Impact of the CMS No-Pay Policy on Hospital-Acquired Fall Prevention Related Practice Patterns

Enhancing Patient Safety Through an Integrated Internet of Things Patient Care System: Large Quasi-Experimental Study on Fall Prevention

BACKGROUND

The challenge of preventing in-patient falls remains one of the most critical concerns in health care.

OBJECTIVE

This study aims to investigate the effect of an integrated Internet of Things (IoT) smart patient care system on fall prevention.

METHODS

A quasi-experimental study design is used. The smart patient care system is an integrated IoT system combining a motion-sensing mattress for bed-exit detection, specifying different types of patient calls, integrating a health care staff scheduling system, and allowing health care staff to receive and respond to alarms via mobile devices. Unadjusted and adjusted logistic regression models were used to investigate the relationship between the use of the IoT system and bedside falls compared with a traditional patient care system.

RESULTS

In total, 1300 patients were recruited from a medical center in Taiwan. The IoT patient care system detected an average of 13.5 potential falls per day without any false alarms, whereas the traditional system issued about 11 bed-exit alarms daily, with approximately 4 being false, effectively identifying 7 potential falls. The bedside fall incidence during hospitalization was 1.2% (n=8) in the traditional patient care system ward and 0.1% (n=1) in the smart ward. We found that the likelihood of bedside falls in wards with the IoT system was reduced by 88% (odds ratio 0.12, 95% CI 0.01-0.97; P=.047).

CONCLUSIONS

The integrated IoT smart patient care system might prevent falls by assisting health care staff with efficient and resilient responses to bed-exit detection. Future product development and research are recommended to introduce IoT into patient care systems combining bed-exit alerts to prevent inpatient falls and address challenges in patient safety.

Preoperative frailty predicts postoperative falls in older patients with cancer

INTRODUCTION

Patient falls in the hospital lead to adverse outcomes and impaired quality of life. Older adults with cancer who are frail may be at heightened risk of falls in the postoperative period. We sought to evaluate the association between degree of preoperative frailty and risk of inpatient postoperative falls and other outcomes among older adults with cancer.

MATERIALS AND METHODS

We identified 7,661 patients aged 65 years or older who underwent elective cancer surgery from 2014 to 2020, had a hospital stay of ≥1 day, and had Memorial Sloan Kettering-Frailty Index (MSK-FI) data to allow assessment of frailty. Univariable logistic regression analysis was performed to evaluate the association between frailty and falls. Multivariable logistic regression analysis was performed to evaluate the composite outcome of 30-day readmission or 90-day death, with frailty, falls, and the interaction between frailty and falls as predictors; the analysis was adjusted for age, sex, race, and preoperative albumin level.

RESULTS

In total, 7,661 patients were included in the analysis. Seventy-one (0.9%) had a fall, of whom eight (11%) were readmitted to the hospital within 30 days and seven (10%) died within 90 days. Higher MSK-FI score was associated with higher risk of falls (odds ratio [OR], 1.40 [95% confidence interval [CI], 1.21-1.59]). The risk of falls for a patient with an MSK-FI score of 1 was 0.6%, compared with 1.7% for a patient with an MSK-FI score of 4. Poor outcome was associated with frailty (OR, 1.07 [95% CI, 1.02-1.13]) but not with falls (OR, 1.17 [95% CI, 0.57-2.22]).

DISCUSSION

Preoperative frailty is associated with risk of inpatient postoperative falls and with other adverse outcomes after surgery among older adults with cancer. Screening for frailty in the preoperative setting would enable healthcare institutions to implement interventions aimed at reducing the incidence of inpatient postoperative falls to reduce fall-related adverse events.

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.

Revealing the tension: The relationship between high fall risk categorization and low patient mobility

BACKGROUND

Using an inpatient fall risk assessment tool helps categorize patients into risk groups which can then be targeted with fall prevention strategies. While potentially important in preventing patient injury, fall risk assessment may unintentionally lead to reduced mobility among hospitalized patients. Here we examined the relationship between fall risk assessment and ambulatory status among hospitalized patients.

