Assisted and unassisted falls: different events, different outcomes, different implications for quality of hospital care

Towards human-centered AI and robotics to reduce hospital falls: finding opportunities to enhance patient-nurse interactions during toileting

Introduction: Patients who are hospitalized may be at a higher risk for falling, which can result in additional injuries, longer hospitalizations, and extra cost for healthcare organizations. A frequent context for these falls is when a hospitalized patient needs to use the bathroom. While it is possible that "high-tech" tools like robots and AI applications can help, adopting a human-centered approach and engaging users and other affected stakeholders in the design process can help to maximize benefits and avoid unintended consequences. Methods: Here, we detail our findings from a human-centered design research effort to investigate how the process of toileting a patient can be ameliorated through the application of advanced tools like robots and AI. We engaged healthcare professionals in interviews, focus groups, and a co-creation session in order to recognize common barriers in the toileting process and find opportunities for improvement. Results: In our conversations with participants, who were primarily nurses, we learned that toileting is more than a nuisance for technology to remove through automation. Nurses seem keenly aware and responsive to the physical and emotional pains experienced by patients during the toileting process, and did not see technology as a feasible or welcomed substitute. Instead, nurses wanted tools which supported them in providing this care to their patients. Participants envisioned tools which helped them anticipate and understand patient toileting assistance needs so they could plan to assist at convenient times during their existing workflows. Participants also expressed favorability towards mechanical assistive features which were incorporated into existing equipment to ensure ubiquitous availability when needed without adding additional mass to an already cramped and awkward environment. Discussion: We discovered that the act of toileting served more than one function, and can be viewed as a valuable touchpoint in which nurses can assess, support, and encourage their patients to engage in their own recovery process as they perform a necessary and normal function of life. While we found opportunities for technology to make the process safer and less burdensome for patients and clinical staff alike, we believe that designers should preserve and enhance the therapeutic elements of the nurse-patient interaction rather than eliminate it through automation.

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.

Patient Acceptability of a Novel Technological Solution (Ambient Intelligent Geriatric Management System) to Prevent Falls in Geriatric and General Medicine Wards: A Mixed-Methods Study

Introduction

As effective interventions to prevent inpatient falls are lacking, a novel technological intervention was trialed. The Ambient Intelligent Geriatric Management (AmbIGeM) system used wearable sensors that detected and alerted staff of patient movements requiring supervision. While the system did not reduce falls rate, it is important to evaluate the acceptability, usability, and safety of the AmbIGeM system, from the perspectives of patients and informal carers.

Methods

We conducted a mixed-methods study using semistructured interviews, a pre-survey and post-survey. The AmbIGeM clinical trial was conducted in two geriatric evaluation and management units and a general medical ward, in two Australian hospitals, and a subset of participants were recruited. Within 3 days of being admitted to the study wards and enrolling in the trial, 31 participants completed the pre-survey. Prior to discharge (post-intervention), 30 participants completed the post-survey and 27 participants were interviewed. Interview data were thematically analyzed and survey data were descriptively analyzed.

Results

Survey and interview participants had an average age of 83 (SD 9) years, 65% were female, and 41% were admitted with a fall. Participants considered the AmbIGeM system a good idea. Most but not all thought the singlet and sensor component as acceptable and comfortable, with no privacy concerns. Participants felt reassured with extra monitoring, although sometimes misunderstood the purpose of AmbIGeM as detecting patient falls. Participants' acceptability was strongly positive, with median 8+ (0–10 scale) on pre- and post-surveys.

Discussion/Conclusion

Patients' acceptability is important to optimize outcomes. Overall older patients considered the AmbIGeM system as acceptable, usable, and improving safety. The findings will be important to guide refinement of this and other similar technology developments.

Using human factors and ergonomics principles to prevent inpatient falls

Inpatient falls are frequently reported incidents in hospitals around the world. The recent COVID-19 pandemic has further exacerbated the risk. With the rising importance of human factors and ergonomics (HF&E), a fall prevention programme was introduced by applying HF&E principles to reduce inpatient falls from a systems engineering perspective. The programme was conducted in an acute public hospital with around 750 inpatient beds in Hong Kong. A hospital falls review team (the team) was formed in June 2020 to plan and implement the programme. The ‘Define, Measure, Analyse, Improve and Control’ (DMAIC) method was adopted. Improvement actions following each fall review were implemented. Fall rates in the ‘pre-COVID-19’ period (January–December 2019), ‘COVID-19’ period (January–June 2020) and ‘programme’ period (July 2020–August 2021) were used for evaluation of the programme effectiveness. A total of 120, 85 and 142 inpatient falls in the ‘pre-COVID-19’, ‘COVID-19’ and ‘programme’ periods were reviewed, respectively. Thirteen areas with fall risks were identified by the team where improvement actions applying HF&E principles were implemented accordingly. The average fall rates were 0.476, 0.773 and 0.547 per 1000 patient bed days in these periods, respectively. The average fall rates were found to be significantly increased from the pre-COVID-19 to COVID-19 periods (mean difference=0.297 (95% CI 0.068 to 0.526), p=0.009), which demonstrated that the COVID-19 pandemic might have affected the hospitals fall rates, while a significant decrease was noted between the COVID-19 and programme periods (mean difference=−0.226 (95% CI −0.449 to –0.003), p=0.047), which proved that the programme in apply HF&E principles to prevent falls was effective. Since HF&E principles are universal, the programme can be generalised to other healthcare institutes, which the participation of staff trained in HF&E in the quality improvement team is vital to its success.

The use of predictive fall models for older adults receiving aged care, using routinely collected electronic health record data: a systematic review

BACKGROUND

Falls in older adults remain a pressing health concern. With advancements in data analytics and increasing uptake of electronic health records, developing comprehensive predictive models for fall risk is now possible. We aimed to systematically identify studies involving the development and implementation of predictive falls models which used routinely collected electronic health record data in home-based, community and residential aged care settings.

