Introduction
Falls and dysphagia (or difficulty swallowing) are common problems among
older patients. Falls are the most frequently reported adverse event in
acute care settings [1]. Rates of falls range from approximately 2
to 8 falls per 1000 patient-days among hospitalized patients [2].
The proportion of these falls that result in some injury ranges from
30% to 51% [3]. Moreover, falls can prolong hospitalization,
increase cost of care and induce fear of falling [3]. Dysphagia can
cause patients to aspirate food or liquids into their lungs [4].
Approximately 15% of people older than 65 years of age suffer from
dysphagia [4]. Presence of dysphagia at admission is associated with
poor outcomes, including poor functional ability, institutionalisation,
and increased mortality [5].
Colour-coded wristbands (CCWs) have been implemented in hospitals to
prevent falls and mitigate the adverse effects of dysphagia [6].
CCWs are widely used to signal special patient status in order to
increase awareness among health care professionals. Over 25 American
state hospital associations have provided their hospitals with
guidelines on standardized colours for CCWs [7]. Additionally,
Sevdalist et al. [8] found that out of 62 hospitals in the British
National Health Service they reviewed, at least 42 had implemented CCWs.
Evidence on the effectiveness of CCWs is limited and contradictory.
Forster et al. [9] investigated the use of pink and grey wristbands
for indicating the target oxygen saturation of patients. The researchers
found the CCWs to be beneficial in improving the safe prescription of
oxygen to inpatients. However, two other studies that investigated the
effect of CCWs for indicating patients with an increased risk of falling
both showed no benefit of the CCWs in reducing the number of falls
[10,11]. To our knowledge, there are no studies into the effectivity
of CCWs for signalling dysphagia.
In addition to the limited evidence for the effectivity of CCWs, little
is known about the feasibility of CCWs in daily practice. Forster et al.
[9] report that the CCWs for indicating the target oxygen saturation
of patients were positively evaluated by patients and staff members.
However, other publications reveal several issues related to the
implementation of CCWs, such as: the colour coding may not be understood
by care professionals [12], the CCWs may not be visible or seen
[12,13], the CCWs may not be issued consistently to patients with a
special patient status [14], and the colour coding may be not be
standardized between or within hospitals [8]. Poor implementation of
CCWs may reduce their effectiveness and may even be hazardous. To
illustrate, failure to consistently issue the CCWs according to protocol
can cause them to not accurately represent a special patient status
[14]. Moreover, a provider’s misunderstanding of a colour’s meaning
can trigger an incorrect response, possibly resulting in an adverse
event [13]. Nonetheless, for
most of these issues it is unclear how prevalent they are and how they
can be best prevented, given that there is little documentation on the
implementation of CCWs.
In December 2016, the neurology ward of Maastricht University Medical
Center+ (MUMC+), located in Maastricht, the Netherlands, implemented
CCWs for patients with an increased risk of falling and for patients
with dysphagia. This study aims to evaluate the implementation process
of this intervention. Saunders, Evans and Joshi [15] suggest that a
process evaluation should focus on the following components of an
implementation process: reach, fidelity, dose delivered (i.e.,
completeness), dose received (i.e., exposure and satisfaction),
recruitment, and context. Using these components as a guideline,
this process evaluation aims to
assess the extent to which the care professionals were informed of the
intervention (reach) , the extent to which the different
components of the intervention were performed according to protocol(fidelity and dose delivered) , the extent to which the patients
were compliant with the CCWs according to the care professionals(dose received- exposure), the opinion of the care professionals
on the CCWs (dose received- satisfaction) , and the contextual
factors affected the implementation of the CCWs (context) .