Nationwide time trends and risk factors for in-hospital falls-related major injuries

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.

The Association of Pain with Incident Falls in People with Chronic Obstructive Pulmonary Disease: Evidence from the English Longitudinal Study of Ageing

People with chronic obstructive pulmonary disease (COPD) have a higher prevalence of pain and a greater risk of falls than their healthy peers. As pain has been associated with an increased risk of falls in older adults, this study investigated the association between pain and falls in people with COPD compared to healthy controls. Data from the English Longitudinal Study of Ageing were used to establish an association between pain and falls when modelled with a generalised ordinal logistic regression and adjusted for sex, age, wealth, and education (complete case analysis only; n = 806 COPD, n = 3898 healthy controls). The odds were then converted to the predicted probabilities of falling. The predicted probability of falling for people with COPD was greater across all pain categories than for healthy controls; for COPD with (predicted probability % [95%CI]), no pain was 20% [17 to 25], with mild pain was 28% [18 to 38], with moderate pain was 28% [22 to 34] with severe pain was 39% [30 to 47] and for healthy controls with no pain was 17% [16 to 18], mild pain 22% [18 to 27], moderate pain 25% [20 to 29] and severe pain 27% [20 to 35]. The probability of falling increased across pain categories in individuals with COPD, with the most severe pain category at a nearly 40% probability of falling, indicating a potential interaction between COPD and pain.

A Case-Control Study of Accidental Falls During Surgical Hospitalizations

BACKGROUND

Postoperative falls are preventable complications. The study aims were to describe the rate and circumstances surrounding postoperative falls and explore potential associations with patient and procedural characteristics with emphasis on the use of sedative medications.

METHODS

Medical records of hospitalized patients undergoing non-lower extremity surgery under general anesthesia from January 1, 2010, through April 30, 2018 were reviewed for falls within 72 postoperative hours. Perioperative use of sedatives, sleep aids, gabapentinoids, and opioids were abstracted. Each fall case was matched with two controls on age, sex, and procedure type. Descriptive statistics and multivariable analysis accounting for the matched design were performed.

RESULTS

There were 343 falls among 200 186 hospitalized surgical patients (incidence of 17.1 [95% CI: 15.4, 19.0] falls per 10 000 procedures) with largest proportion of falls occurring on postoperative day 2 (n = 134, 39.1%). Most falls occurred in the general hospital wards (n = 304, 88.6%) and were unwitnessed (n = 186, 55.9%). The incidence of major injuries was 1.0 (95% CI: .1 - 3.6) per 100 000 procedures. Home use of non-benzodiazepine hypnotics (odds ratio 2.68, 95% CI: 1.47, 4.88, P=.001) and blood transfusions were associated with increased fall risk. Hospital stay was longer in patients who fall (7 [4, 15] vs. 5 [3, 9] days, P < .001).

CONCLUSIONS

The rate of postoperative falls in our institution was low and frequently unwitnessed. The use of non-benzodiazepine hypnotics is a modifiable risk factor associated with postoperative falls. Serious complications after falls were rare.

A retrospective cohort study of factors associated with severity of falls in hospital patients

Severity of falls in hospital patients are threat to patient safety which can result in a financial burden on the patient’s family and health care services. Both patient specific and environmental and organisational factors are associated with severity of falls in hospital. It is important to continuously analyse the factors associated with severity of fall which can inform the implementation of any fall preventive strategies. This study aims to identify factors associated with the severity of falls in hospitalised adult patients in Western Australia. This study involved a retrospective cohort analysis of inpatient falls records extracted from the hospital’s Clinical Incident Database from May 2014 to April 2019. Severity of falls were classified as three Severity Assessment Code (SAC): SAC 1 was “high” causing serious harm or death; SAC 2 was “medium” causing moderate or minor harm; and SAC 3 was “low” indicating no harm. Univariable and multivariable generalised ordinal logistic regression models were used to quantify the magnitude of effects of the potential risk factors on severity of falls at 5% level of significance and reported the crude odds and adjusted odds ratio of falling at a higher severity level. There were 3705 complete reported cases of falls with the average age of the patients was 68.5 ± 17.0 years, with 40.2% identified as female. The risk of falling at a higher level of severity increased by patient age over 50 years. Females were 15.1% more likely to fall at higher severity level compared to females. Fall incidents occurred during toileting and showering activities and incidents in a communal area were 14.5% and 26% more likely to occur at a higher severity respectively. Similarly, depression (167%), influence of alcohol or illicit drugs (more than 300%), use of medications (86%) and fragile skin (75%) significantly increased the odds of falling at higher level of severity. Identification of underlying risk factors associated with fall severity provides information which can guide nurses and clinicians to design and implement effective interventional strategies that mitigate the risk of serious fall injuries. The results suggest that fall prevention strategies should target patients with these risk factors to avoid severity of falls.