METHODS

A systematic search of entries in Cochrane Library, CINAHL, MEDLINE, Scopus, and Web of Science was conducted in July 2020 using search terms relevant to aged care, prediction, and falls. Selection criteria included English-language studies, published in peer-reviewed journals, had an outcome of falls, and involved fall risk modelling using routinely collected electronic health record data. Screening, data extraction and quality appraisal using the Critical Appraisal Skills Program for Clinical Prediction Rule Studies were conducted. Study content was synthesised and reported narratively.

RESULTS

From 7,329 unique entries, four relevant studies were identified. All predictive models were built using different statistical techniques. Predictors across seven categories were used: demographics, assessments of care, fall history, medication use, health conditions, physical abilities, and environmental factors. Only one of the four studies had been validated externally. Three studies reported on the performance of the models.

CONCLUSIONS

Adopting predictive modelling in aged care services for adverse events, such as falls, is in its infancy. The increased availability of electronic health record data and the potential of predictive modelling to document fall risk and inform appropriate interventions is making use of such models achievable. Having a dynamic prediction model that reflects the changing status of an aged care client is key to this moving forward for fall prevention interventions.

Hospital Inpatient Falls across Clinical Departments

Background: Inpatient falls are common hospital adverse events. We aimed to determine inpatient fall rates in an urban public hospital and analyzed their characteristics across clinical departments. Methods: The study was conducted in a 350-bed urban, multi-specialty public hospital in the 2013–2019 period. Patient data were retrieved from the hospital’s standardized falls reporting system. Descriptive statistics and statistical tests: chi2 and ANOVA tests with multiple comparison tests (post-hoc analysis) were used. For fall incidence estimation a joint-point regression was applied. p-value of 0.05 was considered as statistically significant for all the calculations. Results: The highest prevalence of falls was reported in the rehabilitation and internal medicine wards (1.915% and 1.181%, respectively), the lowest in the orthopedic (0.145%) and rheumatology wards (0.213%) (p < 0.001). The vast majority of falls took place in the late evening and during the night (56.711%) and were classified as bed falls (55.858%). The crude incidence rate (cIR) of falls was 6.484 per one thousand hospitalizations. In the 2013–2017 period, an increase in total cIR was observed, reaching the peak value in 2016; it was followed by a slight decline from 2017 to 2019, however, differences in changes were observed between the wards. Conclusion: Fall rates and trends as well as circumstances of inpatient falls varied significantly among clinical departments, probably due to differences in patient characteristics.

Association Between Characteristics of Injurious Falls and Fall Preventive Interventions in Acute Medical and Surgical Units

BACKGROUND

Hospital falls remain common and approximately 30% of falls in hospital result in injury. The aims of the study were the following: (i) to identify the association between fall interventions present at the time of the injurious fall and injurious faller characteristics and (ii) to identify the association between fall preventive interventions present at the time of the injurious fall and the injurious fall circumstances.

METHODS

Secondary data analysis of deidentified case series of injurious falls across 24 acute medical/surgical units in the United States. Variables of interest were falls prevention interventions (physical therapy, bed alarm, physical restraint, room change, or a sitter) in place at the time of fall. Data were analyzed using logistic regression and hazard ratios.

RESULTS

There were 1,033 patients with an injurious fall, occurrence peaked between Day 1 and Day 4, with 46.8% of injurious falls having occurred by Day 3 of admission. Injurious fallers with a recorded mental state change 24 hours prior to the fall were more likely to have a bed alarm provided (adjusted odds ratio [OR] 2.56, 95% confidence interval [CI] 1.61, 4.08) and receive a physical restraint as fall prevention interventions (adjusted OR 6.36, 95% CI 4.35, 9.30). Injurious fallers restrained fell later (stay Day 6) than those without a restraint (stay Day 4) (p = .007) and had significantly longer lengths of stay (13 days vs 9 days).

CONCLUSIONS

On medical/surgical units, injurious falls occur early following admission suggesting interventions should be commenced immediately. Injurious fallers who had a physical restraint as an intervention had longer lengths of stay.

Patient Falls and Injuries in U.S. Psychiatric Care: Incidence and Trends

OBJECTIVE

The goal of this study was to estimate the incidence of falls (total, injurious, and assisted) in U.S. psychiatric care across 6 years (April 2013-March 2019).

METHODS

Data on falls among patients of adult and geriatric psychiatric units of general, acute care, and psychiatric hospital inpatient units from the National Database of Nursing Quality Indicators were used for this 6-year study. Total falls, assisted falls (i.e., falls broken or slowed by staff), and injurious falls were calculated, along with trends in total and injurious fall rates.

RESULTS

The sample included 1,159 units in 720 hospitals. Of the 119,246 falls reported, 25,807 (21.6%) resulted in injury. Only 7.0% of the total falls in psychiatric units were assisted by a staff member. Falling unassisted was associated with a higher likelihood of fall-related injury (adjusted odds ratio=1.69, 95% confidence interval=1.59 to 1.80). The total fall rate (8.55 per 1,000 patient-days) and injurious fall rate (1.97 per 1,000 patient-days) were highest for geriatric psychiatric units in general hospitals. Total and injurious fall rates in psychiatric units in general hospitals declined during the study (total fall rate declined by 10% for adult psychiatric units in general hospitals). There was no clear trend in total or injurious fall rates for units in psychiatric hospitals.

CONCLUSIONS

Falls are a persistent problem in psychiatric care settings. Few fall-prevention programs have been tested in these settings, which have unique risk factors for falls. Additional research is needed to develop fall-prevention interventions in psychiatric care.

