Where are falls prevention resources allocated by hospitals and what do they cost? A cross sectional survey using semi-structured interviews of key informants at six Australian health services

Implementing falls prevention patient education in hospitals - older people's views on barriers and enablers

BACKGROUND

World falls guidelines recommend that hospitalised older patients receive individualised falls prevention education, yet no studies have sought older people's feedback on how best to deliver falls prevention education in hospitals. The objective of the study was to explore the perspectives of older people and their caregivers about barriers and enablers to implementation of a tailored hospital falls education program.

METHODS

A qualitative descriptive design was used. Three focus groups and 16 semi-structured interviews were conducted. A purposive sample of older people who had previous hospital admissions and caregivers of older people were selected to review a co-designed patient falls education program (the revised Safe Recovery program). They provided feedback on how to implement the program in hospital settings. Data were thematically analysed taking an deductive-inductive approach.

RESULTS

Participants were 37 older people [female n = 24 (64.9%), age range 64 to 89 years] and nine caregivers (female n = 8). The first theme was that the Safe Recovery Program resources were of high quality, enabling strong patient engagement and increased knowledge and awareness about falls prevention in hospitals. The second theme identified practical strategies to enable program delivery in hospital wards. The key enablers identified were: timing of delivery around wellness and the patient's mobility; tailoring messages for each older patient; key staff members being assigned to lead program delivery. Participants recommended that staff assist older patients to set appropriate behavioural goals in relation to preventing falls in hospitals. They also recommended that staff raise older patients' confidence and motivation to take action to reduce the risk of falls. Providing resources in other languages and alternative shorter versions was recommended to enable broad dissemination.

CONCLUSIONS

Older people and their caregivers advised that implementing falls education in hospitals can be enabled by using high quality resources, delivering falls education in a timely manner and personalising the education and support to individual needs.

'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.

Interactions that support older inpatients with cognitive impairments to engage with falls prevention in hospitals: An ethnographic study

AIMS

To explore the nature of interactions that enable older inpatients with cognitive impairments to engage with hospital staff on falls prevention.

DESIGN

Ethnographic study.

METHODS

Ethnographic observations on orthopaedic and older person wards in English hospitals (251.25 h) and semi-structured qualitative interviews with 50 staff, 28 patients and three carers. Findings were analysed using a framework approach.

RESULTS

Interactions were often informal and personalised. Staff qualities that supported engagement in falls prevention included the ability to empathise and negotiate, taking patient perspectives into account. Although registered nurses had limited time for this, families/carers and other staff, including engagement workers, did so and passed information to nurses.

CONCLUSIONS

Some older inpatients with cognitive impairments engaged with staff on falls prevention. Engagement enabled them to express their needs and collaborate, to an extent, on falls prevention activities. To support this, we recommend wider adoption in hospitals of engagement workers and developing the relational skills that underpin engagement in training programmes for patient-facing staff.

IMPLICATIONS FOR PROFESSION AND PATIENT CARE

Interactions that support cognitively impaired inpatients to engage in falls prevention can involve not only nurses, but also families/carers and non-nursing staff, with potential to reduce pressures on busy nurses and improve patient safety.

REPORTING METHOD

The paper adheres to EQUATOR guidelines, Standards for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

Patient/public contributors were involved in study design, evaluation and data analysis. They co-authored this manuscript.

Evaluation of a concise fall risk stratification among older adults with cataracts in day surgery settings: A historically controlled study

AIM

This study aimed to evaluate the use of a concise fall risk stratification in assessing and predicting falls compared with the Morse Falls Scale among older adults with cataracts in day surgery settings.

METHODS

A historically controlled study conducted from July 2020 to June 2022 was used in a municipal ophthalmic hospital in China. The concise fall risk stratification which directly graded fall risk by multifactorial judgment was used during the intervention period, while the Morse Falls Scale which graded fall risk by scale scores was used during the control period. The fall risk levels, fall assessment time, fall rates, fall-related injuries, predictive validity, and patient satisfaction with day surgery care were extracted. Propensity score matching was performed to balance baselines.

RESULTS

After matching, 4132 patients were included in the final analysis. Compared with the control group, the intervention group had significantly higher assessment results for fall risk level, a significantly shorter (by 48.15%) fall assessment time, and higher patient satisfaction. There were no differences in fall rates and fall-related injuries. Compared with the Morse Falls Scale, the concise fall risk stratification had higher sensitivity and negative predictive validity, and lower specificity and positive predictive validity, while the area under curve did not differ significantly.

