Factors Associated With Function-Focused Care Among Hospitalized Older Adults With Dementia

BACKGROUND

Function-focused care is an approach used to increase physical activity in hospitalized older adults with dementia.

OBJECTIVE

To explore factors associated with participation in function-focused care in this patient population.

METHODS

This was a cross-sectional descriptive study using baseline data from the first 294 participants in an ongoing study on testing function-focused care for acute care using the evidence integration triangle. Structural equation modeling was used for model testing.

RESULTS

The mean (SD) age of the study participants was 83.2 (8.0) years, and the majority were women (64%) and White (69%). Sixteen of the 29 hypothesized paths were significant and explained 25% of the variance in participation in function-focused care. Cognition, quality of care interactions, behavioral and psychological symptoms associated with dementia, physical resilience, comorbidities, tethers, and pain were all indirectly associated with function-focused care through function and/or pain. Tethers, function, and quality of care interactions were all directly associated with function-focused care. The χ2/df was 47.7/7, the normed fit index was 0.88, and the root mean square error of approximation was 0.14.

CONCLUSION

For hospitalized patients with dementia, the focus of care should be on treating pain and behavioral symptoms, reducing the use of tethers, and improving the quality of care interactions in order to optimize physical resilience, function, and participation in function-focused care.

Requests for Compensation in Cases Involving Patients' Falls in Healthcare Settings: A Retrospective Analysis

Falls are the most frequent adverse events recorded in healthcare facilities. By employing a multifaceted strategy to ensure prevention interventions that are specific to the patient type and environmental risk management, risk factor evaluation may help to reduce falls in the hospital setting. Patient falls are one of the main causes of lawsuits against hospitals, which has led to the development of validated instruments that are beneficial in treating the patient after the incident and effective in minimizing the frequency of falls. The aim of our study is to evaluate compensation claims asserting healthcare culpability in situations where a patient fell in a hospital setting. The collected data relate to judgments issued in Italy until December 2022 regarding 30 episodes of falls that occurred between 2003 and 2018. Our research revealed that approximately 50% of Italian healthcare organizations lose the case in court when a patient falls in a hospital setting and dies or is injured. In half of these cases, the failure of the medical staff to use protective equipment against falls is what led to the court's acceptance of the compensation claim. In order to improve the quality of healthcare services, fall prevention techniques must continue to be implemented.

Optimizing aged care environments to promote resident functional mobility and reduce staff injury risk

Introduction: This study aimed to evaluate the suitability and usability of the Pro-Mobility patient/person handling assessment tool (ProMob) within residential aged care. Physiological changes associated with ageing influence an older person's ability to perform functional mobility tasks such as transferring from furniture and walking. Strategies that improve capability and/or reduce the physical demands of the task have the potential to promote an older person's mobility, independence and wellbeing. Environment-related strategies in Manual Handling of People (MHP), such as optimum seated heights, in part address this challenge, as they can promote resident functional mobility while also protecting staff from injury. The ProMob tool was developed to address this issue through systematic evaluation of these environmental factors. Methods: The participants in this study were seven (7) residential aged care facilities (RACFs) operated by a not-for-profit aged care organization. A qualified assessor evaluated MHP risk management with the ProMob tool at each RACF through collection of data for a random sample of residents (n = 67) regarding their living environments and available mobility information. Data was transferred to an SPSS-22 statistical software database for analysis which involved descriptive statistics and cross tabulations. Results: Application of the ProMob tool provided effective quantification of the nature and extent of environment-related MHP interventions that may influence resident mobility. Areas for improvement with MHP risk management were identified, with variation evident across RACF's within the same organisation, which was not consistent with levels of care (e.g., lack of clear space to facilitate mobility). Low level care facilities were observed to have fewer adaptive environmental features that could potentially slow decline in independence. Discussion: Features of the aged care environment can be used to facilitate the functional mobility of aged care residents, and simultaneously reduce injury risk for staff in MHP interactions. The ProMob tool can be used for auditing care facilities, planning re-development, and continual improvement in provision of care and management of staff injury risk exposure.

