Nurse staffing and patient falls on acute care hospital units

Changes in health care financing, beginning in the 1980's, resulted in reduced nurse staffing and skill levels in acute care hospitals. Research has shown that reduced nurse staffing has endangered some aspects of patient safety. This study estimated the relationship between three aspects of nurse staffing and the patient fall rate for four types of acute care units. The association was estimated using a generalized linear mixed model with data for 2002 from 1751 hospital units in the National Database of Nursing Quality Indicators. Higher fall rates were associated with fewer nursing hours per patient day and a lower percentage of registered nurses, although the relationship varied by unit type. Smaller hospitals also had higher fall rates. Information on unit type and different aspects of nurse staffing, with advanced statistical modeling, resulted in a more precise understanding of the relationship between nurse staffing and falls.     

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.     

Fall prevention in a Swiss acute care hospital setting Reducing multiple falls

Preventing in-hospital falls is an important goal in avoiding poor patient outcomes. In this quasi-experimental study, the authors evaluated the effectiveness of a nurse-led fall prevention program in a 300-bed Swiss hospital. Four hundred and nine patients (internal medicine) were included: intervention group (n = 198), usual-care group (n = 211). The program consisted of training nurses in the use of the Morse Fall Scale, and the implementation of 15 selected preventive interventions. In the intervention group, the proportion of patients at risk for falls was higher (p = .048), and fewer patients with multiple falls were observed (p = .009). The intervention program showed an effect in preventing multiple falls, but not first falls. The prolonged mean time to a first fall in a subgroup of fallers in the intervention group may indicate an increased awareness of the nurses and the appropriateness of the interventions used.     

Prevention of falls among older patients in the hospital environment

Falls among older inpatients are a significant cause for concern, yet currently there is no national guidance on falls prevention programmes, and little evidence from the research literature on the effectiveness of hospital prevention programmes. This article explores the unique problems associated with falls in hospital, particularly the issues related to observation and supervision of patients with cognitive impairment. The evidence base for falls risk assessment and prevention strategies is examined. An interprofessional, multidimensional approach to falls and injury prevention is suggested as the most likely approach to be effective in hospital, and the contribution of specific strategies such as exercise and hip protection are examined. Ethical issues are considered and the role of restraint in falls management is rejected. The Kings College Hospital inpatient falls prevention programme is described as a practice example of an interprofessional, multidimensional approach. Finally, the nurse's role in implementing falls prevention strategies and leading future practice development is identified.     

Evaluation of falls by inpatients in an acute care hospital in Korea using the Morse Fall Scale

The purpose of this study was to determine the cut‐off values of the Korean version of the Morse Fall Scale (MFS‐K) that would be most useful in identifying hospitalized patients at risk of falls in an acute‐care setting in Korea. This study was conducted using the medical records of 66 patients who fell and 100 patients who did not fall (no‐fall patients) sampled from inpatients hospitalized at a tertiary acute‐care hospital in Seoul during the period from 1 January to 30 November 2009. The optimal cut‐off point for the MFS‐K was found to be 45 points, which produced an acceptable sensitivity and a fairly good specificity, negative predictive value and accuracy. The highest peak on the receiver operating characteristic curve was a cut‐off score of 45 points in the MFS‐K. Further research needs to be performed to determine the optimal cut‐off score according to subjects' conditions through daily measurement with the MFS in medical or surgical patients who are relatively homogeneous in terms of individual and disease‐related factors.     

Patient falls from bed and the role of bedrails in the acute care setting.

The use of bedrails in preventing patient falls from bed remains highly controversial and has received only limited research attention throughout the last decade. The present study questioned the relationship between bedrail use and patient falls from bed particularly in terms of age-gender characteristics, mental status and the severity of injuries sustained. A retrospective, cross-sectional analysis was conducted of 419 patient falls occurring in an urban, acute care hospital from 1993-2000. This audit identified 136 falls from bed. It was found that for all age-gender groups the incidence of falls from bed with bedrails elevated was equal to or higher than when bedrails were not elevated. Patients in a 'non rational' state at the time of falling were significantly more likely to have fallen with the bedrails elevated (chi 2 = 19.463, p < 0.001). Whilst there was no statistically significant relationship between the position of bedrails and the severity of injuries sustained (chi 2 = 1.088, p = 0.780) the fact that there was a patient death resulting from a fall from bed over elevated bedrails was considered to be of particular clinical significance. Thus the role of bedrails as protective or safety devices was challenged and an urgent re-evaluation of current practices recommended.     

