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Fall Prevention: Are bed alarms overused?

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    Background and Rationale
    Falls among any individual can cause significant trauma, often leading to an increase in mortality. According to the Centers for Disease Control and Prevention (2012), one in every three adults over the age of 65 falls each year. Long-term care facilities account for many of these falls, with an average of 1.5 falls occurring per nursing home bed annually (Vu, Weintraub, & Rubenstein, 2004). In 2001, the American Geriatric Society, British Geriatric Society, and the American Academy of Orthopaedic Surgeons Panel on Falls Prevention published specific guidelines to prevent falls in long-term care settings (Shimada, Tiedemann, Lord, & Suzuki, 2009). These guidelines included “staff education programs; gait training and advice on the appropriate use of assistive devices; and review and modification of medications” (Shimada et al., 2009, page 825). However, according to Shimada et al. (2009), these interventions have helped prevent falls in long-term care residents who are independently mobile and cognitively intact, but have limited effectiveness on those who are not as independently ambulatory and cognitively impaired.

    Some research studies suggest that scheduled patient rounding leading to enhanced supervision will decrease the number of falls in residents of long-term care communities. Interventions included in this scheduled patient rounding include, but are not limited to, checking rooms every hour, offering and assisting with toileting, removing obstacles in resident’s rooms, and providing a diversion activity for those who are more subject to wandering (Shimada et al., 2009).

    Many facilities, however, continue to utilize bed alarms in place of scheduled rounding as part of comprehensive fall prevention programs (Hubbartt, Davis, & Kautz, 2011). This alarm can be heard throughout the entire unit once a presumed fall risk patient attempts to get out of bed without using his or her call light. Can the use of bed alarms be an adequate substitute to frequent, scheduled patient rounding in preventing falls? PICO Question

    The population selected for this literature review is residents of long-term care facilities. These residents are typically in need of further care to carry out their activities of daily living. Due to the increase in home care opportunities, the population that currently resides in long-term care facilities consists more of individuals with higher level of disability and cognitive impairment, making them higher fall risks (Spector, Fleishman, Pezzin & Spillman, 2001).

    The identified intervention is scheduled patient rounding. As listed above, scheduled patient rounding is having a provider check on the patient at least hourly to enhance supervision of residents. During the scheduled patient rounding, the provider may survey the scene for safety, offer and assist with toileting, and provide diversion activities to those who are subject to wandering.

    The comparison intervention is the use of bed alarms. The idea is that if the patient tries to get out of bed without assist, the bed alarm will sound and a staff member will assist the patient out of bed diminishing the need for scheduled rounding.

    The outcome is a decrease in fall rates. Decreasing falls will help prevent the 20-30% of people who suffer moderate to severe trauma such as head injuries, hip fractures, and skin breakdown due to falls (CDC, 2012).

    Thus, this leads to the PICO question: In residents of long-term care facilities, does a scheduled patient rounding program or the generalized use of bed alarms cause a greater reduction in the annual fall rate?

    Search Strategies
    The clinical question that is deemed significant for further review is: In residents of long-term care facilities, does hourly rounding or the generalized use of bed alarms cause a greater reduction in fall rates? A literature review was completed using the University of North Dakota’s Harley French Library online search. CINAHL, PubMed, and The Cochrane Library were the online databases used to access journal articles related to scheduled hourly patient rounding, bed alarms, and fall rates. Initially, a search using the CINAHL database with CINAHL heading bed alarm and limited to the English language yielded 14 articles, three which were appropriate to this study. The CINAHL headings bed alarm AND hourly rounding did not generate any results. However, CINAHL headings hourly rounding AND fall generated one article that was useful to this study. PubMed was the second database used to search articles relating to the clinical question. In the PubMed advanced search builder, bed alarm AND falls yielded 11 articles, one of which was applicable to this study. When hourly rounding AND falls were included in the PubMed advanced search builder, six articles were found. One article was not useful due to it being a systematic review of articles that are already of use to this study causing duplication. Two of these articles were valuable to this study. The Cochrane Library search with the MeSH heading accidental falls yielded 7694 articles. To further narrow the search, the MeSH headings bed alarm AND hourly rounding were added. This yielded six articles, one of which was applicable to this study. Finally, one article was found by conducting a search of the identified article’s reference section. This article was searched by title on the Cochrane database and was found useful to the clinical question. A total of nine articles pertaining to the clinical question are of use to this literature review. Synthesis of Literature

