Presentation is loading. Please wait.

Presentation is loading. Please wait.

Best Practices for Assessing Fall Risk in Perinatal Units NS 400 University of Alaska Anchorage Matrika Arrington, Nick Barney, MJ Jones, Mara Krey, Camille.

Similar presentations


Presentation on theme: "Best Practices for Assessing Fall Risk in Perinatal Units NS 400 University of Alaska Anchorage Matrika Arrington, Nick Barney, MJ Jones, Mara Krey, Camille."— Presentation transcript:

1

2 Best Practices for Assessing Fall Risk in Perinatal Units NS 400 University of Alaska Anchorage Matrika Arrington, Nick Barney, MJ Jones, Mara Krey, Camille McArdle

3 Importance:  “falls are the most common cause of minor injury during pregnancy and are estimated to cause 17–39% of trauma associated with emergency department visits and hospital admissions, second only to motor vehicle crashes,” (Dunning et al., 2009).  “Knowledge of characteristics specifically associated with injury among pregnant women can be used to help identify women who may be at higher risk for experiencing an injury during pregnancy and can potentially inform the development of prevention programs for women to reduce the risk of injury during pregnancy” (Tinker et. al, 2010). Summary of Evidence: Falls in the perinatal population are preventable. Anticipatory guidance with patient teaching would be effective at reducing incidences of falls (Dunning, et. al, 2009) Antepartum or at home bed rest duration information may be an assessment criteria to review upon receiving a postpartum patient to reduce the risk for falls (Maloni & Park, 2005) Patients with a decreased perception of balance might benefit from widening their stance (Jang, Hsiao, & Hsiao-Wecksler, 2008) Tandem stance with eyes open most effective at predicting fall risk. (Hanson, Mansson, Ringsberg, & Hakansson, 2008) 51.6% of all injuries reported during pregnancy were from falls. Falls more likely to be reported in the second and third trimesters Improved balance observed for combinations of interventions that involve exercise (Day et. al., 2002) During the second and third trimester of pregnancy the center of pressure is wider resulting in a decline in postural stability (Butler, Colon, Druzin & Rose, 2006) Evidence shows implementation of a fall risk tool specifically for pregnant women will decrease falls (Heafner, et. al., 2011) Searchable Question: What are the best practices for assessing fall risk in the perinatal units? Databases Searched: CINAHL PubMed Google Scholar Matrika Arrington, Nick Barney, Michelle Jones, Mara Krey, Camille McArdle Level of Evidence Citation Key MeasuresSetting and SampleResearch DesignKey Strengths and WeaknessesResults Level of Evidence: IV McCrory, J., Chambers, A., Daftary, A., & Redfern, M. (2011). Ground reaction forces during gait in pregnant fallers and non- fallers. Gait & Posture, 34, IV: pregnant women DV: Ground Reaction Forces Walking velocity Setting: Human Movement and Balance Laboratory on the campus of the University of Pittsburgh Sample, n=81 41 pregnant females 40 non pregnant females age Non-Experimental Quasai-Experimental Retrospective Observational Strengths: Easy to conduct First Step toward demonstrating causation Weaknesses: No intervention No causation and correlation First and second trimester pregnant women have a slower walking velocity (1.34, 1.29m/s) compared to non-pregnant (1.47m/s). (p=0.048) Level of Evidence: IV Lord, S., Lloyd, D., & Li, S. (1996). Sensori- motor function, gait patterns and falls in community-dwelling women. Age and Ageing, (25), IV: Pregnant women DV: 80+ measurements of sensori-motor function. Most important: Walking velocity Setting: Community Setting Sample, n=183 aged Group over 65 years of age: n=96 Non-experimental Quasai-Experimental Prospective Observational Strengths: Immense amount of data collected Shows a great way to measure falls without making the event happen Weaknesses: Small number of faller group Not fully randomized due to convenience sample of young people There was a difference between multiple fallers and non fallers of 0.08 SD. The p value was not <0.05 but increasing the sample size could make this result significant. Level of Evidence: IV Jang, J., Hsiao, K., Hsiao-Wecksler, E. (May 2008). Balance (perceived and actual) and preferred stance width during pregnancy. Clinical Biomechanics, 23(4): IV: pregnancy DV: balance & stance width Setting: Community Setting Sample, n=30 15 pregnant women 15 non-pregnant women Non-experimental Prospective Repeated