Factors influencing patient falls in a private hospital group in the Cape Metropole of the Western Cape

Background

The fall rate of patients in hospitals is a worldwide concern due to the impact falls have on patients, the family or relatives, as well as the healthcare setting. Factors influencing patient falls are categorised as intrinsic and extrinsic. Intrinsic factors refers to physical conditions and the extrinsic factors include the environment of the patient, nursing staffing levels and skill mix.

Aim

The study aimed to determine the factors that influence patient falls.

Setting

A private hospital group in the Cape Metropole of the Western Cape.

Methods

A quantitative retrospective descriptive research approach was used by analysing 134 records of patients that have fallen from October 2016 to February 2018. Data was collected using a data extraction sheet and analysed using the Statistical Package for the Social Sciences (SPSS).

Results

Intrinsic factors contributing to patient falls includedthe patient’s age, hypertension, co-morbidities and the use of benzodiazepines as a sedative. Extrinsic factors were the incorrect use of bed rails and the skill mix of the staff. In over half of the cases (n = 68; 50.7%), risk assessments were not performed according to the protocol. Only 5 (3.7%) patients sustained major injuries due to the falls. However, the risk of more severe falls increased 2.4 times with the lack of risk assessment.

Conclusion

The lack of accurate and consistent patient fall risk assessments, use of benzodiazepines as a sedative and the staff skill mix were contributors to the fall rate in these hospitals.

Unit-level variation in bed alarm use in US hospitals

Bed and chair alarms are widely used in hospitals, despite lack of effectiveness and unintended negative consequences. In this cross-sectional, observational study, we examined alarm prevalence and contributions of patient- and unit-level factors to alarm use on 59 acute care nursing units in 57 US hospitals participating in the National Database of Nursing Quality Indicators®. Nursing unit staff reported data on patient-level fall risk and fall prevention measures for 1,489 patients. Patient-level propensity scores for alarm use were estimated using logistic regression. Expected alarm use on each unit, defined as the mean patient propensity-for-alarm score, was compared with the observed rate of alarm use. Over one-third of patients assessed had an alarm in the "on" position. Patient characteristics associated with higher odds of alarm use included recent fall, need for ambulation assistance, poor mobility judgment, and altered mental status. Observed rates of unit alarm use ranged from 0% to 100% (median 33%, 10th percentile 5%, 90th percentile 67%). Expected alarm use varied less (median 31%, 10th percentile 27%, and 90th percentile 45%). Only 29% of variability in observed alarm use was accounted for by expected alarm use. Unit assignment was a stronger predictor of alarm use than patient-level fall risk variables. Alarm use is common, varies widely across hospitals, and cannot be fully explained by patient fall risk factors; alarm use is driven largely by unit practices. Alarms are used too frequently and too indiscriminately, and guidance is needed for optimizing alarm use to reduce noise and encourage mobility in appropriate patients.

Hospital falls prevention with patient education: a scoping review

Background

Hospital falls remain a frequent and debilitating problem worldwide. Most hospital falls prevention strategies have targeted clinician education, environmental modifications, assistive devices, hospital systems and medication reviews. The role that patients can play in preventing falls whilst in hospital has received less attention. This critical review scopes patient falls education interventions for hospitals. The quality of the educational designs under-pinning patient falls education programmes was also evaluated. The outcomes of patient-centred falls prevention programs were considered for a range of hospital settings and diagnoses.

Methods

The Arksey and O’Malley (2005) framework for scoping reviews was adapted using Joanna Briggs Institute and PRISMA-ScR guidelines. Eight databases, including grey literature, were searched from January 2008 until February 2020. Two reviewers independently screened the articles and data were extracted and summarised thematically. The quality of falls prevention education programs for patients was also appraised using a modified quality metric tool.

Results

Forty-three articles were included in the final analysis. The interventions included: (i) direct face-to-face patient education about falls risks and mitigation; (ii) educational tools; (iii) patient-focussed consumer materials such as pamphlets, brochures and handouts; and (iv) hospital systems, policies and procedures to assist patients to prevent falls. The included studies assessed falls or education related outcomes before and after patient falls prevention education. Few studies reported incorporating education design principles or educational theories. When reported, most educational programs were of low to moderate quality from an educational design perspective.

Conclusions

There is emerging evidence that hospital falls prevention interventions that incorporate patient education can reduce falls and associated injuries such as bruising, lacerations or fractures. The design, mode of delivery and quality of educational design influence outcomes. Well-designed education programs can improve knowledge and self-perception of risk, empowering patients to reduce their risk of falling whilst in hospital.

Exploring hospital patient sitters' fall prevention task readiness: A cross-sectional survey

RATIONALE, AIMS, AND OBJECTIVES

Patient sitters provide one-to-one care for hospital patients at high risk of falls. The study aimed to explore patient sitters' task readiness to assist in fall prevention on hospital wards.

METHOD

We conducted a cross-sectional survey. Respondents were patient sitters working in five hospitals providing medical, surgical, and aged care. The survey was developed using a theory of health behaviour change and used closed and open-ended items. Qualitative data were analysed using deductive content analysis.

RESULTS

Participants (n = 90) identified that patient factors, such as confusion, were the most frequent cause of falls (n = 338, 74%); however, the most frequent strategies identified to prevent falls were focused on the environment (n = 164, 63%). The most frequent barrier participants identified to preventing falls (n = 124, 67%) also pertained to patients, including aggressive patient behaviours. In contrast, staff factors, such as handovers being adequate, were identified as the main enabler for sitters being able to complete their tasks effectively (n = 60, 81%). Participants strongly suggested (71%) that further, preferably practical, training would be helpful, even though 84% reported receiving prior fall prevention training. Nearly all participants (98%) were motivated to prevent their patients from falling.

