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de Medeiros ARP, Gonçalves LS. Fall Tailoring Interventions for Patient Safety Brazil Program: an evaluability study in a teaching hospital. Rev Bras Enferm 2024; 77:e20230348. [PMID: 38808898 PMCID: PMC11135911 DOI: 10.1590/0034-7167-2023-0348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/02/2024] [Indexed: 05/30/2024] Open
Abstract
OBJECTIVES to present the theoretical model, logic model, and the analysis and judgment matrix of the Fall TIPS Brazil Program. METHODS a qualitative, participatory research approach, in the form of an evaluability study, encompassing the phases (1) problem analysis; (2) program design, development, and adaptation to the Brazilian context; (3) program dissemination. Data were collected through document analysis and workshops. RESULTS through document analysis, workshops with stakeholders from the participating institution, and validation with key informants, it was possible to identify the program's objectives, expected outcomes, and the target audience. This allowed the construction of theoretical and logic models and, through evaluative questions, the identification of indicators for the evaluation of the Fall TIPS Brazil Program. FINAL CONSIDERATIONS this study has provided insights into the Fall TIPS program, the topic of hospital fall prevention, and the proposed models and indicators can be employed in the implementation and future evaluative processes of the program.
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Randell R, McVey L, Wright J, Zaman H, Cheong VL, Woodcock DM, Healey F, Dowding D, Gardner P, Hardiker NR, Lynch A, Todd C, Davey C, Alvarado N. Practices of falls risk assessment and prevention in acute hospital settings: a realist investigation. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-194. [PMID: 38511977 DOI: 10.3310/jwqc5771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Background Falls are the most common safety incident reported by acute hospitals. The National Institute of Health and Care Excellence recommends multifactorial falls risk assessment and tailored interventions, but implementation is variable. Aim To determine how and in what contexts multifactorial falls risk assessment and tailored interventions are used in acute National Health Service hospitals in England. Design Realist review and multisite case study. (1) Systematic searches to identify stakeholders' theories, tested using empirical data from primary studies. Review of falls prevention policies of acute Trusts. (2) Theory testing and refinement through observation, staff interviews (n = 50), patient and carer interviews (n = 31) and record review (n = 60). Setting Three Trusts, one orthopaedic and one older person ward in each. Results Seventy-eight studies were used for theory construction and 50 for theory testing. Four theories were explored. (1) Leadership: wards had falls link practitioners but authority to allocate resources for falls prevention resided with senior nurses. (2) Shared responsibility: a key falls prevention strategy was patient supervision. This fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared. (3) Facilitation: assessments were consistently documented but workload pressures could reduce this to a tick-box exercise. Assessment items varied. While individual patient risk factors were identified, patients were categorised as high or low risk to determine who should receive supervision. (4) Patient participation: nursing staff lacked time to explain to patients their falls risks or how to prevent themselves from falling, although other staff could do so. Sensitive communication could prevent patients taking actions that increase their risk of falling. Limitations Within the realist review, we completed synthesis for only two theories. We could not access patient records before observations, preventing assessment of whether care plans were enacted. Conclusions (1) Leadership: There should be a clear distinction between senior nurses' roles and falls link practitioners in relation to falls prevention; (2) shared responsibility: Trusts should consider how processes and systems, including the electronic health record, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses, and ensure items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling. Future work (1) Development and evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, multifactorial falls risk assessment and selection and delivery of tailored interventions; (2) mixed method and economic evaluations of patient supervision; (3) evaluation of engagement support workers, volunteers and/or carers to support falls prevention. Research should include those with cognitive impairment and patients who do not speak English. Study registration This study is registered as PROSPERO CRD42020184458. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129488) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Rebecca Randell
- Faculty of Health Studies, University of Bradford, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
| | - Lynn McVey
- Faculty of Health Studies, University of Bradford, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
| | - Judy Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Hadar Zaman
- Faculty of Life Sciences, University of Bradford, Bradford, UK
| | | | | | | | - Dawn Dowding
- Division of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK
| | - Peter Gardner
- Wolfson Centre for Applied Health Research, Bradford, UK
- Faculty of Life Sciences, University of Bradford, Bradford, UK
| | - Nicholas R Hardiker
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Alison Lynch
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Chris Todd
- Division of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK
| | | | - Natasha Alvarado
- Faculty of Health Studies, University of Bradford, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
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Stewart BC, Dai S, Havens KL, Eggleston JD, Bagwell JJ, Deering RE, Little EE, Catena RD. Determining fall risk change throughout pregnancy: the accuracy of postpartum survey and relationship to fall efficacy. ERGONOMICS 2023:1-10. [PMID: 38131152 DOI: 10.1080/00140139.2023.2296827] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Abstract
All epidemiological studies on pregnancy fall risk to date have relied on postpartum recall. This study investigated the accuracy of postpartum recall of falls that were reported during pregnancy, including assessment of fall efficacy as a possible reason for recall inaccuracy. Twenty participants reported fall experiences weekly during pregnancy, but one participant was excluded as an outlier. A fall efficacy questionnaire was completed every six weeks during pregnancy. A postpartum survey to mimic previous studies (Dunning, Lemasters, and Bhattacharya 2010; Dunning et al. 2003) was delivered to determine recall accuracy. Postpartum recall of fall events each gestational month matches the previous study (Dunning, Lemasters, and Bhattacharya 2010). However, recall of falls is 16% underestimated and recall of all fall events is 30% overestimated in postpartum survey. There is a slight relationship between fall efficacy and true falls, but not between fall efficacy and fall recall. Our study suggests fall risk needs to be intermittently surveyed throughout pregnancy rather than assessed via postpartum survey.Practitioner summary: This study investigated the accuracy of postpartum survey of fall risk during pregnancy and the possibility of fall efficacy as a covariate. We used three corresponding surveys. We found inaccuracies in postpartum survey, not explain by fall efficacy.