    While nine articles were found to be useful to this study, not all of them researched bed alarms and hourly rounding together. Most of the available evidence has studied either the risk and rate of falls with the intervention of bed alarms or the risk and rate of falls with hourly rounding implementation. Some of the evidence is a combination of multiple fall prevention interventions, so it is hard to tell whether bed alarms or hourly rounding is the specific intervention that caused a statistical significant
    outcome.

    Of the nine articles found, the study design and level of evidence varied immensely. One systematic review was found in the literature search, but discarded due to having a number of articles under study that were not applicable to this specific clinical question. No meta-analysis studies were found. The highest level of evidence that was applicable to this literature review was a randomized controlled trial. Out of the nine articles, there were only two available randomized controlled trials that were appropriate. There were also two quasi-experimental and three pilot studies, accordingly. One article was a case-controlled study and one was a descriptive and repeated measures design.

    While synthesizing the evidence, there was difficulty in finding studies that specifically matched the selected population—residents of long-term care facilities. Many studies were done in an acute care setting in which the population may have a broader range of age. Although one unit was considered a geriatric unit, it was still acute care. The compiler of this literature review felt these studies still reflected the clinical question. Although residents in a long-term care facility may have more diagnoses of dementia and Alzheimer’s disease, a medical-surgical unit will add those who may have psychiatric disorders and drug/alcohol withdrawal along with confused/delirious patients. Both long-term care facilities and acute care settings will have residents or patients who are considered fall risks.

    However, there were two studies that are questioned for appropriateness of population. TIdeiksaar, Feiner, and Maby (1993) found no statistical change in fall rate between control and experimental group after adding bed alarms to a fall prevention protocol. Fall data was not collected before the study and both control and experimental groups had low fall rates. Another study by Lowe and Hodgson (2012) showed no falls in the two weeks that hourly rounding was implemented. However, fall data shows that there were not falls for two months prior to the study on this unit. Were these units appropriately selected to be studied? Should other units that showed a greater need for change have been designated?

    Moreover, the studies did show evidence as to whether bed alarms or a scheduled hourly rounding system reduced the fall rate. A few of the studies displayed a theme that, in terms of the PICO question, bed alarms did not decrease the fall rate. Three of the studies found this to be true. Shorr et al. (2012) conducted a pair matched cluster randomized controlled trial that evaluated whether an increased usage of bed alarms will lead to a decrease in falls and a decrease in the use of restraints. This study was from a large sample size of 27,672 patients from an acute care setting. It found that increase usage of bed alarms did not have a statistically significant effect on the rate of falls, injury from falls, or the use of restraints when compared to control group. A smaller case-controlled study by Tideiksaar, Feiner, and Maby (1993) concurs that increased usage of bed alarms showed no statistically significant reduction in fall rates. A pilot study conducted by Hubbartt, Davis, and Kautz (2011) also found that adding the intervention of bed alarms to a unit in an acute care setting did not decrease the fall rate.

    However, one study found that a seven step individualized fall prevention program, which occasionally included the use of bed alarms, decreased the fall rate beyond the benchmark rate set by the facility. Capan and Lynch (2007) conducted a pilot study in which a multidisciplinary approach to fall prevention was integrated. The facility set a benchmark outcome that they wanted the fall rate to decrease from 0.45 falls per 100 patient-days to 0.35 falls per 100 patient-days. After the multidisciplinary program was in use for 100 days, the fall rate decreased to 0.32 falls per 100 patient-days. The study did not say whether this was statistically significant, but rather that they surpassed their outcome. Nonetheless, this study cannot contribute success solely to bed alarm usage but rather an individualized multidisciplinary approach to fall prevention. No study found that solely adding bed alarms as a fall prevention intervention decreased fall rates.

