaceted falls prevention interventions. None of the randomised trials of falls alarms as sole interventions have showed significant effect on falls or falls with injury. Further, use of bed and chair alarms did not change patients' fear of falling, length of hospital stay, functional status, discharge destination or health related quality of life. The aim of this study was to explore nurses' experiences of using bed and chair alarms. A qualitative descriptive study using semi-structured interviews with a purposive sample of 12 nurses was conducted on a 32-bed Geriatric Evaluation and Management ward in Melbourne, Australia. Participants were interviewed between 27 January and 12 March 2021.Transcribed audio-recordings of interviews were analysed using inductive thematic analysis. NVIVO 12.6 was used to manage the study data. Three major themes and four subthemes were constructed from the data: i) negative impacts of falls alarms (subthemes: noisy technology, imperfect technology), ii) juggling the safety-risk conflict, and iii) negotiating falls alarm use (subthemes: nurse decision making and falls alarm overuse). Nurses' experience of using falls alarms was predominantly negative and there was tension between falls alarms having limited impact on patient safety and risks associated with their use. Nurses described a need to support nurse decision making related to falls alarms use in practice and policy, and a desire to be empowered to manage falls risk in other ways.

Assessment and Management of Older Adults Undergoing PCI, Part 1: A JACC: Advances Expert Panel

As the population ages, older adults represent an increasing proportion of patients referred to the cardiac catheterization laboratory. Older adults are the highest-risk group for morbidity and mortality, particularly after complex, high-risk percutaneous coronary interventions. Structured risk assessment plays a key role in differentiating patients who are likely to derive net benefit vs those who have disproportionate risks for harm. Conventional risk assessment tools from national cardiovascular societies typically rely on 3 pillars: 1) cardiovascular risk; 2) physiologic and hemodynamic risk; and 3) anatomic and procedural risks. We propose adding a fourth pillar: geriatric syndromes, as geriatric domains can supersede all other aspects of risk.

Original Research: Patient Perception of Fall Risk in the Acute Care Setting

PURPOSE

Hospitals are implementing a variety of fall prevention programs to reduce the fall rates of hospitalized patients. But if patients don't perceive themselves to be at risk for falling and don't adhere to fall prevention strategies, such programs are likely to be less effective. The purpose of this study was to describe the perceptions of fall risk among hospitalized patients across four acute care specialty services.

METHODS

One hundred patients who had been admitted to the study hospital and who had a Morse Fall Scale score over 45 were asked to complete the Patient Perception Questionnaire, a tool designed to explore a patient's confidence regarding their fall risk, fear of falling, and intention to engage in fall prevention activities. Morse Fall Scale scores were collected via retrospective chart review. Data were analyzed using descriptive statistics, Pearson correlation coefficients, and independent sample t tests.

RESULTS

Participants' mean age was 65 years; 52% were male, 48% female. Although all 100 participants were deemed at risk for falls per their Morse Fall Scale scores, only 55% considered themselves to be at such risk. As patients' confidence in their ability to perform mobility tasks increased, their intention to ask for help and fear of falling significantly decreased. Patients who had been admitted as the result of a fall demonstrated significantly lower confidence scores and higher fear scores.

CONCLUSIONS

Patients who score high on fall risk assessments often don't perceive themselves to be at high risk for falling, and thus might not engage in fall prevention activities. Developing a fall risk assessment method that incorporates both a patient's physiological condition and their perception of their fall risk could help reduce fall rates in the acute care setting.

The Combined Effect of Delirium and Falls on Length of Stay and Discharge

INTRODUCTION

Delirium or a fall are associated with many negative outcomes including increased length of stay (LOS) and discharge to a facility; however, this relationship is incompletely understood.

METHODS

A cross-sectional study of all hospitalizations in a large, tertiary care hospital evaluated the effect of delirium and a fall on the outcomes of LOS and risk of being discharged to a facility.

