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Background: Assisted falls occur when staff try to minimize the impact of falls by slowing a patient’s descent. Assisting a patient fall may decrease patient injury risk, but biomechanical risk of injury to staff has not been evaluated. Assisted falls virtual reality (VR) simulations were conducted to examine staff low back injury risk during common assisted falls scenarios. Methods: VR simulations of a toilet to wheelchair transfer were developed with a male patient avatar for three assisted falls scenarios: standing up from toilet, sitting down on wheelchair, and ambulation. Patient avatar weight was modified to reflect normal, underweight, and overweight adult patients. The average spinal compression force at L5/S1 was calculated for each participant with five trials per three scenarios while utilizing physical ergonomic techniques and compared to the safe spinal compression limit of 3,400 Newtons (N). Findings: Six staff participants completed 90 VR simulations in total. The average calculated spinal compression force ranged from 7,132 N to 27,901 N. All participant trials exceeded the safe spinal compression limit of 3,400 N for every assisted falls scenario and avatar weight despite application of ergonomic techniques including wide stance, knees bent, and backs straight. Conclusions/Application to Practice: Staff are at risk for low back injury if they assist falls regardless of the adult patient weight and application of ergonomic techniques. Safer alternatives like the implementation of mobility screening tools and safe patient handling and mobility technology are needed to help prevent assisted falls to decrease injury risk to both patients and staff.

Evaluate the potential of a wheelchair assistive technology (StandBar) to promote power wheelchair users' ability to safely stand independently from their power wheelchair and determine the impact of the device use on psychological well-being for both power wheelchair users and their caregivers.A convenience sample of 11 power wheelchair users and caregiver dyads provided study data. Participants included power wheelchair users who were existing StandBar users or currently in training with the StandBar as part of their rehabilitation. Assessments were conducted at baseline and at six-month follow-up and included physiological assessments and functional testing with and without the StandBar. Monthly follow-up phone calls were completed to collect information on adverse events (e.g., falls, hospitalizations, and skin breakdown). A qualitative interview assessed StandBar users' and caregivers' perception at six-month follow-up.StandBar use provided power wheelchair users a higher level of independence, confidence, and safety. All participants highly recommended StandBar use to others with similar levels of functional impairment. StandBar use allowed many participants the ability to complete functional tasks that were otherwise not possible without assistance. Qualitative interviews reported improved independence and psychological well-being for StandBar users as well as reduced levels of anxiety and burden of care by caregivers. The StandBar is a cost-effective assistive technology that promotes independence and functionality for power wheelchair users and improves the psychological well-being of users and their caregivers. Implications for Rehabilitation

The prevalence of injurious falls is high in the Veterans Health Administration (VHA) and a major patient safety issue. The VHA is embracing technology such as simulation to improve patient care. Little is known regarding nurse thought processes while undergoing a post fall assessment simulation in the VHA. This article examines the benefit of using an evidence-based post fall simulation to improve nurse assessment skills while providing opportunity for practice without harm to patients.

INTRODUCTION To provide up-to-date data on fall prevalence and trends in Veterans Health Administration (VHA) hospitals. METHODS Data were collected by the VHA Inpatient Evaluation Center (IPEC) between 2011 and 2017, to establish prevalence and trends of falls and major injuries occurring in acute care/intensive care units (AC/ICU), behavior health (BH), and community living center (CLC)/long-term care, using bed days of care (BDOC) as denominators. RESULTS A total of 204,681 falls were reported (rate = 4.8 falls/1,000 BDOC) during the study period, of which 2,549 (1.2%) resulted in a major injury (rate = 6.0/100,000 BDOC). Fall rates decreased over the 6-year study period for all unit types: 10% decrease for BH (p < .0001), 9% decrease for AC/ICU (p < .0001), and 3% decrease for CLC (p = .0043). Major injury rates remained consistent. CONCLUSIONS In this large descriptive study, fall and major injury rates varied by nursing unit type in VHA hospitals. Over the 6-year study period, a clinically and statistically significant decrease in fall rates for BH and AC/ICU units was observed as well as a small but statistically significant decrease in fall rates for CLC units. No trend was observed for major injury rates.

Background Injurious falls continue to challenge health care. Causes of serious falls from the largest health care system in the United States can direct future prevention efforts. Purpose This article analyzes injurious falls in the Veterans Health Administration and provides generalizable recommended actions to prevent future events. Methods We categorized root cause analysis (RCA) reports and coded injury type, fall type, location, and root causes. We describe interventions during the fall and provide resources for future prevention. Results There were 154 reported fall RCAs during this time. Most (83%, n = 128) resulted in major injury: hip fractures (43%, n = 66), other fractures (25%, n = 38), and head injury (16%, n = 24). Most falls were unwitnessed (75%, n = 116). Conclusions Patients who fell were not wearing hip or head protection. Most falls were unwitnessed, and none were on 1:1 observation. Such interventions may help prevent future injurious falls.