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Affiliation(s)
| | - Shenghai Dai
- Washington State University, Pullman, Washington, USA
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Alvarado N, McVey L, Wright J, Healey F, Dowding D, Cheong VL, Gardner P, Hardiker N, Lynch A, Zaman H, Smith H, Randell R. Exploring variation in implementation of multifactorial falls risk assessment and tailored interventions: a realist review. BMC Geriatr 2023; 23:381. [PMID: 37344760 DOI: 10.1186/s12877-023-04045-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/16/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Falls are the most common safety incident reported by acute hospitals. In England national guidance recommends delivery of a multifactorial falls risk assessment (MFRA) and interventions tailored to address individual falls risk factors. However, there is variation in how these practices are implemented. This study aimed to explore the variation by examining what supports or constrains delivery of MFRAs and tailored interventions in acute hospitals. METHODS A realist review of literature was conducted with searches completed in three stages: (1) to construct hypotheses in the form of Context, Mechanism, Outcome configurations (CMOc) about how MFRAs and interventions are delivered, (2) to scope the breadth and depth of evidence available in Embase to test the CMOcs, and (3) following prioritisation of CMOcs, to refine search strategies for use in multiple databases. Citations were managed in EndNote; titles, abstracts, and full texts were screened, with 10% independently screened by two reviewers. RESULTS Two CMOcs were prioritised for testing labelled: Facilitation via MFRA tools, and Patient Participation in interventions. Analysis indicated that MFRA tools can prompt action, but the number and type of falls risk factors included in tools differ across organisations leading to variation in practice. Furthermore, the extent to which tools work as prompts is influenced by complex ward conditions such as changes in patient condition, bed swaps, and availability of falls prevention interventions. Patient participation in falls prevention interventions is more likely where patient directed messaging takes individual circumstances into account, e.g., not wanting to disturb nurses by using the call bell. However, interactions that elicit individual circumstances can be resource intensive and patients with cognitive impairment may not be able to participate despite appropriately directed messaging. CONCLUSIONS Organisations should consider how tools can be developed in ways that better support consistent and comprehensive identification of patients' individual falls risk factors and the complex ward conditions that can disrupt how tools work as facilitators. Ward staff should be supported to deliver patient directed messaging that is informed by their individual circumstances to encourage participation in falls prevention interventions, where appropriate. TRIAL REGISTRATION PROSPERO: CRD42020184458.
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Affiliation(s)
- Natasha Alvarado
- Wolfson Centre for Applied Health Research, Bradford, UK.
- University of Bradford, Bradford, UK.