RESULTS

The study included 29,655 hospital admissions. A total of 3,707 (12.5%) patients screened positive for delirium and 286 (0.96%) had a reported fall. After adjustment for covariates, relative to patients without delirium or a fall, patients with delirium only had a 1.64-fold longer LOS; patients with fall only had a 1.96-fold longer LOS; and patients who had delirium and fall had a 2.84-fold longer LOS. The adjusted odds of discharge to a facility, relative to those without delirium or a fall, was 8.98 times higher in those with delirium and a fall.

CONCLUSIONS

Delirium and falls influence LOS and likelihood of being discharged to a facility. The joint impact of falls and delirium on LOS and facility discharge was more than additive. Hospitals should consider the integrated management of delirium and falls.

[Development and evaluation of complex interventions in nursing : Application of the medical research council's framework using the example of interventions to prevent physical restraints]

Many nursing interventions are complex. They comprise different intervention elements (components) and aim to change processes or behaviours of individuals or groups. A framework of the British Medical Research Council comprises methodological recommendations for the development and evaluation of complex interventions. This narrative review describes the framework's methodological recommendations using an example of interventions to reduce physical restraints in hospital and long-term care settings, such as bedrails or belts in chairs and beds. In addition to the characteristics of the complex interventions, the development and theoretical foundation of the interventions as well as the feasibility test and evaluation is described.

Recruitment of family caregivers of persons with dementia: Lessons learned from a pilot randomized controlled trial

Family caregivers play an essential role in supporting the health and well-being of older adults with dementia, a population projected to increase rapidly over the coming decades. Enrolling caregivers of people with dementia (PWD) in research studies is vital to generating the evidence necessary to support broader implementation of efficacious intervention programs in real-world care delivery, but a range of challenges impede recruitment and enrollment of sufficiently large and representative sample sizes. In this article, we characterize the challenges and lessons learned from recruiting caregivers of PWD to participate in a pilot randomized control trial. We utilize Bronfenbrenner's ecological model to categorize the challenges into three levels: individual (i.e., understanding caregivers' time constraints and motivations), community (i.e., reaching underrepresented populations and accessing caregiver support groups) and institutional (i.e., obtaining informed consent and navigating research registries). We found that establishing rapport and maintaining flexibility with participants was crucial for motivating individuals to enroll in our study. Building trust with local communities by collaborating with support group leaders, appointing a co-investigator who is already embedded within a given community, and establishing equitable partnerships with organizations increased recruitment rates. At the institutional level, engaging experts in regulatory affairs and geriatrics may help overcome barriers in obtaining approval from institutional review boards. We also recommend using research registries of individuals who offer their contact information to researchers. The lessons learned from our research-including the challenges and potential solutions to overcome them-may promote more effective and efficient recruitment in future research.

Clinical Sensor-Based Fall Risk Assessment at an Orthopedic Clinic: A Case Study of the Staff's Views on Utility and Effectiveness

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.

Association of Sonographic Sarcopenia and Falls in Older Adults Presenting to the Emergency Department

BACKGROUND AND OBJECTIVE

To determine the association between point-of-care-ultrasonography (POCUS)-measured sarcopenia and grip strength, as well as the history of prior-year falls among older adults admitted to the emergency department observation unit (EDOU).

MATERIALS AND METHODS

This cross-sectional observational study was conducted over 8 months at a large urban teaching hospital. A consecutive sample of patients who were 65 years or older and admitted to the EDOU were enrolled in the study. Using standardized techniques, trained research assistants and co-investigators measured patients' biceps brachii and thigh quadriceps muscles via a linear transducer. Grip strength was measured using a Jamar Hydraulic Hand Dynamometer. Participants were surveyed regarding their history of falls in the prior year. Logistic regression analyses assessed the relationship of sarcopenia and grip strength to a history of falls (the primary outcome).

