A failed fall prevention study in an acute care setting: lessons from the swamp

Association Between Low Serum Phosphate Level and Risk of Falls in Hospitalized Patients Over 50 Years of Age: A Retrospective Observational Cohort Study

Purpose

Falls are the leading cause of injury among hospitalized patients, particularly among older patients. We investigated the association between serum phosphate (s-phosphate) levels and the risk of in-hospital falls.

Patients and Methods

This retrospective observational cohort study included all patients aged over 50 years who were admitted to Yongin Severance Hospital in South Korea between January 2018 and March 2021. Demographic, anthropometric, and biochemical parameters were recorded on admission. S-phosphate levels were classified into three groups: below normal (<2.8 mg/dL), normal (2.8–4.4 mg/dL), and above normal (≥4.5 mg/dL). The normal group was further stratified into tertiles (2.8–3.2, 3.3–3.7, and 3.8–4.4 mg/dL). The incidence of in-hospital falls was compared between the five groups. Logistic regression analyses were performed to assess the association between s-phosphate levels and the incidence of falls during the hospital stay, with clinical factors included as covariates in the multivariable models.

Results

A total of 15,485 patients (female: 52.1%) with a median age of 70.0 years (interquartile range: 60.0–79.0 years) were included in the analysis, of whom 295 (1.9%) experienced a fall during the hospital stay. The incidence of falls was significantly higher among patients with lower s-phosphate levels, and this relationship also applied among patients with s-phosphate levels within the normal range as well. The association between lower s-phosphate levels and increased risk of falls remained significant in the adjusted analyses.

Conclusion

A lower s-phosphate level on admission was independently associated with an increased risk of in-hospital falls. Further studies are needed to determine whether the s-phosphate level on admission could improve prediction of the risk of in-hospital falls.

Implementing Patient Falls Education in Hospitals: A Mixed-Methods Trial

Patient education is key to preventing hospital falls yet is inconsistently implemented by health professionals. A mixed methods study was conducted involving a ward-based evaluation of patients receiving education from health professionals using a scripted conversation guide with a falls prevention brochure, followed by semi-structured qualitative interviews with a purposive sample of health professionals involved in delivering the intervention. Over five weeks, 37 patients consented to surveys (intervention n = 27; control n = 10). The quantitative evaluation showed that falls prevention education was not systematically implemented in the trial ward. Seven individual interviews were conducted with health professionals to understand the reasons why implementation failed. Perceived barriers included time constraints, limited interprofessional collaboration, and a lack of staff input into designing the research project and patient interventions. Perceived enablers included support from senior staff, consistent reinforcement of falls education by health professionals, and fostering patient empowerment and engagement. Recommended strategies to enhance implementation included ensuring processes were in place supporting health professional accountability, the inclusion of stakeholder input in designing the falls intervention and implementation processes, as well as leadership engagement in falls prevention education. Although health professionals play a key role in delivering evidence-based falls prevention education in hospitals, implementation can be compromised by staff capacity, capability, and opportunities for co-design with patients and researchers. Organisational buy-in to practice change facilitates the implementation of evidence-based falls prevention activities.

Prediction of fall events during admission using eXtreme gradient boosting: a comparative validation study

As the performance of current fall risk assessment tools is limited, clinicians face significant challenges in identifying patients at risk of falling. This study proposes an automatic fall risk prediction model based on eXtreme gradient boosting (XGB), using a data-driven approach to the standardized medical records. This study analyzed a cohort of 639 participants (297 fall patients and 342 controls) from Chang Gung Memorial Hospital, Chiayi Branch, Taiwan. A derivation cohort of 507 participants (257 fall patients and 250 controls) was collected for constructing the prediction model using the XGB algorithm. A comparative validation of XGB and the Morse Fall Scale (MFS) was conducted with a prospective cohort of 132 participants (40 fall patients and 92 controls). The areas under the curves (AUCs) of the receiver operating characteristic (ROC) curves were used to compare the prediction models. This machine learning method provided a higher sensitivity than the standard method for fall risk stratification. In addition, the most important predictors found (Department of Neuro-Rehabilitation, Department of Surgery, cardiovascular medication use, admission from the Emergency Department, and bed rest) provided new information on in-hospital fall event prediction and the identification of patients with a high fall risk.

Factors Influencing Falls in High- and Low-Risk Patients in a Tertiary Hospital in Korea

The purpose of this study was to explore the characteristics and predictors of falls in high- and low-risk inpatients in a tertiary hospital in Korea.

Additional exercise for older subacute hospital inpatients to prevent falls: benefits and barriers to implementation and evaluation

Objective: To evaluate the clinical effectiveness and implementation of a falls prevention exercise programme for preventing falls in the subacute hospital setting.