CONCLUSIONS

There is a gap between what patient sitters report as the cause of falls (patient factors) and what was suggested to prevent falls (environment factors). Education and practical training addressing challenging patient behaviours may improve sitters' task readiness to assist in preventing falls on wards. Improving communication and cooperation between patient sitters and nursing staff is also important.

Epilepsy monitoring units can be safe places; a prospective study in a large cohort

OBJECTIVE

No international guideline is available for minimum safety measures at epilepsy monitoring units (EMUs), although recommendations for preferred practices exist. These are mostly based on expert opinion, without evidence of effectiveness. We do not apply all of these preferred practices at our EMU setting. We audited adverse events and diagnostic utility at our EMU over one year.

METHODS

From May 2018 to May 2019, we prospectively collected data concerning adverse events and diagnostic utility of all EMU admissions (noninvasive video-electroencephalogram (EEG) recordings); during these admissions, individuals can be ambulant within their EMU room.

RESULTS

There were 1062 admissions comprising 1518 EMU days. In 2% of the admissions, a complication occurred, mostly a fall without injury (n = 6). In almost half of the falls, this was from the bed. Complications occurred most often during admissions for presurgical evaluation. Antiseizure medication (ASM) was tapered in 86% of presurgical cases, but no serious injury occurred, and occurring seizures were effectively treated with intranasal midazolam if needed.

CONCLUSIONS

The overall adverse event rate was low. Falls are the most common adverse event comparable with previously published fall rates at other EMUs where people are restricted to their bed. We showed that restricted ambulation at a well-monitored EMU is not necessary and possibly unwanted. No serious injury due to tapering of ASM occurred, and intranasal midazolam was shown to be effective as acute seizure treatment.

Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study

Background

Unassisted falls are more likely to result in injury than assisted falls. However, little is known about risk factors for falling unassisted. Furthermore, rural hospitals, which care for a high proportion of older adults, are underrepresented in research on hospital falls. This study identified risk factors for unassisted and injurious falls in rural hospitals.

Methods

Seventeen hospitals reported 353 falls over 2 years. We categorized falls by type (assisted vs. unassisted) and outcome (injurious vs. non-injurious). We used multivariate logistic regression to determine factors that predicted fall type and outcome.

Results

With all other factors being equal, the odds of falling unassisted were 2.55 times greater for a patient aged ≥65 than < 65 (95% confidence interval [CI] = 1.30–5.03), 3.70 times greater for a patient with cognitive impairment than without (95% CI = 2.06–6.63), and 6.97 times greater if a gait belt was not identified as an intervention for a patient than if it was identified (95% CI = 3.75–12.94). With all other factors being equal, the odds of an injurious fall were 2.55 times greater for a patient aged ≥65 than < 65 (95% CI = 1.32–4.94), 2.48 times greater if a fall occurred in the bathroom vs. other locations (95% CI = 1.41–4.36), and 3.65 times greater if the fall occurred when hands-on assistance was provided without a gait belt, compared to hands-on assistance with a gait belt (95% CI = 1.34–9.97).

Conclusions

Many factors associated with unassisted or injurious falls in rural hospitals were consistent with research conducted in larger facilities. A novel finding is that identifying a gait belt as an intervention decreased the odds of patients falling unassisted. Additionally, using a gait belt during an assisted fall decreased the odds of injury. We expanded upon other research that found an association between assistance during falls and injury by discovering that the manner in which a fall is assisted is an important consideration for risk mitigation.

Evaluating the use of multiteam systems to manage the complexity of inpatient falls in rural hospitals

OBJECTIVE

To evaluate the implementation and outcomes of evidence-based fall-risk-reduction processes when those processes are implemented using a multiteam system (MTS) structure.

DATA SOURCES/STUDY SETTING

Fall-risk-reduction process and outcome measures from 16 small rural hospitals participating in a research demonstration and dissemination study from August 2012 to July 2014. Previously, these hospitals lacked a fall-event reporting system to drive improvement.

STUDY DESIGN

A one-group pretest-posttest embedded in a participatory research framework. We required hospitals to implement MTSs, which we supported by conducting education, developing an online toolkit, and establishing a fall-event reporting system.

DATA COLLECTION

Hospitals used gap analyses to assess the presence of fall-risk-reduction processes at study beginning and their frequency and effectiveness at study end; they reported fall-event data throughout the study.

PRINCIPAL FINDINGS

The extent to which hospitals implemented 21 processes to coordinate the fall-risk-reduction program and trained staff specifically about the program predicted unassisted and injurious fall rates during the end-of-study period (January 2014-July 2014). Bedside fall-risk-reduction processes were not significant predictors of these outcomes.

CONCLUSIONS

Multiteam systems that effectively coordinate fall-risk-reduction processes may improve the capacity of hospitals to manage the complex patient, environmental, and system factors that result in falls.

The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project

BACKGROUND

Conducting post-fall huddles is considered an integral component of a fall-risk-reduction program. However, there is no evidence linking post-fall huddles to patient outcomes or perceptions of teamwork and safety culture. The purpose of this study is to determine associations between conducting post-fall huddles and repeat fall rates and between post-fall huddle participation and perceptions of teamwork and safety culture.

METHODS

During a two-year demonstration project, we developed a system for 16 small rural hospitals to report, benchmark, and learn from fall events, and we trained them to conduct post-fall huddles. To calculate a hospital's repeat fall rate, we divided the total number of falls reported by the hospital by the number of unique medical record numbers associated with each fall. We used Spearman correlations with exact P values to determine the association between the proportion of falls followed by a huddle and the repeat fall rate. At study end, we used the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) to assess perceptions of teamwork support for fall-risk reduction and the Hospital Survey on Patient Safety Culture (HSOPS) to assess perceptions of safety culture. We added an item to the T-TPQ for respondents to indicate the number of post-fall huddles in which they had participated. We used a binary logistic regression with a logit link to examine the effect of participation in post-fall huddles on respondent-level percent positive T-TPQ and HSOPS scores. We accounted for clustering of respondents within hospitals with random effects using the GLIMMIX procedure in SAS/STAT.