| | - Lynn McVey
- Wolfson Centre for Applied Health Research, Bradford, UK
- University of Bradford, Bradford, UK
| | - Judy Wright
- University of Leeds, Leeds, West Yorkshire, UK
| | | | | | | | - Peter Gardner
- Wolfson Centre for Applied Health Research, Bradford, UK
- University of Bradford, Bradford, UK
| | | | - Alison Lynch
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Heather Smith
- Leeds Office of NHS West Yorkshire Integrated Care, Leeds, UK
| | - Rebecca Randell
- Wolfson Centre for Applied Health Research, Bradford, UK
- University of Bradford, Bradford, UK
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Dykes PC, Curtin-Bowen M, Lipsitz S, Franz C, Adelman J, Adkison L, Bogaisky M, Carroll D, Carter E, Herlihy L, Lindros ME, Ryan V, Scanlan M, Walsh MA, Wien M, Bates DW. Cost of Inpatient Falls and Cost-Benefit Analysis of Implementation of an Evidence-Based Fall Prevention Program. JAMA HEALTH FORUM 2023; 4:e225125. [PMID: 36662505 PMCID: PMC9860521 DOI: 10.1001/jamahealthforum.2022.5125] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Importance There is insufficient research on the costs of patient falls in health care systems, a leading source of nonreimbursable adverse events. Objective To report the costs of inpatient falls and the cost savings associated with implementation of an evidence-based fall prevention program. Design, Setting, and Participants In this economic evaluation, a matched case-control study used the findings from an interrupted time series analysis that assessed changes in fall rates following implementation of an evidence-based fall prevention program to understand the cost of inpatient falls. An economic analysis was then performed to assess the cost benefits associated with program implementation across 2 US health care systems from June 1, 2013, to August 31, 2019, in New York, New York, and Boston, Massachusetts. All adults hospitalized in participating units were included in the analysis. Data analysis was performed from October 2021 to November 2022. Interventions Evidence-based fall prevention program implemented in 33 medical and surgical units in 8 hospitals. Main Outcomes and Measures Primary outcome was cost of inpatient falls. Secondary outcome was the costs and cost savings associated with the evidence-based fall prevention program. Results A total of 10 176 patients who had a fall event (injurious or noninjurious) with 29 161 matched controls (no fall event) were included in the case-control study and the economic analysis (51.9% were 65-74 years of age, 67.1% were White, and 53.6% were male). Before the intervention, there were 2503 falls and 900 injuries; after the intervention, there were 2078 falls and 758 injuries. Based on a 19% reduction in falls and 20% reduction in injurious falls from the beginning to the end of the postintervention period, the economic analysis demonstrated that noninjurious and injurious falls were associated with cost increases of $35 365 and $36 776, respectively. The implementation of the evidence-based fall prevention program was associated with $14 600 in net avoided costs per 1000 patient-days. Conclusions and Relevance This economic evaluation found that fall-related adverse events represented a clinical and financial burden to health care systems and that the current Medicare policy limits reimbursement. In this study, costs of falls only differed marginally by injury level. Policies that incentivize organizations to implement evidence-based strategies that reduce the incidence of all falls may be effective in reducing both harm and costs.
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Affiliation(s)
- Patricia C. Dykes
- Center for Patient Safety, Research, and Practice, Department of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Mica Curtin-Bowen
- Center for Patient Safety, Research, and Practice, Department of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Stuart Lipsitz
- Center for Patient Safety, Research, and Practice, Department of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Calvin Franz
- Eastern Research Group, Lexington, Massachusetts
| | - Jason Adelman
- Division of General Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian, New York, New York
| | - Lesley Adkison
- Department of Nursing, Newton Wellesley Hospital, Newton, Massachusetts
| | - Michael Bogaisky
- Division of Geriatrics, Montefiore Medical Center, Bronx, New York
| | - Diane Carroll
- Munn Center for Nursing Research, Department of Nursing and Patient Care Services, Massachusetts General Hospital, Boston, Massachusetts
| | - Eileen Carter
- Division of General Medicine, Columbia University Irving Medical Center/NewYork-Presbyterian, New York, New York,School of Nursing, Columbia University, New York, New York
| | - Lisa Herlihy
- Department of Patient Safety and Quality, North Shore Medical Center, Salem, Massachusetts
| | - Mary Ellen Lindros
- Department of Nursing and Patient Care Services, Montefiore Medical Center Hospitals, Bronx, New York
| | - Virginia Ryan
- Department of Nursing and Patient Care Services, Brigham and Women’s Faulkner Hospital, Boston, Massachusetts
| | - Maureen Scanlan
- Department of Nursing and Patient Care Services, Montefiore Medical Center Hospitals, Bronx, New York
| | - Mary-Ann Walsh
- Munn Center for Nursing Research, Department of Nursing and Patient Care Services, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthew Wien
- Center for Patient Safety, Research, and Practice, Department of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - David W. Bates
- Center for Patient Safety, Research, and Practice, Department of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
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Chauhan A, Newman B, Walpola RL, Seale H, Manias E, Wilson C, Harrison R. Assessing the environment for engagement in health services: The Audit for Consumer Engagement (ACE) tool. Health Expect 2022; 25:3027-3039. [DOI: 10.1111/hex.13610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/07/2022] [Accepted: 09/10/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ashfaq Chauhan
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences Macquarie University North Ryde New South Wales Australia
| | - Bronwyn Newman
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences Macquarie University North Ryde New South Wales Australia
| | - Ramesh Lahiru Walpola
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney Kensington New South Wales Australia
| | - Holly Seale
- School of Population Health, Faculty of Medicine and Health, UNSW Sydney Kensington New South Wales Australia
| | - Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation Deakin University Melbourne Victoria Australia
| | - Carlene Wilson
- Olivia Newton‐John Cancer Wellness and Research Centre Austin Health Heidelberg Victoria Australia
- School of Psychology and Public Health La Trobe University Bundoora Victoria Australia
| | - Reema Harrison
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences Macquarie University North Ryde New South Wales Australia
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Kim EJ, Nam IC, Koo YR. Reframing Patient Experience Approaches and Methods to Achieve Patient-Centeredness in Healthcare: Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159163. [PMID: 35954517 PMCID: PMC9367952 DOI: 10.3390/ijerph19159163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 07/15/2022] [Accepted: 07/25/2022] [Indexed: 02/04/2023]
Abstract
(1) There has been growing attention among healthcare researchers on new and innovative methodologies for improving patient experience. This study reviewed the approaches and methods used in current patient experience research by applying the perspective of design thinking to discuss practical methodologies for a patient-centered approach and creative problem-solving. (2) A scoping review was performed to identify research trends in healthcare. A four-stage design thinking process (“Discover”, “Define”, “Develop”, and “Deliver”) and five themes (“User focus”, “Problem-framing”, “Visualization”, “Experimentation”, and “Diversity”), characterizing the concept, were used for the analysis framework. (3) After reviewing 67 studies, the current studies show that the iterative process of divergent and convergent thinking is lacking, which is a core concept of design thinking, and it is necessary to employ an integrative methodology to actively apply collaborative, multidisciplinary, and creative attributes for a specific and tangible solution. (4) For creative problem-solving to improve patient experience, we should explore the possibilities of various solutions by an iterative process of divergent and convergent thinking. A concrete and visualized solution should be sought through active user interactions from various fields. For this, a specific methodology that allows users to collaborate by applying the integrative viewpoint of design thinking should be introduced.
