The Relationship Between Functional Independence Scores on Admission and Patient Falls After Stroke

Falls in Patients With Communication Disability Secondary to Stroke

Patients with stroke are at high risk of falls during inpatient rehabilitation admission. Communication disability is common following stroke; however, this population is often excluded from falls research. This study aimed to examine the falls of patients with communication disability following stroke, including the circumstances, contributing factors, and outcomes of the fall. This medical record review used the Generic Reference Model of patient safety as the analytical lens and data were analyzed descriptively. The study included 109 patients who experienced 308 falls. The most common type of fall was an "unwitnessed roll from bed." Patient factors contributed to half of all falls, injuries occurred in 15% of falls, and impacts to the hospital system included additional costs and staffing. Understanding the reasons why patients are attempting to get out of bed may identify ways to reduce the risk and incidence of falls in this population.

A validity study to consult on a protocol of a home hazard management program for falls prevention among community dwelling stroke survivors

OBJECTIVE

A fall after a stroke is common but the consequences can be devastating not only for the stroke survivors, but also for caregivers, healthcare, and the society. However, research on falls prevention among the stroke population are limited, particularly on home hazards assessment and home modifications, demanding for a study to be conducted. The aim of the study is to validate the protocol and content of a home hazard management program guided by the Person-Environment-Occupation (PEO) Model for falls prevention among community dwelling stroke survivors.

METHOD

Researchers developed their own questionnaire for content validation which consist of 23 items that covers two domains, namely justification for telehealth home hazard management practice and the protocol's overall methodology. Occupational therapists with at least one year of experience in conducting a home hazard assessment were consulted for the content validation of a two-group clinical controlled trial protocol utilizing a home hazard assessment, home modifications and education over the usual care. Written consent was obtained prior to the study. The occupational therapists were given a Google Form link to review the protocol and intervention based on the questionnaire and rated each item using a four-point Likert scale for relevance and feasibility. Open-ended feedback was also recorded on the google form. Content Validity Index (CVI), Modified Kappa Index and Cronbach's Alpha was calculated for the content validity and reliability analysis.

RESULTS

A total of sixteen occupational therapists participated in the study. 43.7% of participants had a master's degree, 93.7% worked in the government sector and 56.2% had six years and more experience on conducting home hazard assessments. Content validity of the protocol is satisfactory for relevancy and feasibility (CVI = 0.84, ranging from 0.5 to 1.00), and for the reliability (α = 0.94 (relevance) and α = 0.97 (feasibility), respectively. The Modified Kappa ranged from 0.38 to 1.00 for all items. Feedback was also received regarding the design and procedure of the study protocol which included participant's selection criteria, sample size, equipment provided, cost, location, and care for the participants during the intervention.

CONCLUSIONS

Introducing a home hazard management program to prevent falls among the stroke population is viewed relevant and feasible. Practical suggestions from the consultation panel were adopted, and minor adjustments were required to strengthen the protocol's overall methodology. This study established a rigorous and robust experimental protocol for future undertaking.

Difficulty of the subtasks comprising bed-wheelchair transfer in patients with subacute strokes: A cohort study

OBJECTIVE

Bed-wheelchair transfer comprises multiple subtasks; hence, it is important to know the difficulty of each subtask to identify and prioritize subtasks that must be practiced. This study aimed to investigate the difficulty of the subtasks that comprise bed-wheelchair transfer upon admission and reacquiring subtask skills during hospitalization.

MATERIALS AND METHODS

This was a single-center prospective cohort study. We enrolled 137 consecutive stroke patients (mean age: 69.8 years) admitted to subacute rehabilitation wards who used wheelchairs upon admission. The degree of independence in each of the 25 subtasks that comprised transferring was assessed using the Bed-wheelchair transfer Tasks Assessment Form every 2 weeks. The number of patients who were independent in the subtasks upon admission and those who were not but became independent during hospitalization were examined.