CONCLUSION

The use of the concise fall risk stratification reduced fall assessment time, improved patient satisfaction, and is unlikely to impact falls with an overall predictive performance comparable to that of the Morse Falls Scale for older cataract adults in day surgery settings.

A Stepped-Wedge Cluster-Randomized Controlled Trial of a Multi-interventional Approach for Fall Prevention

BACKGROUND AND OBJECTIVES

Falls are one of the most common adverse events at hospitals that may result in injury and even death. They are also associated with raised length of stay (LOS) and hospitalization costs. This experiment aimed to examine the effectiveness of multiple interventions in reducing inpatient fall rates and the consequent injuries.

METHODS

The present study was a stepped-wedge cluster-randomized controlled trial. It was done in 18 units in a public university hospital over 36 weeks. Patients included in this research were at risk of falls. Overall, 33 856 patients were admitted, of whom 4766 were considered high-risk patients. During the intervention phases, a series of preventive and control measures were considered, namely staff training; patient education; placement of nursing call bells; adequate lighting; supervision of high-risk patients during transmission and handovers; mobility device allocation; placement of call bell and safe guard in bathrooms; placing "fall alert" signs above patients' beds; nurses informing physicians timely about complications such as delirium and hypoxia; encouraging appropriate use of eyeglasses, hearing aids and footwear; keeping side rails up; and reassessing patients after each fall. The primary outcome was participant falls per 1000 patient-days. Secondary outcomes were fall-related injuries and LOS.

RESULTS

The results revealed a decrease in fall rate (n = 4 per 1000 patient-days vs 1.34 per 1000 patient-days, incidence rate ratio (IRR) = 0.19 [95% confidence interval (CI), 0.14-0.26]; P = .001) and injuries (n = 2.4 per 1000 patient-days vs 0.79 per 1000 patient-days, IRR = 0.22 [95% CI, 0.15-0.32]; P = .001) in exposed compared with unexposed phases. There was not a significant difference in LOS (exposed mean 10.63 days [95% CI, 10.26-10.97], unexposed mean 10.84 days [95% CI, 10.59-11.09], mean difference = -0.13 [95% CI, -0.53 to 0.27], P = .52).

CONCLUSIONS

This multi-interventional trial showed a reduction in falls and fall rates with injury but without an overall effect on LOS. Further research is needed to understand the sustainability of multiple fall prevention strategies in hospitals and their long-term impacts.

The experiences of older adults with cognitive impairment in using falls prevention alarms in hospital: A qualitative descriptive study

INTRODUCTION

Bed and chair sensor alarms are commonly used for falls prevention in hospitals, despite questionable efficacy. Research analysing older adults' experiences of alarms is scarce, and adults with cognitive impairment are consistently excluded.

AIM

The aim of this study was to explore how older adults with cognitive impairment perceive and experience falls prevention alarms in hospital.

METHOD

A qualitative descriptive design investigated older adults' experiences of alarms in a Geriatric Evaluation and Management ward in Melbourne. Patients were included if they had been provided an alarm. Semi-structured interviews were the primary method of data collection with two observation sessions and medical record analyses completed to enable triangulation of findings. Data were subjected to thematic analysis, and the Person-Environment-Occupation framework was chosen to add insight into the complexities of older adults' experiences of alarms.

FINDINGS

All 11 participants had a level of cognitive impairment with delirium, confusion, or impulsiveness recorded in their medical file. Two overarching themes were identified: communication and collaboration with staff and rationalisation of alarm use. Participants' perceived staff were focussed on falls prevention but experienced a lack of communication about the purpose of alarms. Participants wanted an individualised approach to alarms. Some were comforted with the thought of alarms alerting staff, making them feel well cared for and believed alarms were a useful 'back-up'. Others found alarms uncomfortable, frustrating, and restricting. Application of the Person-Environment-Occupation framework provided insight into how enabling and restrictive factors can impact whether the alarm is experienced positively or negatively. Seven unwitnessed falls occurred during the participants' admissions. Thirty-four per cent of alarm triggers observed were considered false alerts.