The aims of the study were to evaluate and to compare protective properties of commercially available medical helmets for a set of standardized head injury risk measures.Eleven helmet types were evaluated to represent the variety of commercially available medical helmet designs and manufacturers. A test mannequin and sensor apparatus were used to simulate a backward-standing fall. The head/neck size, mass, and "standing" height of the mannequin (5'9″) were representative of a 50th percentile male. A triaxial array was placed at the head center of mass to position 3 linear accelerometers and 3 angular rate sensors. Data were collected for 5 single trials for each helmet, as well as 5 repeated trials. Five trials were also collected with no helmet scenarios. Three head injury risk measures were examined (linear acceleration, angular acceleration, and head injury criterion). Data were analyzed by clinical cutoff thresholds and continuous values.Helmets varied in their performance across head injury risk measures. All helmets provided higher levels of protection compared with no helmet scenarios. No helmets were protective for subdural hematoma (measured by angular acceleration). All helmets lost protective properties with repeated falls. Results for skull fracture risk were inconsistent between linear acceleration and head injury criterion injury risk measures.No helmets were protective across all head injury risk measures. Medical helmets may reduce some fall injury severity but may not prevent all types of head injury. All helmets exhibited worsening of protective properties with repeated falls. We recommend medical helmets be replaced after each fall incident where the helmet impacts another surface.

Aims: To reduce preventable falls and fall related injuries in State Veterans Homes (SVHs), we conducted a virtual breakthrough series (VBTS) quality improvement collaborative.Methods: Participatin...

Objective Examine mortality and associations with baseline characteristics among Veterans with early dementia. Methods Participants included dyads of community-based Veterans with early dementia and their caregivers (N=143) enrolled in a previous longitudinal study. Department of Veterans Health Affairs' electronic records were used to retrospectively collect Veteran mortality outcomes, over a 6-year period. Measures included baseline: demographics, dementia-related factors, other comorbid conditions, functioning, and medication use. Associations with baseline characteristics and mortality were examined with bivariate analyses and a series of Cox proportional hazard models. Results Over 6 years of study follow-up, 53.1% of participants died. The mean time to death was 3.09 years, with a range of 54 days to 5.91 years. Female sex, better cognition, and higher scores on the Tinetti Gait and Balance scale were protective factors in the final multivariable model, adjusting for other characteristics. Conclusions While newly diagnosed with early dementia, over half of our sample died in the 6-year follow-up period, with the average death occurring only 3 years after initial diagnosis. The finding of lower mortality associated with better performance on gait/balance testing indicates an important opportunity for focused interventions and early detection of gait and balance changes early during cognitive decline.

Background: Persons with dementia are at risk of a missing incident, which is defined as an instance in which a demented person’s whereabouts are unknown to the caregiver and the individual is not in an expected location. Since it is critical to determine the missing person’s location as quickly as possible, we evaluated whether commercially available tracking technologies can assist in a rapid recovery. Methods: This study examined 7 commercially available tracking devices: 3 radio frequency (RF) based and 4 global positioning system (GPS) based, employing realistic tracking scenarios. Outcome measures were time to discovery and degree of deviation from a straight intercept course. Results/Conclusion: Across all scenarios tested, GPS devices were found to be approximately twice as efficient as the RF devices in locating a “missing person.” While the RF devices showed reasonable performance at close proximity, the GPS devices were found to be more appropriate overall for tracking/locating missing persons over unknown and larger distances.

This quality improvement project seeks to provide guidance on whether caregivers should attempt to “assist” fallers, and if so, the safest way to minimize injury to themselves and the faller. Primary aims were to: 1) Identify common characteristics of documented assisted falls, 2) Identify cases where injuries to patients and/or staff occur, and 3) Provide guidance to the clinical field. Data sources for this project includes secondary databases of assisted falls events as well as primary data collection using computer simulation. Initial results for 2 VA quality tracking databases of assisted falls over a 9-year period are presented. Qualitative matrix analyses were conducted for both assisted falls datasets, which separately examined patient and employee injuries related to assisted falls. Two trained qualitative experts analyzed 195 fall narratives from the datasets to develop insights about the most common fall scenarios that result in injury. The most commonly reported assisted falls scenarios included 1) related to toileting, 2) while ambulating, and 3) while transferring from wheelchair. Findings of these analyses indicate current documentation does not capture the nuance of assisted falls. Additional variables such as 1) the direction of the fall; 2) the fall scenario; 3) how staff sought to assist; 4) staff injury description and 5) and other key variables (patient symptoms, environmental factors) that could improve fall documentation and understanding of assisted falls. Preliminary efforts are providing information for development of a computer simulation using a virtual environment to repeatedly test common fall scenarios and influences of caregiver assistance.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home.The articles in this new installment of the series explain principles for promoting safe mobility that nurses should reinforce with family caregivers. Each article also includes an informational tear sheet-Information for Family Caregivers-that contains links to instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then encourage the caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses.

To investigate baseline factors associated with caregiver-reported wandering among community-dwelling veterans with mild dementia.Veterans with mild dementia (N = 143) and their caregivers participated in a 2-year prospective longitudinal study. Measures assessed wandering, daily function, behavior, cognition, and personality features. Wandering was dichotomized as present or absent across study periods, and associations with baseline characteristics were examined.One-quarter of participants demonstrated caregiver-reported wandering at 1 or more study visits, with 14% to 15% wandering at any 1 visit. Wandering was associated with significantly lower baseline scores in performance of daily function, behavioral response to stress, gait, and balance, and conscientiousness.This novel study evaluated wandering in a community-dwelling sample of veterans with mild dementia. Wandering was associated with a specific personality trait, poorer behavioral response to stress as well as greater functional and gait/balance impairment. These findings may assist in developing community-based interventions for caregivers.