    As well not showing evidence to support bed alarm usage, the studies supported using an hourly rounding schedule as a fall prevention technique.

    Meade, Burselff, and Ketelsen (2006) conducted a quasi-experimental nonequivalent groups design study that evaluated an hourly and every two hour nurse rounding protocol. There was a statistically significant decrease in the fall rate with the hourly rounding protocol. Another study by Tucker, Bieber, Attlesey-Pries, Olson, and Dierkhising (2012) evaluated a structured hourly rounding program on two orthopedic units. They found a statistically significant decrease in falls after the program was initiated. Lastly, a quasi-experimental study by Olrich, Kalman, and Nigolian (2012) showed a 23% decrease in the fall rate after an hourly rounding program was introduced. While this was not statistically significant, the authors believed this was clinically significant to that specific unit. Not included in these three studies was the study by Lowe and Hodgson (2012) which also researched hourly rounding. This unit did not have any falls during the hourly rounding implementation; however, as described earlier, this unit did not have any falls two months before the hourly rounding implementation either.

    Nevertheless, one study found that hourly rounding did not reduce the fall rate. Krepper et al. (2012) implemented an hourly rounding protocol to study the effects on fall rates, patient satisfaction scores, call light usage, readmission rates, and number of steps taken by nurses per shift. The study found that hourly rounding did not statistically decrease the fall rate; however, it did find that hourly rounding reduced the number of steps for nurses and patient call light usage.

    Using the United States Preventative Services Task Force (USPSTF) evidence grading schema, I would rate the combination of evidence for this review as category B and fair quality. The evidence is sufficient to determine what the health outcome may be with this intervention, but there could have been larger studies or systematic reviews contributed to add to the literature review. This also means that the practice of hourly rounding would be recommended to eligible patients based on fair evidence findings and no harm imposed on the patient. I chose the USPTSTF evidence grading schema because categories for grading were very clear due to an algorithm provided. An article review summary is provided in the appendix. Practice Recommendations

    With the above information, I believe there is room for further research. Some of the research was performed on very small populations, which makes it challenging to form a generalized recommendation. Recommendation #1

    Given that only one study did not find hourly rounding to reduce the fall rate while three found that hourly rounding did reduce the fall rate, I would recommend that implementing an hourly rounding protocol would be advantageous to a fall prevention program. Three studies found that bed alarms will not reduce fall rates, while one study found the fall rate to decrease after a multidisciplinary individualized approach to fall prevention. This multidisciplinary individualized approach to fall prevention sometimes included a bed alarm, but not on every patient. The bed alarm was only used on confused or impulsive patients.

    This hourly rounding protocol should be a teamwork driven program that includes both registered nurses and nursing assistants. These individuals could be assigned certain hours to round on certain patients. For example, the registered nurse could always round on the patients on the even hours, while the nursing assistant rounds on the odd hours. Recommendation #2

    Consequently, my second recommendation would be to use bed alarms sparingly in fall prevention programs and not automatically put a bed alarm on any fall risk. This would include using a bed alarm for those patients who are confused and impulsive. This decision should be left to the discretion of the registered nurse taking care of the patient. The long-term care facility or hospital unit could have a questionnaire or flow sheet that registered nurses can reference to help decide if a certain patient is appropriate for a bed alarm. For example, if there is a confused patient who is immobile and not impulsive there would be no need for a bed alarm. This alarm would most likely only set off when nurses or nursing assistants are turning the patient. This leads to false alarms which could lead to alarm exhaustion and less timely responses from nurses. Strength of Recommendation

    The strength of recommendation was found by using “Strength of Recommendation Taxonomy” or “SORT” (Ebell et al., 2004). Both
    recommendations were found to have a strength of “B” or “recommendation based on inconsistent or limited-quality patient-oriented experience” (Ebell et al., 2004). In order to achieve a strength of “A” the literature must consist of two randomized controlled trials that support the recommendation. There also were not any systematic reviews or meta-analysis’ found that consistently support the recommendation. However, it did not receive the grading of “C” which is more of an opinion based recommendation due to it having some evidence-based practice support (Ebell et al., 2004).

