Close Observation Unit to Prevent Falls and Minimize Use of Patient Care Companions

Practices of falls risk assessment and prevention in acute hospital settings: a realist investigation

Background

Falls are the most common safety incident reported by acute hospitals. The National Institute of Health and Care Excellence recommends multifactorial falls risk assessment and tailored interventions, but implementation is variable.

Aim

To determine how and in what contexts multifactorial falls risk assessment and tailored interventions are used in acute National Health Service hospitals in England.

Design

Realist review and multisite case study. (1) Systematic searches to identify stakeholders' theories, tested using empirical data from primary studies. Review of falls prevention policies of acute Trusts. (2) Theory testing and refinement through observation, staff interviews (n = 50), patient and carer interviews (n = 31) and record review (n = 60).

Setting

Three Trusts, one orthopaedic and one older person ward in each.

Results

Seventy-eight studies were used for theory construction and 50 for theory testing. Four theories were explored. (1) Leadership: wards had falls link practitioners but authority to allocate resources for falls prevention resided with senior nurses. (2) Shared responsibility: a key falls prevention strategy was patient supervision. This fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared. (3) Facilitation: assessments were consistently documented but workload pressures could reduce this to a tick-box exercise. Assessment items varied. While individual patient risk factors were identified, patients were categorised as high or low risk to determine who should receive supervision. (4) Patient participation: nursing staff lacked time to explain to patients their falls risks or how to prevent themselves from falling, although other staff could do so. Sensitive communication could prevent patients taking actions that increase their risk of falling.

Limitations

Within the realist review, we completed synthesis for only two theories. We could not access patient records before observations, preventing assessment of whether care plans were enacted.

Conclusions

(1) Leadership: There should be a clear distinction between senior nurses' roles and falls link practitioners in relation to falls prevention; (2) shared responsibility: Trusts should consider how processes and systems, including the electronic health record, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses, and ensure items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling.

Future work

(1) Development and evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, multifactorial falls risk assessment and selection and delivery of tailored interventions; (2) mixed method and economic evaluations of patient supervision; (3) evaluation of engagement support workers, volunteers and/or carers to support falls prevention. Research should include those with cognitive impairment and patients who do not speak English.

Study registration

This study is registered as PROSPERO CRD42020184458.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129488) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Sitters as a Patient Safety Strategy to Reduce Hospital Falls: A Systematic Review

BACKGROUND

Bedside "sitters" are often used for patients at high risk for falls, but they are expensive and their effectiveness is unclear.

PURPOSE

To review evidence about the effect of sitters and alternatives to sitters on patient falls in acute care hospitals.

DATA SOURCES

PubMed searches to 8 October 2019, other databases from inception to December 2018, citation searches on key articles, and a Google search (22 October 2019).

STUDY SELECTION

English-language studies of any design that assessed the effect of adding sitters to usual care or compared alternatives to sitters (for example, video monitors or "close observation units") for adult patients on general wards of acute care hospitals and reported falls as a primary outcome.

DATA EXTRACTION

Dual-reviewer extraction of study data and risk of bias; single reviewer with group discussion for GRADE (Grading of Recommendations Assessment, Development and Evaluation) certainty of evidence.

DATA SYNTHESIS

Of 20 studies meeting inclusion criteria, 2 added sitters to usual care and 18 compared alternatives to sitters. There were no randomized trials, 11 time-series studies, 1 retrospective quasi-experimental study, and 8 pre-post studies. All studies had at least 1 methodological limitation. Two studies provided very-low-certainty evidence that adding sitters reduced falls. Eight studies provided moderate-certainty evidence that interventions that included video monitoring reduced sitter use and either did not affect or reduced the number of falls. Very-low-certainty evidence suggested that interventions that included nurse assessment tools (3 studies) or a close observation unit (2 studies) were effective alternatives to sitters.

LIMITATION

No studies had low risk of bias, publication bias is likely, and studies may have been missed.

CONCLUSION

Despite a compelling rationale, evidence is scant that adding sitters to usual care reduces falls.

PRIMARY FUNDING SOURCE

Veterans Affairs Quality Enhancement Research Initiative. (PROSPERO: CRD42019127424).

One to one specialling and sitters in acute care hospitals: A scoping review

BACKGROUND

One to one specialling is a type of care which is provided to ensure the safety of patients who may be suffering from cognitive impairment, exhibit challenging behaviour, or may be at risk of falls or of causing harm to themselves or others. Care such as this, often referred to as 'specialling' or 'sitting' is common practice in most hospitals around the world, but there is a lack of evidence regarding its cost effectiveness and the quality of care provided.

AIM

The aim of this scoping review was to explore the breadth and scope of literature on one to one specialling, sitters and similar types of care in acute secondary care settings, in order to identify the challenges and concerns relating to the quality of care (process and outcomes) and cost effectiveness emerging from the literature, and determine the implications of this for policy, practice and future research.

DESIGN

This review was based on scoping review methodology following a five stage scoping review process. A keyword search was conducted in the following databases: MEDLINE, Scopus, CINAHL Plus, Web of Science, ProQuest Social Science, and ProQuest Nursing and Allied Health. The time limit placed on the search was January 2000 to April 2016. Inclusion and exclusion criteria were applied. The Mixed Methods Appraisal Tool was used to assess the quality of primary research articles.

FINDINGS

Forty-four articles were included in the review. We found a lack of clarity in the terms used to describe one to one specialling and variability in what this type of care entails, who provides the care and the needs of patients requiring this type of care. High costs of specialling are often seen as a concern, but there was a lack of economic evaluations considering the full cost of specialling and balancing these against the benefits. Some of the articles proposed alternatives to one to one specialling or the use of sitters, but only some of these were evaluated.

CONCLUSION

There is wide variation in what specialling and one to one care entails, which can in turn lead to the provision of poor quality care. A reduction in this variation and improved quality care might be achieved through the development of guidelines, training and standardized decision-making tools. Further research on the impact of one to one specialling on patient outcomes and cost would be beneficial, as well as robust evaluations of the alternatives to specialling.