Balance impairment not predictive of falls in geriatric rehabilitation wards

Valid Indicators for Predicting Falls in Community-Dwelling Older Adults Under Ongoing Exercise Intervention to Prevent Care Requirement

Physical exercise interventions to prevent falls for older adults at risk of falling are widespread in many countries; however, there is insufficient knowledge of the impact of long-term exercise on the fall discriminating ability of existing fall-prediction indicators. This study measured physical and cognitive indicators of the fall risk, including the timed up and go (TUG), walking speed (WS), and plantar tactile threshold (PTT), in 124 community-dwelling older adults with care needs who were continuing an exercise program. Logistic regression analyses were used to determine factors associated with falls in the 87 participants who could adhere to the exercise continuously for 12 months. The PTT was significantly higher in fallers, while the TUG and WS did not differ significantly between fallers and non-fallers. The only index significantly associated with falls was the PTT (OR = 1.20). The fall identification ability was better for PTT (AUC = 0.63), whereas TUG (AUC = 0.57) and WS (AUC = 0.52) were lower than previously reported scores. In conclusion, long-term exercise was found to improve scores on the fallprediction indicators by physical performance, but to decrease their ability to identify future falls. PTT may complement the ability to identify falls in such elderly populations.

A Stepped-Wedge Cluster-Randomized Controlled Trial of Multi-interventional Approach for Fall Prevention

BACKGROUND AND OBJECTIVES

Falls are one of the most common adverse events at hospitals that may result in injury and even death. They are also associated with raised length of stay (LOS) and hospitalization costs. This experiment aimed to examine the effectiveness of multiple interventions in reducing inpatient fall rates and the consequent injuries.

METHODS

The present study was a stepped-wedge cluster-randomized controlled trial. It was done in 18 units in a public university hospital over 36 weeks. Patients included in this research were at risk of falls. Overall, 33 856 patients were admitted, of whom 4766 were considered high-risk patients. During the intervention phases, a series of preventive and control measures were considered, namely staff training; patient education; placement of nursing call bells; adequate lighting; supervision of high-risk patients during transmission and handovers; mobility device allocation; placement of call bell and safe guard in bathrooms; placing "fall alert" signs above patients' beds; nurses informing physicians timely about complications such as delirium and hypoxia; encouraging appropriate use of eyeglasses, hearing aids and footwear; keeping side rails up; and reassessing patients after each fall. The primary outcome was participant falls per 1000 patient-days. Secondary outcomes were fall-related injuries and LOS.

RESULTS

The results revealed a decrease in fall rate (n = 4 per 1000 patient-days vs 1.34 per 1000 patient-days, incidence rate ratio (IRR) = 0.19 [95% confidence interval (CI), 0.14-0.26]; P = .001) and injuries (n = 2.4 per 1000 patient-days vs 0.79 per 1000 patient-days, IRR = 0.22 [95% CI, 0.15-0.32]; P = .001) in exposed compared with unexposed phases. There was not a significant difference in LOS (exposed mean 10.63 days [95% CI, 10.26-10.97], unexposed mean 10.84 days [95% CI, 10.59-11.09], mean difference = -0.13 [95% CI, -0.53 to 0.27], P = .52).

CONCLUSIONS

This multi-interventional trial showed a reduction in falls and fall rates with injury but without an overall effect on LOS. Further research is needed to understand the sustainability of multiple fall prevention strategies in hospitals and their long-term impacts.

Relationship between inspiratory muscle strength and balance in women: A cross-sectional study

BACKGROUND

There is scarce evidence on changes at the functional level associated with the respiratory area in women. This study aims to analyse the relationship between inspiratory muscle strength and balance in women.

MATERIAL AND METHODS

In this cross-sectional observational study, the sample consisted of groups according to the results obtained in the balance test. Inspiratory muscle weakness was defined as maximum inspiratory pressure (MIP) ≤ 80% of the predictive value. MIP was carried out using through a mouthpiece, with an electronic manometer. Logistic regression model was used to examine if MIP predicts balance.

RESULTS

159 women participated in the study. Approximately 20% of them achieved balance ≤ 2 seconds and 18% presented MIP≤80%. MIP was associated with the time achieved in the one-leg support test. Subjects with MIP ≤ 80% of the predictive value show 3 times more risk of having a lower performance in the balance test (OR = 3.26).