    Implementing these recommendations would entail a lot of time and adherence. First, this would need to be brought to management of the facility for approval. Approaching management by stating the problem of falls and current research found in this literature review would be appropriate. In addition, stating the cost of falls would further attest to the need for the most superlative fall prevention protocol. According to the Centers for Disease Control and Prevention (2012), the average fall in a person over 72 years of age is $19,440. If these recommendations were approved for a new fall prevention protocol, it would then be introduced to the staff and implemented slowly. First, nurses and nursing assistants would need education through online training or a class on how to properly implement this protocol and other units’ successes with it. It may be appropriate to introduce a flow sheet on how to determine if a patient or resident is worthy of a bed alarm. Once the staff is properly educated, it is time to start the implementation of the program. It may be a good idea to start with just a few rooms on the unit to get registered nurses and nursing assistants used to the idea. This could allow the program to be incorporated and allow for increased adherence to the rounding. Auditing may be necessary, because without everybody doing his or her part, the hourly rounding program will be ineffective. Once auditing has shown adherence, gradually introducing the rest of the unit to the program is appropriate. Finally, a follow up audit and staff opinions regarding the new program should be incorporated into the new plan. If the fall rates have been reduced since the program has started, this should be shared with the staff as well so they can see the success of their work. Conclusion

    Ultimately, the research on whether hourly rounding or bed alarms generate a greater reduction in fall rates should be studied further to expand the available evidence. The above recommendation provides a general guideline on a fall prevention program that this literature review supports. An hourly rounding protocol with bed alarm usage in appropriate patients would be beneficial to residents of long-term care facilities. The existing evidence supports this may lead to a decrease in fall rate, which could lead to elongating lives of many elderly people.

    References
    Capan, K., & Lynch, B. (2007). Reports from the field: patient safety. a hospital fall assessment and intervention project. Journal of Clinical Outcomes Management: JCOM, 14(3), 155-160. Centers for Disease Control and Prevention, Division of Unintentional Injury Prevention. (2012). Falls among older adults: an overview. Retrieved from website: http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Ebell, M., Siwek, J., Woolf, S., Susman, J., Ewigman, B., Bowman, M., & Weiss, B. (2004). Strength of recommendation taxonomy: a patient-centered approach to grading evidence in the medical literature. Journal of the American Academy of Family Physicians, Retrieved from http://www.aafp.org/afp/2004/0201/p548.html Hubbartt, B., Davis, S., & Kautz, D. (2011). Nurses’ experiences with bed exit alarms may lead to ambivalence about their effectiveness. Rehabilitation Nursing, 36(5), 196-199. Krepper, R., Vallejo, B., Smith, C., Lindy, C., Fullmer, C., Messimer, S., Xing, Y., & Myers, K. (2012). Evaluation of a standardized hourly rounding process (sharp). Journal for Healthcare Quality, 00(0), 1-7. Lowe, L., & Hodson, G. (2012). Hourly rounding in a high dependency unit. Nursing Standard, 27(8), 35-41. Meade, C., Bursell, A., & Ketelsen, L. (2006). Effects of nursing rounds on patients’ call light use, satisfaction, and safety. American Journal of Nursing, 106(9), 58-70. Olrich, T., Kalman, M., & Nigolian, C. (2012). Hourly rounding: a replication study. Medsurg Nursing, 27(1), 23-26. Shimada, H., Tiedermann, A., Lord, S., & Suzuki, T. (2009). The effect of enhanced supervision on fall rates in residential aged care. Amercian Journal of physical medicine & rehabilitation, 88, 823-828. doi: 10.1097/PHM.0b013e3181b71ec2 Shorr, R., Chandler, M., Mion, L., Waters,
    T., Liu, M., Daniels, M., Kessler, L., & Miller, S. (2012). Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients . American College of Physicians, 157(10), 692-699. Spector, W. D., Fleishman, J. A., Pezzin, L. E., & Spillman, B. C. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2001). The characteristics of long-term care users. (00-0049). Retrieved from AHRQ Publications website: http://www.ahrq.gov/research/ltcusers. Tideiksaar, R., Friner, C., & Maby, J. (1993). Fall prevention: the efficacy of a bed alarm system in an acute-care setting. The Mount Sinai Journal of Medicine, 60(6), 522-527. Tucker, S., Bieber, P., Attlesey-Pries, J., Olson, M., & Dierkhising, R. (2012). Outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units. Worldviews on Evidence-Based Nursing, 18-29. Vu, M. Q., Weintraub, N., & Rubenstein, L. Z. (2004). Falls in the nursing home: are they preventable?. Journal of the american medical directors association , 5(6), 401-406. Retrieved from CINAHL electronic database

