Academic Master

Health Care

Fall Prevention in Elderly/Dementia Patients in Acute Care Setting

Impact of the Problem on the Patient

Patients’ fall has become very common as in acute care settings, they contribute to around 38% of all physical accidents and injuries which may also bring financial loss to the patient. Moreover, there are many more adverse consequences of fall when it occurs during hospitalization. About 30 to 40% of falls result in certain types of injuries including soft tissue injury, cranial trauma, and fractures. If a fall occurs in an acute care hospital, nearly 7% of patients get treatment in the orthopedic surgery ward due to hip fractures. There may be some negative psychological effects on the patients along with physical injury. The patient may develop a layer of fear in his mind or lose his confidence during specific mobility tasks. The above-mentioned factors are responsible for a long stay at the hospital and may increase the likelihood of discharge to residential care. Hence, every hospital focuses majorly on preventing falls for patients.

Impact of the Problem on the Organization

Not only patients but also other people also get affected by the fall such as health care providers, staff, and family members of the patients. These events reflect a bad image of hospitals and health care centers. Fall also contributes to increased financial burdens such as medical bills, therapies, procedures, surgeries, etc., and consequently increases the length of stay (LOS). There are few studies that show that falls can be quantified as it has the potential to increase health expenditure for a family. For example, according to an estimation by the Quality in Australian Health Care Study, $2.1 million per annum is the estimated total cost of falls in the hospital. The researchers have also studied the nature, frequency, and outcomes of adverse events which occur due to falls and significantly impact the hospital.

Therefore, falls have a lot of adverse effects on patients and organizations, and methods to deal with this problem are being focused on.

Identify the PICO components

P – Fall-prone older adults

I – Exercise

C – Excessive rest

O – Reduction in fall risk and improved physical strength

Evidence-Based Practice Question

Does exercise effectively increase physical strength and reduce fall risk for fall-prone older adults as compared to excessive rest?

Research Article

Background Introduction

According to the authors, there are various studies available related to fall prevention in the past, and methods were advised which mostly consist of home safety interventions, home-based exercise programs, and assessments based on different factors (Chan et al., 2015). All these different kinds of intervention programs minimize the rate at which falls occurs. But these invention programs do not fully target visually impaired individuals and consequently, they fail to bring any solution for the visually impaired persons such as physical exercise is of no use to cognitively impaired individuals. Therefore, in light of the research gap, further study was conducted to address and cater to the issue of falls for visually impaired persons. Hence, the objective of this study was to investigate whether older adults with cognitive impairment are affected by physical exercise in minimizing falls (Chan et al., 2015).

Methodology

Different reports and writings were searched i.e. “MEDLINE; EMBASE; PsycINFO; the Cumulative Index to Nursing & Allied Health Literature; the Cochrane Central Register of Controlled Trials; the Cochrane Bone, Joint, and Muscle Trauma Group Specialized Register; ClinicalTrials.gov; and the UK Clinical Research Network Study Portfolio up to July 2013” by two researchers. It was clear in those publications that to check the efficiency of physical exercise in the prevention of falls for older adults with cognitive impairment, random trials were performed and those trials were based on the criteria formulated for the Cochrane review of fall prevention trials. The ratio of falls was determined as an outcome factor while a meta-analysis was performed to get the pooled rate ratio. This concluded the effects of physical exercise in the prevention of falls for older adults with cognitive impairment (Chan et al., 2015).

Level of Evidence

Level 2

Data Analysis

To check whether the results are influenced by one large study or by a study with a major result, a sensitivity analysis was performed by removing one study at a time. Then, the funnel is used to check the possibility of publication bias and whether ten or more ten trials have been included in the analysis.

Ethical Considerations

Authors have conducted and described their research by adhering to the core principles of conducting ethical nursing research where private data is not comprised. Also, only the relevant components of the research are discussed.

Quality Rating

The quality rating of the research-based article according to the JHNEBP model is high.

Analysis of the Results / Conclusions

This is the first research study that specifically examines the efficacy of physical exercise for older people with cognitive impairment by using a meta-analysis. The presented meta-analysis shows that the risk of falls reduces due to physical exercise in visually impaired older persons. The present study was done on 781 individuals along with seven RCTs. The results came out to be nearly like those achieved by normal people and groups. The pooled RR for visually impaired people was 0.68 whereas the RaR for home-based exercise in community-dwelling people was 0.68 and for group exercise it was 0.71. There was not much difference between the intervention and control groups, only two of the trials reported some fractures. Since the trial was specifically for older aged people with visually impaired issues, the case cannot be the same for all patients. Therefore, exercises can be varied according to the people with different cognitive functions. Moreover, different factors like modality, frequency, and intensity can be changed to set the adjustment of the exercise programs according to different cognitive functions.