METHODS

We conducted a retrospective cohort study of consecutively admitted adult patients (n = 48,271) to a quaternary urban hospital that provides care for patients of broad socioeconomic and demographic backgrounds. Non-ambulatory status, the primary outcome, was defined as a median Johns Hopkins Highest Level of Mobility <6 (i.e., patient walks less than 10 steps) throughout hospitalization. The primary exposure variable was the Johns Hopkins Fall Risk Assessment Tool (JHFRAT) category (Low, Moderate, High). The capacity to ambulate was assessed using the Activity Measure for Post-Acute Care (AM-PAC). Multivariable regression analysis controlled for clinical demographics, JHFRAT items, AM-PAC, comorbidity count, and length of stay.

RESULTS

8% of patients at low risk for falls were non-ambulatory, compared to 25% and 54% of patients at moderate and high risk for falls, respectively. Patients categorized as high risk and moderate risk for falls were 4.6 (95% CI: 3.9-5.5) and 2.6 (95% CI: 2.4-2.9) times more likely to be non-ambulatory compared to patients categorized as low risk, respectively. For patients with high ambulatory potential (AM-PAC 18-24), those categorized as high risk for falls were 4.3 (95% CI: 3.5-5.3) times more likely to be non-ambulatory compared to patients categorized as low risk.

CONCLUSIONS

Patients categorized into higher fall risk groups had decreased mobility throughout their hospitalization, even when they had the functional capacity to ambulate.

Analyzing a Multifactorial Fall Prevention Program Using ARIMA Models

BACKGROUND

Preventing inpatient falls is challenging for hospitals to improve and often leads to patient injury.

PURPOSE

To describe multifactorial patient-tailored interventions and to evaluate whether they were associated with a sustained decline in total and injury falls.

METHODS

A multifactorial fall prevention program was instituted over the course of several years. An interrupted time series design was used to assess the effect of each intervention on total and injury fall rates. ARIMA models were built to assess the step and ramp change.

RESULTS

Total fall rates decreased from 4.3 to 3.6 falls per 1000 patient days (16.28% decrease), and injury fall rates decreased from 1.02 to 0.8 falls per 1000 patient days (21.57% decrease). All the interventions contributed to fall reduction, with specific interventions contributing more than others.

CONCLUSIONS

Using multiple interventions that are sustained long enough to demonstrate success reduced the total fall rate and injury fall rate.

Cost-Effectiveness and Value of Information Analysis of an Ambient Intelligent Geriatric Management (AmbIGeM) System Compared to Usual Care to Prevent Falls in Older People in Hospitals

BACKGROUND

The Ambient Intelligent Geriatric Management (AmbIGeM) system combines wearable sensors with artificial intelligence to trigger alerts to hospital staff before a fall. A clinical trial found no effect across a heterogenous population, but reported a reduction in the injurious falls rate in a post hoc analysis of patients on Geriatric Evaluation Management Unit (GEMU) wards. Cost-effectiveness and Value of Information (VoI) analyses of the AmbIGeM system in GEMU wards was undertaken.

METHODS

An Australian health-care system perspective and 5-year time horizon were used for the cost-effectiveness analysis. Implementation costs, inpatient costs and falls data were collected. Injurious falls were defined as causing bruising, laceration, fracture, loss of consciousness, or if the patient reported persistent pain. To compare costs and outcomes, generalised linear regression models were used to adjust for baseline differences between the intervention and usual care groups. Bootstrapping was used to represent uncertainty. For the VoI analysis, 10,000 different sample sizes with randomly sampled values ranging from 1 to 50,000 were tested to estimate the optimal sample size of a new trial that maximised the Expected Net Benefits of Sampling.

RESULTS

An adjusted 0.036 fewer injurious falls (adjusted rate ratio of 0.56) and AUD$4554 lower costs were seen in the intervention group. However, uncertainty that the intervention is cost effective for the prevention of an injurious fall was present at all monetary values of this effectiveness outcome. A new trial with a sample of 4376 patients was estimated to maximise the Expected Net Benefit of Sampling, generating a net benefit of AUD$186,632 at a benefit-to-cost ratio of 1.1.

CONCLUSIONS

The benefits to cost ratio suggests that a new trial of the AmbIGeM system in GEMU wards may not be high-value compared to other potential trials, and that the system should be implemented. However, a broader analysis of options for preventing falls in GEMU is required to fully inform decision making.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry (ACTRN 12617000981325).

Promoting Safe Mobility Strategies for partnering with caregivers to maximize older adults' functional ability

This article is the fifth in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Olson,L.M., et al. Promote Safe Mobility. Am J Nurs 2022; 122(7): 46-52.

