Falls in hospital increase length of stay regardless of degree of harm

The Impact of Adding a 2-Way Video Monitoring System on Falls and Costs for High-Risk Inpatients

OBJECTIVES

We aimed to investigate the value of adding a video monitoring (VM) system with falls and costs for patients at high risk.

METHODS

We conducted a retrospective, historically controlled study of adults (≥18 y old) at high risk of fall admitted at the University of Miami Hospital and Clinics from January 1 to November 30, 2020 (pre-VM) and January 1 to November 30, 2021 (post-VM); in-person sitters were available in both periods. Fall risk assessment was conducted on admission and at every nursing shift; we defined patients as high risk if their Morse Fall Scale was ≥60. We conducted a multivariable logistic regression model to evaluate the association of period (pre- versus post-VM) with falls and performed a cost analysis.

RESULTS

Our primary cohort consisted of 9,034 patients at high risk of falls, 4,207 (46.6%) in the pre-VM and 4,827 (53.4%) in the post-VM period. Fall rates were higher in the pre- than the post-VM periods (3.5% versus 2.7%, P = 0.043). After adjustment, being admitted during the post-VM period was associated with a lower odds of fall (odds ratio [95% confidence interval], 0.49 [0.37-0.64], P < 0.001). The median adjusted hospital cost (in 2020 dollars) was $1,969 more for patients who fell than for patients who did not (interquartile range, $880-$2,273). Considering start-up and ongoing costs, we estimate VM implementation to partly replace in-person monitoring has potential annual cost savings of >$800,000 for a hospital similar to ours.

CONCLUSIONS

Video monitoring to augment in-person sitters is an effective fall prevention initiative for patients at high risk of falls, which is likely also cost-effective.

Predictors and Outcomes of Falls in Older Adults Presenting to the Emergency Room in Saudi Arabia: A Cross-Sectional Analysis

INTRODUCTION

Saudi Arabia is witnessing a demographic shift characterized by a rising elderly population. Cases of fall in this demographic have emerged as a significant health concern, especially in emergency room (ER) settings. Despite this, there is limited research on the causes and outcomes of such incidents. This study intends to bridge the gap in understanding the factors leading to falls in elderly patients presenting to ERs and the subsequent outcomes. Such understanding is pivotal for the formulation of effective prevention strategies and enhanced healthcare services for the elderly.

METHODS

To achieve the study's objectives, we employed SPSS software for Windows, version 28.0 (IBM Corp., Armonk, NY) for data analysis. We collected demographic information, including age, gender, education, employment status, and location, to measure patient satisfaction with the quality and responsiveness of emergency care, using Likert scale responses via electronic survey conducted as a cross-sectional study from January 2023 to August 2023, summarizing it using descriptive statistics. We analyzed categorical variables by frequencies and percentages. Chi-square tests were utilized to examine differences in distribution across categories for fall factors, and a p-value below 0.05 was deemed significant. Through logistic regression, we pinpointed the predictors of falls among older adults, showcasing the strength and direction of these relationships. Adjusted odds ratios with 95% confidence intervals were documented. A perception survey was also conducted to evaluate ER patient satisfaction.

RESULTS

Our results shed light on various aspects of fall prevention and emergency care. There was a pronounced representation in age groups of 18-24 and 25-34 years, indicating the need for interventions tailored to different age groups. Patterns were identified where subjects engaged in limited physical activity and consumed alcohol infrequently. Mobility and balance problems were commonly found, stressing the need to address these issues. Chronic conditions such as hypertension and diabetes correlated with fall incidents. Additionally, sociodemographic factors like gender, education, and employment status played a role in influencing the risk of falls. Although age and location seemed to have a less pronounced effect, there exists an opportunity to enhance communication and patient participation in emergency care for improved experiences.

CONCLUSION

The findings from our study provide crucial insights into the prevention of falls and enhancement of emergency care for Saudi Arabia's elderly population. By revealing the intricate relationships between sociodemographic attributes, health indicators, chronic ailments, and incidents of falls, we emphasize the need for well-rounded interventions. There is a pressing requirement for comprehensive fall prevention initiatives tailored to specific risk groups. Additionally, improving ER services is integral to ensuring the safety and well-being of older adults. This research can serve as a foundational resource for healthcare professionals and policymakers to devise robust strategies to reduce fall-related injuries and elevate the quality of emergency care outcomes.

Activities of Daily Living Assessment Early in Hospitalization Is Associated With Key Outcomes

IMPORTANCE

Assessing patients' activities of daily living (ADLs) function early in hospitalization may help identify patients at risk for poor outcomes.

OBJECTIVE

To investigate the association between patients' ADL function at hospital admission and length of stay, inpatient falls, hospital-acquired pressure injuries, and discharge disposition.

DESIGN

Retrospective cohort study using scores collected on the Activity Measure for Post-Acute Care Inpatient Activity Short Form (AM-PAC IASF) in routine care at admission.

SETTING

Two inpatient units at the Johns Hopkins Hospital.

PARTICIPANTS

Hospitalized patients with various diagnoses, including neurosurgical, stroke, and general neurology (N = 1,899).

RESULTS

People with lower AM-PAC scores (every 10-point difference) had increased odds (odds ratio [OR] = 1.6; 95% confidence interval [CI] = 1.4-1.8) of being in the highest length-of-stay quartile (≥8 days), having an injurious fall (OR = 1.7; 95% CI = 1.3-2.2), acquiring a pressure injury (OR = 2.7; 95% CI = 1.5-5.3), and being discharged to a postacute care facility (OR = 3.02; 95% CI = 2.1-2.7).

CONCLUSIONS AND RELEVANCE

Greater functional impairments in ADLs, measured with the AM-PACS IASF, were significantly associated with worse outcomes. AM-PAC IASF scores may be useful in identifying patients with ADL deficits and targeting occupational therapy services for patients who are at higher risk for negative outcomes. What This Article Adds: Early assessment of ADL function in routine care of hospitalized patients may aid in treatment and care plan decisions, particularly for inpatients who may be at higher risk for adverse outcomes.

The Combined Effect of Delirium and Falls on Length of Stay and Discharge

INTRODUCTION

Delirium or a fall are associated with many negative outcomes including increased length of stay (LOS) and discharge to a facility; however, this relationship is incompletely understood.

METHODS

A cross-sectional study of all hospitalizations in a large, tertiary care hospital evaluated the effect of delirium and a fall on the outcomes of LOS and risk of being discharged to a facility.

RESULTS

The study included 29,655 hospital admissions. A total of 3,707 (12.5%) patients screened positive for delirium and 286 (0.96%) had a reported fall. After adjustment for covariates, relative to patients without delirium or a fall, patients with delirium only had a 1.64-fold longer LOS; patients with fall only had a 1.96-fold longer LOS; and patients who had delirium and fall had a 2.84-fold longer LOS. The adjusted odds of discharge to a facility, relative to those without delirium or a fall, was 8.98 times higher in those with delirium and a fall.

CONCLUSIONS

Delirium and falls influence LOS and likelihood of being discharged to a facility. The joint impact of falls and delirium on LOS and facility discharge was more than additive. Hospitals should consider the integrated management of delirium and falls.

