Shock-absorbing flooring for fall-related injury prevention in older adults and staff in hospitals and care homes: the SAFEST systematic review

BACKGROUND

Injurious falls in hospitals and care homes are a life-limiting and costly international issue. Shock-absorbing flooring may offer part of the solution; however, evidence is required to inform decision-making.

OBJECTIVES

The objectives were to assess the clinical effectiveness and cost-effectiveness of shock-absorbing flooring for fall-related injury prevention among older adults in care settings.

REVIEW METHODS

A systematic review was conducted of experimental, observational, qualitative and economic studies evaluating flooring in care settings targeting older adults and/or staff. Studies identified by a scoping review (inception to May 2016) were screened, and the search of MEDLINE, AgeLine and Scopus (to September 2019) was updated, alongside other sources. Two independent reviewers assessed risk of bias in duplicate (using Cochrane's Risk of Bias 2.0 tool, the Risk Of Bias In Non-randomized Studies - of Interventions tool, or the Joanna Briggs Institute's qualitative tool).

RESULTS

Of the 22 included studies, 20 assessed the outcomes (three randomised controlled trials; and seven observational, five qualitative and five economic studies) on novel floors (n = 12), sports floors (n = 5), carpet (n = 5) and wooden subfloors (n = 1). Quantitative data related to 11,857 patient/resident falls (nine studies) and 163 staff injuries (one study). Qualitative studies included patients/residents (n = 20), visitors (n = 8) and staff (n = 119). Hospital-based randomised controlled trial data were too imprecise; however, very low-quality evidence indicated that novel/sports flooring reduced injurious falls from three per 1000 patients per day on vinyl with concrete subfloors to two per 1000 patients per day (rate ratio 0.55, 95% confidence interval 0.36 to 0.84; two studies), without increasing falls rates (two studies). One care home-based randomised controlled trial found that a novel underlay produces similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to those of a plywood underlay with vinyl overlays and concrete subfloors. Very low-quality data demonstrated that, compared with rigid floors, novel/sports flooring reduced the number of falls resulting in injury in care homes (26.4% vs. 33.0%; risk ratio 0.80, 95% confidence interval 0.70 to 0.91; three studies) and hospitals (27.1% vs. 42.4%; risk ratio 0.64, 95% confidence interval 0.44 to 0.93; two studies). Fracture and head injury outcomes were imprecise; however, hip fractures reduced from 30 per 1000 falls on concrete to 18 per 1000 falls on wooden subfloors in care homes (odds ratio 0.59, 95% confidence interval 0.45 to 0.78; one study; very low-quality evidence). Four low-quality economic studies concluded that shock-absorbing flooring reduced costs and improved outcomes (three studies), or increased costs and improved outcomes (one study). One, more robust, study estimated that shock-absorbing flooring resulted in fewer quality-adjusted life-years and lower costs, if the number of falls increased on shock-absorbing floors, but that shock-absorbing flooring would be a dominant economic strategy if the number of falls remained the same. Staff found moving wheeled equipment more difficult on shock-absorbing floors, leading to workplace adaptations. Staff injuries were observed; however, very low-quality evidence suggests that these are no less frequent on rigid floors.

LIMITATIONS

Evidence favouring shock-absorbing flooring is of very low quality; thus, much uncertainty remains.

CONCLUSIONS

Robust evidence is lacking in hospitals and indicates that one novel floor may not be effective in care homes. Very low-quality evidence indicates that shock-absorbing floors may be beneficial; however, wider workplace implications need to be addressed. Work is required to establish a core outcome set, and future research needs to more comprehensively deal with confounding and the paucity of hospital-based studies, and better plan for workplace adaptations in the study design.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019118834.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 5. See the NIHR Journals Library website for further project information.

The SAFEST review: a mixed methods systematic review of shock-absorbing flooring for fall-related injury prevention

BACKGROUND

Shock-absorbing flooring may minimise impact forces incurred from falls to reduce fall-related injuries; however, synthesized evidence is required to inform decision-making in hospitals and care homes.

METHODS

This is a Health Technology Assessment mixed methods systematic review of flooring interventions targeting older adults and staff in care settings. Our search incorporated the findings from a previous scoping review, MEDLINE, AgeLine, and Scopus (to September 2019) and other sources. Two independent reviewers selected, assessed, and extracted data from studies. We assessed risk of bias using Cochrane and Joanna Briggs Institute tools, undertook meta-analyses, and meta-aggregation.