Cost of Inpatient Falls and Cost-Benefit Analysis of Implementation of an Evidence-Based Fall Prevention Program

Importance

There is insufficient research on the costs of patient falls in health care systems, a leading source of nonreimbursable adverse events.

Objective

To report the costs of inpatient falls and the cost savings associated with implementation of an evidence-based fall prevention program.

Design, Setting, and Participants

In this economic evaluation, a matched case-control study used the findings from an interrupted time series analysis that assessed changes in fall rates following implementation of an evidence-based fall prevention program to understand the cost of inpatient falls. An economic analysis was then performed to assess the cost benefits associated with program implementation across 2 US health care systems from June 1, 2013, to August 31, 2019, in New York, New York, and Boston, Massachusetts. All adults hospitalized in participating units were included in the analysis. Data analysis was performed from October 2021 to November 2022.

Interventions

Evidence-based fall prevention program implemented in 33 medical and surgical units in 8 hospitals.

Main Outcomes and Measures

Primary outcome was cost of inpatient falls. Secondary outcome was the costs and cost savings associated with the evidence-based fall prevention program.

Results

A total of 10 176 patients who had a fall event (injurious or noninjurious) with 29 161 matched controls (no fall event) were included in the case-control study and the economic analysis (51.9% were 65-74 years of age, 67.1% were White, and 53.6% were male). Before the intervention, there were 2503 falls and 900 injuries; after the intervention, there were 2078 falls and 758 injuries. Based on a 19% reduction in falls and 20% reduction in injurious falls from the beginning to the end of the postintervention period, the economic analysis demonstrated that noninjurious and injurious falls were associated with cost increases of $35 365 and $36 776, respectively. The implementation of the evidence-based fall prevention program was associated with $14 600 in net avoided costs per 1000 patient-days.

Conclusions and Relevance

This economic evaluation found that fall-related adverse events represented a clinical and financial burden to health care systems and that the current Medicare policy limits reimbursement. In this study, costs of falls only differed marginally by injury level. Policies that incentivize organizations to implement evidence-based strategies that reduce the incidence of all falls may be effective in reducing both harm and costs.

Assessment of a wearable fall prevention system at a veterans health administration hospital

Objective

In-hospital falls are a significant cause of morbidity and mortality. The Veterans Health Administration (VHA) has designated fall prevention as a major focus area. The objective of this report is to assess the performance of a new sensor-enabled wearable system to prevent patient falls.

Methods

An integrated sensor-enabled wearable SmartSock system was utilized to prevent falls at the acute care wards of a large VA hospital. Individual patients were only provided the SmartSocks when they were determined to be at high risk of falling. All fall count rates, with and without using the SmartSock, were evaluated and compared for individual patients. SmartSock sensor and electronic health record data were combined to assess the system's performance from February 10, 2021, through October 31, 2021.

Results

There were 20.7 falls per 1000 ward days of care (WDOC) for those not using the SmartSocks compared to 9.2 falls per 1000 WDOC for patients using the SmartSocks. This represents a reduction of falls by more than half. These findings are further confirmed with a negative binomial regression model, which showed the use of the SmartSock had a statistically significant effect on the rate of falls (p = 0.03) when length of stay was held constant and demonstrated the odds of fall incident rate of 0.48 (95% CI, 0.24-0.92), that is less than half compared to when patients were not wearing the SmartSock.

Conclusion

The use of a sensor-enabled wearable SmartSock fall prevention system resulted in a clinically meaningful and statistically significant decrease in falls in the acute care setting.

Prevalence and Risk Factors of Postoperative Falls Following Foot and Ankle Surgery

BACKGROUND

No study has examined the incidence of risk factors for postoperative falls following foot and ankle surgery. We investigated the incidence and risk factors for postoperative falls in foot and ankle surgery using inpatient and outpatient population.

METHODS

A single fellowship-trained foot and ankle surgeon instituted collection of a postoperative fall questionnaire at 2 and 6 weeks postoperatively. A retrospective review of 135 patients with complete prospectively collected fall questionnaire data was performed. Patient demographic information, injury characteristics, comorbidities, baseline medications, length of hospital stay, visual analog scale (VAS) pain scores were collected. After univariable analysis, a multivariable binary logistic regression was conducted to assess independent risk factors for postoperative falls.