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Affiliation(s)
- Eun-Jeong Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, The Catholic Medical Center, The Catholic University of Korea, Seoul 06591, Korea;
| | - Inn-Chul Nam
- Department of Otorhinolaryngology-Head and Neck Surgery, Incheon St. Mary’s Hospital, The Catholic University of Korea, Seoul 21431, Korea
- Correspondence: (I.-C.N.); (Y.-R.K.)
| | - Yoo-Ri Koo
- Department of Service Design, Graduate School of Industrial Arts, Hongik University, Seoul 04066, Korea
- Correspondence: (I.-C.N.); (Y.-R.K.)
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8
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Bloemberg D, Musters SCW, Wal-Huisman HVD, Dieren SV, Nieveen van Dijkum EJM, Eskes AM. Impact of family visit restrictions due to COVID-19 policy on patient outcomes: A cohort study. J Adv Nurs 2022; 78:4042-4053. [PMID: 35699245 PMCID: PMC9350069 DOI: 10.1111/jan.15325] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/21/2022] [Accepted: 05/29/2022] [Indexed: 11/27/2022]
Abstract
Aim To investigate the impact of family visit restrictions during the COVID‐19 pandemic on deliriums, falls, pneumonia, pressure ulcers and readmissions among surgical inpatients with gastrointestinal (oncologic) diseases. Design Cohort study. Methods This study was conducted among adult inpatients undergoing gastrointestinal surgery in two academic hospitals. During the COVID‐19 outbreak in 2020, over a 10‐week period, one cohort was subjected to family visit restrictions. Per patient, one person per day was allowed to visit for a maximum of 30 min. This cohort was compared with another cohort in which patients were not subjected to such restrictions during a 10‐week period in 2019. Logistic regression analyses were used to investigate the impact of the restrictions on deliriums, falls, pneumonia, pressure ulcers and readmissions. Results In total, 287 patients were included in the 2020 cohort and 243 in the 2019 cohort. No differences were observed in the cohorts with respect to baseline characteristics. Logistic regression analyses showed no significant differences in deliriums, falls, pneumonia, pressure ulcers and readmissions between the cohorts. Conclusion We cautiously conclude that the family visit restrictions during the COVID‐19 pandemic did not contribute to deliriums, falls, pneumonia, pressure ulcers or readmissions in surgical patients with gastrointestinal (oncologic) diseases. Impact COVID‐19 influenced family‐centred care due to family visit restrictions. Nurses need to continue monitoring outcomes known to be sensitive to family‐centred care to gain insight into the effects of visit restrictions and share the results in order to include nurses' perspectives in COVID‐19‐decision‐making. Re‐implementing of family visit restrictions should be carefully considered in policy‐making.
