Summary
This paper is an assessment of the fall prevention practices at University Hospital Sharjah, a 350-bed multispecialty facility located in the UAE. Its fall prevention policies and practices follow the 2005 evidence-based guidelines set by the Singaporean Ministry of Health. However, a comparison of the document and the hospital’s internal papers reveals some divergence, while an analysis of the practical environment found several problems. An analysis of the more recent evidence discovered several problems in University Hospital Sharjah’s practices and offered solutions to several, but not all, problems. Further analysis of current research articles provided insights into several potential pathways that can be taken to help reduce the facility’s fall incidence. The usage of technology is a particularly prevalent theme, with many different promising potential applications, but reviewing previously non-considered approaches to traditional interventions and educating patients also appear to be valid approaches.
Introduction
University Hospital Sharjah is located next to the University of Sharjah in the United Arab Emirates. It offers an extensive suite of medical services in most fields, gathering highly skilled physicians, nurses, and other workers to ensure that the patients receive the highest possible standard of care. At the same time, it is used as a learning environment for the University’s students, where they can learn medicine under the supervision of highly skilled professionals. The hospital’s inpatient department has 350 beds that are provided to patients with different issues. Many of the patients staying at the facility have mobility issues and are at risk of falls. University Hospital Sharjah staff are aware of this possibility and work to prevent such a problem from happening. The purpose of this assessment is to review the guidelines that they follow in doing so, check the hospital’s compliance with them, and provide evidence-based improvement suggestions.
Evidence Base and Its Implementation
Primarily, University Hospital Sharjah relies on the 2005 fall prevention guidelines formulated by Singapore’s Ministry of Health. These suggestions rely on an extensive evidence base that covers risk assessment, interventions to prevent falls, and post-fall analysis and management in case a fall takes place regardless. Every set of suggestions is also rated based on the strength of the evidence found for it in the report. With that said, while this transparency is beneficial, many of the statements made in the guidelines have the lowest level of trustworthiness, that based on expert opinions and work with similarly weak evidence. The understanding of fall prevention, as well as the evidence, has likely advanced significantly since 2005, addressing these issues. However, the guidelines still offer an acceptable baseline on which the hospital’s performance can be rated.
In terms of prevention, University Hospital Sharjah does not necessarily follow the guidelines adequately. The guidelines suggest screening every patient for the risk of falls within 24 hours of their admission to the facility, a recommendation that receives a high degree of confidence (1). However, as indicated by (2), University Hospital Sharjah’s internal policies do not set out an urgency requirement and recommend only screening patients over 65, those in wheelchairs, patients taking IV medications, and pediatric patients. They add that the list includes these patients but is not limited to them, but, in practice, these patients tend to be the only ones receiving assessments. With that said, the facility’s modified Morse fall risk assessment tool (3) includes all of the components mentioned in (1). Moreover, (4) includes environmental aspects, which are omitted in (1) but can play a significant role in facilitating falls.
While (1) does not consider checking the patient’s environmental hazards, it considers environmental interventions, expecting them to be taken into account for all patients. Additionally, it considers approaches such as observation, assistance, medication reviews, education, and tailored exercise for long-term care recipients (1). The interventions recommended by the hospital (5) include all of these prevention methods with the possible exception of tailored exercise, though they feature rehabilitative therapy that may incorporate them. In practice, all of these interventions are regularly applied wherever necessary, and workers are aware of them and apply them. Moreover, the policy provides more detailed guidelines than (1) does, with a variety of specific approaches such as the usage of handlebars in washrooms. The hospital is well-equipped with the tools necessary to reduce fall incidence and uses them to their full effect.
For post-fall analysis and management, the Ministry of Health guidelines consist of three simple steps: take care of the patient’s injuries, conduct a medical review to exclude acute fall causes, and determine the root reason for the fall (1). With that said, these guidelines are backed with the lowest possible level of evidence, though overall, they appear to be adequate. The University Hospital Sharjah guidelines, as presented in (6), are more detailed, including the assessment of vital signs and motion range checks. These actions are included in the competency assessment, and each worker needs to confirm that they are proficient in performing them and prove it to the verification committee’s satisfaction. Otherwise, they need to undergo retraining in these particular skills, which ensures that the staff’s abilities stay freshly memorized and ready for application at any time.
