Abstract
Patient falls are frequent in patients taking psychiatric medications, and such adverse events are associated with both physical injuries and extra treatment costs. The paper reviews current knowledge on fall reduction strategies in psychiatric populations. As the literature review suggests, strategies that are the most beneficial to psychiatric patients include the use of the WSFRAT tool designed for this patient group and blood pressure monitoring for risk evaluation.
The majority of risk measurement tools that form the basis of prevention strategies are not intended for use in patients taking psychiatric drugs. Thus, they do not consider this group’s specific risk factors associated with the side-effects of medications. The listed strategies are included in the proposed practice change to be implemented after additional research and testing. The strategy to measure its effectiveness in the intended population is also discussed.
Introduction
Patient safety is among the key priorities in nursing, but there are multiple events that pose threats to it. The problem of patient falls belongs to the key issues faced by healthcare organizations, and reducing its health and financial outcomes in different populations and units is a task of importance. The EBP review is aimed at investigating strategies to decrease falls among sedated psychiatric patients.
Background of the Problem
Hospital falls can be defined as events that lead to patients’ resting on the floor and lead to traumas. This paper will focus on the prevention of falls in psychiatrically sedated populations. The problem is that a large number of psychiatric medications have common adverse effects adding to the risks of falls. Among them are temporary blurred vision, dizziness, muscle weakness, loss of coordination, abnormal sleepiness, and similar effects impacting a person’s general well-being and the ability to interact with physical space.
Additionally, psychiatric diseases per se can contribute to falls since they often involve changes to perception, thus affecting the process of hazard recognition and decreasing one’s special intelligence. In general, there is a wide variety of factors that make patients in psychiatric units extremely likely to experience falls and the resulting injuries.
The first reason why the problem of falls in psychiatric patients is significant and should be studied in a thorough manner relates to the disproportionate attention to falls in different populations. The history of fall prevention and management research indicates that the needs of psychiatric populations have been neglected for a long time. According to the review by Xu and Xie (2015), the majority of fall prevention studies in the 1980s and the subsequent decades focused on elderly adults, clients in residential facilities, or post-surgery patients.
That discrimination took place despite the unique risk factors linked with psychiatric disorders and fall rates in psychiatric facilities that almost approached those in geriatric and rehabilitation care units (Xu & Xie, 2015). Since falls heavily affect the selected group, further studies and improved fall prevention protocols developed for psychiatrically sedated patients are absolutely necessary.
The second reason to explain the problem’s significance is presented by the health and financial consequences of patient falls. On average, between 30% and 50% of all hospital falls result in certain forms of injuries and traumas (Xu & Xie, 2015).
Up to 5% of falls lead to quite severe injuries, including bone fractures, bone dislocation, and even intracranial hemorrhage (Xu & Xie, 2015). In some instances, falls produce life-threatening health conditions and can contribute to mental health problems (phobias, anxiety, etc.), which is specifically dangerous for psychiatric patients. In terms of financial burden, expenses associated with falls amount to millions of dollars, including extra treatment costs, legal expenses, and longer hospital stays (Xu & Xie, 2015). In summary, effective fall prevention programs in psychiatric units would benefit both hospitals and patients.
Methods for Searching Evidence
To define the best strategies to reduce fall rates applicable to psychiatrically sedated patients, the group conducted a literature search with the help of PubMed. From the considerations of data relevance, the “last five years” search filter was used. The group applied different combinations of keywords to find topic-specific sources. The combinations included the keywords that referred to the care problem (“patient falls,” “fall prevention,” “fall reduction strategies,” etc.) and pointed to the population in question (“psychiatric patients,” “psychiatric units/hospitals,” and so on). The search results were analyzed on an individual basis to establish whether the articles reviewed fall prevention and reduction strategies in the required population and contained enough evidence to justify conclusions.