Design: Randomized controlled trial, subgroup analysis.

Participants: Patients of a metropolitan subacute/aged rehabilitation hospital who were recommended for a falls prevention exercise programme when enrolled in a larger randomized controlled trial of a falls prevention programme.

Methods: Participants in both the control and intervention groups who were recommended for the exercise programme intervention were followed for the duration of their hospital stay to determine if falls occurred. Participants had their balance, strength and mobility assessed upon referral for the exercise programme and then again prior to discharge. Participation rates in the exercise programme were also recorded.

Results: Intervention group participants in this subgroup analysis had a significantly lower incidence of falls than their control group counterparts (control: 16.0 falls/1000 participant-days, intervention: 8.2 falls/1000 participant-days, log-rank test: P = 0.007). However few differences in secondary balance, strength and mobility outcomes were evident.

Conclusion: This exercise programme provided in addition to usual care may assist in the prevention of falls in the subacute hospital setting.

Patient education to prevent falls in subacute care

Objective: To evaluate the effectiveness of a patient education programme for preventing falls in the subacute hospital setting.

Design: Randomized controlled trial, subgroup analysis.

Participants: Patients of a metropolitan subacute/aged rehabilitation hospital who were recommended for a patient education intervention for the prevention of falls when enrolled in a larger randomized controlled trial of a falls prevention programme.

Methods: Participants in both the control and intervention groups who were recommended for the education programme intervention were followed for the duration of their hospital stay to determine if falls occurred. Only participants in the intervention group who were recommended for this intervention actually received it. In addition, these participants completed an evaluation survey at the completion of their education programme.

Results: Intervention group participants in this subgroup analysis had a significantly lower incidence of falls than their control group counterparts (control: 16.0 falls/1000 participant-days, intervention: 8.2 falls/1000 participant-days, log-rank test: P = 0.007). However the difference in the proportion of fallers was not significant (relative risk 1.21, 95% confidence interval 0.68 to 2.14).

Conclusion: Patient education is an important part of a multiple intervention falls prevention approach for the subacute hospital setting.

A Study of Rate and Predictors of Fall Among Elderly Patients in a University Hospital

INTRODUCTION

Falls represent a serious problem facing hospital-admitted patients, and the severity of fall-related complications rises steadily after the age of 65 years.

OBJECTIVES

The aims of this study were (a) to calculate the rate of falls among elderly patients in the internal medicine departments in Ain Shams University Hospital, (b) to identify different predictors and characteristics of falls, and (c) to assess clinical consequences and hospitalization outcomes of falls.

SUBJECTS AND METHODS

An observational longitudinal study has been conducted in Ain Shams University Hospital, where 411 elderly patients admitted to the internal medicine departments were included. Upon admission, the patients were assessed for their risk for falling using the Morse Fall Scale (MFS). Information about their medical condition and drugs administered was obtained. Functional assessment of the patients regarding their ability to perform different daily activities was also performed. The patients were followed up during their stay, and once a fall event occurred, complete details regarding the circumstances and consequences of that event were obtained.

RESULTS

The incidence rate of falls was found to be 16.9 per 1000 patient days. The fallers had a significantly high risk for falling according to the MFS (P = 0.02). The MFS was able to predict patients at risk for falling and identified correctly 82.6% of the fallers. The most common medical conditions associated with falls were diabetes (48.7%), hypertension (58.7%), and visual impairment (41.3%). Anemia (P = 0.05) and osteoporosis (P = 0.02) showed a statistically significant difference between the fallers and the nonfallers. Presence of a history of a fall and increased length of hospital stay were highly significant (P = 0.01) factors that predisposed to falls. Logistic regression analysis showed that anemia, osteoporosis, and history of a fall were independent predictors of falls. Most falls had no serious consequences, approximately 18% had contusions, 2% had subdural hematomas, and 4% had fractures and lacerations.

CONCLUSIONS

Elderly patients with anemia, osteoporosis, and history of a fall are more prone to falls and should be considered in fall protective measures.

Translation of falls prevention knowledge into action in hospitals: what should be translated and how should it be done?

INTRODUCTION

Falls prevention evidence has changed and evolved over time with positive and negative studies revealing that a "one-size fits all" approach is not the solution. Care must be taken to critically appraise the evidence and the potential applicability of that evidence to the specific hospital setting.

METHOD

A narrative account of the evolution of research evidence in this field is first presented. How this evidence should be applied in clinical practice is challenging, with a lack of translational evidence for the hospital setting we draw on broader theory of translating knowledge to action.

CONCLUSIONS

The journey should begin with formation of a management and engagement committee. A review of existing practices and the difference between existing practice and evidence-based practice should be undertaken to identify the "evidence-practice gap." Engagement with staff is recommended to inform a plan for practice change. Plans for resourcing, targeting, and evaluating these strategies should also be undertaken.