RESULT

Repeat fall rates were negatively associated with the proportion of falls followed by a huddle. As compared to hospital staff who did not participate in huddles, those who participated in huddles had more positive perceptions of four domains of safety culture and how team structure, team leadership, and situation monitoring supported fall-risk reduction.

CONCLUSIONS

Post-fall huddles may reduce the risk of repeat falls. Staff who participate in post-fall huddles are likely to have positive perceptions of teamwork support for fall-risk reduction and safety culture because huddles are a team-based approach to reporting, adapting, and learning.

Characteristics of falls with damage to hospitalized patients

OBJECTIVE

Describe the characteristics of falls in patients with damage, their risk factors and injuries.

METHOD

Retrospective and longitudinal study of 260 records of falls with damage of adult patients in clinical and surgical units of a general hospital, from September 2012 to June 2017. Data were collected in May 2018 from the electronic fall and electronic record research instrument, and the statistical analysis was described.

RESULTS

There were 260 falls with damage, mostly in the elderly (78%), female (55%), in clinical treatment (68%) and unaccompanied (59.4%). The falls occurred at the same height (63.4%) and in the patient's room (67.3%). The severity of the damage was mild in 80.8% of cases, severe in 11.9% and moderate in 7.3%.

CONCLUSION

Improving understanding of falls and their consequences can assist professionals in identifying and assessing risks and in establishing preventive measures.

Fall Rates in Urban and Rural Nursing Units: Does Location Matter?

Patient falls remain a leading adverse event in hospitals. In a study of 65 rural hospitals with 222 nursing units and 560 urban hospitals with 4274 nursing units, we found that geographic region, unit type, and nurse staffing, education, experience, and outcomes were associated with fall rates. Implications include specific attention to fall prevention in rehabilitation units, creating better work environments that promote nurse retention, and provide RN-BSN educational opportunities.

In-Hospital Sequelae of Injurious Falls in 24 Medical/Surgical Units in Four Hospitals in the United States

BACKGROUND

Up to 50% of patient falls in the hospital result in injury. This study was conducted to determine whether injurious falls were associated with increased hospital length of stay (LOS), discharge to a place other than home, and in-hospital mortality.

METHODS

A secondary data analysis from a prospective case-control study was conducted in 24 medical/surgical units in four hospitals in the United States. Patients who fell and sustained an injury were matched with at least one control patient who was on the same unit, at the same time, for a similar number of days on the unit at the time of the fall. Data were collected by viewing patients' electronic health records, as well as the hospitals' incident reporting systems. Logistic regression and Cox regression analyses were conducted.

RESULTS

The 1,033 patients (mean age, 63.7 years; 510 males [49.4%]) who sustained an injurious fall were matched with 1,206 controls (mean age, 61.6 years; 486 males [40.3%]). Fallers were significantly more likely than controls to stay longer than 10 days in the hospital (odds ratio [OR], 1.59; 95% confidence interval [CI] = 1.46-1.74) and to be discharged to a place other than home (OR, 1.52; 95% CI = 1.21-1.91).

CONCLUSION

Compared to controls, hospital patients who sustained an injurious fall had longer LOS and were more likely discharged to a place other than home. These associations remained when controlling for patient-level confounders, suggesting that the fall altered trajectory was sustained toward these outcomes. Injurious falls were not significantly associated with increased risk of mortality.

Good Catch! Using Interdisciplinary Teams and Team Reflexivity to Improve Patient Safety

Interdisciplinary teams play an important role implementing innovations that facilitate the quality and safety of patient care. This article examined the role of reflexivity in team innovation implementation and its association with an objective patient safety outcome, inpatient fall rates (a fall is an unintended downward displacement of a patient’s body to the ground or other object). In this study, we implemented, supported, and evaluated interdisciplinary teams intended to decrease fall risk in 16 small rural hospitals. These hospitals were part of a collaborative that sought to increase knowledge and facilitate reflexivity about fall event reporting and fall risk reduction structures and processes. We assessed team reflexivity at the start and at the end of the 2-year intervention and innovation implementation at the end of the intervention. The 16 hospitals reported objective fall event data and patient days throughout the project, which we used to calculate comparative rates for assisted, unassisted, and injurious falls. The results suggest that teams benefited from the intervention, increasing reflexivity from the start of the project to the end, which was related to innovation implementation and decreases in fall rates. Theoretical and practical applications of the results are discussed.

Actions of the fall prevention protocol: mapping with the classification of nursing interventions

Objective:

to analyze the correspondence between the actions contained in the fall prevention protocol of the Ministry of Health and the Nursing Interventions Classification (NIC) by a cross-mapping.

Method:

this is a descriptive study carried out in four stages: protocol survey, identification of NIC interventions related to nursing diagnosis, the risk of falls, cross-mapping, and validation of the mapping from the Delphi technique.

Results:

there were 51 actions identified in the protocol and 42 interventions in the NIC. Two rounds of mapping evaluation were carried out by the experts. There were 47 protocol actions corresponding to 25 NIC interventions. The NIC interventions that presented the highest correspondence with protocol actions were: fall prevention, environmental-safety control, and risk identification. Regarding the classification of similarity and comprehensiveness of the 47 actions of the protocol mapped, 44.7% were considered more detailed and specific than the NIC, 29.8% less specific than the NIC and 25.5% were classified as similar in significance to the NIC.

Conclusion:

most of the actions contained in the protocol are more specific and detailed, however, the NIC contemplates a greater diversity of interventions and may base a review of the protocol to increase actions related to falls prevention..