This study examined mortality in relation to baseline characteristics amongst participants in a longitudinal study of persons diagnosed with early dementia (N = 143). Department of Veterans Affairs’ health records were used to collect participant mortality outcomes, for a standardized six-year observation period. Study measures assessed participant: demographics; functioning (Inventory of Activities of Daily Living; Tinetti Gait and Balance); cognitive- (Mini-Mental State Examination [MMSE], Trails-Making Test B) and dementia-related (Clinical Dementia Rating [CDR]) factors; as well as medication use (categorized into cholinesterase-inhibitors and confusion-related medications]). Bivariate analyses examined associations with baseline characteristics and mortality. A series of Cox proportional hazard models were conducted examining associations with baseline variables, both in univariate as well as multivariable models (controlling for age and gender, where appropriate). Over the six years of study follow-up, 48.3% of participants died. The mean time to death was 2.98 years (SD = 1.44), with a minimum of 54 days and a maximum of 5.91 years. Across all univariate models, only the model including the MMSE was statistically significant. Multivariable model results indicated female gender and higher cognition (as measured by the MMSE) were associated with a reduced likelihood of death, controlling for other factors. This study examined mortality in persons with early dementia living in the community, and associations with baseline factors. Cognitive decline was significantly associated with mortality, even amongst persons early in the course of dementia. Findings underscore the terminal nature of dementia, frequently underappreciated by family and caregivers in the community.

The risk of adverse events (AEs) such as infection and amputation related to diabetic foot ulcers (DFUs) has been studied, but less is known about rate of other AEs such as falls. As part of a quality improvement project, AEs in veterans with diabetes mellitus (DM) with and without a DFU were examined. Demographic data including ICD-9 codes, AEs, and comorbidities for all patients with a diagnosis of DM and/or DFU treated between 2009 and 2014 at the James A. Haley Veterans' Hospital, Tampa, FL, were reviewed retrospectively utilizing the Corporate Data Warehouse (CDW) database. Identifiable protected health information data using patient scrambled social security numbers were collected from the CDW to allow the longitudinal data to be linked at the unique patient level. Descriptive statistics (eg, mean, standard deviation) were determined for demographics, AE, and comorbidities. Adjusted models of AE association with DM and DFU were analyzed using regression modeling via a statistical analysis system. The models were adjusted for age, race, gender, marital status, and comorbidities. Data extracted included individuals diagnosed with diabetes with a DFU (n = 3238, average age 66.0 ± 10.6 years) and diabetes without DFU (n= 41 324, average age 64.4 ± 11.5 years). Participants were mostly Caucasian in both the DFU and non-DFU cohorts (2655 [82.0%] and 32 269 [78.1%], respectively) and male (3129 [96.6%] and 39 580 [95.8%], respectively). The most common comorbidities in this population were peripheral vascular disease (PVD, 39.5%) and peripheral neuropathy (PN, 23.2%). PVD was more common in veterans with (39.5%) than without a DFU (9.2%). Compared to individuals with DM, those with DM and DFU were significantly more likely to experience an infection (OR = 9.43; 95% CI 8.54-10.4), undergo an amputation (OR = 7.40; 95% CI 6.16-8.89), or experience a fracture (OR = 3.65; 95% CI 2.59-5.15) or fall (OR = 2.26; 95% CI 1.96-2.60) (P.01 for all variables). Although the increased risk of infection and amputation among persons with DFUs has been documented, less is known about the rate of falls and fractures. The current findings will serve as baseline data for future implementation trials to reduce DFU-associated AEs, and clinicians may want to consider expanding DFU patient education efforts to include fall risk.

Objective: To report the implementation/adoption of the Safe Home Program to support caregivers of persons with dementia in (1) ongoing surveillance, (2) provision of care, (3) prevention of injuries, and (4) improving home safety. Methods: For this demonstration project 4 assessment questionnaires (Safety Assessment Scale, Vigilance Scale, Peace of Mind Scale, and Sleep Disorders Inventory) were administered to each dyad to understand their technological needs. After identification and installation of appropriate technologies and education of the caregiver, a final visit (at 3 months) determined whether technologies were useful and being used. Results: The majority of caregivers utilized technologies for ongoing surveillance; other technologies included an identification program and medication organizer. Conclusion: Technologies focused on ongoing surveillance for persons with dementia at the home are needed. These technologies could be quickly adopted by caregivers to ameliorate some of the stress and burden associated with providing care for persons with dementia.

