Case Study: Hospital Fall of an Elderly Patient

Case Study: Hospital Fall of an Elderly Patient A case study of a critical incident based on a hospital fall of an elderly patient with memory problems who has had several falls at home and has been admitted to a community hospital for assessment. It is suggested that the consequences of patient falls are a serious issue for patients and society. A fall is defined as an unexpected, involuntary loss of balance by which a person comes to rest at a lower or ground level (Commodore 1995). The older population is growing in number, and falling is common in this group. Up to one-third of people over the age of 65 fall each year, with half reporting multiple falling episodes (Bludau and Lipsitz 1997). Fall-related injury is the sixth highest cause of death in older people Savage and Matheis-Kraft 2001). Half of those aged over 75 years who fracture their hip as a result of a fall die within one year (Rawskey 1998), and those who survive rarely regain complete mobility (Marotolli 1992). Falls are also a leading cause of head injury, the most serious being subdural haematoma (Tideiksaar 1998). Falls are associated with major morbidity, functional decline and increased healthcare expenditure (Tinetti 1994). In a hospital setting, 10 per cent of older patients who have fallen die before discharge, and a clustering of falls in one patient results in increased mortality (Tideiksaar 1998). In the United Kingdom about 310,000 fractures occur each year in older people (Woolf and Akesson 2003). Fourteen thousand people a year die each year as a result of an osteoporotic hip fracture, with up to 33 per cent of hip fracture patients dying within one year of fracture (Department of Health (DoH) 2001). It is posited that the effects of falls extend beyond obvious physical and direct cost. Even if falls do not cause physical injury, the psychological effect can be long-lasting. â€Å"Post-fall syndrome† results in hesitancy and a loss of confidence leading to loss of mobility and independence (Cannard 1996). Arguably, this can cause shame and unwillingness to admit to falls. Consequently, falls are underreported. They may not even be remembered by fallers, especially those with cognitive imp airment (Lord et al 2001). It is debated that the term â€Å"fall† is now considered contentious because those who fall are perceived quite negatively as old, frail and dependent (DoH 2001). Family members are also affected by falls: they may be concerned for the safety of an older family member, his or her ability to remain independent and the possibility of long-term care. There have been few studies investigating nurses’ views of falls in patients, although Fitzgibbon and Roberts (1988) found that nurses experience fear of blame, anxiety, guilt and distress following a fall by a patient in their care. As a consequence of the effects of a fall on the patient, health professional and healthcare organisation, various risk assessment tools and prevention strategies have been developed. This paper will examine the critical incident of a fall by an elderly lady who has had repeated falls at home. She was admitted to hospital for assessment because of the falls at home. However, when she was an inpatient she fell on the ward to which she was admitted. For the purpose of this assignment and for confidentiality reasons as expounded in the Nursing and Midwifery Council (NMC 2004) code of professional conduct, the patient will be know as patient A. Patient A is a 77 year old female who is in frail health. She has experienced numerous falls at home and is showing symptoms of dementia. Patient A was admitted to a general hospital because her diabetes was extremely unstable. Unstable diabetes is a known risk factor for falls in older people with dementia (Lord et al 2001). During her stay in hospital, patient A became disorientated and fell â€Å"en route† to the bathroom. She sustained a neck of femur fracture that required surgery and consequently a long hospital stay. On discharge she was referred to her community hospital rehabilitation unit for assessment. The process of ageing creates irreversible changes in all body systems that can lead to reduced efficiency or performance over time. As physical ability and reactions change, so does cognitive ability. For most people this will have little or no consequence for daily living or independence. However, for older people with cognitive impairment or dementia, changes in mood, memory and thought processes in addition to changed physical health can result in increased risk and vulnerability that includes an increase in the potential for falling, as in the case of patient A (Oliver et al 2007). These risks are greatly compounded by admission to hospital or institutional