CONCLUSIONS

Inspiratory muscle weakness is associated with deficient balance in this sample. It shows the need for multidimensional assessment and rehabilitation strategies for patients identified as having MIP weakness and/or balance disorders.

App-Based Evaluation of Older People's Fall Risk Using the mHealth App Lindera Mobility Analysis: Exploratory Study

Background

Falls and the risk of falling in older people pose a high risk for losing independence. As the risk of falling progresses over time, it is often not adequately diagnosed due to the long intervals between contacts with health care professionals. This leads to the risk of falling being not properly detected until the first fall. App-based software able to screen fall risks of older adults and to monitor the progress and presence of fall risk factors could detect a developing fall risk at an early stage prior to the first fall. As smartphones become more common in the elderly population, this approach is easily available and feasible.

Objective

The aim of the study is to evaluate the app Lindera Mobility Analysis (LIN). The reference standards determined the risk of falling and validated functional assessments of mobility.

Methods

The LIN app was utilized in home- and community-dwelling older adults aged 65 years or more. The Berg Balance Scale (BBS), the Tinetti Test (TIN), and the Timed Up & Go Test (TUG) were used as reference standards. In addition to descriptive statistics, data correlation and the comparison of the mean difference of analog measures (reference standards) and digital measures were tested. Spearman rank correlation analysis was performed and Bland-Altman (B-A) plots drawn.

Results

Data of 42 participants could be obtained (n=25, 59.5%, women). There was a significant correlation between the LIN app and the BBS (r=–0.587, P<.001), TUG (r=0.474, P=.002), and TIN (r=–0.464, P=.002). B-A plots showed only few data points outside the predefined limits of agreement (LOA) when combining functional tests and results of LIN.

Conclusions

The digital app LIN has the potential to detect the risk of falling in older people. Further steps in establishing the validity of the LIN app should include its clinical applicability.

Trial Registration

German Clinical Trials Register DRKS00025352; https://tinyurl.com/65awrd6a

Interventions to reduce falls in hospitals: a systematic review and meta-analysis

BACKGROUND

Falls remain a common and debilitating problem in hospitals worldwide. The aim of this study was to investigate the effects of falls prevention interventions on falls rates and the risk of falling in hospital.

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

Hospitalised adults.

INTERVENTION

Prevention methods included staff and patient education, environmental modifications, assistive devices, policies and systems, rehabilitation, medication management and management of cognitive impairment. We evaluated single and multi-factorial approaches.

OUTCOME MEASURES

Falls rate ratios (rate ratio: RaR) and falls risk, as defined by the odds of being a faller in the intervention compared to control group (odds ratio: OR).

RESULTS

There were 43 studies that satisfied the systematic review criteria and 23 were included in meta-analyses. There was marked heterogeneity in intervention methods and study designs. The only intervention that yielded a significant result in the meta-analysis was education, with a reduction in falls rates (RaR = 0.70 [0.51-0.96], P = 0.03) and the odds of falling (OR = 0.62 [0.47-0.83], P = 0.001). The patient and staff education studies in the meta-analysis were of high quality on the GRADE tool. Individual trials in the systematic review showed evidence for clinician education, some multi-factorial interventions, select rehabilitation therapies, and systems, with low to moderate risk of bias.

CONCLUSION

Patient and staff education can reduce hospital falls. Multi-factorial interventions had a tendency towards producing a positive impact. Chair alarms, bed alarms, wearable sensors and use of scored risk assessment tools were not associated with significant fall reductions.

Reliability of stair-climbing speed in two cohorts of older adults

Background/Aims

The ability to climb stairs is an important prerequisite for activities of daily living and social participation in older adults, and is therefore an important part of rehabilitation. However, there is no consensus on how to measure stair-climbing ability. The aim of this study was to investigate the test–retest reliability of the measurement of stair-climbing speed (steps per second) as a parameter for functional ability in older adults.

Methods

A total of 57 participants who were in hospital and 56 participants who were community-dwelling and did not have any limitations in activities in daily living, all aged 60 years and over, ascended and descended a set of 13 stairs twice. The halfway point of the staircase was marked in order to split the time required for both the ascending and the descending actions. Additional measurements consisted of the Functional Reach Test, the Timed Up and Go Test, walking ability using the GAITRite walkway system and the isometric strength of four muscle groups of the lower extremities using a handheld dynamometer.

