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) .