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Affiliation(s)
- Daphne Bloemberg
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Selma C W Musters
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Hanneke van der Wal-Huisman
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Susan van Dieren
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Els J M Nieveen van Dijkum
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Anne M Eskes
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Menzies Health Institute Queensland and School of Nursing and Midwifery, Griffith University, Gold Coast, G40 Griffith Health Centre, Level 8.86 Gold Coast campus Griffith University, Nathan, Qld, Australia
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9
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Dykes PC, Khasnabish S, Burns Z, Adkison LE, Alfieri L, Bogaisky M, Carroll DL, Carter EJ, Hurley AC, Jackson E, Kurian S, Lindros ME, Ryan V, Scanlan M, Sessler K, Shelley A, Spivack LB, Walsh MA, Bates DW, Adelman JS. Development and Validation of a Fall Prevention Efficiency Scale. J Patient Saf 2022; 18:94-101. [PMID: 33480645 PMCID: PMC8292432 DOI: 10.1097/pts.0000000000000811] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Fall TIPS (Tailoring Interventions for Patient Safety) is an evidence-based fall prevention program that led to a 25% reduction in falls in hospitalized adults. Because it would be helpful to assess nurses' perceptions of burdens imposed on them by using Fall TIPS or other fall prevention program, we conducted a study to learn benefits and burdens. METHODS A 3-phase mixed-method study was conducted at 3 hospitals in Massachusetts and 3 in New York: (1) initial qualitative, elicited and categorized nurses' views of time spent implementing Fall TIPS; (2) second qualitative, used nurses' quotes to develop items, research team inputs for refinement and organization, and clinical nurses' evaluation and suggestions to develop the prototype scale; and (3) quantitative, evaluated psychometric properties. RESULTS Four "time" themes emerged: (1) efficiency, (2) inefficiency, (3) balances out, and (4) valued. A 20-item prototype Fall Prevention Efficiency Scale was developed, administered to 383 clinical nurses, and reduced to 13 items. Individual items demonstrated robust stability with Pearson correlations of 0.349 to 0.550 and paired t tests of 0.155 to 1.636. Four factors explained 74.3% variance and provided empirical support for the scale's conceptual basis. The scale achieved excellent internal consistency values (0.82-0.92) when examined with the test, validation, and paired (both test and retest) samples. CONCLUSIONS This new scale assess nurses' perceptions of how a fall prevention program affects their efficiency, which impacts the likelihood of use. Learning nurses' beliefs about time wasted when implementing new programs allows hospitals to correct problems that squander time.
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Affiliation(s)
| | | | | | | | - Lois Alfieri
- Montefiore Medical Center Hospitals, New York, NY
| | | | | | - Eileen J. Carter
- Columbia University School of Nursing, New York, NY
- New York-Presbyterian Hospital
| | | | | | - Susan Kurian
- Montefiore Medical Center Hospitals, New York, NY
| | | | | | | | | | | | | | | | - David W. Bates
- Partners HealthCare, Boston, MA
- Harvard Medical School, Boston, MA
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10
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Multifactorial falls interventions for people over 65 years in the acute hospital setting: An integrative review. Collegian 2022. [DOI: 10.1016/j.colegn.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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11
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A Multicenter Cohort Study of Falls Among Patients Admitted to the ICU. Crit Care Med 2022; 50:810-818. [PMID: 34995212 DOI: 10.1097/ccm.0000000000005423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the incidence of falls, risk factors, and adverse outcomes, among patients admitted to the ICU. DESIGN Retrospective cohort study. SETTING Seventeen ICUs in Alberta, Canada. PATIENTS Seventy-three thousand four hundred ninety-five consecutive adult patient admissions between January 1, 2014, and December 31, 2019. MEASUREMENTS AND MAIN RESULTS A mixed-effects negative binomial regression model was used to examine risk factors associated with falls. Linear and logistic regression models were used to evaluate adverse outcomes. Six hundred forty patients experienced 710 falls over 398,223 patient days (incidence rate of 1.78 falls per 1,000 patient days [95% CI, 1.65-1.91]). The daily incidence of falls increased during the ICU stay (e.g., day 1 vs day 7; 0.51 vs 2.43 falls per 1,000 patient days) and varied significantly between ICUs (range, 0.37-4.64 falls per 1,000 patient days). Male sex (incidence rate ratio [IRR], 1.37; 95% CI, 1.15-1.63), previous invasive mechanical ventilation (IRR, 1.82; 95% CI, 1.40-2.38), previous sedative and analgesic medication infusions (IRR, 1.60; 95% CI, 1.15-2.24), delirium (IRR, 3.85; 95% CI, 3.23-4.58), and patient mobilization (IRR, 1.26; 95% CI, 1.21-1.30) were risk factors for falling. Falls were associated with longer ICU (ratio of means [RM], 3.10; 95% CI, 2.86-3.36) and hospital (RM, 2.21; 95% CI, 2.01-2.42) stays, but lower odds of death in the ICU (odds ratio [OR], 0.09; 95% CI, 0.05-0.17) and hospital (OR, 0.21; 95% CI, 0.14-0.30). CONCLUSIONS We observed that among ICU patients, falls occur frequently, vary substantially between ICUs, and are associated with modifiable risk factors, longer ICU and hospital stays, and lower risk of death. Our study suggests that fall prevention strategies should be considered for critically ill patients admitted to ICU.
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12
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Cerilo PC, Siegmund LA. Pilot testing of nurse led multimodal intervention for falls prevention. Geriatr Nurs 2021; 43:242-248. [PMID: 34952307 DOI: 10.1016/j.gerinurse.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022]
Abstract
Patient fall-risk awareness, self-efficacy, and engagement in fall-prevention activities are important aspects of fall-prevention. The current pilot study examined the effect of a nurse-led multimodal intervention on hospitalized adults' levels of fall risk awareness, self-efficacy, and engagement in fall prevention. Sixty hospitalized older adults in an acute care setting in Florida participated in the study. There were significant differences [pre-test (M = 19.02, SD=1.152) and post-test (M = 21.71, SD=0.527); t (17.355) = 58, p≤.001] on level of fall risk awareness in fall prevention. There were no significant findings for fall self-efficacy and engagement. Study findings suggested that the higher the fall self-efficacy, the higher the engagement. Future research is needed to examine self-efficacy and engagement for fall prevention in larger diverse cohorts of hospitalized older adults.
