Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial.

BACKGROUND: Bed alarm systems intended to prevent hospital falls have not been formally evaluated. OBJECTIVE: To investigate whether an intervention aimed at increasing bed alarm use decreases hospital falls and related events. DESIGN: Pair-matched, cluster randomized trial over 18 months. Nursing units were allocated by computer-generated randomization on the basis of baseline fall rates. Patients and outcome assessors were blinded to unit assignment; outcome assessors may have become unblinded. (ClinicalTrials.gov registration number: NCT00183053) SETTING: 16 nursing units in an urban community hospital. PATIENTS: 27 672 inpatients in general medical, surgical, and specialty units. INTERVENTION: Education, training, and technical support to promote use of a standard bed alarm system (intervention units); bed alarms available but not formally promoted or supported (control units). MEASUREMENTS: Pre-post difference in change in falls per 1000 patient-days (primary end point); number of patients who fell, fall-related injuries, and number of patients restrained (secondary end points). RESULTS: Prevalence of alarm use was 64.41 days per 1000 patient-days on intervention units and 1.79 days per 1000 patient-days on control units (P = 0.004). There was no difference in change in fall rates per 1000 patient-days (risk ratio, 1.09 [95% CI, 0.85 to 1.53]; difference, 0.41 [CI, -1.05 to 2.47], which corresponds to a greater difference in falls in control vs. intervention units) or in the number of patients who fell, injurious fall rates, or the number of patients physically restrained on intervention units compared with control units. LIMITATION: The study was conducted at a single site and was slightly underpowered compared with the initial design. CONCLUSION: An intervention designed to increase bed alarm use in an urban hospital increased alarm use but had no statistically or clinically significant effect on fall-related events or physical restraint use. PRIMARY FUNDING SOURCE: National Institute on Aging.

Is it possible to identify risks for injurious falls in hospitalized patients?

BACKGROUND: Patient falls are among the most commonly reported adverse hospital events with more than one million occurring annually in the United States; approximately 10% result in serious injury. A retrospective study was conducted to determine predictors and outcomes of fall injuries among a cohort of adult hospitalized patients. METHODS: Data were obtained regarding patients who sustained an initial fall in hospital during a 26-month period from 16 adult general medical and surgical units in an urban university-affiliated community hospital. Data on intrinsic (individual) factors, extrinsic (environmental) factors, and situational activities were collected via nurse and patient interviews, patient examinations, and audits of incident reports and electronic health records. Fall injuries were classified as none/any for analyses. Unadjusted odds ratios [ORs] and 95% confidence intervals [CIs] for each of the variables of interest with fall injury were generated using logistic regressions. RESULTS: The 784 patients had a median age of 63.5 years (range, 20 to > 90 years), 390 (50%) were women, and 526 (67%) were black. Some 228 (29%) fallers sustained injury; patients who were white (OR: 2.23; 95% CI: 1.62, 3.08), or were administered a selective serotonin reuptake inhibitor (OR: 1.04; 95% CI: 1.04, 2.67), two antipsychotic agents (OR: 3.26; 95% CI: 1.20, 8.90), an opiate (OR: 1.59; 95%; CI: 1.14, 2.20), or a diuretic non-antihypertensive agent (OR: 1.53; 95% CI: 1.03, 2.26) were more likely to sustain an injury. Home-based wheelchair use was protective of fall injury (OR: 0.20; 95% CI: 0.05, 0.84). Seventy-nine percent of the patients had been designated as "high" fall risk within 24 hours before the fall. CONCLUSIONS: Few variables were able to distinguish patients who sustained injury after a hospital fall, further challenging clinicians' efforts to minimize hospital-related fall injury.

Falls following discharge after an in-hospital fall.