RESULTS

The median (interquartile range) age was 52 (21) and body mass index was 32.7 (11.1). A total of 108 patients (80%) underwent outpatient procedures. Thirty-nine of the 135 patients (28.9%) reported experiencing a fall in the first 6 weeks after surgery. In multivariable analysis, antidepressant use (adjusted odds ratio 3.41, 95% CI 1.19-9.81) and higher VAS pain scores at 2 weeks postoperatively (adjusted odds ratio 1.27, 95% CI 1.08-1.50) were found to be independent risk factors for postoperative falls.

CONCLUSION

This study found a high incidence of postoperative falls in the first 6 weeks after foot and ankle surgery. Baseline antidepressant use and higher 2-week VAS pain scores were associated with postoperative falls. Foot and ankle surgeons should discuss the risk of falling with patients especially those with risk factors.

LEVEL OF EVIDENCE

Level III, retrospective cohort study at a single institution.

Patient Falls, Nurse Communication, and Nurse Hourly Rounding in Acute Care: Linking Patient Experience and Outcomes

Research has consistently found a link between hourly nurse rounding and patient outcomes, including reduced falls, reduced pressure ulcers, reduced call light usage, and improved patient experience; however, little research exists specific to patient falls and nurse rounding in acute care settings. This study adds to the body of knowledge by statistically quantifying and providing linkages between nurse rounding frequency and patient fall rates using data from 31 military treatment facilities comprehensively over a period from fiscal year (FY) 2017 through FY2019. Poisson regression results indicated that hourly nurse rounding was associated with a reduction of more than 21% in fall rates (incidence rate ratio = 0.79, P < .01) relative to infrequent rounding, and poorly rated nurse communication was associated with an 8.6-fold increase in patient fall rates relative to highly rated nurse communication (incidence rate ratio = 8.6, P < .01).

Call to Action: Addressing Pediatric Fall Safety in Ambulatory Environments

BACKGROUND

Pediatric falls in the ambulatory environment are a patient safety concern. Historically, fall safety efforts have focused on inpatient settings and are not transferrable to ambulatory environments. Minimal research and absence of ambulatory-specific guidelines from regulatory and global benchmarking bodies contribute to the void of knowledge. Consequently, there has been minimal progress in developing fall reduction strategies for the ambulatory environment.

PURPOSE

To review research evidence and findings from environmental assessments that included interprofessional stakeholder feedback to make recommendations for improving fall safety in the pediatric ambulatory environment.

METHODS

Implementation science was employed in two large pediatric quaternary hospitals to identify existing gaps and provided the foundation for translation of findings in the development of fall safety practice recommendations in the ambulatory environment.

RESULTS

Recommendations from the findings included identified barriers and tangible interventions within three broad categories: equipment and furniture, environment, and people. Purposeful inclusion of all areas in the ambulatory environment, integration of high reliability concepts, and partnering with parents were identified as pertinent factors associated with these recommendations.

CONCLUSION

This call to action recognizes the importance of utilizing an evidence-based approach for improvement and provides a framework for conducting an environmental assessment, which is an essential starting point to improve fall safety in the pediatric ambulatory environment. Guidance and support from research, regulatory and collaborative bodies, and healthcare organizations remains a critical need in improving fall safety.

CE: Reimagining Injurious Falls and Safe Mobility

ABSTRACT

Injurious falls remain among the most common, dangerous, and costly adverse events in hospitals, despite the widespread implementation of fall prevention programs. Many current health care system policies and nursing practices oversimplify fall prevention by focusing on limiting the person's mobility and making the environment safer, or simply documenting a fall risk score. But most falls are caused by factors intrinsic to that individual; merely limiting their mobility can increase preventable hospital complications and readmissions, and still leaves them at risk for falls. This article proposes a new approach to reducing injurious falls in older adults-one grounded in evidence-based protocols known to positively impact the health of older adults. The approach, called by the acronym ERA-Electronic health record integration, Risk factors that matter, Assessment and care plans-allows nurses to use a validated fall risk assessment tool to reframe fall risk factors as part of the comprehensive care plan, and to map modifiable risk factors to interventions that address the underlying causes of falls and promote safer mobility. The ERA approach can help nurses use their time more effectively by focusing on targeted actions that improve patient outcomes, working in coordination with an interprofessional, cross-continuum care team.