Rehabilitation nurses are in a critical position to lead interdisciplinary team fall prevention management, including injury risk reduction. This article provides an update for rehabilitation nurses on evidence-based strategies to reduce patients'risk of fall-related injuries. This content builds on existing literature by focusing on knowledge to promote patient responses that reduce the risk of falls and ultimately fall-related injuries. Although rehabilitation nurses understand the complex nature of falls, addressing the intrinsic and extrinsic risk factors that increase the risk of fall-related injuries requires both individually based treatment programs and a system-wide commitment. A plethora of literature discusses fall risks and falls, but this article profiles the at-risk patient and describes current and emerging evidence-based interventions to protect patients from fall-related injuries by reducing risk factors. This discussion is limited to exercise, environmental redesign, osteoporosis prevention, and hip protectors.

On the basis of fall injury program characteristics across multiple inpatient medical-surgical units from 6 medical centers, we developed and implemented an operational strategic plan to address fall and injury prevention program attributes and enhance program infrastructure and capacity. Expert faculty provided lectures and served as coaches and mentors through triweekly conference calls and collaborative e-mail exchange. Statistically significant findings support improved fall and injury prevention program components and processes at the organizational and unit levels.

The goal of this study was to apply sociotechnical probabilistic risk assessment to prioritize risks and prevention strategies for serious injurious falls of residents in nursing homes. Risk modeling teams consisted of 26 clinical and nonclinical staff from three Department of Veterans Affairs community living centers and one state Veteran's nursing home. Participants met in groups several times to identify and assign probabilities to provider and resident at-risk behaviors and equipment failures. They identified prevention strategies for the failures that accounted for the highest levels of risk. Six scenarios were modeled: (1) transferring from bed to wheelchair, (2) propelling from bedside to bathroom, (3) transferring from wheelchair to toilet, (4) transferring from toilet to wheelchair, (5) propelling from bathroom to bedside, and (6) transferring from wheelchair to bed. The greatest paths of risk were for residents with impaired mobility and high fragility. A 26% reduction in injurious falls could be achieved by (1) reducing the number of unassisted transfers through a modest improvement in response time to alarms, (2) installing automatic brake locks on 90% of wheelchairs, (3) making the wheelchair maintenance process highly reliable, and (4) decreasing improper transfer techniques by 10%.

Behavioral symptoms of dementia often present the greatest challenge for informal caregivers. One behavior, that is a constant concern for caregivers, is the person with dementia leaving a designated area such that their whereabouts become unknown to the caregiver or a missing incident. Based on an extensive literature review and published findings of their own research, members of the International Consortium on Wandering and Missing Incidents constructed a preliminary missing incidents model. Examining the evidence base, specific factors within each category of the model were further described, reviewed and modified until consensus was reached regarding the final model. The model begins to explain in particular the variety of antecedents that are related to missing incidents. The model presented in this paper is designed to be heuristic and may be used to stimulate discussion and the development of effective preventative and response strategies for missing incidents among persons with dementia.

Background: The recent withdrawal of Vioxx (rofecoxib) from the market and emerging evidence that cyclooxygenase (COX) 2 inhibitors as a class of drugs may raise the risk of adverse cardiovascular events have highlighted the limitations of current postlicensing surveillance systems in the United States. We explored the use of linking national Veterans Health Administration (VHA) administrative datasets into a medication surveillance system to examine hospitalizations for stroke or myocardial infarction (MI) among COX-2 users compared with nonusers. Methods: We conducted a descriptive study of 719,058 inpatient hospitalizations within the VHA system over a 2-year period, 2002-2003. We analyzed the frequencies of strokes or MI among COX-2 users and nonusers, as well as mutually exclusive celecoxib or rofecoxib groups. We identified a total of 110,583 unique COX-2 users who had 708,617 COX-2 prescriptions. We then linked the COX-2 patients to acute hospital care for stroke or MI and analyzed frequencies by age strata. Results: Approximately 2% of COX-2 users (2246 individuals) had a stroke or MI, which represents 9.2% of all 24,452 hospitalized COX-2 patients. This is slightly higher than the 8.8% of all stroke or MI patients (63,548) accounted for in the total of 719,058 unique hospitalizations. However, adjustments for age produced mixed results in all analyses. Conclusions: Currently in the United States, medication safety programs are largely focused on monitoring and voluntary reporting of known risks and side effects of drugs as identified by the drug manufacturers, and medication administration process measure reporting. These approaches do not facilitate identification and analysis of a medication's safety where the drug is an independent risk factor for an adverse health outcome that may not have been previously identified. This study demonstrates that a medication surveillance system based on large-scale national administrative datasets can be used to rapidly evaluate a reported medication risk or harm. More importantly, in the absence of a reported medication risk or harm, especially for outpatient medications, a medication surveillance system based on the emerging VHA model could be used to facilitate efficient, timely, and proactive postlicensing medication surveillance.

