• Found that outdoor activities, waking up frequently during the night, glaucoma/retinal degenerations were all major risk factors

• The patient in Case Study 10 was known to have an ulcer "right in the center of his cornea" which would progress unless aggresively treated, had the lights dimmed and curtains drawn in room to create a dark environment (simulating night) and fell outside at main hospital entrance

EBP interventions that could have helped to prevent these environmental factors of darkness, outside dangers, and extreme visual degenerations include focus on better screening and understanding of risk factors contributing to likelihood of falls, especially in those with visual impairment. A thorough screening of this patient would have identified multiple risk factors that made him more likely to fall, and he would have been placed on fall precautions and given more resources (such as walking aids, alarms, or a nurse with him at all times), making it harder for him to fall. More research such as this study should be conducted in order to generate better assessment guidelines and identify high risk patients before adverse events occur.

N.G.

Ouyang, S., Zheng, C., Lin, Z., Zhang, X., Li, H., Fang, Y., Hu, Y., Yu, H., & Wu, G. (2022). Risk factors of falls in elderly patients with visual impairment. Frontiers in Public Health, 10(10), 984199. https://doi.org/10.3389/fpubh.2022.984199

• Colin fall could've been due to many things his severe nearsightedness, not having his eyeglasses, environmental hazards (i.e. missing fall precautions in the hospitals), and lack of staffing. Which possibly led to the unassisted and accidental fall during his stay.

Based on Jones et al. (2021), who evaluated automated video monitoring systems (AVMSs) in 15 small rural hospitals, evidence shows that:

• Implementation of 1–2 mobile AVMS units reduced unassisted bed exits (UBEs) by 89% and decreased total inpatient fall rates by 37%, and injurious falls by 78%

• The median lead time was 28.5 seconds, giving nurses critical time to intervene before bed exit and potential falls

• System sensitivity was 97.4%, with a positive predictive value of roughly 60% during the intervention period

Interventions that could've helped are assigning AVMS mobile camera to high-risk patient room during vulnerable times, ensure monitoring staff watch alerts 24/7 and notify bedside nurse within 30 seconds, and educating patient and family about video monitoring policy and purpose. Research showed that AVMs reduced unintended bed/chair exits, and the alerts provided staff time to safely assist.

D.W.

Jones, K. J., Haynatzki, G., & Sabalka, L. (2021). Evaluation of automated video monitoring to decrease the risk of unattended bed exits in small rural hospitals. Journal of Patient Safety, 17(8), e716–e726. https://doi.org/10.1097/PTS.0000000000000789

Strini et al. (2021) recommends a thorough assessment of visual impairment during the physical assessment and using findings to determine fall risk, and that such patients should receive multifactorial and tailored interventions based on the nature of their impairment. They also note that the Morse Fall Risk, while useful, does not fully capture unique sensory impairments and therefore is not a substitute for a thorough physical assessment. Schoberer et al. (2022) found that in a study of 1,125 participants, the use of a fall risk assessment had no effect on falls (Mean Difference: 0.06) or fall related injuries (Mean Difference: 0.01), and incurred a significant cost with no demonstrable benefit. Similarly, this study recommended a multifactorial approach tailored to each patient, rather than the use of a fall risk assessment.

Rather than adding yet another endless standardized assessment, it is most advisable that nurses be encouraged to use their clinical judgment to carefully evaluate each patient's risk of injury from falls, regardless of age. This is supported by the evidence (Schoberer et al., 2022) and would have prevented Colin's fall since his marked visual impairment would have been noted and judged to pose a risk to his ambulation.

In cases where repeated assessments of visual acuity are necessary, such as in the case of Colin Lake as his condition evolved, hospitals could include app-based visual assessments (performed on tablets or iPads) which have been shown to be high quality, repeatable, and objective assessments for visual acuity and tailor interventions based off of results. Results that indicate low visual acuity could trigger precautions such as single or multiple assists for patients when ambulating (Suo et al., 2022).