Deriving Multiple-Layer Information from a Motion-Sensing Mattress for Precision Care

Bed is often the personal care unit in hospitals, nursing homes, and individuals' homes. Rich care-related information can be derived from the sensing data from bed. Patient fall is a significant issue in hospitals, many of which are related to getting in and/or out of bed. To prevent bed falls, a motion-sensing mattress was developed for bed-exit detection. A machine learning algorithm deployed on the chip in the control box of the mattress identified the in-bed postures based on the on/off pressure pattern of 30 sensing areas to capture the users' bed-exit intention. This study aimed to explore how sleep-related data derived from the on/off status of 30 sensing areas of this motion-sensing mattress can be used for multiple layers of precision care information, including wellbeing status on the dashboard and big data analysis for living pattern clustering. This study describes how multiple layers of personalized care-related information are further derived from the motion-sensing mattress, including real-time in-bed/off-bed status, daily records, sleep quality, prolonged pressure areas, and long-term living patterns. Twenty-four mattresses and the smart mattress care system (SMCS) were installed in a dementia nursing home in Taiwan for a field trial. Residents' on-bed/off-bed data were collected for 12 weeks from August to October 2021. The SMCS was developed to display care-related information via an integrated dashboard as well as sending reminders to caregivers when detecting events such as bed exits and changes in patients' sleep and living patterns. The ultimate goal is to support caregivers with precision care, reduce their care burden, and increase the quality of care. At the end of the field trial, we interviewed four caregivers for their subjective opinions about whether and how the SMCS helped their work. The caregivers' main responses included that the SMCS helped caregivers notice the abnormal situation for people with dementia, communicate with family members of the residents, confirm medication adjustments, and whether the standard care procedure was appropriately conducted. Future studies are suggested to focus on integrated care strategy recommendations based on users' personalized sleep-related data.

The 'Bermuda Triangle' of orthostatic hypotension, cognitive impairment and reduced mobility: prospective associations with falls and fractures in The Irish Longitudinal Study on Ageing

BACKGROUND

Orthostatic hypotension (OH), cognitive impairment (Cog) and mobility impairment (MI) frequently co-occur in older adults who fall. This study examines clustering of these three geriatric syndromes and ascertains their relationship with future falls/fractures in a large cohort of community-dwelling people ≥ 65 years during 8-year follow-up.

METHODS

OH was defined as an orthostatic drop ≥ 20 mmHg in systolic blood pressure (from seated to standing) and/or reporting orthostatic unsteadiness. CI was defined as Mini Mental State Examination ≤ 24 and/or self-reporting memory as fair/poor. MI was defined as Timed Up and Go ≥12 s. Logistic regression models, including three-way interactions, assessed the longitudinal association with future falls (explained and unexplained) and fractures.

RESULTS

Almost 10% (88/2,108) of participants had all three Bermuda syndromes. One-fifth of participants had an unexplained fall during follow-up, whereas 1/10 had a fracture. There was a graded relationship with incident unexplained falls and fracture as the number of Bermuda syndromes accumulated. In fully adjusted models, the cluster of OH, CI and MI was most strongly associated with unexplained falls (odds ratios (OR) 4.33 (2.59-7.24); P < 0.001) and incident fracture (OR 2.51 (1.26-4.98); P = 0.045). Other clusters significantly associated with unexplained falls included OH; CI and MI; MI and OH; CI and OH. No other clusters were associated with fracture.

DISCUSSION

The 'Bermuda Triangle' of OH, CI and MI was independently associated with future unexplained falls and fractures amongst community-dwelling older people. This simple risk identification scheme may represent an ideal target for multifaceted falls prevention strategies in community-dwelling older adults.

Two factors that can increase the length of hospital stay of patients with dementia

OBJECTIVES

Patients with dementia are at greater risk of a long hospital stay and this is associated with adverse outcomes. The aim of this service evaluation was to identify variables most predictive of increased length of hospital stay amongst patients with dementia.

METHODS/DESIGN

We conducted a retrospective analysis on a cross-sectional hospital dataset for the period January-December 2016. Excluding length of stay less than 24h and readmissions, the sample comprised of 1133 patients who had a dementia diagnosis on record.

RESULTS

The highest incidence rate ratio for length of stay in the dementia sample was: (a) discharge to a care home (IRR: 2.443, 95% CI 1.778-3.357), (b) falls without harm (IRR: 2.486, 95% CI 2.029-3.045).

CONCLUSIONS

Based on this dataset, we conclude that improvements made to falls prevention strategies in hospitals and discharge planning procedures can help to reduce the length of stay for patients with dementia.

Patient-level and organizational-level factors influencing in-hospital falls

AIM

In-hospital fall is one key safety issue in a healthcare setting. Although healthcare providers apply several strategies for preventing falls, falls still occur in hospitals. The aim of this study was to investigate patient-level and organizational-level factors influencing in-hospital falls.

DESIGN

A multicentre retrospective observational study.

METHODS

This study used the national healthcare database and supplemented with organizational data obtained through a survey. Data extraction and survey were conducted between July and August 2020. A mixed-effect logistic regression model was used to analyse factors influencing in in-hospital falls.

RESULTS

A total of 43,286 patients admitted in 86 hospitals were included in this study. Fall rate was 0.85 per 1000 days. Length of stay was significantly longer for fall patients than for no-fall patients. Patient-level factors (including age, mobility impairment and surgery) and organizational-level factors (including nurse staffing and proportion of new nurses) were significant factors influencing in-hospital falls.

CONCLUSION

Since in-hospital falls increase economic burden to patients, we should consider various fall prevention strategies to reduce falls. For a strategy to be applied stably to patients, organizational factors must be supported.

IMPACT

Proactive fall management in acute settings is essential to ensure patient safety. Considering that the number of patients with fall risk is increasing due to ageing, organizational factors should be supported to provide quality nursing care for fall risk patients. Therefore, nurse leaders should primarily ensure an appropriate level of nurse staffing. They also need to make efforts to strengthen clinical competency of nurses.

Using consensus methods to prioritize modifiable risk factors for development of manifestations of frailty in hospitalized older adults

AIM

The aim of the study was to reach consensus on modifiable risk factors for a novel system of care to address Manifestations of Frailty in hospitalized older adults.

DESIGN

Consensus study.

METHOD

A modified nominal group technique, incorporating expert group face-to-face interaction, review of existing evidence and pre/post-meeting questionnaire completion was undertaken November 2019-February 2020.

RESULTS

Seventy-one risk factors, within seven risk factor domains (pain, medication, fluid and nutrition intake, mobility, elimination, infection, additional patient factors) were considered. It was agreed that 44 risk factors incorporating patient, organizational and environmental risk factors were modifiable and should be included in a novel system of care.

