Cost analysis of a falls-prevention program in an orthopaedic setting

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.

Association between fall-related serious injury and activity during fall in an acute care hospital

OBJECTIVES

Few studies have evaluated the mechanism of serious injury in acute hospitalization. Thus, the association between fall-related serious injury and activity during falls in acute care hospital remains unclear. Herein, we investigated the relationship between serious injury caused by fall and activity at the time of the fall in an acute care hospital.

METHODS

This retrospective cohort study was conducted at Asa Citizens Hospital. All inpatients aged 65 years and older were eligible for the study, which was conducted from April 1, 2021, through March 31, 2022. The magnitude of the association between injury severity and activity during the fall was quantified using odds ratio.

RESULTS

Among the 318 patients with reported falls, 268 (84.3%) had no related injury, 40 (12.6%) experienced minor injury, 3 (0.9%) experienced moderate injury, 7 (2.2%) experienced major injury. Moderate or major injuries caused by a fall was associated with the activity during the fall (odds ratio: 5.20; confidence intervals: 1.43-18.9, p = 0.013).

CONCLUSION

This study recognizes that falling during ambulation caused moderate or major injuries in an acute care hospital. Our study suggests that falls while ambulating in an acute care hospital were associated not only with fractures, but also with lacerations requiring sutures and brain injuries. Among the patients with moderate or major injuries, more falls occurred outside the patient's bedroom as compared with patients with minor or no injuries. Therefore, it is important to prevent moderate or major injuries related to falls that occur while the patient is walking outside their bedroom in an acute care hospital.

Turkish adaptation of Wilson-Sims psychiatric fall risk assessment scale

PURPOSE

This study aimed to adapt the Wilson-Sims Fall Scale to Turkish and assess the levels of sensitivity and selectivity.

DESIGN AND METHODS

The scale consisting of two sections and 15 items including age, gender, mental and physical status, elimination, impairments, gait/balance, falls' history, medications, and detox protocol was administered to 750 patients in psychiatric clinic.

FINDINGS

The kappa coefficient of the study (K: 0.44, p < .000) showed a moderate agreement. The sensitivity and selectivity rates of the scale were 78.5% and 77.6%, respectively. Positive and negative predictive values were 6.25% and 99.4%.

PRACTICE IMPLICATIONS

The scale has acceptable sensitivity and selectivity values. It is best practice to use both Wilson-Sims and Itaki Scale simultaneously for identification of patients at risk of falling.

Fall prevention implementation strategies in use at 60 United States hospitals: a descriptive study

BACKGROUND

To guide fall prevention efforts, United States organisations, such as the Joint Commission and the Agency for Healthcare Research and Quality, have recommended organisational-level implementation strategies: leadership support, interdisciplinary falls committees, electronic health record tools, and staff, family and patient education. It is unclear whether hospitals adhere to such strategies or how these strategies are operationalised.

OBJECTIVE

To identify and describe the prevalence of specific hospital fall prevention implementation strategies.

METHODS

In 2017, we surveyed 80 US hospitals participating in the National Database of Nursing Quality Indicators who volunteered for the study. We conducted descriptive statistics by calculating percentages for categorical variables and the median and IQR for count variables.

RESULTS

A total of 60/80 (75%) of hospitals completed the survey. The majority of hospitals were not-for-profit (98%) and urban (90%); more than half were Magnet (53%), small (53%) and teaching (52%). Hospitals were more likely to use leadership strategies, such as updating fall policies in the past 3 years (98%) but less likely to reward staff (40%). Hospitals commonly used interdisciplinary falls committees (83%) but membership rarely included physicians. Hospitals lacked access to electronic health record tools, such as high-risk medication warnings (27%). Education strategies were commonly used; 100% of hospitals provided fall education at staff orientation, but only 22% educated all employees (not just nursing staff).