To assess credibility, the most relevant studies were investigated with reference to the famous levels of evidence pyramid – the model that draws parallels between the types of studies and worthiness in terms of knowledge. The topic of fall prevention in psychiatric patients continues to be less popular compared to that in other populations, which impacts the results of the literature search. Level two studies included the systematic review of high-quality studies by Xu and Xie (2015) and a prospective study conducted by Bugajski et al. (2017). Among the sources of level three evidence, there was a retrospective comparative study by Wong and Pang (2019).
Less valuable evidence was in a non-systematic review and a single qualitative study by Abraham (2016a; 2016b), a case series study by Tohotoa, Wynaden, and Heslop (2016), and an exploratory case study by Bayramzadeh, Portillo, and Carmel-Gilfilen (2019). No RCTs or reviews of RCTs were found, which increases the need for testing the proposed change.
Literature Review
The problem of falls in people with mental health issues is a major concern among hospital staff members and other professionals tasked with care provision. Overall, hospital falls are classified into several groups depending on the degree to which the related risks are obvious and find reflection in patients’ past medical history and current issues. Therefore, the falls taking place in hospitals vary greatly in terms of predictability, treatment costs, and other factors.
The majority of sources included in the review contain information regarding the role of proper risk assessment tools in preventing falls in adult or elderly hospitalized patients with mental health illnesses. According to Abraham (2016b), as perceived by the directors of psychiatric units, the most significant predictors of falls that require assessment include patient gait, individual history of falls, and being treated with multiple drugs. The identified areas of assessment find reflection in widely known risk assessment tools, including EPFRAT.
The selected studies contain evaluations of common risk assessment tools. The Morse scale is actually used in psychiatry settings, but it was initially developed for surgical wards, whereas EPFRAT and WSFRAT were created for psychiatric patients (Abraham, 2016b; Bugajski et al., 2017). In the study by Yates and Tart, the Morse scale combined with safety interventions (slip-resistant shoes) and patient education on falls reduced the number of psychiatric falls by 32% (Xu & Xie, 2015). EPFRAT, the tool for psychiatric patients, demonstrates greater sensitivity in severely ill psychiatric patients compared to the Morse scale (Xu & Xie, 2015).
Thus, it allows conducting accurate assessments to implement risk management strategies. According to the review by Abraham (2016a), WSFRAT and EPFRAT can be considered the most reliable tools in psychiatric patients, whereas the Morse scale does not significantly decrease fall rates in geropsychiatric populations. Another study focusing on older adults with mental health issues proves WSFRAT to be better for risk assessments compared to the Morse scale (Wong & Pang, 2019). Thus, the use of the Morse scale in psychiatric settings involves some age-related limitations.
There have been attempts to implement new risk assessment tools helping to prevent falls in psychiatric patients. Combining general risk factors for falls and information on the effects of psychiatric medications, Tohotoa et al. (2016) propose the MHFRMT tool to assess risks in psychiatrically treated older adults with mental health issues. The tool is to increase the frequency of risk assessments from one to four times a month, which makes hospital staff more prepared for rapid changes but also increases the workload (Tohotoa et al., 2016). Thus, among the proposed interventions are more frequent risk assessments and the use of tools that consider the degree to which different psychiatric medications influence the risks of patient falls.
Overall, the selection of proper risk assessment tools is widely regarded as the prerequisite to success in reducing falls. Bugajski et al. (2017) aim to increase the number of such tools available for mental health providers by testing the BHHRFA, “a high-risk falls assessment for medical-surgical patients,” in psychiatric patients (p. 115). What makes the BHHRFA tool applicable to people put on psychiatric medications is that it “captures medication profiles that could be considered psychiatric specific (narcotics, sedatives, hypnotics)” (Bugajski et al., 2017, p. 118).
Other suggestions for risk assessment and management in psychiatric patients include the Timed Up and Go test (TUG). According to the retrospective study by Struble-Fitzsimmons (2018), the TUG test is a successful tool to conduct risk assessments in elderly patients with mental health diseases.
Apart from patient-related factors, modern authors also recommend focusing on the risks linked to the hospital environment to reduce falls in psychiatric units. As an example, the case study by Bayramzadeh et al. (2019) outlines specific vulnerabilities to be taken into account. Among them are risk factors associated with inadequate lightning, uneven and sloping floors, and the presence of spaces that are hard to monitor. Another helpful strategy is the introduction of policies to monitor blood pressure – in the study by Murdock et al., such intervention reduced psychiatric falls by more than 32% (Xu & Xie, 2015).