CONCLUSION

Older adults commonly reported negative experiences using bed/chair sensor alarms. Occupational therapists have the training to collaborate with people with cognitive impairment and assess the usefulness of alarms in reducing falls, based on how they interact with the older adult's unique person, environment, and occupation domains.

Preventing hospital falls: feasibility of care workforce redesign to optimise patient falls education

OBJECTIVE

To examine the feasibility of using allied health assistants to deliver patient falls prevention education within 48 h after hospital admission.

DESIGN AND SETTING

Feasibility study with hospital patients randomly allocated to usual care or usual care plus additional patient falls prevention education delivered by supervised allied health assistants using an evidence-based scripted conversation and educational pamphlet.

PARTICIPANTS

(i) allied health assistants and (ii) patients admitted to participating hospital wards over a 20-week period.

OUTCOMES

(i) feasibility of allied health assistant delivery of patient education; (ii) hospital falls per 1,000 bed days; (iii) injurious falls; (iv) number of falls requiring transfer to an acute medical facility.

RESULTS

541 patients participated (median age 81 years); 270 control group and 271 experimental group. Allied health assistants (n = 12) delivered scripted education sessions to 254 patients in the experimental group, 97% within 24 h after admission. There were 32 falls in the control group and 22 in the experimental group. The falls rate was 8.07 falls per 1,000 bed days in the control group and 5.69 falls per 1,000 bed days for the experimental group (incidence rate ratio = 0.66 (95% CI 0.32, 1.36; P = 0.26)). There were 2.02 injurious falls per 1,000 bed days for the control group and 1.03 for the experimental group. Nine falls (7 control, 2 experimental) required transfer to an acute facility. No adverse events were attributable to the experimental group intervention.

CONCLUSIONS

It is feasible and of benefit to supplement usual care with patient education delivered by allied health assistants.

Evaluation of the cost-effectiveness of a multicomponent fall prevention program in hospitalized patients

The aim of this pre- and post-interventional study was to analyze the cost-effectiveness of the multicomponent fall prevention program in hospitalized patients. To achieve this aim, cost-effectiveness analysis performed using decision tree modeling was compared with the implementation of the fall prevention program and usual care. The primary outcome was the number of patient falls. The uncertainty in cost and effectiveness data was evaluated using one-way sensitivity analysis, best-worst-case scenario analysis, and probabilistic sensitivity analysis. According to cost-effectiveness analysis, implementation of the fall prevention program was dominantly cost-effective. As a result of the probabilistic sensitivity analysis, it was revealed that, even if willing-to-pay per-fall prevented value was 0, the probability of being cost-effective was 54.4% for the fall prevention program. Economic evaluation results showed that implementing the multicomponent fall prevention program was dominantly cost-effective in hospitalized patients. Nurses and nurse managers can benefit from economic evaluations in their decision-making processes to implement fall prevention programs.

'I don't want to impose on anybody': Older people and their families discuss their perceptions of risk, cause and care in the context of falls

BACKGROUND

Falls in hospitalised patients remain an ongoing challenge for healthcare systems internationally. Limited research exists on the perspectives of older people on falls risk, cause and care.

OBJECTIVES

This study explored the experiences of patients and their families after a fall in a healthcare facility.

METHODS

Semi-structured interviews were conducted with patients and families to explore the experience of having a fall. Data were analysed thematically.

RESULTS

The themes that emerged from the 14 interviews included the following: explanations; physical environment; communication; experiences of care; perceptions of risk; ageism; feelings towards the fall; and independence and dignity.

CONCLUSIONS

This research emphasises the diversity in older people's experiences after experiencing a fall. Falls prevention should be incorporated as one part of healthy, dignified ageing.

IMPLICATIONS FOR PRACTICE

Falls prevention and management strategies should be multifactorial, including enhanced communication with the patient and their families. When engaging in education and awareness, falls prevention should be positioned as one component of independent and dignified healthy ageing.

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.