Nurse-led home modification interventions for community-dwelling older adults with dementia and their impact on falls prevention

This quasi-experimental study aimed to investigate the effects of nurse-led home modification interventions on the family members of home-dwelling older adults with dementia. The sample consisted of 42 older adults diagnosed with dementia and their family members. A number of validated tools were used. Three home visits were undertaken, a training package with family members was instigated, and the patients were followed up for a 6-month period. It was determined that there was a decrease in falls in the first 3-month period (p=0.002). The number of falls in the second 3-month period was lower in the older adults who had their homes modified (p=0.000). Family-centred, nurse-led home-modification interventions can be effective in the prevention and reducing of falls in older adults with dementia.

Potentially inappropriate medications and their effect on falls during hospital admission

OBJECTIVE

to investigate the effect of potentially inappropriate medications (PIMs) on inpatient falls and to identify whether PIMs as defined by STOPPFall or the designated section K for falls of STOPP v2 have a stronger association with inpatient falls when compared to the general tool STOPP v2.

METHODS

a retrospective observational matching study using an electronic health records dataset of patients (≥70 years) admitted to an academic hospital (2015-19), including free text to identify inpatient falls. PIMs were identified using the STOPP v2, section K of STOPP v2 and STOPPFall. We first matched admissions with PIMs to those without PIMs on confounding factors. We then applied multinomial logistic regression analysis and Cox proportional hazards analysis on the matched datasets to identify effects of PIMs on inpatient falls.

RESULTS

the dataset included 16,678 hospital admissions, with a mean age of 77.2 years. Inpatient falls occurred during 446 (2.7%) admissions. Adjusted odds ratio (OR) (95% confidence interval (CI)) for the association between PIM exposure and falls were 7.9 (6.1-10.3) for STOPP section K, 2.2 (2.0-2.5) for STOPP and 1.4 (1.3-1.5) for STOPPFall. Adjusted hazard ratio (HR) (95% CI) for the effect on time to first fall were 2.8 (2.3-3.5) for STOPP section K, 1.5 (1.3-1.6) for STOPP and 1.3 (1.2-1.5) for STOPPFall.

CONCLUSIONS

we identified an independent association of PIMs on inpatient falls for all applied (de)prescribing tools. The strongest effect was identified for STOPP section K, which is restricted to high-risk medication for falls. Our results suggest that decreasing PIM exposure during hospital stay might benefit fall prevention, but intervention studies are warranted.

The Internet of Things in Geriatric Healthcare

There is a significant increase in the geriatric population across the globe. With the increase in the number of geriatric people and their associated health issues, the need for larger healthcare resources is inevitable. Because of this, healthcare service-providing industries are facing a severe challenge. However, technological advancement in recent years has enabled researchers to develop intelligent devices to deal with the scarcity of healthcare resources. In this regard, the Internet of things (IoT) technology has been a boon for healthcare services industries. It not only allows the monitoring of the health parameters of geriatric patients from a remote location but also lets them live an independent life in a cost-efficient way. The current paper provides up-to-date comprehensive knowledge of IoT-based technologies for geriatric healthcare applications. The study also discusses the current trends, issues, challenges, and future scope of research in the area of geriatric healthcare using IoT technology. Information provided in this paper will be helpful to develop futuristic solutions and provide efficient cost-effective healthcare services to the needy.

