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Death after an accidental fall of a 101 year old hospitalized patient. Medico-legal implication of falling in geriatrics

, 1 , 2 , 2 , 3 , 2

BMC Surgery

BioMed Central

XXV National Congress of the Italian Society of Geriatric Surgery

10-11 May 2012

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      Abstract

      Background

      The case presented by the authors gives the opportunity to discuss the medico-legal issues related to lack of prevention of falls in elderly hospitalized patients.

      Case presentation

      A 101 year old Caucasian female was admitted to a surgery division for evaluation of abdominal pain of uncertain origin. During hospitalization, after bilateral bed rails were raised, she fell and reported a femoral fracture. Before surgical treatment of the fracture, scheduled for the day after injury, the patient reported a slight reduction in hemoglobin. She received blood transfusion but her general condition suddenly worsened; heart failure was observed and pulseless electrical activity was documented. The patient died 1 day after the fall. Patient relatives requested a judicial evaluation of the case.

      The case was studied with a methodological approach based on the following steps: 1) examination of clinical records; 2) autopsy; 3) evaluation of clinicians’ behavior, in the light of necroscopic findings and a review of the literature.

      Conclusions

      The case shows that an accurate evaluation of clinical and environmental risk factors should be always performed at the moment of admission also in surgery divisions. A multidisciplinary approach is always recommended also with the involvement of the family members. In some cases, as in this one a fall of the patient is expectable but not always avoidable. Physical restraint use should be avoided when not necessary and used only if there are no practical alternatives.

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      Most cited references 14

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      Interventions to reduce fear of falling in community-living older people: a systematic review.

      The objective was to assess which interventions effectively reduce fear of falling in community-living older people. An extensive search for relevant literature comprised a database search of PubMed, EMBASE, PsycINFO, and the Cochrane Central Register of Controlled Trials; expert consultation; and manually searching reference lists from potentially relevant papers. Randomized, controlled trials that assessed fear of falling in community-living older people were included. Two independent reviewers extracted data from full papers on study characteristics, methodological quality, outcomes, and process characteristics of the intervention. The search identified 599 abstracts, and 19 papers met the inclusion criteria. Seven of those papers were identified using expert consultation. Fifty-five percent of all validity items and 39% of process characteristic items were fulfilled across the 19 trials. Twelve of the 19 papers were of higher methodological quality. In 11 of these trials, fear of falling was lower in the intervention group than in the control group. Interventions that showed effectiveness were fall-related multifactorial programs (n=5), tai chi interventions (n=3), exercise interventions (n=2), and a hip protector intervention (n=1). Three of these interventions explicitly aimed to reduce fear of falling. Several interventions, including interventions not explicitly aimed at fear of falling, resulted in a reduction of fear of falling in community-living older people. Limited but fairly consistent findings in trials of higher methodological quality showed that home-based exercise and fall-related multifactorial programs and community-based tai chi delivered in group format have been effective in reducing fear of falling in community-living older people.
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        Effect of a guideline-based multicomponent intervention on use of physical restraints in nursing homes: a randomized controlled trial.

        Despite unambiguous legal regulation and evidence for lack of effectiveness and safety, physical restraints are still frequently administered in nursing homes. To reduce physical restraint prevalence in nursing homes using a guideline- and theory-based multicomponent intervention. Cluster randomized controlled trial of 6 months' duration conducted in 2 German cities between February 2009 and April 2010. Nursing homes were eligible if they had 20% or more residents with physical restraints. Using external concealed randomization, 18 nursing home clusters were included in the intervention group (2283 residents) and 18 in the control group (2166 residents). The intervention was based on a specifically developed evidence-based guideline and applied the theory of planned behavior. Components were group sessions for all nursing staff; additional training for nominated key nurses; and supportive material for nurses, residents, relatives, and legal guardians. Control group clusters received standard information. Primary outcome was percentage of residents with physical restraints (bilateral bed rails, belts, fixed tables, and other measures limiting free body movement) at 6 months, assessed through direct unannounced observation by blinded investigators on 3 occasions during 1 day. Secondary outcomes included restraint use at 3 months, falls, fall-related fractures, and psychotropic medication prescriptions. All nursing homes completed the study and all residents were included in the analysis. At baseline, 30.6% of control group residents had physical restraints vs 31.5% of intervention group residents. At 6 months, rates were 29.1% vs 22.6%, respectively, a difference of 6.5% (95% CI, 0.6% to 12.4%; cluster-adjusted odds ratio, 0.71; 95% CI, 0.52 to 0.97; P = .03). All physical restraint measures were used less frequently in the intervention group. Rates were stable from 3 to 6 months. There were no statistically significant differences in falls, fall-related fractures, and psychotropic medication prescriptions. A guideline- and theory-based multicomponent intervention compared with standard information reduced physical restraint use in nursing homes. isrctn.org Identifier: ISRCTN34974819.
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          Use of physical restraint in nursing homes: clinical-ethical considerations.

          This article gives a brief overview of the state of the art concerning physical restraint use among older persons in nursing homes. Within this context we identify some essential values and norms that must be observed in an ethical evaluation of physical restraint. These values and norms provide the ethical foundation for a number of concrete recommendations that could give clinical and ethical support to caregivers when they make decisions about physical restraint. Respect for the autonomy and overall wellbeing of older persons, a proportional assessment of the advantages and disadvantages, a priority focus on the alternatives to physical restraint, individualised care, interdisciplinary decision making, and an institutional policy are the central points that make it possible to deal responsibly with the use of physical restraint for older persons in nursing homes.
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            Author and article information

            Affiliations
            [1 ]Department of Molecular Medicine, University of Padua, Italy
            [2 ]Department of Surgical and Gastroenterological Sciences, University of Padua, Italy
            [3 ]University of Naples Federico II - Department of General Surgery, Italy
            Contributors
            Conference
            BMC Surg
            BMC Surg
            BMC Surgery
            BioMed Central
            1471-2482
            2012
            15 November 2012
            : 12
            : Suppl 1
            : S34
            23173622
            3499262
            1471-2482-12-S1-S34
            10.1186/1471-2482-12-S1-S34
            Copyright ©2012 Terranova et al; licensee BioMed Central Ltd.

            This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

            XXV National Congress of the Italian Society of Geriatric Surgery
            Padova, Italy
            10-11 May 2012
            Categories
            Research Article

            Surgery

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