However, RCTs helped in analyzing the effect of exercise on fall prevention among people with different cognitive functions particularly supporting the main argument of the current evidence-based question.

Non-Research Article

Background Introduction

The purpose of the article “Summary of factors contributing to falls in older adults and nursing implications” by Enderlin et al. (2015) is to investigate and discuss the contemporary practices on screening fear of falling and fall risks. The authors have also discussed different fall prevention strategies including exercise and required resources to help gerontological healthcare staff to reduce the ratio of falls in older patients (Enderlin et al., 2015).

Type of Evidence

The evidence in the article is a type of clinical practice guideline where the authors have presented a review of different fall risk factors and appropriate strategies to overcome them.

Level of Evidence

Level 2

Quality Rating

Good

Author’s Recommendations

The authors have emphasized the implementation of different fall prevention strategies i.e. exercise, screening and management of sensory deficits, vitamin D supplementation, and medication modification. Moreover, based on their review of different fall risks, they have recommended timely identification of any factors that can lead to such risks. Therefore, these findings are extremely helpful in answering my research-based questions as the authors have incorporated in-depth details and a review of existing resources on the prevention of falls which support exercise as an effective way to reduce fall risks.

Recommended Practice Change Based on Evidence-Based Practice Question

After analyzing the findings and guidelines of both articles discussed above, it can be assessed that exercise programs can significantly prevent falls risks of elderly patients in acute care settings and therefore, this practice is recommended for implementation on the organizational level.

Key Stakeholders

The key stakeholders to successfully implement the exercise program are the management of the organization, the healthcare staff, and the patients themselves. At the organizational level, the top management can make the SOP according to the latest research and can implement them to avoid falls in elderly patients (Enderlin et al., 2015). Like the researchers suggested that fall prevention strategies should be multifaceted, and they should involve STRATIFY supplementation with the clinical history of the patient (Dominic, M.,2016). Once this is achieved, the staff particularly the nursing cohort can be trained for evidence-based practice. Researchers have regarded nurses as one of the prime stakeholders for screening, educating, and intervening in previous practices in order to achieve better outcomes (Enderlin et al., 2015). The foremost stakeholder is the patient, although the education of the patient will be dependent on the implementation of the above-mentioned measures.

Together the three stakeholders can contribute to the implementation of the fall prevention strategy.

Barrier to Implementation

The potential barrier to the implementation of the exercise program could possibly be covering the gap in the contemporary research areas and the treatment options used in the hospitals. Furthermore, the lack of motivation of staff members and insufficient resources can also restrict the effectiveness of the program (Chan et al., 2015).

Strategy to Overcome the Implementation Barrier

The strategy for the implementation is the evidence-based practice of the medical staff. Moreover, conducting workshops and seminars for learning and adapting the newer techniques. This will also ensure the active participation of the medical staff. Moreover, more emphasis is put on devising individual exercise plans for the patients depending upon age group, disease, and most importantly clinical history. A higher staff-to-patient ratio strategy can lift the implementation barrier.

Indicators to Measure the Outcome

Implementing the evidence-based practice during hospital stays and home sessions, anticipating the fall risks, and devising the exercise plans accordingly (Dominic, M.,2016). Moreover, according to physical health, neuromuscular health, and medication dosage test tasks (e.g.; walking) can be done bimonthly or every week to match the patient’s progress with the anticipated results.

References

Chan, W. C., Fai Yeung, J. W., Man Wong, C. S., Wa Lam, L. C., Chung, K. F., Hay Luk, J. K., Wah Lee, J. S., & Kin Law, A. C. (2015). Efficacy of Physical Exercise in Preventing Falls in Older Adults with Cognitive Impairment: A Systematic Review and Meta-Analysis. Journal of the American Medical Directors Association, 16(2), 149–154. https://doi.org/10.1016/j.jamda.2014.08.007

Enderlin, C., Rooker, J., Ball, S., Hippensteel, D., Alderman, J., Fisher, S. J., McLeskey, N., & Jordan, K. (2015). Summary of factors contributing to falls in older adults and nursing implications. Geriatric Nursing36(5), 397–406. https://doi.org/10.1016/j.gerinurse.2015.08.006

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