Slide 1

Slide 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 Slide 3 Importance: falls are the most common cause of minor injury during pregnancy and are estimated to cause 1739% 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, 524-528 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 18-45 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), 292-299. IV: Pregnant women DV: 80+ measurements of sensori-motor function. Most important: Walking velocity Setting: Community Setting Sample, n=183 aged 22-99 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 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), 128-131. 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, 19972005. Journal Of Womens Health, 19(12), 2211-2218. doi:10.1089= jwh.2010.2160 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), 248- 262 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, 163- 171.http://dx. doi.org/10.1177/0884217504274416 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, 720-725. http://dx.doi.org/DOI 10.1007/s10995-009-0511-0 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 1108. doi:10.1016/j.ajog.2006.06.015 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