Inpatient hip fractures: understanding and addressing the risk of this common injury

INTRODUCTION

The impact and outcome of hip fractures are well described for people living in the community, but inpatient hip fracture (IHF) have not been extensively studied. In this study, we examine the patient characteristics, common falls risk factors and clinical outcomes of this condition.

METHODS

Between January 2016 and December 2017, we analysed all inpatient falls that resulted in hip fracture within Aneurin Bevan University Health Board (ABUHB) in Wales.

RESULTS

The overall falls rate was 8.7/1000 occupied bed days (OBD). Over the 2 years, 118 patients sustained an IHF, giving a rate of 0.12/1000 OBD. The mean age was 81.8 ± 9.5 (range 49-97) years and 60% were women. Most patients (n = 112) were admitted from their own home. Mean Charlson Comorbidity Index and the number of medications on admission were 5.5 ± 1.9 and 8.5 ± 3.7, respectively.Fifty-three patients (45%) sustained the IHF following their first inpatient fall. Twenty-four IHF (20%) occurred within 72 h. Mean length of stay was 84.9 ± 55.8 days. Only 43% were discharged back to their original place of residence following an IHF; 27% were discharged to a care home (26 new care home discharges), and 30% died as an inpatient. One-year mortality was 54% (n = 64/118). The most common comorbidity was dementia (63%).

CONCLUSION

Mortality and need for care home placement are both much higher after IHF than following community hip fracture. Most people who suffer a hip fracture in hospital have already demonstrated their need for falls risk management by having fallen previously during the same admission.

Protocol for the SAFEST review: the Shock-Absorbing Flooring Effectiveness SysTematic review including older adults and staff in hospitals and care homes

INTRODUCTION

Falls in hospitals and care homes are a major issue of international concern. Inpatient falls are the most commonly reported safety incident in the UK's National Health Service (NHS), costing the NHS £630 million a year. Injurious falls are particularly life-limiting and costly. There is a growing body of evidence on shock-absorbing flooring for fall-related injury prevention; however, no systematic review exists to inform practice.

METHODS AND ANALYSIS

We will systematically identify, appraise and summarise studies investigating the clinical and cost-effectiveness, and experiences of shock-absorbing flooring in hospitals and care homes. Our search will build on an extensive search conducted by a scoping review (inception to May 2016). We will search electronic databases (AgeLine, CINAHL, MEDLINE, NHS Economic Evaluation Database, Scopus and Web of Science; May 2016-present), trial registries and grey literature. We will conduct backward and forward citation searches of included studies, and liaise with study researchers. We will evaluate the influence of floors on fall-related injuries, falls and staff work-related injuries through randomised and non-randomised studies, consider economic and qualitative evidence, and implementation factors. We will consider risk of bias, assess heterogeneity and explore potential effect modifiers via subgroup analyses and sensitivity analyses. Where appropriate we will combine studies through meta-analysis. We will use the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach to evaluate the quality of evidence and present the results using summary of findings tables, and adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines.

ETHICS AND DISSEMINATION

We will follow the ethical principles of systematic review conduct, by attending to publication ethics, transparency and rigour. Our dissemination plan includes peer-reviewed publication, presentations, press release, stakeholder symposium, patient video and targeted knowledge-to-action reports. This review will inform decision-making around falls management in care settings and identify important directions for future research.

PROSPERO REGISTRATION NUMBER

CRD42019118834.

Quality Improvement in Parkinson's Disease: A Successful Program to Enhance Timely Administration of Levodopa in the Hospital

BACKGROUND

Patients hospitalized with Parkinson's disease (PD) require timely delivery of carbidopa-levodopa (C/L) medication. Ill-timed administration of C/L doses is associated with greater morbidity and longer lengths of stay.

OBJECTIVE

To understand the barriers to timely C/L administration, and implement strategies to improve the administration of the drug to hospitalized PD patients.

