Introduction to Evidence based practice Assessment answers

Assignment Topic

How can the risk of falls be reduced for adult in-patients?

Assignment guidelines – Introduction to Evidence based practice

A 3,000-word written assignment

Select a research question relating to your field of nursing from the list on Moodle. Conduct a literature search using the skills developed during the module. Explain and reflect on the literature searching process and include a table of the search terms used. Choose 5-6 articles related to the question from the search and describe them, comment on why you chose them, their findings and their relevance to your nursing practice.

100% Weighting

40% Pass Mark

Introduction (approx. 300-400 words)

Introduce the assignment and outline clearly what you aim to do.

Tell the reader what will be included in the assignment and in what order.

Introduce, define and discuss the importance of evidence based practice in relation to your field of nursing including the use and definition of evidence based practice models

Search (approx. 800 words)

Introduce your search terms.

Outline how you performed your literature search i.e what databases you used, inclusion and exclusion criteria, any other filters used and provide rationale for these decisions with references.

Outline how you identified your key articles. Include enough detail so that your search could be conducted by the person reading it. Include a copy of your search in the appendices

Discussion (approx. 1000 -1200 words)

Give an overview of the key articles in detail, using the following questions;

What were the studies about?

How were they conducted?

What did they find?

Remember to use research terminology e.g. quantitative, qualitative and provide definitions to explain these terms.

Conclusions (approx. 200-300 words)

This should summarise how you conducted the literature search and the results that you found as well as the key points from your articles.

Revisit the original research question to ensure this has been answered.

Implications for practice (approx. 200-300 words)

Outline the implications for your practice as a nurse. What has the evidence added to your knowledge base? What further information would you like to know? How does the process of searching for the evidence inform your practice? Were there gaps in the evidence?

References

Reference the assignment throughout using the LSBU-HARVARD system, including a reference list.

Appendices

Add this table here, label it and refer to it in the text

General tips:

• Succinct writing: keeping within the word limit (3000 words +/- 10%)
• Good, clear presentation with correct grammar and spelling
• Use supporting references for the points that you make.
• All work must use font size 12 with double spacing
• Avoid using the first person

Assignment Answer

Title: To investigate the effect of methods used in Reduction of falls in adult in-patients.

Introduction:

Inpatient Falls and fall-related injuries pose a safety hazard for the elderly population contributing to increase in the length of hospital stay, cost of hospitalization and in some cases permanent disability. Fall injuries impose a huge economic burden on the patients as well as the hospitals. These injuries are highly preventable. Older people, living alone in the community are highly prone to such incidents however, they are equally common among the adult inpatients in the hospital (Morris and O'Riordan, 2017). Hospital Studies show an average of 20 falls per 1000 patient-days. The risk of falling increases with the factors such as cognitive impairment, balance problems, chronic pain in the joints, Osteoporosis, usage of sedative medication, orthostatic hypotension etc., (Cuevas-Trisan, 2017)

Fall preventing interventions look promising when they address a variety of factors, that contribute to the falls such as, infrastructure in the hospital rooms, footwear of the patients, education of the staff members, fall-related awareness among the patients, slipperiness of the floor, muscular tone of the patient and orientation of the patients due to their mental state.

In this paper, a total of five studies that recruited the methods to reduce the falls in the elderly in-patients are listed. Search strategy is mentioned below to reflect the path followed in selecting these studies. Each study is discussed briefly regarding the size of the population, research design, the settings it is performed in, the type of intervention used and its effect on improving the quality of life. A conclusion is provided with an additional implication for a clinical practice (Mazur et al., 2016).

Best practices in medicine refer to protocols that contribute to positive health outcome. Evidence based practise (EBP) is defined as conscientious and judicious use of the available evidence to provide high quality care. EBP assists in keeping the nurses and physicians up to date with the latest developments, it aids in reducing the costs through the effective usage of resources without compromising on quality. Clinical practise changes on a regular basis and new research brings in opportunities to improve the services. The data available should be checked for its application on a specific population and hence the use of relevant evidence is highly recommended (Reid et al., 2017)

Search strategy:

Studies were selected from the research database such as PubMed.gov. The search period included all the articles published between January 2008 to December 2019. The search words included Fall prevention AND hospitalised /inpatients AND adult population AND methods. The publications that are available only in English are preferred. There were about 1634 results obtained for this search. Only the free full text articles were selected which reduced the available number to 622 articles. The filter ‘randomised control trials’ were included and the rest books, documents, editorials, systematic reviews, meta-analysis, and clinical trials were disregarded giving 108 results. Additional filters for the age of the population in the studies is at least 65 years. There was no selection for the type of intervention implemented in the study all were considered the best approached methods. Among the 90 articles the titles that did not fulfil the criteria were screened.