Results

Test–retest reliability of the first and second half of the stair-climbing for both ascending and descending showed excellent results for the group of hospitalised participants (intraclass correlation coefficient, [ICC] 0.87, 95% confidence interval [CI] 0.79–0.93 to 0.94, 95% CI 0.9 – 0.97 for comparison of first vs second half of stair climbing; ICC 0.9, 95% CI 0.83-0.94 to ICC 0.95, 95% CI 0.92–0.97 for comparing first vs second measurement)) and moderate to excellent results for the group of community-dwelling participants with no limitations (ICC 0.58, 95% CI 0.37–0.73 to ICC 0.76, 95% 95% CI 0.63-0.85 for comparison of first vs second half of stair climbing; ICC 0.82, 95% CI 0.71-0.89 to 0.92, 95% CI 0.87–0.95 for comparing first vs second measurement). As expected, hospitalised participants took significantly longer descending than ascending stairs (t(56)=6.98, P<0.001, d=0.93). A general and significant trend of increasing speed while descending could be observed in both groups (performing paired sample t-tests).

Conclusions

The results indicate that stair-climbing speed is not constant and that different patterns exist in older adults who have no limitations and in those who are hospitalised. The use of stair-climbing speed as an assessment tool should include both stair ascent and descent, because differences in these speeds seem to be indicators of stair-climbing ability.

Functional Reach Test, Single-Leg Stance Test, and Tinetti Performance-Oriented Mobility Assessment for the Prediction of Falls in Older Adults: A Systematic Review

OBJECTIVE

The authors sought to systematically review the existing literature on the falls-related diagnostic test properties of the Functional Reach Test (FRT), single-leg stance test (SLST), and Tinetti Performance-Oriented Mobility Assessment (POMA) in older adults across settings and patient populations.

METHODS

The PubMed, EMBASE, and CINAHL databases were searched (inception-July 2020). Inclusion criteria were participants aged 60 years or more, prospectively recorded falls, and the reporting of falls-related predictive validity. Manuscripts not published in English were excluded. Methodological quality of reporting was assessed using the Tooth Scale.

RESULTS

Of 1071 studies reviewed, 21 met the inclusion criteria (12 POMA, 8 FRT, 6 SLST). Seven studies (58.3%) used a modified version of the POMA, and 3 (37.5%) used a modified FRT. For the outcome of any fall, the respective ranges of sensitivity and specificity were 0.076 to 0.615 and 0.695 to 0.97 for the POMA, 0.27 to 0.70 and 0.52 to 0.83 for the modified POMA, 0.73 and 0.88 for the FRT, 0.47 to 0.682 and 0.59 to 0.788 for the modified FRT, and 0.51 and 0.61 for the SLST in community-dwelling older adults. For the SLST, the sensitivity and specificity for recurrent falls in the community-dwelling setting were 0.33 and 0.712, respectively.

CONCLUSION

All the clinical tests of balance demonstrated an overall low diagnostic accuracy and a consistent inability to correctly identify fallers. None of these tests individually are able to predict future falls in older adults. Future research should develop a better understanding of the role that clinical tests of balance play in the comprehensive assessment of falls risk in older adults.

IMPACT

Neither the FRT, SLST, nor POMA alone shows consistent evidence of being able to correctly identify fallers across fall types, settings, or older adult subpopulations. These clinical tests of balance cannot substitute a comprehensive falls risk assessment and thus should be incorporated in practice solely to identify and track balance impairment in older adults.

Performance of the Hendrich Fall Risk Model II in Patients Discharged from Rehabilitation Wards. A Preliminary Study of Predictive Ability

(1) Background: Falls are a dangerous adverse event in patients discharged from rehabilitation units, with the risk of falling being higher in the first weeks after discharge. In this study, we assessed the predictive performance of the Hendrich Fall Risk Model II tool (HIIFRM) when administered before discharging patients to their home from rehabilitative units in orthopedic (OR), neurologic (NR) and pulmonary (PR) rehabilitation wards. (2) Methods: Over a 6-month period, all adult patients who returned home after discharge were assessed by HIIFRM. At six months from discharge the occurrence of falls was obtained by performing a structured survey. The HIIFRM predictive performance was determined by the area under the ROC curve (AUC), sensitivity (Se) and specificity (Sp) for the whole sample and split by ward. (3) Results: 85 of 141 discharged patients were living at home and agreed to take part in the survey. Of these, 19 subjects fell, 6 suffered fractures or head traumas and 5 were hospitalized. The AUC was 0.809 (95% CI: 0.656–0.963), Se was 0.67 (0.30–0.93) and Sp was 0.79 (0.63–0.90) for OR patients. (4) Conclusions: Our preliminary results support the use of HIIFRM as a tool to be administered to OR patients at discharge and provides data for the design of a large study of predictive ability.