Relying on myself: The lived experience of being at risk for falling in the hospital among older adults

Inpatient fall rates have not significantly decreased the last decade. Older adults have an estimated 50% greater inpatient fall rate than younger adults. How older adults perceive their own fall risk affects their adherence to fall prevention recommendations. The aim of this phenomenological study was to understand the lived experiences of being at risk for falling in the hospital among older adults. Nine participants (N=9) aged 65 years and older (female=55%) were interviewed twice using online video-conferencing after hospital discharge, and interview data was analyzed using van Manen's interpretive phenomenological method. Five major interpretive themes emerged: Relying on Myself, Managing Balance Problems in an Unfamiliar Environment, Struggling to Maintain Identity, Following the Hospital Rules, and Maintaining Dignity in the Relationships with Nursing Staff. Hospitalized older adults employed their self-efficacy to manage balance problems in the hospital. Additional fall prevention interventions supporting hospitalized older adults' self-management of fall risk are needed.

Allogeneic haematopoietic stem cell transplantation and patient falls: impact of lower extremity muscle strength

OBJECTIVES

Patients undergoing allogeneic haematopoietic stem cell transplantation (allo-HSCT) have a higher risk of falls than those receiving other therapies for haematological disorders. This study aimed to investigate the impact of pretransplant lower extremity muscle strength (LEMS) on post-transplant falls.

METHODS

In this retrospective cohort study, patients aged ≥18 years who underwent allo-HSCT were included. All data were extracted from medical records. LEMS was defined as the knee extension force measured by a handheld dynamometer divided by the patient's weight. The receiver operating characteristic (ROC) curve was used to calculate the optimal LEMS cut-off value for prediction of falls. Patients were categorised into low and normal LEMS groups based on the cut-off value. The impact of pretransplant LEMS on post-transplant falls was analysed using a Cox proportional hazards model.

RESULTS

In total, 101 patients were analysed. During the observation period, falls occurred in 32 patients (31.7%). The ROC curve analysis results showed that the optimal LEMS cut-off value for prediction of falls was 45.4% per body weight. In multivariate analysis, pretransplant low LEMS was a significant predictor of falls in model 1 with patient characteristics as a confounding factor and model 2 with medications-inducing falls as a confounding factor, respectively (model 1: HR 3.23, 95% CI 1.37 to 7.64; model 2: HR 2.82, 95% CI 1.20 to 6.59).

CONCLUSIONS

Pretransplant LEMS was a significant predictor of post-transplant falls. The results of this study may help to prevent falls in patients undergoing allo-HSCT.

Modelling falls in Parkinson’s disease and normal ageing in mice using a complex motor task

Falls resulting from multifactorial deficits are common in both normal ageing and Parkinson’s disease. Resultant injuries can lead to increased hospitalisation and excess mortality. As the disease progresses, gait and balance deficits are relatively refractory to dopaminergic treatments suggesting another system is involved. Attentional impairment is a significant risk factor for falls, and disruption to both the cortical cholinergic system and striatal dopaminergic system increases falls in rats undergoing a complex motor task with high attentional load. However, it is unclear whether this translates to mice and whether normal ageing induces similar deficits. In this study, we use a complex motor task to test the effects of acute dopaminergic and cholinergic antagonism using alpha-flupentixol and scopolamine, respectively, in mice. We also test the effects of normal ageing on complex motor performance and whether these changes are sensitive to a clinical dose of the non-steroidal anti-inflammatory Rimadyl. Consistent with previous work, we show that cholinergic but not dopaminergic antagonism impaired task performance. However, a combined approach did not potentiate the deficit beyond observed with cholinergic antagonism alone. We also show that task performance is impaired in aged mice relative to younger controls, and that Rimadyl reduces number of foot slips in an age-specific manner. Overall, these data support prior work showing the importance of the cholinergic system in falls. The studies in aged mice found age-related impairments and a role for inflammation but did not find evidence of an interaction with attentional load, although only one manipulation was tested.

Hospital performance comparison of inpatient fall rates; the impact of risk adjusting for patient-related factors: a multicentre cross-sectional survey

BACKGROUND

Comparing inpatient fall rates can serve as a benchmark for quality improvement. To improve the comparability of performance between hospitals, adjustments for patient-related fall risk factors that are not modifiable by care are recommended. Thereafter, the remaining variability in risk-adjusted fall rates can be attributed to differences in quality of care provided by a hospital. Research on risk-adjusted fall rates and their impact on hospital comparisons is currently sparse. Therefore, the aims of this study were to develop an inpatient fall risk adjustment model based on patient-related fall risk factors, and to analyse the impact of applying this model on comparisons of inpatient fall rates in acute care hospitals in Switzerland.

METHODS

Data on inpatient falls in Swiss acute care hospitals were collected on one day in 2017, 2018 and 2019, as part of an annual multicentre cross-sectional survey. After excluding maternity and outpatient wards, all inpatients older than 18 years were included. Two-level logistic regression models were used to construct unadjusted and risk-adjusted caterpillar plots to compare inter-hospital variability in inpatient fall rates.

RESULTS

One hundred thirty eight hospitals and 35,998 patients were included in the analysis. Risk adjustment showed that the following factors were associated with a higher risk of falling: increasing care dependency (to a great extent care dependent, odds ratio 3.43, 95% confidence interval 2.78-4.23), a fall in the last 12 months (OR 2.14, CI 1.89-2.42), the intake of sedative and or psychotropic medications (OR 1.74, CI 1.54-1.98), mental and behavioural disorders (OR 1.55, CI 1.36-1.77) and higher age (OR 1.01, CI 1.01-1.02). With odds ratios between 1.26 and 0.67, eight further ICD-10 diagnosis groups were included. Female sex (OR 0.78, CI 0.70-0.88) and postoperative patients (OR 0.83, CI 0.73-0.95) were associated with a lower risk of falling. Unadjusted caterpillar plots identified 20 low- and 3 high-performing hospitals. After risk adjustment, 2 low-performing hospitals remained.

CONCLUSIONS

Risk adjustment of inpatient fall rates could reduce misclassification of hospital performance and enables a fairer basis for decision-making and quality improvement measures. Patient-related fall risk factors such as care dependency, history of falls and cognitive impairment should be routinely assessed.

Extrapancreatic Complications in Hospitalized Patients With Mild Acute Pancreatitis Are Associated With Poorer Outcomes: Results From a Single-Center Study

OBJECTIVE

Patients with acute pancreatitis (AP) are at risk for extrapancreatic complications (EPCs) when admitted to the intensive care unit (ICU). We assessed the prevalence of EPCs in non-ICU AP patients and their outcomes.

METHODS

We retrospectively studied EPCs in non-ICU AP patients between 2008 and 2018. Outcomes such as length of stay (LOS), inpatient mortality, and 30-day readmission rates were compared between those with and without EPC.

RESULTS

Of the 830 AP patients, 151 (18.1%) had at least 1 EPC. These included urinary tract infection (15.9%), Clostridium difficile infection (17.2%), pneumonia (7.3%), bacteremia (17.2%), acute kidney injury requiring dialysis (3.3%), gastrointestinal bleeding (12.5%), alcohol withdrawal (24.5%), delirium (14.5%), and falls (1.32%). Patients with EPC had increased mean LOS (6.98 vs 4.42 days; P < 0.001) and 30-day readmissions (32.5% vs 19%; P < 0.001). On multivariate regression, EPCs were independently associated with higher LOS (odds ratio, 1.45 [95% confidence interval, 1.36-1.56]; P < 0.001) and 30-day readmissions (odds ratio, 1.94 [95% confidence interval 1.28-2.95]; P < 0.001).