care (Oliver et al 2007). As already mentioned falls are the most common patient safety incident reported from inpatient services and are responsible for at least 40 per cent of all accidents in hospital (National Patient Safety Agency 2007). By nature of the nurse-patient relationship, nurses are well placed to identify the multiple risks that older people can encounter in hospital from illness and from the care environment, and can work with the patient and care team to identify ways of reducing them. Falls in older people can occur for a wide variety of reasons. In addition to physical disorders, they can also be a feature of a number of neurodegenerative disorders, including dementia. Hospital environments can also present significant challenges and threats to older people with mental health problems, particularly because their functional and/or organic decline can increase vulnerability and their risk of having a fall (Lord et al 2001). It is also suggested that those with dementia are less likely or able to take the initiative in managing their own health in general and that this increases the likelihood of falls (DoH 2001). With regard to patient A, she was exhibiting memory loss and behaviours symptomatic of dementia. She had not engaged with the medical services for some time and her physical health had degenerated leaving her frail and unable to cope with activities of daily living. As a consequence her diabetes had become dangerously unstable resulting in her collapsing at home and then being admitted to hospital where the fall that fractured her hip took place. As mentioned, the consequences of falls are varied but, can be life-limiting and at worst, life-threatening (DoH 2001). As well as the consequences of physical change, the effects on mental state can further delay the recovery process, for example, by inducing depression (Lenze et al 2004). Risk assessment processes therefore should identify those most likely to fall, offer guidance on interventions to reduce those risks and be subject to frequent multidisciplinary review. It is posited that the role of nursing in helping the person with memory loss/dementia to cope with and adapt to changes created by illness relies on a continuous process of assessment of the whole person (Kitwood 1997). The environment, in which this process takes place and the patient’s response to it, should be given equal consideration. Patient A was admitted to a specialist rehabilitation unit that particularly cares for the elderly and their needs. Part of the unit’s remit is to assess an individuals’ risk of falling and put strategies into place for the prevention of further falls, and to that end the unit’s environment is managed in such a way that helps to prevent falls. It is posited that the need to assess risk from the outset of care is paramount for the care to be meaningful, relevant and appropriate (NMC 2004). The support of the nurse in offering interventions that promote recovery and maximisation of potential towards independence or less dependence should decrease the risks of falls and fractures. Assessing the risk of falls can highlight areas of greatest vulnerability and, therefore, direct the formulation of the plan of care towards deficits or areas of unmet need. Debatably, the patient who has been admitted to hospital because of deterioration in mental state or cognitive function will be most at risk because of that change. The person may decline to stay, become distressed at separation from a partner or family, and feel persecuted or vulnerable. Although, patient A was admitted for clinical reasons it is debated that as she had underlying cognitive and memory problems her mental state quickly deteriorated. Biological features may add to the clinical presentation and behavioural changes may create practical difficulties with managing safety (Oliver et al 2004). This was the case with regard to patient A. There are numerous rating scales in existence that measure behaviour, mood and functional abilities of older people (Burns et al 2004). Assessment of physiological aspects of recovery, for example: pain monitoring, tissue viability, nutrition and mobility is often more evident in clinical practice. However, it is suggested that for those with cognitive impairment or dementia, risk-rating scales should be able to combine evaluation of physical and psychological areas of need, as well as the behavioural and functional components of presentation. If a patient is unable to address risks, nursing staff need to consider their role in addressing need and act on the patient’s behalf if necessary. Although comprehensive assessment of the patient’s presentation, needs and abilities is a continuous and evolving process (Oliver et al 2004), it became clear that