Balance and muscle strength tests in patients with osteoporotic vertebral fractures to develop tailored rehabilitation programs

Authors perform a cross-sectional study of functional abilities of the patients with osteoporotic vertebral fractures (VFs). Trunk muscle isometric strength and postural balance impairments were estimated. The development of osteoporotic VFs is associated with a significant decrease in strength of all the body muscles, especially the deep spinal stabilization system, i.e trunk extensor (TE), trunk flexsor (TF), where the VFs contribute to inappropriate distribution of back muscle strength with TE:TF ration of 1:1 instead of 3:2, observed both normally and in patients with uncomplicated osteoporosis. There is also a deterioration of stabilometry and functional coordination assessment tests in patients with pathological VFs, that indicate abnormalities of both static and dynamic postural balance. The obtained data should be taken into account when developing rehabilitation programmes for osteoporosis patients who have suffered compression VFs.

Diagnostic Balance Tests for Assessing Risk of Falls and Distinguishing Older Adult Fallers and Non-Fallers: A Systematic Review with Meta-Analysis

Falls are a major cause of injury and morbidity in older adults. To reduce the incidence of falls, a systematic assessment of the risk of falling is of paramount importance. The purpose of this systematic review was to provide a comprehensive comparison of the diagnostic balance tests used to predict falls and for distinguishing older adults with and without a history of falls. We conducted a systematic review of the studies in which instrumented (force plate body sway assessment) or other non-instrumented balance tests were used. We analyzed the data from 19 prospective and 48 retrospective/case-control studies. Among the non-instrumented tests, the single-leg stance test appears to be the most promising for discrimination between fallers and non-fallers. In terms of body sway measures, the center-of-pressure area was most consistently associated with falls. No evidence was found for increased benefit of the body sway test when cognitive tasks were added, or the vision was eliminated. While our analyses are limited due to the unbalanced representation of different test and outcome measures across studies, we can recommend the single-leg test for the assessment of the risk of falling, and the measurements of body sway for a more comprehensive assessment.

Implementing a 'Safe Recovery' fall prevention program: Refining intervention theory using realist methods

OBJECTIVES

This research aimed to explain how the Safe Recovery Programme (SRP) may best work to reduce falls in older adults undergoing rehabilitation in four wards in an older person's health and rehabilitation service.

METHODS

Qualitative realist methods were used, including surveys completed by patients and staff, and qualitative interviews or focus groups exploring views of patients, ward staff and SRP educators.

RESULTS

Emphasising different types of information for patients with different pre-existing understandings may facilitate their responses to SRP messaging. Consistency and coherence of SRP messaging within ward routines varied in response to staff SRP training and ongoing feedback mechanisms from SRP educators.

CONCLUSIONS

Tailored individualised approaches for patients with specific characteristics may lead to patients being less likely to engage in risky behaviours. Staff training and processes for facilitating ongoing feedback between patients, SRP and ward staff are required to ensure consistency and coherence of SRP messaging.

The association of malnutrition with falls and harm from falls in hospital inpatients: Findings from a 5-year observational study

BACKGROUND

Inpatient falls continue to be a significant clinical issue, and while malnutrition is a known risk factors for falls, few studies have investigated its association with inpatient falls. This study aimed to explore the independent association between malnutrition and fall risk as well as harm from falls in hospital inpatients.

METHODS

Malnutrition identified in annual malnutrition audits was combined with inpatient fall data captured through the electronic patient incident reporting system in the 12 months following audit days. Audit data were available for 1,849 inpatients across 2011-2015, and covariate associations between age, gender, BMI, malnutrition, falls and harmful falls were analysed. The reporting of this paper is in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations (see Appendix S1).

