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The beginning of the journey to study patient safety and care quality in hospital settings using inpatient falls as an example

By Esther Hall,2014-11-19 14:14
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The beginning of the journey to study patient safety and care quality in hospital settings using inpatient falls as an example

    The beginning of the journey to study patient safety and care quality in hospital settings using inpatient falls as an example 护理学杂志20115月第26卷第1O(外科版)?1?

    ?

    专家论坛?

    编者按:病人安全是wH02006年启动的一项全球性工作.我国卫生部与国家中医

    药管理局在20052007年开展的医院

    管理年活动中,都将提高医疗质量和保证医疗安全作为重中之重.本刊特邀曾惠明

    (Huey-MingTzeng)博士,美国密歇根大学护

    理学院副主任,教授,美国中西部护理研究协会会员,撰写了《病人安全与护理照护

    的研究旅程:以住院病人跌倒为例》.曾教授在

    护理研究尤其是病人安全方面有很高的造诣,取得了极为丰硕的成果,1O年来

    发表SCI论文84(其中第一作者72),主持

    科研项目12.担任《NursingEthics)),NurseEducator)),《护理学杂志》等杂志

    编委或审稿专家.在本文中曾教授详细介绍了

    自己研究病人安全的历程,毫无保留地分享了研究经验与方法,尤其指出在做科研

    的过程中,首先要选择自己热爱的方向,并始终

    保持这种热情.相信此文能够带给读者启迪.

    Thebeginningofthejourneytostudypatientsafetyandcare

    qualityinhospltalsettmgsuslnginpatienttallsasanexample1??1?1'???1

    HueyMingTzeng

    Abstract:Thepurposeofthispaperistosharewithreadersthebeginningofmyjourneytostudypatientsafetyandcarequalityin

    hospitalsettingswithafocusoninpatientfalls.Studyingpatientsafetyandcarequalitycanbeoverwhelmingbecauseofthebreadth

    anddepthofthissubjectandthemanygapsthatmustbeaddressedtomovenursingscienceforward.Iusedagraphicmethod,con

    ceptmapping,tocapturemyresearchjourney.Datasourcesusedinmyprogramspecifictoinpatientfallsforadultsinhospitalin

    patientcareinclude:(1)publiclyavailabledatasets;(2)publishedlegalcases;(3)archivedhospitaldata;(4)surveys;and(5)

    interviews,focusgroups,observation,andfieldstudies.Ihavesummarizedaseriesofmystudiesrelatedtotherelationshipbe

    tweennursingstaffsresponsetimetocalllightsandtheprevalenceoroccurrenceofinpatientfallsinacutehospitalsettings.These

    studiesillustratethedevelopmentofalineofresearchoninpatientfalls.Finally,Idiscussthepivotalpointsinpursuingthisre

    searchandscholarship.Tosustainthepersistenceandresilienceonthisjourneyrequirespassionforthesubjectsofpatientsafety

    andcarequality.

    Keywords:accidentalfalls;patientsafety;qualityofcare;hospitals;nursingcare 1.Introduction

    Studyingpatientsafetyandcarequalitycanbeover

    whelmingbecauseofthebreadthanddepthofthissubjectand

    themanygapsthatmustbeaddressedtomovenursingscience

    forward.Thepurposeofthispaperistosharewithreadersthe

    beginningofmyjourneytostudypatientsafetyandcarequali

    tyinhospitalsettingswithafocusoninpatientfalls.Data

    sourcesusedinmyprogramofresearchspecifictofallreduc

    tionforadultsinhospitalinpatientcaresettingsarediscussed.

    Studiesrelatedtotherelationshipbetweennursingstaffsre

    sponsetimetocalllightsandtheoccurrenceofinjuriousfalls

    aresummarized.Thesestudiesillustratethedevelopmentof

    mylineofresearchoninpatientfalls.

    2.Patientfallsasthetargetedoutcomeindicator

SinceOctober2008intheUnitedStates,Medicare,afe

    deralinsuranceprogram,nolongerreimbursesacutecarehos

    pitalsforthecostsofadditionalcarerequiredduetohospital

    acquiredinjuries.suchasinjuriousfalls[.Topreventfinan

    AuthorsAffiliation:DepartmentofNursing,SchoolofHealthProfes

    sionsandStudies,TheUniversityofMichiganFlint,FlintUSA,Zip

    Code48502.