METHODS

Several key strategies were employed in 2015 to improve the timely delivery of C/L doses: 1. three kinds of nursing alert in the electronic medical record (EMR); 2. staff in-service education; 3. stocking immediate-release C/L into automated medication dispensing machines on key hospital units; 4. reports to nurse unit managers on timeliness of C/L administration; and 5. reconciliation of inpatient and outpatient levodopa orders by the hospital pharmacist upon admission. The primary outcome was the percent of C/L doses administered within 60, 30, and 15 minutes of scheduled time.

RESULTS

Our urban hospital, affiliated with a Parkinson's Foundation Center of Excellence, had 5,939 C/L administrations in 2018. There was sustained improvement in timely delivery of doses, from 89.3% in 2012 to 96.5% in 2018 (within 60 minutes of the scheduled time), 65.5% to 86.4% (30 minutes), and 42.3% to 71.1% (15 minutes) (all p < 0.001).

CONCLUSIONS

With multifaceted but relatively simple measures, we were able to "change the culture" so that hospitalized patients with Parkinson's disease receive levodopa on time.

A Literature Review of Factors Influencing Injurious Falls

Falls pose substantial challenges to health care institutions. This review aims to provide a synthesis and critique of studies that investigated fall injury risk factors and to identify significant risk factors that predispose patients to injurious falls. A comprehensive literature search was conducted in PubMed, COCHRANE, Embase, Cumulative Index to Nursing and Allied Heath Literature, and Scopus. Additional records were searched through Google Scholar and bibliographies of the retrieved articles. Twenty-three primary research studies were included. Demographic, intrinsic, and extrinsic factors have been identified. Demographics include age, gender, and marital status. Intrinsic factors include body mass index, medication, and preexisting conditions, and extrinsic factors include environmental factors. Several factors were found to be inconclusive. These factors should be considered and examined further. Future research may evaluate interventions focusing on targeted risk factors of injurious falls. Clinical guidelines addressing the factors in this review may be considered after further testing and research.

The risk of fall accidents for home dwellers with dementia-A register- and population-based case-control study

Introduction

Institutionalized people with dementia have an increased risk of fall accidents, but little is known about whether this increased risk holds for home dwellers.

Methods

This register- and population-based study comprised 115,584 cases and 394,679 controls. Cases were individuals with any fall between 2009 and 2014, and matched with up to six controls on age, sex, and geographic location. Individuals were excluded if they (1) had any fall in 2008, or (2) lived in a nursing home on the date of the fall. Dementia, other chronic diseases, and sedative medicines were assessed from Danish national registers.

Results

After adjusting for potential confounders, older people with dementia living at home had a 1.89-fold higher risk of fall (odds ratio = 1.89, 95% confidence interval [1.84–1.94], P < .001).

Discussion

Dementia almost doubles the risk of fall for older Danish people living at home. This highlights the need for effective fall preventions that target people with dementia.

Depression and risk of fracture and bone loss: an updated meta-analysis of prospective studies

This meta-analysis pooled results from 23 qualifying individual cohort studies and found that depression was significantly associated with an increased risk of fractures and bone loss.

INTRODUCTION

The association between depression and risk of fracture remains controversial. We conducted a comprehensive meta-analysis to examine the effect of depression on the risk of osteoporotic fractures and bone loss.

METHODS

We searched databases and reviewed citations in relevant articles for eligible cohort studies. Two investigators independently conducted study selection, appraisal, and data abstraction through the use of a standardized protocol. Random effect models were used for meta-analysis. Cochrane Q and I² statistics were used to assess heterogeneity. Funnel plots and rank correlation tests were used to evaluate publication bias.

RESULTS

Twenty-three studies were included for meta-analysis. In studies that reported hazard ratio (HR) as the outcome (nine studies [n = 309,862]), depression was associated with 26% increase in fracture risk (HR = 1.26, 95% CI, 1.10-1.43, p < 0.001). Studies that reported risk ratio (RR) as the outcome (seven studies [n = 64,975]) suggested that depression was associated with 39% increase in fracture risk (RR = 1.39, 95% CI, 1.19-1.62, p < 0.001). Among studies that reported hip bone mineral density (BMD) as an outcome (eight studies [n = 15,442]), depression was associated with a reduced mean annual bone loss rate of 0.35% (0.18-0.53%, p < 0.001). The increased risk of fracture and bone loss associated with depression was consistent in all meta-analysis having modified inclusion criteria and in different subgroup analyses as well. Significant heterogeneity was observed in the meta-analysis; however, no significant publication bias was detected.

