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Fall Prevention in Dementia Unit Through Continuous Education to Cna and Nurses to Avoid Complication Related to Fall

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Your 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. Hand hygiene to prevent spread of nosocomial infection is an example of a patient safety practice that avoids patient harm without interfering with the patient's medical care. As you read through this section, think about how you can integrate your fall prevention program with the variety of acute medical treatments that your hospital must deliver. Another key point to remember is that fall prevention alone cannot be the goal of a fall prevention program. A theoretical example can illustrate this point. In theory, we could prevent all falls by restraining all patients, thereby preventing them from leaving the bed (in actuality, restraints may not prevent falls). But restraining patients would be unethical and represent poor care. It would conflict with the principles of patient autonomy and cause all the complications of bed rest, such as deconditioning, pressure ulcers, aspiration, and deep vein thrombosis, thereby keeping the patient in the hospital longer and making it harder for the patient to recover.

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Staff in acute care hospitals have a complex and potentially conflicting set of goals when treating patients. Hospital personnel need to treat the problem that prompted the patient‘s admission, keep the patient safe, and help the patient to maintain or recover physical and mental function. Thus, fall prevention must be balanced against other priorities. Fall prevention involves managing a patient‘s underlying fall risk factors (e.g., problems with walking and transfers, medication side effects, confusion, frequent toileting needs) and optimizing the hospital‘s physical design and environment. A number of practices have been shown to reduce the occurrence of falls, but these practices are not used systematically in all hospitals. Fall prevention requires an interdisciplinary approach to care. Some parts of fall prevention care are highly routinized; other aspects must be tailored to each patient‘s specific risk profile. No clinician working alone, regardless of how talented, can prevent all falls. Rather, fall prevention requires the active engagement of many individuals, including the multiple disciplines and teams involved in caring for the patient

To accomplish this coordination, high-quality prevention requires an organizational culture and operational practices that promote teamwork and communication, as well as individual expertise. Fall prevention activities also need to be balanced with other considerations, such as minimizing restraints and maintaining patients‘ mobility, to provide the best possible care to the patient. Therefore, improvement in fall prevention requires a system focus to make needed changes.

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The occurrence of patient falls has been identified by Centers for Medicare and Medicaid Services (CMS) as one of eight “never events” for hospital settings. Never events are high-cost, high-volume events that could be reasonably prevented by the application of evidence-based guidelines. A recent impact assessment, however, found that the CMS policy has had no effect on the rates of injurious falls, perhaps because there are no evidence-based practice guidelines for fall prevention (Waters et al., 2015), and few intervention studies have been conducted on fall prevention in hospital settings with minimal evidence to inform practice. Of those conducted, results have been mixed. A 2012 Cochrane review (Cameron et al., 2012) found that multifactorial programs are effective for patients who have a longer length of stay, but no recommendations could be made for any component of these programs. Other systematic reviews found that either there was no conclusive evidence that fall prevention programs reduce the number of falls or that multifaceted interventions may have a modest effect on falls, but not on fractures. In hospitals, patient falls have a multifactorial etiology that can be subdivided into three categories: (a) physiological anticipated (gait instability, fall history, and current risk for falls); (b) physiological unanticipated (fainting); and (c) environmental (external hazards or equipment failure). In addition, individual inpatient units have unique characteristics related to type of patients, staffing ratios, model of care, environment, and equipment availability, which also affect patient fall rates. Due to the complexity of falls in hospital settings, a one-size-fits-all approach to reducing or preventing patient falls may not be feasible. Staff nurses may have the greatest impact on reducing patient falls. Due to their 24-hr presence, nurses have the most consistent contact with patients and continually monitor for conditional changes. However, no research has been conducted on how nurses approach fall prevention or the multiple strategies they use to reduce the risk or prevent falls in older adult patients

When falls occur, nurses often become the “second victim” expressing increased stress, anxiety, guilt, concern for liability, and self-doubt about the quality of care they provide.

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In sum, in the community setting, identification of the best timing for screening and reassessment is needed. Identification of methods to build fall- and injury-prevention programs in the community is needed to guide policymakers. In the acute and long-term care settings, large multisite intervention studies that use multimodal interventions tailored for individual risk factors and that control for comorbidities, acuity, staffing, and other environmental factors are needed. Cost-effectiveness studies to characterize the impact of fall- and injury-prevention programs are needed in the acute and long-term care settings.

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Effect of Medicare's nonpayment for Hospital-Acquired Conditions: lessons for future policy. Waters TM, Daniels MJ, Bazzoli GJ, Perencevich E, Dunton N, Staggs VS, Potter C, Fareed N, Liu M, Shorr RI JAMA Intern Med. 2015 Mar; 175(3):347-54.

Interventions for preventing falls in older people in care facilities and hospitals. Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG, Kerse N Cochrane Database Syst Rev. 2012 Dec 12; 12():CD005465.

Oliver D. McMurdo M. Daly F., & Martin F (2004). Risk factors and risk assessment tools for falls in hospital in-patients: A systematic review. Age Ageing, 33, 122–130. doi:10.1093/ageing/afh017

Rosenthal M. B. (2007). Nonpayment for performance? Medicare’s new reimbursement rule. New England Journal of Medicine, 357, 1573–1575

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