PICOT Question For patients aged 65 and older who are hospitalized

For patients aged 65 and older who are hospitalized (population), is increased healthcare facility staffing a better deterrent (intervention), in comparison to fall prevention programs (comparative/ alternative intervention) that are readily utilized in hospital settings, to help minimize in-patient falls (outcome) during the patient’s hospitalization (time)?

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Literature Review (PICOT Question For patients aged 65 and older who are hospitalized)

1. Aiken, Clarke, and Sloane theoretical framework” to explain the effect of organizational characteristics and nurse staffing on patient fall outcomes Everhart et al., (2014) discuses Patient falls in acute care hospitals represent a significant patient safety concern. The aim of this study was to determine whether hospitals can be categorized into fall rate trajectory groups over time and to identify nurse staffing and hospital characteristics associated with hospital fall rate trajectory groups. Methodology used was a 54-month longitudinal study of acute care general hospitals participating in the National Database for Nursing Quality Indicators (2007). Hospitals were categorized into groups based on their long-term fall rates. Nurse staffing and hospital fall rate were identified. Findings were that Hospitals with higher total nurse staffing, Magnet status, and bed size greater than 300 beds were significantly less likely to be categorized in the “consistently high” fall rate group. The authors concluded that fall prevention measures in addition to maintaining greater nurse staffing ratios in Magnet hospitals reduced falls.

2. Pearson, K. et Couburn, A.,(2011) EVIDENCE-BASED FALLS PREVENTION IN CAHS

Inpatient falls are a serious patient safety problem in Critical Access Hospitals (CAHs). Injuries from falls are also costly — it is estimated that patients injured in a fall sustain upwards of 60% higher total charges than other hospitalized patients. This brief is one in a series of policy briefs identifying and assessing evidence-based patient safety and quality improvement interventions appropriate for use by state Flex Programs and CAHs.

KEY FINDINGS:

Hospital falls are a serious patient safety problem, accounting for nearly 84% of all inpatient incidents. Most falls commonly occur as a result of medication related issues, toileting needs, and hospital environmental conditions.

Effective falls interventions target both intrinsic (e.g. physiologic) and extrinsic (e.g. environmental) risk factors.

Effective falls prevention teams are interdisciplinary and are embedded in a culture of patient safety.

Education for and communication across all staff contributes to successful falls prevention programs.

3. Kane RL, Shamliyan T, Mueller C, Duval S, Wilt TJ.(2007) Nurse staffing and quality of patient care. To assess how nurse to patient ratios and nurse work hours were associated with patient outcomes in acute care hospitals, factors that influence nurse staffing policies, and nurse staffing strategies that improved patient outcomes. PICOT Question For patients aged 65 and older who are hospitalized

Methods In the absence of randomized controlled trials, observational studies were reviewed to examine the relationship between nurse staffing and outcomes. Meta-analysis tested the consistency of the association between nurse staffing and patient outcomes; classes of patient and hospital characteristics were analyzed separately. Higher registered nurse staffing was associated with less hospital-related mortality, failure to rescue, cardiac arrest, hospital acquired pneumonia, and other adverse events. The effect of increased registered nurse staffing on patients safety was strong and consistent in intensive care units and in surgical patients. Greater registered nurse hours spent on direct patient care were associated with decreased risk of hospital-related death and shorter lengths of stay. Limited evidence suggests that the higher proportion of registered nurses with BSN degrees was associated with lower mortality and failure to rescue.

Conclusion Increased nursing staffing in hospitals was associated with lower hospital-related mortality, failure to rescue, and other patient outcomes,

4. Curtin, L. (2008) An Integrated Analysis of Nurse Staffing and Related Variables: Effects on Patient Outcomes the impact of organizational characteristics on nurse staffing patterns, patient outcomes, and costs; and the impact of nurses’ experience on patient outcomes. The author concludes research indicates that nurse staffing has a definite and measurable impact on patient outcomes, medical errors, length of stay, nurse turnover, and patient mortality. Moreover, the literature reports data that help determine what is, indeed, appropriate staffing. Ratios are important – a consensus seems to be emerging supporting a range of from 4 to 6 patients per nurse in most acute care hospital inpatient settings, with no more than one to two patients per nurse in areas of high patient acuity. However, ratios must be modified by the nurses’ level of experience, the organization’s characteristics, and the quality of clinical interaction between and among physicians, nurses, and administrators.