RESULTS

The most difficult subtask for independent patients upon admission was "Manipulate the handrail for the bed" (18.3%), followed by "Ready the wheelchair for transfer" (19.3%), "Maneuver the wheelchair toward the appropriate place for transfer to the bed" (20.6%), "Wear shoes/brace" (24.8%), and "Turn while standing" (25.5%). The most difficult subtask for those who were not independent but became independent was "Ready the wheelchair for transfer" (32.1%), followed by "Manipulate the handrail for the bed" (32.9%), "Press the nurse call button" (36.4%), "Press the nurse call button (wheelchair-to-bed)" (36.7%), and "Lock the wheelchair brakes" (37.3%).

CONCLUSIONS

Subtasks related to preparation for transfer were difficult upon admission, and this tendency became more pronounced during the skill acquisition process.

Effect of Communication and Education within the Rehabilitation Team: Therapists' and Nurses' Views

Objective

To improve the rehabilitation team's awareness of patient mobility and participation by improving communication between therapists and nurses and conducting patient education.

Design

This study used a non-equivalent control group with a nonsynchronized design. To facilitate communication between therapists and nurses, we used a manual for mobility management to improve the sharing of information on the functional status of patients. We also implemented patient education to improve their awareness of mobility and participation. Finally, we conducted newly devised surveys related to patient functional status and awareness that were applied by therapists and nurses.

Results

The nurses reported significantly lower functional levels of patients compared to those assessed by therapists. After the intervention, the kappa values representing the concordance between therapists and nurses improved to almost perfect agreement for transfer ability (κ=0.836), mobility (κ=0.664), and toileting (κ=1.000). We also observed a statistically significant increase in questionnaire scores with respect to nurses' awareness (p < 0.05).

Conclusion

Improving communication among the rehabilitation team, including nurses through the use of a continuous education program, was effective in promoting the mobility and functional level of patients in the inpatient ward.

Falls in hospital patients with acquired communication disability secondary to stroke: A systematic review and meta-analysis

BACKGROUND

Falls are a common safety incident in people with stroke. Studies report that between 14% and 65% of people with stroke fall at least once during their hospital admission. Risk factors for falls in people with stroke have been reported to include neglect, balance and dependence for activities of daily living. Communication disability has been identified as a risk factor for patient safety incidents in hospital that has not been closely examined as a potential risk factor for falls in people with stroke.

AIM

To determine the association between communication disability secondary to stroke and falls in people with stroke in hospital.

METHODS & PROCEDURES

Systematic searches of five electronic databases were conducted in June 2019 using the key concepts of 'falls' and 'stroke' (PROSPERO CRD 42019137199). Included studies provided comparative data of falls in patients with stroke with and without communication disability. The methodological quality of the studies was examined using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). Both a narrative synthesis and a meta-analysis were completed.

MAIN CONTRIBUTION

A total of 15 studies met the criteria for inclusion and 11 were included in a meta-analysis. Three studies found people with communication disability had an increased rate of falls in hospital. However, a meta-analysis showed no significant association between a non-specific classification of communication disability and an increased risk of falls. There was some indication from individual studies that higher risk of falls may be associated with severe communication disability, but there were insufficient data reported on the severity of the communication disability to draw robust conclusions.

CONCLUSION & IMPLICATIONS

The results of this systematic review suggest that a generic classification of communication disability following stroke is not a risk factor for falls. However, further research that is inclusive of this population and considers severity of communication disability more specifically is required. What this paper adds What is already known on the subject The association between communication disability following stroke and falls in hospital is unclear. The literature reports mixed results regarding the impact of a communication disability following stroke on falls risk or rates of falls during hospital admission. What this paper adds to existing knowledge This review is the first to bring together this diverse literature to examine the association between communication disability following stroke and falls in hospital. The results suggest that a generic classification of communication disability following stroke is not a risk factor for falls. What are the potential or actual clinical implications of this work? There is a possibility that moderate to severe communication disability may be related to falls in patients in hospital. Further research is indicated to be more inclusive of people with communication disability, including those with severe communication disability.

An analysis of fall incidence rate and risk factors in an inpatient rehabilitation unit: A retrospective study

BACKGROUND

Accurate prediction of fall likelihood is advantageous for instituting fall prevention program in rehabilitation facilities.

