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21st Century Visions of Nursing Conference

September 12, 2012

New Interventions for Fall Prevention in

Hospitalized Older Adults

Barbara E Harrison, PhD GNP, BC

Acknowledgements

• Oakland University Rochester Michigan

– Ann Whall PhD RN Nursing

– Marisa A Ferrari, DNP Nursing

– Osamah A Rawashdeh, PhD Engineering

• William Beaumont Hospital, Royal Oak, Michigan

– Yvonne Avery BSN

– Michael Maddens, MD

– Robert Hammond, PhD Research

Objectives

1. Comprehend the significance and impact of falls in acute

care settings on health care outcomes for older adults.

2. Understand the evidence for fall prevention interventions.

3. Recognize the limitations to current fall prevention

interventions.

4. Identify new interventions for fall prevention.

Significance and Prevalence of falls

• Falls are the most common safety incident for older adults

in hospitals with approximately 1 million/ year (Titler, et al. 2011)

• Older adults are at high risk for falls in acute care settings

with rates between 2.3 and 13/1000 patient days (Tinetti &

Kumar, 2010) .

• Older adult fallers with cognitive impairment have more

severe fall injuries than those without impairment (Tzeng,

2010).

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Problem Statement

• Millions of older adults are admitted to acute care setting

each year and are at risk for noscomial injuries due to falls.

• Nursing is the discipline with primary responsibility for fall

prevention in hospitals. (Titler, et al. 2011)

• Cognitive work analysis suggests that physical environment

is a major factor in falls and that nurses are “frustrated with

fall prevention” tasks. (Lopez, Gerling, Cary, Kanak, 2010)

Joint Commission requirements

• Individual research suggest that many falls in hospitals can be

prevented ( Dykes et al., 2010, Haines, Hill, et al., 2011).

• Joint Commission requires all healthcare facilities to have a fall-

prevention program in place and to conduct ongoing evaluations of

that program.

• Bed alarms are one component of fall-prevention programs, specially

for patients who have cognitive impairments.

Older adult falls

Hospital falls are different

• Fall Risk factors differ between settings.

• The hospitalized patient is ill, in unfamiliar environments and has lost

control in performance of personal activities.

• Often physical dependent on staff.

• Rapid changes in condition (delirium) and the need for nursing staff to

make adjustments.

• We cannot simply translate evidence generated outside of the

hospital setting and expect that it will work in this environment.

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Review

Risk Factors for older adult falls

• Ambulation assistance, disorientation, medications

• Urine/bowel control problems, and fall history among hospitalized

medical-surg. patients.

• Inattention and mobility contribute to hospital falls among older adults.

– Ferrari and Harrison (2011)

Units are different

• An intervention may be effective for one group of patients but not for

others.

• A randomized trial of a falls patient education program combined

with trained health professional follow-up education approach.

• Falls risk alert card with information brochure, exercise programme,

education programme, and hip protectors.

• Successfully reduced falls by approximately 50% for cognitively

intact older hospital patients, but not for those with cognitive

impairment.

(Haines, Hill et al., 2011).

Example

• One Setting: A midwest 1,061 bed Magnet® hospital.

– 986 falls in 2009

• 26% of falls (n = 254) resulted in injuries

• 86 falls occurred on unit where high risk patients were often

admitted

What are the risks ?

• Falls

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Mortality due to falls

• According to the World Health Organization (WHO), falls are the

leading cause of injury mortality worldwide, accounting for 1/3rd of

unintentional injury deaths among adults ages 60 years and older.

• In the North American region alone, falls account for 43% of the total

number of injury deaths in this age group (WHO, 2011).

• Fall mortality rates have increased in the past decade— a 62%

increase from 1999 to 2008 in fall mortality rates in adults ages

60 years and older (U.S. Centers for Disease Control and

Prevention [CDC], 2011).

Injuries due to falls

• Almost 30% of older adults who fall experience moderate to severe

injuries including:

– hip fracture,

– head trauma, and

– lacerations

(Sterling, O’Connor, & Bonadies, 2001).

Falls are a Quality measure

• The 2011 Institute of Medicine report, The Future of Nursing Leading

Change, Advancing Health reported evidence linking nursing to high

quality care for patients including protecting their safety.

• When caring for hospitalized older adults, one of nurses’ primary

responsibilities is maintaining patient safety and preventing

iatrogenic events which include falls.

Quality outcomes Fractures

• Of those who fall in hospital, 10-20 % experience a fracture .

• The most common fractures are of the vertebrae, hip, forearm, leg,

ankle, pelvis, upper arm, and hand (Scott, 1990).

• Incidence of hip fracture is greater in older women but death from hip

fracture is higher among older men (Fransen et al 2002).