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Affiliation(s)
- Perlita C Cerilo
- Nursing Operations Manager, Cleveland Clinic, Weston, Florida 33331, USA.
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Newman B, Joseph K, Chauhan A, Seale H, Li J, Manias E, Walton M, Mears S, Jones B, Harrison R. Do patient engagement interventions work for all patients? A systematic review and realist synthesis of interventions to enhance patient safety. Health Expect 2021; 24:1905-1923. [PMID: 34432339 PMCID: PMC8628590 DOI: 10.1111/hex.13343] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/14/2021] [Accepted: 08/04/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Patients are increasingly being asked for feedback about their healthcare and treatment, including safety, despite little evidence to support this trend. This review identifies the strategies used to engage patients in safety during direct care, explores who is engaged and determines the mechanisms that impact effectiveness. METHODS A systematic review was performed of seven databases (CINAHL, Cochrane, Cochrane-Central, Embase, ISI Web of Science, Medline, PsycINFO) that included research published between 2010 and 2020 focused on patient engagement interventions to increase safety during direct care and reported using PRISMA. All research designs were eligible; two reviewers applied criteria independently to determine eligibility and quality. A narrative review and realist synthesis were conducted. RESULTS Twenty-six papers reporting on twenty-seven patient engagement strategies were included and classified as consultation (9), involvement (7) and partnership (11). The definitions of 'patient engagement' varied, and we found limited details about participant characteristics or interactions between people utilizing strategies. Collaborative strategy development, a user-friendly design, proactive messaging and agency sponsorship were identified as mechanisms to improve engagement about safety at the point of direct care. CONCLUSIONS Agency sponsorship of collaboration between staff and patients is essential in the development and implementation of strategies to keep patients safe during direct care. Insufficient details about participant characteristics and patient-provider interactions limit recommendations for practice change. More needs to be learned about how patients are engaged in discussions about safety, particularly minority groups unable to engage with standard information. PATIENT OR PUBLIC CONTRIBUTION Review progress was reported to the CanEngage team, including the consumer steering group, to inform project priorities (PROSPERO CRD42020196453).
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Affiliation(s)
- Bronwyn Newman
- Centre for Health Systems and Safety Research (CHSSR), Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Kathryn Joseph
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Ashfaq Chauhan
- Centre for Health Systems and Safety Research (CHSSR), Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Holly Seale
- Faculty of Medicine and Health, School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jiadai Li
- Centre for Health Systems and Safety Research (CHSSR), Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Merrilyn Walton
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Stephen Mears
- Hunter New England Health Libraries, John Hunter Hospital, HRMC, Newcastle, New South Wales, Australia
| | - Benjamin Jones
- Faculty of Medicine and Health, School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Reema Harrison
- Centre for Health Systems and Safety Research (CHSSR), Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
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14
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Dykes PC, Khasnabish S, Adkison LE, Bates DW, Bogaisky M, Burns Z, Carroll DL, Carter E, Hurley AC, Jackson E, Kurian SS, Lindros ME, Ryan V, Scanlan M, Spivack L, Walsh MA, Adelman J. Use of a perceived efficacy tool to evaluate the FallTIPS program. J Am Geriatr Soc 2021; 69:3595-3601. [PMID: 34460098 DOI: 10.1111/jgs.17436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/14/2021] [Accepted: 07/26/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND/OBJECTIVES To assess nurses' opinions of the efficacy of using the FallTIPS (Tailoring Interventions for Patient Safety) fall prevention program. DESIGN Survey research. SETTING Seven adult acute-care hospitals in 2 hospital centers located in Boston and NYC. PARTICIPANTS A total of 298 medical-surgical nurses on 14 randomly selected units. INTERVENTION Three-step FallTIPS fall prevention program that had been in use as a clinical program for a minimum of 2 years in each hospital. MEASUREMENTS Fall Prevention Efficiency Scale (FPES), range 13-52; four-factorilly derived subscales: valued, efficiency, balances out and inefficiency; and 13 psychometrically validated individual items. RESULTS Nurses perceived the FallTIPS fall prevention program to be efficacious. The FPES mean score of 38.55 (SD = 5.05) and median of 39 were well above the lowest possible score of 13 and scale midpoint of 32.5. Most nurses (N = 270, 90.6%) scored above 33. There were no differences in FPES scores between nurses who had only used FallTIPS and nurses who had previously used a different fall prevention program. CONCLUSION The nurses who used FallTIPS perceived that efficiencies in patient care compensated for the time spent on FallTIPS. Nurses valued the program and findings confirmed the importance of patient and family engagement with staff in the fall prevention process. Regardless of the fall prevention program used, organizations should examine staff perceptions of their fall prevention program because programs that are not perceived as being useful, efficient, and valuable will lead to nonadherence over time and then will not reduce falls and injuries. The recently developed FPES used in this study is a brief tool available for organizations to assess nurses' perceptions of the efficacy of their fall prevention program. Additional FPES research is needed with larger and more diverse samples.
