Risk Factors and Risk

Postoperative Patient Falls

Hospitalized patient falls affect health in huge way as they directly affect safety of patients as well as the concern for the quality of healthcare public health facilities around the world provide to patients. While limited data and information is available concerning inpatient falls following patients going on surgery, falls among hospitalized patients have been extensively studies. Falls is one of the major causes of morbidity like lacerations, closed head injuries and fractures among patients (Vhurch et al., 2011).

It has been shown that fall measurements determine patient outcomes since falls are often reported as adverse events in hospitals among the adult patient population. Falls make up a big part of the problems plaguing the health sector globally. Of all the adverse events in a hospital setting, falls is one of the most significant with nearly 3-20% of inpatients experiencing a fall at least once over the time they are hospitalized. Of these falls, 30 to 51% cause injuries (Quigly & White, 2003). 6% to 44% of the injuries are similarly classed (e.g. subdural hematomas, excessive bleeding, fracture) and may cause death. It therefore goes that reducing the number of falls and improving patient care quality is a goal of most governments and health care workers the world over.

Quality and Safety Education for Nurses (QSEN) Competencies

Quality and Safety Education for Nurses (QSEN), as an organization, has the goal of meeting the challenge of equipping future nurses with the knowledge, attitudes and skills needed to constantly better the safety and quality of healthcare services and systems where they work. The safety and quality skills and competencies earmarked to be imparted on nurses include: safety, informatics, teamwork, collaboration, patient-centered care and evidence-based practice (Dolansky & Moore, 2013; Cronenwett et al., 2007). As far as patient falls is concerned, the key competencies are safety, team work, collaboration, quality improvement and patient-centered care.

Case Study

A 62-year-old patient who had gone through dialysis and went back home, was having feelings of lightheadedness as he climbed the stairs in his home. He then fell face forward on the concrete. On calling 911, medics arrived and he was taken for evaluation at the ER. He ended up being admitted in a medical surgical unit on September 15, 2015. He told the medics that he was experiencing great pain on the lower right extremities. When X-rays were done, they revealed a right femoral neck fracture. The patient has complained before that on getting a dialysis, he often experiences feeling of dizziness. He had had other falls in the past due to the dizziness. On September 18, 2015 a total arthroplasty on the right hip was done and the patient fell down on September 19, 2015. It was noted that the pain being experienced by the patient was 8/10 on the numeric scale. My observation leads me to believe that the patient is indeed prone to fall risk but there weren't any fall prevention measures and protocols put in place to prevent further falls. Signs were lacking on the floor mat, bed alarms, alert wristband and the door.

Relation of problem to QSEN competency and KSAs

Safety

The knowledge required involves an examination of human factors and various other principles plus commonly applied but unsafe way of doing things like unclear abbreviations and work-arounds. The skills needed comprise of the ability to competently use standard practices and technology in ensuring patient safety. Lastly, attitudes deal with valuing the importance of standardization in ensuring safety

Patient-Centered Care:

The knowledge required involves integration of various facts of patient centered care like care integration and coordination, education, communication and information, provision of emotional and physical support, getting friends and family actively involved and providing a smooth transition to normalcy. The skills needed involve an ability to communicate the patient's values and preferences to other professionals while the requisite attitudes involve having a good understanding of the importance of seeking healthcare situations from the patient's point-of-view as well as respecting and encouraging self-expression of preferences, needs and values.

Quality Improvement:

Knowledge required involves an ability to describe and define the strategies to be used in learning more about patient outcomes and being able to identify and decode commonly applied but unsafe ways of doing things like unclear abbreviations and work-arounds. The health care provider should possess the skills necessary in looking for information that can help in improving healthcare quality. They should also be able to competently use standard practices and technology in ensuring patient safety. As far attitudes go, they should be able to appreciate the importance of continuous and consistent quality improvement efforts and value the importance of standardization in ensuring safety.

Teamwork and Collaboration:

Knowledge required involves knowing team members' roles and the scope of such roles as well as the contributions made by other people to advance the common agenda. Skills needed include an ability to communicate effectively with team members. They should have an attitude that values contribution at both inter- and intra-professional levels.