Currently, the most significant gap in the hospital’s fall management is in its patient observation. Risk-prone patients are sometimes left unobserved due to staff shortages, which leads to them suffering falls when they try to leave their beds by themselves. Additionally, sometimes patients fall that have never been assessed for risks of such events and consequently not assigned interventions that would be determined to have been necessary after the incident. As a result, help can be slow getting to them since they have not been assigned supervision the same way another patient would. Lastly, the environment at the hospital appears to sometimes facilitate falls by making patients slip or stumble while walking despite the measures taken to do so. The current guidelines are being followed, and these issues may be the result of faults in them.
Field Observation and Current Evidence
Since 2005, a considerable amount of research has been conducted to help improve the ability of hospitals to prevent falls among their patients. Advancements have taken place, both technologically and methodologically, that have made the older guidelines obsolete in many regards. At the same time, some of the new developments have proven to be less effective than others and have been dismissed. As such, it is essential to review recent findings and guidelines to determine what approaches and interventions are currently considered best practices. There is a variety of different guidelines available, but some of them can be challenging to access due to various restrictions. Moreover, they do not necessarily reflect the latest findings in the field, given the constant developments that take place in it. As such, the author has chosen to source evidence on the latest clinical best practice from (7), a meta-synthesis of the science.
For the problem of unsupervised patients trying to move independently and falling as a result, (7) offers three potential answers: alarms, sitters, and intentional rounding. Alarms are designed to activate if the patient tries to leave their bed or chair, calling medical personnel to the location. However, (7) finds strong evidence that they are ineffective at preventing falls, though more advanced versions are emerging that may change this trend. Sitters who devote extensive time to a patient are already covered in (1), but this approach is not used because of the high staff workload it creates. Lastly, intentional rounding is an approach where workers visit patients regularly, proactively taking care of their needs. However, per (7), the evidence for its effectiveness is weak, and it also increases the burden on the staff. As such, it appears that current evidence does not have an answer to the issue other than placing a higher burden on the staff.
The problem of unassessed patients falling can be addressed by following the guideline provided in (1) of screening all individuals regardless of their apparent risk factors. Moreover, (7) reinforces the suggestion by also claiming that fall risk assessments such as (3) are ineffective at preventing falls. Risks are transitory, requiring regular reassessments, which University Hospital Sharjah provides per (3). However, (7) claims that such tools are not noticeably more effective than nursing judgment and recommends abandoning them in favor of considering all patients over 65 high-risk. Moreover, (7) suggests that, rather than determine the overall probability of the patient suffering a fall, it is more important to identify specific fall risk factors and address them in advance. Overall, current research suggests that the hospital’s fall risk assessment measures require a significant overhaul to save effort and improve results.
Lastly, for environmental factors, progress is being made, but it is not necessarily fast. Both (1) and (7) oppose the usage of restraints for patients to reduce their risk of falling, and University Hospital Sharjah has never used these tools during the author’s time at the facility. However, the hospital uses carpeted floors and nonslip socks to reduce the risk of the patient slipping and falling as a result. (7) finds weak evidence that vinyl floors may be safer for patients than their carpet counterparts. Moreover, (7) also discovers that the support base for nonslip socks is weak, with no strong evidence of their properties, while they are known to increase the risk of drug-resistant infection spread. As such, while there are few specific improvement suggestions, some of the methods used at University Hospital Sharjah may need to be abandoned.
Research Study Description
Modern technologies provide a large number of options for the improvement of patient safety and reduction of fall risk. (8) suggests using a supportive exoskeleton that reduces pain associated with movement and significantly reduces the risk of falling in the patients using it, even compared to other interventions such as exercise. With that said, the technology is still in the early stages and has not seen widespread adoption in most spheres, and some caution and additional research may be required. A more accessible option may be provided in (9), which suggests using virtual reality technology to help patients enjoy their exercise more. The participants demonstrated positive attitudes toward this approach compared to just training, which may make them more willing to participate in it. As a result, they would put more effort into training and become more physically fit and resistant to falls.
Another option for leveraging technology would be in addressing the current failings of risk assessment tools. As (7) notes, they are characterized by low amounts of evidence for any particular model, with many facilities using a homemade checklist that has received little to no validation. (10) offers an alternative using machine learning, aggregating large amounts of assessments and fall incident data and analyzing it through the high computational power of modern technology. In theory, this system could create a universal, heavily evidence-based assessment and risk identification tool that may even discover currently unknown risk factors. However, issues related to machine learning, such as input data bias, patient privacy concerns, and the obfuscated mechanism by which decisions are reached have to be considered.