BACKGROUND: Falls are among the most common adverse events reported in hospitalized patients. While there is a growing body of literature on fall prevention in the hospital, the data examining the fall rate and risk factors for falls in the immediate post-hospitalization period has not been well described. The objectives of the present study were to determine the fall rate of in-hospital fallers at home and to explore the risk factors for falls during the immediate post-hospitalization period. METHODS: We identified patients who sustained a fall on one of 16 medical/surgical nursing units during an inpatient admission to an urban community teaching hospital. After discharge, falls were ascertained using weekly telephone surveillance for 4 weeks post-discharge. Patients were followed until death, loss to follow up or end of study (four weeks). Time spent rehospitalized or institutionalized was censored in rate calculations. RESULTS: Of 95 hospitalized patients who fell during recruitment, 65 (68%) met inclusion criteria and agreed to participate. These subjects contributed 1498 person-days to the study (mean duration of follow-up = 23 days). Seventy-five percent were African-American and 43% were women. Sixteen patients (25%) had multiple falls during hospitalization and 23 patients (35%) suffered a fall-related injury during hospitalization. Nineteen patients (29%) experienced 38 falls at their homes, yielding a fall rate of 25.4/1,000 person-days (95% CI: 17.3-33.4). Twenty-three patients (35%) were readmitted and 3(5%) died. One patient experienced a hip fracture. In exploratory univariate analysis, persons who were likely to fall at home were those who sustained multiple falls in the hospital (p = 0.008). CONCLUSION: Patients who fall during hospitalization, especially on more than one occasion, are at high risk for falling at home following hospital discharge. Interventions to reduce falls would be appropriate to test in this high-risk population.

A captive audience: a pilot study of screening and counseling hospitalized women for fracture risk.

BACKGROUND: Innovative methods are needed to improve screening for osteoporosis, especially in women with multiple comorbid conditions. OBJECTIVES: Determine whether a fracture risk-screening program including a bedside calcaneal ultrasound is feasible in hospitalized women, and determine whether identification of fracture risks results in behavior change after discharge. DESIGN: Prospective uncontrolled feasibility study. SETTING: Five hundred twenty-eight bed academic hospital. PARTICIPANTS: One hundred three hospitalized women age 60 years or older. METHODS: A bedside calcaneal ultrasound was used to estimate bone mineral density. Clinical fracture risks were obtained via interview. The patient and primary care physician received personalized risk information and educational material. RESULTS: Of 103 eligible women, 59 (57%) agreed to undergo bedside screening and counseling. Of these 59 women, 49 (83%) had at least one major clinical risk factor for fracture. The median T-score was -2.5. Among the 42 women available for phone follow-up 2 months after hospital discharge, 34 (81%) reported after at least 1 recommendation to diminish fracture risk. CONCLUSION: A hospital-based osteoporosis screening program using calcaneal ultrasound is feasible and identifies women at risk of fracture. Feedback of low bone mineral density and fracture risk during hospitalization may promote behavior change to diminish fracture risk after discharge.

Delayed administration of antibiotics and atypical presentation in community-acquired pneumonia.

OBJECTIVES: The time to the first antibiotic dose (TFAD) has been adopted as a measure of quality of care in patients with community-acquired pneumonia (CAP) based on two retrospective studies of large Medicare databases. The mechanism by which a difference of a few hours in receiving antibiotics can be deleterious is difficult to understand given the historical data regarding how long it takes for antibiotics to influence outcome. We investigated the factors that predict a prolonged TFAD and their association with mortality. DESIGN: Prospective cohort study. SETTING: A large tertiary hospital. PATIENTS: Immunocompetent adults admitted to the hospital with CAP. RESULTS: A total of 451 patients with CAP were studied. A TFAD of > 4 h was associated with increased mortality (p = 0.017). Altered mental state (p = 0.001), absence of fever (p = 0.02), absence of hypoxia (p = 0.025), and increasing age (p = 0.038) were significant predictors of a TFAD of > 4 h. After adjusting for these factors, the association between TFAD and mortality was not statistically significant (p = 0.131). Similar findings were observed in patients who were > or = 65 years. CONCLUSIONS: A delay in administering antibiotics in patients with CAP is more common in patients who present with an altered mental state or minimal signs of sepsis. TFAD is likely to be a marker of comorbidities driving both an atypical presentation and mortality rather than directly contributing to outcome. Using TFAD as an indicator of quality of care in patients with CAP without significant additional clinical information is potentially misleading as the relationships among TFAD, comorbidities, and outcome are complex.