The studies were checked for the size of the population with at least 400 patients in the trial and ranging about 20,000 patients in the cluster randomised trials. In most of the studies the mean average age of the patients is about 70 years. Adults lack the muscular tone and are prone to numerous gait disorders by the age of 65 years with an additional possibility of cognitive and visual impairment and hence are prone to falls. Hence a group of above 65 years is ideal for the study and intervention of fall prevention. The duration of the studies was at least for a period of 12 months and up to 1000 bed days.

Table 1 : Appendix table with the details of databases searched

Inclusion criteria:

• The participants are hospitalised patients and those that are at high risk of falling were included.
• Studies were not restricted to U.K but also included Australia and U.S acute hospital settings.
• Participants with without any previous falls were included.
• Participants are at least 65 years old in these studies.
• Studies are primary and are involved in direct research in a hospital setting were included.
• Quantitative studies supported by numerical data and with a statistical significance value of p>0.05 were included.

Exclusion criteria:

• The outpatients or the ones that stayed for a single day, staff members who were admitted or visiting adults were excluded. The studies reported that with the increase in the length of the stay the number of falls recorded also increased and hence the one day stay of outpatients was not considered. On the other hand, the staff members are well aware of the hospital environment and are at a better position to gauge the risk of fall and thus interfering with the data.
• Studies that evaluated the risk assessment among the elderly without interventions are excluded. These articles only provided the possibility of the falls which does not provide any solution for the intended study.
• Studies that are focussed on the risk of falling in adults post the hospital stay, discharge design and the post discharge at home services are excluded. The environment out of the hospital hugely differs from the hospital and the familiarity of the surrounding reduces the falls.
• Systematic reviews, meta-analysis of various interventions is excluded.
• Case study observations of single patient are excluded. The factors responsible for the falls significantly vary for each and every patient and a single case study does not support all the details or the prevention methods need a larger population to check for their efficiency.
• Qualitative studies conveying the outcome of an intervention group were excluded as they did not provide concrete evidence and the results may be provided from the perspective of the individual recording the observation.
• Quantitative studies only supported by graphical representation were excluded.
• Studies conducted in nursing homes, rehabilitation centres and care facilities were excluded.
• Studies with the patients suffering from the mental health disorders, Parkinson’s disease, dementia and end of life stage illness were excluded. With these ailments the individuals are often prone to loss of memory of their surroundings leading to relatively higher number of fall-related injuries.
• Participants with recorded previous falls and those who have previously attended fall prevention programme were excluded.

Discussion:

Beyond Socks, Signs, and Alarms: A Reflective Accountability Model for Fall Prevention (Hoke and Guarracino, 2016)

This study was conducted by clinical nurses in the Hospital of University of Pennsylvania and found the close connection between the patient falls and unassisted incidents. The purpose of the program is to reduce the number of falls through the inculcation of accountability of every fall of a patient under a nurse. Initial studies provided an insight into the imported turnover and overall satisfaction of the patients with an display of accountability in nurses (Ethridge, 1987) A reflective email is issued to every nurse post fall to reflect on the incident and to identify the problem areas, critically analyse and consult the patient, other staff members regarding the alternative care options to prevent the fall. These measures were further developed with addition of fall-safe strategies in place. Majority of the reflection reflected the need to assisted the patients to toilet. The novice nurse extract maximum benefits through the reflective method(Kim et al., 2018) Another initiative call bell response is to train the patients to use the call bell before moving from the bed and thereby alerting the available nurse within a minute’s time. The results displayed a rapid decline in the number of falls from 3.9 per 1000 patient days to 1.39 falls thus indicating the reliability of this approach.