Review of literature: annotated bibliography

Finn, D. M., Agarwal, R. R., Ilfeld, B. M., Madison, S. J., Ball, S. T., Ferguson, E. J., &... Morris, B. A. (2016). Fall Risk Associated with Continuous Peripheral Nerve Blocks Following Knee and Hip Arthroplasty. MEDSURG Nursing, 25(1), 25.

The goal of the study was to ascertain a connection between the use of CPNB (continuous peripheral nerve block) and falls in hospitals among patients undergoing total knee arthroplasty (TKA) or THA, particularly if there is an increase in the risk of falls that comes with (CPNB). The study was carried out at a big medical facility in Southern California. The fall rates recorded for the period between 2003 and 2005 after TKA/THA were compared to the rates between 2007 and 2010 after a CPNB program had been implemented. The primary or main end point was the percentage of patients that had been through THA or TKA and later fell after and before the routine use of CPNB. Secondary end points covered comparisons between the hospital-wide falls and those falls that occurred after THA and TKA. The Results obtained from the study point to a certain connection between risk of falls and CPNB among patients who are on general orthopedic units after a knee or hip orthoplasty. When a CPNB program was implemented at the medical facility where the study was carried out, there was a significant increase in falls among knee and hip arthoplasty patients. Most of the falls took place while these patients were unattended. The findings show that there is need for more and better patient education, organizational monitoring, as well as. physicians and nurses being more vigilant.

Vitor, A.F., Moura, L.A., Fernandes, A.P., Botarelli, F.R., Araujo, J.N. & Vitorino, I.C. (2015). Risk for Falls in Patients in The Postoperative Period, Cogitare Enferm. 20(1):29-37.

The aim of the study was identifying fall risk as well as the major risk factors postoperative phase patients face while in the hospital. The study was cross-sectional and descriptive and used quantitative approaches. It was designed in a public tertiary teaching hospital found in the Municipality of Natal/Rio Grande do Norte, Brazil. Criteria used for sample exclusion was: to present emergency life threatening situations during data collection. The researches performed statistical analysis as per descriptive and associative statistics principles, obtained means, frequencies, confidence intervals and standard deviations. They also applied Kolmogorov-Smirnov test to help them find out the findings' normality. The risk of falls ND was found to be in 69 of the participating patients which accounted for 86.25%. By characterizing Risk for falls ND among the postoperative patients, it was found that the major risk factors are postoperative condition, narcotics or opiate use, fall history, and using medication meant to control hypertension. Since the factors were very diverse among the postoperative phase patients, it is important that they be detected early so that preventive action can be taken swiftly to reduce any risks.

Ikutomo, H., Nagai, K., Nakagawa, N., & Masuhara, K. (2015). Falls in patients after total hip arthroplasty in Japan. Journal of Orthopaedic Science: Official Journal of the Japanese Orthopaedic Association, 20(4), 663-668. doi:10.1007/s00776-015-0715-7

This study's aim was investigating the circumstances and incidences surrounding such falls and identify any factors that may have contributed to the patients falls. A self administered questionnaire was used to conduct the investigation and the circumstances as well as conditions surrounding the fall were studied. The authors also noted the functional score as well as ambulatory ability based on the Oxford Hip Score. The factors that influence the falls were analyzed using the multivariate logistic regression analysis. The main causation to the fall was tied mainly to the medication they were on as well as postoperative duration. It therefore points to a possibility where patients are more at risk of falling and sustaining injuries from falls following THA. The connection with postoperative duration and medication means that it is necessary that falls are actively prevented among those who've been through TSA, especially in the early stages where medication is still being administered.

Johnson, R. L., Kopp, S. L., Hebl, J. R., Erwin, P. J. and Mantilla, C. B. (2013). Falls and major orthopaedic surgery with peripheral nerve blockade: a systematic review and meta-analysis, Br. J. Anaesth. doi: 10.1093/bja/aet013