OBJECTIVE

This study was designed to determine the clinical measures, which can predict the risk of fall events in a rehabilitation hospital.

METHODS

Medical records of 166 patients (114 males and 52 females) who were hospitalized in an adult inpatient unit of a rehabilitation hospital were retrospectively analyzed for this study. As predictor variables for assessing fall risk, demographic data and the following measurements were selectively collected from patient's medical records: Tinetti Performance-Oriented Mobility Assessment-Ambulation (POMA-G), Timed Up and Go test (TUG), 10 m walk test, 2 min walk test, Korean version Mini-Mental State Examination (K-MMSE), Korean version of the Modified Barthel Index (KMBI), Berg Balance Scale (BBS), Global Deterioration Scale (GDS), and Morse Fall Scale (Morse FS).

RESULTS

The Morse FS, TUG, and age were found to be risk factors for the classification of faller and non-faller groups.

CONCLUSION

This study suggests Morse FS, TUG, and age in the routine initial assessment upon admission in a rehabilitation setting, as key variables for screening the risk of fall. Additionally, the cutoff scores of Morse FS and TUG were observed to be more rigid than other clinical settings.

Effect of Underwater Treadmill Gait Training With Water-Jet Resistance on Balance and Gait Ability in Patients With Chronic Stroke: A Randomized Controlled Pilot Trial

Objective: The purpose of this study was to determine the effects of underwater treadmill gait training with water-jet resistance and underwater treadmill gait training with ankle weights on balance and gait abilities in chronic stroke patients.

Methods: Twenty-two inpatients and outpatients with stroke-induced impairments were randomly assigned into two groups: an underwater treadmill gait training with water-jet resistance group (n = 11) and an underwater treadmill gait training with ankle weights group (n = 11). Participants received conventional physical therapy for 30 min and underwater treadmill gait training with water-jet resistance or ankle weights for 30 min. Intervention was performed 5 days a week for 4 weeks. The Balance System SD was used to assess static and dynamic balance. The GAITRite system was used to assess gait velocity, cadence, step length, stride length, and swing phase. All measurements were performed at the beginning of the study and 4 weeks after the intervention.

Results: The water-jet resistance group and ankle weights group showed significant improvement in static balance (P < 0.00 vs. P = 0.01), dynamic balance (P < 0.00 vs. P = 0.57), gait velocity (P < 0.00 vs. P = 0.037), cadence (P < 0.00 vs. P = 0.001), step length (P < 0.00 vs. P = 0.003), stride length (P < 0.00 vs. P = 0.023), and swing phase (P < 0.00 vs. P < 0.00). However, the static and dynamic balance ability score (P < 0.00), gait velocity (P < 0.00), cadence (P < 0.00), step length (P < 0.00), stride length (P < 0.00), and swing phase (P = 0.023) in the group that received underwater treadmill gait training with water-jet resistance improved more than in the group that received underwater treadmill gait training with ankle weights.

Conclusions: Our results demonstrated that underwater treadmill gait training with water-jet resistance is effective in improving static and dynamic balance as well as gait abilities in chronic stroke patients. Thus, training using underwater treadmill gait training with water-jet resistance may be useful in facilitating active rehabilitation in chronic stroke patients.

Using Functional Independence Measure Subscales to Predict Falls-Rapid Assessment

BACKGROUND

Falls remain a major issue in inpatient rehabilitation. Decreased scores on the Functional Independence Measure (FIM), given to every patient, have been shown to predict falls risk.

PURPOSE

The aim of the study was to extend previous research using FIM to predict falls by using only subscales assessed earliest during admissions to indicate high risk of falls.

DESIGN

Retrospective cohort study.

METHODS

Two consecutive samples of patients (n1 = 1,553, n2 = 12,301) admitted to a rehabilitation hospital over 9-month and 5-year periods, respectively, were used to evaluate the predictive utility of using only a small number of FIM subscales. Subscales were selected from those assessed earliest and were related to previously published research on falls risk factors. The metric was developed using a historical data set and was validated with a second, separate group of patients. Receiver operating characteristic curves were used to evaluate predictive utility.