Preventing falls in acute care: an innovative approach

Falls among elderly individuals have been significant sources of disability and death. Falls have affected as many as 10% of older adults during an acute care inpatient stay. The acute care environment has contributed to elderly patient falls. Additionally, manifestations of acute illness, polypharmacy, and medication side effects have been risk factors for falls in the acute care setting. Individualized fall prevention strategies, initial patient assessments, and ongoing patient reassessments have been linked to a decrease in falls in the acute care setting. Approaches to fall prevention have included identification of high-risk patients, communication among staff and family members about an individual's risk of falls, and both case-specific and universal interventions for fall prevention. The purpose of this article is to describe a fall prevention program instituted in an acute care setting in southern Arizona that has produced encouraging results. Moreover, this article addresses individualizing interventions through a continuous clinical feedback loop, which provides patient care areas with relevant information about their patients who fell and recommendations for improving fall prevention.     

Patient falls in the acute care setting: identifying risk factors

A retrospective comparative chart audit was conducted to identify patient characteristics associated with falls in the acute care setting, to examine the extent to which the significant characteristics explained if falls occurred, and to test the ability of variables believed to be risk factors to predict falls. Patients aged 60 and older who fell during hospitalization (n = 331) were compared with a random sample of patients aged 60 and older who were hospitalized during the same time period but did not fall (n = 300). Two days of documentation were sampled: admission day and day preceding the fall for the fall group, and admission day and a random day of hospital stay for the no-fall group. Findings supported the idea that fall-prone patients can be identified and that significant differences between those who do and do not fall are evident at hospital admission. The findings also suggested an alteration in the constellation of characteristics nurses use to identify fall-prone patients. Of 11 variables representing standard risk factors, only 6 were significantly related to fall status; 5 entered the regression equation as significantly contributing to the 22% explained variance. When potential predictor variables were expanded to include additional patient characteristics, the explained variances for fall status were 31% from the admission day data and 34.5% from the fall/random day data.     

Therapeutic touch in an acute care community hospital.

Therapeutic touch now has a 25-year history of practice and research. Based on the idea that within all living things there is a drive toward growth, order and wholeness--and that healing is a natural part of this process--therapeutic touch has been shown to induce relaxation, decrease anxiety and speed healing. It also enables caregivers to embrace their compassion and to touch people with effect.     

Prevention of falls in the elderly population

In response to the challenge posed by falls in the elderly, the Jewish Institute for Geriatric Care established a Falls Clinic. The coordinated expertise of a geriatrician, neurologist, cardiologist, and physiatrist were combined with resources in audiology, ophthalmology, and podiatry. Thirty-six patients enrolled in the study had sustained a total of 36 falls, which resulted in 13 fractures and seven soft-tissue injuries. Falls were a daily occurrence for three patients, weekly for five patients, monthly for ten, semiannually for 14, and yearly for four patients. After a one-year follow-up, 77% of the patients experienced no further falls. We suggest that falls are a multidisciplinary issue and recommend a team approach for successful management.     

Impact of California mandated acute care hospital nurse staffing ratios: a literature synthesis

California is the first state to enact legislation mandating minimum nurse-to-patient ratios at all times in acute care hospitals. This synthesis examines 12 studies of the impact of California's ratios on patient care cost, quality, and outcomes in acute care hospitals. A key finding from this synthesis is that the implementation of minimum nurse-to-patient ratios reduced the number of patients per licensed nurse and increased the number of worked nursing hours per patient day in hospitals. Another finding is that there were no significant impacts of these improved staffing measures on measures of nursing quality and patient safety indicators across hospitals. A critical observation may be that adverse outcomes did not increase despite the increasing patient severity reflected in case mix index. We cautiously posit that this finding may actually suggest an impact of ratios in preventing adverse events in the presence of increased patient risk.     

Patient advocacy and advance care planning in the acute hospital setting.