CONCLUSIONS

The EPCs are common among noncritical AP patients and contribute to poor outcomes like increased LOS and 30-day readmissions.

Implementation and experience of an innovative smart patient care system: a cross-sectional study

Background

Although a patient care system may help nurses handle patients’ requests or provide timely assistance to those in need, there are a number of barriers faced by nurses in handling alarms.

Methods

The aim of the study was to describe the implementation and experience of an innovative smart patient care system (SPCS). This study applied a cross-sectional descriptive design. We recruited 82 nurses from a medical center in Taiwan, with 25 nurses from a ward that had introduced an SPCS and 57 nurses from wards that used the traditional patient care system (TPCS). The major advantages of the SPCS compared to the TPCS include the specification of alarm purposes, the routing of alarms directly to the mobile phone; the capability of immediate communication via phone; and three-stage bed-exit alerts with low false alarm rate.

Results

Approximately 56% of nurses in the TPCS wards perceived that the bed-exit alert was easily ignorable, while this rate was reduced to 32% in the SPCS ward. The immediate communication via phone was considered as the most helpful function of the SPCS, with a weighted average score of 3.92/5, and 52% of nurses strongly agreed (5/5) that this function was helpful. The second-highest ranked function was the three-stage bed-exit alert, with an average score of 3.68/5, with approximately 24% of nurses strongly agreeing (5/5) that this function was helpful. The average response time using TPCS was 145.66 s while it was 59.02 s using the SPCS (P < .001). Among the 110 observed alarms in the SPCS ward, none of them were false bed-exit alarms. In comparison, among 120 observed alarms in the TPCS wards, 42 (35%) of them were false bed-exit alarms (P < .001). In this study, we found that 30.91% of alarms using SPCS were processed because nurses received and responded to the alert via mobile phone.

Conclusions

A smart patient care system is needed to help nurses make more informed prioritization decisions between responding to alarms and ongoing tasks and finally assist them in adjusting their work in various situations to improve work efficiency and care quality.

Prevalence and impact of malnutrition on length of stay, readmission, and discharge destination

BACKGROUND

Studies indicate one in three hospitalized patients are malnourished upon admission, however, the documented malnutrition rate in acute care hospitals is often lower. This study measured prevalence of malnutrition upon admission and correlated the relationship among malnutrition status, length of stay (LOS), discharge disposition, and readmission rate.

MATERIALS AND METHODS

A prospective observational cohort study was performed across nine tertiary care hospitals in Houston, Texas. Registered Dietitians screened patients age ≥18 within 24 hours of admission for 2 consecutive days per hospital. Malnourished patients were diagnosed using a modified version of 2012 Consensus Statement from the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition. Data collected included demographics, LOS, discharge disposition, and 30-day re-admission status.

RESULTS

In 416 patients, 31.7% were malnourished upon admission. Malnourished patients were significantly older (67.8 vs 57.6 years, P<.001) and had a lower BMI (26.2 vs 32.4 kg/m² , P<.001) than nonmalnourished patients. Malnourished patients had higher odds of having a LOS ≥3 days (2.38 [95% CI 1.45-3.88], P<.001) and higher odds of readmitting within 30 days (2.28 [95% CI 1.26-4.12], P<.006) when compared to nonmalnourished patients. There were no significantly different clinical outcomes between moderately and severely malnourished groups.

CONCLUSION

The study successfully utilized the modified AND-ASPEN criteria to show that approximately one in three patients presented with malnutrition upon admission. Malnourished patients were more likely to have longer LOS and more likely to be readmitted within 30 days. This article is protected by copyright. All rights reserved.

Testing of Reliability and Validity of the Peninsula Health Falls Risk Assessment Tool (PHFRAT) in Acute Care: A Cross-Sectional Study

Purpose

The purpose of this study was to evaluate the validity and reliability of the Peninsula Health Fall Risk Assessment Tool (PHFRAT) in acute care in various medical specialties. The assessment has not been previously studied in acute care.

Methods

The cross-sectional study was conducted in a large acute care hospital system. The retrospective medical data were used to explore the validity of the PHFRAT. The data consisted of all adult inpatients (≥ 18 age) evaluated by the PHFRAT during 2014-2016 (n = 22,700). The Poisson regression, logistic regression, sensitivity, specificity, and the area under the ROC curve were evaluated. The data for the reliability study were collected in 2016 in twelve units by evaluating the patients (n = 359) twice using the PHFRAT. The prospective data were analyzed using Fleiss' Kappa, and the content validity index was also counted.

Results

In the somatic data, the change in the risk level from low risk to high risk increases the probability of falls by a factor of 2.8 (p<0.01). When the cut-off point was 9, sensitivity and specificity were 72% and 59%, respectively, and the area under the ROC curve was 0.67 (p<0.01). Validity varied by medical specialties. In the validity analysis, it was not possible to calculate the statistical significance from the psychiatry data. The inter-rater reliability was 0.68 (p<0.01).

Conclusion

This study shows that the PHFRAT proved to be moderately suitable for detecting the risk of falling for adult patients admitted to somatic units in acute care. The reliability of the PHFRAT was moderate. The results indicate the need to study the PHFRAT more broadly in psychiatric care as well as some specialties in somatic care.

Elderly patients and falls: a systematic review and meta-analysis

OBJECTIVE

The predetermination of the risk for falls in elderly patients, who will have or had a surgery, enables one to carry out the protective/preventive interventions on this matter. The aim of this review was to provide an up-to-date meta-analysis with regard to falls in elderly surgical patients.

MATERIALS AND METHODS

The studies, which were carried out on elderly patients between January 2009 and November 2019 and which investigated the risk factors for falls in elderly surgical patients, were screened on the databases of Google Scholar, Pubmed, Ovid, Cinahl through various combinations of keywords, such as "geriatrics", "aged", "surgery", "accidental falls" in English or Turkish, to determine the risk factors for the falls in elderly surgical patients.

RESULTS

Meeting the study inclusion criteria, 18 studies were analyzed. Of these studies, three were retrospective, seven descriptive, two case-control, four cross-sectional, and two prospective. The kappa value of the general rate of agreement was found as 0.84. No publication bias found in the studies included (Kendall's tau b = 0.31; p = 0.07) in the meta-analysis based on the values calculated.

CONCLUSION

In this meta-analysis, it was determined that the falls in elderly surgical patients were quite a prevalent public health problem, that the presence of chronic diseases and previous history of falls constituted an extremely high risk for the falls in elderly patients, and that the age or the presence of a gait-inhibiting condition did not constitute any risk for the falls in elderly patients.

Nurses' view of implementation evidence-based fall prevention interventions: A qualitative study

AIM

The purpose of this descriptive qualitative study was to evaluate nurses' views of implementation evidence-based fall prevention interventions.

METHODS

The study was conducted with participation of nurses who worked in a training and research hospital after evidence-based fall prevention interventions had been implemented. Interviews were done with 17 nurses who participated in all training courses.

RESULTS

The evaluation of the interventions was examined, and three themes were extracted through analysis: 'effectiveness of training programme', 'barriers' and 'suggestions'.