    Author (Year)
    Title
    Journal
    Purpose/Problem/
    Objective
    Study Design and Level of Evidence
    Sample
    (Setting)
    Data Collection/
    Methods
    Measurement/
    Data Analysis
    Results/Findings
    Implications
    Strengths/
    Limitations
    Shorr, R., Chandler, M., Mion, L., Waters, T., Minzhao, L., Daniels, M., Kessler, L. & Miller, S. (2012)

    Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients

    Annals of Internal Medicine
    1. Evaluate whether increased usage of bed alarms will lead to a decrease in falls and a decrease in the use of restraints. Pair matched, cluster RCT
    A 16 unit hospital consisting of 27,672 patients from general medical, surgical, and specialty units.

    The nursing units were given a number 1-16 randomly. They paired up with a neighbor number and one was the control/one was the intervention. Nursing units were randomly assigned into either a control or intervention group. Data was collected over six months

    Control: Continue use of current fall prevention program including bed alarms on high fall risk patients.

    Intervention: Use of an alarm system in bed, chairs, and toilets in every patient room Distribution of falls was examined using a Wilcoxon test.

    A negative binomial regression model was used to study difference between groups.

    Rates were adjusted based on covariates such as staffing, demographic, and psychotropic drug administration variables. Increase in bed alarm usage did not have a statistical significant effect on the rate of falls, injuries from falls, or the use of restraints when compared to control group.

    Clinical significance could indicate hospitals may be improperly/overusing bed alarms as a fall prevention technique. Strengths:
    1. RCT
    2. Large sample size
    3. Data collection recognized contributing covariates and adjusted rates based on these.

    Limitations:
    1. Study held only at one site.
    2. Not a blinded study

    APPENDIX 1

    Author (Year)
    Title
    Journal
    Purpose/Problem/
    Objective
    Study Design/Level of Evidence
    Sample
    (Setting)
    Data Collection/
    Methods
    Measurement/
    Data Analysis
    Results/Findings
    Implications
    Strengths/
    Limitations
    Krepper, R., Vallejo, B., Smith, C., Lindy, C., Fullmer, C., Messimer, S. & Xing, Y. (2012)

    Evaluation of a standardized hourly rounding process (SHaRP).

    Journal for Healthcare Quality
    To discover whether an hourly rounding protocol will result in improved patient satisfaction, quality, safety, and efficiency scores. RCT
    Two 32 bed cardiovascular surgery units.

    The units had almost identical characteristics such as census, number of admissions/discharges/transfers, hours in patient day and staff turnover.
    Data was collected over a six month period.

    Control group: No hourly rounding protocol implemented

    Intervention group: Hourly rounding protocol implementation

    Use of independent sample t-tests to compare call light use between both groups.

    Survey regression methods were used to analyze nurse’s perception of “having enough time.”

    Chi-square tests measured patient satisfaction between the two groups

    Wilcoxon two-sample non parametric tests were used to evaluate crude fall rates and readmission rates between the groups.

    The intervention group showed statistically significant reduction in both call light use and number of steps taken per nurse during a day shift.

    There was no statistical significance in patient falls, 30-day readmission rates, and patient satisfaction scores.

    Clinical significance could indicate hourly rounding reducing call lights and number of steps taken by nurses per shift. Strengths:
    1. RCT
    2. Previous studies usually conducted over 4 weeks—this one was over 6 months. 3. Inexpensive intervention.
    4. Intervention and control units had similar/almost identical characteristics as stated in the sample section.

