Case Analysis of Factors Contributing to Patient Falls.

Falls are a constant risk for patients in acute-care hospitals, which can lead to serious consequences. The purpose of this study was to examine hospital fall case studies and to learn the contributing factors for patient falls. This was achieved by conducting a secondary analysis of 11 fall case studies obtained from two previous studies. The fall cases used the Senior Falls Investigative Methodology (SFIM) approach, which provided detailed analysis of the circumstances surrounding the falls. A total of 549 contributing factors were identified in the 11 case studies, where major categories were classified according to the four different layers of defenses using Reason's Swiss Cheese Model of Accident Causation (organizational factors, supervision, preconditions, and unsafe acts). Hospital policies, reduced supervision, disease processes, the environment, and patients transferring without assistance dominated the reasons for increased risk. Additional strategies were recommended for all layers of defense to reduce patient falls.

Comparison of the Prophylactic Effect Between Acupuncture and Acupressure on Menstrual Migraine: Results of a Pilot Study.

OBJECTIVES: To compare between acupuncture and acupressure for preventing menstrual migraine (MM). METHODS: MM is one kind of migraine associated with menses in female. It is often associated with increased menstrual distress and disability, leading to decreased daily activity and quality of life. A randomized and controlled pilot study was conducted with three groups: verum acupuncture (VA) group, acupressure (AP) group, and control acupuncture (CA) group. The study lasted for 7 cycle-months, with a 1 cycle-month baseline observation (T1), a 3 cycle-month intervention (3 times per cycle-month) (T2-T4), and a 3 cycle-month follow-up (T5-T7). Outcome measures were number of migraine days, average and peak pain, total duration period of MM, and percentage of patients with ≥50% reduction in the number of MM days. RESULTS: A total of 18 participants were included in the analysis (VA, n = 7; AP, n = 6; CA, n = 5). Both VA and AP were significantly more effective than CA for reducing MM days during the intervention period. Both VA and AP tended to be more effective than CA for reducing peak pain during the intervention period. No significant differences for the outcomes were observed among VA, AP, and CA during the follow-up period. No serious adverse events were reported. DISCUSSION: Results of the pilot study suggest that both VA and AP could be considered as alternative and safe prophylactic interventions for MM. Register ClinicalTrials.gov Identifier: NCT02592681.

MoCA cutoff score in relation to the functional assessment of seniors living in a rural Canadian community.

INTRODUCTION: Research suggests that the Montreal Cognitive Assessment (MoCA) normal cutoff score of 26 may not be appropriate for all populations and ages. We sought to determine an appropriate MoCA cutoff score for community-dwelling seniors living in a rural Canadian community. METHODS: We conducted a retrospective chart review at a health centre in rural northern Ontario. The sample included community-dwelling seniors presenting between Dec. 1, 2013, and July 31, 2015. We generated a receiver operating characteristic curve to evaluate MoCA cutoff scores in relation to functional assessment, using the dichotomous categories of "no deficiencies in activities of daily living/instrumental activities of daily living (ADL/IADL) and "deficiencies in ADL/IADL." RESULTS: A total of 95 charts were included in the chart review. We identified MoCA scores of 20 (sensitivity 85%, specificity 62%) and 21 (sensitivity 77%, specificity 77%) as cutoff scores for the identification of impairment in this rural population. CONCLUSION: Our results suggest the normal range in MoCA score for the community-dwelling rural senior to be between 22 and 30. Although the MoCA demonstrated satisfactory performance as a screening measure, the importance of including ADL and IADL functional assessments before making clinical decisions cannot be overemphasized.

