Tag Archives: Accidental Falls

What is the recent evidence for intentional rounds in the intensive care unit?

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Searched CINAHL and PubMed for patient rounds AND (“intensive care” OR “critical care”)  with a limit of English.

Six quasi-experimental studies in CINAHL measuring nurse satisfaction, ventilator-associated pneumonia, cental-line associated bloodstream infection, nosocomial infections, healthcare outcomes, family presence, and facilitators and barriers to patient care rounds
Adding intensive care or critical care eliminates many studies that may also be relevant.

(MH “Patient Rounds”) AND (hourly OR intentional OR proactive OR comfort)
These results include several experimental and quasi-experimental studies. If you want to look at specific outcomes, see the following searches for particular topics:

Falls – (MH “Patient Rounds”) AND (hourly OR intentional OR proactive OR comfort) AND falls

Patient satisfaction – (MH “Patient Rounds”) AND (hourly OR intentional OR proactive OR comfort) AND patient satisfaction

Patient centered care – (MH “Patient Rounds”) AND (MH “Patient centered care”)

Papers in PubMed search: (rounds OR rounding) AND (intentional OR hourly OR time factors OR proactive) AND (nurses OR nursing) AND (safety OR quality improvement OR infection OR pneumonia OR pressure ulcers OR falls OR patient satisfaction OR patient outcome assessment OR outcomes assessments) AND (“intensive care” OR “critical care”)
This search retrieves papers examining common outcomes in the intensive care unit.  Other outcomes can be included in the search.

Reviewed and updated 5/1/2014 ldt

Is use of color in the healthcare environment effective at reducing the rate of falls in inpatients?

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Bottom line:  No published research has been identified on the use of color  in hospital settings to reduce falls other than to alert healthcare staff, but there is research on the ability to perceive color in adults with visual impairment, which affects many older patients.

Summary:  For a review of perception of color and discussion of implications for healthcare environments, see
J Clin Nurs. 2009 Feb;18(3):366-72.
Källstrand-Ericson J, Hildingh C. Visual impairment and falls: a register study.
Discussion on p. 369 includes review of literature on color perception in visual impairment.

Searched Joanna Briggs, PubMed, CINAHL, and Web of Science

Reviewed 4/9/2014 ldt

What is the prevalence of falls for hospitalized psychiatric and geriatric patients?

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Observational studies:

Enloe M, et al.  Falls in Acute Care: An Academic Medical Center Six-Year Review.  J Patient Safety.  2005; 1(4): 208-214.
Retrospective study of falls at an academic medical center over 6 years.  RESULTS:  Table 2 shows the unadjusted annual fall rates were 5.86/1,000 patient days on the psychiatry units and Table 3 shows that broken down by age (regardless of service the patient was on), the fall rate for patients age 55-74 was 2.90/1,000 patient days and the rate for patients ages 75 and older was 4.08/1,000 patient days.

Schwendimann R, et al.  Characteristics of hospital inpatient falls across clinical departments.  Gerontology. 2008;54(6):342-8
Prospective study at 1,300 bed academic hospital over 13 weeks.  RESULTS:  Rate of falls on geriatrics units was 10.7/1,000 patient days.

Kerzman H, et al.  Characteristics of falls in hospitalized patients.  J Adv Nursing 2004; 47(2), 223–229.
Retrospective study of falls at a 2000-bed medical center in 1998.  RESULTS:  The rates of falls was 115/1,000 hospital admissions in the geriatric wards and 91 per 1,000 admissions in the psychiatric wards.  Rates per 1,000 inpatient days were not reported.

Are there randomized controlled trials of multi-pronged interventions to reduce falls in acute care settings?

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There are two randomized controlled trials on multiple interventions to prevent falls in acute care settings.

Dykes PC, et al.  Fall prevention in acute care hospitals : A randomized trial.  JAMA. 2010;304(17):1912-1918.
This study randomly assigned nursing units 1) to use an intervention including a specific risk assessment tool, care plan based on the assessment, patient and family education materials or 2) to provide usual care (control). Baseline characteristics of units were similar. Table 3 (p. 1916) summarizes differences in fall rates (per 1,000 patient days) for all patients as well as specifically for patients aged 65+. Significant differences favored the units using the intervention.

Ang E, Mordiffi SZ, Wong HB. Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial. J Adv Nurs. 2011;67(9):1984-1992.
There were 912 and 910 participants in the control and intervention groups, respectively. Intervention group patients received usual care and targeted multiple interventions based on individual risk factors of the Hendrich II Falls Risk Model; unfortunately, the article does not provide examples of interventional techniques. The fall incidence rates were 1·5% (95% CI: 0·9-2·6) and 0·4% (95% CI: 0·2-1·1) in the control and intervention groups, respectively. The relative risk estimate of 0·29 (95% CI: 0·1-0·87) favors the intervention group.