Older patients with a distal symmetric polyneuropathy are at markedly increase risk for falls and fall-related injuries. Despite this, few studies have investigated the effect of exercise regimens on gait and balance in this high-risk group.One hundred older patients with distal symmetric polyneuropathy were randomized to one of three interventions: functional balance training, Tai Chi, or education-only control. The subjects in each group received instruction in ten 1-hr weekly sessions. Outcome measures were determined at baseline and the end of the 10-wk intervention. Gait, balance, and falls self-efficacy were assessed with various well established clinical (Berg Balance Scale, 8 Foot Up and Go Test, and Modified Falls Efficacy Scale) and laboratory-based measures (three-dimensional gait analysis and NeuroCom limits of stability and sensory organization tests).The Tai Chi subjects demonstrated a decreased (faster) Timed Up and Go and increased stride length and time spent in single limb support at the end of intervention as compared with baseline. The functional balance training group demonstrated a significant increase in ankle plantar flexor power and near significant decreases in step width and step width variability. No changes in the education-only control group were observed.Older patients with distal symmetric polyneuropathy may benefit from Tai Chi and/or functional balance training, with the former improving functional mobility and gait and the latter possibly improving trunk stabilization and forward progression (Lythgo N, Cofré LE: Relationship between ankle plantar flexor power and EMG muscle activity during gait. 30th Annual Conference of Biomechanics in Sports [Melbourne, 2012]. Available at: https://ojs.ub.uni-konstanz.de/cap/article/viewFile/5320/4891). Whether these laudable changes can be maintained or translate into decreased risk for falls and fall-related injuries is unknown.

Despite much research on falls occurring on medical-surgical units and in long-term care settings, falls on inpatient psychiatry units are understudied. On the basis of fall injury program characteristics across multiple inpatient psychiatry units, we developed and implemented an operational strategic plan to address each falls prevention program element and enhance program infrastructure and capacity. Expert faculty provided lectures, coaching, and mentoring through biweekly conference calls and collaborative e-mail exchange. Findings support continued efforts to integrate measures to reduce serious fall-related injuries.

Maximum step length is a brief clinical test involving stepping out and back as far as possible with the arms folded across the chest. This test has been shown to predict fall risk, but the biomechanics of this test are not fully understood. Knee and hip kinetics (moments and powers) are greater for longer steps and for younger subjects, but younger subjects also step farther.To separate the effects of step length, age, and fall history on joint kinetics; healthy younger (age=27(5), N=14), older non-fallers (age=72(5), N=14), and older fallers (age=75(6), N=11) all stepped to the same relative target distances of 20-80% of their height. Knee and hip kinetics and knee co-contraction were calculated.Hip and knee kinetics and knee co-contraction all increased with step length, but older non-fallers and fallers utilized greater stepping hip and less stepping knee extensor kinetics. Fallers had greater stepping knee co-contraction than non-fallers. Stance knee co-contraction of non-fallers was similar to young for shorter steps and similar to fallers for longer steps.Age had minimal effects and fall history had no effects on joint kinetics of steps to similar distances. Effects of age and fall history on knee co-contraction may contribute to age-related kinetic differences and shorter maximal step lengths of older non-fallers and fallers, but step length correlated with every variable tested. Thus, declines in maximum step length could indicate declines in hip and knee extensor kinetics and impaired performance on similar tasks like recovering from a trip.

Aging in men is associated with modest changes of the secretory and regulatory functions of the hypothalamic-pituitary-testicular axis. Similarly, some age-related changes in spermatogenesis have been reported. The clinical implications of these age-associated alterations are not yet clear.

Strength training that overloads lengthening muscle fibers may result in greater strength gains with less effort and perceived exertion than conventional training modalities. This study evaluates a device capable of this overloading (a motor-driven and computer-controlled leg press) to develop recommendations for future training interventions. Unimpaired younger and older men and women (7/group, total n = 28) performed three maximal-effort trials for both directions of footplate motion (IN and OUT) at three speed profiles (knee rotation speeds of 15, 25, and 35°/s) on a motor-driven and computer-controlled leg press. Normalized forces were tested for effects of age group, sex, direction of footplate motion, and knee rotation speed. Peak forces were 57% greater for younger and 20% greater for IN. Trends of greater IN relative to OUT forces (IN overloading) were present in women, but this was due to an inverse correlation between strength and IN overloading that was independent of age group and sex. Leg press strength training on a device that is capable of overloading lengthening muscle fibers is a promising new training method that appears to have the greatest potential benefits for the weakest participants. Training target profiles on the device tested and others similar to it should be set based on participant-specific maximums across the ROM in both IN and OUT directions at a speed in the middle of the range to be trained.

Background: Fall-related injuries (FRIs) result in morbidity and mortality for patients, as well as unnecessary expense to health care institutions. Objectives: (a) Estimate the incidence of falls and FRIs with a nursing home as the source of admission in Veterans Administration (VA) and non-VA facilities. (b) Estimate the cost of hospitalizations for each level of FRI severity. Research Design: Retrospective analysis of falls and FRI resulting in a hospitalization whose source of admission was a VA nursing home. Data: Falls and FRIs were obtained from Minimum Data Set (MDS) reports (January 2007-June 2009). Costs were obtained from the VA Decision Support System reports and Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) reports (2000-2006). Measures: Incidence of falls, fracture incidence, number of hospitalizations for FRIs, and costs associated with hospitalization for by level of FRI severity. Results: Fall incidence was 10.6% in VA and 13.1% in CMS facilities. Fracture incidence was 0.9% in VHA and 1.65% in CMS facilities. Over a 3-year period, there were 2,400 admissions to VHA hospitals for FRI, with 55.4% hip fractures and10.1% intracranial injuries, with an average cost of US$23,723 per admission. Over a 9-year period, there were 141,308 admissions from nursing homes to non-VA hospitals for FRIs, with 38.8% hip fractures, 35.7% other fractures, and 11.1% intracranial injuries, with an average cost of US$31,507 per admission. Conclusions: Prevention program emphasis should shift away from a focus on preventing falls as a measure of quality care to decreasing FRIs. These findings support implementation of injury prevention programs for the elderly that reduces risk for injury as the primary outcome.

