Inpatient falls in adult acute care settings: influence of patients’ mental status

tzeng h.-m. (2010)  Inpatient falls in adult acute care settings: influence of patients’ mental status. Journal of Advanced Nursing   66 (8), 1741–1746. Inpatient falls in adult acute care settings: influence of patients’ mental status. This paper is a report of a study of fallers’ mental status as one of the patient-related intrinsic risk factors for falls.Whether confusion is one of the most important risk factors associated with risk of falling in hospital settings is unclear. Literature reviews have not identified consistent evidence for effective preventive interventions for patients with mental status deficits.This retrospective research was conducted in six adult acute care units in a community hospital in the United States of America. The data source was the 1017 fall incidents occurring between 1 July 2005 and 30 April 2009. Descriptive statistics and Pearson chi-square tests were used to analyse the data.The presence of mental status deficits was identified as the dominant issue in 346 (34%) falls. The group of fallers with mental status deficits (32·1%, n  = 111) seemed to have fewer toileting-related falls than those without mental status deficits (46·7%, n  = 314). Fallers with mental status deficits tended to have more severe fall injuries than those without mental status deficits (χ 2  = 10·08, d.f. = 3, P  = 0·018).Risk assessment and targeted surveillance should be used as part of falls prevention policy. Involving nursing staff and family members in assessing a patient’s mental status may help to prevent falls caused by mental status deficits.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79196/1/j.1365-2648.2010.05343.x.pd

How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England

Background Health systems worldwide are increasingly holding boards of healthcare organisations accountable for the quality of care that they provide. Previous empirical research has found associations between certain board practices and higher quality patient care; however, little is known about how boards govern for quality improvement (QI). Methods We conducted fieldwork over a 30-month period in 15 healthcare provider organisations in England as part of a wider evaluation of a board-level organisational development intervention. Our data comprised board member interviews (n=65), board meeting observations (60 hours) and documents (30 sets of board meeting papers, 15 board minutes and 15 Quality Accounts). We analysed the data using a framework developed from existing evidence of links between board practices and quality of care. We mapped the variation in how boards enacted governance of QI and constructed a measure of QI governance maturity. We then compared organisations to identify the characteristics of those with mature QI governance. Results We found that boards with higher levels of maturity in relation to governing for QI had the following characteristics: explicitly prioritising QI; balancing short-term (external) priorities with long-term (internal) investment in QI; using data for QI, not just quality assurance; engaging staff and patients in QI; and encouraging a culture of continuous improvement. These characteristics appeared to be particularly enabled and facilitated by board-level clinical leaders. Conclusions This study contributes to a deeper understanding of how boards govern for QI. The identified characteristics of organisations with mature QI governance seemed to be enabled by active clinical leadership. Future research should explore the biographies, identities and work practices of board-level clinical leaders and their role in organisation-wide QI

Perspectives of staff nurses of the reasons for and the nature of patient-initiated call lights: an exploratory survey study in four USA hospitals

<p>Abstract</p> <p>Background</p> <p>Little research has been done on patient call light use and staff response time, which were found to be associated with inpatient falls and satisfaction. Nurses' perspectives may moderate or mediate the aforementioned relationships. This exploratory study intended to understand staff's perspectives about call lights, staff responsiveness, and the reasons for and the nature of call light use. It also explored differences among hospitals and identified significant predictors of the nature of call light use.</p> <p>Methods</p> <p>This cross-sectional, multihospital survey study was conducted from September 2008 to January 2009 in four hospitals located in the Midwestern region of the United States. A brief survey was used. All 2309 licensed and unlicensed nursing staff members who provide direct patient care in 27 adult care units were invited to participate. A total of 808 completed surveys were retrieved for an overall response rate of 35%. The SPSS 16.0 Window version was used. Descriptive and binary logistic regression analyses were conducted.</p> <p>Results</p> <p>The primary reasons for patient-initiated calls were for toileting assistance, pain medication, and intravenous problems. Toileting assistance was the leading reason. Each staff responded to 6 to 7 calls per hour and a call was answered within 4 minutes (estimated). 49% of staff perceived that patient-initiated calls mattered to patient safety. 77% agreed that that these calls were meaningful. 52% thought that these calls required the attention of nursing staff. 53% thought that answering calls prevented them from doing the critical aspects of their role. Staff's perceptions about the nature of calls varied across hospitals. Junior staff tended to overlook the importance of answering calls. A nurse participant tended to perceive calls as more likely requiring nursing staff's attention than a nurse aide participant.</p> <p>Conclusions</p> <p>If answering calls was a high priority among nursing tasks, staff would perceive calls as being important, requiring nursing staff's attention, and being meaningful. Therefore, answering calls should not be perceived as preventing staff from doing the critical aspects of their role. Additional efforts are necessary to reach the ideal or even a reasonable level of patient safety-first practice in current hospital environments.</p