RESULTS

The prevalence of malnutrition was 32.4% (n = 543), and 171 (9.2%) inpatients experienced a fall with 0.7% (n = 13) categorised as harmful. In bivariate analysis, patients who fell were more likely to be older (median 79.0 vs. 70.0 years; p < .0001) or malnourished (40.9% vs. 31.5%; p = .021). Malnutrition (p < .0001) and having a lower BMI (p = .026) were significant predictors of harmful falls. Regression modelling demonstrated that only increasing age increased the likelihood of having an inpatient fall (OR 1.022 95% CI 1.021-1.046; p < .0001). Malnourished inpatients were almost 8 times more likely to have a harmful fall than those not malnourished (OR 7.94 95% CI 1.457-43.338; p = .017), independent of age and BMI.

CONCLUSIONS

Malnourished patients are more likely to experience a harmful fall. Assessment of malnutrition should be incorporated into fall risk assessments as a way of highlighting those patients at greater risk and to link to nutritional care pathways.

Functional Performances on Admission Predict In-Hospital Falls, Injurious Falls, and Fractures in Older Patients: A Prospective Study

Falls are common among older inpatients and remain a great challenge for hospitals. Despite the relevance of physical impairments to falls, the prognostic value of performance-based functional measures for in-hospital falls and injurious falls remains unknown. This study aimed to determine the predictive ability and accuracy of various functional tests administered at or close to admission in a geriatric hospital to identify in-hospital fallers and injurious fallers. In this prospective study, conducted in a geriatric hospital in Geneva, Switzerland, 807 inpatients (mean age 85.0 years) were subjected to a battery of functional tests administered by physiotherapists within 3 days (interquartile range 1 to 6) of admission, including Short Physical Performance Battery (SPPB), simplified Tinetti, and Timed Up and Go tests. Patients were prospectively followed up for falls and injurious falls until discharge using mandatory standardized incident report forms and electronic patients' records. During a median length of hospital stay of 23 days (interquartile range 14 to 36), 329 falls occurred in 189 (23.4%) patients, including 161 injurious falls of which 24 were serious. In-hospital fallers displayed significantly poorer functional performances at admission on all tests compared with non-fallers (p < 0.001 for all). In multivariate analysis controlling for age, sex, previous falls, and fall as cause of admission, poorer functional performances on all functional tests predicted in-hospital falls and injurious falls (p < 0.001 for all). The SPPB only significantly predicted serious injurious falls (adjusted odds ratio [OR] = 0.76; 95% confidence interval [CI] 0.60-0.96) and fractures (adjusted OR = 0.76; 95% CI 0.59-0.98). In conclusion, poor functional performances, as assessed by SPPB, are independent predictors of in-hospital falls, injurious falls, and fractures in patients admitted to a geriatric hospital. These findings should help to design preventive strategies for in-hospital falls and support the adoption of objective performance-based functional measures into routine hospital practice. © 2018 American Society for Bone and Mineral Research.

Effects of falls prevention interventions on falls outcomes for hospitalised adults: protocol for a systematic review with meta-analysis

INTRODUCTION

Falls are a major global public health problem and leading cause of accidental or unintentional injury and hospitalisation. Falls in hospital are associated with longer length of stay, readmissions and poor outcomes. Falls prevention is informed by knowledge of reversible falls risk factors and accurate risk identification. The extent to which hospital falls are prevented by evidence-based practice, patient self-management initiatives, environmental modifications and optimisation of falls prevention systems awaits confirmation. Published reviews have mainly evaluated community settings and residential care facilities. A better understanding of hospital falls and the most effective strategies to prevent them is vital to keeping people safe.

OBJECTIVES

To evaluate the effectiveness of falls prevention interventions on reducing falls in hospitalised adults (acute and subacute wards, rehabilitation, mental health, operating theatre and emergency departments). We also summarise components of effective falls prevention interventions.

METHODS AND ANALYSIS

This protocol has been registered. The systematic review will be informed by Cochrane guidelines and reported according to the Preferred Reporting Items for Systematic review and Meta-Analysis statement.

INCLUSION CRITERIA

randomised controlled trials, quasi-randomised trials or controlled clinical trials that evaluate falls prevention interventions for use by hospitalised adults or employees. Electronic databases will be searched using key terms including falls, accidental falls, prevention, hospital, rehabilitation, emergency, mental health, acute and subacute. Pairs of independent reviewers will conduct all review steps. Included studies will be evaluated for risk of bias. Data for variables such as age, participant characteristics, settings and interventions will be extracted and analysed with descriptive statistics and meta-analysis where possible. The results will be presented textually, with flow charts, summary tables, statistical analysis (and meta-analysis where possible) and narrative summaries.

