VA Sunshine Healthcare Network
Patient Safety Center of Inquiry (PSCI) Research
Falls among people over 65 years of age are a major public health and economic problem. Patient falls are the most frequent adverse event with injury within the VHA (Office of the DAS for Program/Data Analysis, 2000) and are the leading cause of injury-related deaths among people age 65 and older (CDC, 2000). Fractures are the major category of serious injuries produced by falls, with 87% of all fractures in older adults caused by falls.
The two most serious fall-related injuries are hip fractures and intracranial hemorrhages. In 2000, in USA, direct medical costs of falls totaled a little over $19 billion—$179 million for fatal falls and $19 billion for nonfatal fall injuries (Stevens, Corso, Finkelstein & Miller, 2006). By 2020, more than 4 million older Americans are projected to incur a fall with injury annually, with a total cost of $47 billion when adjusted to 2010 dollars (CDC, 2000; Wu et al., 2010).
Falls are caused by a complex interaction among multiple risk factors, which are divided into intrinsic (person related, like peripheral neuropathy, arthritis, orthostasis, etc.) and extrinsic (outside of the person, like medications or environmental hazards). Falls in the hospital are associated with higher rates of morbidity and mortality in older patients, and are linked to poorer overall functioning, and early admission to long-term care facilities (Hill, Wu & Walsh, 2007).
Effective fall prevention has the potential to reduce serious fall related injuries, emergency room visits, hospitalizations, nursing home placements and functional decline (Rubenstein & Josephson, 2002; Gillespie et al., 2009). In 2008 and 2010 falls were identified as one of the top 10 sentinel event categories by the Joint Commission (Joint Commission, 2012). Fall rates in hospitals range from 4 to 14 per 1,000 patient days (Oliver, Hopper & Seed, 2000).
Among older adults , falls are the leading cause of injury death, the most common cause of nonfatal injuries and hospital admissions for trauma (CDC, 2012). According to a Cochrane review, the rate of injurious falls decreased after the introduction of population-based programs focusing on age, diagnosis of osteoporosis or history of hip fracture, and use of anticoagulation therapy.
The updated Falls Prevention Guideline from the American Geriatrics Society/British Geriatrics Society recommends a multifactorial risk assessment that drives individualized interventions to reduce falls in individuals over 65 years of age (AGS Panel, 2011; Michael et al, 2010.)
Wandering and Missing Incidents in Persons with Dementia
Wandering, a behavioral symptom of dementia, generally refers to repetitive walking or travel that is not associated with normal daily activities in terms of the times and locations that the behavior occurs. Some aspects of wandering maybe hazardous such as elopement, weight loss, fatigue, sleep disturbances, falls with injuries such as fractures, abuse from caregivers and other patients, premature institutional placement and untimely death.
In the VHA, wandering is most often reported in long term care, psychiatric units, rehabilitation units where persons with brain injuries are treated, and in the community.
Missing incidents can be life-threatening and everyone with cognitive impairment is at risk even in the most closely monitored settings. In a prospective study, nearly half of the sample of Veterans with dementia had a missing incident in a year follow-up. Most only have a single incident but some individuals do have repeated missing incidents. The missing individual is most frequented unharmed on their own property or neighborhood. However for those not found quickly, both law enforcement and good Samaritans are essential in safe recoveries.
For those missing more than 24 hours, the death rate can be as high as 50% with the most common causes of death being exposure to natural elements, drowning and vehicular accidents.
Home and Community Safety concerns include home emergencies such as fire, burns from the stove or iron, or floods. Persons with dementia (PWD) lack the cognitive skills to manage emergencies or to get out of harm’s way. Safety concerns increase for PWD who exit the home unattended, which can lead to them getting lost, injured, or even dying Many PWD experience altered sleep-wake patterns which may cause activity at night. This can lead to falls and injury caused by poor judgment, not using necessary walking aids or improper lighting. Some of the barriers to creating a safe home environment include:
-Conflicts between the care giver’s needs to accomplish daily tasks and the needs of the PWD for constant supervision, especially when there is only one care giver
-Care givers may not recognize the extent of the PWD’s cognitive impairment, leading them to minimize risks
-Care givers may be unwilling to make safety enhancing changes to the home, equating them with an institutional look or barricading the PWD in ?
-The care giver may be dependent upon the PWD as a driver.
Besides offering respite for caregivers living in the community, technologies were introduced and well received to assist with keeping the PWD safe in the community and reducing CG burden.
Safe Patient Handling and Mobility
Healthcare workers have the highest rates of nonfatal occupational injuries and illness compared to all industries; almost half of these injuries are musculoskeletal related, and most of these are related to manual patient handling and moving (BLS, 2007). The National Institute of Occupational Safety and Health (NIOSH) reported that forceful exertions, awkward postures and repetitive motions associated with patient handling tasks (e.g. lifting and moving patients), contributed to musculoskeletal injuries in nurses (NIOSH, 1997).
In the past, efforts to reduce work-related musculoskeletal injuries have relied on body mechanics classes or training in lifting techniques, both of which have been unsuccessful (Collins et al., 2004; Garg et al., 2002; Marras et al., 1999; Nelson et al., 2004; Nelson et al., 2006; Zhuang et al., 1999).
Caregiver safety and patient safety are integrally linked by organizational culture, principles, methods and tools for creating safety, yet many health care organizations continue to “silo” worker from patient safety (The Joint Commission, 2010).
Over the past decade, an evidence-based, ergonomics approach to patient handling is replacing manual patient handling (Nelson et al., 2006), resulting in both decreased patient handling-related injuries among caregivers (Collins et al., 2004; Edlich et al., 2004; Garg & Owen, 2002; Marras et al., 1999; Nelson, 2006; Zhuang et al., 1999) and improved patient outcomes. Patients are moved more frequently when caregivers have access to mechanical transfer devices, and consequently they experience less combativeness (Collins et al., 2006), decreased risk for immobility-related consequences such as pressure ulcers, falls, and urinary dysfunction (Gucer et al., 3013; Nelson et al., 2008), lower levels of depression, and higher engagement in activities (Nelson, et al. 2008).
In 2008, the VHA funded a 3-year initiative for $205 million to implement the VISN 8 PSCI SPHM program at every VA. Evaluation of the program revealed a 35% decrease in patient handling musculoskeletal injury rate among nurses. Furthermore, evidence supported a multi-component approach to SPH programs that included equipment, a broad training program and programmatic and contextual considerations (Powell-Cope et al., unpublished data).
Specifically, the facility coordinator link with safety committee, achievement of program milestones, program support from key stakeholders, and peer leader effectiveness were all associated with program success.
As with the introduction of any new programs or technology into healthcare, the potential exists for unanticipated negative consequences such as improper use of equipment and equipment failures that threaten patient safety. A series of projects have examined these issues. Previously, we surveyed VA SPHM coordinators nationwide to collect information about patient related adverse events (mainly skin and falls). Based on that project, our current projects further investigated patient safety aspects of SPHM.
We developed a Technology Resource Guide to assist those in the field with identifying the types of equipment that are available. We do not have any more information other than what is presented in the guides and suggest that you contact individual manufacturers with specific equipment questions. The current Guide can be found on the Foundation site.http://www.tampavaref.org/safe-patient-handling/implementation-tools.htm.
We also work closely with the Tampa VA Research and Education Foundation to supply cutting-edge conferences on Patient Safety go to the Foundation site.