Case Study: Evidence based practice in health service management.
In this study patient fall in the hospital is identified as the evidence. Based on the evidences available, it was decided to implement patient fall prevention strategy in a 100 bed hospital. There are lots of literatures available for, the evidence of fall, reasons of fall, its consequences and strategies to prevent the fall in hospitals. On an average the rate of fall in hospitals is between 3 – 10 per 1000 patients. Out of total fall patients, injury was reported in 30 – 50 % patients and 1- 2% patients experience hip fractures. This fall percentage of the patient is during different activities and at different positions. At the time of ambulation 19 %, when coming out of the bed 11 %, while sitting and standing 9 %, and while using toilet 4 % fall of the patients occur. Fall percentage also varies from place to place. In patient room 80 %, patient bathroom 11% and 10 % fall occur in the treatment room (Hitcho et al, 2004; Krauss et al, 2007). More falls in patient happen between 65-85 yrs. of age and it increases with age. Fall percentage is more in the woman than the male.
Falls is a very common community health problem worldwide, specifically in the elder patients. There are numerous reasons for the fall of the patient. These reasons for the fall are due to physical, physiological and psychological condition of the patient. Reasons responsible for the fall of the patient may be external or internal. Internal reasons include disturbance in balance and gait, different types of medications with improper consultation, visual impairment with loss of visual motor coordination, memory problems and cardiovascular problems mainly hypotension. External reasons include inadequate light, improper stairs, floors with slippery nature, unsuitable clothing and shoes and deficient in walking sticks, grab bars and hanging straps. Fall at one time may lead to consequences for a long time in terms of injury or fear of fall lead to less movement which results in functional loss and more risk of fall (Kannus et al, 2005; Evans et al, 2001).
Moreover, there is evidence and the results of the studies available for less occurrence of fall, prevention of injury due to the fall, improvement in the patient condition due to implementation of fall prevention strategy in the hospitals. Also use of fall evidence to implement in practice already gave an idea of effective management of fall of patients. For implementation of patient fall strategy all the parameters are well established in different studies. These parameters include screening of patients for risk of fall, intervention for fall and injury prevention. These parameters are applied in this case to implement patient fall prevention strategy in the 100 bed hospital.
In general, patient fall is the neglected subject in the hospitals. This topic is neglected because most of the hospitals didn’t report fall cases anywhere due to safeguard reason. When a patient is admitted to the hospital, most of the attention is used to give to the primary condition of the patient. Both family members and healthcare staff concerned about the primary condition of the patient. However, this fall and its subsequent consequences can be very serious and harmful to the patient. This fall can be prevented by the minimal efforts from the family members and healthcare staff. Consequences from this fall are alarming and disturbing the work of every stakeholder of the patient care. This patient fall leads to extra stress on everybody. Moreover, problem of this issue can be taken care very comfortably by taking extra care. Implementation of fall prevention strategy is also a value addition to the hospital, because this implementation fall strategy upgrades the value of hospital both in terms of economic and social terms. Recently, lots of studies have supported the importance of this fall condition in the elderly patients. There is lots of literature available containing causes, effects, consequences and prevention strategies for the fall of the patient (Oliver, Healey, & Haines, 2010).
Fall of the elderly patient in the hospital is more serious and dangerous than original or primary health condition of the patient. So it is very much required to change strategy to reduce, these fall events in the hospital. These fall events complicate the treatment strategy for the primary health condition. There is a double burden on the patient, family members and health care staff. This fall leads to the increase in the sufferings for the patient and there is both physical and mental downfall of the patient. There may be possibility of patients not responding to the treatment of the primary condition due to fear of falling again, pain due to injury and loss of confidence. By keeping in mind overall wellbeing of the patient and family members, it is very much required to change the strategy of the hospital to prevent the fall of the patient. Moreover, there is the possibility of serious nature of injury to the patient and it remains for a long time, which can disturb day to day activities of the patient. For this long term injury or disability, patient and family requires more amount of money. It also includes more stay in the hospital that increase burden on the patient mentally and it costs more. Also it has been proved that, if a patient falls 2 or 3 times, there is possibility of falling again and again. Falls prevention programmes have been successfully implemented in few hospitals. Looking at all the above issues, it is very much required to change the strategy in the hospital to prevent the fall of the patient (Inouye, Brown, & Tinetti, 2009).