FINDINGS

The combination of Toileting and Expression subscales yielded a comparable area under the curve to the full FIM, and both were greater than the existing method of falls risk assessment. Likelihood of falling was strongly linearly related to score on the Toileting/Expression metric.

CONCLUSIONS

The sum of two FIM subscales can be used to predict which patients may fall during their stay in a rehabilitation hospital.

CLINICAL RELEVANCE

The FIM scores are assessed early during a patient's stay, are required for all Medicare patients, and may be useful for simple, rapid, and accurate assignment of falls risk.

A systematic review of falls in hospital for patients with communication disability: Highlighting an invisible population

BACKGROUND

Patients with communication disability, associated with impairments of speech, language, or voice, have a three-fold increased risk of adverse events in hospital. However, little research yet examines the causal relationship between communication disability and risk for specific adverse events in hospital.

OBJECTIVE

To examine the impact of a patient's communication disability on their falls risk in hospital.

METHODS

This systematic review examined 61 studies on falls of adult hospital patients with communication disability, and patients at high risk of communication disability, to determine whether or not communication disability increased risk for falls, and the nature of and reasons for any increased risk.

RESULTS

In total, 46 of the included studies (75%) reported on participants with communication disability, and the remainder included patients with health conditions placing them at high risk for communication disability. Two thirds of the studies examining falls risk identified communication disability as contributing to falls. Commonly, patients with communication disability were actively excluded from participation; measures of communication or cognition were not reported; and reasons for any increased risk of falls were not discussed.

CONCLUSIONS

There is some evidence that communication disability is associated with increased risk of falls. However, the role of communication disability in falls is under-researched, and reasons for the increased risk remain unclear. Practical applications: Including patients with communication disability in falls research is necessary to determine reasons for their increased risk of adverse events in hospital. Their inclusion might be helped by the involvement of speech-language pathologists in falls research teams.

Risk Factors for Falls Among Hospitalized Acute Post-Ischemic Stroke Patients

BACKGROUND

Falls remain an important benchmarking indicator for hospitals. Research identifies factors associated with falls among hospitalized patients in general. Similarly, the stroke literature outlines fall risk factors in the inpatient rehabilitation and community setting.

PURPOSE

The aim of this study was to identify prevalence and risk factors for falls among acute, hospitalized AIS patients within an urban public healthcare system. Secondary aims were to identify activities present at the time of the fall and outcomes associated with falling.

METHODS

This is a retrospective case-control study. Data were abstracted and merged from hospital stroke and fall registries and matched with medical records from 2013 to 2015 among all adult patients admitted for AIS.

RESULTS

The study included 856 patients with AIS, with 2.3% experiencing a fall during the acute care hospitalization period. Falls among patients with AIS accounted for 1.4% of all hospitalized adult falls. Bivariate analysis indicate that a higher proportion of falls occurred among male patients when compared with female patients (75% male; χ = 3.964, P < .05) and among patients with a history of previous myocardial infarction or renal insufficiency (χ = 5.260, P < .05; χ = 11.116, P < .001, respectively). Multivariate analyses identify previous myocardial infarction (OR, 2.5; 95% confidence interval, 1.0-6.3; P = .04) and renal insufficiency (odds ratio, 4.2; 95% confidence interval, 1.5-12.2; P = .008) as strongest predictors of falls. The occurrence of a fall resulted in increased hospital length of stay (7.1 vs 4.0 days, P < .000) and slightly decreased functional outcome at discharge. Most falls occurred during the day shift while toileting, despite implementation and adherence to fall prevention programs.

CONCLUSIONS

Fall rates among hospitalized patients with AIS are low, which may be reflective of increased vigilance among providers and widespread integration of fall prevention strategies. Consistent with the fall literature among other populations, the occurrence of a fall in the inpatient setting can substantially increase length of stay.

Do Falls Experienced During Inpatient Stroke Rehabilitation Affect Length of Stay, Functional Status, and Discharge Destination?