    Weaknesses:
    1. Due to differences in staffing between day/night, 2-3 shifts/week were randomly sampled. 2. Study only held at one hospital on sister units.
    Author (Year)
    Title
    Journal
    Purpose/Problem/
    Objective
    Study Design/Level of Evidence
    Sample
    (Setting)
    Data Collection/
    Methods
    Measurement/
    Data Analysis
    Results/Findings
    Implications
    Strengths/
    Limitations
    Capan, K. & Lynch, B. (2007).

    Reports from the field: patient safety. A hospital fall assessment and intervention project.

    Journal of clinical outcomes management: JCOM
    To describe a specified developed fall protocol and the effects of implementation on fall rates of patients on a hospital unit. Pilot study
    Medical/Neurology unit in hospital setting. This floor specifically had a high incidence of falls and showed a need and readiness for a new fall prevention tool/protocol. They measured the fall rate over 100 patient-days with the multi-disciplinary fall prevention protocol in place.

    This protocol individualized fall risks by 7 risk factors and implemented interventions specific to the patient. Interventions included: wrist band, door magnet, fall prevention guide, hip protectors, orthostatic hypotension assessment, low bed, bed alarms, toileting, medication reviews.

    The research group set outcomes such as benchmark goals (0.35 fall rate per 100 patient-days) for what they want to see change in the fall rate.

    Along with measuring the fall rate, they also measured the severity of falls by categorizing into 3 groups—no inury, minor injury, and severe injury

    In this specific pilot study, it was found that the fall prevention protocol decreased fall rates from 0.45 to 0.32—surpassing their benchmark outcome.

    Implications: This may lead to more studies arising that examine individualization of fall prevention protocols. Strengths:
    1. Gives reason for future studies regarding individualization of fall protocols to develop. 2. Inexpensive interventions.
    3. Set outcome.

    Limitations:
    1. It is a pilot study, so is not the highest level of evidence. (Only one hospital; one unit). 2. Did not analyze whether the change in fall rate was statistically significant.

    Author (Year)
    Title
    Journal
    Purpose/Problem/
    Objective
    Study Design/Level of Evidence
    Sample
    (Setting)
    Data Collection/
    Methods
    Measurement/
    Data Analysis
    Results/Findings
    Implications
    Strengths/
    Limitations
    Meade, C., Burselff, A., & Ketelsen, L. (2006).

    Effects of nursing rounds on patients’ call light use, satisfaction, and safety

    American Journal of Nursing
    Aim is to study reasons for call light usage, effects of one and two hour nursing rounds on use of call light, patient satisfaction, and patient safety. Quasi-experimental nonequivalent groups design

    14 hospitals (27 medical, surgical, or medical/surgical units) Data was collected for six weeks.

    Each unit either used an hourly rounding system or every two hour rounding system.

    Data was collected by analyzing the number of call lights, patient satisfaction surveys and fall rates.

    Control group: Units without hourly rounding or 2 hour rounding implementation

    Experimental group: Units with hourly rounding or q2h rounding Binomial testing was done between experimental and control groups to test for significant differences.

    Statistical computations were performed with STATS software using the difference between two independent means procedure.

    Paired t-tests were used to analyze difference in number of falls. There was a statistically significant decline in the number of call lights with both hourly and 2 hour rounding.

    There was a statistically significant increase in patient satisfaction scores with the hourly rounding.

    There was a statistically significant decrease in the fall rate with hourly
    rounding.

    Implication to incorporate an hourly rounding program on hospital units. Strengths:
    1. Control and experimental groups matched by similar characteristics/census, etc. 2. Statistically significant results that could provide practice implications.

    Limitations:
    1. Had to drop 8 hospitals (19 units) from study due to non-compliance 2. Nurse/CNA’s satisfaction scores not taken.

    Author (Year)
    Title
    Journal
    Purpose/Problem/
    Objective
    Study Design/Level of Evidence
    Sample
    (Setting)
    Data Collection/
    Methods
    Measurement/
    Data Analysis
    Results/Findings
    Implications
    Strengths/
    Limitations
    Tideiksaar, R., Feiner, C., & Maby, J. (1993).