The use of homatropine, a mydriatic agent, was also determined to have played a causal role in Colin's fall since it altered his visual acuity. Research by Szpernal et al. (2022) corroborated that the use of these mydriatic agents contributes to an increased fall risk. Hospitals could implement a policy where patients who had undergone pupil dilation would require assisted ambulation for the first 6-10 hours after administration.

K.D.

Schoberer, D., Breimaier, H. E., Zuschnegg, J., Findling, T., Schaffer, S., & Archan, T. (2022). Fall prevention in hospitals and nursing homes: Clinical practice guideline. Worldviews on Evidence‐Based Nursing, 19(2), 86-93.

Suo, L., Ke, X., Zhang, D., Qin, X., Chen, X., Hong, Y., ... & Zhang, D. (2022). Use of mobile apps for visual acuity assessment: systematic review and meta-analysis. JMIR mHealth and uHealth, 10(2), e26275.

Strini, V., Schiavolin, R., & Prendin, A. (2021). Fall risk assessment scales: A systematic literature review. Nursing Reports, 11(2), 430-443.

Szpernal, J., Bachman Groth, J. A., Wynne, N., Williams, V., Spellecy, R., Thuruthumaly, C., & Carroll, J. (2022). Pupillary dilation in research: more than meets the eye. Current eye research, 47(7), 965-977.

According to Alrefai et al. (2024), providing mobility aids with the proper education on when and how to use them can significantly reduce accidental falls in a hospital setting. The key part of mobility aids as an intervention that is highlighted by this study is the patient education. Education on when and how to use a walker should be given by the nurse to any patients identified as a fall risk. In addition to nurse-led education, occupational and physical therapy should be consulted for evaluation and further education on how to use mobility aids and reduce the risk of falls.

This intervention works well in this setting because even if Colin's true fall risk status is missed, placing a walker at the bedside and educating him on how to use it could have prevented the incident. Getting PT/OT involved in Colin's care could have also helped identify his risk status and teach him about the mobility aids he should use for ambulation due to his visual impairment. Mobility aids are a fantastic and under-utilized intervention in hospitals currently. They protect our patients from injury while also promoting independence and movement, which we know to be beneficial for overall health and wellbeing.

Alrefai, Y. E., Al-Omari, M. D. A., Sabr, F. A. A., Al-Jahni, A., Salman, K., Al-Anzi, N. M. A., Al-Shahrani, H. H. M., Al-Anzi, N. D., Alamri, F. D., Al Sharif, A. A., & Al Shamrani, Z. A. (2024). Falls prevention and mobility support in geriatric nursing: Evidence-based interventions. Journal of International Crisis and Risk Communication Research, 7(S8), 1518–1525. https://doi.org/10.63278/jicrcr.vi.1061

MK

In Sweeting et al (2020), they noted that vision impairment is often used as a contraindication for physical activity. However, they found that increasing low-intensity physical activities aided in mobility and functional ability within the 5-6 week period participants were observed.

While most patients would not be admitted for that length of time, the recommendation could be extended to the peri-inpatient period after patients are discharged to decrease the likelihood of falls and to increase the overall quality of life for patients. This aligns well with the capabilities of OTs/PTs and could be a point of improvement for hospitals as well as out-patient follow-ups. Had Colin worked with OTs/PTs from the point of admission, they could have increased physical activity to not only increase his balance but to help acclimate him to his reduced vision. Similarly, they likely would have been able to notice the blindspot his decreased vision had created near his feet and been able to educate him on how to look in sweeping motions to clear blind spots. This possibly could have prevented his fall.

As an additional point, Sweeting et al (2020) also recommended further research would be beneficial to future recommendations as the studies were limited in scope and time, stating they would benefit from longer-term studies with a larger sample size.

P.S.

Sweeting, J., Merom, D., Astuti, P. A. S., Antoun, M., Edwards, K., & Ding, D. (2020). Physical activity interventions for adults who are visually impaired: a systematic review and meta-analysis. BMJ open, 10(2), e034036. https://doi.org/10.1136/bmjopen-2019-034036

This presentation investigates some evidence based practice interventions that could have been implemented to address one of the the root causes of his fall, which was his visual impairment and lack of screening/monitoring conducted on him as a patient at high risk of falls.