CONCLUSIONS

Our study is the first to our knowledge to examine which expert-recommended implementation strategies are being used and how they are being operationalised in US hospitals. Future studies are needed to document fall prevention implementation strategies in detail and to test which implementation strategies are most effective at reducing falls. Additionally, research is needed to evaluate the quality of implementation (eg, fidelity) of fall prevention interventions.

Implementation of Fall Preventions Over the Past 15 Years: Impact on Inpatient Injury and Insights for the Future

BACKGROUND

Hospital fall rates have changed minimally with preventive measures; however, the effect on injury rate is unclear.

PURPOSE

The purpose was to determine whether fall-related injuries have changed over time.

METHODS

A retrospective comparison was done of 1134 adult inpatient falls in 2017 to 1235 falls in 2001-2002 for injury and fall circumstances. Separate comparisons were made of patient characteristics by service line for 2017.

RESULTS

Severe fall injuries declined from 6% to 2.4%. Elimination issues remained the most common circumstance (38.9% and 42%). In 2017, malnutrition (31.6%), low function (61.4%), fall history (26.3%), and use of high-risk medications (83.2%) were common in patients who fell. Predictors of falls with injury by patient population were as follows: surgery-male gender (P = .01), low function (P = .006), elimination issues (P = .04); oncology-low function (P = .04); and neurology-low function (P = .02).

CONCLUSIONS

Severe fall-related injuries have decreased in the past 15 years. The most common circumstance for falls remains elimination issues.

Preventing inpatient falls with injuries using integrative machine learning prediction: a cohort study

Patient falls during hospitalization can lead to severe injuries and remain one of the most vexing patient-safety problems facing hospitals. They lead to increased medical care costs, lengthened hospital stays, more litigation, and even death. Existing methods and technology to address this problem mostly focus on stratifying inpatients at risk, without predicting fall severity or injuries. Here, a retrospective cohort study was designed and performed to predict the severity of inpatient falls, based on a machine learning classifier integrating multi-view ensemble learning and model-based missing data imputation method. As input, over two thousand inpatient fall patients’ demographic characteristics, diagnoses, procedural data, and bone density measurements were retrieved from the HMH clinical data warehouse from two separate time periods. The predictive classifier developed based on multi-view ensemble learning with missing values (MELMV) outperformed other three baseline models; achieved a cross-validated AUC of 0.713 (95% CI, 0.701–0.725), an AUC of 0.808 (95% CI, 0.740–0.876) on the separate testing set. Our studies show the efficacy of integrative machine-learning based classifier model in dealing with multi-source patient data, which in this case delivers robust predictive performance on the severity of patient falls. The severe fall index provided by the MELMV classifier is calculated to identify inpatients who are at risk of having severe injuries if they fall, thus triggering additional steps of intervention to prevent a harmful fall, beyond the standard-of-care procedure for all high-risk fall patients.

Cost analysis of a brief intervention for the prevention of falls after discharge from an emergency department

RATIONALE, AIMS AND OBJECTIVES

There is considerable uncertainty around the cost-effectiveness of interventions for preventing secondary falls in older people presenting to emergency departments (ED). The objective was to complete an economic evaluation of a brief educational ED intervention aimed at preventing falls in older people post discharge.

METHODS

A net cost analysis was completed from the health system perspective, using data from a controlled clinical trial, where an education intervention was compared to standard care. Patients aged 65 and older presenting to the ED with any diagnosis were enrolled. The costs, using Australian dollars (A$) at 2015 values, included resources required for the intervention and any health care cost incurred in the 6-month follow-up period (time horizon). Cost data were sourced through institutional billing records and liaison with the patient and their general practitioner. Mean costs and differences were analysed through nonparametric bootstrapping.