RESULTS

Among 199 participants (55% female), 46% reported falling in the prior year. The median biceps thickness was 2.22 cm with an Interquartile range [IQR] of 1.87-2.74, and the median thigh muscle thickness was 2.91 cm with an IQR of 2.40-3.49. A univariate logistic regression analysis demonstrated a correlation between higher thigh muscle thickness, normal grip strength, and history of prior-year falling, with an odds ratio [OR] of 0.67 (95% conference interval [95%CI] 0.47-0.95) and an OR of 0.51 (95%CI 0.29-0.91), respectively. In multivariate logistic regression, only higher thigh muscle thickness was correlated with a history of prior-year falls, with an OR of 0.59 (95% CI 0.38-0.91).

CONCLUSIONS

POCUS-measured thigh muscle thickness has the potential to identify patients who have fallen and thus are at high risk for future falls.

Smartphones and Threshold-Based Monitoring Methods Effectively Detect Falls Remotely: A Systematic Review

In the US, at least one fall occurs in at least 28.7% of community-dwelling seniors 65 and older each year. Falls had medical costs of USD 51 billion in 2015 and are projected to reach USD 100 billion by 2030. This review aims to discuss the extent of smartphone (SP) usage in fall detection and prevention across a range of care settings. A computerized search was conducted on six electronic databases to investigate the use of remote sensing technology, wireless technology, and other related MeSH terms for detecting and preventing falls. After applying inclusion and exclusion criteria, 44 studies were included. Most of the studies targeted detecting falls, two focused on detecting and preventing falls, and one only looked at preventing falls. Accelerometers were employed in all the experiments for the detection and/or prevention of falls. The most frequent course of action following a fall event was an alarm to the guardian. Numerous studies investigated in this research used accelerometer data analysis, machine learning, and data from previous falls to devise a boundary and increase detection accuracy. SP was found to have potential as a fall detection system but is not widely implemented. Technology-based applications are being developed to protect at-risk individuals from falls, with the objective of providing more effective and efficient interventions than traditional means. Successful healthcare technology implementation requires cooperation between engineers, clinicians, and administrators.

Falls Incidence Compared Between a Multibedded Ward Hospital and a 100% Single-Occupancy Room Hospital: An Uncontrolled Before-After Study

BACKGROUND

Single-occupancy patient rooms in hospitals have become popular because of the privacy they offer. A downside, however, is the lack of social control from other patients, which might increase the risk of falls and undetected delirium.

AIM

To study whether the incidence of falls in single-occupancy patient rooms differs from that in multibedded patient rooms. Secondary aims were to establish differences in the context of falls and differences in delirium incidence.

METHODS

An uncontrolled observational before-after study was performed during 16 months before and 16 after moving to a hospital with 100% single-occupancy patient rooms. Fall data were retrieved from the hospital incident reporting system. The Delirium Observation Screening Scale (DOSS) was retrieved from the hospital electronic patient data system. Main outcomes were the number of falls per 1,000 patient days, assessed with a Poisson regression analysis, and delirium incidence in fallers.

RESULTS

The incidence of falls was not significantly different between the before period (1.39 falls/1,000 patient days) and the after period (1.38 falls/1,000 patient days; p = .924). In the after period, falls in the bathroom were significantly more frequent than in the before period, respectively, 17.2% and 9.4% (p = .003). In both periods, one quarter of the patients who fell had been assessed for delirium. In the before period, 57/73 (78%) of those were suspected for delirium (DOSS ≥ 3) versus 37/55 (67%) in the after period (p = .225).

CONCLUSIONS

In this study, we observed no change in incidence of falls after moving to a hospital with 100% single-occupancy bed rooms.

Perception of Health Teams on the Implementation of Strategies to Decrease Nursing Errors and Enhance Patient Safety

Background

Patient care is a public health issue all over the world, with nursing errors in hospitals being a significant source of harm to patients and a hindrance to the healthcare system's efficiency.

Purpose

The purpose of this study was to investigate health teams' perceptions of strategies used to reduce nursing error that affects patient safety.

Patients and Methods

A descriptive study was conducted from January to March 2022 at Najran University Hospital and KKH to better understand the issue. The study included 400 healthcare team members, including nurses, physicians, nurse aides, health workers, and others. The data was collected through the analysis of the health team's characteristics, nursing errors, and strategies for error reduction.