Patient Education to Prevent Falls Among Older Hospital Inpatients (Haines et al., 2011)

This study conducted by Hines et al. is a randomised control study with 3 groups with a total number of 1200 of participants. The average age of the older participants 65 years. These patients are admitted in to orthopaedic, respiratory and rehabilitation departments into a Swan Districts hospital in Perth Australia. This program compared the outcome of video-based instructions that mentioned the cause of falls, spots or areas where there are major risks of falls and the prevention measures including the holding the railings, posture while getting up etc., Visual instructions are more effective and are easy to follow even with the individuals belonging to diverse groups and cognitive impairment (Najafi et al., 2017). The physiotherapy program was conducted at their bed side to aid the free movement and reduce the restriction in the mobility. Physiotherapy strengthens the muscles and improves the circulation and alleviates the stiffness in joints (Calthorpe et al., 2014) The groups included the control individuals with intervention, test group one with professional health training and the second group only received the materials and video instruction without any professional training.

The data was collected in a single blind manner where the research assistants are randomly allocated the patients to record the data. Results conveyed a significant reduction in the number of falls among those who have received the instructions and professional training. However, the individuals with reported cognitive impairment did not fare well whereas the cognitively intact individuals showed positive results with only 4.0 falls per 1000 patient days in comparison to 8.1 falls per 1000 patient days. Cognitive decline is associated with low retention of information and poor understanding (Glisky) The ethical approval of the participants was collected and were assured that their personal information and the clinical information was kept confidential.

Reducing medical-surgical inpatient falls and injuries with videos, icons and alarms (Cuttler et al., 2017)

Fall Prevention programmes in acute care hospitals help in screening the patients who are at high risk of falls. Fear of falling is observed in many patients due to a lack of clarity of their immediate physical surroundings (Rajagopalan et al., 2017). There are numerous studies suggesting the improvement in the falls through interventions involving increasing patient awareness and exit bed alarms.

The patients were shown a 4-minute video on the measures to be taken while getting out of the bed to eliminate the risks of falling. The video involved the guidance from nursing staff, physicians. The hospital setting involved usage of icons on the bed for a quick identification. Patients were provided with one to one assistance by the research assistance. The falls were recorded under three categories as the without injury, with minor to moderate injury and severe injury. The number of falls were calculated for 1000 patient days

An introduction in the three-mode bed alarm system showed a steady decline at least by 20% in the rates of fall beyond the year 2010. The results in this study hold a promising future for the application of bed exit alarms.

REFINE (Reducing Falls in In-patient Elderly) - a randomised controlled trial (Vass et al., 2009)

The usage of pressure sensor in sensing the movements of the patients that are vulnerable to falls is the hypothesis that is tested in the study. Study is carried out in an acute care hospital setting on the population that are highly prone to falls and would receive highest physical and economical benefit out of this intervention in the form of reduced length of hospital stay (Galbraith et al., 2011). This is a randomised controlled double blinded trial at Nottingham University Hospital. The ethical consent was received form the individuals that are cognitively intact and the ones experiencing delirium they are received from caregivers (Ecarnot et al., 2017).
Pressure sensors are highly sensitive to slightest change in the pressure and are relevant (Subermaniam et al., 2017) in geriatric population The pressure sensor is placed in between the mattress and the bed and is activated. The foam envelop protects it from the damage. The moment the patient shifts in their position a radio signal is sent to the nursing staff and thereby providing the window to reach the patient to ensure safety. This sensor paging system showed a promising 30% reduction in the bed side falls in the hospital among the group with intervention with a base 8.0 fall rate per 1000 days. REFINE study is one of the cost-efficient methods used for fall prevention program.

The Royal College of Physicians’ Fall safe care bundles applied trust wide: the Northumbria experience 2013 (Richardson et al., 2015)

This study is carried out as a part of restructuring the clinical practise with an intent of prevention of falls in old and vulnerable population at Northumbria Healthcare NHS Foundation Trust (NHFCT)
general hospitals with a capacity of 1,048 beds. The set of preventive measure are grouped under care bundles in this programme. Currently the general and the old and vulnerable population care bundle interventions are being discussed.

They include the primary audit of history of falls or high risk of falls for a patient is recorded, night sedation prescriptions are avoided to avoid the patients from feeling dizziness during the night wakes, the foot wear are changed to the ones with better grip on the floor and thus stabilizing the patient, a call bell is attached near the bed to call for assistance while they need to visit a doctor, bathroom etc., Any modification to the surroundings of the patient with an improved access may contribute positively towards prevention of falls (Pynoos et al., 2010)The individuals those use spectacles are placed safely on the side table to provide easy access . The aids that help in movement in the vulnerable patients are placed right beside the bed and a quick cognitive, delirium and visual impairment assessment is conducted.