• About 5% of older adults with hip fractures die while hospitalized;

overall mortality in the 12 months after a hip fracture ranges from 12%

to 67% (Beers & Berkow, 2005).

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Falls as a Safety Outcomes

• Physical and functional impairments,

• Loss of independence, disability, (Hughes, et al 2008).

• Psychological consequences like increased fear of falling, anxiety,

helplessness, or depression (Nordell, Andreasson, Gall, Thorngren, 2009).

• At least 50% of elderly persons who were ambulatory before fracturing

a hip do not recover their prefracture mobility (Beers & Berkow, 2005).

• According to Veteran’s Admin. study of fracture related injuries, 55.4%

resulted in hip fractures and 10.1% intracranial injuries.

• Average cost of US $23,723 per admission.

Quigley, P. A., et al. (2012). Clinical nursing research, 21 ,10-23.

•

Risk Factors for fracture after a fall

• Risk factors for serious injury include diagnoses of :

– osteoporosis, previous joint replacement, and spinal

abnormalities, current use of anticoagulants, low platelet count or

elevated INR or other clotting factors.

Some hospitals have a post-fall protocol that includes assessment

for signs or symptoms of fracture or potential for spinal injury before

the patient is moved to improve outcomes.

Surveillance

• Surveillance is a nursing intervention that has been identified as

important to patient quality and safety outcomes (Schmidt, 2010).

• Defined in Keeping Patients Safe as “observing changes in patient

conditions that may signal a decline in condition along with an

action to prevent complications”. (Institute of Medicine, 2003).

• Categories of actions such as knowing what's going on and watching

are hypothesized as actions that improve both quality and safety

(Schmidt, 2010).

Evidence for current fall prevention

interventions

• Bed alarms

• Sitters

• Rounding

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State of the Art - Surveillance

• Alarms

– 90% of acute care fall prevention plans include bed alarms.

(Shever, Titler, Mackin, Kueny, 2011).

– Only 1 study that supports use (Tideiksaar, et al 1993).

– These systems often have poor specificity (Lopez, 2011).

Bed Alarms

Evidence on alarms • 2 types of bed-exit alarms to detect bed-exiting body movements:

– pressure-sensitive and

– pressure sensitive combined with infrared beam detectors (dual

sensor system).

• Study evaluated bed exit alarms

• the occurrence of nuisance alarms, or alarms that are activated when

a participant does not attempt to get out of bed.

• 14 nursing home residents were observed for a total of 256 nights

• a marginally significant difference (p = 0.059) between the alarm

groups on the number of true positives for pressure-sensitive vs. dual

sensor alarm.

• the dual sensor alarm may have a higher number of true positives..

Bed Alarms

• The dual sensor bed-exit alarm was more accurate than the

pressure sensitive alarm in identifying bed-exiting body movements

and reducing the incidence of false alarms,

• False alarms were not eliminated altogether

• Capezuuti, E. Brush B., Lane, S., Rabinowitz, H.,Secic, M. (2009). Bed-exit alarm

effectiveness. Archives of Gerontology & Geriatrics, 49, 27–31.

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Alarms

• The literature recommends use of alarms with patients who cannot

be constantly supervised and need frequent reminders (Kelly,

Phillips, Cain,Polissar, & Kelly, 2002).

• Two studies (Cumming, 2002; Cumming et al., 2008; Vassallo et al.,

2004) recommended using alarms with patients who have delirium

and cognitive impairment, cannot safely walk unsupported, or have

unsafe gait.

Sitters

• The sitter utilization study was unable to provide correlation of sitter

use to decreased fall rates, elopement, or assault behaviors.

• Currently, there is no research to suggest the use of constant

observation reduces the risk of patient harm related to their risk for

falling or harming themselves.

Harding, A. D. (2010). Observation assistants: Sitter effectiveness and industry

measures. Nursing Economic$, 28(5), 330-336.

Sitters

• Pardee hospital saw a decrease in fall and fall-related fracture rates

since implementing the “no sitter orders.”

• Pardee Hospital now uses fewer sitters and the nurses report that they

appreciate not losing coworkers to a sitter assignment.

• Nurses, instead of sitters, help prevent patient harm through:

– setting bed alarms,

– putting fall precaution magnets on patient doors and fall precaution

stickers on ID bands,

– providing slip-resistant socks,

– encouraging family members to stay when possible.

Weeks, S. K. (2011). Reducing sitter use: Decision outcomes. Nursing Management,

42(12) 37-38.

Rounding

• One study findings suggested that a significant reduction of fall and

after the implementation of hourly nurse rounding.

• Nurse rounds also increased patient satisfaction (P < 0.05).

Saleh BS, Nusair H, Zubadi NAL, Al Shloul S, Saleh U. (2011). The nursing rounds

system: Effect of patient’s call light use, bed sores, fall and satisfaction level. International

Journal of Nursing Practice,17, 299–303.