ETHICS AND DISSEMINATION

Ethical approval is not required. The systematic review will be published in a peer-reviewed journal and disseminated electronically, in print and at conferences. Updates will guide healthcare translation into practice.

TRAIL REGISTRATION NUMBER

PROSPERO 2017: CRD 42017058887. Available from https://www.crd.york.ac.uk/prospero.

Functional Measures for Fall Risk in the Acute Care Setting: A Review

This review explores the evidence pertaining to the use of functional ability measures for fall risk in the acute care setting. We included studies from six bibliographic databases that investigated fall risk functional ability measures in hospitalized older adults (≥55 years). We utilized the following search terms: acute care, subacute care, critical care, inpatient, fall, and fall prevention. Nineteen articles met the inclusion criteria. Timed "Up and Go" (TUG) was identified as a feasible fall risk functional ability measure for clinicians; it demonstrated clinical performance of fair sensitivity (56%-68%) and good specificity (74%-80%). Clinical performance of other measures (Berg Balance Scale and Functional Reach test) was not as favorable as the TUG. Functional ability measures are underutilized in the acute care setting, potentially due to limited knowledge and training on administration. Combining functional measures with subjective screening tools may optimize performance and accuracy of identifying fall risk identification.

Educators' perspectives about how older hospital patients can engage in a falls prevention education programme: a qualitative process evaluation

OBJECTIVES

Falls are the most frequent adverse event reported in hospitals. Patient and staff education delivered by trained educators significantly reduced falls and injurious falls in an older rehabilitation population. The purpose of the study was to explore the educators' perspectives of delivering the education and to conceptualise how the programme worked to prevent falls among older patients who received the education.

DESIGN

A qualitative exploratory study.

METHODS

Data were gathered from three sources: conducting a focus group and an interview (n=10 educators), written educator notes and reflective researcher field notes based on interactions with the educators during the primary study. The educators delivered the programme on eight rehabilitation wards for periods of between 10 and 40 weeks. They provided older patients with individualised education to engage in falls prevention and provided staff with education to support patient actions. Data were thematically analysed and presented using a conceptual framework.

RESULTS

Falls prevention education led to mutual understanding between staff and patients which assisted patients to engage in falls prevention behaviours. Mutual understanding was derived from the following observations: the educators perceived that they could facilitate an effective three-way interaction between staff actions, patient actions and the ward environment which led to behaviour change on the wards. This included engaging with staff and patients, and assisting them to reconcile differing perspectives about falls prevention behaviours.

CONCLUSIONS

Individualised falls prevention education effectively provides patients who receive it with the capability and motivation to develop and undertake behavioural strategies that reduce their falls, if supported by staff and the ward environment.

Fall rates in hospital rehabilitation units after individualised patient and staff education programmes: a pragmatic, stepped-wedge, cluster-randomised controlled trial

BACKGROUND

Falls are the most frequent adverse events that are reported in hospitals. We examined the effectiveness of individualised falls-prevention education for patients, supported by training and feedback for staff, delivered as a ward-level programme.

METHODS

Eight rehabilitation units in general hospitals in Australia participated in this stepped-wedge, cluster-randomised study, undertaken during a 50 week period. Units were randomly assigned to intervention or control groups by use of computer-generated, random allocation sequences. We included patients admitted to the unit during the study with a Mini-Mental State Examination (MMSE) score of more than 23/30 to receive individualised education that was based on principles of changes in health behaviour from a trained health professional, in addition to usual care. We provided information about patients' goals, feedback about the ward environment, and perceived barriers to engagement in falls-prevention strategies to staff who were trained to support the uptake of strategies by patients. The coprimary outcome measures were patient rate of falls per 1000 patient-days and the proportion of patients who were fallers. All analyses were by intention to treat. This trial is registered with the Australian New Zealand Clinical Trials registry, number ACTRN12612000877886).

FINDINGS

Between Jan 13, and Dec 27, 2013, 3606 patients were admitted to the eight units (n=1983 control period; n=1623 intervention period). There were fewer falls (n=196, 7·80/1000 patient-days vs n=380, 13·78/1000 patient-days, adjusted rate ratio 0·60 [robust 95% CI 0·42-0·94], p=0·003), injurious falls (n=66, 2·63/1000 patient-days vs 131, 4·75/1000 patient-days, 0·65 [robust 95% CI 0·42-0·88], p=0·006), and fallers (n=136 [8·38%] vs n=248 [12·51%] adjusted odds ratio 0·55 [robust 95% CI 0·38 to 0·81], p=0·003) in the intervention compared with the control group. There was no significant difference in length of stay (intervention median 11 days [IQR 7-19], control 10 days [6-18]).