Disinvestment in the presence of uncertainty: Description of a novel, multi-group, disinvestment trial design and protocol for an application to reduce or cease use of mobilisation alarms for preventing falls in hospitals

Disinvestment is the removal or reduction of previously provided practices or services, and has typically been undertaken where a practice or service has been clearly shown to be ineffective, inefficient and/or harmful. However, practices and services that have uncertain evidence of effectiveness, efficiency and safety can also be considered as candidates for disinvestment. Disinvestment from these practices and services is risky as they may yet prove to be beneficial if further evidence becomes available. A novel research approach has previously been described for this situation, allowing disinvestment to take place while simultaneously generating evidence previously missing from consideration. In this paper, we describe how this approach can be expanded to situations where three or more conditions are of relevance, and describe the protocol for a trial examining the reduction and elimination of use of mobilisation alarms on hospital wards to prevent patient falls. Our approach utilises a 3-group, concurrent, non-inferiority, stepped wedge, randomised design with an embedded parallel, cluster randomised design. Eighteen hospital wards with high rates of alarm use (≥3%) will be paired within their health service and randomly allocated to a calendar month when they will transition to a “Reduced” (<3%) or “Eliminated” (0%) mobilisation alarm condition. Dynamic randomisation will be used to determine which ward in each pair will be allocated to either the reduced or eliminated condition to promote equivalence between wards for the embedded parallel, cluster randomised component of the design. A project governance committee will set non-inferiority margins. The primary outcome will be rates of falls. Secondary clinical, process, safety, and economic outcomes will be collected and a concurrent economic evaluation undertaken.

Digital storytelling to facilitate consumer engagement in healthcare research

ISSUES ADDRESSED

Consumer engagement in healthcare research presents with challenges, one of which is ensuring that the consumers have comprehended the often complex concepts in scientific research. This study aimed to compare how well older adult consumers understood video-based versus written and verbal description approaches to provision of information.

METHODS

Twenty adults in the community aged 60 years and older were recruited for this study; half were randomised to receive the information via a digital story, and the other half received the same information from a written brief. Both mediums were presented via video teleconferencing. An interviewer was present to ask questions and address queries.

RESULTS

Participants who viewed the digital story requested for clarifications less frequently compared to those who received the written brief. Difficulty in understanding the information rose with complexity, but providing concrete examples aided comprehension of the information.

CONCLUSIONS

Complex concepts benefit from the provision of concrete examples to facilitate understanding. Video-based approaches to provision of information are acceptable forms of participant engagement in research and require less human resources to successfully convey key information and facilitate understanding of the information. Research procedures that employ large amounts of data collection and/or asynchronous methods should consider the use of video-based approaches, such as digital stories, to increase cost-effectiveness.

Redundancy within hospital-related harm prediction tools

The predictive ability and efficiency of inpatient harm screening tools is unclear. We performed a retrospective analysis of approximately 25 000 people admitted to our hospital in 2019. We found that the discriminatory ability of the harm screening tools was at best moderate and could be attributed to one or two questions that overlapped with each other in the harm they predicted.

Falls risk score removal does not impact inpatient falls: A stepped-wedge, cluster-randomised trial

AIMS AND OBJECTIVES

To investigate the impact of removing a falls risk screening tool from an overall falls risk assessment programme on the rate of falls, injurious falls and completion of falls prevention activities by staff.

BACKGROUND

Falls in older patients are common adverse events in hospital settings. Screening and assessing individual patients for risk of falls are a common, but controversial element of falls prevention strategies in hospitals.

DESIGN

A stepped-wedge, cluster-randomised controlled trial using a disinvestment approach.

METHODS

This trial was carried out according to the Consolidated Standards of Reporting Trials (CONSORT). All patients were admitted to 20 health service wards (9 units) over the 10-month study period. The control condition contained a falls risk screening tool element, a full falls risk factor assessment and intervention provision section. In the intervention condition, only the full falls risk factor assessment and intervention provision section was applied, and the falls risk screening tool element was removed. Fall rates were extracted from hospital level data, files were audited for tool completion, and nurses surveyed about tool use.

RESULTS

There did not appear to be an impact on the falls rate per month when the risk screening tool component was removed (incidence rate ratio (IRR) = 0.84-favours intervention, 95%CI = 0.67 to 1.05, p = .14) nor on the falls rate with serious injury (IRR = 0.90, 95%CI = 0.26 to 3.09, p = .87). There was a thirty-six second reduction of time per patient reported by staff to complete paperwork (p < .001). There was no difference in the proportion of patients for whom the tool was completed, nor the number of falls prevention interventions identified for implementation.

CONCLUSION

Removing the falls risk screening tool section did not negatively impact falls and reduced time spent completing falls prevention paperwork.