Recognizing that risk factors for falls are multifactorial and interacting, providers require guidance on the components, intensity, dose, and duration for an effective fall and fall injury prevention program. Administrators of health care facilities require guidance on resources needed for these programs. Clear guidance does not exist for specifying the right combination of interventions to adequately protect specific at-risk populations, such as nursing home residents with dementia or osteoporosis. Staff education about fall prevention and resident fall risk assessment and reassessments has become part of standards of practice; however, the selection, specificity, and combination of fall prevention and injury protection interventions are not standardized. To address these gaps, this team of researchers conducted a critical examination of selected intervention studies relevant to nursing home populations. The objectives of this literature review were to (1) examine the selection and specificity of fall prevention and injury protection interventions described in the literature since 1990; (2) evaluate the strength of evidence for interventions that both prevent falls and protect residents from fall-related injury; and, (3) provide clinical and policy guidance to integrate specific interventions into practice.

An investigation into the mechanical properties of two types of hip protectors, after repeated launderings, was conducted at the VISN 8 Patient Safety Center in Tampa, Florida. A hybrid soft/hard protector and a soft foam protector were used in this study. Both sets of hip protectors were washed and dried in increments of 25 laundering cycles and then impacted in the laboratory. Results indicated that there was a decrease in protective properties with the hybrid protector as the number of launderings increased. In addition, the dome shaped outer shell of this hybrid protector became significantly less pronounced which would allow the transmission of more of the impact force into the greater trochanter. The soft protectors began to show the same downward trend as the hybrid protectors but suddenly reversed when the experimental protocol was altered. These unusual results lead to further testing of the effects of residual moisture content inside soft foam protectors. Data from the subsequent impact tests indicated that indeed residual moisture does play an adverse role in a soft protector’s ability to attenuate force. Results from these experiments should lead one to assure that hard shell protectors keep their protective shape and that soft foam protectors are adequately dried before use.

Tatjana Bulat1, Shawn Applegarth1, Stuart Wilkinson2, Shirley G Fitzgerald1, Shahbaz Ahmed1, Patricia Quigley11VISN 8 Patient Safety Center of Inquiry, Tampa, FL, USA; 2University of South Florida Department of Mechanical Engineering, Tampa, FL, USAAbstract: A variety of external hip protectors are available on the market but no standards for their performance exist and it is unknown if their properties change after repeated fall impacts. The purpose of this study was to determine if protective properties change in different types of new (unused) hip protectors after repeated, simulated falls. Five hip protector brands were chosen to represent different products available on the market and the two mechanisms employed in reducing the force of an impact (shunting or absorbing). Ten pairs of each type (20 pads for each brand) were tested using a 1.8-m Instron Dynatup 9250 HV vertical impact testing tower. The impact testing system was specifically designed for this study by creating a simulated trochanter to provide more accurately a impact area similar to that of a real hip bone. The hip protectors were impacted once a day for 3 consecutive days. Repeated impacts demonstrated the pads’ decreased ability to either absorb or shunt force in all types of hip protectors. However, the mean forces were still in the protective range (force below fracture threshold of 3100 N) for 3 of the 5 brands tested after 3 impacts. The protective properties of external hip protectors do degrade after repeated impacts. The degree of degradation differs from brand to brand. Regardless of type, most pads were still able to bring the force of impact below the fracture threshold of 3100 N. Future studies need to address the issue of durability of different types/brands of hip protectors after repeated laundering and fall impacts to determine when should they be replaced. Additionally, a national or international standard needs to be developed against which the performance of different brands of hip protectors can be compared.Keywords: hip protectors, fall impacts, protective properties, hip fracture

A growing body of research supports the link between exercise and fall prevention. A systematic review of this literature (Gregg et al 2000),found consistent evidence from a series of prospective and case-control studies linking physical activity with a 20%–40% reduced risk of hip fracture. Balance exercise programs can be effective in improving gait and balance, as well as reducing falls and fall-related injuries (Herwaldt and Pottinger 2003; Wolfson et al 1996; Tinetti et al 1996).Further research is needed to gain insight into the underlying mechanisms of dif-ferent type of exercises and their impact on stability in individuals at risk for falls. Despite thousands of research studies published on patient falls, few studies have focused on the effectiveness of interventions (Rubenstein 2004), and fall rates and associated injuries among the elderly continue to rise (CDC 2002). Impaired gait and balance (referred to as impaired stability) is one of the most signifi cant causes and consequences of falls (Robbins et al 1989; American Geriatric Society, British Geriatric Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention 2001; Foster et al 2004).The purpose of this pre-test, post-test clinical intervention study was to determine the effectiveness of 8-week group functional balance training classes on balance out-comes in community-dwelling veterans conducted at the VISN 8 Patient Safety Center from 2001 to 2004. The objectives of this study were to determine: (1) the diagnostic profi le of veterans who participated; (2) class participation rates; (3) the rank order of