INTERPRETATION

Individualised patient education programmes combined with training and feedback to staff added to usual care reduces the rates of falls and injurious falls in older patients in rehabilitation hospital-units.

FUNDING

State Health Research Advisory Council, Department of Health, Government of Western Australia.

Novel use of the Wii Balance Board to prospectively predict falls in community-dwelling older adults

BACKGROUND

The Wii Balance Board has received increasing attention as a balance measurement tool; however its ability to prospectively predict falls is unknown. This exploratory study investigated the use of the Wii Balance Board and other clinical-based measures for prospectively predicting falls among community-dwelling older adults.

METHODS

Seventy-three community-dwelling men and women, aged 60-85years were followed-up over a year for falls. Standing balance was indexed by sway velocities measured using the Wii Balance Board interfaced with a laptop. Clinical-based measures included Short Physical Performance Battery, gait speed and Timed-Up-and-Go test. Multivariable regression analyses were used to assess the ability of the Wii Balance Board measure to complement the TUG test in fall screening.

FINDINGS

Individually, the study found Wii Balance Board anteroposterior (odds ratio 1.98, 95% CI 1.16 to 3.40, P=0.01) and mediolateral (odds ratio 2.80, 95% CI 1.10 to 7.13, p=0.03) sway velocity measures predictive of prospective falls. However, when each velocity measure was adjusted with body mass index and Timed-Up-and-Go, only anteroposterior sway velocity was predictive of prospective falls (odds ratio 2.21, 95% CI 1.18 to 4.14). A faster anteroposterior velocity was associated with increased odds of falling. Area-under-the-curves for Wii Balance Board sway velocities were 0.67 and 0.71 for anteroposterior and mediolateral respectively.

INTERPRETATION

The Wii Balance Board-derived anteroposterior sway velocity measure could complement existing clinical-based measures in predicting future falls among community-dwelling older adults.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry number: ACTRN12610001099011.

A stepped-wedge cluster randomised controlled trial for evaluating rates of falls among inpatients in aged care rehabilitation units receiving tailored multimedia education in addition to usual care: a trial protocol

INTRODUCTION

Falls are the most frequent adverse event reported in hospitals. Approximately 30% of in-hospital falls lead to an injury and up to 2% result in a fracture. A large randomised trial found that a trained health professional providing individualised falls prevention education to older inpatients reduced falls in a cognitively intact subgroup. This study aims to investigate whether this efficacious intervention can reduce falls and be clinically useful and cost-effective when delivered in the real-life clinical environment.

METHODS

A stepped-wedge cluster randomised trial will be used across eight subacute units (clusters) which will be randomised to one of four dates to start the intervention. Usual care on these units includes patient's screening, assessment and implementation of individualised falls prevention strategies, ongoing staff training and environmental strategies. Patients with better levels of cognition (Mini-Mental State Examination >23/30) will receive the individualised education from a trained health professional in addition to usual care while patient's feedback received during education sessions will be provided to unit staff. Unit staff will receive training to assist in intervention delivery and to enhance uptake of strategies by patients. Falls data will be collected by two methods: case note audit by research assistants and the hospital falls reporting system. Cluster-level data including patient's admissions, length of stay and diagnosis will be collected from hospital systems. Data will be analysed allowing for correlation of outcomes (clustering) within units. An economic analysis will be undertaken which includes an incremental cost-effectiveness analysis.

ETHICS AND DISSEMINATION

The study was approved by The University of Notre Dame Australia Human Research Ethics Committee and local hospital ethics committees.

RESULTS

The results will be disseminated through local site networks, and future funding and delivery of falls prevention programmes within WA Health will be informed. Results will also be disseminated through peer-reviewed publications and medical conferences.

TRIAL REGISTRATION

The study is registered with the Australian New Zealand Clinical Trials registry (ACTRN12612000877886).