5. (Bolton et al., 2007, p. 238). Mandated Nurse Staffing Ratios in California A Comparison of Staffing and Nursing-Sensitive Outcomes Pre- and Post-regulation. This article examines the impact of mandated nursing ratios in California on key measures of nursing quality among adults in acute care hospitals. This study is a follow-up and extension of our first analysis exploring nurse staffing and nursing-sensitive outcomes comparing 2002 pre ratios regulation data to 2004 post ratios regulation data. For the current study we used post regulation ratios data from 2004 and 2006 to assess trends in staffing and outcomes. Findings for nurse staffing affirmed the trends noted in 2005 and indicated that changes in nurse staffing were consistent with expected increases in the proportion of licensed staff per patient. This report includes an exploratory examination of the relationship between staffing and nursing-sensitive patient outcomes. However anticipated improvements in nursing-sensitive patient outcomes were not observed. This report contributes to the growing understanding of the impacts of regulatory staffing mandates on hospital operations and patient outcomes.

6. (Agostini et al., 2001, p. 281) A Hospital System Approach at Decreasing Falls with Injuries and Cost. Agostini, Baker, and Boards (2001) collected and described existing evidence on current patient safety practices. Since falls and falls with injury are a serious threat to our patients, and create a cost burden for hospitals, there is a need to identify the quality and financial impact of a standardized fall prevention program for adult patients in the acute care setting. The results of a quality improvement study aimed at identifying the effectiveness of a multifactorial fall prevention program in the acute care setting for adult patients is reported in this article. He program was deployed over a period of 4 months. Using raw data, after 12 months of implementation, the authors identified a decrease in anticipated falls with injuries of 41% after the first year and an additional 31% comparing year 2 to baseline. The authors identified a total decrease in falls in an acute care setting of 58.3% over a 2-year period post implementation of a standardized fall prevention program in this study, the impact of a standardized fall prevention program across 50 acute care hospitals in 11 states was analyzed. The implementation of a standardized multifactorial program for adult patients appears to have reduced falls with injuries by 58.3% over a 2-year period, allowing for a potential cost avoidance reduction of $776,064 in 2013 dollars. Study limitations make it difficult to generalize these findings across all acute care settings in the United States. Further research is required, in the form of randomized control trial, to better understand the effect of individual interventions.

7. The AORN Journal Feb 2012, Vol. 95 Issue 2, p297-298, in an article (Lake ET, et al, 2010) reports on research which was conducted to investigate the relationship between nurse staffing, registered nurse staff composition, hospital Magnet status and patient falls. Researchers studied 5,388 nursing units in 636 acute care hospitals in the U.S. They found that there was a rate of 3.3 falls per 1,000 patient days, that there were higher fall rates on medical units than on surgical units and that nursing staff hours and Magnet status were associated with fall rate.PICOT Question For patients aged 65 and older who are hospitalized

8. Haines et al. BMC Medicine (2013). Cost effectiveness of patient education for the prevention of falls in hospital: economic evaluation from a randomized controlled trial Falls are one of the most frequently occurring adverse events that impact recovery of older hospital inpatients. Falls can threaten both immediate and longer-term health and independence. There is need to identify cost-effective means for preventing falls in hospitals. Hospital-based falls prevention interventions tested in randomized trials have not yet been subjected to economic evaluation. The short-term cost to a health service of one cognitively intact patient being a faller could be as high as A$14,591 (2008). The education program cost A$526 (2008) to prevent one cognitively intact patient becoming a faller and A$294 (2008) to prevent one fall based on primary trial data. These estimates were unstable due to high variability in the hospital costs accrued by individual patients involved in the trial. There was a 52% probability the complete program was both more effective and less costly (from the health service perspective) than providing usual care alone (Haines et al. BMC Medicine 2013).