Decreasing beta-lactam resistance in Pneumococci from the Memphis region: analysis of 2,152 isolates From 1996 to 2001.

STUDY OBJECTIVES: The Memphis region historically has had high pneumococcal antibiotic resistance rates. In recent years, we have seen a significant shift in antibiotic use away from beta-lactams toward the newer quinolones and macrolides. We hypothesized that these changes would cause a shift in pneumococcal antibiotic resistance patterns. DESIGN: Retrospective cohort study. SETTING: A large private hospital system. PATIENTS AND METHODS: We analyzed the antibiotic susceptibility patterns of 2,152 pneumococcal isolates obtained in the Memphis area from 1996 to 2001. Isolates were categorized as invasive or noninvasive and antibiotic resistance was classified according to the 2000 guidelines of the National Committee for Clinical Laboratory Standards. RESULTS: Over the study period, the proportion of penicillin-susceptible noninvasive pneumococcal isolates taken from children increased from 22 to 44% (p = 0.0004 [for trend across the 6-year period]). In noninvasive isolates taken from adults, penicillin susceptibility increased from 22 to 55% (p = 0.002), with a trend toward increasing sensitivity to cefotaxime (p = 0.02) in noninvasive isolates over the same period. The proportion of isolates with high-level penicillin resistance (ie, minimum inhibitory concentration, > or = 4 microg/mL) also decreased between 1996 and 2001 (p = 0.003). Clindamycin resistance in adult noninvasive isolates also declined (p = 0.002). The only adverse trend observed over this period was an increase in erythromycin resistance in noninvasive isolates from adults (p = 0.01). Resistance rates were significantly higher in children than in adults and were higher in noninvasive isolates than in invasive isolates. CONCLUSIONS: The stabilization of beta-lactam resistance rates in our region suggests that a continuous increase in pneumococcal resistance to antibiotics is not inevitable and may be avoidable.

Pharmaceutical industry research and cost savings in community-acquired pneumonia.

OBJECTIVE: To provide financial justification for continuing pharmaceutical research in an environment that has met with increasing resistance from insurance carriers to paying for the care of patients enrolled in research studies. STUDY DESIGN: Matched case-control study of patients enrolled into inpatient community-acquired pneumonia (CAP) pharmaceutical research protocols. PATIENTS AND METHODS: Case patients were enrolled into a CAP pharmaceutical research trial. Control patients were obtained from a prospective cohort study of CAP. Cases were matched to controls on the basis of age, sex, pneumonia severity index (PSI) grade, and comorbid illnesses as measured by the PSI and Acute Physiologic and Chronic Health Evaluation II (APACHE II) scoring systems. Financial data were obtained from hospital billing records. RESULTS: Twenty-five cases were identified and matched to appropriate controls. There was no statistically significant difference in mean PSI and APACHE II scores between cases and controls. There was a significant reduction in the total charges for hospital care of patients enrolled into a pharmaceutical industry trial ($6267 vs $9979; P = .03). As expected, the most dramatic reduction was in pharmacy charges ($642 vs $1797; P = .002), but there were trends toward lower charges in all cost subgroups. Interestingly, there was also a strong trend toward reduced length of hospital stay associated with enrollment in a pharmaceutical trial (4.5 vs 6.0 days; P = .06). CONCLUSION: Enrollment in a pharmaceutical research protocol results in significant cost savings in patients admitted to the hospital with CAP and may lead to earlier hospital discharge.

Use of International Classification of Diseases, Ninth Revision, Clinical Modification, codes to identify inpatient fall-related injuries.