patient A had immediate threats to her safety and therefore needed to be quickly evaluated and prioritised so that appropriate interventions could be initiated with immediate effect.. It is proposed that the use of a risk factor-based approach to assess older people who fall can prevent more than 50 per cent of falls (Close 2001). Therefore, an assessment tool for falls that took into account both the physical and the psychological risk factors was used to assess patient A on admission to the unit and at specified times thereafter. This enabled issues to be addressed that would otherwise not have been elicited via the Single Assessment Process concept of risk assessment (Burns et al 2004). The assessment tool was used in combination with patient A’s care plan. It is suggested that the combination of an assessment tool with a care plan, as in the Fall Risk Assessment Scale for the Elderly (FRASE) tool (Barry 2001), is an example of best practice. However, the FRASE tool does not allow for assessment of mental impairment so this was added to the tool used for patient A. The tool used enabled the nurses and other multi-disciplinary team members to assess patient A’s risk of falling and it included components such as previous fall history, sensory deficit, medication, presence of secondary diagnosis. Balance/gait, age, mobility status and length of time since admission was added in following assessments. This is important as long stays in hospital can enhance functional decline and consequently â€Å"fall risk† (Oliver et al, 2004). In conclusion, for an older person with cognitive impairment or dementia for whom admission to hospital was necessary, the increased exposure to risk requires swift, comprehensive assessment and intervention to reduce the likelihood of falling. An appropriate risk assessment tool should illicit areas of greatest need or deficit, be proactive in suggesting appropriate interventions and form part of a multiprofessional and multifaceted approach to preventing falls in hospital. References Barry E (2001) Preventing accidental falls among older people in long stay units, Irish Medical Journal, 94, 6, 172-176 Bludau J, Lipsitz L (1997) Falls in the elderly: In Wei J, Sheehan M (Eds) Geriatric Medicine: A Case-based Manual, Oxford, UK, Oxford, Medical Publications Burns A, Lawlor B, Craig S (2004) Assessment Scales in Old Age Psychiatry, (2e), Martin Dunitz, London Cannard G (1996) Falling trend, Nursing Times, 92, 1, 36-7 Close J (2001) Interdisciplinary practice in the prevention of falls: a review of working models of care, Age and Ageing, 30, Suppl 4, 8-12 Commodore D (1995) Falls in the elderly population: a look at incidence, risks, healthcare costs, and preventative strategies, Rehabilitation Nursing, 20, 2, 84-89 Department of Health (2001) National Service Framework for Older People: Standard Six: Falls, The Stationery Office, London Fitzgibbon M, Roberts F (1988) Prevention of accidents to hospital patients, Recent Advances in Nursing, 22, 33-48 Kitwood T (1997) Dementia Reconsidered: The Person Comes First, Open University Press, Buckingham Lenze EJ, Munin MC, Dew MA (2004) Adverse effects of depression and cognitive impairment on rehabilitation participation and recovery from hip fracture, International Journal of Geriatric Psychiatry, 19, 5, 472-478 Lord SR, Sherrington C, Menz HB (2001) Falls in Older People: Risk Factors and Strategies for Prevention, Cambridge, Cambridge University Press Marotolli R (1992) Decline in physical function following hip fracture, Journal of the American, Geriatrics Society, 40, 9, 861-866 National Patient Safety Agency (2007) Slips, Trips and Falls in Hospital: Third report from the Patient Safety Observatory, London, NPSA Nursing and Midwifery Council (2004) The NMC code of professional conduct: standards for conduct, performance and ethics London: NMC Oliver D, Connelly JB, Victor CR (2007) Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses, British Medical Journal, 334, 7584, 82-89 Rawskey E (1998) Review of the literature on falls among the elderly, Image: the Journal of Nursing Scholarship, 30, 1, 47-52 Savage T, Matheis-Kraft C (2001) Fall occurrence in a geriatric psychiatry setting before and after a fall prevention program, Journal of Gerontological Nursing, 27, 10, 49-53 Tideiksaar R (1998) Falls in Older Persons: Prevention and Management, (2e), Baltimore MD, Health Professions Press Tinetti M (1994) A multifactorial intervention to reduce the risk of falling among elderly people living in the community, New England Journal of Medicine, 331, 13, 821-827 Woolf A, Akesson K (2003) Preventing fractures in elderly people, British Medical Journal, 327, 7406, 89-96 Hewlett Packard (HP): Leadership Crisis Hewlett Packard (HP): Leadership Crisis