CONCLUSION

Depression is associated with a significant increased risk in fracture and bone loss. Effective prevention may decrease such risk.

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.

Enhancing hospital care of patients with cognitive impairment

Purpose

The patient-centred management of people with cognitive impairment admitted to acute health care facilities can be challenging. The TOP5 intervention utilises carers’ expert biographical and social knowledge of the patient to facilitate personalised care. The purpose of this paper is to explore whether involvement of carers in the TOP5 initiative could improve patient care and healthcare delivery.

Design/methodology/approach

A small-scale longitudinal study was undertaken in two wards of one acute teaching hospital. The wards admitted patients with cognitive impairment, aged 70 years and over, under geriatrician care. Data for patient falls, allocation of one-on-one nurses (“specials”), and length-of-stay (LOS) over 38 months, including baseline, pilot, and establishment phases, were analysed. Surveys of carers and nursing staff were undertaken.

Findings

There was a significant reduction in number of falls and number of patients allocated “specials” over the study period, but no statistically significant reduction in LOS. A downward trend in complaints related to communication issues was identified. All carers (n=43) completing the feedback survey were satisfied or very satisfied that staff supported their role as information provider. Most carers (90 per cent) felt that the initiative had a positive impact and 80 per cent felt that their loved one benefitted. Six months after implementation of the initiative, 80 per cent of nurses agreed or strongly agreed that it was now easier to relate to carers of patients with cognitive impairment. At nine-ten months, this increased to 100 per cent.

Originality/value

Actively engaging carers in management of people with cognitive impairment may improve the patient, staff, and carer journeys, and may improve outcomes for patient care and service delivery.

One-Year Mortality Rates Before and After Implementing Quality-Improvement Initiatives to Prevent Inpatient Falls (2012⁻2016)

Single-room ward design has previously been associated with increased risk of inpatient falls and adverse outcomes. However, following quality initiatives, the incidence of inpatient falls has shown a sustained reduction. Benefits have also been observed in the reduction of hip fractures. However, one-year mortality trends have not been reported. The aim of this observational study is to report the trends in one-year mortality rates before and after implementing quality-improvement initiatives to prevent inpatient falls over the last 5 years (2012⁻2016). This retrospective observational study was conducted for all patients who had sustained an inpatient fall between January 2012 and December 2016. All the incident reports in DATIX patient-safety software which were completed for each inpatient fall were studied, and the clinical information was extracted from Clinical Work Station software. Mortality data were collected on all patients for a minimum of one year following the discharge from the hospital. The results show that 95% patients were admitted from their own homes; 1704 patients had experienced 3408 incidents of an inpatient fall over 5 years. The mean age of females (82.61 ± 10.34 years) was significantly higher than males (79.36 ± 10.14 years). Mean falls/patient = 2.0 ± 2.16, range 1⁻33). Mean hospital stay was 45.43 ± 41.42 days. Mean hospital stay to the first fall was 14.5 ± 20.79 days, and mean days to first fall prior to discharge was 30.8 ± 34.33 days. The results showed a significant and sustained reduction in the incidence of inpatient falls. There was a downward trend in the incidence of hip fractures over the last two years. There was no significant difference in the inpatient and 30-day mortality rate over the last five years. However, mortality trends appear to show a significant downward trend in both six-month and one-year mortality rates over the last two years following the implementation of quality initiatives to prevent inpatient falls. A significant reduction in the incidence of inpatient falls following quality initiatives initially has been observed, followed by a downward trend in the incidence of hip fractures. We have just started to observe a significant reduction in the 6-month and one-year mortality. We propose prompt completion of multifactorial falls risk assessments, and every possible quality initiative should be taken to prevent a 'first inpatient fall', which should result in the sustained improvement of clinical outcomes.