Implementation science issues in understanding, collecting, and using cost estimates: a multi-stakeholder perspective

Understanding the resources needed to achieve desired implementation and effectiveness outcomes is essential to implementing and sustaining evidence-based practices (EBPs). Despite this frequent observation, cost and economic measurement and reporting are rare, but becoming more frequent in implementation science, and when present is seldom reported from the perspective of multiple stakeholders (e.g., the organization, supervisory team), including those who will ultimately implement and sustain EBPs.Incorporating a multi-level framework is useful for understanding and integrating the perspectives and priorities of the diverse set of stakeholders involved in implementation. Stakeholders across levels, from patients to delivery staff to health systems, experience different economic impacts (costs, benefit, and value) related to EBP implementation and have different perspectives on these issues. Economic theory can aid in understanding multi-level perspectives and approaches to addressing potential conflict across perspectives.This paper provides examples of key cost components especially important to different types of stakeholders. It provides specific guidance and recommendations for cost assessment activities that address the concerns of various stakeholder groups, identifies areas of agreement and conflict in priorities, and outlines theoretically informed approaches to understanding conflicts among stakeholder groups and processes to address them. Involving stakeholders throughout the implementation process and presenting economic information in ways that are clear and meaningful to different stakeholder groups can aid in maximizing benefits within the context of limited resources. We posit that such approaches are vital to advancing economic evaluation in implementation science. Finally, we identify directions for future research and application.Considering a range of stakeholders is critical to informing economic evaluation that will support appropriate decisions about resource allocation across contexts to inform decisions about successful adoption, implementation, and sustainment. Not all perspectives need to be addressed in a given project but identifying and understanding perspectives of multiple groups of key stakeholders including patients and direct implementation staff not often explicitly considered in traditional economic evaluation are needed in implementation research.

Towards "mobility is medicine": Socioecological factors and hospital mobility in older adults

BACKGROUND

Understanding the factors that influence hospital mobility, especially in the context of a heightened focus on falls prevention, is needed to improve care.

OBJECTIVE

This qualitative study uses a socioecological framework to explore factors that influence hospital mobility in older adults.

DESIGN

Qualitative research PARTICIPANTS: Semi-structured interviews and focus groups were conducted with medically-ill hospitalized older adults (n = 19) and providers (hospitalists, nurses, and physical and occupational therapists (n = 48) at two hospitals associated with an academic health system.

APPROACH

Interview and focus group guides included questions on perceived need for mobility, communication about mobility, hospital mobility culture, and awareness of patients' walking activity. Data were analyzed thematically and mapped onto the constructs of the socioecological model.

KEY RESULTS

A consistent theme among patients and providers was that "mobility is medicine." Categories of factors reported to influence hospital walking activity included intrapersonal factors (patients' health status, fear of falls), interpersonal factors (patient-provider communication about mobility), organizational factors (clarity about provider roles and responsibilities, knowledge of safe patient handling, reliance on physical therapy for mobility), and environmental factors (falls as a never event, patient geographical locations on hospital units). Several of these factors were identified as potentially modifiable targets for intervention. Patients and providers offered recommendations for improving awareness of patient's ambulatory activity, assigning roles and responsibility for mobility, and enhancing education and communication between patients and providers across disciplines.

CONCLUSION

Patients and providers identified salient factors for future early mobility initiatives targeting hospitalized older adults. Consideration of these factors across all stages of intervention development and implementation will enhance impact and sustainability.

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.

Systems Approach Is Needed for In-Hospital Mobility: A Qualitative Metasynthesis of Patient and Clinician Perspectives

OBJECTIVE

To describe how different key stakeholders (ie, interprofessional clinical care team and patients) perceive their role in promoting in-hospital mobility by systematically synthesizing qualitative literature.

DATA SOURCES

PubMed, Ovid MEDLINE, Ovid PsychInfo, and Cumulative Index to Nursing and Allied Health were searched using terms relevant to mobility, hospitalization, and qualitative research. A total of 510 unique articles were retrieved and screened for eligibility.

STUDY SELECTION

Eligible qualitative studies included stakeholder perspectives on in-hospital mobility, including patients, nursing staff, rehabilitation staff, and physicians. Eleven articles remained after inclusion/exclusion criteria were applied.