Case prepared by Rajgopal Iyengar. In the recent years Hewlett Packard (HP) board of directors have been in the limelight for wrong reasons. Four CEOs were hired and replaced in the last decade and three CEOs changes were within a span of 1.5 years. The board has not been able to find the right leader to fit into the HPs Cultures of doing things. The uncertainties in leadership has led to a huge loss for HP in terms of decreased market value, dissatisfied shareholders and blurred strategic vision. In this paper we study the HP CEOs since 1999, their leadership style, their vision and things that went wrong leading to their ouster. Hewlett Packard History (Till 1990s) The company was founded in a  one-car garage  in Palo Alto by  William (Bill) Redington Hewlett  and  Dave Packard. HP is the  worlds leading PC manufacturer. The company focussed on manufacturing of networking and data storage components in addition to designing, development and delivery of software. The key products manufactured were personal computers, enterprise servers, network and storage products, printers and imaging products. HP marketed its products directly and via online to its customers that included individual consumers, SME (Small Medium Enterprise) and large enterprises. HP also had a solid presence in the service and consulting business for the products it manufactured. HPs culture and management practises know HP Way was based on teamwork, transparency, open door management policies and flexibility in work place. HP treated the employees as assets and strived to provide a better work life balance to the employees. The business goals were profit oriented rather than increasing revenues. In late 1980s, HP started building low margin PCs contrary to the companies principle. By 1990, HP was the one of the top technological companies in the world, a market leader in both printers and UNIX based servers, with a growing presence in PC business. HP had a strong leadership under the founders Bill Hewlett (till 1987) and Dave Packard (till 1994). Hewlett Packard History (In 1990s) In the early 1990s, HP focussed on three major businesses: The test and measurement instrument business, the UNIX server business the HP Printers Computer business. The test and measurement business UNIX Server business provided high margins that were in line with the HP Way of working. However the printer business sold low cost printers at high volume and derived high profitability from the ink cartridges. HPs sales grew by 20% between 1992 1996 with an increasing dependency on the low margin PC Printer business. By 1997, HP was among the top 3 manufacturers of PC. HP faced severe competition from Dell and the Asia crisis in 1998 made HP loose margin on PC business. Lewiss Platt the then CEO of HP hired consultant to determine the problem HP was facing. The consultant suggested hiring an outside CEO with a marketing and sales background who can exude Charisma and increase the companys profile. In May 1999, the board decided on Carly Fiorina. Carly Fiorina (1999-2005) Carly Fiorina was born  in  Austin, Texas, on the 6th of September, 1954. Her father  Joseph Tyree Sneed III  was a very talented and multifaceted person. He was a law school professor, dean, and federal judge. In addition he was also an abstract and portrait artist. Fiorina attended Channing School in London, and later attended  Charles E. Jordan High School  in  Durham, North Carolina, for her senior year. She received a  Bachelor of Arts  in  philosophy  and  medieval history  from  Stanford University  in 1976. Fiorina received an  MBA  in  marketing  from  University of Maryland, College Park  in 1980 and later received a  Master of Science  in  management  from the  MIT Sloan School of Management  under the  Sloan Fellows  program in 1989. ATT and Lucent In 1980 Fiorina joined ATT as a management trainee and rose to the level of senior vice president for the companys hardware and systems division. Fiorina led the spin-off of ATT and Lucent; she also played a key role in planning and implementing of the 1996  initial public offering  of stock and company launch strategy.  In late 1996 she became the president of Lucents consumer products business. In 1997, she was appointed as chairman of Lucents consumer communications joint venture with Philips consumer communications.   