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19/06/2013
1
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?
19/06/2013
2
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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9
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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13
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
19/06/2013
16
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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17
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
19/06/2013
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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