Falls data was collected for 1000 ed days and a total of 3276 episodes were recorded over 9-month period. There is a 6% reduction in the falls which promotes the idea that the care bundles criteria can be implemented by diverse wards and departments.

Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients (Shorr et al., 2012)

This study conducted by Shorr et al. in Methodist University Hospital, Tennessee with a 350 bed size. Fall rates were reported for a period of 12 months. This is a double blinded trial with both the nurse and the patients were not informed about the details of the trial. The ethical approval was collected from the hospital management where the informed consent has been ruled out. The intervention used in this study involved the usage of the bed alarm system placed below the patient and is pressure sensitive. Any sudden movement or loss of contact with the alarm device starts the alarm to alert the nursing staff and caregivers to cater to the patients. There are many modes available such as bed mode, chair mode in this device to adjust based on the kind of position the patient is present in. The intention was to approach the patient from the moment of their attempt to move from their seated locations to prevent the falls. The falls despite the alarm were recorded according to the severity and outcome of the fall as mild, moderate and severe.

The control group during the baseline period a total of 5.76 falls were recorded for 1000 patient days whereas the group that used the alarms as intervention recorded 5.11 fall per 1000 patient days which conveyed no statistical significance. The alarms are standardised to alert at any given movement without complete exit of the patient sometimes causing great inconvenience to the other patients(Jones, 2014)

Conclusion:

Falls affect patients and caregivers differently. Patients are subjected to excruciating pain and physical discomfort, while their caregivers face emotional and economic burden. On the other hand, the hospital staff are retained in the service of these individuals leading to the shortage of hospital staff and other facilities like patient beds. Falls complicate the ailments which further increases the complexity of treatment. (Galbraith et al., 2011). Thus, fall prevention is a priority with many benefits for all the individuals. All the studies mentioned above were conducted towards different ethnic groups and observed to be with similar outcomes. The interventions of usage of bed-side alarms, pressure sensor system and self-reflective studies all showed positive results with a decline in the fall rate of inpatients except for one study which did not show a significant difference in the control and the intervention group (Lee et al., 2013)

Implications for practice:

In the practise of a registered nurse the reduction in the total number of falls is one of the major goals in the inpatient wards. The research conducted so far on the falls, promotes the significance of fall related injuries and their prevention methods in the older patients and may be incorporated in to the objectives of hospital policies. The initiatives adopted in the hospitals include the importance of assisting the patient at all times especially during the visits to bathroom and other troublesome areas.

Usage of bells, bed alarms and pressure sensor systems are cost effective and are user friendly which does not require the nurse to be equipped with the technology and are easily accommodated into the regular hospital settings without many alterations to the surroundings. Open communication and self-reflection is viewed as a tool to improve the quality of care rather than the assessment method by the nursing staff. Allowing the patients and nurse to play active role which promotes the communication and coordination with long term benefits.

However, further information on the effects of long-term usage of the bells and alarms which might cause trouble and nuisance among the patients that are confused due to their mental health status would be helpful in determining the side effects of an intervention. The information regarding rechargeable batteries of the sensor systems and the rate of false alarms should be mentioned. Another important aspect is to provide further research on the accountability as the responsibility and care of the patient is a collective effort of the health agency and the staff (Aveling et al., 2016).

The potential barrier to the practise in acute care setting, patient compliance, volunteering patients in numbers the studies and limitations of the study should be mentioned.(Dellinger, 2017)

References:

AVELING, E.-L., PARKER, M. & DIXON-WOODS, M. 2016. What is the role of individual accountability in patient safety? A multi-site ethnographic study. Sociology of health & illness, 38, 216-232.

CALTHORPE, S., BARBER, E. A., HOLLAND, A. E., KIMMEL, L., WEBB, M. J., HODGSON, C. & GRUEN, R. L. 2014. An intensive physiotherapy program improves mobility for trauma patients. J Trauma Acute Care Surg, 76, 101-6.

CUEVAS-TRISAN, R. 2017. Balance Problems and Fall Risks in the Elderly. Phys Med Rehabil Clin N Am, 28, 727-737.

CUTTLER, S. J., BARR-WALKER, J. & CUTTLER, L. 2017. Reducing medical-surgical inpatient falls and injuries with videos, icons and alarms. BMJ open quality, 6, e000119.

DELLINGER, A. 2017. Older Adult Falls: Effective Approaches to Prevention. Current trauma reports, 3, 118-123.