Changes under Carly Fiorina Leadership Carly Fiorina moved in quickly and tried to revitalize the HP environment. She pruned the reporting units from 82 to 12 and amalgamated back-office functions. She modified the HPs profit sharing program to a performance based incentive program to motivate individuals. She completely rejigged the sales and marketing function. She topped the 50 Most Powerful Women in Business list from Fortune magazine for 5 consecutive years. However her leadership style was controversial and many HP employees disliked her. She was regarded as self-centred, demanding leader who completely destroyed the HP culture. Carly spearheaded the merger of HP Compaq that was opposed by the analysts and board members. These differences lead to a public spat between the board members and the CEO. Eventually the deal was approved with a slight majority of 2.1% where 49% opposed the decision and 51% agreed. The Compaq acquisition did not go well as envisaged by Fiorina. Operating margins dropped from 9% in 2000 to 4% in 2005 (Refer Exhibit1 ). Share prices also continued to drop from $34 in 2000 to $21 in 2005(Refer Exhibit2). Following a string of disappointing financial results the board eventually asked Fiorina to resign on Feb 2005. Mark Hurd (2005-2010) Mark Vincent Hurd  was born in Flushing, New York USA on January 1, 1957. He graduated form Baylor University in the year 1979 with a BBA degree. Hurd was the CEO President of NCR Corporation when he decided to move out and join HP. Mark Hurd increased the revenue of NCR by 7% and net income by five times from the previous year by taking a gamut of operational efficiency initiatives. At NCR Mark Hurd held a variety of positions in general management, operations, and sales and marketing. He also served as head of the companys  Teradata  data-warehousing division for three years. Hurd was a member of the  Technology CEO Council, a consortium of chairmen and chief executive officers of IT companies that develops and advocates public policy positions on technology and trade. Changes Under Mark Hurd This time the HP board decided to hire a person with a strong operational experience and hands on execution capabilities. Mark Hurd was well known in Silicon Valley for operational and cost cutting capabilities. Although Mark had never managed a very large company the size of HP, he had a very good success rate. Mark believed in Management by involvement. He tried to get a deeper understanding of the business by dirtying his hands. Mark believed in the concept of management by walking around.. He would stroll through multiple levels of the company and try to get an understanding of the environment. He strongly believed a company can become great if the CEOs ,boards, and management all think alike. Mark Hurd said: I believe in the principle that Company comes first, Employee second and Self is last Mark Hurd was very aggressive in his approach. Within few months of joining he announced broad restructuring initiatives and laid off 14,500 employee. He reorganized the corporate sale group by reducing the group size and assigning the sales team to specific products. He believed a strong knowledge of the product was essential to sell the product. He gave executives lot of flexibility in managing their budgets and held them accountable for their performance. During the 2008-2009 recessions he deducted 5% from the employee salary and 20% from the executive salary to meet the targets. These cost cutting initiatives helped in boosting HPs share value and profitability. The operating margin increased from 4% in 2005 to 9% in 2010(Refer Exhibit3). Share value of HP rose by 129% under his tenure(Refer Exhibit4). The profit generated was used by Mark Hurd to acquire companies in the software and service space like EDS, Mercury Interactive, Peregrine Systems Palm. Things were not completely fine under the leadership of Mark Hurd. Although the company performed well, the employee morale was down. The cost cutting and tightened management completely killed the HP Way work culture. The RD spending plummeted from 4.5% in 2004 to 2.3% in 2010(Refer Exhibit5). The number of patent applications also plummeted during Mark Hurds tenure resulting in loss of strategic advantages for HP. In 2010, HP was mired in controversy and scandal that led to the resignation of Mark Hurd. A company contractor by the name Jodie Fisher filed a sexual harassment case against Mark Hurd. Investigations revealed Mark Hurd had filed inappropriate expenses to skirt the relationship with the women that violated the HP Code Of Conduct. Mark Hurd was asked to resign by the board of directors. HP was again without a leader. Leo Apotheker (2010-2011) Leo Apotheker was born in Aachen, Germany on Sep18 1953. Apotheker studies economics at the  Hebrew University  in  Jerusalem. Apotheker worked in finance and operation function of several European companies before joining SAP in 1988. At SAP, his growth was phenomenal. In 1995, He became CEO and founder of SAP Belgium and SAP France. In 1997, he was made the president of SAPs South West Europe region and by 1999, the president of SAP EMEA sales region. In 2002 Apotheker joined the SAP