• Another study on an acute medical unit at an academic tertiary care

center, that according to national benchmarks, was one of the

hospital's top 3 units for numbers of falls for several years.

• Interventions including structured hourly rounds had an effect on the

falls rate benchmark.

Murphy, T.,Labonte, P., Klock, M;Houser, L. (2008). Falls prevention for elders in acute

care. Critical care nursing quarterly, 31, 33-39.

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Limitations to current fall prevention

interventions

• No single intervention, including bed alarms, has been shown to be

effective in preventing high-risk patients from falling

• Acute Care is complex environment

• Reliability of devices

• Sensitivity to alarms, etc

• Consistent use of bed alarms by nursing staff is questionable; may

be related to excessive false alarms (Kwok, Mok, Chien, & Tam, 2006).

Limitations- Bed alarms

• Criteria for use of bed alarms have not been clearly established, and

it often is difficult for nurses to predict who will attempt to get out of

bed unassisted.

• Bed-alarm types include systems built into hospital beds, standalone

technology, or portable systems that consist of a sensor pad and a

monitor alarm, voice alarms, and seat belt alarms for wheelchairs.

Acute Care as complex environment

• Communication gaps

• Shever (2011) described nurse manager responses to name fall

prevention interventions.

• The most common fall prevention interventions included bed alarms

(90%), rounds (70%), sitters (68%), and relocating the patient closer

to the nurses' station (56%).

• 29% of nurse managers identified physical restraints as an

intervention to prevent falls

• only 10% mentioned ambulation.

Reliability of devices

• Dependence on alarms for surveillance.

• False positive alarms decreases staff vigilance.

• Four major constraints were identified that inhibit nurses’ ability to

prevent patient falls. (Lopez et al 2010)

• Study at 572-bed Magnet academic medical center on East coast.

• All constraints relate to work processes and the physical work

environment, opposed to safety culture or nursing knowledge, as

currently emphasized.

• The constraints were: cognitive ‘head data’, temporal workload,

inconsistencies in written and verbal transfer of patient data, and

limitations in the physical environment.

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Time- motion

• 55% of time was spent on indirect patient care

– (16% of overall time on clerical duties, 15% communication with

unit staff, 9%shift report,9%using MIS,6% equipment gathering),

• 45% on direct patient care

– (33% time in patient room, 12% preparing and administering

medication).

– (Lopez, Gerling, et al. 2010 Journal of American Medical

Informatic Association, 17:313-321)

New interventions for fall prevention

• Video monitoring

• Motion sensing using accelerometers

• Gait analysis

• Optical sensors

Video monitoring for fall prevention

• Current technology on one 66 bed unit includes:

• 1. Realtime video-monitoring (VM) of 2 private / 3 semi private rooms

on unit.

• 2. Live video streamed to a monitor on unit.

• 3.Audio to room to question/cue.

• This intervention with other interventions reduced falls incidence on

this unit.

Video monitoring

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Technology related themes

• Fatigue

– “Having four hours. I think you lose your mind.

– I don’t think you focus on the patients after a certain period of time.”

– “it’s the most boring job in the entire world.”

– “ I would say that 4 hours is pushing it. 4 hours at a time is the cut off. “

• Stressful

– “when they all start getting agitated sometimes it gets a little stressful.”

– “Some days its cake and some days it chaos”

– “when there are 6 patients that aren’t responding to verbal cues and the

staff are already in the other rooms it just gets a little stressful.”

• Intervention does not fit the patient

– “we’ve gotten a lot of combative people using it.

– …”they really just need to be restrained or have a sitter”

Technology related themes for nursing care

• Efficiency

– “The fact that the monitors are there we can watch those 8 patients a lot

more efficiently”

– “I feel like if you had 9 or 10 patients, that would be a little too much”

– “ I think it works well for directable patients, people you can reason with”

• Setting Priorities

– “your focus is definitely on the ones who are not redirectable cause

you have very limited time to handle the problem”

• Assessment Processes

– “They need a reevaluation process like in a 24 hour or 48 hour”

– “I think it is slightly harder for some people ……when they talk overhead.

The patients can’t understand them”

Limitations

• Limitations with video-monitoring

– Patient privacy

– Cost of video equipment

– Cost of trained observers

– Observer overload

– Observer distraction

Pressure sensing devices

• Smart Carpet is a new technology that has been discovered to

sense falls in the home by using sensors within a foil sheet that is

placed underneath an individual’s own carpet.

• It is able to sense where the person is in the home as well as when

that person is walking, running or lying prone/supine on the floor.

