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The confused older patient: A practice audit, nurse beliefs and the epidemiology of falls and fall injuries

School of Public Health and Preventive Medicine

Ms Renata Morello

6-PACK Project Manger

B.Phty, MPH

Health Services Research Unit

Division of Health Services and Global Health Research

Monash University

Overview 1. Nurse knowledge and beliefs

2. Falls prevention practice audit

3. Fall and fall injury epidemiology

a) Incidence of falls and fall injuries

b) Characteristics of fall injuries

4. Reflections

5. Where to from here?

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Design, participants and setting

Prospective cohort study

• 7 Australian hospitals

• 26 acute hospital wards

• Between September 2011 and June 2012

Data collection

Practice audit (N= 12,820)

– Daily bedside observation

» Falls prevention strategies

– Daily medical record audit of practice

» Falls risk assessment and prevention strategies

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Data collection

Nurse beliefs (N=524)

– 12 focus group sessions (N=94)

– 44 item survey (N=428)

Fall and fall injury data (N=12,820):

– Prospectively collected as part of 6-PACK

– 3 data sources for capturing fall events

• A trained data collector

– Daily medical record audit of all admitted patients

– Daily verbal report from the NUM

• Hospital incident reporting database

Data collection

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The problem of falls in acute hospitals

remains unresolved

Only 57% of nurses believe their current falls

prevention program is effective at reducing

falls

Almost 30% think falls are inevitable in older

patients and cannot be prevented

Managing patients with delirium and

confusion was consistently identified by

nurses as the biggest challenge they face

with falls prevention

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Management programs: Best practice

Australian guideline recommendations:

– Older people with cognitive impairment should have their risk factors for falls assessed

– Identified falls risk factors should be addressed as part of a multifactorial falls prevention program,

– Injury minimisation strategies should be considered

(such as using hip protectors or vitamin D and calcium supplementation)

0

10

20

30

40

50

60

70

Strongly disagree Disagree Neutral Agree Strongly agree

Targeted management programs for patients with

delirium and confusion are used on my ward.

Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7

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What is happening on the wards….. Only 50% of patients with documented delirium or

dementia had a risk tool completed

– Less than 6% of high falls risk patients were

documented as receiving targeted management such as specialised delirium management

program, geriatrician or medication review.

– Hip protectors were infrequently used in these

patients.

What is happening on the wards…..

The most commonly used strategies were:

– High visibility positioning (22%)

– Specials (constant patient observers) (10%)

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What is happening on the wards…..

49% of patients with documented delirium or cognitive impairment on admission were receiving psychoactive

medications:

– Sedatives (8%) – Antipsychotics (27%)

– Antidepressants (17%) or – Anxiolytics (14%)

Nurses felt that whilst geriatricians were vigilant

in reviewing medications to decrease falls risk

other medical staff were less aware and

therefore reviews for this purpose were rarely undertaken.

To improve the use of medication reviews a structured process should be implemented to

trigger reviews.

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What can we do to help….

Nurses indicated they would like more

education and strategies for managing

patients with delirium.

The confused older patient

How and when do they fall?

What are the most common injuries?

What are the risk factors for injury?

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Why is this study important

→ Assist identification of high-risk patients or activities more likely to result in a fall or fall injury

→ Inform and target falls prevention strategies for

enhanced effectiveness

→ Enhance knowledge translation and practice change

Fallers were classified as a confused faller if:

it was documented in the patient medical

record or the nurse unit manager reported that

the patient was confused, disorientated,

delirious, or agitated immediately before or at

the time they fell

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Results: Falls incidence From 12,820 patient admissions:

– 557 patients fell during their hospital admission

– Total of 775 unique falls

Almost 1 in every 20 patients fell during their hospital admission

Results: Characteristics of fallers (n=557)

Mean age: 73 years

Female: 43%

Almost 1 in 5 fallers had three or more falls

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Fall injuries

From the 775 falls:

- 220 injurious falls were recorded

- Total of 304 injuries

More than 1 in 4 falls resulted in at least one

injury

More than 1 in 3 falls and fall injuries

occurred when the patient was

reported to be confused, agitated

or disorientated

With more than 70% unwitnessed

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The confused faller

184 patients with documented confusion fell

during their hospital admission

– Total of 261 unique falls

→ 65 injurious falls

→ Total of 78 injuries

Characteristics of the confused faller

(n=184)

– Mean age: 75 years

– Female: 39%

Almost 1 in 4 confused fallers had three or more falls

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0%

5%

10%

15%

20%

25%

30%

35%

40%

Fall injuries

All fallers (N=557)

0%

5%

10%

15%

20%

25%

30%

35%

40%

Fall injuries

All fallers (N=557) Confused fallers (N=184)

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How are fall injuries occurring?

32%

28%

29%

33%

25%

32%

Bathroom falls

Bed falls

Toilet falls

% of falls resulting in injury Confused fallers (N=184) All fallers (N=557)

N=274

N=218

N=146

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32%

28%

29%

33%

25%

32%

Bathroom falls

Bed falls

Toilet falls

% of falls resulting in injury Confused fallers (N=184) All fallers (N=557)

N=88

N=24

N=124

13%

25%

17%

28%

Roll from low-low bed

Bed fall

Bed fall injuries All fallers (N=557) Confused fallers (N=184)

N=274

N=71

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13%

25%

17%

28%

Roll from low-low bed

Bed fall

Bed fall injuries All fallers (N=557) Confused fallers (N=184)

N=124

N=38

Low-Low beds

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14%

36%

21%

29%

6%

38%

29%

26%

NR

Night

Evening

Morning

When are fall injuries occurring? Confused fallers (N=184) All fallers (N=557)

14%

36%

21%

29%

6%

38%

29%

26%

NR

Night

Evening

Morning

When are fall injuries occurring? Confused fallers (N=184) All fallers (N=557)

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Barriers to implementation of falls

prevention strategies……

Nurses stated that they were uncomfortable staying in the bathroom with some patients as they felt it

compromised their privacy

Implementation of toileting regimes was challenging

Low-low beds had a number of logistical challenges

Reflections

Managing patient confusion continues to be an issue

More than 70% of falls and fall injuries go unwitnessed

Falls and fall injuries often occur in relation to toileting

Bathroom falls result in a higher proportion of injuries

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Reflections

Rolls out of a low-low bed appear to reduce

the risk of a fall related injury

Where to from here……

Further research required in this patient group

• Modelling of risk factors

• Most effective strategies for managing falls

and fall injuries in this patient group

• Use of low-low beds

• Exploration of barrier to implementation

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Ackowledgments Dr Anna Barker

Chief Investigator: 6-PACK falls prevention project

6-PACK project investigators

The seven 6-PACK participating hospital sites

6-PACK site data collectors