Description and Implications of Falls in Patients Hospitalized Due to COVID-19.

BACKGROUND: Many hospital quality indicators, including falls, worsened during the COVID-19 pandemic. Patients hospitalized with COVID-19 may be at risk for falling due to the disease itself, patient characteristics, or aspects of care delivery. PURPOSE: To describe and explore falls in patients hospitalized with COVID-19. METHODS: We pooled data from 107 hospitalized adult patients who fell between March 2020 and April 2021. Patients who fell had a current, pending, or recent diagnosis of COVID-19. We analyzed patient characteristics, fall circumstances, and patient and organizational contributing factors using frequencies, the chi-square test, and Fisher's exact test. RESULTS: Patient contributing factors included patients' lack of safety awareness, impaired physical function, and respiratory concerns. Organizational contributing factors related to staff and the isolation environment. CONCLUSIONS: Recommendations for managing fall risk in patients hospitalized with COVID-19 include frequent reassessment of risk, consideration of respiratory function as a risk factor, ongoing patient education, assisted mobility, and adequate staff training.

Impact of Patient-Engaged Video Surveillance on Nursing Workforce Safety: Patient Aggression/Violence.

BACKGROUND: Health care workers are 4 times more likely to suffer violence than workers in other industries. PURPOSE: The aim was to examine types of patients' verbal/physical abuse against the nursing workforce observed through patient-engaged video surveillance (PEVS) and interventions initiated by monitor technicians. METHODS: A descriptive study was conducted to analyze all types of patient-initiated abuse, physical and verbal, reported from 73 hospitals and patient response to PEVS. RESULTS: Of 150 434 patients whom RNs enrolled into 24-hour PEVS, 5034 patients (3%) were identified by RNs as at risk for aggressive/violent behavior as their primary or secondary reason for PEVS enrollment, and 32 (0.60%) patients exhibited such behavior. A total of 221 patients demonstrated aggressive/violent behaviors, 32 (15%) were identified as at risk, and 189 (85%) were not. However, 5002 (99%; 5002/5034) of the patients identified as a risk for aggressive/violent behaviors did not exhibit these behaviors. CONCLUSIONS: Patient-engaged video surveillance is an effective method to track and trend patient aggression toward nursing staff, increasing patient and nursing workforce safety. Because 99% of the patients who exhibited aggressive/violent behavior were not identified by RNs as at risk, organizations should consider adding violence risk tools as part of patients' admission assessment.

Clinical Risk Factors for Orthostatic Hypotension: Results Among Elderly Fallers in Long-Term Care.

BACKGROUND: Patients at greatest risk for fall-related injuries are older adults with orthostatic hypotension (OH), a condition which drops blood pressure. This study sought to determine salient demographic and patient-level factors increasing risk for OH among a sample of elderly fallers. METHODS: Data analysis for this retrospective study sought to assess the relationship between various demographic and clinical risk factors and the likelihood of OH. Because fallers could experience multiple falls, generalized estimating equations were used to account for patient-level correlations. RESULTS: One hundred seventeen falls occurred in 47 patients, who were primarily female with a mean age of 90.7 years. Falls resulted in 18 cases of OH. Orthostatic hypotension cases were less likely to have a gait in a steady line (5.6% vs 55.6%, P = 0.001). Patients with decreased muscular coordination were almost 5 times more likely to experience OH than those with no coordination problems (odds ratio = 4.86, P = 0.02). Patients with gait in a steady line were less likely to experience OH after a fall (OR = 0.06, P = 0.006). CONCLUSIONS: Orthostatic hypotension is potentially modifiable once detected. Evidenced-based protocol for assessment and management of OH among patients with gait and balance impairment is presented.

Collecting Validity Evidence: A Hands-on Workshop for Medical Education Assessment Instruments.

Introduction: There is an increasing call for developing validity evidence in medical education assessment. The literature lacks a practical resource regarding an actual development process. Our workshop teaches how to apply principles of validity evidence to existing assessment instruments and how to develop new instruments that will yield valid data. Methods: The literature, consensus findings of curricula and content experts, and principles of adult learning guided the content and methodology of the workshop. The workshop underwent stringent peer review prior to presentation at one international and three national academic conferences. In the interactive workshop, selected domains of validity evidence were taught with sequential cycles of didactics, demonstration, and deliberate practice with facilitated feedback. An exercise guide steered participants through a stepwise approach. Using Likert-scale items and open-response questions, an evaluation form rated the workshop's effectiveness, captured details of how learners reached the objectives, and determined participants' plans for future work. Results: The workshop demonstrated generalizability with successful implementation in diverse settings. Sixty-five learners, the majority being clinician-educators, completed evaluations. Learners rated the workshop favorably for each prompt. Qualitative comments corroborated the workshop's effectiveness. The active application and facilitated feedback components allowed learners to reflect in real time as to how they were meeting a particular objective. Discussion: This feasible and practical educational intervention fills a literature gap by showing the medical educator how to apply validity evidence to both existing and in-development assessment instruments. Thus, it holds the potential to significantly impact learner and, subsequently, patient outcomes.