    Falls prevention: The efficacy of a bed alarm system in an acute-care setting

    The Mount Sinai Journal of Medicine.
    Aim of study is to test the clinical efficacy of a bed alarm system in reducing falls in a geriatric hospital unit. Randomized case-controlled
    study
    70 patients—60 women and 10 men between the ages of 67-97 years old in a 16-bed acute care geriatric unit. Patients were randomly assigned.

    Control group: No bed alarms

    Experimental group: bed alarm usage.

    Equal nursing attention was given to each group.

    Collected data on number of alarm activations/reason for activation, true activations, diagnoses, medications taken as well as restraints/siderail usage. Fisher’s exact test was used to determine statistical significance of number of falls before and after the bed alarm intervention.

    Other data collected was used to determine other reasons behind certain findings. No statistical significance was found in number of falls after bed alarm intervention.

    They did find toileting to be the number one reason patients tried to get out of bed without help. This could lead to an implication of timed toileting to lessen the fall rate. Strengths: 1.Randomized controlled study.

    2. Target population for fall risk.

    Limitations:
    1. Small unit
    2. Study from 1993
    3. No data on what fall rate was like before study. Both experiment and control had low fall rates—did this unit always have low fall rates? Should the study have been done elsewhere?

    Author (Year)
    Title
    Journal
    Purpose/Problem/
    Objective
    Study Design/Level of Evidence
    Sample
    (Setting)
    Data Collection/
    Methods
    Measurement/
    Data Analysis
    Results/Findings
    Implications
    Strengths/
    Limitations
    Olrich, T., Kalman, M., & Nigolian, C. (2012).

    Hourly rounding: A replication study

    Medsurg Nursing
    To identify if an hourly rounding program will improve patient fall rates, call light usage, and patient satisfaction scores. Quasi-experimental study
    Two medical-surgical units with similar size/fall rates
    Data consisted of number of falls, number of call lights, and level of patient satisfaction collected over 6 months.

    Control group: no hourly rounding

    Experimental group: hourly rounding

    Nurse managers and CNS’s routinely rounded on RN’s making sure they were completing hourly rounding. Measures of central tendency and spread were calculated for the three variables.

    Chi-square tests and rank sum tests compared pre and post intervention data. The fall rate decreased by 23% after the hourly rounding intervention. This was not statistically significant, but was clinically significant.

    There was a statistically significant difference in the number of call lights in the first week of the study, but not after that due to a reported delirious patient.

    There was no statistically significant change in patient satisfaction. Strengths:
    1. Control and experimental group
    2. Almost identical characteristics of medical/surgical units.

    Limitations:
    1. Small sample size—hospital census decreased greatly during study. 2. Non-randomized sample.
    3. Delirious patient lead to biased call light data.

    Author (Year)
    Title
    Journal
    Purpose/Problem/
    Objective
    Study Design/Level of Evidence
    Sample
    (Setting)
    Data Collection/
    Methods
    Measurement/
    Data Analysis
    Results/Findings
    Implications
    Strengths/
    Limitations
    Lowe, L. & Hodgson, G. (2012).

    Hourly rounding in a high dependency unit.

    Nursing Standard
    Aim is to examine whether hourly rounding will reduce patient harm. Pilot study
    A 14 bed high dependency unit (ICU transfers and post-operative patients). Patients are 15-96 years of age. There were 51 patients involved in the study. Rounding logs were done for 44/51 patients (some patients were admitted part way through the study and were not given a rounding log)

    Data for patient harm was collected using a “safety thermometer.” This measured the number of falls, UTI’s, and pressure ulcers.

    Data was collected for two weeks.
    Data analysis was mostly done by auditing rounding logs and comparing data collected during the time frame to data collected prior to the implementation of hourly rounding. Only 25 out of 44 rounding logs stated the checks had been done every hour.

    One UTI, a new category 2 pressure ulcer, a PE, and a VTE were found when reviewing data.

    There were no patient falls in the two weeks.

    There were no patient complaints on satisfaction surveys for those two weeks. Strengths:
    1. Audited the occurrences of nurses using the rounding logs. 2. Staff were given opportunity to provide feedback.