INTRODUCTION: Des études semblent indiquer que le seuil habituellement utilisé dans la Montreal Cognitive Assessment (MoCA), soit un score de 26, pourrait ne pas convenir à tous les groupes et à toutes les tranches d'âges. Nous avons cherché à déterminer un seuil approprié pour l'évaluation des personnes âgées habitant dans la communauté d'une région rurale canadienne. METHODS: Nous avons mené un examen rétrospectif des dossiers dans un centre de santé d'une région rurale du Nord de l'Ontario. Notre échantillon était composé des personnes âgées habitant dans la communauté qui se sont présentées au centre entre le 1er décembre 2013 et le 31 juillet 2015. Nous avons généré une courbe caractéristique de la performance afin d'évaluer la validité des scores MoCA par rapport à une évaluation fonctionnelle reposant sur des catégories dichotomiques, soit « aucune déficience dans les activités de la vie quotidienne (AVQ)/activités instrumentales de la vie quotidienne (AIVQ) ¼ et « déficiences dans les AVQ/AIVQ ¼. RESULTS: En tout, 95 dossiers ont été examinés. Nous avons conclu que des scores MoCA de 20 (sensibilité de 85 %, spécificité de 62 %) et de 21 (sensibilité de 77 %, spécificité de 77 %) seraient des seuils appropriés pour détecter la déficience chez cette population rurale. CONCLUSION: Nos résultats indiquent que la plage normale de scores MoCA chez les personnes âgées habitant dans la communauté en milieu rural est de 22 à 30. Bien que la MoCA se soit révélée d'une efficacité satisfaisante comme outil de dépistage, nous nous devons d'insister sur l'importance capitale de tenir compte de l'évaluation fonctionnelle des AVQ et des AIVQ dans la prise de décisions cliniques.

Rural cardiac rehabilitation: a 20-year success story.

INTRODUCTION: Data are lacking on long-term participation in a clinically supervised cardiac rehabilitation program in a rural setting. We sought to determine whether there were sustained improvements in physiologic measures and discover what restorative and deteriorative processes took place over time. METHODS: We retrospectively analyzed the records of patients who were enrolled for a least 1 year in the Healthy Hearts Cardiac Rehabilitation Program. Data from stress tests were tracked for up to 18 years to determine whether there were any sustained improvements and what factors were associated with restorative and deteriorative processes. RESULTS: We analyzed data from 85 participants. The mean age of the participants was 72 years, and the mean length of participation was 8 years. Duration of stress testing significantly (p < 0.01) increased by a mean of 15% from the first year to the second year, with a corresponding increase in estimated metabolic equivalent of task (MET) level (Cohen d = 0.82). The increase in duration was sustained into the ninth year, with an overall increase of 35% compared with the first year of testing. After the ninth year, the duration and estimated MET levels declined. CONCLUSION: Participants in the cardiac rehabilitation program demonstrated improved duration of stress testing, and stable rate-pressure product, blood pressure and resting heart rate during long-term participation in the program.

INTRODUCTION: On manque d'information sur la participation à long terme aux programmes de réadaptation cardiaque avec supervision clinique en milieu rural. Nous avons donc cherché à déterminer si ces programmes entraînent une amélioration physiologique permanente et à décrire les processus de guérison et d'aggravation qui surviennent au fil du temps. MÉTHODES: Nous avons procédé à une analyse rétrospective des dossiers de patients qui ont participé au programme Healthy Hearts pendant au moins 1 an. Des données sur leurs résultats aux épreuves d'effort sur une période maximale de 18 ans ont été recueillies pour déterminer la présence d'améliorations durables et mettre en évidence les facteurs associés à la guérison et à l'aggravation. RÉSULTATS: Nous avons étudié les dossiers de 85 patients; la durée de participation moyenne était de 8 ans, et l'âge moyen des participants, de 72 ans. La durée de l'épreuve d'effort a connu une augmentation significative de 15 % en moyenne (p < 0,01) de la première à la deuxième année, associée à une hausse correspondante de l'équivalent métabolique (MET) estimé (d de Cohen = 0,82). Cette augmentation s'est poursuivie jusqu'à la neuvième année, où la durée était supérieure de 35 % à celle de la première année. Par la suite, la durée de l'épreuve et le MET estimé ont commencé à diminuer. CONCLUSION: Au cours de leur participation prolongée au programme, les patients ont réussi à augmenter la durée de leur épreuve d'effort, et le produit de leur tension systolique par la fréquence des contractions cardiaques, leur pression artérielle et leur fréquence cardiaque au repos sont demeurés stables.