AG executive board and became the president of global customer solutions and operations from. He was appointed deputy CEO of SAP in 2007; and promoted to co-CEO of the company in April 2008. On February 7, 2010, the SAP supervisory board decided to terminate Apothekers executive board membership. This decision led Apotheker to resign from SAP. HP Under Leo Apotheker The search for the next CEO was riddled with pessimism from the outset. The dispute over Mark Hurds resignation made the task of search committee very difficult. The board was divided over the selection of internal versus external candidate. The resignation of Mark Hurd complemented with the sacking history of past CEOs had created negative publicity about the company in the job market. Highly talented external candidates were not interested in the job. Leo Apotheker was appointed as the CEO of the company in Oct 2010. The appointment of Leo Apotheker received a gloomy response from the market because of multiple reasons. Firstly the credibility and track record of Leo was not great. An article in Wall Street Journal highlighted: Its very discomforting that Mr. Apoteker has never run the show alone. He abruptly resigned from SAP in less than a year Secondly Leo had no understanding of the HP hardware business. Hence he was a misfit for the HP job. The other disturbing fact was Leo was not interviewed by all the members of the board or even met them. Clearly the indifference of the board towards the selection was evident. Tenure of Leo Apotheker was short-lived and disappointing. Initially Leo worked on the strategy designed by Mark Hurd, but in a short time he started making drastic changes to the strategy. He terminated the initiative of HPs venture into the Tablet market and suggested spin off of the PC division. He also suggested purchasing a business analytics company called Autonomy at 10 times the original price. These incoherent action and adhoc strategy was punished by the market. Stock prices plunged and HP lost 45% of its value(Refer Exhibit). Taking cue of the market dissatisfaction, the board of directors fired Leo Apotheker. Meg Whitman (2011 Till Date) Whitman was born on 4 August 1956 in  Long Island, New York. She was the daughter of Margaret Cushing and Hendricks Hallett Whitman Jr. Whitman graduated from  Cold Spring Harbor High School  in 1974. Margaret took maths and science in Princeton university because she wanted to be a doctor. However, after a summer vacation stint in selling magazine advertisements she got inclined to marketing. She studies economics,   and earned a B.A. with honors in 1977. In 1979, Whitman did her  M.B.A.  from  Harvard Business School. Whitman started her career at Procter and Gamble as a brand manager. She later worked as a consultant for Bain and Company and rose to the rank of Senior Vice President in the organization. She joined Walt Disney in 1989 and became the VP of strategic planning. She quit Walt Disney after 2 years and joined Stride Rite Corporation. In 1995 she was named the CEO of Florists Transworld Delivery. Whitman joined  eBay  as CEO on March 1998. At the time the company had only 30 employees  and revenues of $4  million. She grew the company to approximately 15,000 employees and $8  billion in annual revenue by 2008.Whitman resigned as CEO of eBay in November 2007, but remained on the board and served as an advisor to new CEO  John Donahoe  until late 2008 Whitman has received numerous awards and accolades for her work at eBay. On more than one occasion, she was named among the top five most powerful women by  Fortune  magazine. HP Under Meg Whitman The appointment of Meg Whitman was not taken well by the market. Analysts felt Meg Whitman was inexperienced in managing a complex hardware software based business of HP that was already suffering from scandals, low morale, murky vision and unstable leadership. Meg Whitmans strategy was to focus on strengthening the internal business of HP. She wanted to continue with some of the strategies initiated by Leo Apotheker except the spinoff business. Whitman decided to restructure the business by dropping 30000 jobs and using the money to fuel new product development and improvement of sales force6. She merged the PC Printer business to improve the operational efficiency. Clearly Whitman has a strategy in place to get back HP on its feet. She is strengthening internal HP departments, spending money of new product development that are inline with HP Way of working. She has also managed to set a low expectation in the market for the setting low Future The leaders appointed by HP board were not able to align with the HP Culture and make the difference. It needs to be seen whether Meg Whitman will be able to recuperate HP and restore the past glory.