Results

The results of the study led to the development of five strategies and 28 interventions aimed at reducing nursing errors. The study revealed that two-thirds of the participants had a high perception of strategies for reducing nursing errors, while one-third had a low perception.

Conclusion

The study highlights the importance of addressing nursing errors in the healthcare system and provides evidence-based strategies and interventions to reduce them. The findings emphasize the need for ongoing efforts to enhance the perception and understanding of healthcare professionals in reducing errors and improving patient care.

Risky Business: Factors That Increase Risk of Falls Among Older Adult In-Patients

In hospitals, older patients are at increased risk of falling multiple times. This study incorporated an epidemiologic cross-sectional design consisting of 4,348 older patients (≥65-year-old). Eight hundred eighty five (20.4%) in-patients experienced multiple falls while remaining participants had one fall incident. A patient fall event was recorded with age, sex, incident date, type of fall, and location. Logistic regression assessed risk factors found in patients with multiple falls compared to those with one fall. Significant differences were observed in the proportion of multiple falls: in a bed with no rails, standing, walking, and using a wheel/Geri chair (p < .05). Overall, sex, type of fall, and location were significant in predicting multiple falls (p < .05). Male patients were at 16.1% greater risk of multiple falls, when compared to females (p < .05). A fall in complex care, mental health, or respirology were more likely to experience multiple falls (OR = 2.659, 3.620, 1.593 respectively), while season had no impact.

Evidence-based Clinical Practice Guidelines for Caregivers of Palliative Care Patients on the Prevention of Pressure Ulcer

Objectives

Pressure ulcers are the most common condition among palliative care patients at home care facilities and impose a significant burden on patients, their relatives, and caregivers. Caregivers play a vital role in preventing pressure ulcers. When the caregivers are knowledgeable about preventing pressure ulcers, they will be able to avoid lots of discomfort for the patients. It will help the patient to achieve the best quality of life and spend the last days of life peacefully and comfortably with dignity. It is essential to develop evidence-based guidelines for caregivers of palliative care patients on pressure ulcer prevention, which may play a major role in preventing pressure ulcers. The primary objective is to implement evidence-based guidelines for caregivers of palliative care patients on pressure ulcer prevention.The secondary objective is to improve the knowledge and practice of caregivers and enable them to take measures to prevent pressure ulcer development among palliative care patients, thereby improving the quality of life of palliative care patients.

Materials and Methods

Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), a systematic review was conducted. The search was conducted using electronic databases Pub Med, CINHAL, Cochrane and EMBASE database. The studies selected were in the English language and with free full text. The studies were selected and assessed for quality using the Cochrane risk assessment tool. Clinical practice guidelines, systematic reviews, and randomized controlled trials conducted on pressure ulcer prevention in palliative care patients were selected for the review. Twenty Eight studies were found to be potentially relevant after screening the search results. Twelve studies were not found suitable. 5 RCTs did not meet the inclusion criteria. Finally, four systematic reviews, five RCTs, and two clinical practice guidelines were included in the study, and guidelines were prepared.

Results

Based on the best available research evidence, clinical practice guidelines were developed on skin assessment, skin care, repositioning, mobilization, nutrition, and hydration to prevent pressure ulcers to guide caregivers of palliative care patients.

Conclusion

The evidence-based nursing practice integrates the best research evidence with clinical expertise and patient values. Evidence-based nursing practice leads to a problem-solving approach which is existing or anticipated. This will contribute to choosing appropriate preventive strategies for maintaining patients' comfort, thereby improving the quality of life of palliative care patients. The guidelines were prepared through an extensive systematic review, RCT, and other guidelines followed in different settings and modified to suit the current setting.