There are both the types of assistive and resistive forces for the implementation of the strategy change for elder patient fall in the hospitals. Assistive forces made the stakeholders to implement this policy change in the hospitals. Condition of the patient and family members, those affected more due to this fall, make hospital management to implement fall prevention strategy. As described earlier, injury may be an acute or long term, make patient and family members to request hospital management to implement this strategy in the hospitals. Due to implementation of this fall strategy, there is double burden on family members for the treatment of primary condition and cost due to injury after the fall of the patient. Earlier fall of the patients in the hospitals was not recorded. Now a day, these cases are published in the literature along with the seriousness about this particular issue. This makes hospitals to implement these strategies in the hospitals. Also, preventive strategies to prevent these fall conditions in the elderly patients are available in the literature and positive outcome and success of the strategies make hospitals to implement these strategies in the hospitals. Along with these assistive strategies, there are also resistive strategies which prevent implementation of the fall prevention strategies in the hospitals. In hospitals there are different departments operating at the same time. It is difficult to maintain coordination with all the departments due to large number of patient’s inflow. Also lack of coordination between employees of different departments, prevent implementation of this elderly patient fall prevention strategy. Lack of adequate number of employees and funding is the resistive driving force for implementation of this strategy. Willingness of the top management is most important driving force for the implementation of this fall prevention strategy (Aberg, Lundin-Olsson, & Rosendahl, 2009).
Some of the innovative methods applied to change the policy of the hospital about the fall of the patient. Few of the strategies to prevent patient fall are discussed in this section. At the time of admission to the hospital, patients were screened for fall risk and these susceptible patients for fall risk were selected for the fall prevention strategy. One of the strategies is keeping the colored band on the hand of the fall risk patient, so that anybody can identify the patient as susceptible for the fall and assist the patient for routine work. Education to the family members of the patient to prevent the fall of the patient is very good and effective strategy to prevent fall of the patient. Because family members of the patient can accompany them all the time and fall can be prevented in an efficient way. Moreover, family members can convince the patient to avoid few acts which are prone to the fall. Hence, family members of the patient trained in the fall prevention strategy. Another effective strategy to prevent the fall of the patient is by mentioning fall risk factor in all the reports when shift of the hospital changes. By doing this, healthcare staff attending in the next shift can understand the condition of the patient in a better way and plan their work. To implement a quality strategy of the prevention of the fall of the patient, it is very much required to maintain a proper checklist and documentation. This checklist and documentation will help to prepare standardized procedure to implement fall prevention in the future. Also this documentation also helps to evaluate the regular efficiency of the strategy and amend accordingly to seek for the improvement. Most of the elderly patients are on the antipsychotic medication and these medicines are the major cause of fall of the elderly patients. Consumption of these medications was stopped for the patients with fall sick. Administration of the vitamin D, is one the strategy to prevent fracture in the patient with fall. This antipsychotic drugs withdrawal is one of the fall prevention strategies applied. Implementation of fall prevention strategy in terms of psychological trainings to the patient is the most important strategy for fall prevention. These psychological training include building confidence in the patient, avoiding patient from fear of fall and giving patients feeling of wellbeing. This wellbeing is very important for elderly patient because of memory loss and depression in older age. Patients with risk of fall are trained for exercise to increase physical strength which results in the resistance to fall. All the above description suggests that multifactorial strategy has been applied for fall prevention of the elderly patient. This multifactorial strategy includes both physical, psychological and medicine related strategy, also it include patient and healthcare team (Schwendimann et al, 2006; Vassallo et al, 2004).