measures Strengths: New measurement techniques Addition of control challenges previous findings Weaknesses: Loss of 3 study subjects & small convenience sample Low level of evidence & no intervention Significant sense of balance degradation, increased sway in the anterior-posterior direction (medial-lateral sway decreased), decreased falls & wider stances generally had better balance perception Level of Evidence: III Hanson E, Månsson N, Ringsberg K, Håkansson A. falls among dizzy patients in primary healthcare: an intervention study with control group. International Journal Of Rehabilitation Research, 31(1): IV: vestibular rehabilitation DV: self-perceived handicap r/t dizziness, balance, & falls among dizzy patients Setting: Community Setting Sample, n=58 >65 yo patients “multisensory dizziness” not explained by other diagnosis non-randomized control Non-experimental Quasi-experimental non-equivalent control group Strengths: control group (challenges previous studies non-control findings) DHI tool asked questions about their self- perceived handicap r/t dizziness by defining it as “dizziness or unsteadiness problems” Weaknesses: non-randomized group assignment shortened to accommodate lack of subject time commitment loss of 13 subjects Vestibular rehab was ineffective at reducing falls & patients with poor outcome in “tandem stance with eyes open” assessment had twice the fall risk Level of Evidence: II Day, L., Fildes, B., Gordon, I., Fitzharris, M., Flamer, H., & Lord, S. (2002). Randomized factorial trial of falls prevention among older people living in their own homes. BMJ: British Medical Journal, 325(7356), IV: exercise DV: Quadriceps strength, balance Setting: Participants homes in Australia. Sample, n=1090 Aged 70+ and living at home. Convenience sample Experimental: Randomized Control Trial with a Full Factorial Design Most Significant Intervention to Prevent Falls: Exercise Strengths: RCT, large sample, Intervention not too inconvenient for participants Weaknesses: Convenience sample Study more than 5 years old Significant effect (P < 0.05) was observed for the combinations of interventions that involved exercise. Balance measures improved significantly among the exercise group. Level of Evidence: VI Tinker, S. C., Reefhuis, J., Dellinger, A., & Jamieson, D. (2010). Epidemiology of maternal injuries during pregnancy in a population-based study, 1997–2005. Journal Of Women’s Health, 19(12), doi: = jwh IV: Pregnancy DV: Fall, No Fall Phone interviews with mothers 6 weeks to 2 years after the birth of healthy child. Setting: Arizona, California, Georgia, Iowa, Massachusetts, North Carolina, New Jersey, New York, Texas, Utah Sample, n=6609 Mothers Convenience sample Non-experimental Retrospective, population-based, case-control study Strengths: Large sample, Subjects from multiple states across country, Diverse demographic & socioeconomic backgrounds Weaknesses: Study limited by reliance on self-reported data, Mothers more likely to report only injuries given in examples by the interviewer Slightly more than half of reported injuries were due to falls (51.6%) Data suggests that the occurrence of falls becomes more likely as pregnancy progresses, with nearly 43% of reported falls occurring during the third trimester Level of Evidence: IV Maloni, J. A., & St. Pierre Schneider, B. (2002, May ). Inactivity: Symptoms associated with gastrocnemius muscle disuse during pregnancy. AACN Clinical Issues, 13(2), IV: length of hospital (antepartum) bed rest DV: gastrocnemius muscle reoxygenation time Setting: Hospital antepartum unit Sample, n=65 Convenience Sample of pregnant women prescribed antepartum bed rest Non-experimental Longitudinal, repeated measure study Strengths: Inclusion and Exclusion criteria for population included Data collector education completed prior to enrollment of subjects Interrater reliability for PSC was established and assess quarterly to maintain reliability of 0.95 Weaknesses: Convenience sample Small sample size No intervention No randomization Correlates the length of inactivity on muscle atrophy and the increased time needed for reoxygenation of muscle tissue on postpartum women who received antepartum bed rest. The length of recovery is dependent on the length of bed rest, but findings show that there the recovery period longer due to symptoms still reported at week 6 postpartum. Level of Evidence: IV Maloni, J. A., & Park, S. (2005). Postpartum symptoms after antepartum bed rest. Journal of Obstetric, Gynecology and Neonatal Nursing Clinical