Exploring Hospital Inpatients' Awareness of Their Falls Risk: A Qualitative Exploratory Study

Patient falls in hospital may lead to physical, psychological, social and financial impacts. Understanding patients' perceptions of their fall risk will help to direct fall prevention strategies and understand patient behaviours. The aim of this study was to explore the perceptions and experiences that influence a patient's understanding of their fall risk in regional Australian hospitals. Semi-structured, individual interviews were conducted in wards across three Australian hospitals. Participants were aged 40 years and over, able to communicate in English and were mobile prior to hospital admission. Participants were excluded from the study if they returned a Standardised Mini-Mental State Examination (SMMSE) score of less than 18 when assessed by the researcher. A total of 18 participants with an average age of 69.8 years (SD ± 12.7, range 41 to 84 years) from three regional Victorian hospitals were interviewed for this study. Data were analysed using a reflexive thematic analysis identifying three major themes; (1) Environment (extrinsic) (2) Individual (intrinsic), and (3) Outcomes, as well as eight minor themes. Participants recognised the hazardous nature of a hospital and their personal responsibilities in staying safe. Falls education needs to be consistently delivered, with the focus on empowering the patient to help them adjust to changes in their clinical condition, whether temporary or permanent.

Epidemiology and Management of Proximal Femoral Fractures in Italy between 2001 and 2016 in Older Adults: Analysis of the National Discharge Registry

This study aims to determine the annual incidence of proximal femoral fractures in Italy in the period between 2001 and 2016 among older adults, and to describe the trends in the clinical management of these cases. Data were retrieved from the National Hospital Discharge records issued by the Italian Ministry of Health and from the Italian Institute for Statistics. The number of hospitalizations increased between 2001 and 2016, while the age-adjusted yearly incidence decreased from 832.2 per 100,000 individuals to 706.2. The median age was 83 years (IQR 78-88) with a large majority of females (76.6%). The type of fracture varied with age in female subjects, with older women more frequently reporting pertrochanteric fractures. Therapeutic strategies for the different types of fracture depended on patients' age. During the study years, improvements in fracture classification and management strategies were observed, with a clear decreasing trend for non-operative solutions. In conclusion, the number of proximal femur fractures in older adults is growing, even if at a lower rate compared to population aging. The Italian surgical practice changed during the study period towards the implementation of the most recent guidelines.

Co-Design in Electrical Medical Beds with Caregivers

Among the plethora of instruments present in healthcare environments, the hospital bed is undoubtedly one of the most important for patients and caregivers. However, their design usually follows a top-down approach without considering end-users opinions and desires. Exploiting Human-centered design (HCD) permits these users to have a substantial role in the final product outcome. This study aims to empower caregivers to express their opinion about the hospital bed using a qualitative approach. For a holistic vision, we conducted six focus groups and six semi-structured interviews with nurses, nursing students, social-health operators and physiotherapists belonging to many healthcare situations. We then used thematic analysis to extract the themes that participants faced during the procedures, providing a comprehensive guide to designing the future electrical medical bed. These work results could also help overcome many issues that caregivers face during their everyday working life. Moreover, we identified the User Experience features that could represent the essential elements to consider.

History of Falls and Bedriddenness Ranks are Useful Predictive Factors for in-Hospital Falls: A Single-Center Retrospective Observational Study Using the Saga Fall Risk Model

INTRODUCTION

In our former study, we had validated the previously developed predictive model for in-hospital falls (Saga fall risk model) using eight simple factors (age, sex, emergency admission, department of admission, use of hypnotic medications, history of falls, independence of eating, and Bedriddenness ranks [BRs]), proving its high reliability. We found that only admission to the neurosurgery department, history of falls, and BRs had significant relationships with falls. In the present study, we aimed to clarify whether each of these three items had a significant relationship with falls in a different group of patients.

METHODS

This was a single-center based, retrospective study in an acute care hospital in a rural city of Japan. We enrolled all inpatients aged 20 years or older admitted from April 2015 to March 2018. We randomly selected patients to fulfill the required sample size. We performed multivariable logistic regression analysis using forced entry on the association between falls and each of the eight items in the Saga fall risk model 2.