Outcomes of Patient-Engaged Video Surveillance on Falls and Other Adverse Events.

Patient-engaged video surveillance implemented in 71 hospitals over 1 year revealed low rates in assisted and unassisted falls, room elopement, and line, tube, or drain dislodgement per 1000 days of surveillance. Monitor technicians interacted 20.5 times per day with patients who fell and initiated alarms for urgent unit staff response 2.38 times per day, and this accounted for the low fall rate (1.50 falls/1000 days of surveillance) in an adult population. Data on adverse events and timeliness of nursing response to actual urgent and emergent patient conditions provides evidence of the rapid contribution of patient-engaged video surveillance to patient safety.

Medical Student Participation in Patient- and Family-Centered Rounding: A National Survey of Pediatric Clerkships.

OBJECTIVE: Pediatrics rotations may be medical students' only experience with patient- and family-centered rounding (PFCR). It is unclear how students participate in or are prepared for PFCR. We surveyed national pediatrics clerkships to determine the prevalence of PFCR and the proportion providing orientation in order to inform a needs assessment for PFCR orientation. METHODS: A 5-item peer-reviewed survey was distributed to the Council on Medical Student Education in Pediatrics (COMSEP) membership as part of a larger survey in 2017. Institutional differences among programs performing PFCR were compared using chi-square and t-tests. Responses to 1 open-ended question were coded and grouped into broad categories using content analysis. RESULTS: The full COMSEP survey received answers from 190 participants representing 103 medical schools. Our questions received 174 responses representing 94 schools (98 training sites) and had an 85% (83/98) prevalence of student PFCR participation. Although most (n = 108; 85%) reported that their students received PFCR orientation, half (n = 62; 49%) considered orientation "informal," and only 2 reported using published curricula. After didactics, the most common orientation materials were handouts (n = 33; 26%), videos (n = 13; 10%), and role play (n = 7; 6%). Orientation was most commonly initiated at the start of clerkship (n = 62; 49%) by clerkship administration (n = 38; 30%), but 20% (n = 26) reported resident-led orientation. Qualitative responses (n = 98) were coded and organized into 4 themes; the greatest perceived challenges for medical students on PFCR were communication and anxiety. CONCLUSIONS: Although most students participate in and receive orientation to PFCR, there is wide variability in the content, timing, and administration of orientation. A nationally disseminated, evidence-based orientation curriculum may reduce educational variability and better prepare students for PFCR.

Innovation to Dissemination Workshop: Selecting Outcome Measures to Translate Educational Innovations Into Scholarship.

Introduction: Curricular innovations are invaluable to the improvement of medical education programs, and thus, their dissemination to broader audiences is imperative. However, medical educators often struggle to translate innovative ideas into scholarly pursuits due to a lack of experience or expertise in selecting outcome measures that demonstrate impact. A recent national call for increased focus on outcome measures for medical education research highlights the need for more training in this area. Methods: We developed a 2-hour interactive workshop to improve educator ability to identify outcome measures for educational innovations. This workshop was delivered at a national pediatrics educational conference and at three local institutional faculty development sessions. Results: Participants were diverse in terms of experience, expertise, and roles within their educational programs. Participants rated the workshop positively in each setting and identified next steps in developing their own products of educational scholarship. Discussion: This workshop can provide faculty and faculty developers with a template for developing a skill set in identifying outcome measures and pairing them with educational innovations.

Preventing Falls and Fall-Related Injuries in State Veterans Homes: Virtual Breakthrough Series Collaborative.

This article reports on improved processes and outcomes from a virtual breakthrough series quality improvement collaborative to reduce preventable falls and fall-related injuries in 23 State Veterans Homes. Participating teams implemented 24 interventions (process changes); the most common was the postfall huddle. Teams reduced falls and fall-related injuries. This project highlights the importance of leadership support, interdisciplinary team involvement, and collaboration as essential components of fall prevention work.

Characteristics of the middle-age adult inpatient fall.

PURPOSE: The purpose of this study is to describe characteristics of middle-age inpatients' (ages 45-64) fallers and their fall and fall injury risk factors. BACKGROUND: Middle-age falls were 42-46% of inpatient falls. Studies related to inpatient falls have not targeted this population. METHODS: A 439 retrospective chart review was performed. Middle-age fall and injury rates were compared with ages 21-44 and 65-90. RESULTS: The mean age was 55.75years (SD 5.26). 28.7% (n=126) of falls resulted in injury. Individual fallers (n=386) had a mean of four comorbidities (SD 1.843), including hypertension (46.5%), anxiety/depression (40.2%), and alcohol and drug abuse (32.9%). There was no significant difference (p=.637) in fall rates per 1,000 patient days between ages 45-64 and 65-90. CONCLUSION: Middle-age inpatients' acute illness makes them as vulnerable for fall and injury as the older population. They should not be overlooked for fall prevention measures.

Nursing Home Registered Nurses' and Licensed Practical Nurses' Knowledge of Causes of Falls.