A hospitalist's role in preventing patient falls

Despite decades of fall prevention efforts, patient falls remain a common cause of harm in hospitalized older adults. While fall prevention strategies have been historically championed by nurses, hospitalist physicians, nurse practitioners, and physician assistants play a vital role in the multidisciplinary care team in ensuring the safety of our patients. Multiple fall risk assessment tools exist, but no one tool has demonstrated excellence in predicting patient falls in the hospital. Any fall risk assessment tool should be complemented by a clinician's individualized evaluation of patient-specific, situational, and environmental risk factors. A particular emphasis on medication review is critical, as numerous medication classes can increase the risk of falls, and medications are a potentially modifiable risk factor. Multiple studies of individual and multicomponent nursing-based interventions have failed to demonstrate success in reducing falls or fall injuries. Promising strategies for fall prevention include tailoring interventions to patient risk factors and individualized patient education. In addition to nursing-based interventions, the hospitalist's role in fall prevention is to (1) identify and address potentially modifiable risk factors, (2) reinforce individualized education to patients, and (3) advise behavior choices that promote safe mobility. If a patient does sustain a fall, the hospitalist should partner with the multidisciplinary care team in post fall care to assess for injury, evaluate underlying causes of the fall, and determine plans for secondary prevention.

Guidetomeasure-OT: A mobile 3D application to improve the accuracy, consistency, and efficiency of clinician-led home-based falls-risk assessments

BACKGROUND

A key falls prevention intervention delivered within occupational therapy is the home environment falls-risk assessment process. This involves the clinician visiting the patient's home and using a 2D paper-based measurement guidance booklet to ensure that all measurements are taken and recorded accurately. However, 30% of all assistive devices installed within the home are abandoned by patients, in part as a result of the inaccurate measurements being recorded as part of the home environment falls-risk assessment process. In the absence of more appropriate and effective guidance, high levels of device abandonment are likely to persist.

AIM

This study presents guidetomeasure-OT, a mobile 3D measurement guidance application designed to support occupational therapists in carrying out home environment falls-risk assessments. Furthermore, this study aims to empirically evaluate the performance of guidetomeasure-OT compared with an equivalent paper-based measurement guidance booklet.

METHODS

Thirty-five occupational therapists took part in this within-subjects repeated measures study, delivered within a living lab setting. Participants carried out the home environment falls-risk assessment process under two counterbalanced treatment conditions; using 3D guidetomeasure-OT; and using a 2D paper-based guide. Systems Usability Scale questionnaires and semi-structured interviews were completed at the end of both task. A comparative statistical analysis explored performance relating to measurement accuracy, measurement accuracy consistency, task completion time, and overall system usability, learnability, and effectiveness of guidance. Interview transcripts were analysed using inductive and deductive thematic analysis, the latter was informed by the Unified Theory of Acceptance and Use of Technology model.

RESULTS

The guidetomeasure-OT application significantly outperformed the 2D paper-based guidance in terms task efficiency (p <  0.001), learnability (p <  0.001), system usability (p <  0.001), effectiveness of guidance (p =  0.001). Regarding accuracy, in absolute terms, guidetomeasure-OT produced lower mean error differences for 11 out of 12 items and performed significantly better for six out of 12 items (p = < 0.05). In terms of SUS, guidetomeasure-OT scored 83.7 compared with 70.4 achieved by the booklet. Five high-level themes emerged from interviews: Performance Expectancy, Effort Expectancy, Social Influence, Clinical Benefits, and Augmentation of Clinical Practice. Participants reported that guidetomeasure-OT delivered clearer measurement guidance that was more realistic, intuitive, precise and usable than the paper-based equivalent. Audio instructions and animated prompts were seen as being helpful in reducing the learning overhead required to comprehend measurement guidance and maintain awareness of task progression.

CONCLUSIONS

This study reveals that guidetomeasure-OT enables occupational therapists to carry out significantly more accurate and efficient home environment falls-risk assessments, whilst also providing a measurement guide tool that is considered more usable compared with the paper-based measurement guide that is currently used by clinicians in practice. These results are significant as they indicate that mobile 3D visualisation technologies can be effectively deployed to improve clinical practice, particularly within the home environment falls-risk assessment context. Furthermore, the empirical findings constitute overcoming the challenges associated with the digitisation of health care and delivery of new innovative and enabling technological solutions that health providers and policy makers so urgently need to ease the ever-increasing burden on existing public resources. Future work will focus on the development and empirical evaluation of a mobile 3D application for patient self-assessment and automated assistive equipment prescription. Furthermore, broader User Experience aspects of the application design and the interaction mechanisms that are made available to the user could be considered so as to minimize the effect of cognitive overloading and optimise user performance.

The use of evidence-based guidance to enable reliable and accurate measurements of the home environment

Introduction

High quality guidance in home strategies is needed to enable older people to measure their home environment and become involved in the provision of assistive devices and to promote consistency among professionals. This study aims to investigate the reliability of such guidance and its ability to promote accuracy of results when measurements are taken by both older people and professionals.

