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

Transcription

1 School of Public Health and Preventive Medicine The confused older patient: A practice audit, nurse beliefs and the epidemiology of falls and fall injuries 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? 1

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 2

3 Data collection Nurse beliefs (N=524) 12 focus group sessions (N=94) 44 item survey (N=428) Data collection 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 3

4 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 4

5 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) 70 Targeted management programs for patients with delirium and confusion are used on my ward Strongly disagree Disagree Neutral Agree Strongly agree Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 5

6 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%) 6

7 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. 7

8 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? 8

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 9

10 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 10

11 Fall injuries From the 775 falls: 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 11

12 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 12

13 Fall injuries 40% 35% 30% 25% 20% 15% 10% 5% 0% All fallers (N=557) Fall injuries 40% 35% 30% 25% 20% 15% 10% 5% 0% All fallers (N=557) Confused fallers (N=184) 13

14 How are fall injuries occurring? % of falls resulting in injury Confused fallers (N=184) All fallers (N=557) Toilet falls N=218 29% 32% Bed falls N=274 25% 28% Bathroom falls N=146 33% 32% 14

15 % of falls resulting in injury Confused fallers (N=184) All fallers (N=557) Toilet falls N=88 29% 32% Bed falls N=124 25% 28% Bathroom falls N=24 33% 32% Bed fall injuries All fallers (N=557) Confused fallers (N=184) Bed fall N=274 25% 28% Roll from low-low bed N=71 13% 17% 15

16 All fallers (N=557) Bed fall injuries Confused fallers (N=184) Bed fall N=124 25% 28% Roll from low-low bed N=38 13% 17% Low-Low beds 16

17 When are fall injuries occurring? Confused fallers (N=184) All fallers (N=557) Morning 26% 29% Evening 21% 29% Night 38% 36% NR 6% 14% When are fall injuries occurring? Confused fallers (N=184) All fallers (N=557) Morning 26% 29% Evening 21% 29% Night 38% 36% NR 6% 14% 17

18 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 18

19 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

20 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 20