"People are Getting Lost a Little Bit": Systemic Factors that Contribute to Falls in Community-Dwelling Octogenarians.

Octogenarians living in the community are the fastest-growing demographic in Canada. Simultaneously, they have the highest prevalence of falls and nine times greater risk of injury due to a fall. To understand how to improve the safety of octogenarians' aging-in-place, a systems approach is essential. Understanding how societal factors interact and affect the older adult can help care custodians identify and remove safety deficiencies that bring about falls. The purpose of this study was to identify system-wide factors contributing to falls in community-dwelling octogenarians. Eight falls were investigated using the systemic falls investigative method. Participants ranged in age from 83-90 years. Across-case analyses identified 247 contributing factors, grouped within four distinct themes: (a) everyday living has become risky; (b) supervision limitations; (c) health care system disconnects; and (d) poor fall risk identification and follow-up. This qualitative study provides systemic insights into how and why falls occur in community-dwelling octogenarians.

Understanding safety culture in long-term care: a case study.

OBJECTIVES: This case study aimed to understand safety culture in a high-risk secured unit for cognitively impaired residents in a long-term care (LTC) facility. Specific objectives included the following: diagnosing the present level of safety culture maturity using the Patient Safety Culture Improvement Tool (PSCIT), examining the barriers to a positive safety culture, and identifying actions for improvement. METHODS: A mixed methods design was used within a secured unit for cognitively impaired residents in a Canadian nonprofit LTC facility. Semistructured interviews, a focus group, and the Modified Stanford Patient Safety Culture Survey Instrument were used to explore this topic. Data were synthesized to situate safety maturity of the unit within the PSCIT adapted for LTC. RESULTS: Results indicated a reactive culture, where safety systems were piecemeal and developed only in response to adverse events and/or regulatory requirements. A punitive regulatory environment, inadequate resources, heavy workloads, poor interdisciplinary collaboration, and resident safety training capacity were major barriers to improving safety. CONCLUSIONS: This study highlights the importance of understanding a unit's safety culture and identifies the PSCIT as a useful framework for planning future improvements to safety culture maturity. Incorporating mixed methods in the study of health care safety culture provided a good model that can be recommended for future use in research and LTC practice.

Prostate cancer and occupational whole-body vibration exposure.

Prostate cancer is common and its etiology largely unknown; therefore, it is important to explore all potential risk factors that are biologically plausible. Recent literature suggests a relationship between whole-body vibration (WBV) and prostate cancer risk. The aim of this study was to determine whether occupational WBV was a risk factor for prostate cancer. Existing data, collected on 447 incident cases and 532 population controls (or their proxies), in Montreal, Canada, were used to evaluate this question. Personal interviews collected detailed job descriptions for every job held, the tasks involved, and type of equipment used. For each job, experts assessed the intensity and daily duration of WBV exposure. Inter-rater agreement for WBV ratings was examined using the kappa statistic, with values that ranged from 0.83 to 0.94. Logistic regression models explored the relationship between WBV exposure and prostate cancer, using various combinations of intensity, daily duration, and years of exposure. Potential confounders were also examined. Occupations with WBV exposure demonstrated an increased statistically non-significant risk [odds ratio (OR) = 1.44, 95% confidence interval (CI): 0.99-2.09]. The risk for transport equipment operation, a job with WBV exposure, was significantly elevated (OR = 1.90, 95% CI: 1.07-3.39). These results, together with those of an earlier study, suggest that workers in heavy equipment and transport equipment operation may have increased risk of prostate cancer. Further investigation is warranted.

Exposure to whole-body vibration and seat transmissibility in a large sample of earth scrapers.