OBJECTIVE

To compare length of stay, functional status, and discharge destination between individuals who fell during inpatient stroke rehabilitation and those who did not fall.

DESIGN

Retrospective cohort study.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Individuals who fell during inpatient stroke rehabilitation (n=106; fallers group; mean age, 67.8±12.9y; mean time poststroke, 26.4±28.3d) were matched to individuals who did not fall (n=106; nonfallers group; mean age, 67.3±13.6y; mean time poststroke, 21.9±28.8d) on age and functional status (N=212).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Total length of stay, FIM assessed at discharge, and discharge destination.

RESULTS

The mean length of stay for fallers was 11 days longer than nonfallers (P=.0017). Nonfallers and fallers did not differ on discharge total FIM scores (P=.19), and both groups were discharged home after inpatient rehabilitation (nonfallers: 77%; fallers: 74%; P=.52).

CONCLUSIONS

This study suggests that falls experienced during inpatient stroke rehabilitation may have contributed to a longer length of stay; however, falls did not affect discharge functional status or discharge destination.

Risk analysis of falls in patients undergoing allogeneic hematopoietic stem cell transplantation

To identify fall risks in patients undergoing hematopoietic stem cell transplantation (HSCT), the authors reviewed retrospective data on inpatients from April 2010 to March 2011. Among 77 HSCT patient records reviewed, the authors found that 35 patients had experienced at least one fall, including near-miss episodes (fallers). The main location of the falls was a corridor, and the main activity at the time of the fall was going to the toilet. To investigate fall risks along the HSCT time trajectory, the authors divided the time into pre- and post-engraftment periods and investigated the unique characteristics of each.

An integrative review of factors associated with falls during post-stroke rehabilitation

PURPOSE

Our aims were to evaluate evidence of risk factors for falls among patients in stroke rehabilitation and to offer recommendations for clinical practice and future research.

METHOD

We conducted an integrative review of the literature published from 1990 to 2009 that describes empirical investigations of risk factors for post-stroke falls during inpatient rehabilitation. We searched Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, and Embase databases, using the search terms "accidental falls,""fall risk,""risk factors,""risk assessment,""stroke," and "cerebrovascular disorders." We extracted information regarding study design, sample, potential risk factors, analytic methods, findings, and limitations from the 14 articles that met our inclusion criteria, and we rated the level of evidence for each study.

FINDINGS

Available empirical evidence points to impaired balance, visuospatial hemineglect, and impaired performance of activities of daily living as risk factors for falls during inpatient rehabilitation for stroke. Associations between falls and cognitive function, incontinence, visual field deficits, and stroke type were less clear, while relationships between falls and age, gender, stroke location, and impaired vision and hearing were not supported.

CONCLUSIONS

The relatively sparse literature pertaining to risk factors for falls among stroke rehabilitation inpatients indicates that deficits affecting balance, perception, and self-care significantly increase the likelihood of falls. Particularly intriguing is the less well established role of post-stroke cognition in falls in this population. A conceptual model is needed to guide scientific inquiry and clinical practice in this area.

CLINICAL RELEVANCE

When clinicians in the inpatient stroke rehabilitation setting evaluate which patients are at greatest risk to fall, stroke-specific risk factors such as impaired balance, visuospatial hemineglect, and self-care deficits may be better predictors than more general risk factors such as age, incontinence, and sensory impairments. Patients with these stroke-specific deficits may benefit from the use of aggressive fall prevention interventions.

The FIM instrument to identify patients at risk of falling in geriatric wards: a 10-year retrospective study

OBJECTIVES

the main objective was to evaluate if the admission functional independence measure (FIM) score could be used to predict the risk of falls in geriatric inpatients.

DESIGN

a 10-year retrospective study was performed.

SETTING

the study was conducted in a 298-bed geriatric teaching hospital in Geneva, Switzerland.

SUBJECTS

all patients discharged from the hospital from 1 January 1997 to 31 December 2006 were selected.

MAIN OUTCOME MEASURES

measures used were FIM scores at admission using the FIM instrument and number of falls extracted from the institution's fall report forms.