OBJECTIVES: To compare falls and fall-related injuries that a fall evaluator or hospital incident report identified with injuries identified according to discharge International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for the same set of inpatient episodes of care. DESIGN: Prospective, descriptive study. SETTING: Sixteen adult general medical and surgical units in a major urban teaching hospital. PARTICIPANTS: All adults who sustained a fall with injury during a 5-year period (380 falls with injury). MEASUREMENTS: Falls that a fall evaluator or hospital incident report identified were classified according to their injury severity. Discharge abstracts provided diagnosis codes (ICD-9-CM) for the discharge, including fall-related injury codes. RESULTS: Three hundred forty-three inpatient falls with injury (90.2%) resulted in temporary harm to the individual; the remaining 37 falls (9.8%) resulted in more-serious harm. Sixteen of the 37 falls with injury extending hospitalization or resulting in death were identified using Centers for Medicare and Medicaid Services (CMS)-targeted injury code ranges combined with present-on-admission indicators. Of the 21 falls with injury that were not identified, nine (42.9%) lacked documentation of any injury, and seven (33.3%) identified other injuries outside the CMS-targeted injury code ranges. CONCLUSION: The CMS-targeted ICD-9-CM codes used to identify fall-related injuries in claims data do not always detect the most-serious falls.

Improving the capture of fall events in hospitals: combining a service for evaluating inpatient falls with an incident report system.

OBJECTIVES: To determine the utility of a fall evaluation service to improve the ascertainment of falls in acute care. DESIGN: Six-month observational study. SETTING: Sixteen adult nursing units (349 beds) in an urban, academically affiliated, community hospital. PARTICIPANTS: Patients admitted to the study units during the study period. INTERVENTION: Nursing staff identifying falls were instructed to notify, using a pager, a trained nurse "fall evaluator." Fall evaluators provided 24-hour-per-day 7-day-per-week coverage throughout the study. Data on patient falls gathered by fall evaluators were compared with falls data obtained through the hospital's incident reporting system. RESULTS: During 51,180 patient-days of observation, 191 falls were identified according to incident reports (3.73 falls/1,000 patient-days), whereas the evaluation service identified 228 falls (4.45 falls/1,000 patient-days). Combining falls reported from both data sources yielded 266 falls (5.20 falls/1,000 patient-days), a 39% relative rate increase compared with incident reports alone (P<.001). For falls with injury, combining data from both sources yielded 79 falls (1.54 injurious falls/1,000 patient-days), compared with 57 falls (1.11 injurious falls/1,000 patient-days) filed in incident reports--a 28% increase (P=.06). In the 16 nursing units, the relative percentage increase of captured fall events using the combined data sources versus the incident reporting system alone ranged from 13% to 125%. CONCLUSION: Incident reports significantly underestimate both injurious and noninjurious falls in acute care settings and should not be used as the sole source of data for research or quality improvement initiatives.

Medium-term survival after hospitalization with community-acquired pneumonia.

An episode of community-acquired pneumonia (CAP) has been suggested to predict greater than expected mortality after discharge from hospital. We ascertained the survival status as of December 2002 of a cohort of patients with CAP identified prospectively between November 1998 and June 2001. Cox regression analysis was used to examine the impact of demographic factors, comorbid illnesses, and CAP severity on subsequent mortality. Of 378 CAP survivors we ascertained the survival status of 366 (96.9%), 125 (34.1%) of whom had died. The mean length of follow-up was 1,058 days (range, 602-1,500 days). Independent predictors of mortality were increasing age (p < 0.001), comorbid cerebrovascular (p = 0.002) and cardiovascular (p = 0.023) disease, an altered mental state (p < 0.001), a hematocrit of less than 35% (p = 0.035), and increasing blood glucose level (p = 0.025). In 41- to 80-year-olds without significant comorbidities there was a trend to greater than expected mortality. In conclusion, an episode of CAP in young adults without significant comorbid illnesses does not appear to be an adverse prognostic marker of medium-term survival. The trend to greater than expected mortality in patients over 40 years of age needs further study and physicians should be particularly alert for underlying life-limiting disease processes in patients presenting with acute confusion or a hematocrit of less than 35%.