Effects of falls prevention interventions on falls outcomes for hospitalised adults: protocol for a systematic review with meta-analysis

INTRODUCTION

Falls are a major global public health problem and leading cause of accidental or unintentional injury and hospitalisation. Falls in hospital are associated with longer length of stay, readmissions and poor outcomes. Falls prevention is informed by knowledge of reversible falls risk factors and accurate risk identification. The extent to which hospital falls are prevented by evidence-based practice, patient self-management initiatives, environmental modifications and optimisation of falls prevention systems awaits confirmation. Published reviews have mainly evaluated community settings and residential care facilities. A better understanding of hospital falls and the most effective strategies to prevent them is vital to keeping people safe.

OBJECTIVES

To evaluate the effectiveness of falls prevention interventions on reducing falls in hospitalised adults (acute and subacute wards, rehabilitation, mental health, operating theatre and emergency departments). We also summarise components of effective falls prevention interventions.

METHODS AND ANALYSIS

This protocol has been registered. The systematic review will be informed by Cochrane guidelines and reported according to the Preferred Reporting Items for Systematic review and Meta-Analysis statement.

INCLUSION CRITERIA

randomised controlled trials, quasi-randomised trials or controlled clinical trials that evaluate falls prevention interventions for use by hospitalised adults or employees. Electronic databases will be searched using key terms including falls, accidental falls, prevention, hospital, rehabilitation, emergency, mental health, acute and subacute. Pairs of independent reviewers will conduct all review steps. Included studies will be evaluated for risk of bias. Data for variables such as age, participant characteristics, settings and interventions will be extracted and analysed with descriptive statistics and meta-analysis where possible. The results will be presented textually, with flow charts, summary tables, statistical analysis (and meta-analysis where possible) and narrative summaries.

ETHICS AND DISSEMINATION

Ethical approval is not required. The systematic review will be published in a peer-reviewed journal and disseminated electronically, in print and at conferences. Updates will guide healthcare translation into practice.

TRAIL REGISTRATION NUMBER

PROSPERO 2017: CRD 42017058887. Available from https://www.crd.york.ac.uk/prospero.

Risk Factors Related to Caregivers in Hospitalized Children's Falls

PURPOSE

This study aimed to evaluate the risk factors for falls in hospitalized children in relation to their caregivers.

METHODS

This was a case control study to evaluate the risk factors for falls in hospitalized children in relation to their caregivers. The children included in our study were at the hospital between June 2014 and June 2015. Demographic data of patients, caregivers, some habits; education level; and number of siblings were recorded.

RESULTS

The data of 117 patients were evaluated, and there were 39 patients with a fall event and 78 patients who did not experience a fall. The mean age for the fall group and the non-fall group were 14.71±9.36 and 15.62±10.65months, respectively. The mean age for the caregivers of the fall group and the non-fall group were 29.33±5.89 and 29.53±5.56years, respectively. There was a statistically significant difference in fall risk related to the caregivers' education level (p<0.01) and caregivers' habit of smoking (p<0.01). The analysis of risk factors related to caregivers for pediatric inpatient falls, by multivariate logistic regression, showed that low educational level of caregivers (OR=0.361; CI=0.196-0.665; p<0.01), caregivers' smoking (OR=4.863; CI=1.058-22.358; p<0.05) and increased length of stay for the children (OR=1.994; CI=1.475-2.696; p<0.01) carried a higher risk for pediatric inpatient falls.

CONCLUSIONS AND PRACTICE IMPLICATIONS

The data obtained in our study have shown that caregivers play a key role in fall events in hospitalized children. Nurses and other health workers should consider children's caregivers educational level and habits for prevention of hospitalized children falls.

'It promoted a positive culture around falls prevention': staff response to a patient education programme-a qualitative evaluation

OBJECTIVES

The purpose of this study was to understand how staff responded to individualised patient falls prevention education delivered as part of a cluster randomised trial, including how they perceived the education contributed to falls prevention on their wards.

DESIGN

A qualitative explanatory study.

METHODS

5 focus groups were conducted at participatory hospital sites. The purposive sample of clinical staff (including nurses, physiotherapists and quality improvement staff) worked on aged care rehabilitation wards when a cluster randomised trial evaluating a patient education programme was conducted. During the intervention period, an educator, who was a trained health professional and not a member of staff, provided individualised falls prevention education to patients with good levels of cognition (Mini-Mental State Examination >23/30). Clinical staff were provided with training to support the programme and their feedback was sought after the trial concluded, to understand how they perceived the programme impacted on falls prevention. Data were thematically analysed using NVivo qualitative data analysis software.

RESULTS

5 focus groups were conducted at different hospitals (n=30 participants). Staff perceived that the education created a positive culture around falls prevention and further, facilitated teamwork, whereby patients and staff worked together to address falls prevention. The educator was perceived to be a valuable member of the team. Staff reported that they developed increased knowledge and awareness about creating a safe ward environment. Patients being proactive and empowered to engage in falls prevention strategies, such as ringing the bell for assistance, was viewed as supporting staff falls prevention efforts and motivating staff to change practice.

CONCLUSIONS

Staff responded positively to patient falls prevention education being delivered on their wards. Providing individualised patient education to older patients with good levels of cognition can empower staff and patients to work as a team to address falls prevention on hospital rehabilitation wards.