Among interventions that can be implemented currently without waiting for future technological developments or heavy investment, exercise needs to be considered. Currently, University Hospital Sharjah does not have a standardized exercise program in place, sometimes having therapists assign regimens to individual patients based on their assessments. In (11), the researchers conduct a randomized clinical trial and find that fall-oriented Tai Ji Quan interventions can reduce the probability of falls in older adults at heightened risk significantly compared to both stretching and multimodal exercise. Such approaches, which capitalize on well-established if unorthodox techniques, could be highly promising for the overall reduction of patient risk without incurring high costs. Investigations of other cultural practices for their potentially superior effectiveness compared to established methods may be warranted, as well.
Lastly, if University Hospital Sharjah cannot commit enough resources to continuously monitor patients through either the use of sitters or intentional rounding as outlined in (7), it can attempt to dissuade patients from behaviors that tend to lead to falls. (12) suggests that in patients may not be sufficiently aware of the dangers of falls and their probability of suffering one. As such, they recommend the development of a fall self-awareness scale and educating patients on the common risk factors. People who are aware of the dangers of acting carelessly will be more likely to avoid such behaviors. Then, if they are provided with suitable alternatives for securing help from staff, their likelihood of taking such actions will decline further.
Conclusion
Overall, while University Hospital Sharjah follows many of the suggestions set out in its evidence-based guidelines closely, there is still some divergence that does not necessarily benefit the hospital. Falls are excessively prevalent due to a lack of staff time to check on patients and the usage of some practices that may not necessarily reduce the risk. Moreover, since the release of the original guidelines in 2005, there have been considerable advancements in best practices surrounding fall prevention. Some of the problems affecting University Hospital Sharjah can now be addressed, while others remain unsolved and at its discretion. The hospital can also consider the usage of innovative technologies, both ones that can be used currently and those still in development. Ultimately, there are ways to address many of the current gaps in the facility’s fall prevention, and the rest can be resolved by continually monitoring the field.
References
- Ministry of Health. Prevention of falls in hospitals and long-term care institutions. Singapore: Ministry of Health; 2005. 35 pages.
- University Hospital Sharjah. Criteria for performing patient fall risk assessment in OPD. Sharjah: University Hospital Sharjah; n.d. 1 page.
- University Hospital Sharjah. Policy and procedure title: fall risk assessment and prevention. Sharjah: University Hospital Sharjah; 2014. 18 pages.
- University Hospital Sharjah. Five steps to prevent/reduce falls. Sharjah: University Hospital Sharjah; n.d. 1 page.
- University Hospital Sharjah. Falls prevention interventions are based on assessed risk. Sharjah: University Hospital Sharjah; n.d. 1 page.
- University Hospital Sharjah. Title: fall risk assessment and prevention. Sharjah: University Hospital Sharjah; n.d. 2 pages.
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- Mioskowska M, Stevenson D, Onu M, Trkov M. Compressed gas actuated knee assistive exoskeleton for slip-induced fall prevention during human walking. 2020 IEEE/ASME International Conference on Advanced Intelligent Mechatronics (AIM). 2020; Boston, USA. New York: IEEE; 2020. p. 735-40.
- Phu S, Vogrin S, Al Saedi A, Duque G. Balance training using virtual reality improves balance and physical performance in older adults at high risk of falls. Clinical Interventions in Aging. 2019;14:1567-77.
- Sun R, Hsieh KL, Sosnoff JJ. Fall risk prediction in multiple sclerosis using postural sway measures: a machine learning approach. Scientific Reports. 2019;9(1):1-7.
- Li F, Harmer P, Fitzgerald K, Eckstrom E, Akers L, Chou LS, Pidgeon D, et al. Effectiveness of a Therapeutic Tai Ji Quan Intervention vs a multimodal exercise intervention to prevent falls among older adults at high risk of falling: a randomized clinical trial. JAMA Internal Medicine. 2018; 178(10):1301-10.
- Shyu ML, Huang HC, Wu MJ, Chang HJ. Development and validation of the self-awareness of falls in elderly scale among elderly inpatients. Clinical Nursing Research. 2018;27(1):105-20.