In general terminology evidence is used as experience to understand that particular matter. In health care evidence has broad meaning and includes proof, reasoning, observation and verification. In healthcare, importance of evidence is based on the historical data of the evidence available in the literature. In healthcare there are different types of evidence are present. These evidences are research based evidence, clinical experience based evidence, patients based evidence and local context and environment based evidence. This evidence of elderly fall patient is the overlap of the clinical experience and patient based evidence. In clinical based experience, both clinicians or practitioners and nurses learn from their practical knowledge and implement their experience to make that particular condition as evidence. Patient based evidence is based on the experience of the patient and their family members. These patient and family members’ experiences are very useful in implementing the best healthcare practices because the final aim of the healthcare professional ids to give relief and satisfaction to the patient and family members. Learning from the patient and family members experience helps health professionals to act in that direction and this whole procedure is more effective. Hence this evidence of patient fall, which is based on the clinical and patient experience, is valid evidence for evidence based healthcare management (Rycroft-Malone et al, 2004; Barker, 2000; McCaughan et al, 2001).
Decision making for the implementation of the fall prevention strategy mainly based on the findings from the literature and opinion and discussion of all the stakeholders in this process (Dykes et al, 2010). Decision making process of the fall prevention strategy incorporated all the stakeholders of the healthcare like clinicians or practitioners, experts in hospital management, nurses, ward boy, and pharmacist. Patient and family members also included in the decision making process. For decision making clinician or practitioner critically appraised the evidence. This critical appraisal helps in understanding all the positive and negative aspects of the evidence. This critical appraisal and study of the evidence based healthcare enhances the confidence of the clinician and helpful in decision making. Scientific studies with large number patients are helpful in decision making for the clinicians. So studies with large number of patients were selected for the evidence and decision making. Along with the evidence for the decision making, other factors also involved in the decision making. These factors are associated with resources. All the resources like equipments, availability of rooms, medicine and manpower to handle the additional activities due to implementation of the fall prevention strategy. In terms of manpower, competency of the manpower to handle the change and willingness to accept change was considered for decision making. Patient and family members also considered in decision making, as they have to stay in the hospital for a longer time in the hospital and bear more cost for treatment.
Other than the medical treatment other solutions offered to prevent this fall strategy. More attention was given to the patient safety. Hospital structure was changed to the patient centered. This hospital structure change is very much required because elderly patients are more comfortable with their known environment and due to age they are not ready to accept the change. To make elderly patients more comfortable with the hospital conditions, it is required to change the structure of the hospital. Patient fall risk assessment tool was implemented in the hospital and proper checklist maintained for the analysis of the patient. Training has been provided to the healthcare professionals to prevent the fall of the patient and regular assessment of the trained people has been done to understand their competency. This type of training is very much important because these trained people are very much effective in preventing these falls of the elderly patient. This risk assessment tool helps to separate patients of fall risk from the other patients. Patients with fall risk can be given special attention to prevent the fall. Height of the bed has been reduced for the patient at risk of fall because this is one of the prominent reasons for the fall of the patient during their day to day activities. Different types of accessories have been provided to the patients and trained them along with their family members for utilizing these accessories. These accessories help in giving support to the patient and also it protects the patient from serious injury, though patient fall (Shubert et al, 2014).
Implementation of the evidence based fall prevention strategy results in the number of positive outcomes for the patient. Implementation of the suitable exercise for the patients with the risk of fall, results in the less incidence of the fall. Psychological diseases are more common in the elderly patients, because these patients are on the chronic dosing of the antipsychotic drugs. Withdrawal of these antipsychotic drugs, results in the lesser incidence of fall in the elderly patients. Instead of practicing fall prevention programme on all the elderly patients, it was implemented to the targeted patients i.e. fall risk patients. Result of this targeted patient intervention results in a more efficient outcome as it reduces unnecessary burden on the healthcare team and cost to the hospital management. Working in the multidisciplinary team results in the more effective prevention strategy for the fall of the elderly patient. Multidisciplinary team has a more accurate diagnosis and treatment of the said condition. Administration of vitamin D in the patient with risk of fall, results in less number of fractures and less severity fractures in the hospital. There are different strategies for the prevention of fall, like physical, counseling or training, psychological and medicine based. It has been observed that the combined effect of these strategies gives better results, i.e. multifactorial strategies are more effective as compared to the individual strategies. Implementation of this strategy results in the decreased fall rate in the hospital, recurrent fall and admissions to the hospital due to the fall (Healey et al, 2014).
