Key issues to consider and innovative ideas on fall prevention in the geriatric department of a teaching hospital.

Falls in hospital are common and up to 70% result in injury, leading to increased length of stay and accounting for 10% of patient safety-related deaths. Yet, high-quality evidence guiding best practice is lacking. Fall prevention strategies have worked in some trials but not in others. Differences in study setting (acute, subacute, rehabilitation) and sampling of patients (cognitively intact or impaired) may explain the difference in results. This article discusses these important issues and describes the strategies to prevent falls in the acute hospital setting we have studied, which engage the cognitively impaired who are more likely to fall. We have used video clips rather than verbal instruction to educate patients, and are optimistic that this approach may work. We have also explored the option of co-locating high fall risk patients in a close observation room for supervision, with promising results. Further studies, using larger sample sizes are required to confirm our findings.

A real-world comparison of apnea-hypopnea indices of positive airway pressure device and polysomnography.

The apnea hypopnea index (AHI) reported by positive airway pressure (PAP) device is widely used in clinical practice, yet its correlation with standardized AHI obtained during the sleep study is not established. The current study was conducted to investigate the correlation between AHI estimated by the PAP device and reported on the smart card with the AHI found during the PAP polysomnography (PSG) in the "real world" setting at an academic sleep center. We retrospectively reviewed the medical records of 280 patients who underwent a PAP titration PSG at Drexel sleep center, and were later prescribed a PAP device. The AHI was categorized in clinically relevant subgroups (as AHI ≤5 and AHI >5). The AHI at the final pressure on the PSG and the average AHI from the prescribed PAP device were compared. The results showed that in the majority (77.3%) of patients (126 of 163), the AHI from both PAP device and PSG correlated well and were in the same category (AHI ≤5 and AHI >5 respectively). The majority of patients (80.7%) with PSG AHI of <5 had PAP device AHI <5 as well. By contrast, if PSG AHI was >5, 61.5% patients reported good control, with AHI <5 on PAP device AHI. We conclude that in a majority of patients who were optimally titrated in the sleep laboratory, the PAP device continued to show optimal control at home.

Development of two shortened systematic review formats for clinicians.

BACKGROUND: Systematic reviews provide evidence for clinical questions, however the literature suggests they are not used regularly by physicians for decision-making. A shortened systematic review format is proposed as one possible solution to address barriers, such as lack of time, experienced by busy clinicians. The purpose of this paper is to describe the development process of two shortened formats for a systematic review intended for use by primary care physicians as an information tool for clinical decision-making. METHODS: We developed prototypes for two formats (case-based and evidence-expertise) that represent a summary of a full-length systematic review before seeking input from end-users. The process was composed of the following four phases: 1) selection of a systematic review and creation of initial prototypes that represent a shortened version of the systematic review; 2) a mapping exercise to identify obstacles described by clinicians in using clinical evidence in decision-making; 3) a heuristic evaluation (a usability inspection method); and 4) a review of the clinical content in the prototypes. RESULTS: After the initial prototypes were created (Phase 1), the mapping exercise (Phase 2) identified components that prompted modifications. Similarly, the heuristic evaluation and the clinical content review (Phase 3 and Phase 4) uncovered necessary changes. Revisions were made to the prototypes based on the results. CONCLUSIONS: Documentation of the processes for developing products or tools provides essential information about how they are tailored for the intended user. One step has been described that we hope will increase usability and uptake of these documents to end-users.

Developing a self-reported tool on fall risk based on toileting responses on in-hospital falls.

The aim of this cohort study was to determine the predictive value of a 2-item self-reported questionnaire regarding in-hospital toileting behavior for predicting falls in older inpatients and to compare its performance with an existing state-based falls assessment scale. Between May 28, 2009 and January 30, 2010, we assessed aged care inpatients for risk of falls using the standard STRATIFY fall screening tool and the 2-item self-reported questionnaire developed for this study. The participants were then followed up, with the primary outcome being the occurrence of falls. Results indicated that participants who were unable to answer the 2-item questionnaire appropriately or sensibly were 14.1 times (confidence interval [CI]: 4.4-45, p <. 001) to 17.0 times (CI: 6.7-43, p < .001) more likely to fall than those who gave an appropriate negative or positive answer. Participants who were assessed to be at high risk of falls on the STRATIFY scale were 9.5 times (odds ratio: 9.5, CI: 1.3-72, p = .03) more likely to fall than those who were low risk. In conclusion, a simple bedside questionnaire regarding patients' toileting behavior with a careful appraisal of answers for appropriate and inappropriate answers may be used as a quick screening tool of fall risk.

Management and outcomes of delirious patients with hyperactive symptoms in a secured behavioral unit jointly used by geriatricians and pyschogeriatricians.

To compare the clinical outcomes and length of stay (LOS) between delirious patients with hyperactive symptoms admitted directly and those admitted indirectly from Emergency Department into a secured, behavioral unit jointly used by geriatricians and pyschogeriatricians (the Unit). A retrospective study analyzing data from the medical records of 122 patients with an admission diagnosis of delirium with hyperactive symptoms and subsequently discharged from the Unit, including restraint, one-to-one nursing care, falls, absconding, duration of delirium, recovery from delirium, destination and LOS. Significantly fewer patients with direct admission (n=68) required physical restraint or chemical restraint compared with those transferred (n=54). Patients admitted directly showed a higher discharge rate back home, shorter LOS, shorter duration of delirium and a higher rate of recovery from delirium than transferred patients. Of the transferred patients, more received one-to-one nursing care before transfer than after transfer. Three (5.6%) absconded before transfer, but none absconded from the Unit. The falls rate reduced from 14.2 to 6.7 falls/1000 patient delirium days after transfer. Delirious patients with hyperactive symptoms admitted directly to the Unit fared better in clinical outcomes and LOS. They also required less restraint, less intensive nursing and were unlikely to abscond compared to those transferred.

Evaluation of a medication education program for elderly hospital in-patients.

To improve elderly patients' understanding and safe usage of their medications. English-speaking hospital inpatients aged > or =65 years were recruited. They were self-medicating at home with at least 1 regular medication and had a Mini-Mental State Examination (MMSE) score of at least 20 out of 30. The patients were taught medication details on 3 consecutive days. The patients' medication knowledge was recorded before education and again at a home visit after discharge from hospital. Patient medication knowledge before education showed that participants knew 50% of brand names, dosage and times, 55% of medication purpose, and 15% of major side effects. At follow-up home visits, the relevant figures improved significantly to 90%, 85%, and 25%, respectively (P < or = .05). Similar improvement occurred in the 2 patient groups with an MMSE score of 20 to 24 and 25 to 30 (P = .03). This simple, practical, nursing-staff-conducted program worked well in a hospital setting and resulted in improved medication knowledge, even in patients with mild cognitive impairment.