Can Nursing Units With High Fall Rates Be Identified Using One Year of Data? Reliability of Fall Rates As a Function of the Number of Quarters on Which They Are Based

Reliability-the extent to which multiple measurements of a target yield similar results-is critical in comparing healthcare provider quality. Hospital unit fall rates are widely tracked and used for benchmarking, but their reliability is not well-studied. Our twofold purpose was to estimate fall rate reliability, both in terms of signal (between-unit variability) relative to noise (within-unit variability) and in terms of the accuracy with which units can be classified as high-fall units; and to assess reliability as a function of the number of quarters of data used to compute fall rates. Using year 2013 data from 11,765 critical care, step-down, medical, surgical, medical-surgical, and rehabilitation units in 1,552 US hospitals, we identified high-fall-rate units, computed units' signal-noise reliability, and simulated data to assess accuracy of high-fall-rate unit classification as a function of quarters of data. When critical care units were excluded, median unit type signal-noise reliabilities for annual total and injurious fall rates, respectively, ranged from .74 to .82 and from .53 to .68. In simulation, seven quarters of data were sufficient to achieve top-decile misclassification rates at or below 10% for all unit types except critical care. Top-quartile misclassification rates were higher; even 12 quarters of data did not consistently yield top-quartile misclassification rates below 10%. In the absence of long-term data, and for units with low patient volume and unit types with very low fall rates, comparison with a unit's own historical data may be more helpful for quality monitoring than attempting to rank it among its peers. © 2016 Wiley Periodicals, Inc.

The Cost of Serious Patient Fall-Related Injuries at Hospitals in Turkey: A Matched Case-Control Study

Patient falls cause economic loss in hospitals, as well as patient injuries. This study aimed to calculate the additional hospital cost and length of stay (LOS) due to fall-related serious injuries and to identify the determining factors for both outcomes. A matched case-control design was used in the study. It was conducted with a case group of 39 patients and a control group of 39 patients in 28 hospitals in İzmir, Turkey. The additional hospital cost and LOS due to fall-related serious injuries were calculated to be US$3,302.60 and 14.61 days, respectively. Precautionary initiatives for the injurious falls can prevent patients from getting injured and avoid increases in cost and LOS due to these injuries.

Wide Variability in Emergency Physician Admission Rates: A Target to Reduce Costs Without Compromising Quality

Introduction

Attending physician judgment is the traditional standard of care for emergency department (ED) admission decisions. The extent to which variability in admission decisions affect cost and quality is not well understood. We sought to determine the impact of variability in admission decisions on cost and quality.

Methods

We performed a retrospective observational study of patients presenting to a university-affiliated, urban ED from October 1, 2007, through September 30, 2008. The main outcome measures were admission rate, fiscal indicators (Medicaid-denied payment days), and quality indicators (15- and 30-day ED returns; delayed hospital admissions). We asked each Attending to estimate their inpatient admission rate and correlated their personal assessment with actual admission rates.

Results

Admission rates, even after adjusting for known confounders, were highly variable (15.2%–32.0%) and correlated with Medicaid denied-payment day rates (p=0.038). There was no correlation with quality outcome measures (30-day ED return or delayed hospital admission). There was no significant correlation between actual and self-described admission rate; the range of mis-estimation was 0% to 117%.

Conclusion

Emergency medicine attending admission rates at this institution are highly variable, unexplained by known confounding variables, and unrelated to quality of care, as measured by 30-day ED return or delayed hospital admission. Admission optimization represents an important untapped potential for cost reduction through avoidable hospitalizations, with no apparent adverse effects on quality.

'My independent streak may get in the way': how older adults respond to falls prevention education in hospital

OBJECTIVES

The aim of the study was to determine how providing individualised falls prevention education facilitated behaviour change from the perspective of older hospital patients on rehabilitation wards and what barriers they identified to engaging in preventive strategies.

DESIGN

A prospective qualitative survey.

METHODS

Older patients (n=757) who were eligible (mini-mental state examination score>23/30) received falls prevention education while admitted to eight rehabilitation hospital wards in Western Australia. Subsequently, 610 participants were surveyed using a semistructured questionnaire to gain their response to the in-hospital education and their identified barriers to engaging in falls prevention strategies. Deductive content analysis was used to map responses against conceptual frameworks of health behaviour change and risk taking.

RESULTS

Participants who responded (n=473) stated that the education raised their awareness, knowledge and confidence to actively engage in falls prevention strategies, such as asking for assistance prior to mobilising. Participants' thoughts and feelings about their recovery were the main barriers they identified to engaging in safe strategies, including feeling overconfident or desiring to be independent and thinking that staff would be delayed in providing assistance. The most common task identified as potentially leading to risk-taking behaviour was needing to use the toilet.

CONCLUSIONS

Individualised education assists older hospital rehabilitation patients with good levels of cognition to engage in suitable falls prevention strategies while on the ward. Staff should engage with patients to understand their perceptions about their recovery and support patients to take an active role in planning their rehabilitation.

The SCOPE of Hospital Falls: A Systematic Mixed Studies Review

PURPOSE

This systematic mixed studies review on hospital falls is aimed to facilitate proactive decision-making for patient safety during the healthcare facility design.

BACKGROUND

Falls were identified by the Centers for Medicare & Medicaid Services as a nonreimbursed hospital-acquired condition (HAC) due to volume and cost, and additional financial penalties were introduced with the 2014 U.S. HAC reduction program. In 2015, the Joint Commission alert identified patient falls as one of the top reported sentinel events, and the Occupational Safety & Health Administration (OSHA) added slips, trips, and falls as a focus for investigators' healthcare inspections. Variations in fall rates at both the hospital and the unit level are indicative of an ongoing challenge. The built environment can act as a barrier or enhancement to achieving the desired results in safety complexity that includes the organization, people, and environment.

METHODS

The systematic literature review used Medical Subject Heading terms and key word alternates for hospital falls with searches in MEDLINE, Web of Science, and CINAHL. The search was limited to English-language papers.

RESULTS

Following full-text review, 27 papers were included and critically appraised using an evaluation matrix that included a mixed methods appraisal tool. Themes were coded by broad categories of factors for organization (policy/operations), people (caregivers/staff, patients), and the environment (healthcare facility design). Subcategories were developed to define the physical environment and consider the potential interventions in the context of relative stability.

CONCLUSIONS

Conditions of hospital falls were identified and evaluated through the literature review. A theoretical model was developed to propose a human factors framework while considering the permanence of solutions.