    Limitations:
    1. Pilot study
    2. Inconsistent rounding
    3. No falls in the two months prior to study—was this floor appropriate for study about patient falls?

    Author (Year)
    Title
    Journal
    Purpose/Problem/
    Objective
    Study Design/Level of Evidence
    Sample/
    Setting
    Data Collection/
    Methods
    Measurement/
    Data Analysis
    Results/Findings
    Implications
    Strengths/
    Limitations
    Hubbartt, B. & Davis, S., Kautz, D. (2011).

    Nurses’ experiences with bed exit alarms may lead to ambivalence about their effectiveness

    Rehabilitation nursing
    To determine if bed alarms decrease fall rates and should be used consistently as a fall prevention strategy. Pilot study/
    qualitative design
    First pilot study used 8 patients and second pilot study used 7 patients in an acute care setting. Collected data on number of falls before and during pilot study (first pilot study was 5 months and second pilot study was 2 months).

    Alarms were only used on patients that were confused/demented, had a psychiatric diagnosis, or were going through alcohol/substance withdrawal (contributing to the reason the sample size is so small.

    Monitored pattern and frequency of alarm use and fall rate.

    Also obtained feedback from nurses on their experience.
    Measurement consisted of calculating fall rates for both the 5 month and 2 month period.

    This study also used qualitative measurement to get feedback from nurses on why they do or do not like the bed alarms.

    The study viewed situations in which the patient got out of bed without a fall and what led to this/what this led to. The bed alarms did not decrease the fall rate on the unit.

    One patient had gotten up, walked out of his room and down the hall before the RN’s heard the alarm.

    Patients who appear to benefit from bed alarm are those who have delirium or cognitive impairment along with unsteady gait.

    RN’s felt the bed alarms agitate patient’s more. Others did not think their unit needs to use them because they should be rounding hourly. Many stated alarm overload desensitized them and they did not respond quickly. They stated there were also many false alarms that contributed to this. Strengths:

    1. Qualitative aspect studied (RN’s opinions)
    2. Develops need for further/
    larger studies

    Limitations:
    1. Pilot study
    2. Very small sample size
    3. The authors state their opinions about bed alarms and it can be confused with actual EBP.

    Author (Year)
    Title
    Journal
    Purpose/Problem/
    Objective
    Study Design/Level of Evidence
    Sample
    (Setting)
    Data Collection/
    Methods
    Measurement/
    Data Analysis
    Results/Findings
    Implications
    Strengths/
    Limitations
    Tucker, S., Bieber, P., Attlesey-Pries, J., Olson, M., & Dierkhising, R. (2012).

    Outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units.

    Worldviews on Evidence-Based Nursing
    Aim is to evaluate a structured nursing round intervention’s (SNRI) effect on risk and incidence of patient falls on two inpatient orthopedic units. Descriptive and repeated measures design.
    Patients on two 29-bed postoperative orthopedic units.
    Baseline fall-related data was collected first.

    Study was implemented over 12 week period. A one year follow up measure of fall related data was repeated.

    Data collected includes fall rates, fall risk cores, SNRI fidelity, nursing staff identified barriers to SNRI, and profiles of patients who fell during period. Repeated measure logistic regression models were used for analyzing fall rates and probability of falling during hospitalization.

    Generalized stimating equations (GEEs) with an exchangeable correlation structure accounted for multiple hospitalizations.

    Chi-squared tests derived p values to measure statistical significance. There was a borderline statistical trend that fall rates decreased.

    The higher the fall risk score trending a higher risk of falling was not statistically significant.

    No specific characteristics were found in the patients that fell.

    RN’s found the SNRI had lack of clarity of what they were supposed to do, documentation was a burden, and wondered why their unit was chosen.

    Strengths:
    1. Data was compared with both before and after study data.
    2. Rigorous statistical analysis.

    Limitations:
    1. RN’s were not consistent with charting the hourly rounds. 2. Small sample size.

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    Fall Prevention: Are bed alarms overused?. (2016, Jul 23). Retrieved from https://graduateway.com/fall-prevention-are-bed-alarms-overused/

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