RESULTS

The total costs in the control group (n = 201) were A$1 576 496 compared to A$1 292 130 in the intervention group (n = 211). The mean net cost per patient was A$7749 and A$6187 (P = 0.68) respectively resulting in a mean difference of A$1580 per patient in the intervention group (95% CI: A$-2806 to A$6150). Patients who presented to the ED with a fall diagnosis were reviewed through subgroup analysis. Total costs for patients who presented with a fall in the control group (n = 69) were A$708 995 compared to A$512 874 in the intervention group (n = 97). The mean net cost per patient was A$10 326 and A$5343 respectively (P = 0.33) with an overall saving of A$4624 per patient in the intervention group (95% CI: A$-2868 to A$15 426).

CONCLUSIONS

A brief intervention had no net cost benefit across the whole study population, but is more cost effective in older people presenting to the ED with a fall.

Review of perioperative falls

Falls are a known public health problem, and there is increasing recognition of the importance of perioperative falls for risk prediction and quality assessment. Our objective was to review existing literature regarding the occurrence, injuries, and risk factors of preoperative and postoperative falls. A systematized search of PubMed entries between 1947 and November 2015 produced 24 articles that met inclusion criteria. Most studied orthopaedic surgery patients older than 65 yr. Four were rated 'good' quality. Interrater reliability for the quality assessment was moderate (κ = 0.77). In the 3-12 months before surgery, the proportion of preoperative patients who fell ranged from 24 to 48%. Injuries were common (70%). The rate of postoperative falls ranged from 0.8 to 16.3 per 1000 person-days, with a gradual decline in the months after surgery. Injuries from postoperative falls occurred in 10-70% of fallers, and 5-20% experienced a severe injury. Risk factors were not well studied. Prospective studies reported a higher percentage of falls and fall-related injuries than retrospective studies, suggesting that there may be underdetection of falls and injuries with retrospective studies. Perioperative falls were more common than falls reported in the general community, even up to 12 months after surgery. Surgery-related falls may therefore occur beyond the hospitalization period. Future studies should use a prospective design, validated definitions, and broader populations to study perioperative falls. In particular, investigations of risk factors and follow-up after hospitalization are needed.

REGISTRY NUMBER

PROSPERO registration number CRD42015029971.

Changing the Perceptions of a Culture of Safety for the Patient and the Caregiver: Integrating Improvement Initiatives to Create Sustainable Change

Evidence indicates that chances for a successful patient mobility program, prevention of pressure injury and falls, and safe patient handling are enhanced when an organization possesses an appropriate culture for safety. Frequently, these improvement initiatives are managed within silos often creating a solution for one and a problem for the others. A model of prevention integrating early patient mobility, preventing pressure injuries and falls while ensuring caregiver safety, is introduced. The journey begins by understanding why early mobility and safe patient handling are critical to improving overall patient outcomes. Measuring current culture and understanding the gaps in practice as well as strategies for overcoming some of the major challenges for success in each of these areas will result in sustainable change.

We Will Not Compete on Safety: How Children's Hospitals Have Come Together to Hasten Harm Reduction

BACKGROUND

Launched in 2012, the Children's Hospitals' Solutions for Patient Safety (SPS) Network is a collaborative of children's hospitals in the United States and Canada working together to eliminate patient and employee/staff harm across all children's hospitals.

METHODS

The SPS Network, which has grown from 8 to 137 hospitals, has a foundation of leadership engagement, noncompetition, data-driven learning, attention to safety culture, family engagement, and transparency. The SPS Leadership Group, which consists of more than 150 leaders from participating hospitals, forms condition-specific teams to promote the reduction of hospital-acquired harm in a phased design that includes an ongoing focus on both process improvement and safety culture enhancements. Hospital leaders are engaged through monthly reports, executive webinars, in-person meetings, and biannual training opportunities for boards of trustees. SPS has developed extensive opportunities for learning collaboration, including in-person networkwide learning sessions, regional meetings, general and condition-specific webinars, communications, and a shared website.

RESULTS

Over time, the portfolio has expanded as SPS has achieved harm reduction targets for some conditions and begun work to reduce harm in other, previously unaddressed areas. In 2017 SPS reported a 9%-71% reduction in eight harm conditions by an initial cohort of 33 hospitals. SPS estimates that more than 9,000 children have been spared harm since 2012, with $148.5 million in health care spending avoided.