Method

Twenty-five health professionals and 26 older people participated in a within-group design to test the accuracy of measurements taken (that is, person's popliteal height, baths, toilets, beds, stairs and chairs). Data were analysed with descriptive analysis and the Wilcoxon test. The intra-rater reliability was assessed by correlating measurements taken at two different times with guidance use.

Results

The intra-rater reliability analysis revealed statistical significance (P < 0.05) for all measurements except for the bath internal width. The guidance enabled participants to take 90% of measurements that they were not able to complete otherwise, 80.55% of which lay within the acceptable suggested margin of variation. Accuracy was supported by the significant reduction in the standard deviation of the actual measurements and accuracy scores.

Conclusion

This evidence-based guidance can be used in its current format by older people and professionals to facilitate appropriate measurements. Yet, some users might need help from carers or specialists depending on their impairments.

Traumatic Facial Injuries Among Elderly Nursing Home Residents: Never Event or Frequent Occurrence?

Importance

As the nursing home population continues to increase, an understanding of preventable injuries becomes exceedingly important. Although other fall-related injuries have been characterized, little attention has been dedicated to facial trauma.

Objectives

To estimate the incidence of facial trauma among nursing home residents and detail mechanisms of injury, injury characteristics, and patient demographic data.

Design, Setting, and Participants

The National Electronic Injury Surveillance System was used to calculate a weighted national incidence of facial trauma among individuals older than 60 years from a nationally representative collection of emergency departments from January 1, 2011, through December 31, 2015. Entries were screened for nursing home residents, and diagnosis, anatomical site, demographic data, and mechanism of injury were analyzed.

Results

There were 109 795 nursing home residents (median age, 84.1 years; interquartile range, 79-89 years; 71 466 women [65.1%]) who required emergency department care for facial trauma. Women sustained a greater proportion of injuries with increasing age. The most common injuries were lacerations (48 679 [44.3%]), other soft-tissue injuries (45 911 [41.8%]; avulsions, contusions, and hematomas), and fractures (13 814 [12.6%]). Nasal (9331 [67.5%]) and orbital (1144 [8.3%]) fractures were the most common sites. The most common injury causes were direct contact with structural housing elements or fixed items (62 604 [57.0%]) and transfer to and from bed (24 870 [22.6%]).

Conclusions and Relevance

Despite falls being considered a Centers for Medicare & Medicaid Services preventable never event in hospitals, our analysis in the nursing home setting found more than 100 000 facial injuries during 5 years, suggesting these underappreciated injuries contribute substantially to health care expenditures. Although structural elements facilitated the greatest number of falls, transfer to and from bed remains a significant mechanism, suggesting an area for intervention.

Circumstances of Falls With Fractured Femur in Residents of Australian Nursing Homes: An Analysis of Falls Reports

OBJECTIVE

This study aimed to explore the circumstances and characteristics of falls with fractured femur reported in nursing homes.

METHOD

Mixed methods were used. There were reports on 401 eligible falls from 88 residential care facilities in the Hunter region of Australia. A falls report form was developed for the study and was completed by nursing staff. Information was collected about the circumstances of falls with fractured femur and resident data. Descriptive and qualitative analyses were used.

RESULTS

Falls with fractured neck of femur were associated with being ambulant, having dementia, increasing age, and a high falls risk assessment. Themes from the falls report data were resident-related factors, organizational or environmental issues, and activities at the time of the fall.

DISCUSSION

Falls in residential care settings are very complex and difficult to prevent. Attention should be given to the needs of recently admitted residents and management of the facility environment.

The Safety of Hospital Beds: Ingress, Egress, and In-Bed Mobility

To explore the safety of the standard and the low hospital bed, we report on a microanalysis of 15 patients' ability to ingress, move about the bed, and egress. The 15 participants were purposefully selected with various disabilities. Bed conditions were randomized with side rails up or down and one low bed with side rails down. We explored the patients' use of the side rails, bed height, ability to lift their legs onto the mattress, and ability to turn, egress, and walk back to the chair. The standard bed was too high for some participants, both for ingress and egress. Side rails were used by most participants when entering, turning in bed, and exiting. We recommend that side rails be reconsidered as a means to facilitate in-bed movement, ingress, and egress. Furthermore, single deck height settings for all patients are not optimal. Low beds as a safety measure must be re-evaluated.

Is it possible to identify risks for injurious falls in hospitalized patients?

BACKGROUND

Patient falls are among the most commonly reported adverse hospital events with more than one million occurring annually in the United States; approximately 10% result in serious injury. A retrospective study was conducted to determine predictors and outcomes of fall injuries among a cohort of adult hospitalized patients.