In summary, it is known that WSFRAT and EPFRAT are good as the elements of fall reduction programs in psychiatric wards since they give consideration to risks peculiar to different medications. The Morse scale is not extremely effective in geropsychiatric patients and does not take the classes of medications into account. Concerning what is currently unknown, the evidence to prove the effectiveness of newer tools (MHFRMT, BHHRFA, and TUG) in different age cohorts of psychiatric patients is still scarce.
Discussion of Evidence
Based on the studies discussed above, the risk assessment tools recommended for use in psychiatric populations greatly vary in terms of the scientific community’s familiarization with them. From the considerations of credibility and validity, evidence from the studies that are focused solely on testing new risk assessment strategies will not be used to formulate improvement efforts. The tools that are not well-researched at the present moment and, therefore, can potentially harm high-risk psychiatric patients, include the MHFRMT proposed by Tohotoa et al. (2016). Although the tool considers risks related to the types of medications, its reliability and validity are still to be determined along with its actual contributions to fall reduction and prevention.
Another group of tools for risk assessment and management will be excluded due to such methods’ doubtful applicability to the population in question. The BHHRFA, as is demonstrated by Bugajski et al. (2017), possesses reliability and validity but has not been extensively studied in psychiatric patients yet. The Morse scale has not been validated for use in psychiatric settings and does not demonstrate particular effectiveness in older adults on psychiatric medications (Abraham, 2016b).
Finally, the TUG test shows effectiveness in terms of risk prediction, but it has been tested in geriatric and psychogeriatric populations, which makes its applicability to general psychiatric populations unknown (Struble-Fitzsimmons, 2018). With that in mind, emphasis will be placed on interventions that are designed for psychiatric patients and have demonstrated results in this population.
The evidence from the study by Xu and Xie (2015) suggests that fall reduction interventions are highly heterogeneous, which hinders comparing them in terms of effectiveness. However, according to its results, multi-interventional fall management strategies that involve monitoring medications’ side-effects (blood pressure abnormalities) and considering types of medications in risk assessments are recommended (Xu & Xie, 2015). The results are valid since they are based on the summary of high-quality fall prevention research in psychiatric units, and they can be helpful for different subgroups of psychiatric patients.
Next, Wong and Pang (2019) recommend WSFRAT for use in psychogeriatric and geriatric populations based on their study and also cite EPFRAT as a reliable tool. The study’s conclusions do not contradict the results of previous research on the topic of WSFRAT, which adds to their credibility. As Abraham (2016a) concludes, the existing risk assessment tools differ in terms of advantages, but EPFRAT and WSFRAT are recommended due to their sensitivity of 63% and 100%, respectively.
Such conclusions can be trusted since they are based on a review of relevant clinical studies. As for transferability, Abraham (2016a) cites findings that are universal to different psychiatric patients regardless of the type of used medications. Wong and Pang (2019) focused on psychogeriatric patients, but the tested tool actually has reliability in adult populations on psychiatric medications as well (Abraham, 2016a).
Proposed Change to Practice
Based on the reviewed literature, it can be recommended to resort to two strategies. The first one is selecting a new risk assessment tool to detect high-risk individuals among medically sedated psychiatric patients and implement additional fall prevention measures in a timely manner. Therefore, WSFRAT is a sensitive and accurate tool that assesses risks specifically affecting psychiatric patients and includes nurses’ clinical judgment in evaluations.
The second strategy to be combined with the mentioned tool is the introduction of blood pressure monitoring policies that would be particularly beneficial to patients on psychiatric medications with sedative effects. Concerning the effects on stakeholders, such as patients, the proposed change is expected to reduce falls by improving risk identification practices. It is also supposed to make the currently used approach to fall prevention a bit more personalized. In terms of its effects on psychiatric nurses and the organization, the change will probably help to save time by replacing other fall risk assessment practices.