Validation of the care transition measure in multi-ethnic South-East Asia in Singapore

10.1186/1472-6963-12-256BMC Health Services Research121

An occupational therapy intervention for residents with stroke-related disabilities in UK care homes (OTCH):Cluster randomised controlled trial with economic evaluation

Background: Care home residents with stroke-related disabilities have significant activity limitations. Phase II trial results suggested a potential benefit of occupational therapy (OT) in maintaining residents’ capacity to engage in functional activity. Objective: Evaluate clinical and cost effectiveness of a targeted course of OT in maintaining functional activity and reducing further health risks from inactivity for UK care home residents living with stroke-related disabilities. Design: Pragmatic, parallel-group, cluster randomised controlled trial with economic evaluation. Cluster randomisation occurred at the care home level. Homes were stratified according to trial administrative centre, and type of care provided (nursing or residential) and randomised 1:1 to either the intervention or control arm. Setting: 228 care homes local to 11 trial administrative centres across England and Wales. Participants: 1042 care home residents with a history of stroke or transient ischaemic attack, including residents with communication and cognitive impairments, not receiving end of life care. 114 care homes (n=568 residents) were allocated to the intervention arm; 114 homes (n=474 residents) to the control arm. Randomisation of participating homes occurred between May 2010 and March 2012. Intervention: Personalised three-month course of OT delivered by qualified therapists. Care workers participated in training workshops to support personal activities of daily living. The control condition consisted of usual care for residents. Main outcome measures: Primary outcome at the participant level: Barthel Index of Activities of Daily Living at three months. Secondary outcomes at the participant level: Barthel Index scores at six and twelve months post-randomisation, and the Rivermead Mobility Index, Geriatric Depression Scale-15, and EuroQol EQ-5D-3L questionnaire at all time-points. An economic evaluation examined the incremental cost per quality-adjusted life year (QALY) gain, costs were estimated from the perspective of the NHS and personal social services. Results: Participants mean age= 82.9 years, 665/1042 (64%) were female. 2538 OT sessions were delivered to 498 participants in the intervention group (mean visits/participant =5.1, SD=3.0). No adverse events attributable to the intervention were recorded. The primary outcome showed no significant differences between groups. The adjusted mean difference in the Barthel Index score between groups was 0.19 points higher in the intervention arm (95% CI -0.33 to 0.70, p=0.48, adjusted ICC 0.09). Secondary outcome measures showed no significant differences at all time-points. Mean incremental cost of the OTCH intervention was £438.78 (CI £-360.89 to £1238.46), and the incremental QALY gain was 0.009 (CI -0.030 to 0.048). Conclusion: A three-month individualised course of OT, showed no benefit in maintaining functional activity in an older care home population with stroke-related disabilities. Limitations: A high proportion of participants with very severe activity-based limitations and cognitive impairment have limited capacity to engage in therapy. Future work: There is an urgent need to reduce health-related complications caused by inactivity, and create more of an enabling built environment within care homes. Trial registration: Current controlled trials ISRCTN00757750

Identifying paediatric nursing-sensitive outcomes in linked administrative health data

There is increasing interest in the contribution of the quality of nursing care to patient outcomes. Due to different casemix and risk profiles, algorithms for administrative health data that identify nursing-sensitive outcomes in adult hospitalised patients may not be applicable to paediatric patients. The study purpose was to test adult algorithms in a paediatric hospital population and make amendments to increase the accuracy of identification of hospital acquitted events. The study also aimed to determine whether the use of linked hospital records improved the likelihood of correctly identifying patient outcomes as nursing sensitive rather than being related to their pre-morbid conditions. Algorithm for nursing-sensitive outcomes used in adult populations have to be amended before application to paediatric populations. Using unlinked individual hospitalisation records to estimate rates of nursing-sensitive outcomes is likely to result in inaccurate rates

Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care

BACKGROUND: Crisis Concordat was established to improve outcomes for people experiencing a mental health crisis. The Crisis Concordat sets out four stages of the crisis care pathway: (1) access to support before crisis point; (2) urgent and emergency access to crisis care; (3) quality treatment and care in crisis; and (4) promoting recovery. OBJECTIVES: To evaluate the clinical effectiveness and cost-effectiveness of the models of care for improving outcomes at each stage of the care pathway. DATA SOURCES: Electronic databases were searched for guidelines, reviews and, where necessary, primary studies. The searches were performed on 25 and 26 June 2014 for NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database, and the Health Technology Assessment (HTA) and PROSPERO databases, and on 11 November 2014 for MEDLINE, PsycINFO and the Criminal Justice Abstracts databases. Relevant reports and reference lists of retrieved articles were scanned to identify additional studies. STUDY SELECTION: When guidelines covered a topic comprehensively, further literature was not assessed; however, where there were gaps, systematic reviews and then primary studies were assessed in order of priority. STUDY APPRAISAL AND SYNTHESIS METHODS: Systematic reviews were critically appraised using the Risk Of Bias In Systematic reviews assessment tool, trials were assessed using the Cochrane risk-of-bias tool, studies without a control group were assessed using the National Institute for Health and Care Excellence (NICE) prognostic studies tool and qualitative studies were assessed using the Critical Appraisal Skills Programme quality assessment tool. A narrative synthesis was conducted for each stage of the care pathway structured according to the type of care model assessed. The type and range of evidence identified precluded the use of meta-analysis. RESULTS AND LIMITATIONS: One review of reviews, six systematic reviews, nine guidelines and 15 primary studies were included. There was very limited evidence for access to support before crisis point. There was evidence of benefits for liaison psychiatry teams in improving service-related outcomes in emergency departments, but this was often limited by potential confounding in most studies. There was limited evidence regarding models to improve urgent and emergency access to crisis care to guide police officers in their Mental Health Act responsibilities. There was positive evidence on clinical effectiveness and cost-effectiveness of crisis resolution teams but variability in implementation. Current work from the Crisis resolution team Optimisation and RElapse prevention study aims to improve fidelity in delivering these models. Crisis houses and acute day hospital care are also currently recommended by NICE. There was a large evidence base on promoting recovery with a range of interventions recommended by NICE likely to be important in helping people stay well. CONCLUSIONS AND IMPLICATIONS: Most evidence was rated as low or very low quality, but this partly reflects the difficulty of conducting research into complex interventions for people in a mental health crisis and does not imply that all research was poorly conducted. However, there are currently important gaps in research for a number of stages of the crisis care pathway. Particular gaps in research on access to support before crisis point and urgent and emergency access to crisis care were found. In addition, more high-quality research is needed on the clinical effectiveness and cost-effectiveness of mental health crisis care, including effective components of inpatient care, post-discharge transitional care and Community Mental Health Teams/intensive case management teams. STUDY REGISTRATION: This study is registered as PROSPERO CRD42014013279. FUNDING: The National Institute for Health Research HTA programme

The contribution of staff call light response time to fall and injurious fall rates: an exploratory study in four US hospitals using archived hospital data

Abstract Background Fall prevention programs for hospitalized patients have had limited success, and the effect of programs on decreasing total falls and fall-related injuries is still inconclusive. This exploratory multi-hospital study examined the unique contribution of call light response time to predicting total fall rates and injurious fall rates in inpatient acute care settings. The conceptual model was based on Donabedian's framework of structure, process, and health-care outcomes. The covariates included the hospital, unit type, total nursing hours per patient-day (HPPDs), percentage of the total nursing HPPDs supplied by registered nurses, percentage of patients aged 65 years or older, average case mix index, percentage of patients with altered mental status, percentage of patients with hearing problems, and call light use rate per patient-day. Methods We analyzed data from 28 units from 4 Michigan hospitals, using archived data and chart reviews from January 2004 to May 2009. The patient care unit-month, defined as data aggregated by month for each patient care unit, was the unit of analysis (N = 1063). Hierarchical multiple regression analyses were used. Results Faster call light response time was associated with lower total fall and injurious fall rates. Units with a higher call light use rate had lower total fall and injurious fall rates. A higher percentage of productive nursing hours provided by registered nurses was associated with lower total fall and injurious fall rates. A higher percentage of patients with altered mental status was associated with a higher total fall rate but not a higher injurious fall rate. Units with a higher percentage of patients aged 65 years or older had lower injurious fall rates. Conclusions Faster call light response time appeared to contribute to lower total fall and injurious fall rates, after controlling for the covariates. For practical relevance, hospital and nursing executives should consider strategizing fall and injurious fall prevention efforts by aiming for a decrease in staff response time to call lights. Monitoring call light response time on a regular basis is recommended and could be incorporated into evidence-based practice guidelines for fall prevention.http://deepblue.lib.umich.edu/bitstream/2027.42/112579/1/12913_2011_Article_2004.pd

Developing core elements and checklist items for global hospital antimicrobial stewardship programmes:a consensus approach

International audienc