METHODS

Data were obtained regarding patients who sustained an initial fall in hospital during a 26-month period from 16 adult general medical and surgical units in an urban university-affiliated community hospital. Data on intrinsic (individual) factors, extrinsic (environmental) factors, and situational activities were collected via nurse and patient interviews, patient examinations, and audits of incident reports and electronic health records. Fall injuries were classified as none/any for analyses. Unadjusted odds ratios [ORs] and 95% confidence intervals [CIs] for each of the variables of interest with fall injury were generated using logistic regressions.

RESULTS

The 784 patients had a median age of 63.5 years (range, 20 to > 90 years), 390 (50%) were women, and 526 (67%) were black. Some 228 (29%) fallers sustained injury; patients who were white (OR: 2.23; 95% CI: 1.62, 3.08), or were administered a selective serotonin reuptake inhibitor (OR: 1.04; 95% CI: 1.04, 2.67), two antipsychotic agents (OR: 3.26; 95% CI: 1.20, 8.90), an opiate (OR: 1.59; 95%; CI: 1.14, 2.20), or a diuretic non-antihypertensive agent (OR: 1.53; 95% CI: 1.03, 2.26) were more likely to sustain an injury. Home-based wheelchair use was protective of fall injury (OR: 0.20; 95% CI: 0.05, 0.84). Seventy-nine percent of the patients had been designated as "high" fall risk within 24 hours before the fall.

CONCLUSIONS

Few variables were able to distinguish patients who sustained injury after a hospital fall, further challenging clinicians' efforts to minimize hospital-related fall injury.

How feasible was a bed-height alert system?

This qualitative and descriptive study examined the feasibility of a bed-height alert system as a fall-prevention strategy. The alpha prototype was developed to measure and record bed height, and to remind staff to keep patient beds in the lowest position. This pilot project was conducted in a 52-bed adult acute surgical inpatient care unit of a Michigan community hospital. Qualitative and quantitative information was gathered during semistructured interviews of nursing staff (18 RNs and 13 PCAs; January-April 2011). Descriptive content analysis and descriptive analyses were performed. The overall response rate was 44.9%. The mean values of the feasibility questions are all favorable. Staff's comments also support the view that the alert system would promote patient safety and prevent falls. In short, this system was found to be somewhat useful, feasible, appropriate, and accurate. It has the potential to promote patient safety and prevent bed-associated injurious falls in inpatient care settings.

Fall prevention in the elderly: analysis and comprehensive review of methods used in the hospital and in the home

Falls in the elderly are a significant problem both in and out of the hospital. The Deficit Reduction Act of 2005 and the Fiscal Year 2009 Inpatient Prospective Payment System Final Rule, as outlined by the Centers for Medicare & Medicaid Services, placed on hospitals the financial burden of fall prevention for falls (ie, hospital-acquired conditions) that could have been prevented by following evidence-based guidelines. Multifaceted and individualized programs have been created to prevent falls in the elderly. Many of these interventions are based on expert opinion and statistical trends. Our review of the literature revealed that the risk of fall is only slightly greater in the hospital environment than in the home and that there is no medical evidence that evidence-based guidelines are effective in fall prevention.

Going home better not worse: older adults' views on physical function during hospitalization

Functional decline is a common complication for hospitalized older adults. Illuminating the factors that influence the physical function of hospitalized older adults is critical in order to develop effective interventions to prevent avoidable loss of function. Twenty-four older adults in three senior centres located in metropolitan New York City, who had recent experience with hospitalization, participated in focus groups to discover these factors. An exploratory qualitative design was used. Participants defined physical function as the ability to be mobile and resume the enactment of their roles, routines and relationships. Participants also believed that hospitalization should improve physical function. They described staff and system supports of, as well as the challenges to physical function in the hospital setting. The findings provide evidence for developing education programmes as well as new models of nursing care aimed at preventing functional decline.

Exploring the Factors That Influence Functional Performance Among Nursing Home Residents

Objective: To promote healthy aging in older nursing home (NH) residents, it is important to identify factors that impact functional performance. Using the Disablement Process Model, it was hypothesized that variables from all levels of the model would significantly impact the ability of a NH resident to get up from a chair. Method: A stepwise multiple logistic regression model was used to test the impact of sociodemographic, physiologic, physical, psychosocial, and environmental factors on chair rise. Results: Analysis indicated that three factors, strength, gait, and self-efficacy, were significantly associated with chair-rise ability and together explained approximately 64% of the variance and successfully classified 88.4% of the chair-rise cases. Discussion: These findings indicate that identifying physical and psychosocial variables early in the disablement process will help health care providers tailor medical and restorative care interventions that may help older adults maintain the ability to chair rise.