BACKGROUND: It is often difficult to access a large sample of vehicles in various work environments to evaluate worker exposure to vibration such as in construction and mining. Thus the main purpose of the present research was to test vibration exposure in a relatively large number of earth scrapers. The second aim was to assess vibration exposure values on seat transmissibility. STUDY DESIGN: 33earth scrapers were assessed for both exposure to whole-body vibration and seat transmissibility. METHOD: Two triaxial accelerometers, one placed on the seat and one on the floor directly below the seat, were used to gather whole-body vibration values (a(w)). Each machine was tested for a minimum of three complete work cycles: idling, scraping, travelling full, dumping, travelling empty back to the scrape site. RESULTS: Results showed that idling and scraping produced low levels of vibration when compared to travelling and dumping. Second, when the a(w) values were compared to the EU safety standards for an eight hour work day, the data (z axis) exceeded the exposure action value (0.5 m/s2) in all machines, and the exposure limit value (1.15 m/s2) in some. Implications; Operators of the scrapers were being exposed to unsafe levels of whole-body vibration. When the seats were assessed to see whether they were attenuating operator exposure to vibration, many of the seat effective amplitude transmissibility (SEAT) values exceeded 1.0. This meant that some of the seats were actually amplifying the vibration present at the floor, particularly in the y axis. CONCLUSION: Travelways should be kept smooth, operating speeds reduced, and new seats, effective in all three axes, designed.

Defining program sustainability: differing views of stakeholders.

OBJECTIVES: Sustainability is a highly desired outcome of health promotion programs, yet it often eludes program planners looking to achieve it. This study aimed to uncover how the goal of program sustainability was interpreted by key stakeholders from three fall prevention program demonstration sites. METHOD: Collected as part of a larger study on program sustainability that made use of a multiple case study methodology, semi-structured interviews were conducted with key informants involved in a wide range of program initiatives throughout the two-year funding period. RESULTS: Forty participants across the three sites provided definitions of sustainability. Most stakeholders reported that it was some version of the general fall prevention program that should be sustained. Fewer stakeholders reported that it was the successful elements or solutions to the program goals that should be sustained. The most common suggestions reported by stakeholders for how sustainability should be achieved were awareness raising and securing new funding sources. Although a number of key elements emerged, there were significant differences in stakeholders' definitions of sustainability, both within and between demonstration sites. CONCLUSION: This research provided insight into the unique meanings of sustainability held by different stakeholders during their involvement in a fall prevention program. The array of definitions held by stakeholders demonstrates how easily the efforts of those involved can become fragmented and, therefore, less effective in reaching the end goal of program sustainability when the project team is not working from the same definition of what that goal means.

Utilization of the Seniors Falls Investigation Methodology to identify system-wide causes of falls in community-dwelling seniors.

PURPOSE: As a highly heterogeneous group, seniors live in complex environments influenced by multiple physical and social structures that affect their safety. Until now, the major approach to falls research has been person centered. However, in industrial settings, the individuals involved in an accident are seen as the inheritors of system defects. The objective of the present study was to investigate safety deficiencies that contributed to falls in community-dwelling seniors using a systems approach. DESIGN AND METHODS: The investigations were conducted using the Seniors Falls Investigation Methodology (SFIM), an adapted version of a method used to examine transportation accidents, such as airplane crashes. Fifteen seniors, who experienced a fall or near fall, participated in multiple case studies. A cross-case synthesis was used to summarize findings and identify common patterns of causes and safety deficiencies. RESULTS: Falls and near falls are a result of latent unsafe conditions, and unsafe acts and decisions combined in a diverse set of circumstances. If not identified and removed, these unsafe conditions can cause falls for other seniors. IMPLICATIONS: This study provided compelling evidence that causes of falling are systemic and develop over time. It demonstrated that the systems approach is needed to expand the focus from the individual to multilayered organizational and supervisory causes. The SFIM demonstrated capability to identify causes of falls that will allow better prevention and management programs, hence advancing seniors' safety. SFIM shows great potential for implementation in organized settings, such as hospitals and long-term care homes.