The purpose of this study was to develop a multivariate fall risk assessment model beyond the current fall Resident Assessment Protocol (RAP) triggers for nursing home residents using the Minimum Data Set (MDS).Retrospective, clustered secondary data analysis.National Veterans Health Administration (VHA) long-term care nursing homes (N = 136).The study population consisted of 6577 national VHA nursing home residents who had an annual assessment during FY 2005, identified from the MDS, as well as an earlier annual or admission assessment within a 1-year look-back period.A dichotomous multivariate model of nursing home residents coded with a fall on selected fall risk characteristics from the MDS, estimated with general estimation equations (GEE).There were 17 170 assessments corresponding to 6577 long-term care nursing home residents. The increased odds ratio (OR) of being classified as a faller relative to the omitted "dependent" category of activities of daily living (ADL) ranged from OR = 1.35 for "limited" ADL category up to OR = 1.57 for "extensive-2" ADL (P.0001). Unsteady gait more than doubles the odds of being a faller (OR = 2.63, P.0001). The use of assistive devices such as canes, walkers, or crutches, or the use of wheelchairs increases the odds of being a faller (OR = 1.17, P.0005) or (OR = 1.19, P.0002), respectively. Foot problems may also increase the odds of being a faller (OR = 1.26, P.0016). Alzheimer's or other dementias also increase the odds of being classified as a faller (OR = 1.18, P.0219) or (OR=1.22, P.0001), respectively. In addition, anger (OR = 1.19, P.0065); wandering (OR = 1.53, P.0001); or use of antipsychotic medications (OR = 1.15, P.0039), antianxiety medications (OR = 1.13, P.0323), or antidepressant medications (OR = 1.39, P.0001) was also associated with the odds of being a faller.This national study in one of the largest managed healthcare systems in the United States has empirically confirmed the relative importance of certain risk factors for falls in long-term care settings. The model incorporated an ADL index and adjusted for case mix by including only long-term care nursing home residents. The study offers clinicians practical estimates by combining multiple univariate MDS elements in an empirically based, multivariate fall risk assessment model.

OBJECTIVE: The aim of this study was to identify which specific medications within recognized major problematic drug categories that increase risk of falling were prescribed to veterans before their out-patient treatment for a fall. METHODS: This was a retrospective, cross-sectional national secondary outpatient data analysis with an age- and sex-matched comparison group. The setting was the national Veterans Health Administration (VHA) ambulatory health care system in fiscal year (FY) 2004. The study population was VHA patients aged>or=65 years who had fall-related outpatient clinical health care encounters in FY 2004 (as indicated by diagnostic codes) and who received >or=1 outpatient medication during the study period. The age- and sex-matched comparison group consisted of an equal number of patients with nonspecific chest pain. The percentage of patients in each group receiving medications (at the time of the outpatient encounter) that affect the cardiovascular system (CVS), central nervous system (CNS), or musculoskeletal system (MSS) was compared with Bonferrom-adjusted P values. RESULTS: The study sample consisted of 20,551 patients; the comparison group included the same number of patients. More patients with fall-coded encounters used CNS drugs than those with nonspecific chest pain (42.05% vs 29.29%). Also, within the CNS category, more patients with fall-coded encounters used antiparkinsonian medications (3.67% vs 1.32%), Alzheimer's disease medications (ie, cholinesterase inhibitors [5.40% vs 2.35%]), anticonvulsants/barbiturates (8.95% vs 5.18%), antidepressants (22.50% vs 14.16%), antipsychotics (4.68% vs 2.01%), opioid analgesics and narcotics (11.21% vs 9.09%), and benzodiazepines (7.60% vs 5.96%) (all, P

Background: Benzodiazepines comprise a class of drugs that when used as monotherapy are generally acknowledged to pose a risk for injury by increasing the likelihood of falls, fall-related injuries, adverse drug events and car accidents. Benzodiazepines may also be used concomitantly with other high risk medications that may further exacerbate the risk of injury. The aim of this study is to examine the occurrence of the concomitant use of benzodiazepines and other drugs and then quantify the indirect effect of these drug combinations on the likelihood of an injury-related healthcare episode. Methods: A multivariate model was specified that included outpatient prescription data and inpatient/outpatient medical utilisation records for 13 745 patients at a Veterans Administration hospital system over a 3-year period (1999–2001). We analysed 133 872 outpatient benzodiazepine prescriptions and >1.5 million non-benzodiazepine prescriptions for the study population. Micromedex software was used to identify combinations of benzodiazepines and other drugs that are likely to result in ‘major’ interactions. We then further restricted our focus to the use of these drug combinations within a 30-day period prior to an injury-related medical event. The adjusted odds ratio on a variable characterising concomitant use of a benzodiazepine and another drug within this period was used to quantify the relative risk of injury. The principal outcome was the estimated risk of an injury-related healthcare episode within a 30-day period when taking both a benzodiazepine and another drug with a ‘major’ severity rating as defined by Micromedex. The risk of injury was adjusted for comorbidities, hospital discharges, marital status, age, mean arterial pressure and body mass index, as well as the dose of benzodiazepine (converted to diazepam equivalents) and duration of benzodiazepine treatment. Results: Of the 1110 unique individuals who experienced an injury, 790 (71.2%) patients had used a benzodiazepine in combination with another drug. Furthermore, only 4.3% (320/7522) of the patients taking benzodiazepines who did not have concomitant drug use experienced an injury. The occurrence of this concomitant use increased the odds of an injury >2-fold in the model. Dose and duration of benzodiazepine use, as well as certain comorbidities, were also associated with an increased risk for injury, whereas being married reduced the risk. Conclusions: This is the first large-scale study to quantify the impact of concomitant use of benzodiazepines and other drugs on the risk of injury in a population of Veterans Administration patients. It demonstrates the utility of expanding the focus of inappropriate medication usage to include analyses that link potentially inappropriate drug use with healthcare utilisation for injuries.