Challenges in defining and categorizing falls on diverse unit types: lessons from expansion of the NDNQI Falls Indicator

In 2012, the National Database of Nursing Quality Indicators launched a project to expand its falls indicator for use on pediatric, neonatal, and psychiatric units. We discuss challenges encountered, argue that schemes for categorizing falls by cause or supposed preventability are not suitable for large-scale efforts to track and prevent falls, express concern about the growing burden of collecting increasingly granular quality data, and discuss limitations of total and injurious fall rates as quality measures.

Educators' perspectives about how older hospital patients can engage in a falls prevention education programme: a qualitative process evaluation

OBJECTIVES

Falls are the most frequent adverse event reported in hospitals. Patient and staff education delivered by trained educators significantly reduced falls and injurious falls in an older rehabilitation population. The purpose of the study was to explore the educators' perspectives of delivering the education and to conceptualise how the programme worked to prevent falls among older patients who received the education.

DESIGN

A qualitative exploratory study.

METHODS

Data were gathered from three sources: conducting a focus group and an interview (n=10 educators), written educator notes and reflective researcher field notes based on interactions with the educators during the primary study. The educators delivered the programme on eight rehabilitation wards for periods of between 10 and 40 weeks. They provided older patients with individualised education to engage in falls prevention and provided staff with education to support patient actions. Data were thematically analysed and presented using a conceptual framework.

RESULTS

Falls prevention education led to mutual understanding between staff and patients which assisted patients to engage in falls prevention behaviours. Mutual understanding was derived from the following observations: the educators perceived that they could facilitate an effective three-way interaction between staff actions, patient actions and the ward environment which led to behaviour change on the wards. This included engaging with staff and patients, and assisting them to reconcile differing perspectives about falls prevention behaviours.

CONCLUSIONS

Individualised falls prevention education effectively provides patients who receive it with the capability and motivation to develop and undertake behavioural strategies that reduce their falls, if supported by staff and the ward environment.

Longitudinal Association of Registered Nurse National Nursing Specialty Certification and Patient Falls in Acute Care Hospitals

Supplemental Digital Content is available in the text

Background

Researchers have studied inpatient falls in relation to aspects of nurse staffing, focusing primarily on staffing levels and proportion of nursing care hours provided by registered nurses (RNs). Less attention has been paid to other nursing characteristics, such as RN national nursing specialty certification.

Objective

The aim of the study was to examine the relationship over time between changes in RN national nursing specialty certification rates and changes in total patient fall rates at the patient care unit level.

Methods

We used longitudinal data with standardized variable definitions across sites from the National Database of Nursing Quality Indicators. The sample consisted of 7,583 units in 903 hospitals. Relationships over time were examined using multilevel (units nested in hospitals) latent growth curve modeling.

Results

The model indices indicated a good fit of the data to the model. At the unit level, there was a small statistically significant inverse relationship (r = −.08, p = .04) between RN national nursing specialty certification rates and total fall rates; increases in specialty certification rates over time tended to be associated with improvements in total fall rates over time.

Discussion

Our findings may be supportive of promoting national nursing specialty certification as a means of improving patient safety. Future study recommendations are (a) modeling organizational leadership, culture, and climate as mediating variables between national specialty certification rates and patient outcomes and (b) investigating the association of patient safety and specific national nursing specialty certifications which test plans include patient safety, quality improvement, and diffusion of innovation methods in their certifying examinations.

Fall prevention and bathroom safety in the epilepsy monitoring unit

Falls are one of the most common adverse events occurring in the epilepsy monitoring unit (EMU) and can result in significant injury. Protocols and procedures to reduce falls vary significantly between institutions as it is not yet known what interventions are effective in the EMU setting. This study retrospectively examined the frequency of falls and the impact of serial changes in fall prevention strategies utilized in the EMU between 2001 and 2014 at a single institution. Overall fall rate was 2.81 per 1000 patient days and varied annually from 0 to 9.02 per 1000 patient days. Both seizures and psychogenic nonepileptic events occurring in the bathroom were more likely to result in falls compared with events occurring elsewhere in the room. With initiation of increased patient education, hourly nurse rounding, nocturnal bed alarms, having two persons assisting for high fall risk patients when out of bed, and immediate postfall team review between 2001 and 2013, there was a trend of decreasing fall frequency; however, no specific intervention could be identified as having a particular high impact. In late 2013, a ceiling lift system extending into the bathroom was put in place for use in all EMU patients when out of bed. In the subsequent 15 months, there have been zero falls. The results reinforce both the need for diligent safety standards to prevent falls in the EMU as well as the challenges in identifying the most effective practices to achieve this goal.

Bayesian and frequentist approaches to assessing reliability and precision of health-care provider quality measures

Our purpose was to compare frequentist, empirical Bayes, and Bayesian hierarchical model approaches to estimating reliability of health care quality measures, including construction of credible intervals to quantify uncertainty in reliability estimates, using data on inpatient fall rates on hospital nursing units. Precision of reliability estimates and Bayesian approaches to estimating reliability are not well studied. We analyzed falls data from 2372 medical units; the rate of unassisted falls per 1000 inpatient days was the measure of interest. The Bayesian methods “shrunk” the observed fall rates and frequentist reliability estimates toward their posterior means. We examined the association between reliability and precision in fall rate rankings by plotting the length of a 90% credible interval for each unit’s percentile rank against the unit’s estimated reliability. Precision of rank estimates tended to increase as reliability increased but was limited even at higher reliability levels: Among units with reliability >0.8, only 5.5% had credible interval length <20; among units with reliability >0.9, only 31.9% had credible interval length <20. Thus, a high reliability estimate may not be sufficient to ensure precise differentiation among providers. Bayesian approaches allow for assessment of this precision.