Broadening our understanding: approaching falls as a stigmatizing topic for older adults.

This theoretical paper aims to demonstrate that our current understanding of falls in older adulthood can be improved by viewing falls as a stigmatizing topic. Existing empirical research alludes to the stigmatization of falls for older adults, but until now the explicit link between the study of falls and stigma has not been made. After applying the concepts of identity threat, modified labeling theory, and attribution theory, the research implications of stigma on an older adult's willingness to report and discuss falls will be outlined. As many research investigations use the number of prior falls to assign individuals to study groups, the influence of stigma may be widespread and confounding research findings. By better recognizing and understanding the contribution of stigma to the willingness of older adults to report and discuss falls, we will be better able to mitigate its effects.

Online collaborative learning: quantifying how people learn together online.

BACKGROUND: Curtis and Lawson described a simple but useful method to quantify the interactions of students collaboratively learning online using content analysis to categorise behaviour. We extended Curtis and Lawson's method by allowing responses to interactions to be recorded and analysed. Populations can be partitioned into groups of arbitrary size to address a variety of research questions. AIMS: This paper describes an attempt to explore the utility of this extended method when applied to real online collaborative learning. METHOD: Using an illustrative example from a postgraduate online medical course for general practitioners, we show how rich the dynamics of online interaction can be and how courses can be analysed to suggest improvements. RESULTS: We found that tutors and students differ in how they behave when learning online and according to task type. CONCLUSIONS: We propose that our method could be useful to measure the effectiveness of collaborative exercises and can be applied wherever research is committed into online group behaviour.

Perceiving falls within a family context: a focused ethnographic approach.

The purpose of the present research was to examine the perceptions of risk regarding falling held by older adults and their adult children. Using a focused ethnographic approach, older adults and adult children were interviewed in depth. Thematic analysis was conducted to identify themes within groups and to compare the perspectives of older adults and adult children. Findings highlighted differences in perceptions and approaches to action between older adults and their adult children. There were three approaches to action adopted by these families, which focused around whose actions were dominant: parents' actions, shared actions, and children's secret actions. The results emphasize the value placed on independence by older adults and the impact of multiple family relations taking action to prevent falls. The present study points to the importance of including multiple family perspectives in research concerning injury prevention for older adults.

Seniors Falls Investigative Methodology (SFIM): a systems approach to the study of falls in seniors.

An in-depth understanding of human factors and human error is lacking in current research on seniors' falls. Additional knowledge is needed to understand why seniors are falling. The purpose of this article is to describe the adapting of the Integrated Safety Investigation Methodology (ISIM) (used for investigating transportation and industrial accidents) to studying seniors' falls. An adapted version-the Seniors Falls Investigative Methodology (SFIM)-uses a systems approach to take an investigation beyond the immediate cause of an incident and reveal unsafe acts and deeply imbedded unsafe conditions that contribute to adverse outcomes. An example case study is used to describe six phases of the investigative process in detail. The SFIM has the potential to identify safety deficiencies; utilize existing knowledge about falls; establish a standardized reporting system; shift focus from the faller to the system; and guide targeted prevention.

Defining a fall and reasons for falling: comparisons among the views of seniors, health care providers, and the research literature.

PURPOSE: The purpose of this study was (a) to obtain information about the perceptions held by seniors and health care providers concerning what constitutes a fall and potential reasons for falling, and (b) to compare these perceptions to the research literature. DESIGN AND METHODS: As part of a larger telephone survey, interviewers asked 477 community-dwelling seniors to define a fall and to provide reasons for falling. In addition, we interviewed 31 health care providers from the community on the same topics. In order to capture patterns in conceptualized thinking, we used content analysis to develop codes and categories for a fall definition and reasons for falling. We reviewed selected articles in order to obtain a comprehensive overview of fall definitions currently used in the research and prevention literature. RESULTS: A fall had different meanings for different groups. Seniors and health care providers focused mainly on antecedents and consequences of falling, whereas researchers described the fall event itself. There were substantial differences between the reasons for falling as reported by seniors and the risk factors as identified in the research literature. IMPLICATIONS: If not provided with an appropriate definition, seniors can interpret the meaning of a fall in many different ways. This has the potential to reduce the validity in studies comparing fallers to nonfallers. Research reports and prevention programs should always provide an operational definition of a fall. In communication between health care providers and seniors, an appropriate definition increases the possibility for early detection of seniors in greater need of care and services.