The patients' perspective of sustaining a fall in hospital: A qualitative study

AIMS AND OBJECTIVES

To understand the patient's perspective of falling in hospital.

BACKGROUND

A fall in hospital can affect a patient physically and psychologically, increasing their hospital length of stay and potentially putting them at risk of further complications. Despite a wealth of literature on falls that focuses on risk assessment, preventive interventions and cost, very little research has focused on the experience of the patient that has fallen, particularly within the acute hospital setting.

DESIGN

A qualitative phenomenological design was used to investigate the experience of falling in hospital.

METHODS

Twelve hospital inpatients that had recently fallen were interviewed while in hospital using unstructured interviews. The methodology was guided by Van Manen's approach to data collection and analysis.

FINDINGS

Three key themes emerged from the analysis: Feeling safe, Realising the risk and Recovering independence and identity. These themes describe a continuum whereby falling was not initially a concern to participants, who trusted staff to keep them safe, and tended to not seek assistance. As participants began to appreciate the reality of their falls risk, they felt disempowered by their loss of independence but were more receptive to receiving assistance. Finally, as participants recovered, their desire to regain independence increased. They wanted others to perceive them as physically competent, rather than as a frail older person, meaning they were more willing to take risks with mobility.

CONCLUSION

The participants' perspective of falling describes a continuum of responses with participants positioned at different psychosocial standpoints: from initial denial of their risk of falling to realisation of the importance of their fall and acceptance of its repercussions.

RELEVANCE TO CLINICAL PRACTICE

By understanding the patient's perspective of falling, nurses and other health professionals conducting risk assessment can tailor their discussions and interventions to the patient's perceptions and needs.

Pulmonary Rehabilitation With Balance Training for Fall Reduction in Chronic Obstructive Pulmonary Disease: Protocol for a Randomized Controlled Trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. A growing body of evidence shows that individuals with COPD have important deficits in balance control that may be associated with an increased risk of falls. Pulmonary rehabilitation (PR) is a key therapeutic intervention for individuals with COPD; however, current international guidelines do not include balance training and fall prevention strategies.

OBJECTIVE

The primary aim of this trial is to determine the effects of PR with balance training compared to PR with no balance training on the 12-month rate of falls in individuals with COPD. Secondary aims are to determine the effects of the intervention on balance, balance confidence, and functional lower body strength, and to estimate the cost-effectiveness of the program.

METHODS

A total of 400 individuals from nine PR centers across Canada, Europe, and Australia will be recruited to participate in a randomized controlled trial. Individuals with COPD who have a self-reported decline in balance, a fall in the last 2 years, or recent near fall will be randomly assigned to an intervention or control group. The intervention group will undergo tailored balance training in addition to PR and will receive a personalized home-based balance program. The control group will receive usual PR and a home program that does not include balance training. All participants will receive monthly phone calls to provide support and collect health care utilization and loss of productivity data. Both groups will receive home visits at 3, 6, and 9 months to ensure proper technique and progression of home exercise programs. The primary outcome will be incidence of falls at 12-month follow-up. Falls will be measured using a standardized definition and recorded using monthly self-report fall diary calendars. Participants will be asked to record falls and time spent performing their home exercise program on the fall diary calendars. Completed calendars will be returned to the research centers in prepaid envelopes each month. Secondary measures collected by a blinded assessor at baseline (pre-PR), post-PR, and 12-month follow-up will include clinical measures of balance, balance confidence, functional lower body strength, and health status. The cost-effectiveness of the intervention group compared with the control group will be evaluated using the incremental cost per number of falls averted and the incremental cost per quality-adjusted life years gained.

RESULTS

Recruitment for the study began in January 2017 and is anticipated to be complete by December 2019. Results are expected to be available in 2020.