RESULTS

A total of 2932 patients were randomly selected, of whom 95 (3.2%) fell. The median age was 79 years, and 49.9% were men. Multivariable analysis showed that female sex (odds ratio [OR] 0.6, 95% confidence interval [CI] 0.39-0.93, p = 0.022), having a history of falls (OR 1.9, 95% CI 1.16-2.99, p = 0.010), requiring help with eating (OR 1.9, 95% CI 1.12-3.35, p = 0.019), BR of A (OR 6.6, 95% CI 2.82-15.30, p < 0.001), BR of B (OR 7.5, 95% CI 2.95-19.06, p < 0.001), and BR of C (OR 4.1, 95% CI 1.53-11.04, p = 0.005) were significantly associated with falls.

CONCLUSION

History of falls and BRs were independently associated with in-hospital falls.

Preventing Patient Falls Overnight Using Video Monitoring: A Clinical Evaluation

Inpatient falls are devastating for patients and their families and an ongoing problem for healthcare providers worldwide. Inpatient falls overnight are particularly difficult to predict and prevent. The aim of this cohort study was to evaluate effectiveness of overnight portable video monitoring as an adjunct falls prevention strategy for high falls risk patients in inpatient clinical units. Over three months, three clinical inpatient wards were provided with baby monitor equipment to facilitate portable video monitoring. Portable video monitoring registers were completed nightly and nursing staff were invited to complete surveys (n = 31) to assess their experiences of using portable video monitoring. A total of 494 episodes of portable video monitoring were recorded over the three-month period, with clinical areas reporting a total of four inpatient falls from monitoring participants (0.8% of total portable video monitoring episodes). Overall, there was a statistically significant reduction in total inpatient falls overnight on the target wards. Surveyed nursing staff reported feeling better equipped to prevent falls and indicated they would like to continue using portable monitoring as a falls prevention strategy. This study provides evidence to support the use of portable video monitoring as an effective falls prevention strategy in the hospital environment.

Development and validation of interpretable machine learning models for inpatient fall events and electronic medical record integration

OBJECTIVE

Falls are one of the most frequently occurring adverse events among hospitalized patients. The Morse Fall Scale, which has been widely used for fall risk assessment, has the two limitations of low specificity and difficulty in practical implementation. The aim of this study was to develop and validate an interpretable machine learning model for prediction of falls to be integrated in an electronic medical record (EMR) system.

METHODS

This was a retrospective study involving a tertiary teaching hospital in Seoul, Korea. Based on the literature, 83 known predictors were grouped into seven categories. Interpretable fall event prediction models were developed using multiple machine learning models including gradient boosting and Shapley values.

RESULTS

Overall, 191,778 cases with 272 fall events (0.1%) were included in the analysis. With the validation cohort of 2020, the area under the receiver operating curve (AUROC) of the gradient boosting model was 0.817 (95% confidence interval [CI], 0.720-0.904), better performance than random forest (AUROC, 0.801; 95% CI, 0.708-0.890), logistic regression (AUROC, 0.802; 95% CI, 0.721-0.878), artificial neural net (AUROC, 0.736; 95% CI, 0.650-0.821), and conventional Morse fall score (AUROC, 0.652; 95% CI, 0.570-0.715). The model's interpretability was enhanced at both the population and patient levels. The algorithm was later integrated into the current EMR system.

CONCLUSION

We developed an interpretable machine learning prediction model for inpatient fall events using EMR integration formats.

Balance dysfunction the most significant cause of in-hospital falls in patients taking hypnotic drugs: A retrospective study

Purpose

Preventing falls in patients is one of the most important concerns in acute hospitals. Balance disorder and hypnotic drugs lead to falls. The Standing Test for Imbalance and Disequilibrium (SIDE) is developed for the evaluation of static standing balance ability. There have been no reports of a comprehensive assessment of falls risk including hypnotic drugs and SIDE. The purpose of this study was to investigate the fall rate of each patient who took the hypnotic drug and the factor associated with falls.