Predictors of whole-body vibration exposure experienced by highway transport truck operators.

Whole-body-vibration (WBV) exposure levels experienced by transport truck operators were investigated to determine whether operator's exposure exceeded the 1997 International Standards Organization (ISO) 2631-1 WBV guidelines. A second purpose of the study was to determine which truck characteristics predicted the levels of WBV exposures experienced. The predictor variables selected based on previous literature and our transportation consultant group included road condition, truck type, driver experience, truck mileage and seat type. Tests were conducted on four major highways with 5 min random samples taken every 30 min of travel at speeds greater than or equal to 80 km/h (i.e. highway driving). Results indicated operators were not on average at increased risk of adverse health effects from daily exposures when compared to the ISO WBV guidelines. Significant regression models predicting the frequency-weighted RMS accelerations for the x (F((5,97)) = 8.63, p < 0.01), y (F((5,97)) = 7.74, p < 0.01), z (F((5,61)) = 9.83, p < 0.01) axes and the vector sum of the orthogonal axes (F((5,61)) = 13.89, p < 0.01) were observed. Road condition was a significant predictor (p < 0.01) of the frequency-weighted RMS accelerations for all three axes and the vector sum of the axes, as was truck type (p < 0.01) for the z-axis and vector sum. Future research should explore the effects of seasonal driving, larger vehicle age differences, greater variety of seating and suspension systems and team driving situations.

Factors influencing load-haul-dump operator line of sight in underground mining.

The inability of load-haul-dump (LHD) equipment operators to see people, objects or hazards around the LHD machine they drive is a causal factor in a number of serious accidents. Line of sight evaluations were conducted on 11 different LHD models. Results indicated blind spots were caused by cab posts, and vehicles lights and light brackets. Line of sight impairments were caused by wheel well covers, buckets, fire extinguisher, light posts, radiator covers, booms, radio remote boxes, elevated engine profiles and air intake cylinders. These results were supported by questionnaires completed by 130 LHD operators. The operators indicated the bucket, lights and light brackets, boom and cab impaired line of sight. Line of sight testing and LHD operator feedback indicated line of sight to the right front corner and back right corner were typically worse than line of sight to the front left side of the vehicle. Results of this study have been used to conduct awareness campaigns within the Ontario mining industry and to suggest vehicle design modifications to LHD manufacturers.

An exploratory study of whole-body vibration exposure and dose while operating heavy equipment in the construction industry.

Whole-body vibration measurements were recorded for various types of heavy equipment used within the construction industry. The purpose of these measurements was to provide more information about the potential levels of whole-body vibration experienced by equipment operators in the construction industry, as well as to identify types of equipment warranting further research. In total, 67 pieces of equipment were tested from 14 different equipment types. Testing took place at various construction sites including corporate, public, and residential work projects. Measurements were made (following the 1997 International Standards Organization's 2631-1 whole-body vibration standards) for 20-minute testing periods using a Larson Davis HVM100 vibration monitor and a triaxial accelerometer. The mobile equipment tested was associated with greater levels of whole-body vibration than the stationary equipment. When whole-body vibration levels were compared to the International Standards Organization's 2631-1 standards, wheel loaders, off-road dump trucks, scrapers, skid steer vehicles, backhoes, bulldozers, crawler loaders, and concrete trowel vehicles exceeded the recommendations based on measured vibration dose values. Further research incorporating larger sample sizes and controlled testing conditions is required to better understand the levels of exposure experienced by operators as well as the amount to which seating, terrain, mobility, and vehicle structure might affect whole-body vibration.