CONCLUSION

Nurses emphasized that evidence-based fall prevention interventions are usable in hospital, but team collaboration and administrative support are required for better outcomes.

IMPLICATIONS FOR NURSING MANAGEMENT

The study result shows that fall prevention interventions should be introduced to all health care professionals, through the use of various training methods. Training should be given to patients and their caregivers, and barriers that nurses stated like understaffing, lack of materials and tools that ensure patient safety and internet (research/scientific information) access restriction should be reduced.

Clinical factors associated with increased length of stay and readmission in patients with medication-related hospital admissions: a retrospective study

BACKGROUND

Adverse drug events (ADEs) remain a key contributor to hospitalisations, resulting in long hospital stays and readmissions. Information pertaining to the specific medications and clinical factors associated with these outcomes is limited. Hence, a better understanding of these factors and their relationship to ADEs is required.

OBJECTIVES

To investigate medications involved, clinical manifestations of ADE-related hospitalisations, and their association with length of stay and readmission.

METHODS

A retrospective medical record review of patients admitted to a major, tertiary referral hospital in NSW, Australia, from January 2019 to August 2020 was conducted. ADEs were identified using Australian Refined Diagnosis Related Group (AR-DRG) codes: X40, X61, X62 and X64. Medications were classified per the Anatomical Therapeutic Chemical (ATC) classification system and clinical symptoms were classified per the International Classification of Disease (ICD) 9-CM. Logistic regression was performed to assess the relationship between medication and presentation classes with length of stay (≥2 days vs <2 days) and readmission.

RESULTS

There were 125 patients who met inclusion criteria (median age = 64 [interquartile range, 45-75] years; 53.6% male). Anti-thrombotic agents, opioids, antidepressants, antipsychotics, insulins and NSAIDs were the most implicated pharmacological classes. Neurological medications and falls were associated with a length of stay ≥2 days (adjusted odds ratio [aOR] 3.92, 95% confidence interval [CI] 1.48-10.33 and aOR 3.24, 95% CI 1.05-10.06, respectively). Neurological medications and neurological and cognitive disorders were associated with an increased likelihood of 90-day readmission (aOR 2.63, 95% CI 1.05-6.57 and aOR 3.20, 95% CI 1.17-8.75, respectively).

CONCLUSION

This study identified neurological medications as high-risk for increased length of stay and readmission in those hospitalised due to ADEs. This highlights the need for judicious prescribing and monitoring of these medications.

Minimizing the knowledge-to-action gap; identification of interventions to change nurses' behavior regarding fall prevention, a mixed method study

Background

The need for effective continuing education is especially high in in-hospital geriatric care, as older patients have a higher risk of complications, such as falls. It is important that nurses are able to prevent them. However, it remains unknown which interventions change the behavior of nurses. Therefore, the aim of this study is to identify intervention options to change the behavior of hospital nurses regarding fall prevention among older hospitalized patients.

Methods

This study used a mixed method design. The Behavior Change Wheel (BCW) was used to identify intervention functions and policy categories to change the behavior of nurses regarding fall prevention. This study followed the eight steps of the BCW and two methods of data collection were used: five focus groups and three Delphi rounds. The focus groups were held with hospital nurses (n=26). Geriatric experts (n=11), managers (n=13) and educators (n=13) were included in the Delphi rounds. All data were collected within ten tertiary teaching hospitals in the Netherlands. All participants were included based on predefined in- and exclusion criteria and availability.

Results

In Geriatric experts opinions interventions targeting behavior change of nurses regarding fall prevention should aim at after-care, estimating fall risk and providing information. However, in nurses opinions it should target; providing information, fall prevention and multifactorial fall risk assessment. Nurses experience a diversity of limitations relating to capability, opportunity and motivation to prevent fall incidents among older patients. Based on these limitations educational experts identified three intervention functions: Incentivisation, modelling and enablement. Managers selected the following policy categories; communication/marketing, regulation and environmental/social planning.

Conclusions

The results of this study show there is a discrepancy in opinions of nurses, geriatric experts, managers and educators. Further insight in the role and collaboration of managers, educators and nurses is necessary for the development of education programs strengthening change at the workplace that enable excellence in nursing practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00598-z.

Evaluating resampling methods and structured features to improve fall incident report identification by the severity level

OBJECTIVE

This study aims to improve the classification of the fall incident severity level by considering data imbalance issues and structured features through machine learning.

MATERIALS AND METHODS

We present an incident report classification (IRC) framework to classify the in-hospital fall incident severity level by addressing the imbalanced class problem and incorporating structured attributes. After text preprocessing, bag-of-words features, structured text features, and structured clinical features were extracted from the reports. Next, resampling techniques were incorporated into the training process. Machine learning algorithms were used to build classification models. IRC systems were trained, validated, and tested using a repeated and randomly stratified shuffle-split cross-validation method. Finally, we evaluated the system performance using the F1-measure, precision, and recall over 15 stratified test sets.

RESULTS

The experimental results demonstrated that the classification system setting considering both data imbalance issues and structured features outperformed the other system settings (with a mean macro-averaged F1-measure of 0.733). Considering the structured features and resampling techniques, this classification system setting significantly improved the mean F1-measure for the rare class by 30.88% (P value < .001) and the mean macro-averaged F1-measure by 8.26% from the baseline system setting (P value < .001). In general, the classification system employing the random forest algorithm and random oversampling method outperformed the others.

CONCLUSIONS

Structured features provide essential information for categorizing the fall incident severity level. Resampling methods help rebalance the class distribution of the original incident report data, which improves the performance of machine learning models. The IRC framework presented in this study effectively automates the identification of fall incident reports by the severity level.

Prevalence and characteristics of incident falls related to nocturnal toileting in hospitalized patients

Objectives: Although nocturia is a risk factor for incident falls in the community, studies are required to gain an understanding of incident falls related to nocturnal toileting in hospitals. The aim of this study is to describe the prevalence and characteristics of incident falls in adult hospitalized patients related to nocturnal toileting.Methods: A retrospective review of the electronic incident reporting and learning system and medical records of inpatients that had an incident fall.Results: The prevalence of toileting-related incident falls was 53% (73/137) and 28% of all incident falls were related to nocturnal toileting.Intravenous fluid infusion was associated with falls related to toileting, whereby median perfusion volume during night-time was 375 ml [IQR: 225-578 ml].Conclusions: The prevalence of nocturnal toileting-related incident falls in hospitals is high. Nocturia could be a leading cause of these incident falls. Intravenous fluid infusion might be part of the aetiology of (iatrogenic) nocturia.

Association of preoperative medication with postoperative length of stay in elderly patients undergoing hip fracture surgery

BACKGROUND

For elderly patients who are about to undergo surgery, research on the effects of preoperative medication on postoperative outcomes is rare, especially preoperative discontinuation-requiring medication (PDRM) which needed to be discontinued because of its increased risk of postoperative complications.

AIM

To investigate whether preoperative medication (PDRM and polypharmacy) is associated with postoperative length of hospital stay (LOS) in elderly patients undergoing hip fracture surgery.