CONCLUSIONS

Findings from this study will improve our understanding of the effectiveness and resource uses of tailored balance training for reducing falls in individuals with COPD. If effective, the intervention represents an opportunity to inform international guidelines and health policy for PR in individuals with COPD who are at risk of falling.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02995681; https://clinicaltrials.gov/ct2/show/NCT02995681 (Archived by WebCite at http://www.webcitation.org/6ukhxgAsg).

Acceptability of the 6-PACK falls prevention program: A pre-implementation study in hospitals participating in a cluster randomized controlled trial

There is limited evidence to support the effectiveness of falls prevention interventions in the acute hospital setting. The 6-PACK falls prevention program includes a fall-risk tool; ‘falls alert’ signs; supervision of patients in the bathroom; ensuring patients’ walking aids are within reach; toileting regimes; low-low beds; and bed/chair alarms. This study explored the acceptability of the 6-PACK program from the perspective of nurses and senior staff prior to its implementation in a randomised controlled trial. A mixed-methods approach was applied involving 24 acute wards from six Australian hospitals. Participants were nurses working on participating wards and senior hospital staff including: Nurse Unit Managers; senior physicians; Directors of Nursing; and senior personnel involved in quality and safety or falls prevention. Information on program acceptability (suitability, practicality and benefits) was obtained by surveys, focus groups and interviews. Survey data were analysed descriptively, and focus group and interview data thematically. The survey response rate was 60%. Twelve focus groups (n = 96 nurses) and 24 interviews with senior staff were conducted. Falls were identified as a priority patient safety issue and nurses as key players in falls prevention. The 6-PACK program was perceived to offer practical benefits compared to current practice. Nurses agreed fall-risk tools, low-low beds and alert signs were useful for preventing falls (>70%). Views were mixed regarding positioning patients’ walking aid within reach. Practical issues raised included access to equipment; and risk of staff injury with low-low bed use. Bathroom supervision was seen to be beneficial, however not always practical. Views on the program appropriateness and benefits were consistent across nurses and senior staff. Staff perceived the 6-PACK program as suitable, practical and beneficial, and were open to adopting the program. Some practical concerns were raised highlighting issues to be addressed by the implementation plan.

Risk Factors for In-Hospital Complications of Fall-Related Fractures among Older Chinese: A Retrospective Study

Purpose. The aim of this study was to investigate the risk factors and the efficacy of the preventive measurements for the in-hospital complications of fall-related fractures. Methods. The data on older Chinese patients with fall-related fractures were collected, including information on the patients, diseases, and preventive measurements. The potential risk factors for the in-hospital complications included health status on admission, comorbidity, fractures, preventive measures of the complications, and drugs use for the comorbidity. After univariate analyses, multivariate logistic regression analyses were applied to investigate the impact of the potential risk factors on the number of the complications and each individual complication, respectively, and the efficacy of the preventive measurements. Results. A total of 525 male and 1367 female were included in this study. After univariate analyses, multiple logistic regression showed that dementia, pneumonia, antidepressant, postural hypotension, and cerebral infarction could increase the incidence and number of comorbidities. Meanwhile, dementia has shown the strongest association with each individual complication. Conclusions. Different combinations of comorbidity, medication use, and preventive measurements were related to the in-hospital complications of fall-related fractures. Dementia emerged as the most important risk factor for these complications, while most of the preventive measurements could not reduce their incidences.

The SCOPE of Hospital Falls: A Systematic Mixed Studies Review

PURPOSE

This systematic mixed studies review on hospital falls is aimed to facilitate proactive decision-making for patient safety during the healthcare facility design.

BACKGROUND

Falls were identified by the Centers for Medicare & Medicaid Services as a nonreimbursed hospital-acquired condition (HAC) due to volume and cost, and additional financial penalties were introduced with the 2014 U.S. HAC reduction program. In 2015, the Joint Commission alert identified patient falls as one of the top reported sentinel events, and the Occupational Safety & Health Administration (OSHA) added slips, trips, and falls as a focus for investigators' healthcare inspections. Variations in fall rates at both the hospital and the unit level are indicative of an ongoing challenge. The built environment can act as a barrier or enhancement to achieving the desired results in safety complexity that includes the organization, people, and environment.