IMPACT ON INDUSTRY

This paper will assist hospitals to identify and implement evidence based falls prevention strategies leading to an improvement in patient safety.

Fall Risk Assessments in Home Care: OASIS-C Expectations

The revised version of the Outcome and Assessment Information Set (OASIS-C) contains many changes to the data set including the addition of process measure items, which looks at specific evidence-based practices agencies have in place to address high-risk, high-volume, problem-prone areas. One of these process measure areas, namely, falls prevention, addresses agencies’ processes for assessing fall risk and implementing steps to reduce and prevent falls. This article identifies problems regarding home care falls, details the item in the data set pertaining to fall risk assessment, describes several possible falls risk assessments that can be used, and explores strategies to meet the OASIS-C process measure item for multifactor fall risk assessment. Tests that are multifactorial, along with other more specific focused risk-assessment tools are described.

Patient falls: acute care nurses' experiences

AIM

To describe the findings from a qualitative study exploring acute care nurses' experiences with patient falls.

BACKGROUND

Patient falls continue to be a problem in acute care settings for nurses at the point of care. Despite the growing body of knowledge related to risk factors and interventions for fall prevention, minimal attention has been given to nurses' perspectives of patient falls.

DESIGN

A qualitative descriptive design was used.

METHOD

Focus group discussions were conducted with nurses working on a cross-section of inpatient acute care settings. Audio-taped sessions were transcribed and analysed thematically.

RESULTS

Nurses described their experience of falls as 'knowing the patient as safe', an ongoing affirmation that the patient was free from harm. In this focused, narrowly defined and highly specific knowing, nurses employed the key strategies of assessment, monitoring and communicating. Variable conditions influenced whether these strategies were effective in giving nurses the knowledge they needed to keep the patient safe. When strategies failed to provide nurses with knowledge of their patients as safe and patients fell, this created considerable stress for nurses and prompted them to use a range of coping strategies.

CONCLUSION

Knowing the patient as safe has the potential to resolve the tension between patient safety and independence. The critical, often taken for granted, activities used by nurses in this knowing must be expanded to include the meaning falls have for patients and attend to factors beyond nurses control such as environmental redesign and staffing.

RELEVANCE TO CLINICAL PRACTICE

Nurses play an important role in fall prevention through knowing the patient as safe but must be supported through the use of a multi-faceted approach extending from the individual nurse to the institutional level.

Evaluation of the Morse Fall Scale: Applicability in Chinese hospital populations

BACKGROUND

Patient falls have been identified as a significant health problem in the general hospital patient population. The Morse Fall Scale (MFS) is an individualized criterion-referenced assessment tool designed for measuring the likelihood of patient falls in hospitals. Despite the scale has demonstrated high validity and reliability in the previous researches, this study is to provide additional validity tests to determine the applicability in the Chinese hospital population.

OBJECTIVES

To examine the predictive power of the MFS to predict patient falls. To conduct reliability tests on internal consistency, item analysis, inter-rater and test-retest reliability.

DESIGN

The study was a cross-sectional study.

SETTINGS

The medical and geriatric units of three rehabilitation hospitals in Hong Kong participated in the study.

PARTICIPANTS

A convenience sample of 954 Chinese patients was recruited sequentially upon admission in the hospital ward units. They ranged in age from 17 to 100 years, with a mean of 70.2 years.

METHODS

The patients were assessed for fall risk using the MFS on admission. Data was collected on the number of patients who fell rather than the number of falls.

RESULTS

The scale had a sensitivity of 31% and a specificity of 83% when the cut-off point was determined at 45. The field test demonstrated excellent inter-rater reliability with an ICC value of 0.97 (95%CI 0.94-0.98). Repeatability was high with an ICC of 0.98 (95% CI 0.98-0.99). The evaluation revealed a low Cronbach's alpha coefficient and a low to moderate item-to-scale correlation.

CONCLUSIONS

The evidence collected in this study has shown both the positive and negative aspects of using the MFS in assessing the fall risk of Chinese patients during rehabilitation. The discriminative validity and internal consistency reliability provide researchers and clinicians with a major step in further developing or modifying the scale.

Evaluation of a falls prevention programme in an acute tertiary care hospital

AIMS AND OBJECTIVES

To evaluate a systematic, coordinated approach to limit the severity and minimize the number of falls in an acute care hospital.

BACKGROUND

Patient falls are a significant cause of preventable injury and death, particularly in older patients. Best practice principles mandate that hospitals identify those patients at risk of falling and implement interventions to prevent or minimize them.