METHODS

Patients aged ≥ 65 who were scheduled for hip (limited to femoral tuberosity) fracture surgery were included. Baseline characteristics, preoperative medication and postoperative LOS were collected from the electronic medical record. The primary outcome was postoperative LOS.

RESULTS

A total of 369 hip fracture patients were included. There were 188 and 122 patients exposed to PDRM and polypharmacy, respectively. Multivariate analysis models were constructed using significant factors for prolonged postoperative hospital stay from univariate analysis: Model I (body mass index (BMI), Charlson comorbidity index (CCI) ≥ 7, creatinine clearance rate (Ccr) < 60 and PDRM) and Model II (BMI, Ccr ≥ 7, Ccr < 60 and polypharmacy). CCI was the most significant factor. Its adjusted odds ratio was as large as 2.7 and attributable risk was 63%. In preoperative medication use, both polypharmacy and PDRM showed significant association with postoperative LOS.

CONCLUSION

The present study supported the impact of PDRM on postoperative LOS in geriatric hip fracture patients. The results added a further aspect to preoperative medication optimization in elderly patients undergoing hip fracture surgery.

Development and validation of the fall risk perception questionnaire for patients in acute care hospitals

AIMS AND OBJECTIVES

This study aimed to develop a fall risk perception questionnaire for patients admitted to acute care hospitals and to establish its reliability and validity.

BACKGROUND

To prevent falls during patients' hospitalisation, it is essential for them to accurately perceive their risk of falling.

DESIGN

This methodological study was performed to develop a fall risk perception questionnaire.

METHODS

After generating a preliminary questionnaire, two rounds of content validity testing were performed with nine experts. Following a pilot test, a convenience sample of 236 participants was recruited from an acute care hospital between 2 May 2018 and 15 December 2019. Construct, convergent and known-group validity of the questionnaire was evaluated, and reliability was estimated by calculating the internal consistency reliability coefficients. The study adhered to STROBE guidelines.

RESULTS

Exploratory factor analysis yielded a three-factor solution with 27 items. The questionnaire showed statistically significant positive correlation with the Korean Falls Efficacy Scale-International and the Morse Fall Scale, thus establishing convergent validity. For known-group comparison, Morse Fall Scale scores were categorised into two groups by cut-off score. The risk for falls group had a significantly higher perceived fall risk than the no risk for falls group, thus establishing known-group validity. Cronbach's alpha values indicated good to excellent reliability for the overall questionnaire with 27 items and for each of the three subfactors.

CONCLUSIONS

The fall risk perception questionnaire demonstrated satisfactory reliability and validity in an acute care hospital setting.

RELEVANCE TO CLINICAL PRACTICE

Because understanding patients' perceptions of their fall risk is essential for preventing falls, it is necessary to regularly assess patients' fall risk perception using tools with established reliability and validity.

Clinical deterioration and hospital-acquired complications in adult patients with isolation precautions for infection control: A systematic review

AIM

To review and synthesize literature examining clinical deterioration and hospital-acquired complications in adult patients with isolation precautions for infection control.

BACKGROUND

Isolation precautions are a common infection prevention and control strategy which may have impact on safety and quality of care.

DESIGN

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines guided this systematic review, which was registered with PROSPERO [CRD42019131573].

DATA SOURCES

A search of Medline, Embase, and Cumulative Index to Nursing and Allied Health Literature was conducted for studies published in English up to 5 April 2019.

REVIEW METHODS

Risk of bias was determined using Critical Appraisal Skills Program tools. Quality appraisal was performed using the Grades of Recommendation, Assessment, Development, and Evaluation approach. The primary outcomes of interest were clinical deterioration events and hospital-acquired complications. In-hospital death and hospital length of stay were secondary outcomes. Data were synthesized using a narrative approach.

RESULTS

The search yielded 785 citations after removal of duplicates, of which, six studies were relevant. Certainty of evidence for outcomes of interest was low to very low.

CONCLUSION

There is no strong evidence that adult medical and surgical ward patients in isolation precautions for infection control are more or less likely to experience clinical deterioration or hospital-acquired complications.

IMPACT

What problem did the study address? Are patients in isolation precautions more likely to experience clinical deterioration or hospital-acquired complications than non-isolated patients? What were the main findings? There is no strong evidence that clinical deterioration and hospital-acquired complications are more likely to occur to patients in isolation precautions for infection control. This research is of relevance to acute care nurses.

Comparison of the predictive validity of three fall risk assessment tools and analysis of fall-risk factors at a tertiary teaching hospital

AIMS AND OBJECTIVES

The main purpose of this study was to identify the best fall-risk assessment tool, among the Morse Fall Scale, the Johns Hopkins fall-risk Assessment Tool and the Hendrich II fall-risk Model, for a tertiary teaching hospital. The study also analysed fall-risk factors in the hospital, focusing on the items of each fall assessment tool.

METHODS

Data on falls were obtained from the patient safety reports and electronic nursing records of a tertiary teaching hospital. A retrospective study was conducted to compare the sensitivity, specificity, area under the curve, positive predictive value, negative predictive value, Youden index and accuracy of the Morse Fall Scale, the Johns Hopkins fall-risk Assessment Tool and the Hendrich II fall-risk Model. This study was conducted according to the Strengthening the Reporting of Observational Studies in Epidemiology guideline for reporting case-control studies.

RESULTS

By analysing the association between falls and the items included in the three tools, we identified significant fall-risk factors such as gait, dizziness or vertigo, changes in mental status, impulsivity, history of falling, elimination disorder, drugs affecting falls, and depression.

CONCLUSIONS

The Hendrich II fall-risk Model had the best predictive performance for falls of the three tools, considering the highest in the area under the curve and the Youden index that comprehensively analysed sensitivity and specificity, while the Johns Hopkins fall-risk Assessment Tool had the highest accuracy. The most significant fall-risk predictors are gait, dizziness or vertigo, change in mental state, and history of falling.

RELEVANCE TO CLINICAL PRACTICE

To improve the fall assessment performance of the Morse Fall Scale at the study hospital, we propose that it be supplemented with four most significant fall-risk predictors identified in this study.

The role of lower urinary tract symptoms in fall risk assessment tools in hospitals: a review

A large number of falls in hospitals occur on the way to the toilet. Accordingly, a literature search was conducted in Web of Science, PubMed, Embase, and the Cochrane Library to identify fall risk screening and assessment metrics published between 1980 and 2019 and to study the inclusion of lower urinary tract symptoms (LUTS) and their related parameters in these screening tools. In addition, the literature was searched to explore the relationship between toilet-related falls and LUTS. In total, 23 fall risk scales were selected, from which 11 were applicable for in-hospital patients. In nine of the 11 scales for in-hospital patients, a LUTS or LUTS-related parameter was included. In the 12 risk assessment tools for community-dwelling older people, there were no LUTS included. Frequency, urinary incontinence, and nocturia were mostly reported in the literature as a potential fall risk parameter. It is recommended to create greater awareness of nocturia and other LUTS among caregivers of hospitalized patients to prevent falls.

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.

The role of patients in the delivery of safe care in hospital: Study protocol

AIM

This paper outlines the protocol for a study aimed at exploring perspectives about the role of patients' in the delivery of safe care in hospital.