OBJECTIVE: The aim of this study was to explain the role of patient advocacy in the Advance Care Planning (ACP-ing) process. Nurses rate prolonging the dying process with inappropriate measures as their most disturbing ethical issue and protecting patients' rights to be of great concern (Johnston et al 2002). Paradoxically ethical codes assume nurses have the autonomy to uphold patients' health-care choices. Advance Directives (AD) designed to improve end-of-life care are poorly taken up and acute hospitals are generally not geared for the few they receive. The Respecting Patient Choices Program (RPCP) improves AD utilisation through providing a supportive framework for ACP-ing and primarily equipping nurses as RPC consultants. Assisting patients with this process requires attributes consistent with patient advocacy arising out of nursing's most basic tenet, the care of others. DESIGN: Likert Scales survey administered pre and six months post-intervention to pilot and control groups, with coinciding focus groups. SETTING: Selected wards in an acute care public hospital in South Australia. SUBJECTS: Nurses on the palliative care, respiratory, renal and colo-rectal pilot wards and the haem-oncology, coronary care, cardiology and neurology/geriatric control wards. INTERVENTION: The RPCP during the 2004-2005 South Australian pilot of the (RPCP). MAIN OUTCOMES: The organisational endorsement of ACP-ing gave nurses the autonomy to be patient advocates with respect to end-of-life care, reconciling clinical practice to their code of ethics and easing distress about prolonging the dying process inappropriately. RESULTS: Statistically significant survey results in the post-intervention group showed nurses experienced: encouragement to ensure patients could make informed choices about their end-of-life treatment (84%); the ability to uphold these wishes in practice (73%); and job satisfaction from delivering appropriate end-of-life care (67%); compared to approximately half (42-55%) of respondents in the pre-intervention and control groups. Focus group participants shared that it used to be hard to advocate for patients, but now they could act legitimately and felt ethically comfortable about ensuing end-of-life-care. CONCLUSION: Findings suggested patient advocacy, fostered by the supportive RPC environment, effectuates the ACP-ing process. It is recommended that the RPCP should be recognised and developed as integral to promoting quality end-of-life assurance and associated job satisfaction.     

Prevention of elderly falls

The use of actigraphy to examine sleep disorders is extensively presented in the literature. This quantitative measure for sleep and activity has many other applications to clinical research beyond sleep disorders. Two examples of other applications of actigraphy will be described. The first is a study to examine sleep, pain and rhythms in preoperative and postoperative surgery patients, and the second is a study to examine differences in levels of mobility of elderly long-term care facility residents. A selection of results of actigraph measures for subjects from the above studies will be presented and discussed.     

Incidence and risk factors of hospital falls on long-term care wards in Japan

Rationale, aims and objective Falls among hospitalized patients are an important patient safety issue. In particular, the incidence of falls and risk of related injuries among the elderly are particularly high. Because the epidemiology of falls is not well scrutinized in Japanese long‐term care wards, we evaluated the incidence and risk factors of falls in this setting. Methods A prospective cohort study was conducted on long‐term care wards with 160 beds in a general hospital in Japan. All patients admitted to the wards over 25 months were enrolled and followed until discharge. The baseline characteristics and incidences of falls were measured. Results We enrolled 2973 patients with a mean age of 74 years, and median length of stay was 36 days. During the study period, 657 falls occurred in 411 (14%) patients. The incidence of falls was 3.8 per 1000 patient‐days, and by 15 and 30 days after admission to the ward, 7.3% and 11.4% of patients, respectively, had fallen. Independent risk factors related to falls during hospitalization were advanced age [≥70 years, hazard ratio (HR) 1.5, 95% confidence interval (CI) 1.2–2.0], history of falls (HR 1.2, 95% CI 1.0–1.5), frequent urination (HR 1.4, 95% CI 1.0–1.8) and requirement for toileting assistance (HR 1.4, 95% CI 1.1–1.8). Among patients who fell during the study period, 23% sustained an injury. Conclusions Many patients on long‐term care wards in Japan were elderly and experienced falls during their hospital stay, with consequent injuries. Taking into account the risk factors identified, we need to devise effective strategies to prevent falls and related injuries.