“In elderly patients, what is the impact of individualized patient-centered fall prevention protocols compared to universal unit based protocols during hospital stays?”

PICOT Question:

“In elderly patients, what is the impact of individualized patient-centered fall prevention protocols compared to universal unit based protocols during hospital stays?”

Introduction

The study chosen for this research was the Implementation of a Multifactorial Fall Prevention Protocol by Laura Wilkerson. Laura undertook this study in 2017 as part of her degree of Doctor in Nursing Practice.  The study is a clinical trial in which the subjects receive an intervention, which in this case is a multifactorial approach that would identify the patients at risk of falling and provide an individualized fall prevention intervention for them. The researcher embarked on randomized fall prevention checks and validated the fall prevention education knowledge. Wilkerson’s research question is, “What is the effect of a multifactorial approach with the best interventions on fall rates and related injuries when compared to usual care in the neurosurgical or orthopedic unit over three months?”

Study Description

In this study, the researcher assigns the participants, elderly patients in a not-for-profit hospital in North Central Indiana, to multifactorial fall prevention intervention. In this project, the investigator compares the pre-implementation to post-implementation data to determine whether the new approach had any impacts in reducing the fall-risk to which many patients were exposed. The pre-implementation data included the fall data that the researcher had collected before the initiation of the new intervention. In contrast, the post-implementation data was the fall data that was collected following the initiation of the fall prevention protocol. The researcher collects data from post-fall assessment forms, electronic health records (EHR), NDNQI data, as well as voice reports from the care providers. The project was implemented in October 2016 and completed in December 2016. The researcher uses the data collected within this time as post-implementation data. She then compares the post-, with the pre-implementation data, which was collected from the immediate two years before the individualized fall prevention protocol was initiated (October – December 2014, and October – December 2015).

The study takes place in a neurosurgical or orthopedic unit of a not-for-profit organization of Trinity Health, located in North Central Indiana. The researcher implements the project on 32 beds of the neurosurgical unit, believing that it is the most easily accessible unit to her. Also, the study is performed on patients who were admitted to the unit or transferred from other hospitals. The researcher’s goal was not only to find out the extent to which the intervention reduced the rate of falls, but also to establish the rate of injury, staff compliance, and patient compliance. The fall and injury rates were measures with the number of falls or injuries that took place per 1000 patient days. The researcher measured the patient compliance through evaluating the EHR, VOICE Reports, patient fall event report forms, and NDNQI data forms (Wilkerson, 2017). She then measured staff compliance by the filling and documentation of the fall risk assessment of every shift as per the EHR.

Study Findings

Through this research, the investigator found that the frequency of falls among the patients who looked more alert and oriented increased. This was different from previous studies, which showed that the fall rates were significantly lower among the participants whose cognitive function was intact than among the confused patients. In this study, it is possible that the rates of falls were higher in more alert and oriented patients because they were up and out of bed more frequently and were more likely to ambulate independently without seeking the assistance of care providers. Therefore, this resulted in increased rates of fall. The researcher also found that the patients on opioids fell more than those who were not on any sedation or narcotics. The researcher also found that there was no significant difference between October and December 2014, and October and December 2015 and 2016, meaning that the rate of falls did not reduce significantly following the independent intervention. The findings in this research were not consistent with previous literature of randomized control studies by various researchers, which found that the proportion of falls in the intervention group was significantly lower than in the control group (Wilkerson, 2017). The researcher also found that there were no major or minor injuries in the period between October and December 2014, but there were minor injuries and no major injuries in 2015, and one major injury and one minor injury in 2016.

While these were the major findings of the study, it also had a few limitations. One was that not all patients pre-test and post-test questions matched the patient fall assessment report forms. This means while data may have been collected from several participants, it was limited, and thus limited the data analysis. Also, the project leader did not have access to the huddle forms, some of which contained more data on the patients’ falls. The results would have been more significant if the implementation period was extended to at least six months. The other limitation in the study was the unit had a few recently hired nursing staff members who were not familiar with the fall prevention assessment or intervention as some of the nurses who had worked in the unit for a longer time. Lastly, the researcher did not collect any data from the non-fall risk patients because all the patients in the unit were considered to be fall-risk patients since they all were receiving fall risk medication.

This research by Wilkerson is intensive, although it raises some questions about credibility based on the consistency of results. First, it is evident that she has adequate control over the methodology, but a few things seem dubious, and her expertise is not discernible. The results seem inconsistent with previous research undertaken on the same topic, and the sample size is insufficient in drawing a conclusion of the issue of falls among the elderly and the effectiveness of individualized interventions. Yet, it is important to point out that the researcher has some fairly definitive conclusions, and provides some reasonably consistent recommendations, which she bases on in-depth literature reviews that include orientations from scientific evidence. Based on this knowledge, the Evidence appraisal rating system classifies this study under Grade B, which is neither too good, nor have major flaws, but just good.

Rating Systems

In the Hierarchy of Evidence Rating System, this particular research can be classified under Level I because first, Wilkerson obtains evidence from several randomized control trials, which are the “gold standard” of study design (“What is Evidence-Based Practice in Nursing? | Nurse.com”, 2020). In the evidence sources, the subjects were selected and assigned to groups randomly, before they underwent rigorously controlled interventions or experimental conditions, which in this case was an individualized fall prevention protocol. The research in itself was a kind of a meta-analysis or systematic review of some related RCTs. Wilkerson performed a critical assessment of recent evidence that addresses the individualized fall prevention intervention among hospitalized senior adults. Wilkerson (2017) performs a comprehensive literature review and appraises the findings arrived at by the researchers of the RCTs while reporting the findings systematically. She also uses statistical methods to combine the data and analyze what other RCTs found concerning the issue in question.

References

What is Evidence-Based Practice in Nursing? | Nurse.com. (2020). Retrieved 19 June 2020, from https://www.nurse.com/evidence-based-practice

Wilkerson, L. (2017). Implementation of a Multifactorial Fall Prevention Protocol (Ph.D.). Valparaiso University.