Methods

Fall rates for each hypnotic drug were calculated as follows (number of patients who fell/number of patients prescribed hypnotic drug x 100). We investigated the hypnotic drugs as follows; benzodiazepine drugs, Z-drugs, melatonin receptor agonists, and orexin receptor antagonists. Hypnotic drug fall rate was analyzed using Pearson’s chi-square test. Decision tree analysis is the method we used to discover the most influential factors associated with falls.

Results

This study included 2840 patients taking hypnotic drugs. Accidents involving falls were reported for 211 of inpatients taking hypnotic drugs. Z-drug recipients had the lowest fall rate among the hypnotic drugs. We analyzed to identify independent factors for falls, a decision tree algorithm was created using two divergence variables. The SIDE levels indicating balance disorder were the initial divergence variable. The rate of falls in patients at SIDE level ≦ 2a was 14.7%. On the other hand, the rate of falls in patients at SIDE level ≧ 2b was 2.9%. Gender was the variable for the second classification. In this analysis, drugs weren’t identified as divergence variables for falls.

Conclusion

The SIDE balance assessment was the initial divergence variable by decision tree analysis. In order to prevent falls, it seems important not only to select appropriate hypnotic drugs but also to assess patients for balance and implement preventive measures.

Consensus of the Liaison-Psychiatry Committee of the Colombian Psychiatric Association on the diagnosis and treatment of delirium in the context of the COVID-19 pandemic

The pandemic caused by the new coronavirus named SARS-CoV-2 poses unprecedented challenges in the health care. Among them is the increase in cases of delirium. The severe SARS-CoV-2 disease, COVID-19, has common vulnerabilities with delirium and produces alterations in organs such as the lungs or the brain, among others, which have the potential to trigger the mental disorder. In fact, delirium may be the first manifestation of the infection, before fever, general malaise, cough or respiratory disturbances. It is widely supported that delirium increases the morbidity and mortality in those who suffer from it during hospitalization, so it should be actively sought to carry out the relevant interventions. In the absence of evidence on the approach to delirium in the context of COVID-19, this consensus was developed on three fundamental aspects: diagnosis, non-pharmacological treatment and pharmacological treatment, in patients admitted to the general hospital. The document contains recommendations on the systematic use of diagnostic tools, when to hospitalize the patient with delirium, the application of non-pharmacological actions within the restrictions imposed by COVID-19, and the use of antipsychotics, taking into account the most relevant side effects and pharmacological interactions.

Prévention des chutes chez les personnes âgées fragiles hospitalisées en court séjour : utilisation des chaussettes antidérapantes. Une revue systématique de littérature

INTRODUCTION

Falls among hospitalized frail elderly patients are a worrying, major daily phenomenon.

CONTEXT

Inadequate footwear, frequently observed in this population, is one of the main risk factors behind falls. Several hospitals use non-slip socks as a preventive measure. However, in the context of evidence-based medicine, it is important to verify the existence of strong evidence for their effectiveness.

OBJECTIVE

The aim of this study is to determine the preventive effectiveness of non-slip socks.

METHOD

Five databases were investigated (PubMed, PEDro, Cochrane, ScienceDirect, and Google Scholar). Eligibility criteria were established (using the PICO method), for studies including elderly hospitalized patients.

RESULTS

Seven studies were included. Non-slip socks showed a preventive effect in reducing the recurrence of falls (p=0.009) and the prevalence of falls related to urinary incontinence.

DISCUSSION

Several studies conclude on the added value of non-slip socks compared to traditional socks or slippers. The limitations inherent in the selected studies are taken into account when drawing conclusions.

CONCLUSION

Footwear that is considered safe by therapists and secure by the patient is currently the most recommended option. However, more clinical studies are needed to support our findings.

