Does delirium prevention reduce risk of in-patient falls among older adults? A systematic review and trial sequential meta-analysis

Hospital falls clinical practice guidelines: a global analysis and systematic review

BACKGROUND

Hospital falls continue to be a persistent global issue with serious harmful consequences for patients and health services. Many clinical practice guidelines now exist for hospital falls, and there is a need to appraise recommendations.

METHOD

A systematic review and critical appraisal of the global literature was conducted, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Web of Science, Embase, CINAHL, MEDLINE, Epistemonikos, Infobase of Clinical Practice Guidelines, Cochrane CENTRAL and PEDro databases were searched from 1 January 1993 to 1 February 2024. The quality of guidelines was assessed by two independent reviewers using Appraisal of Guidelines for Research and Evaluation Global Rating Scale and Appraisal of Guidelines of Research and Evaluation Recommendation Excellence (AGREE-REX). Certainty of findings was rated using Grading of Recommendations Assessment, Development and Evaluation Confidence in Evidence from Reviews of Qualitative Research. Data were analysed using thematic synthesis.

RESULTS

2404 records were screened, 77 assessed for eligibility, and 20 hospital falls guidelines were included. Ten had high AGREE-REX quality scores. Key analytic themes were as follows: (i) there was mixed support for falls risk screening at hospital admission, but scored screening tools were no longer recommended; (ii) comprehensive falls assessment was recommended for older or frail patients; (iii) single and multifactorial falls interventions were consistently recommended; (iv) a large gap existed in patient engagement in guideline development and implementation; (v) barriers to implementation included ambiguities in how staff and patient falls education should be conducted, how delirium and dementia are managed to prevent falls, and documentation of hospital falls.

CONCLUSION

Evidence-based hospital falls guidelines are now available, yet systematic implementation across the hospital sector is more limited. There is a need to ensure an integrated and consistent approach to evidence-based falls prevention for a diverse range of hospital patients.

Prevalence of Older Hospitalised Adults with Sustained Fractures after a Fall in Regional Australian Hospitals

Falls commonly occur in hospitals, particularly among older adults. Fractures in the older population can cause major morbidity, which can result in long hospital admissions and increased care costs. This study aimed to characterise the demographics of patients aged 65 years and over who fell in hospital and to determine the type of fractures they sustained. A descriptive study was undertaken to examine hospital data of older inpatients who had a fall during admission in two regional Queensland hospitals in Australia over a 2.5-year period. The prevalence of inpatient falls was 1.28%. Most falls were unwitnessed (77.34%) and they had an average of seven medical comorbidities. The mean age was 80.4 years and 63% were male. Women who fell were significantly older than men (p = 0.004). The mean length of stay of in-hospital fallers was 22.77 days and same admission mortality was 9.3%. Thirty-three fall events (3.8%) resulted in fractures, some with multiple injuries. The most common fracture was neck of femur, followed by rib, femur, and facial fractures. In conclusion, this study identifies the incidence of falls increased with age, most falls were unwitnessed, as well as provides evidence that patients with falls had multiple comorbidities and long hospital admissions. The data could be used to optimise fall prevention strategies and to refine post-fall assessment pathways.

Inpatients' experiences of falls: A qualitative meta-synthesis

OBJECTIVES

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

RESEARCH DESIGN

Qualitative meta-synthesis.

METHODS

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

DATA SOURCES

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

RESULTS

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

CONCLUSIONS

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

IMPACT

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

IMPLICATIONS FOR PATIENT CARE

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

REPORTING METHOD

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

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

REGISTRATION

PROSPERO CRD42023445279.

Post-operative delirium in the patient with hip fracture: The journey from hospital arrival to discharge

Delirium- an acute disorder of attention and cognition- is the commonest complication following hip fracture. Patients with hip fracture are particularly vulnerable to delirium, and many of the lessons from the care of the patient with hip fracture will extend to other surgical cohorts. Prevention and management of delirium for patients presenting with hip fracture, extending along a continuum from arrival through to the post-operative setting. Best practice guidelines emphasize multidisciplinary care including management by an orthogeriatric service, regular delirium screening, and multimodal interventions. The evidence base for prevention is strongest in terms of multifaceted interventions, while once delirium has set in, early recognition and identification of the cause are key. Integration of effective strategies is often suboptimal, and may be supported by approaches such as interactive teaching methodologies, routine feedback, and clear protocol dissemination. Partnering with patients and carers will support person centered care, improve patient experiences, and may improve outcomes. Ongoing work needs to focus on implementing recognized best practice, in order to minimize the health, social and economic costs of delirium.