Research, 34, http://dx. doi.org/ / IV: antepartum bed rest DV: physiological and psychological postpartum symptoms Setting: Three perinatal tertiary care hospitals in two cities in the Midwest Sample, n=106 Convenience sample of pregnant women, with a single high-risk pregnancy and treated with antepartum bed rest Non-experimental Longitudinal, repeated measure study Strengths: Use of Postpartum Symptom Checklist (PSC) to gather data Exclusion criteria for population included musculoskeletal and neurological disorders Weakness: Clarity needed when determining differences in symptoms of vaginal vs. cesarean deliveries – are symptoms related to delivery or extended bedrest No intervention No randomization Length of hospital antepartum bed rest is associated with increased issues and symptoms postpartum. Since bed rest causes musculoskeletal and cardiopulmonary deconditioning ambulation will restore function, but since reconditioning takes at least 6 weeks or longer postpartum caution should be used to prevent falls. Level of Evidence: IV Dunning, K., LeMasters, G., & Bhattacharya, A. (2009, August 13). A major public health issue: The high incidence of falls during pregnancy. Maternal Child Health Journal, 14, /s DV: falls participants were research via survey in the mail, telephone and internet questioned about falls during pregnancy. Setting: Postpartum women contacted in Ohio, Kentucky, and Indiana communities Sample, n=3997 Females selected from birth certificate data; eligible if they had delivered within the last 8 weeks. Non-experimental Single Correlational Cohort Study Strengths Large Sample size Minimal Participant Bias Randomization when choosing sample Weakness Medical record review limited Maternal inclusion criteria not specified within the study Suggest that falls with this population are completely preventable; most associated with slippery floors, lack of appropriate footwear and using insufficient safety measures. Falls in the pregnant community are similar to those compared to the elderly. Level of Evidence: IV Butler, E., Colon, I., Druzin, M., Rose, J. (2006). Postural equilibrium during pregnancy: Decreased stability with an increased reliance on visual cues. American Journal of Obstetrics and Gynecology, 195, 1104 – doi: /j.ajog IV: Pregnancy DV: change in postural stability (center of pressure) and the incidence of falls Setting: Sample, n=24 12 Pregnant Women, 12 Nulligravid Women. Exclusion criteria included any medical condition that affects postural stability. Non-experimental Correlational Strengths: Control Group Informed Consent Study protocol was approved by Stanford Committee Weakness: Small Sample Size Unknown Attained Sample Study Published in 2006 During the second and third trimester of pregnancy the center of pressure was wider resulting in a decline in postural stability and remains diminished 6 to 8 weeks post- delivery compared to the non-pregnant women who had a narrow center of pressure. Out of the 8 women who returned for the postpartum visit, 2 women reported sustaining a fall during their 2nd and 3rd trimester. For each center of pressure measurement the value of P is always P<0.05. Level of Evidence: Heafner, L., Suda, D. E., Casalenuovo, N. M., Leach, L., & Gawlinski, A. (2011). 'Catch a falling star': The development of the obstetric falls risk. doi: /j _10.x IV: Impatient Pregnant Women DV: Falling Setting: Obstetric in-patients in Phase I and II. Sample, n=100 Proposed population in Phase III is 100epiduralized obstetric patients post anesthesia. Non-experimental: Quasi-experimental Strengths: Developed by a panel of expert perinatal nurses & validated through literature review. Financially feasible Weaknesses: Judgment of inexperienced nurses using OFRAS may be less accurate Study still in progress; sample size of Phase I & II unknown Phase I of the study was the development and implementation of Obstetric Falls Risk Assessment System (OFRAS); falls decreased from 6 to 1 in an 8 month period. Phase II –Systematic assessment of ante-, intra-, and postpartum patients using a scoring system to quantify fall risk. Seven obstetric patient falls and 14 near misses were analyzed retrospectively using the OFRAS. Preliminary analysis revealed additional risk factors which were then incorporated into the OFRAS. Phase III -Began by implementing the OFRAS into the EMR Future Research: Based on lack of research: development of assessment tools controlled trials Meta analysis to accurately determine the best assessment techniques