Reviewed and updated 4/10/2014 ldt

Does hourly or intentional rounding reduce the rate of accidental falls in acute care facilities?

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Bottom line:  Intentional rounding and hourly rounding are associated with reduced fall rates, but higher quality study designs are needed to determine the extent of benefit in various settings.

Summary:
Halm MA.  Hourly rounds: What does the evidence indicate? Am J Crit Care 2009;18:581-584.
Seven of nine studies in which falls were evaluated found a decrease in fall rates upon implementation of hourly rounding. Table 1 (p. 582) of this review summarizes effect on fall rates, as well as patient satisfaction and other indicators, in recent studies on hourly rounding.

Meade C, et al. (2006) is a highly cited study included in the review by Halm. This quasi-experimental, non-randomized study compared fall rates among units assigned to one of three groups:  1) hourly rounding 7am-3pm & every 2 hours 3pm-7am, 2) rounding every 2 hours, or 3) no specific procedure for rounding.  Groups 1 and 2 had specific procedure to follow.
RESULTS: Group 1 (hourly) – 25 falls during baseline period reduced to 12 falls during study period (p=0.01); Group 2 (every 2 hours) – 19 falls reduced to 13 falls; Group 3 (control) – 18 falls reduced to 17 falls.

Of the 11 articles not included in the review by Halm listed here, eight found a reduction in falls upon implementation of intentional rounds; note that some of the ten articles’ institutions implemented other fall prevention strategies in addition to intentional rounds. Only one of the eight articles stated that the reduction in falls was significant (Saleh et al., 2013). For the two remaining articles, the difference in the number of falls was not found to be significant in one article due to the infrequency of falls (Krepper et al., 2014), one did not experience consistently improved outcomes (Dyck et al, 2013), and the total number of falls did not change but the number of falls with injury was reduced (Sherrod, 2012). Dyck et al. (2013) discusses how they sustained participation in the program despite inconsistent outcomes.

Reviewed and updated 4/15/2014 ldt

What are the most common factors associated with accidental falls in acute care facilities?

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All four systematic reviews determined that impaired mental status and a history of falls are common factors associated with accidental falls in acute settings. See below for other risk factors.

Summary:

Arch Phys Med Rehabil. 2014 Jan;95(1):50-57.
After conducting a systematic review of the literature to identify risk factors, researchers linked the 88 factors to 66 International Classification of Functioning, Disability, and Health (ICF) categories and 5 personal factors (see Appendix 1). Twenty multidisciplinary participants from different institutions completed three rounds of rating the importance of each category and factor regarding falls in acute rehabilitation settings using a 5-point Likert scale.
RESULTS: Thirty-four ICF categories and two personal factors achived threshold values of importance, and their scores are listed in Table 1. Of these, items scored 4.9 or 5.0 include four body functions (consciousness fuctions (i.e. confusion/disorientation), sensations association with hearing and vestibular function (i.e. dizziness/vertigo), muscle power functions (i.e. motor status related to stroke), and gait pattern functions (i.e. gait stability)), one activity (walking), and one personal factor (previous falls).

Arch Gerontol Geriatr. 2013 May-Jun;56(3):407-415.
Systematic review with ten studies that met the inclusion criteria for studies on older hospital patients. When there were at least 3 studies investigating a factor in a comparable way in a specific setting, researchers computed the pooled odds ratio (OR) using random effect models.
RESULTS: Six risk factors for older hospital inpatients (HI) were considered, and the strongest association was a history of falls (OR=2.85). Other risk factors that were significantly associated with falls were cognitive impairment (OR = 1.52 overall, OR = 1.65 multivariate), use of sedatives (OR = 1.89 overall and multivariate), and use of antidepressants (OR = 1.98 overall and multivariate).

Age Ageing. 2004 Mar;33(2):122-30.
This is a systematic review of thirteen studies that described risk factors in a variety of inpatient settings.
RESULTS: A small number of factors were repeatedly found to be significant: gait instability, lower limb weakness, previous fall history, medications, toileting factors (urinary incontinence/frequency or need for assistance), and agitation/confusion or impaired judgement. See Table 3 for odds ratios and confidence intervals for all risk factors.

Int J Nurs Pract. 2001 Feb;7(1):38-45
This is a systematic review of 13 case-control and 5 cohort studies of patient falls in hospitals.
RESULTS: Factors associated with increased risk of falling included special toileting needs (incontinence, needing assistance, having diarrhea), impaired mobility or use of mobility aid, impaired mental status, and history of falling. Doesn’t provide any numerical risk data.

Reviewed and updated 4/10/2014 ldt