• This advance in technology allows the equipment to call for help if

the person is unresponsive, (Aud, et al. 2008)

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Pressure sensors

• Fall sensors in shoes

• http://www.youtube.com/watch?v=y5mkyOD7rPE

Motion Sensors

Accelerometers

• How accelerometers work

http://www.youtube.com/watch?v=KZVgKu6v808

• Human Movement captured with accelerometers

• Intel

– http://www.youtube.com/watch?v=WufwYYSJ5xY

Research on Motion sensors

• Pilot study tested the feasibility of a wireless five sensor, motion

detection system (5S-MDS) in an acute care setting with

hospitalized older adults.

• Specific Aim: To determine if a motion detection system is clinically

feasible for the hospitalized older adult patient.

– Are sensors acceptable to hospitalized older adults?

– Do hospitalized older adults wearing sensors maintain skin

integrity under the sensor?

– Does data from the sensors (motion monitoring system) correlate

with video monitoring data?

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Methods

• Setting: older adults in a Midwest hospital unit in 2011.

• Five older adult subjects wore the sensors (5S-MDS) for 8 hours.

• They completed a set of 32 scripted movement tasks.

• Sensors attached to ankles, wrists and chest while performing

scripted movement scenarios.

Measures

• Skin assessment tool

– Dichotomous rating

– The prototypical wireless system included 5 sensors (4.5 cm in

length, 2.8 cm in width, and 1.3 cm in height).

• Acceptance questionnaire

– VAS for acceptance of sensor at each body location.

Technology

Results

N = 5 Hospitalized older adults

1 Male and 4 female

Mean age 90.2 (5.6)

• Day of testing = Mean day 4.2 (range 1-16)

• All were assessed as “high risk for falls”

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Results

• Acceptance by subjects

– Overall acceptance= 4.77 out of 5

• Skin Assessment

– Alteration in skin integrity = 0

– Skin integrity was maintained 100%

• Sensor Accuracy

– Electronic sensor data output always matched the video output

– No time delay between the sensor data output and video output

Patient Acceptance

Overall acceptance= 4.77 out of 5

• Wrist acceptance= 4.72 out of 5

• Leg acceptance= 4.64 out of 5

• Chest acceptance=4.96 out of 5

Research using Optical fibers

• Optical fibers in the carpet's underlay create a 2D pressure map that

distorts when stepped on.

• Sensors around the carpet's edges then relay signals to a computer

which is used to analyze the footstep patterns.

• When a change is detected - such as a sudden stumble and fall - an

alarm can be set to sound.

• By monitoring footsteps over time, the system can also learn

people's walking patterns and watch out for subtle changes, such as

a gradual favouring of one leg over the other.

Optical sensing devices

• Defining the user requirements for wearable and optical fall

prediction and fall detection devices for home use

• A qualitative study about the development of fall prediction sensors

and systems.

• Interviews to discuss wearable and optical sensors in the home.

• Optical sensors in high-risk areas such as the bathroom and toilet.

• Wearable sensors were at a higher preference than optical sensors

because of their unobtrusiveness.

• Security and mobility were prime reasons for use.

• Govercin et al 2010

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Intel’s Global Director of Product Research

• http://www.youtube.com/watch?v=C7uYZ1_gyU4

– Start at 2 minutes

Passive Fall detection

• http://www.youtube.com/watch?feature=endscreen&NR=1&v=09YrJ

cMhy9w

Questions

• Thank you !

References Anderson, O., Boshier, P., & Hanna, G. (2010). Interventions designed to prevent healthcare bed-related

injuries in patients. The Cochrane Collaboration, (1), 1-30.

Aud, M., Abbott, C., Tyrer, H., Neelgund, R., Shriniwar, U., Mohammed, A., & Devarakonda, K. (2010).

Smart Carpet: developing a sensor system to detect falls and summon assistance. Journal Of

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Bailey, C., Buckley, V. (2011). Recruiting and retaining older persons within a home-based pilot study using

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Health & Social Care , 177-187.

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Harding, A. D. (2010). Observation assistants: Sitter effectiveness and industry measures.

Nursing Economic$, 28(5), 330-336.

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Quigley, P. A., Campbell, R. R; Bulat, T., Olney, R. L., Buerhaus, P., et al. (2012). Clinical

nursing research, 21 ,10-23.

References

Rochat, S., Büla, C., Martin, E., Seematter-Bagnoud, L., Karmaniola, A., Aminian, K., &

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New patients

1 in 5 newly admitted nursing home patients has a fall within 1 month.

Based on Medicare/Medicaid data on more than 230,000 first-time

residents admitted to nearly 10,000 nursing homes across US in 2006.

21 percent had at least one fall during their first 30 days in the facility.

Patient were in a new place and are unfamiliar to the staff.

• Natalie Leland, a research OT - University of Southern California, in Journal of the

American Geriatrics Society.2012