    Huey-MingTzeng:PhD,RN,ProfessorandAssociateDirectorofUn

    dergraduatePrograms;E-mail:tzenghm@gmail.com cialconsequencesduetopreventablehospitalacquiredinjuries,

    hospitalsandclinicianshavebeenimploredtoimprovequality ofcareandtoreduceeventsthatharmpatients.Thecausesof fallsaremultifactorialinnatureandassociatedwithmultiple intrinsicriskfactors(e.g.,medical,functional,andcognitive conditions)alongwithextrinsicriskfactors(e.g.,physical environment,staffingpatterns,nursingpracticeculture)_2_4]. Theextrinsicfactorsarethoseassociatedwithhospitalwide

    andunitbasedsituations(e.g.,hospitalpoliciesrelatedtoa fallpreventionprotocolandstaffingpatterns)butnotdirectly linkedtoapatientsdemographiccharacteristicsandmedical conditionsc.

    Theextrinsicfactorsforfallsmaybeamendableandinter

    ventionsmaybedevelopedtoeliminatethesefactors.Howe

    ver,developing,testing,andevaluatinganyfacilitysystem levelinterventionstoeliminateriskfactorsforfallspresent manychallenges.Facilitysystemlevelinterventionsreferto unitbasedorhospital-wideinterventions,suchasoffering nursingeducationorcreatingandusingcomputersystemsthat supportdecisionmaking.Thesechallengesoftenrelatetose

    lectingfeasibleinterventionsanddeterminingwhetherstaff

memberswillacceptandadopttheinterventions[6].Forexam

    pie,inastudyperformedattwohospitalsinSingaporeE,a multifacetedstrategyfortheimplementationofafallpreven

    ?

    2?

    tionprogramwaseffectiveinincreasingnursesknowledgeof andcompliancewithfallriskassessment.However,thismul

    tifacetedstrategydidnothaveasignificanteffectonreducing theprevalenceofinpatientfallswithorwithoutinjuries. GutierrezandSmith[.]claimedthatfallpreventionpro

    gramsaregenerallynursingcentered.Therefore,itistom

    monlyassumedthatstaffingshouldbetheprimaryissueine

    liminatingrisksofpatientfallsduringhospitalstays. However,improvednursingstaffing(e.g.,increasingtotal nursinghoursperpatientday,thepercentageofnursinghours

    workedbylicensednurses.useofsitters)doesnotseemtobe theconclusiveanswertopreventinpatientfallsandinjurious falls.

    Forexample,Tzeng,Yin,andGrunawalt_9_evaluatedthe impactofadoptingthePatientAttendantAssessmentToolon nursesrequestsforsittersoruseofrestraintsandfallsand fallinjuryrates.Datawerecollectedfromtwoadultacute medicalunitsinaMichiganhospitalfromAugust2005toFeb

    ruary2007.ThefindingsshowedthatthePatientAttendant AssessmentToolhelpedimprovethefill/requestratesforsit

    tersandtheuseofsoftlimbholdersdecreasedafteradoptionof thistoo1.Theresultsalsoshowedthatifthenumberofsitter requestswashigher,thetotalnumberofrestraintswouldbe lower,butthetotalfallratewouldbehigher.Itwaseonelu

    dedthathospitalsshouldincludeatoolsimilartothePatient

    AttendantAssessmentToolinguidelinesrelatedtoprovision ofconstantobservationoruseofsitters.

    AnexploratorystudyconductedbyTzengandassociates[.] determinedtheuniquecontributionsofinpatientsatisfaction measuresandnursingstaffindicatorsonthehospitalacquired

    JournalofNursingScienceMay2011Vo1.26No.10(SurgeryEdition) injuriousfallratesintheUnitedStates.Theinpatientsatisfac

    tionmeasuresservedasproxyfactorsforthequalityofahos pitalsdeliveryofcare.Multipledatasourcesfromthehospi

    talslocatedinCalifornia,Florida,andNewYorkwereused foranalysis.Thelevelofanalysiswasthehospita1.Thisstudy foundthathospitalswouldhavelowerinjuriousfallratesif theyhadhigherinpatientsatisfactionmeasureswiththeenvi

    ronmentsquietness,lowerallnursingpersonnelfulltimee

    quivalent(FTE)ratio,andlowerpercentageofregistered nurse(RN)FTEs.

    Intheirstudy.Tzengandassociates[.]wereunableto generateaformulaforcalculatingoptimalnursestaffing.Ifa hospitalhas100ofRNsastotalnursingpersonnelFTEs, theinstitutionmighthavefewerinjuriousfallsthaniftheinsti

    tutionhadfewerRNFTEs.Furtherinvestigationsoftheopti

    mumcombinationofstaffingpatternsandinfrastructureare neededtopromotesaferhospitalstaysl9_.Meaningfulap

    proachestomodifyingtheextrinsicfactorsareclearlyover

    dueE.

    3.Mappingaprogramofresearchinpatientsafetyandquality ofcare

    Agraphicmethod,conceptmapping[,capturesmy

    journeyinresearchingpatientsafetyandcarequality(Figure 1).AsshowninFigure1,throughoutmycareerIhavealso

beencommittedtoaddressingemergingclinicalissuesthataf

    feetthesafetyofpatientsandnursesatthebedside(e.g.,e

    motionalissuesofpatientsandnursesduringtheoutbreaksof

    SARSandH5N1/avianflu;ethicsandcliniciansprofessional

    obligationrelatedtocaringforpatientswithSARSandavian

    flu)[1316].