Cost effectiveness of patient education for the prevention of falls in hospital: economic evaluation from a randomized controlled trial

BACKGROUND

Falls are one of the most frequently occurring adverse events that impact upon the recovery of older hospital inpatients. Falls can threaten both immediate and longer-term health and independence. There is need to identify cost-effective means for preventing falls in hospitals. Hospital-based falls prevention interventions tested in randomized trials have not yet been subjected to economic evaluation.

METHODS

Incremental cost-effectiveness analysis was undertaken from the health service provider perspective, over the period of hospitalization (time horizon) using the Australian Dollar (A$) at 2008 values. Analyses were based on data from a randomized trial among n = 1,206 acute and rehabilitation inpatients. Decision tree modeling with three-way sensitivity analyses were conducted using burden of disease estimates developed from trial data and previous research. The intervention was a multimedia patient education program provided with trained health professional follow-up shown to reduce falls among cognitively intact hospital patients.

RESULTS

The short-term cost to a health service of one cognitively intact patient being a faller could be as high as A$14,591 (2008). The education program cost A$526 (2008) to prevent one cognitively intact patient becoming a faller and A$294 (2008) to prevent one fall based on primary trial data. These estimates were unstable due to high variability in the hospital costs accrued by individual patients involved in the trial. There was a 52% probability the complete program was both more effective and less costly (from the health service perspective) than providing usual care alone. Decision tree modeling sensitivity analyses identified that when provided in real life contexts, the program would be both more effective in preventing falls among cognitively intact inpatients and cost saving where the proportion of these patients who would otherwise fall under usual care conditions is at least 4.0%.

CONCLUSIONS

This economic evaluation was designed to assist health care providers decide in what circumstances this intervention should be provided. If the proportion of cognitively intact patients falling on a ward under usual care conditions is 4% or greater, then provision of the complete program in addition to usual care will likely both prevent falls and reduce costs for a health service.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register: ACTRN12608000015347.

Translation of falls prevention knowledge into action in hospitals: what should be translated and how should it be done?

INTRODUCTION

Falls prevention evidence has changed and evolved over time with positive and negative studies revealing that a "one-size fits all" approach is not the solution. Care must be taken to critically appraise the evidence and the potential applicability of that evidence to the specific hospital setting.

METHOD

A narrative account of the evolution of research evidence in this field is first presented. How this evidence should be applied in clinical practice is challenging, with a lack of translational evidence for the hospital setting we draw on broader theory of translating knowledge to action.

CONCLUSIONS

The journey should begin with formation of a management and engagement committee. A review of existing practices and the difference between existing practice and evidence-based practice should be undertaken to identify the "evidence-practice gap." Engagement with staff is recommended to inform a plan for practice change. Plans for resourcing, targeting, and evaluating these strategies should also be undertaken.

IMPACT ON INDUSTRY

This paper will assist hospitals to identify and implement evidence based falls prevention strategies leading to an improvement in patient safety.

Nutritional status and associations with falls, balance, mobility and functionality during hospital admission

OBJECTIVES

To explore associations between nutritional status, falls and selected falls risk factors amongst older hospitalized people. Lengths of stay amongst fallers and the malnourished were assessed.

DESIGN

An observational longitudinal cohort study.

SETTING

Geriatric Assessment and Rehabilitation Unit (GARU) of a tertiary teaching hospital.

PARTICIPANTS

Admissions to the GARU during a six-month period were included.

MEASUREMENTS

Associations between nutritional status and falls during hospitalization, reported preadmission history of falls, functional status, balance and mobility during GARU admission were analysed. Associations between nutritional status or experiencing a hospital fall and length of stay were also examined.

RESULTS

Malnutrition prevalence was 39% (75/194, 95% CI 32-46%) with odds of falling during admission being 1.49 (95%CI: 0.81, 2.75), p< 0.20). Patients assessed as malnourished were older (p<0.001) and more likely to have a poorer score on both the admission (p<0.05) and discharge (p<0.009) timed "Up and Go" test. Malnutrition was associated with reduced mobility (p<0.05). Those who fell during admission had statistically greater lengths of stay compared with non-fallers [median (range): 57.0 (7-127) vs 35.0 (5-227) days; p<0.002].

CONCLUSION

Evidence of reduced mobility was evident during GARU admission amongst older people assessed as malnourished. Considering the results, a larger study concerning nutritional status, functionality and falls in the hospitalized population is warranted. The influence of nutritional status upon a person's physical functioning should be considered more broadly in falls research.