There are different stakeholders involve like patient, family members, clinician or practitioner, nurses, wardboy, and pharmacist. Implementation of this strategy is very beneficial to the patients. This helps patients to be more positive about the fall. Patients’ needn’t be worried much about their fall because most of the matters related to the fall are taken care by the other stakeholders from the family and healthcare profession. Family members also feel relaxed after the implementation of this strategy. Because family members needn’t required to take the patient to the other hospital or other department after the fall of the patient. Also in terms of cost of the treatment also, there is a noteworthy reduction in the cost of treatment as all the segments of the treatment are happening at the same place. For the healthcare professional, there is so many tasks are there to perform after the implementation of the strategy. Also, there is lots of learning for the healthcare professionals in all this exercise. Clinicians and practitioners visited the patients frequently and attended the cases. There is double work load on clinicians. Nurses became more systematic and documentation became more standardized for the nurses. Nurses are completely occupied with their patients because their frequency of attending the patient has increased more than double to the patient. Wardboy has to lots of work for patients like adjusting the bed height to the low height, assisting patient for toilets, helping patients in changing cloths and providing patients with accessories for fall prevention. These are the extra tasks, wardboy has to perform. Pharmacist have to be very careful while dispensing medicine. Pharmacist should study all the medicines for the patient for adverse reactions and drug interactions among the provided medicines.
There are noteworthy changes in the approach and thinking of so many stakeholders of the hospital. Top management generally thinks in the business oriented direction. However, in this change top management of the hospital accepted the change for the wellbeing of the patients and improving the healthcare qualities of the hospital. There are number of professional qualities has been developed in the existing staff due to implementation of this strategy. These qualities include leadership, ownership, team work, interdisciplinary access, commitment and discipline. There are lots of learning for every stakeholder in this process. Staff of the hospital is ready for the change, staff is working with certain goals and staff is excited about this change. Many standardized protocols have been introduced in the hospital for evaluation of risk factors for the fall of the patient and also procedures have been established for the treatment and prevention of the fall. These protocols and procedures are useful for the long time, also it increases the speed of the services at the hospitals due to set guidelines and there are very less chances of errors in implementing this strategy. Training programmes have been developed for the patient, family members and healthcare staff, to educate them about protocols and procedures. There is the improvement in creative thinking, deep rooted literature search, and strategic communications of the staff of the hospital. This overall exercise resulted in the quality of the services at the hospital.
With the implementation of this strategy there is linkage happened between healthcare professionals of the hospital, educationalist, policy makers in the medical field and top management of the hospital. Association of all these stakeholders makes the implementation of this change more valid and robust. All these stakeholders agreed that ‘evidence’ is one of the important criteria to make necessary decisions to improve the health care services and manage the services more effectively. If we look at above mentioned discussion, mainly four topics plays a major role. These four topics are, critical thought process and interpretation, collecting most useful information, critical appraisal of the selected evidence and application of evidence in decision making. These four areas collectively are very effective in healthcare service management. It leads to the quality up gradation of the hospital and matching with the global health policy. There is overall improvement in the economics and budgeting of the hospital. This change in strategy for fall of the elderly patient gives complete justification to the functions of the healthcare management. These healthcare management functions include working in changed scenario, adopting new skills during change, effective planning, managing human resource and improving personal performance.
We can use basis of the evidence for further changes in both the terms i.e. screening for fall risk and intervention of the fall i.e. prevention of fall and treatment of injury due to fall. Recommendations for the screening include, compulsory screening of all the patients above a certain age, and standardized protocol for screening which is globally acceptable. Recommendation for intervention include, monitoring of medication for all elderly patients, compulsory administration of vitamin D, isolated and specialized room for the elderly patient in the hospital and establishment of compulsory accident or trauma unit in each hospital.
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Dykes, P. C., Carroll, D.L., Hurley, Ann., Lipsitz, S., et al. (2010). Fall prevention in acute care hospitals a randomized trial. Journal of the American Medical Association, 304(17), 1912–1918.
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Healey, F., Lowe, D., Darowski, A., Windsor, J. et al. (2014). Falls prevention in hospitals and mental health units: an extended evaluation of the FallSafe quality improvement project. Age Ageing, 43(4), 484-91.
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