4 Significance of the Problem  “falls are the most common cause of minor injury during pregnancy and are estimated to cause 17–39% of trauma associated with emergency department visits and hospital admissions, second only to motor vehicle crashes,” (Dunning et al., 2009, p. 720).  “Knowledge of characteristics specifically associated with injury among pregnant women can be used to help identify women who may be at higher risk for experiencing an injury during pregnancy and can potentially inform the development of prevention programs for women to reduce the risk of injury during pregnancy” (Tinker et. al, 2010)

5 Searchable Question What are the best practices for assessing fall risk in the Perinatal units?

6 A major public health issue: The high incidence of falls during pregnancy (Dunning et al., 2009)  Non-experimental single correlational study, Level IV  Participants reflecting on falls during pregnancy  3997 postpartum women  Falls related to insufficient safety measures Strengths  Large Sample size  Minimal Participant Bias  Randomization when choosing sample Weakness  Medical record review limited  Maternal inclusion criteria not specified within the study

7 Postpartum symptoms after antepartum bed rest (Maloni, J. A., & Park, S. 2005)  Non-experimental longitudinal study, Level IV evidence  106 post partum women prescribed bed rest during antepartum period  Findings show that combined with bed rest recovery as well as delivery healing can put a perinatal patient at a risk for falls Strengths  Use of Postpartum Symptom Checklist (PSC) to gather data  Exclusion criteria included musculoskeletal and neurological disorders Weakness  Clarification regarding vaginal vs. cesarean deliveries – are symptoms related to delivery or extended bedrest

8 Inactivity: Symptoms associated with gastrocnemius muscle disuse during pregnancy (Maloni & St. Pierre Schneider, 2002)  Non-experimental longitudinal study, Level IV evidence  65 pregnant women hospitalized for antepartum bed rest  Findings show increase in muscle re-oxygenation times from 48 hours of delivery up to 6 weeks postpartum with antepartum bedrest Strengths  Inclusion and Exclusion criteria  Data collector education completed prior to enrollment of subjects  Interrater reliability for PSC was established and assess quarterly to maintain reliability of 0.95 Weakness  Convenience sample and small sample size  Data collected is a subset of subjects who participated in another larger study

9 Randomized Factorial Trial of Falls Prevention Among Older People Living in Their Own Homes (Day, Fildes, Gordon, Fitzharris, Flamer, & Lord, 2002)  Randomized Control Trial with a full Factorial Design, Level II  1090 Adults age 70 and over living at home who rated their health as good to excellent  Convenience Sample/Random Group Assignment  Interventions: group based exercise, home hazard management, vision improvement Strengths  RCT, large sample  Interventions not too inconvenient on participants Weaknesses  Convenience sample

10 Ground reaction forces during gait in pregnant fallers and non-fallers (McCrory et al., 2011)  Quasai Experimental- level 4  41 pregnant, 40 pregnant females age  Non-experimental, restrospective, observational study  Findings: No change in GRF however, control subjects walk at a faster pace Strengths  Easy to conduct  First step toward demonstrating causation Weaknessess  No intervention  No causation or correlation

11 Sensori-motor function, gait patterns and falls in community-dwelling women (Lord et al., 1996)  Quasai Experimental- level 4  183 women total aged  Non-experimental, observational, prospective  Findings: walking velocity was less in multiple fallers compared to non fallers Strengths  Immense amount of data collected  Shows a great way to measure falls without making the event happen Weaknesses  Small number of faller group  Not fully randomized due to convenience sample of young people

12 Balance (perceived and actual) and preferred stance width during pregnancy (Jang, Hsiao, & Hsiao-Wecksler, 2008)  Non-experimental, prospective, repeated- measures study; Level IV  15 pregnant & 15 non- pregnant women  Measured perceived balance, postural sway, stance width, & falls  Perceived balance degraded & AP sway increased in pregnant group, while falls decreased; wider stance width  better perception of balance Strengths  Stabilogram Diffusion Analysis measurement techniques  Use of control challenges previous findings Weaknesses  Loss of 3 study subjects  Small convenience sample  Lack of an intervention

13 Falls among dizzy patients in healthcare: an intervention study with control group (Hanson, Mansson, Ringsberg, & Hakansson, 2008)  Quasi-experimental, non- equivalent control group; level III  58 multi-sensory dizziness patients  Self-perceived handicap related to dizziness, balance, & falls  Balance measures were effective in predicting falls; Vestibular rehab training was not effective Strengths  Research definitions: “self-perceived handicap” & “unsteadiness problems”  Use of control challenges previous findings Weaknesses  Non-randomized sampling  Study shortened  Loss of 13 subjects

14 Epidemiology of Maternal Injuries During Pregnancy in a Population-Based Study (Tinker, Reefhuis, Dellinger, & Jamieson, 2010)  Non-experimental, Retrospective; Level VI  6609 mothers of infants: random sample  No intervention; Instrument used was telephone interviews  51.6% injuries reported from falls. Falls more likely to be reported in the second and third trimesters Strengths  Large sample  Population-based study subjects from multiple states across country  Diverse demographic & socioeconomic background Weaknesses  Study limited by reliance on self-reported data  Mothers more likely to report only injuries given in examples by the interviewer

15 Postural equilibrium during pregnancy: Decreased stability with an increased reliance on visual cues (Butler, Colon, Druzin & Rose, 2006)  Non-experimental, Correlational, Level IV  12 Pregnant Women, 12 Non-pregnant Women  Does not explain how sample was attained.  Postural Stability Declines during pregnancy Strengths  Control Group  Informed Consent  Study protocol was approved by Stanford Committee Weakness  Small Sample Size  Unknown Attained Sample