Heat shock protein 70-2+1267 AA homozygotes have an increased risk of septic shock in adults with community-acquired pneumonia.

OBJECTIVE: Heat shock protein (HSP)70-2 is an important immunomodulatory protein induced in response to inflammatory stimuli. We assessed whether HSP70-2+1267 genotype influenced the risk of septic shock in a prospective cohort study of community-acquired pneumonia and whether HSP70-2+1267 genotype is a better predictor of septic shock than the genotype at lymphotoxin-alpha +250. DESIGN: Prospective cohort study. SETTING: A large, nonprofit, private hospital system in Memphis, TN. PATIENTS: Adults admitted with community-acquired pneumonia between 1998 and 2001. Septic shock was defined according to consensus criteria (American College of Chest Physicians/Society of Critical Care Medicine, 1992). INTERVENTIONS: Blood sampling. MEASUREMENTS AND MAIN RESULTS: A total of 343 subjects were enrolled; 30 had septic shock. HSP70-2+1267 and lymphotoxin-alpha +250 genotype was determined using polymerase chain reaction and restriction enzyme digestion. HSP70-2+1267 AA genotype was the strongest predictor of septic shock (p =.0005; relative risk, 3.5). Lymphotoxin-alpha +250 AA genotype was also associated with an increased risk of septic shock (p =.002; relative risk, 2.7). Logistic regression analysis found only age (p =.04) and HSP70-2+1267 genotype (p =.006) were predictors of septic shock. The greatest risk of septic shock was associated with carriage of the HSP70-2+1267 A/lymphotoxin-alpha +250 A haplotype (p <.0001). CONCLUSIONS: HSP70-2+1267 genotype is a stronger predictor of septic shock in patients with community-acquired pneumonia than lymphotoxin-alpha +250 genotype.

Association between surfactant protein B + 1580 polymorphism and the risk of respiratory failure in adults with community-acquired pneumonia.

OBJECTIVE: Pulmonary surfactant protein (SP)-B plays a vital role in the formation and function of surfactant in the lung. A genetic polymorphism (SP-B + 1580) is postulated to result in diminished activity of SP-B. The objective was to determine whether the SP-B + 1580 CC genotype is associated with an increased risk of respiratory failure and ARDS in adults with community-acquired pneumonia. DESIGN: Prospective cohort of adults diagnosed with community-acquired pneumonia. SETTING: Hospital system. PATIENTS: We enrolled 402 adults > or = 18 yrs of age with community-acquired pneumonia; 158 were white, 243 were African American, and one was Asian. INTERVENTIONS: Genotypic analysis was performed on DNA isolated from whole blood using polymerase chain reaction amplification and DdeI restriction enzyme digestion. MEASUREMENTS AND MAIN RESULTS: We recorded the requirement for mechanical ventilation, the presence of acute respiratory distress syndrome (ARDS) or septic shock, and mortality. Sixty-three patients required mechanical ventilation, 12 patients developed ARDS, and 35 patients developed septic shock. Genotypic frequencies at the SP-B + 1580 site were T/T 183 of 402 (0.45), T/C 160 of 402 (0.40), and C/C 59 of 402 (0.15). Of the 59 patients who were C/C at the SP-B + 1580 site, 21 (0.356) required mechanical ventilation, compared with 26 of 160 patients (0.163) who were T/C and 16 of 183 (0.087) patients who were T/T (p < .001). ARDS developed in five of 59 (0.085) patients with the C/C genotype, compared with six of 160 (.038) patients with T/C and one of 183 patients with T/T (0.005, p < .009). Septic shock occurred in 12 of 59 (0.203) patients with the C/C genotype, compared with 13 of 160 (0.081) patients with T/C and ten of 183 (0.055) patients with T/T (p < .001). Mortality rate was not different between the three genotypes. CONCLUSION: Carriage of the C allele at the SP-B + 1580 site is associated with ARDS, septic shock, and the need for mechanical ventilation in adults with community-acquired pneumonia.