Although the change is based on widely recommended and effective strategies, one needs to consider that the combination of WSFRAT and BP monitoring protocols has not been tested. To eliminate risks, it is reasonable to initiate further research and compare this approach to fall prevention with usual care in a substantial sample of psychiatric patients (about 60 participants) after receiving IRB approval.
Methods to Measure Outcomes
The Iowa model of evidence-based practice will be used to plan for the proposed project and determine the effectiveness of the mentioned change. The model consists of six steps and involves forming teams to evaluate the available evidence and make decisions concerning the need for future research. The indicators to be measured in both intervention and usual care groups will include nurse-to-patient ratios. Also, the nurse-perceived workload will be measured with the help of the NASA Task Load Index – a valid tool used in healthcare and some other domains.
The tools to measure actual outcomes will include hospital incident reports specifying fall rates, the percentage of falls leading to traumas, and so on. Concerning sample size, to observe changes, it is proposed to draw comparisons between two groups of 30 adult psychiatric patients on antipsychotics/narcotics.
Concerning the feasible for data collection, the tool to measure the nurse-perceived workload is easy to implement, can be accessed for free, and does not involve additional costs. Data collection using hospital incident reports also does not involve extra costs, which proves its attractiveness for the planned study. The minimal time for the project is about four months, which includes a month for planning the change and recruiting participants, two months for actual research, and a month for data collection.
As for the essential resources, incident reports, technical equipment for the administration of the questionnaire, and tools for statistical analysis will be required. The costs will include expenses associated with nurse education on the use of new tools and data analysis activities. For data analysis, fall rates and perceived workload on nurses in intervention and comparison groups will be comparatively analyzed using statistical tests for independent samples. Nurse educators and psychiatric nurses in the organization will be involved in project implementation.
Conclusion
Falls in psychiatric patients are common and costly, and the purpose of this EBP project is to consider the ways to reduce this problem without changing psychiatric treatment schemes. Based on the literature review, it is proposed to implement fall risk assessment tools for patients with mental health diseases (WSFRAT) and introduce blood pressure monitoring policies to make informed decisions concerning high-risk fall precautions. Since both strategies have been demonstrated to cause improvements, the findings are significant to mental health nursing. They are easily implemented into practice, and the results of the planned project will further contribute to filling in research gaps associated with falls in psychiatric settings.
References
Abraham, S. (2016a). Looking for a psychiatric fall risk assessment tool. Annals of Psychiatry and Mental Health, 4(2), 1061-1064.
Abraham, S. (2016b). Managing patient falls in psychiatric inpatient units. The Health Care Manager, 35(2), 121-133.
Bayramzadeh, S., Portillo, M., & Carmel-Gilfilen, C. (2019). Understanding design vulnerabilities in the physical environment relating to patient fall patterns in a psychiatric hospital: Seven years of sentinel events. Journal of the American Psychiatric Nurses Association, 25(2), 134-145.
Bugajski, A., Lengerich, A., McCowan, D., Merritt, S., Moe, K., Hall, B., … Brockopp, D. (2017). The Baptist Health High-Risk Falls Assessment: One assessment fits all. Journal of Nursing Care Quality, 32(2), 114–119.
Struble-Fitzsimmons, D. (2018). Exploring the use of the Timed Up and Go Test to identify patient fall risk in an inpatient geriatric psychiatry unit (Doctoral dissertation, Seton Hall University, South Orange, New Jersey). Web.
Tohotoa, J., Wynaden, D., & Heslop, K. (2016). Development of a falls risk assessment and management tool for older adult mental health units. Annals of Nursing and Practice, 3(1), 1-10.
Wong, M. M. C., & Pang, P. F. (2019). Factors associated with falls in psychogeriatric inpatients and comparison of two fall risk assessment tools. East Asian Archives of Psychiatry, 29(1), 10-14.
Xu, C., & Xie, H. (2015). Translating evidence from a systematic review to the development of an evidence-based fall prevention program in a tertiary psychiatric hospital. Nursing Reports, 5(1), 13-18.