Adult Inpatients’ Perceptions of Their Fall Risk: A Scoping Review

Patient falls in hospitals continue to be a global concern due to the poor health outcomes and costs that can occur. A large number of falls in hospitals are unwitnessed and mostly occur due to patient behaviours and not seeking assistance. Understanding these patient behaviours may help to direct fall prevention strategies, with evidence suggesting the need to integrate patients’ perspectives into fall management. The aim of this scoping review was to explore the extent of the literature about patients’ perceptions and experiences of their fall risk in hospital and/or of falling in hospital. This review was conducted using a five-stage methodological framework recommended by Arksey and O’Malley. A total of nine databases were searched using key search terms such as “fall*”, “perception” and “hospital.” International peer-reviewed and grey literature were searched between the years 2011 and 2021. A total of 41 articles, ranging in study design, met the inclusion criteria. After reporting on the article demographics and fall perception constructs and measures, the qualitative and quantitative findings were organised into five domains: Fall Risk Perception Measures, Patients’ Perceptions of Fall Risk, Patients’ Perceptions of Falling in Hospital, Patients’ Fear of Falling and Barriers to Fall Prevention in Hospital. Approximately two-thirds of study participants did not accurately identify their fall risk compared to that defined by a health professional. This demonstrates the importance of partnering with patients and obtaining their insights on their perceived fall risk, as this may help to inform fall management and care. This review identified further areas for research that may help to inform fall prevention in a hospital setting, including the need for further research into fall risk perception measures.

Restraint practice in the somatic acute care hospital: A participant observation study

AIMS AND OBJECTIVES

We aimed to describe daily restraint practices and the factors which influence their use, from an outsider's perspective.

BACKGROUND

A reduction in restraint use is recommended in health care. However, somatic acute care hospital settings currently lack effective reduction strategies. Thus far, hospital restraint practice is described in terms of quantitative assessments and the 'insider' view of healthcare professionals. However, as factors such as routine or personal beliefs seem to play a relevant role in restraint use, these approaches might be incomplete and biased.

DESIGN

A qualitative observation study design was employed.

METHODS

Fieldwork with unstructured participant observation was conducted at a department of geriatrics and a department of intensive care in Switzerland between November 2019 and January 2020. Data were recorded as field notes. The analysis was conducted iteratively in two coding cycles using descriptive coding followed by pattern coding. We adhered to the Standards for Reporting Qualitative Research (SRQR).

RESULTS

A total of 67 hours of observation were conducted. We found that daily restraint practice can be described in three categories: the context in which restraints are used, the decision-making process on the use and continued use of restraints, and the avoidance of restraint use. Most processes and decisions seem to take place unconsciously, and their standardisation is weak.

CONCLUSIONS

The lack of standardisation favours intuitive and unreflective action, which is prompted by what is also known as heuristic decision-making. To transform daily restraint practice, a technical solution that leads restraint management in line with ethical and legal requirements might be useful.

RELEVANCE TO CLINICAL PRACTICE

The outsider perspective has allowed daily restraint practice to be described independently of existing routines, departmental cultures and personal attitudes. This is important to comprehensively describe restrictive practices, which is a prerequisite for the development of effective restraint reduction strategies.

The Impact of Nurse Staffing on Falls Performance within a Healthcare System: A Descriptive Study

AIM

The purpose of this study was to examine the impact of nurse staffing on inpatient falls performance across a multi-hospital system.

BACKGROUND

Evidence to support which staffing variables influence fall performance so that healthcare organizations can better allocate resources is lacking.

METHOD

A descriptive study design was used to analyze the impact of nurse staffing and falls performance, with units dichotomized as either high or low performing based on national benchmarking data. The impact was evaluated using 10 nurse staffing variables.

RESULTS

A total of 9 units were included (5 high and 4 low performing). Higher performing units showed less use of sitters and travelers, had fewer nurses working overtime hours, and employed more expert-level clinical nurses and combined nursing assistant/health unit coordinator positions, than lower performing units.

CONCLUSION

Findings provide evidence of how staffing variables affect a unit's falls performance. While significant relationships were found, further evaluation is needed to explore the relationship of staffing variables and quality outcomes.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing managers may consider trying to reduce use of sitters and travelers, and utilize innovative staffing models, such as using combined nursing assistant/health unit coordinator positions, to help improve their falls performance.