Falls in hospitalized older adults and the use of fall risk-increasing drugs and anticholinergic medications in Colombia: a case‒control study

Introduction

In-hospital falls are multicausal in older hospitalized patients. Drugs with anticholinergic load and psychotropic effects can increase the risk of falling.

Objective

This study aimed to determine the associations between fall risk-increasing drugs (FRIDs) and the anticholinergic risk score (ARS) with falls in hospitalized older hospitalized patients.

Methods

This was a case‒control study of patients ≥65 years of age of either sex treated in four clinics in Colombia between 2018 and 2020. Each patient who suffered a fall during hospitalization was matched with four hospitalized patients who did not. Sociodemographic, clinical, and pharmacologic variables and the use of the ARS and FRIDs were evaluated. The risk associated with FRIDs was estimated using conditional logistic regression.

Results

There were 250 patients and 1,000 controls (ratio of 1:4), with a mean age of 77.4 ± 7.4 years and a predominance of men (n = 800, 64.0%). The majority of falls occurred during hospitalization (n = 192 patients, 76.8%). Polypharmacy, calcium channel blockers, antiepileptics, antipsychotics, sodium-glucose cotransporter type 2 inhibitors, and nonsteroidal anti-inflammatory drugs were associated with falls during hospitalization. With an ARS score of 3, the probability of falling during the hospital stay increased (aOR: 2.34; 95% CI: 1.64-3.32).

Conclusion

There is an association between suffering a fall and the use of drugs with anticholinergic load or FRIDs in hospitalized adults more than 65 years of age in Colombia.

Falls in oldest-old adults hospitalized in acute geriatric ward

PURPOSE

The study aims to identify risk factors for falling among acutely ill older patients, hospitalized in acute geriatric ward.

METHODS

A retrospective study of 260 cases of patients who had fallen and 439 controls was conducted in a geriatric ward. We retrieved from the electronic hospital records data including patient demographics, medical diagnoses, and laboratory results, and drugs taken prior to the fall were reviewed. In addition, data on functional and cognitive status were recorded. Admission Morse Falls Scale for every patient was also retrieved.

RESULTS

The following on-admission diagnoses were associated with a higher incidence of falls during hospitalization: hypertension (84% vs. 38%), congestive heart failure (CHF), 74% vs 16%, dementia (36% vs. 5%), and delirium (36% vs 5%). A higher percentage of fallers compared to controls consumed beta blockers (69% vs. 53%), benzodiazepines (46% vs. 32%), antidepressants (33% vs. 23%), oral diabetes drugs (20% vs. 11%) and opiates (8% vs. 4%). On-admission Morse Falls Scale score was found to be higher in the patients who fell (59 vs.53). The strongest predictors of falling during hospitalization were CHF, hypertension, dementia, delirium, assisted mobility and dependence.

CONCLUSION

A systematic screening of risk factors for falls and identification of them might contribute to reducing the risk associated with falls during hospitalization.

A Retrospective Cross-sectional Study on the Risk Factors of Recurrent Falls Among Inpatients

BACKGROUND

Recurrent falls are more likely to cause injuries and disabilities than single falls.

PURPOSE

This study investigated the incidence and risk factors of recurrent falls among inpatients.

METHODS

We analyzed inpatient fall data from the anomaly event notification database and electronic medical records of a hospital. We collected data regarding 1059 inpatients who had fallen during their hospital stay. Among these inpatients, 390 (36.83%) had fallen within the previous year.

RESULTS

Inpatients in the orthopedics and neurology wards were at a higher risk of recurrent falls than those in surgical wards; inpatients who were physically dependent were at a higher risk of recurrent falls than those who were physically independent; inpatients with poor vision were at a lower risk of recurrent falls than those without this issue; and inpatients who were using antidepressants were at a higher risk of recurrent falls than those who were not using antidepressants.

CONCLUSION

The risk of recurrent falls is highly correlated with ward type, physical independence, self-perceived good vision, and use of antidepressants.

Risk Factors Preventing Immediate Fall Detection: A Study Using Zero-Inflated Negative Binomial Regression

PURPOSE

Falls are the most common accidents in healthcare facilities, and timely intervention can have a positive effect on the hazards and trauma experienced by patients after a fall. This study determined the factors affecting the time taken to detect a fall.

METHODS

A total of 3,470 cases of falls reported through the Korea Patient Safety Reporting and Learning System were included in the analysis. A zero-inflated negative binomial regression method was used for this retrospective secondary data analysis study.