DATA EXTRACTION

At least 2 authors independently read, coded, and derived themes from each study. We used a team-based inductive approach to thematic synthesis informed by critical realism and the socioecological model. Reciprocal translation unified convergent and divergent constructs across primary studies. Investigator triangulation enhanced interpretation.

DATA SYNTHESIS

Three primary themes emerged: (1) patient, family, and clinician expectations shape roles in in-hospital mobility; (2) stakeholders' role in mobility depends on hospital environment, infrastructure, culture, and resources; and (3) teamwork creates successful in-hospital mobility, but lack of coordination and cooperation leads to delay in mobilizing. Studies suggested that while mobility is an essential construct in the professional role of clinicians and in the personal identity of patients, the ability of stakeholders to realize their role in mobility is highly dependent on the hospital physical and cultural environment, administrative support, clarity in professional roles, and teamwork.

CONCLUSIONS

Interventions designed to address the problem of low hospital mobility should take a systems approach and consider allocation of resources, clarity around professional responsibilities, and elevation of patient and clinician expectations surrounding mobility.

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.

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.

Nurses' Perception of the Bed Alarm System in Acute-Care Hospitals

Introduction

In hospitals, the nurse uses the bed alarm system for patients' safety, which may have some forms of physical restraints included, depending on the situation. However, the nurses' perceptions of the bed alarm system with reference to restraints are yet to be clarified. Moreover, there were no reports that can shed light upon the factors that relate to nurses' perceptions about the bed alarm system in Japan. The objective of this study is to investigate the nurses' perception on whether the bed alarm can be considered as a form of physical restraint and to elucidate the factors that pertain to the nurses' perceptions regarding the bed alarm.

Methods

This study conducted a quantitative cross-sectional survey. We used bivariate logistic regression analyses to investigate the nurses' perception and the factors affecting these perception. Ethical approval was obtained from the research ethics committee of the Kyoto University. Participants opted for answering the questionnaire voluntarily.

Results

The sample population comprised of 289 nurses from 10 acute-care hospitals. Out of these, 214 (74.0%) nurses considered the bed alarm system as a form of restraint, and 75 nurses (26.0%) did not. Furthermore, the nurses' perception was relevant to the hospitals that they belonged to, their years of experience, and the content of education. It was especially interesting that the group of nurses with little experience had the consciousness of being considered the bed alarm as restraint compared with nurses with many years of experience.

Conclusion

The alarm systems are gradually being considered to be classified as a restraint. Hospitals should ensure providing an ethically sensitive climate and appropriate educational opportunities to help nurses build these perceptions for patient care. An ethically sensitive climate and appropriate educational opportunities would lead to an environment that nurtures nurses with the ability to recognize problems in daily care.

Validation of the Hendrich II Fall Risk Model: The imperative to reduce modifiable risk factors

AIM

To validate the psychometrics of the Hendrich II Fall Risk Model (HIIFRM) and identify the prevalence of intrinsic fall risk factors in a diverse, multisite population.

BACKGROUND

Injurious inpatient falls are common events, and hospitals have implemented programs to achieve "zero" inpatient falls.

METHODS

Retrospective analysis of patient data from electronic health records at nine hospitals that are part of Ascension. Participants were adult inpatients (N = 214,358) consecutively admitted to the study hospitals from January 2016 through December 2018. Fall risk was assessed using the HIIFRM on admission and one time or more per nursing shift.

RESULTS

Overall fall rate was 0.29%. At the standard threshold of HIIFRM score ≥ 5, 492 falls and 76,800 non-falls were identified (fall rate 0.36%; HIIFRM specificity 64.07%, sensitivity 78.72%). Area under the receiver operating characteristic curve was 0.765 (standard error 0.008; 95% confidence interval 0.748, 0.781; p < 0.001), indicating moderate accuracy of the HIIFRM to predict falls. At a lower cut-off score of ≥4, an additional 74 falls could have been identified, with an improvement in sensitivity (90.56%) and reduction in specificity (44.43%).

CONCLUSION

Analysis of this very large inpatient sample confirmed the strong psychometric characteristics of the HIIFRM. The study also identified a large number of inpatients with multiple fall risk factors (n = 77,292), which are typically not actively managed during hospitalization, leaving patients at risk in the hospital and after discharge. This finding represents an opportunity to reduce injurious falls through the active management of modifiable risk factors.