Hip fractures among elderly people frequently result in permanent disabilities, nursing home placement, and death. The bulk of hip fracture research focuses on elderly women. Within the Veterans Health Administration (VHA), the majority of patients are men. There are no published national reports on hip fractures with large male samples, or on related inpatient mortality among veterans. This retrospective study of 13,546 veterans with hip fracture discharges from 1998-2002 found unadjusted mortality rates are higher in the VHA, compared with the general population. VHA patients tend to be older men in poor health who stay in the hospital longer Increased knowledge about the risks and outcomes associated with hip fractures in men could lead to improved primary and secondary injury-prevention programs. Rehabilitation nurses in acute care can be catalysts in proactively incorporating protective devices, screening for osteoporosis, and initiating lifestyle changes in their plans of care to optimize outcomes for hip fracture patients.

New technologies designed to help prevent adverse events related to the mobility of geriatric patients (ie, patient falls, bed-rail entrapment, patient handling, and wandering) are described. Technology offers the potential to eliminate or mitigate preventable adverse events that interfere with treatment, delay rehabilitation, potentiate impairment, and compromise patient safety. Unchecked, these adverse events can have a negative impact on patient health, functional status, and quality of life. It is not surprising that the elderly constitute the population at highest risk for adverse events, based on poor health, chronic conditions, long hospitalizations, and institutional care. Patient falls are a high-risk, high-volume, and high-cost adverse event. Key technologies to prevent falls and fall-related injuries include hip protectors, wheelchair/scooter safety features, intelligent walkers, fall alarms, and environmental aids. Bed-rail entrapment is a serious adverse event, which includes patients being trapped, entangled, or strangled in beds. New technologies to prevent bed-rail entrapment include new hospital bed designs, height-adjustable low beds, devices to close gaps in legacy beds, and bedside floor mats. Patients with mobility impairments necessitate physical assistance in transfers and other patient-handling tasks, which increases risk for the caregiver and the patient. Featured technologies to prevent patient handling injuries include innovations in floor-based lifts, new ceiling-mounted patient lifts, and improvements in powered standing lifts, new friction-reducing devices, and new patient transport technology. Wandering affects 39% of cognitively impaired nursing home residents and up to 70% of community-residing elderly persons with cognitive impairments. New technologies to prevent adverse events associated with wandering include door alarms and signal-transmitting devices. Nurses in geriatric settings would benefit from exposure to technologies that could improve patient and caregiver safety. To maximize the benefits of technology, it is critical that front-line nursing staff be involved in the testing and selection of devices that will be used in their practice. Further, to reap the full benefits of technology, a careful plan for implementation needs to be developed that would include integrating the new technology with existing infrastructure. Training needs to be provided for all staff who will be using the technology, and efforts to ensure competency over time is needed. A major barrier to widespread use of new technology is cost. Further research is needed to demonstrate the cost effectiveness of these devices. Results from these studies will help to build a business case, demonstrating that initial capital investments will result in cost savings, improved quality of care, and other benefits.

Background. Hip protectors have been found to be effective in preventing hip fractures; unfortunately adherence with their use seems to be poor, especially long-term. We wanted to identify key barriers and facilitators influencing their use in long-term care from staff’s perspective and patient-perceived barriers and facilitators among elderly outpatients. Methods. A series of focus groups and individual interviews were conducted with nursing home staff and outpatients seen in a falls clinic and deemed to be high risk for falls and fall-related injuries. Forty-one nursing home staff members and 38 outpatients (3 months after receiving a multidisciplinary fall evaluation during which external hip protectors were provided) participated. Using content analysis, responses were grouped into categories. Results. In the long-term care setting, the main perceived advantage was improvement in quality of care, particularly the prevention of hip fractures. Perceived barriers were categorized into administrative constraints (cost, availability), characteristics of hip protectors, and patient and staff concerns. Facilitators were supportive managers and administrators, families and co-workers. In the outpatient setting, adherence with hip protector use was poor (34%) at 3 months despite substantial encouragement and education from the providers. All respondents gave multiple reasons for not using protectors, most commonly related to comfort and difficulty in taking them on and off. The majority of outpatients was not willing to wear them. Conclusion. Important barriers to the use of hip protectors exist from both patient and provider perspectives. Knowledge of these barriers will be used to design and evaluate targeted implementation strategies to better integrate these highly effective devices into clinical practice.