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Affiliation(s)
- Patricia C Dykes
- Division General Internal Medicine and Primary Care, Center for Patient Safety, Research and Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Srijesa Khasnabish
- Division General Internal Medicine and Primary Care, Center for Patient Safety, Research and Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - David W Bates
- Division General Internal Medicine and Primary Care, Center for Patient Safety, Research and Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | | | - Zoe Burns
- Division General Internal Medicine and Primary Care, Center for Patient Safety, Research and Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Eileen Carter
- School of Nursing, University of Connecticut, Storrs, Connecticut, USA
| | - Ann C Hurley
- Division General Internal Medicine and Primary Care, Center for Patient Safety, Research and Practice, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emily Jackson
- New York-Presbyterian, Columbia University Irving Medical Center, New York, New York, USA
| | | | | | - Virginia Ryan
- Department of Nursing, Brigham and Women's Faulkner Hospital, Boston, Massachusetts, USA
| | | | | | - Mary-Ann Walsh
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jason Adelman
- New York-Presbyterian, Columbia University Irving Medical Center, New York, New York, USA
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15
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DiGerolamo KA, Chen-Lim ML. An Educational Intervention to Improve Staff Collaboration and Enhance Knowledge of Fall Risk Factors and Prevention Guidelines. J Pediatr Nurs 2021; 57:43-49. [PMID: 33221696 DOI: 10.1016/j.pedn.2020.10.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Magnet®-designated hospitals are seeking to reduce the frequency of falls that lead to injury, which is considered a hospital-acquired condition. Patients with cancer are at high risk to fall, due to multiple factors. Synthesis of the literature supports team efforts and shared learning sessions for patient-care staff as part of the fall prevention process. The purpose was to improve collaboration between Registered Nurses (RNs) and Senior Nurse Aides (SNAs), as well as to enhance their knowledge of fall risk factors and evidence-based prevention guidelines for pediatric oncology patients. METHODS An evidence-based practice project was implemented using a quality improvement pilot based on the Magnet® framework. Oncology RNs and SNAs at a large pediatric hospital were invited to attend one of five educational sessions. Pre-and post-session learning was assessed based on an adapted fall risk knowledge assessment tool. FINDINGS Thirty participants attended an educational session with 27 (25 RNs and 2 SNAs) matched pre- and post-session assessments. Median post-session assessment scores were statistically significantly higher than pre-session scores (Z = -3.11, p = 0.001). Overall knowledge scores increased for 63% of participants. DISCUSSION An educational intervention focused on pediatric oncology nursing enhanced knowledge of patient-care roles and fall prevention efforts, leading to improved fall outcomes. APPLICATION TO PRACTICE Ensuring that RNs and SNAs fully embrace their shared role in harm prevention is vital when considering the complexity of delivering nursing care in our current healthcare environment.
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Affiliation(s)
- Kimberly A DiGerolamo
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd. Philadelphia, PA 19104, United States of America.
| | - Mei Lin Chen-Lim
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd. Philadelphia, PA 19104, United States of America
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16
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Dykes PC, Burns Z, Adelman J, Benneyan J, Bogaisky M, Carter E, Ergai A, Lindros ME, Lipsitz SR, Scanlan M, Shaykevich S, Bates DW. Evaluation of a Patient-Centered Fall-Prevention Tool Kit to Reduce Falls and Injuries: A Nonrandomized Controlled Trial. JAMA Netw Open 2020; 3:e2025889. [PMID: 33201236 PMCID: PMC7672520 DOI: 10.1001/jamanetworkopen.2020.25889] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Falls represent a leading cause of preventable injury in hospitals and a frequently reported serious adverse event. Hospitalization is associated with an increased risk for falls and serious injuries including hip fractures, subdural hematomas, or even death. Multifactorial strategies have been shown to reduce falls in acute care hospitals, but evidence for fall-related injury prevention in hospitals is lacking. OBJECTIVE To assess whether a fall-prevention tool kit that engages patients and families in the fall-prevention process throughout hospitalization is associated with reduced falls and injurious falls. DESIGN, SETTING, AND PARTICIPANTS This nonrandomized controlled trial using stepped wedge design was conducted between November 1, 2015, and October 31, 2018, in 14 medical units within 3 academic medical centers in Boston and New York City. All adult inpatients hospitalized in participating units were included in the analysis. INTERVENTIONS A nurse-led fall-prevention tool kit linking evidence-based preventive interventions to patient-specific fall risk factors and designed to integrate continuous patient and family engagement in the fall-prevention process. MAIN OUTCOMES AND MEASURES The primary outcome was the rate of patient falls per 1000 patient-days in targeted units during the study period. The secondary outcome was the rate of falls with injury per 1000 patient-days. RESULTS During the interrupted time series, 37 231 patients were evaluated, including 17 948 before the intervention (mean [SD] age, 60.56 [18.30] years; 9723 [54.17%] women) and 19 283 after the intervention (mean [SD] age, 60.92 [18.10] years; 10 325 [53.54%] women). There was an overall adjusted 15% reduction in falls after implementation of the fall-prevention tool kit compared with before implementation (2.92 vs 2.49 falls per 1000 patient-days [95% CI, 2.06-3.00 falls per 1000 patient-days]; adjusted rate ratio 0.85; 95% CI, 0.75-0.96; P = .01) and an adjusted 34% reduction in injurious falls (0.73 vs 0.48 injurious falls per 1000 patient-days [95% CI, 0.34-0.70 injurious falls per 1000 patient-days]; adjusted rate ratio, 0.66; 95% CI, 0.53-0.88; P = .003). CONCLUSIONS AND RELEVANCE In this nonrandomized controlled trial, implementation of a fall-prevention tool kit was associated with a significant reduction in falls and related injuries. A patient-care team partnership appears to be beneficial for prevention of falls and fall-related injuries. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02969343.