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    护理学杂志20115月第26卷第1O(外科版)

    Mycurrentprogramofresearchistounderstandthede

    terminantsoffallsandtodevelopandtestinterventionstopre

    ventfallsandfallinjuriesinadultsinhospitalsettings.Ichose inpatientfallsasmyresearchfocusbecausetheoccurrenceof injuriousfallshaslongbeenconsideredanindicatorofthe qualityofcare[.Inaddition,theconceptofinpatientfallsis auniversalphenomenonandcommonlyperceivedasanurse- sensitiveoutcomeindicator[18].

    Ibelievethatinacutecareinpatientsettings,detectinga patientsintrinsicriskfactorsforfallsisnotsufficienttopre

    ventfalls.Therationaleisthattheintrinsicriskfactorsfor falls(e.g..medicalconditions)tendtobeunchangeableand theeffectsofinterventionsmaynotbeobservedduringhospital

staysfortreatingacutemedicalconditions.However,inter

    ventionsmaybedevelopedbasedontheindividualpatientdata collectedandcompletedbyanurse.Forexample,thestudy conductedbyDykesandassociates[.]investigatedwhethera fallpreventiontool(software)usinghealthinformationtech

    nologydecreasespatientfallsinhospitals.Basedonafallrisk assessmentscalecompletedbyanurse,thistooltailorsfall preventioninterventionstoaddressapatientsspecificdetermi

    nantsoffallrisk.0ver6months,theuseofthistoolinfour U.S.hospitalinpatientcareunitssignificantlyreducedtotal fallratesbutnottheinjuriousfallratescomparedwithfour"u

    suaIcare"unitsinwhichthetoo1wasnotused.

    Myresearchprogressedundertheassumptionthatnursing executives,front-linemanagers,andclinicianscanhaveanim

    pactonreducingtheoccurrencesofinjuriousfallsforadultsin inpatientcaresettingsbymodifyingtheextrinsicriskfactors. Therefore,mytargetedinterventionshavefocusedonaddres

    singextrinsicriskfactorsforfalls.

    4.ApproachestakentoaddresstheSillbjectofinpatientfallsin hospitalsettings

    Myrecentpaper["]summarizedfivetypesofdatasources thatmaybeusedtostudyissuesrelatedtopatientsafetyand qualitywithafocusonfallreductionforhospitalizedadultpa

    tients.Ihaveusedallfiveofthesetypesofdatasourcesforre

    search.Thesedatasourcesare:(1)publiclyavailabledatasets (e.g.,thedemographiccharacte"sticsofhospitals,the processandoutcomesindicatorsrelatedtothequalityofcare deliveredinhospitals,publishedstudiesonthestateofthe scienceexaminingfallpreventionresearch);(2)publishedle

    galcases(e.g.,publishedlegalcasesorverdictsinwriting);

(3)archivedhospitaldata(e.g.,patientdemographicdata

    base,insurancereimbursementdatabase,chartreviewofpaper chartsorelectrichealthrecords,staffingorpayrolldata,pa

    tientfallincidentreports,calllighttrackingdata);(4)sur

    veysofpatients,families,orclinicians;and(5)interviews, focusgroups,observation,andfieldstudiesofpatients,fami

    lies,orclinicians.

    Thefourdatarelatedissuesthatresearchersmustexamine are:(1)unitofanalysis;(2)computerdataprocessing capabilities;(3)mergingofdatasetsfromdifferentsources; and(4)dataabstraction,aggregation.anddataanalytictech

    ?

    3?

    niquesrequiredbasedonthenatureoftheinformation[. My

    studiesrelatedtotherelationshipbetweennursingstaffsre

    sponsetimetocalllightsandtheinjuriousfallratesaresum

    marizedheretoillustratethedevelopmentofalineofresearch withafocusoninpatientfalls.Thesestudiescanbecategorized basedontheunitofanalysis,thatis:(1)thepatient;(2)the unitmonthandtheunit-week(byinpatientcareunitswith multiplemonthlyorweeklydatapoints);and(3)thehospita1. Thefirststudy[.usedthepatientastheunitofanalysis.It wasconductedinanacuterehabilitationinpatientcareunit.This studyfoundadifferenceinnursesaveragecalllightresponsetime betweenfallersandnon-railersbutonlyafterafalloccurred.The conclusionwasthatnursescalllightresponsivenesscouldbethe compensatorymechanisminrespondingtofallincidentsonthe unit.Inaddition,fallerswithinjurieswouldincreasepatientscall

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