METHODS

A before and after design was used for the study. All patients admitted to three medical wards and a geriatric evaluation management unit were enrolled over a six-month period. Patients' risk of falling was assessed using a falls risk assessment tool and appropriate interventions implemented using a falls care plan. Data related to the number and severity of falls were obtained from the Australian Incident Monitoring System database used at the study site.

RESULTS

In this study, 1357 patient admissions were included. According to their risk category, 37% of patients (n = 496) were grouped as low risk (score = 1-10), 58% (n = 774) medium risk (score = 11-20) and 5% (n = 63) high risk (score = 21-33) for falls. The incidence of falls (per average occupied bed day) was eight per 1000 bed days for the study period. Compared with the same months in 2002/2003, there was a significant reduction in falls from 0.95 to 0.80 (95% CI for the difference -0.14 to -0.16, P < 0.001).

CONCLUSION

We evaluated a systematic, coordinated approach to falls management that included a falls risk assessment tool and falls care plan in the acute care setting. Although a significant reduction in falls was found in this study, it could not be attributed to any specific interventions.

RELEVANCE TO CLINICAL PRACTICE

Preventing falls where possible is essential. Assessment of risk and use of appropriate interventions can reduce the incidence of falls.

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.

The relationship between patient blood pathology values and patient falls in an acute-care setting: a retrospective analysis

Few studies have investigated the relationship between patient falls and patient blood pathology values, which can reveal objective information about the health and nutritional status of a patient. It could be that some abnormal values are associated with patients that fall. The objectives of the current study were to determine whether blood pathology values were different in patients who fell compared to patients who did not fall, and whether there was a difference in the type and number of currently documented risk factors for falls found for patients who fell compared to patients who did not fall. A retrospective audit of patient incident reports and medical records was conducted in an acute-care hospital for 220 patients who fell and who did not fall. Faller and non-faller patients were matched by casemix type and length of stay. Findings revealed a significant relationship between patients who fell and the variables of age, confusion status and alkaline phosphatase blood values.

Falls prevention revisited: a call for a new approach

BACKGROUND

Patient falls constitute a major threat to health services' ability to provide care. Previous studies confirm that nurses can identify patients at risk and that a preventative programme can reduce the rate of falls but few studies have been evaluated over time.

AIMS AND OBJECTIVES

A study was undertaken to test a Falls Prevention Programme in an acute medical area that was re-evaluated 5 years later to determine if the effects were sustainable.

DESIGN

The design included two groups of patients admitted before and after the programme. Variables such as staffing, equipment, environment and routines were controlled. However, because of ethical approval constraints, some variables such as age, mental status, mobility and gender were not.

METHODS

The programme included a risk assessment tool, a choice of interventions, a graphic that alerted others to 'at risk patients' and simple patient and staff education. Data were collected using incident forms and a formula was used to calculate a rate of falls. A non-paired t-test compared rates and anova examined the relationship of age, gender, mobility and mental status on the incidence of falls. Control graphs determined the stability of the process.

RESULTS

The falls rate was significantly reduced. Control graphs demonstrate that the process achieved greater control with less variation. In the next 5 years the falls rate increased to preprogramme levels and control graphs demonstrated that the process was no longer controlled. Compliance with the programme had deteriorated.

CONCLUSIONS

The practice review considered skill mix, patient activity and acuity but provided no definitive answers to explain non-compliance. The implications to nursing are discussed.

RELEVANCE TO CLINICAL PRACTICE

Clinicians are called to conduct more rigorous research into falls prevention but it may be more useful to direct research towards examining nursing work and increasing nurse autonomy in falls prevention.

Hospital fall risk assessment tools: a critique of the literature

There are numerous fall risk assessment tools developed for use by nurses in hospitals; however, few of them have established validity and reliability. This article will examine the current state of knowledge in regard to fall risk assessment tools through review and critique of the literature on the topic. Recommendations for future research on fall risk assessment tools will be made and a conceptual framework detailing the relationship between the variables involved in assessing the accuracy of fall risk assessment tools will be presented.

Fall risk assessment: a prospective investigation of nurses' clinical judgement and risk assessment tools in predicting patient falls

A prospective cohort study was used to determine the reliability and validity of two fall risk assessment tools and nurses' clinical judgement in predicting patient falls. The study wards comprised two aged care and rehabilitation wards within a 570 bed acute care tertiary teaching hospital in Western Australia. Instrument testing included test-retest reliability and calculations of sensitivity, specificity, positive predictive value, negative predictive value and accuracy. The test retest reliability of all methods was good. In this setting, the three methods of assessing fall risk showed good sensitivity but poor specificity. Also, all methods had limited accuracy, and overall, exhibited an inability to adequately discriminate between patient populations at risk of falling and those not at risk of falling. Consequently, neither nurses' clinical judgement nor the fall risk assessment tools could be recommended for assessing fall risk in this clinical setting.