Impact of the Hospital-Acquired Conditions Initiative on Falls and Physical Restraints: A Longitudinal Study

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) implemented the Hospital-Acquired Conditions (HACs) Initiative in October 2008; the CMS no longer reimbursed hospitals for fall injury. The effects of this payment change on fall and fall injury rates are not well described, nor its effect on physical restraint use.

OBJECTIVE

The aim of this study was to examine the effects of the 2008 HACs Initiative on the rates of falls, injurious falls, and physical restraint use.

DESIGN/SETTING

This was a nine-year retrospective cohort study (July 2006-December 2015) involving 2,862 adult medical, medical-surgical, and surgical nursing units from 734 hospitals.

MEASUREMENTS

Annual rates of change in falls, injurious falls, and physical restraint use during the two years before the payment rule went into effect were compared with one-, four-, and seven-year rates of annual change after implementation, adjusting for unit- and facility-level covariates. Stratified analyses were conducted according to bed size and teaching status.

RESULTS

Compared with prior to the payment change, there was stable acceleration in the one-, four-, and seven-year annual rates of decline in falls as follows: -2.1% (-3.3%, -0.9%), -2.2% (-3.2%, -1.1%), and -2.2% (-3.4%, -1.0%) respectively. For injurious falls, there was an increasing acceleration in the annual declines, achieving statistical significance only at seven years post CMS change as follows: -3.2% (-5.5%, -1.0%). Physical restraint use prevalence decreased from 1.6% to 0.6%. Changes in the rates of falls, injurious falls, and restraint use varied according to hospital bed size and teaching status.

CONCLUSIONS AND RELEVANCE

Since the HACs Initiative, there was at best a modest decline in the rates of falls and injurious falls observed primarily in larger, major teaching hospitals. An increase in restraint use was not observed. Falls remain a difficult patient safety problem for hospitals, and further research is required to develop cost-effective, generalizable strategies for their prevention.

Posthospital Fall Injuries and 30-Day Readmissions in Adults 65 Years and Older

IMPORTANCE

Falls are common among older adults, particularly those with previous falls and cognitive impairment and in the postdischarge period. Hospitals have financial incentives to reduce both inpatient falls and hospital readmissions, yet little is known about whether fall-related injuries (FRIs) are common diagnoses for 30-day hospital readmissions.

OBJECTIVE

To compare fall-related readmissions with other leading rehospitalization diagnoses, including for patients at greatest risk of readmission.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of the Hospital Cost and Utilization Project's Nationwide Readmissions Database of nationally representative US hospital discharges among Medicare beneficiaries aged 65 years and older from January 1, 2013, to November 30, 2014. The prevalence and ranking of FRIs compared with other diagnostic factors for 30-day unplanned hospital-wide readmissions were determined, overall and for 2 acute geriatric cohorts, classified by fall injury or cognitive impairment diagnoses observed at the index admission. Analyses were also stratified by patient discharge disposition (home, home health care, skilled nursing facility). Analyses were conducted from February 1, 2018, to February 26, 2018.

MAIN OUTCOMES AND MEASURES

Unplanned hospital-wide readmission within 30 days of discharge.

RESULTS

From the database, 8 382 074 eligible index admissions were identified, including 746 397 (8.9%) in the FRI cohort and 1 367 759 (16.3%) in the cognitive impairment cohort. Among the entire 8 382 074-discharge cohort, mean (SD) age was 77.7 (7.8) years and 4 736 281 (56.5%) were female. Overall, 1 205 962 (14.4%) of index admissions resulted in readmission, with readmission rates of 12.9% for those with a previous fall and 16.0% for patients with cognitive impairment. Overall, FRIs ranked as the third-leading readmission diagnosis, accounting for 60 954 (5.1%) of all readmission diagnoses. Within the novel acute geriatric cohorts, FRIs were the second-leading diagnosis for readmission both for patients with an FRI at index admission (10.3% of all readmission diagnoses) and those with cognitive impairment (7.0% of all readmission diagnoses). For those with an FRI at index admission and discharged home or to home health care, FRIs were the leading readmission diagnosis.

CONCLUSIONS AND RELEVANCE

This study found that posthospital FRIs were a leading readmission diagnosis, particularly for patients originally admitted with a FRI or cognitive impairment. Targeting at-risk hospitalized older adults, particularly those discharged to home or home health care, is an underexplored, cost-effective mechanism with potential to reduce readmissions and improve patient care.

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.