RESULTS

There were 537 patients whose falls were not detected immediately; the count model was used to predict risk factors that delayed fall detection. Women aged 60-69 years-compared to those below 60 years and an evening nursing shift, compared to a day shift-were identified as significant factors. The fall detection time of about 2,933 patients was zero; therefore, the logit model was applied to predict a patient's possibility of belonging to the group whose fall was detected immediately. Comparisons of tertiary hospitals with general hospitals and hospitals, of the evening shift with the day shift, and of the day shift with the night shift indicated significant influencing factors.

CONCLUSIONS

These findings can assist nurses in recognizing patient and hospital characteristics related to delayed fall detection. Strategies to improve patient safety in healthcare facilities that focus on patient characteristics such as age can be recommended. Furthermore, nurse staffing requires improvement to detect fall incidents immediately.

Clinical prediction models for hospital falls: a scoping review protocol

INTRODUCTION

Falls remain one of the most prevalent adverse events in hospitals and are associated with substantial negative health impacts and costs. Approaches to assess patients' fall risk have been implemented in hospitals internationally, ranging from brief screening questions to multifactorial risk assessments and complex prediction models, despite a lack of clear evidence of effect in reducing falls in acute hospital environments. The increasing digitisation of hospital systems provides new opportunities to understand and predict falls using routinely recorded data, with potential to integrate fall prediction models into real-time or near-real-time computerised decision support for clinical teams seeking to mitigate fall risk. However, the use of non-traditional approaches to fall risk prediction, including machine learning using integrated electronic medical records, has not yet been reviewed relative to more traditional fall prediction models. This scoping review will summarise methodologies used to develop existing hospital fall prediction models, including reporting quality assessment.

METHODS AND ANALYSIS

This scoping review will follow the Arksey and O'Malley framework and its recent advances, and will be reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews recommendations. Four electronic databases (CINAHL via EBSCOhost, PubMed, IEEE Xplore and Embase) will be initially searched for studies up to 12 November 2020, and searches may be updated prior to final reporting. Additional studies will be identified by reference list review and citation analysis of included studies. No restriction will be placed on the date or language of identified studies. Screening of search results and extraction of data will be performed by two independent reviewers. Reporting quality will be assessed by the adherence to the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study. Findings will be disseminated through peer-reviewed publication and scientific conferences.

The Impact of the Built Environment on Patient Falls in Hospital Rooms: An Integrative Review

OBJECTIVES

The aims of this study were to identify and evaluate scientific evidence examining the impact of the built environment on patient falls in hospital rooms.

METHODS

An integrative review (IR) with a systematic literature search was performed using the patient, intervention, comparison, outcome framework. We searched CINAHL, PsychINFO, PubMED, and Web of Science databases. The search included peer-reviewed studies from 1990 to 2017 written in English. An additional hand search was also conducted. Selected articles were reviewed and rated based on a hierarchical categorization, comprising six evidence levels, developed by the American Association of Critical-Care Nurses and adapted for evidence-based design systematic literature reviews.

RESULTS

After a multitiered process, 30 articles met the selection criteria. Thematic areas were created based on the examined elements of the physical environment including patient room configuration and available space, bathroom configuration, bathtub and shower, door, bed height and bed rail, flooring, floor mats, patient chair, lighting, toilet, handrail, grab bars, intravenous pole, sink, ceiling lift, and wheelchair and walking aids. Findings of studies on each element are discussed in detail.

CONCLUSIONS

Some environmental elements have not been examined in past relational or causal studies, and the level of evidence for the examined attributes is not high enough to gain robust confidence in healthcare design decision-making. Because of the low level of evidence for several environmental elements, conclusions must be taken with caution. More studies using quantitative, relational, or causal designs are recommended to develop actionable interventions on patient falls in hospital rooms.

Patient Perspectives on Hospital Falls Prevention Education

Hospital falls remain an intractable problem worldwide and patient education is one approach to falls mitigation. Although educating patients can help their understanding of risks and empower them with prevention strategies, patient experiences of hospital falls education are poorly understood. This study aimed to understand the perspectives and preferences of hospitalized patients about falls prevention education. Three focus groups were conducted in Australian hospitals. A phenomenological approach was used to explore patient perspectives and data were analyzed thematically. The focus groups revealed that most people did not realize their own risk of falling whilst an inpatient. Experiences of falls prevention education were inconsistent and sometimes linked to beliefs that falls were not relevant to them because they were being cared for in hospital. Other barriers to falls mitigation included poor patient knowledge about hospital falls risk and inconsistencies in the delivery of falls prevention education. A strong theme was that individualized, consistent education, and small interactive groups were helpful.