DESIGN

Qualitative exploratory study.

METHODS

Research Ethics Committee approval for this study was obtained in October 2018. The study will be conducted between February-April 2019 with data collected through focus group discussions and semi-structured interviews and will involve patients and healthcare professionals from hospitals in Tabriz. A descriptive qualitative approach will be adopted, and the data will be managed and analysed using MAXQDA 10 software.

DISCUSSION

The role of patients in furthering their own safety whilst in hospital cannot be underestimated and the results from this study can be used to support the development of practical strategies that address the delivery of safe hospital care and which involve patients and their caregivers.

Falls in individuals with stroke during inpatient rehabilitation at a tertiary care hospital in Saudi Arabia

Objectives:

To determine the incidence and risk factors of falls in individuals with stroke undergoing inpatient rehabilitation.

Methods:

Retrospective analysis of all patients with stroke admitted to from January 2011 to June 2013 was carried out in Inpatient rehabilitation Unit at King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia. Data collected included demographic variables, types of stroke, comorbidities, characteristics of falls, factors affecting falls and length of hospital stay. Data was descriptively analyzed. The Pearson Chi-square test was used to determine any significant relationship between the categorical variables. Binary logistic regression was used to evaluate predictors of falls during rehabilitation.

Results:

Results: Out of 146 stroke survivors, 36 patients had a fall during inpatient rehabilitation. Majority did not sustain any injury. Fall status was significantly associated with age group (p=0.048), type of stroke (p=0.005) and previous history of stroke (p=0.020). The side of stroke (p=0.011) and fall risk were statistically significantly related to fall outcomes (p=0.005). Length of hospital stay (LOS) was also associated with fall outcome (p=0.044).

Conclusion:

Age, hemorrhagic stroke, laterality of stroke and previous history of stroke were identified as risk factors associated with falls. Injured patients tend to stay longer for inpatient rehabilitation. Due to different culturual, environmental and health system variations, development of regional guidelines for fall prevention in stroke survivors can help to reduce the risk of falls.

Drug Treatment, Postural Control, and Falls: An Observational Cohort Study of 504 Patients With Acute Stroke, the Fall Study of Gothenburg

OBJECTIVE

To identify whether, and to what extent, treatment with cardiovascular drugs and neurotropic drugs are associated with postural control and falls in patients with acute stroke.

DESIGN

Observational cohort study.

SETTING

A stroke unit at a university hospital.

PARTICIPANTS

A consecutive sample of patients (N=504) with acute stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Postural control was assessed using the modified version of the Postural Assessment Scale for Stroke Patients. Data including baseline characteristics, all drug treatments, and falls were derived from medical records. Univariable and multivariable logistic regression and Cox proportional hazards models were used to analyze the association of drug treatment and baseline characteristics with postural control and with falls.

RESULTS

In the multivariable logistic regression analysis, factors significantly associated with impaired postural control were treatment with neurotropic drugs (eg, opioids, sedatives, hypnotics, antidepressants) with an odds ratio (OR) of 1.73 (95% confidence interval [CI], 1.01-2.97, P=.046); treatment with opioids (OR 9.23, 95% CI, 1.58-54.00, P=0.014); age (OR 1.09, 95% CI, 1.07-1.12, P<.0001), stroke severity, which had a high National Institutes of Health Stroke Scale-score (OR 1.29, 95% CI, 1.15-1.45, P<.0001), and sedentary life style (OR 4.32, 95% CI, 1.32-14.17, P=.016). No association was found between neurotropic drugs or cardiovascular drugs and falls.

CONCLUSIONS

Treatment with neurotropic drugs, particularly opioids, in the acute phase after stroke, is associated with impaired postural control. Since impaired postural control is the major cause of falls in patients with acute stroke, these results suggest opioids should be used with caution in these patients.

Patient safety: understanding human error in intensive nursing care

OBJECTIVE

To analyze the active failures and the latent conditions related to errors in intensive nursing care and to discuss the reactive and proactive measures mentioned by the nursing team.

METHOD

Qualitative, descriptive, exploratory study conducted at the Intensive Care Unit of a general hospital. Data were collected through interviews, participant observation and submitted to lexical analysis in the ALCESTE® software and to ethnographic analysis.

RESULTS

36 professionals of the nursing team participated in the study. The analysis originated three lexical classes: Error in intensive care nursing; Active failures and latent conditions related to errors in the intensive care nursing team; Reactive and proactive measures adopted by the nursing team regarding errors in intensive care.

CONCLUSION

Reactive and proactive measures influenced the safety culture, in particular, the recognition of errors by professionals, contributing to their prevention, safety and quality care.

Do portable nursing stations within bays of hospital wards reduce the rate of inpatient falls? An interrupted time-series analysis

Background

falls can negatively affect patients, resulting in loss of independence and functional decline and have substantial healthcare costs. Hospitals are a high-risk falls environment and regularly introduce, but seldom evaluate, policies to reduce inpatient falls. This study evaluated whether introducing portable nursing stations in ward bays to maximise nurse-patient contact time reduced inpatient falls.

Methods

inpatient falls data from local hospital incident reporting software (Datix) were collected monthly (April 2014-December 2017) from 17 wards in Stoke Mandeville and Wycombe General Hospitals, the UK. Portable nursing stations were introduced in bays on these wards from April 2016. We used a natural experimental study design and interrupted time series analysis to evaluate changes in fall rates, measured by the monthly rate of falls per 1000 occupied bed days (OBDs).

Results

the wards reported 2875 falls (April 2014-December 2017). The fallers' mean age was 78 (SD = 13) and 58% (1624/2817) were men. Most falls, 99.41% (2858/2875), resulted in none, low or moderate harm, 0.45% (13/2875) in severe harm and 0.14% (4/2875) in death. The monthly falls rate increased by 0.119 per 1000 OBDs (95% CI: 0.045, 0.194; P = 0.002) before April 2016, then decreased by 0.222 per 1000 OBDs (95% CI: -0.350, -0.093; P = 0.001) until December 2017. At 12 months post-intervention, the absolute difference between the estimated post-intervention trend and pre-intervention projected estimate was 2.84 falls per 1000 OBDs, a relative reduction of 26.71%.

Conclusion

portable nursing stations were associated with lower monthly falls rates and could reduce inpatient falls across the NHS.

The Cumulative Complexity Model and Repeat Falls: A Quality Improvement Project

PURPOSE OF PROJECT

The purpose of this article is to demonstrate the effectiveness of the Cumulative Complexity Model as a framework to build an Excel tool and a Pareto tool that will enable inpatient case managers to predict the increased risk for and prevent repeat falls. The Excel tool is based on work explained in a previous article by and uses a macro to analyze the factors causing the repeat falls and then calculate the probability of it happening again. This enables the case manager to identify trends in how the patient is transitioning toward goals of care and identify problems before they become barriers to the smooth transition to other levels of care. Thus, the case manager will save the facility money by avoiding unneeded days of care and avoiding the costs that result from rendering medical care for the patient who has fallen.