METHODS

The systematic literature review used Medical Subject Heading terms and key word alternates for hospital falls with searches in MEDLINE, Web of Science, and CINAHL. The search was limited to English-language papers.

RESULTS

Following full-text review, 27 papers were included and critically appraised using an evaluation matrix that included a mixed methods appraisal tool. Themes were coded by broad categories of factors for organization (policy/operations), people (caregivers/staff, patients), and the environment (healthcare facility design). Subcategories were developed to define the physical environment and consider the potential interventions in the context of relative stability.

CONCLUSIONS

Conditions of hospital falls were identified and evaluated through the literature review. A theoretical model was developed to propose a human factors framework while considering the permanence of solutions.

Development of an implementation plan for the 6-PACK falls prevention programme as part of a randomised controlled trial: protocol for a series of preimplementation studies

BACKGROUND

Inhospital falls cause morbidity, staff burden and increased healthcare costs. It is unclear if the persistent problem of inhospital falls is due to the use of ineffective interventions or their suboptimal implementation. The 6-PACK programme appears to reduce fall injuries and a randomised controlled trial (RCT) was undertaken to confirm effects. This paper describes the protocol for the preimplementation studies that aimed to identify moderators of the effective use of the 6-PACK programme to inform the development of an implementation plan to be applied in the RCT.

METHODS

The 6-PACK project included five preimplementation studies: (1) a profile of safety climate; (2) review of current falls prevention practice; (3) epidemiology of inhospital falls; (4) acceptability of the 6-PACK programme; and (5) barriers and enablers to implementation of the 6-PACK programme. The Theoretical Domain Framework that includes 12 behaviour change domains informed the design of these studies that involved 540 staff and 8877 patients from 24 wards from six Australian hospitals. Qualitative and quantitative methods were applied with data collected via: structured bedside observation; daily nurse unit manager verbal report of falls; audit of medical records, incident reporting and hospital administrative data; surveys of ward nurses; focus groups with ward nurses; and key informant interviews with senior staff.

DISCUSSION

Information on contextual, system, intervention, patient and provider level factors is critical to the development of an implementation plan. Information gained from these studies was used to develop a plan applied in the RCT that addressed the barriers and harnessed enablers.

TRIAL REGISTRATION NUMBER

The RCT is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000332921.

6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial

OBJECTIVE

To evaluate the effect of the 6-PACK programme on falls and fall injuries in acute wards.

DESIGN

Cluster randomised controlled trial.

SETTING

Six Australian hospitals.

PARTICIPANTS

All patients admitted to 24 acute wards during the trial period.

INTERVENTIONS

Participating wards were randomly assigned to receive either the nurse led 6-PACK programme or usual care over 12 months. The 6-PACK programme included a fall risk tool and individualised use of one or more of six interventions: "falls alert" sign, supervision of patients in the bathroom, ensuring patients' walking aids are within reach, a toileting regimen, use of a low-low bed, and use of a bed/chair alarm.

MAIN OUTCOME MEASURES

The co-primary outcomes were falls and fall injuries per 1000 occupied bed days.

RESULTS

During the trial, 46 245 admissions to 16 medical and eight surgical wards occurred. As many people were admitted more than once, this represented 31 411 individual patients. Patients' characteristics and length of stay were similar for intervention and control wards. Use of 6-PACK programme components was higher on intervention wards than on control wards (incidence rate ratio 3.05, 95% confidence interval 2.14 to 4.34; P<0.001). In all, 1831 falls and 613 fall injuries occurred, and the rates of falls (incidence rate ratio 1.04, 0.78 to 1.37; P=0.796) and fall injuries (0.96, 0.72 to 1.27; P=0.766) were similar in intervention and control wards.

CONCLUSIONS

Positive changes in falls prevention practice occurred following the introduction of the 6-PACK programme. However, no difference was seen in falls or fall injuries between groups. High quality evidence showing the effectiveness of falls prevention interventions in acute wards remains absent. Novel solutions to the problem of in-hospital falls are urgently needed.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12611000332921.