RESULTS

during the study period, there were 23,966 hospital stays. A total of 8,254 falls occurred. Of these, 7,995 falls were linked to 4,651 stays. Falls were recorded in 19.4% of hospital stays, with a mean incidence of 7.84 falls per 1,000 patients-days. Although there was a statistically significant relationship between total FIM score, its subscales, and the risk of falling, the sensitivity, specificity, positive predictive value and negative predictive value obtained with receiver operating characteristic curves were insufficient to permit fall prediction. This might be due in part to a non-linear relationship between FIM score and fall risk.

CONCLUSION

in this study, the FIM instrument was found to be unable to predict risk of falls in general geriatric wards.

[Falls: incidence and risk factors after stroke. A systematic literature review]

Falls are common after stroke. This article presents a literature review of the incidence and risk factors of falls and the consequences for professionals working with stroke patients. It is important to consider the specific problems after stroke. Depression and cognitive impairments were found to be risk factors for fall incidents after stroke. In the relevant literature many different risk factors and circumstances are described. When patients move from bed to chair, walk to the bathroom and the first few days after the patient is discharged to another setting, - all these circumstances showed high percentages of falling. A fall during hospital stay is a significant risk factor for future fall incidents. A reliable index to measure the fall risk is not (yet) available. But scores on the Barthel Index and the Timed-Up-and-Go test can be used as fall risk indicators. Fear of falling is an important complication after a fall and therefore it is recommended prior to discharge to inquire about the patient's self efficacy in maintaining balance. Few intervention studies use the number of falls as an outcome measure. Exercising balance following a mass training protocol seems to diminish the risk of falling.

Risk factors for falls in stroke patients during inpatient rehabilitation

Objectives: To assess the incidence and circumstances of falls among stroke patients in a rehabilitation ward, the frequency of fall-related fractures, the relationship between falls and rehabilitation outcomes, and risk factors for falls.

Design: Prospective observational study.

Setting: Neurological rehabilitation ward.

Patients: In total 1155 patients (56% men; mean age 61.5 ± 14.3 years) admitted to the neurological rehabilitation ward after a stroke. Median (interquartile range) time since stroke onset was 36.5 (68) days.

Main measures: Patients' falls were registered during hospitalization (1—74 days) and variables relating to the type and symptoms of stroke, current medications, neurological deficit (Scandinavian Stroke Scale) and disability (Barthel Index) were collected from medical records.

Results: A total of 252 falls were recorded for 189 (16.3%) patients and 45 patients experienced 108 repeated falls. The incidence rate for falls was 7.6/1000 patient-days (95% confidence interval (CI) 6.6—8.5). Most patients fell while being transferred (33.9%) and while seated (21.5%), and 1.2% of falls resulted in fractures (n = 3). Increased risk of both first and multiple falls was strongly associated with initial Barthel score below 15 (hazard ratio (HR) 5.2 and 4.5, respectively) and time since stroke onset ≥12 weeks (HR 2.3 and 2.3, respectively). First falls were significantly associated with visuo-spatial neglect (HR 1.5). Repeated falls were related to age greater than 65 years (HR 1.4).

Conclusions: Patients with severe stroke-related disability in the early period after stroke are prone to falls during rehabilitation. Multiple falls are most frequent in patients over 65 years of age.

Evidence-based Management Practice: Reducing Falls in Hospital

This paper reports on a falls prevention and management program at one regional Western Australian hospital. The report focuses on the processes and outcomes of a quality management initiative to reduce falls in hospital to illustrate the nexus between research and quality improvement in clinical practice. The Falls Prevention program was based on statistical evidence of the level of risk in the hospital and development of an evidence-based multidimensional, multidisciplinary program to reduce the risks of falling and the number of falling events. Evaluative data demonstrate the effectiveness of the program in terms of a substantial reduction in falls. The program illustrates the value of evidence-based practice, particularly in relation to evidence-based management practice. It supports the merits of creating an organisational climate where all clinicians are encouraged to use research data to plan strategies for quality improvement and risk management and, in the process, advance clinical nursing knowledge development.