PRIMARY PRACTICE SETTINGS

In July 2015, a group of nurses at a small Veterans Health Administration Hospital in the Northwest collaborated to find ways to reverse a trend of increasing falls and repeat falls.

METHODOLOGY AND SAMPLE

A retrospective chart review of all falls and repeat falls (N = 73) that happened between January 2013 and July 2015 was used to generate a list of top 11 contributing variables that enabled evaluation of the data. A bundle of 3 interventions was instituted in October 2015: (1) development of a dedicated charge nurse/resource nurse, (2) use of a standardized method of rounding, and (3) use of a noncontact patient monitoring system ("virtual nurses"). Falls pre- and postimplementation (N = 109) were analyzed using linear and logistic regression analyses. Data were entered into an Excel sheet and analyzed to identify the major contributing factors to falls and repeat falls and to identify trends. These data were also evaluated to find out whether length of stay and nurse workload contributed to falls.

RESULTS

Fifteen months after implementation of the aforementioned interventions, falls on the unit went down from 30 aggregate falls in 2015 to 17 aggregate falls in 2016. Repeat falls in 2015 went from 9 repeat falls after admission to the unit down to 2 repeat falls in 2016. Each additional extrinsic variable that was present added an additional 1.43 to the odds ratio (OR) for a fall. Similarly, each additional intrinsic variable present added 2.08 to the OR for a fall. The linear regression of length of stay and falls demonstrated that 17.5% of falls correlated with length of stay, F(1,36) = 7.63, p = .009, R = .175, adjusted R = .152. Workload correlated with work 17% of the time, as measured by using ward days of care, F(1,100) = 20.84, p = .00001, R = .17, adjusted R = .16.

IMPLICATIONS FOR CASE MANAGERS

Two examples of the how to use these tools are located in the "Discussion" section of the article.

Testing the Predictive Validity of the Hendrich II Fall Risk Model

Cumulative data on patient fall risk have been compiled in electronic medical records systems, and it is possible to test the validity of fall-risk assessment tools using these data between the times of admission and occurrence of a fall. The Hendrich II Fall Risk Model scores assessed during three time points of hospital stays were extracted and used for testing the predictive validity: (a) upon admission, (b) when the maximum fall-risk score from admission to falling or discharge, and (c) immediately before falling or discharge. Predictive validity was examined using seven predictive indicators. In addition, logistic regression analysis was used to identify factors that significantly affect the occurrence of a fall. Among the different time points, the maximum fall-risk score assessed between admission and falling or discharge showed the best predictive performance. Confusion or disorientation and having a poor ability to rise from a sitting position were significant risk factors for a fall.

Patients' Experience After a Fall and Their Perceptions of Fall Prevention: A Qualitative Study

An exploratory descriptive study was conducted to explore the perspectives of patients who had fallen in the hospital; 100 patients were interviewed. An inductive content analysis approach was adopted. Six themes emerged: Apathetic toward falls, self-blame behavior, reluctance to impose on busy nurses, negative feelings toward nurses, overestimating own ability, and poor retention of information. Patients often downplayed the risks of falls and were reluctant to call for help.

Does acute care for the elderly (ACE) unit decrease the incidence of falls?

To determine whether acute care for the elderly (ACE) units decrease the incidence of patient falls compared to general medical and surgical (GMS) units, a non-concurrent prospective study included individuals aged 65 and older admitted to ACE or GMS units over a 2-year span was done. There were 7069 admissions corresponded to 28,401 patient-days. A total of 149 falls were reported for an overall incidence rate (IR) of 5.2 falls per 1000 patient-days, 95% CI, 4.4/1000-6.1/1000 patient-days. The falls IR ratio for patients in ACE unit compared to those in non-ACE units after adjusting for age, sex, prescribed psychotropics and hypnotics, and Morse Fall Score was 0.27/1000 patient-days; 95% CI, 0.13-0.54; p < 0.001. So, an estimated 73% reduction in patient falls between ACE unit and non-ACE units. Hospitals may consider investing in ACE units to decrease the risk of falls and the associated medical and financial costs.

Program Interruptions and Short-Stay Transfers Represent Potential Targets for Inpatient Rehabilitation Care-Improvement Efforts

OBJECTIVE

The objective of this work was to present comprehensive descriptive summaries of program interruptions and short-stay transfers among Medicare fee-for-service beneficiaries receiving inpatient rehabilitation after stroke, traumatic brain injury (TBI), and traumatic spinal cord injury (SCI).

DESIGN

Retrospective cohort study of Medicare beneficiaries with any of the 3 conditions of interest who were admitted to inpatient rehabilitation directly from an acute hospital between July 1, 2012, and November 15, 2013.

RESULTS

In the final sample (stroke, n = 71 769; TBI, n = 7109; SCI, n = 659), program interruption rates were 0.9% (stroke), 0.8% (TBI), and 1.4% (SCI). Short-stay transfer rates were 22.3% (stroke), 21.8% (TBI), and 31.6% (SCI); 14.7% of short-stay transfers and 12.3% of interruptions resulting in a return to acute care were identified as potentially preventable among those with stroke; 10.2% of transfers and 11.7% of interruptions among those with TBI, and 3.8% of transfers and 11.1% of interruptions among those with SCI.

CONCLUSIONS

Broad health care policies aimed at improving quality and reducing costs are currently being implemented. Reducing program interruptions and short-stay transfers during inpatient rehabilitative care represents a potential target for care-improvement efforts. Future research focused on identifying modifiable risk factors for potentially undesirable outcomes will allow for targeted preventative interventions.

The economic burden of nurse-sensitive adverse events in 22 medical-surgical units: retrospective and matching analysis

AIMS

The aim of this study was to assess the economic burden of nurse-sensitive adverse events in 22 acute-care units in Quebec by estimating excess hospital-related costs and calculating resulting additional hospital days.

BACKGROUND

Recent changes in the worldwide economic and financial contexts have made the cost of patient safety a topical issue. Yet, our knowledge about the economic burden of safety of nursing care is quite limited in Canada in general and Quebec in particular.

DESIGN

Retrospective analysis of charts of 2699 patients hospitalized between July 2008 - August 2009 for at least 2 days of 30-day periods in 22 medical-surgical units in 11 hospitals in Quebec.

METHODS

Data were collected from September 2009 to August 2010. Nurse-sensitive adverse events analysed were pressure ulcers, falls, medication administration errors, pneumonia and urinary tract infections. Descriptive statistics identified numbers of cases for each nurse-sensitive adverse event. A literature analysis was used to estimate excess median hospital-related costs of treatments with these nurse-sensitive adverse events. Costs were calculated in 2014 Canadian dollars. Additional hospital days were estimated by comparing lengths of stay of patients with nurse-sensitive adverse events with those of similar patients without nurse-sensitive adverse events.

RESULTS

This study found that five adverse events considered nurse-sensitive caused nearly 1300 additional hospital days for 166 patients and generated more than Canadian dollars 600,000 in excess treatment costs.

CONCLUSION

The results present the financial consequences of the nurse-sensitive adverse events. Government should invest in prevention and in improvements to care quality and patient safety. Managers need to strengthen safety processes in their facilities and nurses should take greater precautions.

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.