9. Frances, H. and Adam, D. (2007). Older patients and falls in hospital. In the tenth article over a quarter of a million falls are reported by the UK hospitals each year, predominantly harming older patients whose vulnerability to falling arises from a complex interaction of risk factors, including impaired mobility, dementia, delirium, medication and the effects of long term and acute illness. Systematic review of research trials indicates that multifactorial assessment and intervention to treat, modify or better manage these underlying risk factors can reduce falls by 20-30%. However, the evidence base is not always reflected in hospitals’ falls prevention policies, and is not consistently delivered to patients. The organizational culture and processes that can increase the effective delivery of evidence-based falls prevention are discussed, alongside learning from quality improvement projects. Systematic learning from reported falls and essential care after an inpatient fall are also explored (Frances, H. and Adam, D. 2007).

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10. In another article published By Hayes, N (2004) in British Journal of Nursing, problems associated with fall in hospital are explored, 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

11. Hill, E. RN PHD et al (2009). Falls and Fall Prevention in Older Adults Fall risk assessments are not “one-size-fits-all” or the sole. When considering a fall risk assessment for use, facilities or staff must first evaluate the reliability and validity of the tool for use with their population. Once they select a tool to use, they should develop a comprehensive set of evidence-based interventions for each area in the fall risk assessment. Careful staff education planning and reevaluation for periodic re-education are also integral to any successful fall prevention protocol.

12. Hicks, Darlene (2015) in an article Can Rounding Reduce Patient Falls in Acute Care? Identifies the association of nurse rounding to the decreased cases of falls among patients in hospitals in the U.S. It considers hourly rounding of nurses as an intervention helping them keep patients safe by meeting their needs. The need for nurses to determine ways for patient outcome improvement is also mentioned.

13. Bedside Nurses Leading the Way for Falls Prevention: an article by Cangany, M. et al (2015). The article focuses on a study by the American Association for Critical-Care Nurses (AACN) Clinical Scene Investigator Academy (CSI) which identified accidental falls as their patient improvement project. The purpose of the project entitled “No Fall Zone” was to determine if improved education on the current falls policy, coupled with use of a falls contract and fall prevention signs above patients’ beds, decreased the overall total number of falls. The goal of this project was to decrease the total number of falls by 50% in 1 year. Focusing on 2 specific interventions, combined with the fall bundle, provides the tipping point to have an impact on fall reduction.

14. Swift, Cameron G. and Steve Iliffe (2014). Falls in later life are seen as a major health issue, both in terms of their injurious consequences and their significance as a diagnostic marker. Cost-effective measures for their assessment and prevention are well documented but insufficiently implemented. This Concise Guideline comprises of recommendations for the assessment and prevention of falls in older people based on Clinical Guideline 161 (incorporating CG21) published by the National Institute of Health and Care Excellence (NICE) in 2013. The recommendations are intended to provide both generalists and specialists with an overview of practical strategies for clinical case and/or risk ascertainment and intervention, and for referral

15. 2014 issue by Stinchcombe, A., Kuran, N. and Powell, S. Seniors’ Falls in Canada: discusses the annual Canadian Community Health Survey–Healthy Aging report entitled “Seniors’ Falls in Canada: Second Report.” Data in the report are intended to provide trends on falls, injuries and hospitalizations among Canadian adults aged 65 years and above as a guide to policy makers, researchers and practitioners. It notes the rising incidence of injuries resulting from falls within the age group. Conclusion is that progress in preventing falls and resulting injuries requires continued collaboration between governments, health care providers, nongovernmental organizations, care associations and services as well as Canadians themselves.PICOT Question For patients aged 65 and older who are hospitalized