Mobilisation alarm triggers, response times and utilisation before and after the introduction of policy for alarm reduction or elimination: A descriptive and comparative analysis

BACKGROUND

Mobilisation alarms are a falls prevention strategy used in hospitals to alert staff when an at risk patient is attempting to mobilise. Mobilisation alarms have an estimated annual cost of $AUD58MIL in Australia. There is growing evidence from randomised controlled trials indicating mobilisation alarms are unlikely to prevent falls.

AIM

The primary aim of this study was to describe the rate of mobilisation alarm false triggers and staff response time across different health services. The secondary aim was to compare pre to post mobilisation alarm utilisation following the introduction of policy to reduce or eliminate mobilisation alarms.

METHODS

This descriptive and comparative study was conducted through Monash Partners Falls Alliance across six health services in Melbourne, Australia. This study described true and false alarm triggers and trigger response times across three health services and usual care mobilisation alarm utilisation across six health services; and then compared alarm utilisation across two health services following the introduction of policy to reduce (<2.5%) or eliminate (0.0%) mobilisation alarms in the acute and rehabilitation settings.

RESULTS

The most frequent observation was a false alarm (n = 74, 52%), followed by a true alarm (n = 67, 47%) and no alarm (n = 3, 2%). Time to respond to the true and false alarms was an average of 37 seconds (SD 92) and this included 61 occasions of 0 seconds as a member of staff was present when the alarm triggered. If the 61 occasions of staff being present when the alarm triggered were removed, the average time to respond was 65 seconds (SD114). Usual care mobilisation alarm utilisation in acute was 7% (n = 171/2,338) and in rehabilitation was 11% (n = 286/2,623). Introducing policy for reduced and eliminated mobilisation alarm conditions was successful with a reduced utilisation rate of 1.8% (n = 11/609) and an eliminated utilisation rate of 0.0% (n = 0/521).

CONCLUSION

Half of mobilisation alarm triggers are false and when alarms trigger without staff present, staff take about a minute to respond. While usual care has one in fourteen patients in acute and one in nine patients in rehabilitation using a mobilisation alarm, it is possible to introduce policy which will change practice to reduce or eliminate the use of mobilisation alarms, providing evidence of feasibility for future disinvestment effectiveness studies that it is feasible to disinvest in the alarms.

Hospitalist Perceptions of Fall Prevention: A Comparison of Two Health Care Systems

Inpatient falls are common, but little is known about hospitalist perceptions regarding their exact role in fall prevention. The authors conducted a cross-sectional analysis of hospitalists' attitudes and perceived barriers to fall prevention practices in 2 different hospital systems in Portland, Oregon. A total of 42 responses were collected. Although hospitalists in both groups agreed that all patients admitted should undergo fall risk assessments (FRAs), both groups disagreed that hospitalists should be responsible for performing them. Neither group felt that they had the time to complete FRAs and were either neutral or felt the lack of expertise to conduct them. These findings suggest that the hospitalist role in inpatient fall prevention multidisciplinary teams may be unclear to physician providers and that health care systems may benefit from examining this further.

Hypoglycemia and hyperglycemia are risk factors for falls in the hospital population

OBJECTIVE

To determine the role of hypoglycemia, hyperglycemia or the combination of both as independent risk factors for falls in a hospital population. Secondary objectives included evaluation of other risk factors for falling and their relationships with glucose levels.

RESEARCH DESIGN AND METHODS

Retrospective cohort study over 2 years on hospitalized subjects (N = 57411) analyzing in-hospital-falls and capillary glucose values. Bivariate analysis (χ² test) and multivariate analysis (logistic regression) were performed to test for correlation of glucose values, age, sex, Charlson index, service of care, diagnosis at discharge and diabetes treatment with risk of in-hospital-falls.

RESULTS

The comparison of patients who experienced a fall (fall population) with the non-fall population suggested that: glucose determinations were significantly more frequent in the fall population (OR 3.45; CI 2.98-3.99; p < 0.0001); values of glucose below 70 mg/dl and over 200 mg/dl were significantly associated to falls during hospitalization (OR 1.76; CI 1.42-2.19; p < 0.001) as compared to glycemic values between 70 and 200 mg/dl; diabetes treatment was significantly correlated to risk of fall (OR 2.97; CI 2.54-3.49; p < 0.001); the frequency of glycemia measurements below 70 mg/dl and over 200 mg/dl in the same subject was significantly associated to falls during hospitalization (OR 1.01; CI 1.01-1.02; p < 0.001).