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Affiliation(s)
- Patricia C. Dykes
- Center for Patient Safety, Research and Practice, Division of General and Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Zoe Burns
- Center for Patient Safety, Research and Practice, Division of General and Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jason Adelman
- School of Nursing, Columbia University, New York, New York
- Columbia University Irving Medical Center/New York–Presbyterian, New York, New York
| | - James Benneyan
- Institute of Healthcare Systems Engineering, Boston, Massachusetts
| | | | - Eileen Carter
- School of Nursing, Columbia University, New York, New York
- Columbia University Irving Medical Center/New York–Presbyterian, New York, New York
| | | | | | - Stuart R. Lipsitz
- Center for Patient Safety, Research and Practice, Division of General and Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | | | - Shimon Shaykevich
- Center for Patient Safety, Research and Practice, Division of General and Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - David Westfall Bates
- Center for Patient Safety, Research and Practice, Division of General and Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Harvard University, Boston, Massachusetts
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17
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Tzeng HM, Okpalauwaekwe U, Lyons EJ. Barriers and Facilitators to Older Adults Participating in Fall-Prevention Strategies After Transitioning Home from Acute Hospitalization: A Scoping Review. Clin Interv Aging 2020; 15:971-989. [PMID: 32612356 PMCID: PMC7323788 DOI: 10.2147/cia.s256599] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/10/2020] [Indexed: 01/11/2023] Open
Abstract
Purpose Approximately, 14% of older adults aged 65 years and over experience a fall within 1 month post-hospital discharge. Adequate self-management may minimize the impact of these falls; however, research is lacking on why some older adults engage in self-management to prevent falls while others do not. Methods We conducted a scoping review to identify barriers and facilitators to older adults participating in fall-prevention strategies after transitioning home from acute hospitalization. Eligibility criteria were peer-reviewed journal articles published during 2009-2019 which were written in English and contained any of the following keywords or their synonyms: "fall-prevention," "older adults," "post-discharge" and "transition care." We systematically and selectively summarized the findings of these articles using the Joanna Briggs Institute guidelines and the PRISMA-ScR reporting guidelines. Seven bibliographic databases were searched: PubMed/MEDLINE, ERIC, CINAHL, Cochrane Library, Scopus, PsycINFO, and Web of Science. We used the Capability-Opportunity-Motivation-Behavior (COM-B) model of health behavior change as a framework to guide the content, thematic analysis, and descriptive results. Results Seventeen articles were finally selected. The most frequently mentioned barriers and facilitators for each COM-B dimension differed. Motivation factors include such as older adults lacking inner drive and self-denial of being at risk for falls (barriers) and following-up with older adults and correcting inaccurate perceptions of falls and fall-prevention strategies (facilitators). Conclusion This scoping review revealed gaps and future research areas in fall prevention relative to behavioral changes. These findings may enable tailoring feasible fall-prevention interventions for older adults after transitioning home from acute hospitalization.
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Affiliation(s)
- Huey-Ming Tzeng
- The University of Texas Medical Branch, School of Nursing, Galveston, TX, USA
| | - Udoka Okpalauwaekwe
- University of Saskatchewan, College of Medicine, Saskatoon, Saskatchewan S7N 2Z4, Canada
| | - Elizabeth J Lyons
- University of Texas Medical Branch, Department of Nutrition and Metabolism, School of Health Professions, Galveston, TX, USA
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Christiansen TL, Lipsitz S, Scanlan M, Yu SP, Lindros ME, Leung WY, Adelman J, Bates DW, Dykes PC. Patient Activation Related to Fall Prevention: A Multisite Study. Jt Comm J Qual Patient Saf 2020; 46:129-135. [DOI: 10.1016/j.jcjq.2019.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 11/15/2019] [Accepted: 11/26/2019] [Indexed: 11/26/2022]
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