RELEVANCE TO CLINICAL PRACTICE

Falls prevention is an important issue in health services. Removal of a screening risk tool is unlikely to impact falls. This has the potential to reduce nursing administration time that may be otherwise redirected to individual approaches to falls prevention.

Mobilisation alarm triggers, response times and utilisation before and after the introduction of policy for alarm reduction or elimination: A descriptive and comparative analysis

BACKGROUND

Mobilisation alarms are a falls prevention strategy used in hospitals to alert staff when an at risk patient is attempting to mobilise. Mobilisation alarms have an estimated annual cost of $AUD58MIL in Australia. There is growing evidence from randomised controlled trials indicating mobilisation alarms are unlikely to prevent falls.

AIM

The primary aim of this study was to describe the rate of mobilisation alarm false triggers and staff response time across different health services. The secondary aim was to compare pre to post mobilisation alarm utilisation following the introduction of policy to reduce or eliminate mobilisation alarms.

METHODS

This descriptive and comparative study was conducted through Monash Partners Falls Alliance across six health services in Melbourne, Australia. This study described true and false alarm triggers and trigger response times across three health services and usual care mobilisation alarm utilisation across six health services; and then compared alarm utilisation across two health services following the introduction of policy to reduce (<2.5%) or eliminate (0.0%) mobilisation alarms in the acute and rehabilitation settings.

RESULTS

The most frequent observation was a false alarm (n = 74, 52%), followed by a true alarm (n = 67, 47%) and no alarm (n = 3, 2%). Time to respond to the true and false alarms was an average of 37 seconds (SD 92) and this included 61 occasions of 0 seconds as a member of staff was present when the alarm triggered. If the 61 occasions of staff being present when the alarm triggered were removed, the average time to respond was 65 seconds (SD114). Usual care mobilisation alarm utilisation in acute was 7% (n = 171/2,338) and in rehabilitation was 11% (n = 286/2,623). Introducing policy for reduced and eliminated mobilisation alarm conditions was successful with a reduced utilisation rate of 1.8% (n = 11/609) and an eliminated utilisation rate of 0.0% (n = 0/521).

CONCLUSION

Half of mobilisation alarm triggers are false and when alarms trigger without staff present, staff take about a minute to respond. While usual care has one in fourteen patients in acute and one in nine patients in rehabilitation using a mobilisation alarm, it is possible to introduce policy which will change practice to reduce or eliminate the use of mobilisation alarms, providing evidence of feasibility for future disinvestment effectiveness studies that it is feasible to disinvest in the alarms.

What are we asking for when requesting "Specialling" for the confused hospitalised older person? A concept analysis

BACKGROUND AND/OR RATIONALE: "Specialling" is a common nursing practice in hospitals which entails the allocation of extra staff to be with an older person who is confused to maintain safety. Despite ongoing use, this practice has little evidence of effectiveness. To facilitate further investigation, a concept analysis of "specialling" was undertaken.

AIMS

The aim of this paper was to report on a concept analysis on the practice of "specialling" pertaining to older people who have cognitive impairment when in hospital.

METHODS

This study used Rodgers evolutionary approach to concept analysis to clarify the attributes, antecedents and consequences of the concept to determine a definition of "specialling." Web of Science (Core Collection and Web of Science Medline), CINAHL and SCOPUS databases were searched to identify relevant literature. Due to the scarcity of papers, the search was broadened to include all sources that could add understanding.

FINDINGS

A total of (n = 43) sources were identified. The attributes were themed to 5 categories: Labels and descriptions; the "Special" role; Patient safety; Patient care; and Communication. The antecedents to 2 themes: Patient characteristics; and Organisational risk. The consequences of "specialling" were diverse with 6 themes: the "Special" role; the Older persons experience; Costly; "Special" use and nursing beliefs; Safety outcomes; and Opportunities.

DISCUSSION

The process of concept analysis provided a means to identify knowledge gaps and practice challenges. The definition determined from this analysis has provided a reflective opportunity for clinicians and researchers to consider when implementing care initiatives to support older people in hospital. Important is the lack of person-centred approaches and the opportunities in developing nurse leadership through empowerment. The findings from this analysis will inform a PhD study.

IMPLICATIONS FOR PRACTICE

Nurses have an opportunity to lead care improvements by ensuring person-centred approaches in the care of older people with cognitive impairment.