CONCLUSION

Hypoglycemia and hyperglycemia during hospital stays are correlated with an increased risk for falls in the hospitalized population. Presence of diabetes, use of insulin or glucose variability could potentially constitute risk factors for falls inside the hospital as well.

Fall Rates in Urban and Rural Nursing Units: Does Location Matter?

Patient falls remain a leading adverse event in hospitals. In a study of 65 rural hospitals with 222 nursing units and 560 urban hospitals with 4274 nursing units, we found that geographic region, unit type, and nurse staffing, education, experience, and outcomes were associated with fall rates. Implications include specific attention to fall prevention in rehabilitation units, creating better work environments that promote nurse retention, and provide RN-BSN educational opportunities.

Geriatric falls in the context of a hospital fall prevention program: delirium, low body mass index, and other risk factors

BACKGROUND

Inpatient geriatric falls are a frequent complication of hospital care that results in significant morbidity and mortality.

OBJECTIVE

Evaluate factors associated with falls in geriatric inpatients after implementation of the fall prevention program.

METHODS

Prospective observational study comprised of 788 consecutive patients aged 79.5±7.6 years ( [Formula: see text] ± standard deviation) (66% women and 34% men) admitted to the subacute geriatric ward. Comprehensive geriatric assessment (including Mini-Mental State Examination, Barthel Index of Activities of Daily Living, and modified Get-up and Go Test) was performed. Confusion Assessment Method was used for diagnosis of delirium. Patients were categorized into low, moderate, or high fall risk groups after clinical and functional assessment.

RESULTS

About 15.9%, 21.1%, and 63.1% of participants were classified into low, moderate, and high fall risk groups, respectively. Twenty-seven falls were recorded in 26 patients. Increased fall probability was associated with age ≥76 years (P<0.001), body mass index (BMI) <23.5 (P=0.007), Mini-Mental State Examination <20 (P=0.004), Barthel Index <65 (P=0.002), hemoglobin <7.69 mmol/L (P=0.017), serum protein <70 g/L (P=0.008), albumin <32 g/L (P=0.001), and calcium level <2.27 mmol/L. Four independent factors associated with fall risk were included in the multivariate logistic regression model: delirium (odds ratio [OR] =7.33; 95% confidence interval [95% CI] =2.76-19.49; P<0.001), history of falls (OR =2.55; 95% CI =1.05-6.19; P=0.039), age (OR =1.14; 95% CI =1.05-1.23; P=0.001), and BMI (OR =0.91; 95% CI =0.83-0.99; P=0.034).

CONCLUSION

Delirium, history of falls, and advanced age seem to be the primary risk factors for geriatric falls in the context of a hospital fall prevention program. Higher BMI appears to be associated with protection against inpatient geriatric falls.

Improving patient safety by optimizing the use of nursing human resources

Background

Recent ecological studies have suggested that inadequate nurse staffing may contribute to the incidence of adverse events in acute care hospitals. However, longitudinal studies are needed to further examine these associations and to identify the staffing patterns that are of greatest risk. The aims of this study are to determine if (a) nurse staffing levels are associated with an increased risk of adverse events, (b) the risk of adverse events in relationship to nurse staffing levels is modified by the complexity of patient requirements, and (c) optimal nurse staffing levels can be established.

Methods/design

A dynamic cohort of all adult medical, surgical, and intensive care unit patients admitted between 2010 and 2015 to a Canadian academic health center will be followed during the inpatient and 7-day post-discharge period to assess the occurrence and frequency of adverse events in relationship to antecedent nurse staffing levels. Four potentially preventable adverse events will be measured: (a) hospital-acquired pneumonia, (b) ventilator-associated pneumonia, (c) venous thromboembolism, and (d) in-hospital fall. These events were selected for their high incidence, morbidity and mortality rates, and because they are hypothesized to be related to nurse staffing levels. Adverse events will be ascertained from electronic health record data using validated automated detection algorithms. Patient exposure to nurse staffing will be measured on every shift of the hospitalization using electronic payroll records. To examine the association between nurse staffing levels and the risk of adverse events, four Cox proportional hazards regression models will be used (one for each adverse event), while adjusting for patient characteristics and risk factors of adverse event occurrence. To determine if the association between nurse staffing levels and the occurrence of adverse events is modified by the complexity of patient requirements, interaction terms will be included in the regression models, and their significance assessed. To assess for the presence of optimal nurse staffing levels, flexible nonlinear spline functions will be fitted.

Discussion

This study will likely generate evidence-based information that will assist managers in making the most effective use of scarce nursing resources and in identifying staffing patterns that minimize the risk of adverse events.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0278-1) contains supplementary material, which is available to authorized users.