This study's objective was determining the risk for falls following orthopedic surgery for the serious condition of peripheral nerve blockade. The study employed independent reviewers who extracted outcomes data, validity and characteristics of the studies. Each of the studies was subjected to Peto Odds ratio with 95% confidence interval that drew comparisons between continuous lumbar plexus blockade and non-continuous blockade or lack of blockade by utilizing fixed effects model. Ten of the studies (covering 4014 patients) looked into the number of falls as an outcome. Comparison groups were absent in five of the studies. Meta-analyzing five studies drew comparisons between lumbar plexus blockade covering 631 patients and non-continuous blockade or no blockade covering 964 patients. There were fourteen falls among the non-continuous block and 5 five among the non-continuous block or no block. Risk of falls was found to significantly increase with continuous lumbar plexus (Peto OR 3.85; 95% CI (1.52, 9.72); P=0.005; I2= 0%). Evidence ranged from weak to strong. Continuous lumbar plexus blockade among adult patients undergoing major lower extremity orthopedic surgery does increase postoperative fall risk significantly more than non-continuous blockade or no blockade. Nonetheless, attributable risk still fell inside expected probability of orthopedic surgery postoperative falls.

Ackerman, D.B., Trousdale, R.T., Bieber, P., Henely, J., Pagnano, M.W. & Berry, D.J. (2010). Postoperative patient falls on an orthopedic inpatient unit. J Arthrop. 25(1):10 -- 14. doi:10.1016/j.arth.2008.09.025

The study's purpose was identifying risk factors for falls among inpatients on a specific postoperative orthopedic unit with the objective of providing insights to aid future design and building of fall prevention programs specifically tailored to postoperative orthopedic inpatients. The unit was in Rochester, MN and had 50 beds. Seventy-one percent of those studied underwent revision or primary knee and hip arthoplasty over the period of study. Characteristics and nature of falls were described using summary statistics, frequency distributions, count percentage and averages. The likelihood of falls in connection with linked risk factors was evaluated using univariate regression models. Seventy patients, representing 1%, fell amounting to 2.5 falls for every 1000 musculoskeletal inpatient days. A majority of the falls (n=45, 64%) were related to bathroom activities, not assisted (n=54, 77%), and took place at night or in the evening (n=46, 66%). 13 patients (19%) were injured. The odds ratio for females was 1.9, while the odds ratios for age older than 65, prolonged admission, and admission on the grounds of revision of primary knee arthroplasty were 1.7, 1.7 and 5.0 respectively. All these are risk factors are found to be significant. The study's results revealed that patient characteristics and activities might have contributed to the falls in the unit. A majority of the falls took place when the patients had no assistance. This means that the number of falls can be reduced if efforts are directed appropriately.

Nursing implications

Practice

No strong evidence was found to support a falls prevention exercise program as a standalone intervention. One component of the larger multifaceted RCT project examined the effectiveness of an exercise program which comprises tai chi, functional movements and activity visualization. An intervention group received exercise sessions delivered weekly to a group of up to patients. Exercises were made up of a combination of tai chi mixed with functional movements and activity visualization. The control group received usual care which included nursing care, a falls risk screen, regular medical review, physiotherapy, OT sessions, podiatry, dietetics, social work and speech pathology (Johnson et al., 2013; Ackerman et al., 2010). Physiotherapy and OT sessions were for one hour each and delivered five times per week. Intervention group members also received usual care. A significant reduction in the incidence of falls was seen in those undergoing the exercise program compared with controls.

Nursing practice to deal with patient falls should be tailored to the organization. The program is more likely to be successfully implemented and sustained when it is compatible with hospital priorities and what is best for the patient. The hospital's first priority is acute medical care; patients come to the hospital because they are ill and their primary purpose is to receive treatment for their illness. The goal of patient safety practices like fall prevention is to prevent additional harm to patients while they are hospitalized (Mandl et al., 2013). Another key point to remember is that fall prevention alone cannot be the goal of a fall prevention program.

Education

Education has a key role to detect and refer, intervene, and create new strategies for those at risk of developing cognitive impairment. As health educators, nurses can talk to patients, family members, and communities about ways to promote successful cognitive aging. Preventive health strategies to recommend include avoiding substance use, exercising, and eating well, as well as staying cognitively viable through educational pursuits, physically stimulating activities, and cognitive remediation therapy. A point to stress regarding physical health stimulation is that such activities must be novel and not too strenuous. Novelty encourages neural plasticity, which results in maintaining or improving stability and cognitive and reserve. The physical stimulation must make participants' "muscle sweat" -- a corollary to physical exercise (Ikutomo et al., 2015; Johnson et al., 2013). Nurses should encourage patients to use a variety of cognitive strategies; relying on the same type of stimulation, such as walks, is not physically stannous if this is the only type of physical exercise in which one engages.