CONCLUSION

Participation in the SPS Network has been associated with improved safety in children's hospitals. Widespread participation in this or similar collaborations has the potential to dramatically decrease harm to patients, employees, and staff.

Reducing medical-surgical inpatient falls and injuries with videos, icons and alarms

Background

Inpatient falls and subsequent injuries are among the most common hospital-acquired conditions with few effective prevention methods.

Objective

To evaluate the effectiveness of patient education videos and fall prevention visual signalling icons when added to bed exit alarms in improving acutely hospitalised medical-surgical inpatient fall and injury rates.

Design

Performance improvement study with historic control.

Setting

Four medical-surgical units in one US public acute care hospital.

Study participants

Adult medical-surgical inpatients units.

Interventions

A 4 min video was shown to patients by trained volunteers. Icons of individual patient risk factors and interventions were placed at patients’ bedsides. Beds with integrated three-mode sensitivity exit alarms were activated for confused patients at risk of falling.

Main outcome measures

The main outcome measure is the incident rate per 1000 patient days (PDs) for patient falls, falls with any injury and falls with serious injury. The incident rate ratio (IRR) for each measure compared January 2009–September 2010 (baseline) with the follow-up period of January 2015–December 2015 (intervention).

Results

Falls decreased 20% from 4.78 to 3.80 per 1000 PDs (IRR 0.80, 95% CI 0.66 to 0.96); falls with any injury decreased 40% from 1.01 to 0.61 per 1000 PDs (IRR 0.60, 95% CI 0.38 to 0.94); and falls with serious injury 85% from 0.159 to 0.023 per 1000 PDs (IRR 0.15, 95% CI 0.01 to 0.85). Icons were not fully implemented.

Conclusion

The first known significant reduction of falls, falls with injury and falls with serious injury among medical-surgical inpatients was achieved. Patient education and continued use of bed exit alarms were associated with large decreases in injury. Icons require further testing. Multicentre randomised controlled trials are needed to confirm the effectiveness of icons and video interventions and exit alarms.

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.

Effectiveness of team training on fall prevention

A longitudinal, repeated-measures design with intervention and comparison groups was used to evaluate the effect of a training curriculum based on TeamSTEPPS with video vignettes focusing on fall prevention. Questionnaires, behavioral observations, and fall data were collected over 9 months from both groups located at separate hospitals. The intervention group questionnaire scores improved on all measures except teamwork perception, while observations revealed an improvement in communication compared with the control group. Furthermore, a 60% fall reduction rate was reported in the intervention group. Team training may be a promising intervention to reduce falls.

Prevalence and cost of imaging in inpatient falls: the rising cost of falling

OBJECTIVE

To quantify the type, prevalence, and cost of imaging following inpatient falls, identify factors associated with post-fall imaging, and determine correlates of positive versus negative imaging.

DESIGN

Single-center retrospective cohort study of inpatient falls. Data were collected from the hospital's adverse event reporting system, DrQuality. Age, sex, date, time, and location of fall, clinical service, Morse Fall Scale/fall protocol, admitting diagnosis, and fall-related imaging studies were reviewed. Cost included professional and facilities fees for each study.

SETTING

Four hundred and fifteen bed urban academic hospital over 3 years (2008-2010).

PATIENTS

All adult inpatient falls during the study period were included. Falls experienced by patients aged <18 years, outpatient and emergency patients, visitors to the hospital, and staff were excluded.

MEASUREMENTS AND MAIN RESULTS

Five hundred and thirty inpatient falls occurred during the study period, average patient age 60.7 years (range 20-98). More than half of falls were men (55%) and patients considered at risk of falls (56%). Falls were evenly distributed across morning (33%), evening (34%), and night (33%) shifts. Of 530 falls, 178 (34%) patients were imaged with 262 studies. Twenty percent of patients imaged had at least one positive imaging study attributed to the fall and 82% of studies were negative. Total cost of imaging was $160,897, 63% ($100,700) from head computed tomography (CT).