ECARNOT, F., QUENOT, J.-P., BESCH, G. & PITON, G. 2017. Ethical challenges involved in obtaining consent for research from patients hospitalized in the intensive care unit. Annals of translational medicine, 5, S41-S41.

ETHRIDGE, P. 1987. Nurse accountability program improves satisfaction, turnover. Health Prog, 68, 44-9.

GALBRAITH, J. G., BUTLER, J. S., MEMON, A. R., DOLAN, M. A. & HARTY, J. A. 2011. Cost analysis of a falls-prevention program in an orthopaedic setting. Clinical orthopaedics and related research, 469, 3462-3468.

GLISKY, E. L. Changes in cognitive funcion in human aging, 2007. URL http://www. ncbi. nlm. nih. gov/books/NBK3885.

HAINES, T. P., HILL, A.-M., HILL, K. D., MCPHAIL, S., OLIVER, D., BRAUER, S., HOFFMANN, T. & BEER, C. 2011. Patient education to prevent falls among older hospital inpatients: a randomized controlled trial. Archives of internal medicine, 171, 516-524.

HOKE, L. M. & GUARRACINO, D. 2016. Beyond socks, signs, and alarms: a reflective accountability model for fall prevention. AJN The American Journal of Nursing, 116, 42-47.

JONES, K. 2014. Alarm fatigue a top patient safety hazard. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 186, 178-178.

KIM, Y. H., MIN, J., KIM, S. H. & SHIN, S. 2018. Effects of a work-based critical reflection program for novice nurses. BMC medical education, 18, 30-30.

LEE, A., LEE, K.-W. & KHANG, P. 2013. Preventing falls in the geriatric population. The Permanente journal, 17, 37-39.

MAZUR, K., WILCZYŃSKI, K. & SZEWIECZEK, J. 2016. Geriatric falls in the context of a hospital fall prevention program: delirium, low body mass index, and other risk factors. Clinical interventions in aging, 11, 1253-1261.

MORRIS, R. & O'RIORDAN, S. 2017. Prevention of falls in hospital. Clinical medicine (London, England), 17, 360-362.

NAJAFI, Z., BARGHI, M., KOOSHYAR, H., KARIMI-MOUNAGHI, H. & RODI, M. Z. 2017. A Comparison of the Effect of Education through Video versus Demonstration on Fear of Falling in Nursing Home Residents of Mashhad, Iran. Iranian journal of nursing and midwifery research, 22, 195-200.

PYNOOS, J., STEINMAN, B. A. & NGUYEN, A. Q. D. 2010. Environmental assessment and modification as fall-prevention strategies for older adults. Clinics in geriatric medicine, 26, 633-644.

RAJAGOPALAN, R., LITVAN, I. & JUNG, T.-P. 2017. Fall Prediction and Prevention Systems: Recent Trends, Challenges, and Future Research Directions. Sensors (Basel, Switzerland), 17, 2509.

REID, J., BRIGGS, J., CARLISLE, S., SCOTT, D. & LEWIS, C. 2017. Enhancing utility and understanding of evidence based practice through undergraduate nurse education. BMC nursing, 16, 58-58.

RICHARDSON, D. A., BHAGWAT, A., FORSTER, K., HIBBERT, R., ROBERTSON, L., WHITELAW, P., MCARDLE, A. & THOMPSON, E. 2015. The Royal College of Physicians’ Fallsafe care bundles applied trustwide: the Northumbria experience 2013. Clinical Medicine, 15, 530-535.

SHORR, R. I., CHANDLER, A. M., MION, L. C., WATERS, T. M., LIU, M., DANIELS, M. J., KESSLER, L. A. & MILLER, S. T. 2012. Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial. Annals of internal medicine, 157, 692-699.

SUBERMANIAM, K., WELFRED, R., SUBRAMANIAN, P., CHINNA, K., IBRAHIM, F., MOHKTAR, M. S. & TAN, M. P. 2017. The Effectiveness of a Wireless Modular Bed Absence Sensor Device for Fall Prevention among Older Inpatients. Frontiers in public health, 4, 292-292.

VASS, C. D., SAHOTA, O., DRUMMOND, A., KENDRICK, D., GLADMAN, J., SACH, T., AVIS, M. & GRAINGE, M. 2009. REFINE (Reducing Falls in In-patient Elderly)-a randomised controlled trial. Trials, 10, 83.