Factors associated with falls during hospitalization in an older adult population.

BACKGROUND: Falls of hospitalized older adults are of concern for patients, family members, third-party payers, and caregivers. Falls are the most common safety incident among hospitalized patients with fall rates from 2.9-13 per 1,000 patient days. Little effectiveness research has been conducted on nursing interventions and other variables associated with falls of older adults during hospitalization. PURPOSE: The purpose of this exploratory outcomes effectiveness study was to examine variables associated with falls during hospitalization of older adults. METHOD: An effectiveness research model composed of patient characteristics, clinical conditions, nursing unit characteristics, medical, pharmacy, and nursing interventions was tested using generalized estimating equations (GEE) analysis. The sample consisted of 10,187 hospitalizations of 7,851 patients, aged 60 or older, admitted for acute care services over a 4-year period. Those included in the sample either had received the Nursing Interventions Classification (NIC) intervention of Fall Prevention (defined as "instituting special precautions with patient at risk for injury from falling" [Dochterman & Bulechek, 2004, p. 363]) or were at risk for falling as defined by a fall risk assessment scale. Data were obtained retrospectively from 9 clinical and administrative data repositories from 1 tertiary care hospital. DISCUSSION: Variables that were positively associated with falls, after controlling for other variables in the model, included several medical and nursing treatments; several types of medications including antidepressants, benzodiazepines, antipsychotic, and psychotropic agents; and several types of nursing treatments including restraints and neurologic monitoring (at low use rates of < 2 times a day). Variables inversely associated with falls included registered nurse (RN) skill mix, pressure ulcer care, pain management, and tube care. CONCLUSIONS: The study demonstrates the importance of conducting interdisciplinary effectiveness research that includes nursing care. Most of the variables associated with falls were interventions (medical, pharmacy, and nursing). Dose of nursing treatments and RN skill mix were also associated with falls.

Cognitive work analysis to evaluate the problem of patient falls in an inpatient setting.

OBJECTIVE: To identify factors in the nursing work domain that contribute to the problem of inpatient falls, aside from patient risk, using cognitive work analysis. DESIGN: A mix of qualitative and quantitative methods were used to identify work constraints imposed on nurses, which may underlie patient falls. MEASUREMENTS: Data collection was done on a neurology unit staffed by 27 registered nurses and utilized field observations, focus groups, time-motion studies and written surveys (AHRQ Hospital Survey on Patient Culture, NASA-TLX, and custom Nursing Knowledge of Fall Prevention Subscale). RESULTS: Four major constraints were identified that inhibit nurses' ability to prevent patient falls. All constraints relate to work processes and the physical work environment, opposed to safety culture or nursing knowledge, as currently emphasized. The constraints were: cognitive 'head data', temporal workload, inconsistencies in written and verbal transfer of patient data, and limitations in the physical environment. To deal with these constraints, the nurses tend to employ four workarounds: written and mental chunking schemas, bed alarms, informal querying of the previous care nurse, and informal video and audio surveillance. These workarounds reflect systemic design flaws and may only be minimally effective in decreasing risk to patients. CONCLUSION: Cognitive engineering techniques helped identify seemingly hidden constraints in the work domain that impact the problem of patient falls. System redesign strategies aimed at improving work processes and environmental limitations hold promise for decreasing the incidence of falls in inpatient nursing units.

The effects of hospitalization on multiple units.

Patients are often cared for on multiple units during the course of a hospitalization. This study used general linear modeling and logistic regression analyses to demonstrate the effect of hospitalization on multiple units upon selected nursing treatments, resource use, and clinical outcomes. Primary medical diagnosis, comorbid medical conditions, and severity of illness were controlled for in the analyses. A significant association was found between hospitalizations on multiple units and selected nursing treatments, resource use, and all clinical outcomes except for mortality. Nurses play a central role in coordinating the care that patients receive across inpatient units and are positioned to develop and implement strategies to mediate the negative impacts associated with patients moving across multiple units.