CONCLUSION

Inpatient falls affect patients of both sexes, all ages, occur at any time of day and lead to expensive imaging, mainly from head CTs. Further study should be targeted toward clarifying the indications for head CT after inpatient falls and validating risk models for positive and negative imaging, in order to decrease unnecessary imaging and thereby limit unnecessary cost and radiation exposure.

A cost analysis of internal fixation versus nonoperative treatment in adult midshaft clavicle fractures using multiple randomized controlled trials

BACKGROUND

To determine whether the cost of nonoperative treatment, including those who require delayed operative treatment, is less than those receiving initial operative management.

METHODS

We identified 4 recent randomized controlled trials comparing operative and nonoperative treatment of displaced midshaft clavicle fractures in adults with a minimum of 1-year follow-up. A decision tree was then created from these data using reoperation for those treated with surgery or delayed operative treatment of those treated nonoperatively as end points. Actual costs estimated from 2013 Medicare reimbursement rates were applied and adjusted to better reflect private insurance rates. We then performed a 2-way sensitivity analysis to test the stability of our model.

RESULTS

Based on our decision tree, the expected costs for operative and nonoperative treatment were $14,763.21 and $3112.65, respectively, producing a cost savings of $11,650.56 with nonoperative treatment. After application of a 2-way sensitivity analysis, our model remains valid until delayed operative treatment for nonoperative patients approaches 95% and reoperation after initial operative management falls below 15%.

CONCLUSIONS

From the perspective of a single payer, initial nonoperative treatment of midshaft clavicle fractures followed by delayed surgery as needed is less costly than initial operative fixation.

LEVEL OF EVIDENCE

Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Developing a multidisciplinary fall reduction program for lower-extremity joint arthroplasty patients

With the anticipated increase in the number of total joint arthroplasty surgeries and associated fall risks, a fall reduction program can provide greater safety for patients in the postoperative period. Although further prospective studies are needed among total joint arthroplasty patients, there is sufficient evidence to show that a successful fall reduction program can be implemented. Common components to date have included a multidisciplinary team, multicomponent interventions specific to the risks associated with total knee and hip arthroplasty patients, education of patients and staff, and strategies to promote adherence to the program.

Have bilateral total knee arthroplasties become safer? A population-based trend analysis

BACKGROUND

Studies suggest a trend in the selection of younger and healthier individuals to undergo bilateral TKAs in an attempt to diminish the incidence of complications. It remains unclear whether this development has reduced overall perioperative morbidity and mortality.

QUESTIONS/PURPOSES

We investigated whether changes in demographics and comorbidity patterns of patients undergoing bilateral TKAs are detectable and coincide with changes in length and cost of hospitalization, incidence of perioperative complications, morbidity, and mortality.

METHODS

We accessed Nationwide Inpatient Survey data files between 1999 and 2008. One-year periods were created and changes in demographics, length of in-hospital stay, and perioperative morbidity and mortality were analyzed.

RESULTS

An estimated 258,524 bilateral TKAs were performed between 1999 and 2008 in the United States. The number of annual procedures increased from 19,288 to 33,679 (75%). Length of hospital stay decreased from 4.98 to 4.01 days. Absolute in-hospital mortality rates decreased at an average rate of 10% per year. The unadjusted percent and adjusted incidence per 1000 inpatient days decreased from 0.42% and 0.85 to 0.16% and 0.39. Although the unadjusted incidence of pneumonia, pulmonary embolism, and nonmyocardial infarction cardiac complications did not change, an increase with time was detectible after adjustment for length of stay. No changes in adjusted incidence were seen for other complications.

CONCLUSIONS

Although a decreased incidence was seen for some major complications, others either remained unchanged or had an increased incidence when adjusted for length of stay. Future interventions should focus on reducing perioperative risk to improve patient safety.