Reducing falls in nursing homes requires a knowledgeable nursing workforce. To test knowledge, 8 validated vignettes representing multifactorial fall causes were administered to 47 nurses from 3 nursing homes. Although licensed practical nurses scored higher than registered nurses in individual categories of falls, when we computed the average score of all 8 categories between groups of registered nurses and licensed practical nurses, registered nurses scored higher (F = 4.106; P < .05) in identifying 8 causal reasons for older adults to fall.

Evidence Levels: Applied to Select Fall and Fall Injury Prevention Practices.

PROBLEM: Rehabilitation nurses know the impact of injury on function, independence, and quality of life, complicated by age-related changes associated with decreased strength, endurance, reserve, frailty, and social and financial resources. Multidisciplinary teams are essential to provide expert, age specific health care delivery to this vulnerable population across settings of care. PURPOSE: The purpose of this article is to apply level of evidence rating scales to identify the best practice interventions to prevent falls on rehabilitation units. KEY FINDINGS AND CLINICAL RELEVANCE: The evidence supports the importance of determining specific risk factors and initiating multifactorial fall risk factors tailored to the individual. Yet, little evidence exists for single interventions, universal fall prevention strategies, and population-specific fall prevention strategies. A review of the literature confirms the effectiveness of many fall prevention practices and interventions remains insufficient. Of particular concern are rehabilitation units in hospitals that have higher fall rates compared to other acute units.

Reducing Falls and Fall-Related Injuries in Medical-Surgical Units: One-Year Multihospital Falls Collaborative.

On the basis of fall injury program characteristics across multiple inpatient medical-surgical units from 6 medical centers, we developed and implemented an operational strategic plan to address fall and injury prevention program attributes and enhance program infrastructure and capacity. Expert faculty provided lectures and served as coaches and mentors through triweekly conference calls and collaborative e-mail exchange. Statistically significant findings support improved fall and injury prevention program components and processes at the organizational and unit levels.

A randomized controlled trial on Stroke telerehabilitation: The effects on falls self-efficacy and satisfaction with care.

We determined the effect of a multifaceted stroke telerehabilitation (STeleR) intervention on falls-related self-efficacy and satisfaction with care. We conducted a prospective, randomized, multisite, single-blinded trial in 52 veterans from three Veterans Affairs Medical Centers. Participants who experienced a stroke in the past 24 months were randomized to the STeleR intervention or usual care. Participants in the intervention arm were administered an exit interview to gather specific patient satisfaction data three months after their final outcome measure. The STeleR intervention consisted of three home visits, five telephone calls, and an in-home messaging device provided over three months to instruct patients in functionally based exercises and adaptive strategies. The outcome measures included Falls Efficacy Scale to measure fall-related self-efficacy and a Stroke-Specific Patient Satisfaction with Care (SSPSC) scale, a measure separated into two subscales (satisfaction with home care and satisfaction with hospital care) was employed to measure the participants' satisfaction. At six months, compared with the usual care group, the STeleR group showed statistically significant improvements in one of the two SSPSC scales (satisfaction with hospital care, p = .029) and approached significance in the second SSPSC scale (satisfaction with home care, p = .077). There were no improvements in fall-related self-efficacy. Core concepts identified were: (a) beneficial impact of the trained assistant; (b) exercises helpful; (c) home use of technology. The STeleR intervention improved satisfaction with care, especially as it relates to care following their experience from the hospital. With the limited resources available for in-home rehabilitation for stroke survivors, STeleR (and especially its exercise components) can be a useful complement to traditional post-stroke rehabilitation.

A qualitative understanding of patient falls in inpatient mental health units.

BACKGROUND: Falls are the leading cause of injury-related deaths among people age 65 and older, and fractures are the major category of serious injuries produced by falls. OBJECTIVE: Determine market segment-specific recommendations for "selling" falls prevention in acute inpatient psychiatry. DESIGN: Descriptive using focus groups. SETTING: One inpatient unit at a Veterans' hospital in the Southeastern United States and one national conference of psychiatric and mental health nurses. PATIENTS: A convenience sample of 22 registered nurses and advanced practice nurses, one physical therapist and two physicians participated in one of six focus groups. INTERVENTION: None. MEASUREMENTS: Focus groups were conducted by expert facilitators using a semistructured interview guide. Focus groups were recorded and transcribed. Content analysis was used to organize findings. RESULTS: Findings were grouped into fall risk assessment, clinical fall risk precautions, programmatic fall prevention, and "selling" fall prevention in psychiatry. Participants focused on falls prevention instead of fall injury prevention, were committed to reducing risk, and were receptive to learning how to improve safety. Participants recognized unique features of their patients and care settings that defined risk, and were highly motivated to work with other disciplines to keep patients safe. CONCLUSIONS: Selling fall injury prevention to staff in psychiatric settings is similar to selling fall injury prevention to staff in other health care settings. Appealing to the larger construct of patient safety will motivate staff in psychiatric settings to implement best practices and customize these to account for unique population needs characteristics.