16 Catch a Falling Star: The Development of the Obstetric Falls Risk Assessment System (Heafner, Suda, Casalenuovo, Leach, & Gawlinski, 2011)  Quasi-experimental, Level III evidence  Obstetric in-patients in Phase I and II. Proposed population in Phase III is 100 epiduralized obstetric patients postanesthesia  Obstetric Falls Risk Assessment System, (OFRAS)  Following implementation of Phase I, falls decreased from 6 to 1 in an 8 month period. Strengths  Developed by a panel of expert perinatal nurses & validated through literature review.  Financially feasible Weaknesses  Judgment of inexperienced nurses using OFRAS may be less accurate  Study still in progress; sample size of Phase I & II unknown

17 Summary of Evidence  Falls in the perinatal population are preventable. Anticipatory guidance with patient teaching would be effective at reducing incidences of falls (Dunning, et. al, 2009)  Antepartum or at home bed rest duration information may be an assessment criteria to review upon receiving a postpartum patient to reduce the risk for falls (Maloni & Park, 2005)  Patients with a decreased perception of balance might benefit from widening their stance (Jang, Hsiao, & Hsiao-Wecksler, 2008)  Tandem stance with eyes open most effective at predicting fall risk. (Hanson, Mansson, Ringsberg, & Hakansson, 2008)

18 Summary of Evidence  51.6% of all injuries reported during pregnancy were from falls. Falls more likely to be reported in the second and third trimesters (Tinker et al., 2010)  Improved balance observed for combinations of interventions that involve exercise (Day et. al., 2002)  During the second and third trimester of pregnancy the center of pressure is wider resulting in a decline in postural stability (Butler, Colon, Druzin & Rose, 2006)  Evidence shows implementation of a fall risk tool specifically for pregnant women will decrease falls (Heafner, et. al., 2011)

19 Implementation/Evaluation  Searching the literature failed to provide enough evidence to answer the question of the best way to assess falls in the perinatal setting  Due to lack of evidence addressing our research question, we are unable to recommend any techniques or tools

20 Results  Evidence is inconclusive and does not answer the research question  There is a need for an assessment tool specific to pregnant women  Research on fall risk assessment in perinatal patients is justified  Higher level research is needed to answer this question

21 Suggestion for Future Research  Based on lack of evidence:  development of assessment tools  controlled trials  Meta analysis to accurately determine the best assessment techniques

22 References Butler, E., Colon, I., Druzin, M., Rose, J. (2006). Postural equilibrium during pregnancy: Decreased stability with an increased reliance on visual cues. American Journal of Obstetrics and Gynecology, 195, 1104 – doi: /j.ajog Day, L., Fildes, B., Gordon, I., Fitzharris, M., Flamer, H., & Lord, S. (2002). Randomized factorial trial of falls prevention among older people living in their own homes. BMJ: British Medical Journal, 325(7356), Dunning, K., LeMasters, G., & Bhattacharya, A. (2009, August 13). A major public health issue: The high incidence of falls during pregnancy. Maternal Child Health Journal, 14, /s Hanson E, Månsson N, Ringsberg K, Håkansson A. falls among dizzy patients in primary healthcare: an intervention study with control group. International Journal Of Rehabilitation Research, 31(1):51-57.

23 References Heafner, L., Suda, D. E., Casalenuovo, N. M., Leach, L., & Gawlinski, A. (2011). 'Catch a falling star': The development of the obstetric falls risk. doi: /j _10.x Jang, J., Hsiao, K., Hsiao-Wecksler, E. (May 2008). Balance (perceived and actual) and preferred stance width during pregnancy. Clinical Biomechanics, 23(4): Lord, S., Lloyd, D., & Li, S. (1996). Sensori-motor function, gait patterns and falls in community-dwelling women. Age and Ageing, (25), Maloni, J. A., & St. Pierre Schneider, B. (2002, May ). Inactivity: Symptoms associated with gastrocnemius muscle disuse during pregnancy. AACN Clinical Issues, 13(2),

24 References Maloni, J. A., & Park, S. (2005). Postpartum symptoms after antepartum bed rest. Journal of Obstetric, Gynecology and Neonatal Nursing Clinical Research, 34, McCrory, J., Chambers, A., Daftary, A., & Redfern, M. (2011). Ground reaction forces during gait in pregnant fallers and non-fallers. Gait & Posture, 34, Tinker, S. C., Reefhuis, J., Dellinger, A., & Jamieson, D. (2010). Epidemiology of maternal injuries during pregnancy in a population-based study, 1997–2005. Journal Of Women’s Health, 19(12), doi: =jwh


Download ppt "Best Practices for Assessing Fall Risk in Perinatal Units NS 400 University of Alaska Anchorage Matrika Arrington, Nick Barney, MJ Jones, Mara Krey, Camille."

Similar presentations


Ads by Google