RESULTS

20 of 22 included studies assessed our outcomes (3 Randomised Controlled Trials (RCTs); 7 observational; 5 qualitative; 5 economic), on novel floors (N = 12), sports floors (N = 5), carpet (N = 5), and wooden sub-floors (N = 1). Quantitative data related to 11,857 patient falls (9 studies), and 163 staff injuries (1 study). One care home-based RCT found a novel underlay produced similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to a plywood underlay with vinyl overlay and concrete sub-floors. Very low-quality evidence suggested that shock-absorbing flooring may reduce injuries in hospitals (Rate Ratio 0.55, 95% CI 0.36 to 0.84, 2 studies; 27.1% vs. 42.4%; Risk Ratio (RR) = 0.64, 95% CI 0.44 to 0.93, 2 studies) and care homes (26.4% vs. 33.0%; RR 0.80, 95% CI 0.70 to 0.91, 3 studies), without increasing falls. Economic evidence indicated that if injuries are fewer and falls not increased, then shock-absorbing flooring would be a dominant strategy. Fracture outcomes were imprecise; however, hip fractures reduced from 30 in 1000 falls on concrete to 18 in 1000 falls on wooden sub-floors (OR 0.59, 95% CI 0.45 to 0.78; one study; very low-quality evidence). Staff found moving wheeled equipment harder on shock-absorbing floors leading to workplace adaptations. Very low-quality evidence suggests staff injuries were no less frequent on rigid floors.

CONCLUSION

Evidence favouring shock-absorbing flooring is uncertain and of very low quality. Robust research following a core outcome set is required, with attention to wider staff workplace implications.

TRIAL REGISTRATION

PROSPERO CRD42019118834 .

The Impact of the Built Environment on Patient Falls in Hospital Rooms: An Integrative Review

OBJECTIVES

The aims of this study were to identify and evaluate scientific evidence examining the impact of the built environment on patient falls in hospital rooms.

METHODS

An integrative review (IR) with a systematic literature search was performed using the patient, intervention, comparison, outcome framework. We searched CINAHL, PsychINFO, PubMED, and Web of Science databases. The search included peer-reviewed studies from 1990 to 2017 written in English. An additional hand search was also conducted. Selected articles were reviewed and rated based on a hierarchical categorization, comprising six evidence levels, developed by the American Association of Critical-Care Nurses and adapted for evidence-based design systematic literature reviews.

RESULTS

After a multitiered process, 30 articles met the selection criteria. Thematic areas were created based on the examined elements of the physical environment including patient room configuration and available space, bathroom configuration, bathtub and shower, door, bed height and bed rail, flooring, floor mats, patient chair, lighting, toilet, handrail, grab bars, intravenous pole, sink, ceiling lift, and wheelchair and walking aids. Findings of studies on each element are discussed in detail.

CONCLUSIONS

Some environmental elements have not been examined in past relational or causal studies, and the level of evidence for the examined attributes is not high enough to gain robust confidence in healthcare design decision-making. Because of the low level of evidence for several environmental elements, conclusions must be taken with caution. More studies using quantitative, relational, or causal designs are recommended to develop actionable interventions on patient falls in hospital rooms.

Development of a Novel Computational Model for Evaluating Fall Risk in Patient Room Design

OBJECTIVES

This study proposes a computational model to evaluate patient room design layout and features that contribute to patient stability and mitigate the risk of fall.

BACKGROUND

While common fall risk assessment tools in nursing have an acceptable level of sensitivity and specificity, they focus on intrinsic factors and medications, making risk assessment limited in terms of how the physical environment contributes to fall risk.

METHODS

We use literature to inform a computational model (algorithm) to define the relationship between these factors and the risk of fall. We use a trajectory optimization approach for patient motion prediction.

RESULTS

Based on available data, the algorithm includes static factors of lighting, flooring, supportive objects, and bathroom doors and dynamic factors of patient movement. This preliminary model was tested using four room designs as examples of typical room configurations. Results show the capabilities of the proposed model to identify the risk associated with different room layouts and features.

CONCLUSIONS

This innovative approach to room design evaluation and resulting estimation of patient fall risk show promise as a proactive evidence-based tool to evaluate the relationship of potential fall risk and room design. The development of the model highlights the challenge of heterogeneity in factors and reporting found in the studies of patient falls, which hinder our understanding of the role of the built environment in mitigating risk. A more comprehensive investigation comparing the model with actual patient falls data is needed to further refine model development.

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.

Hospital flooring safety and health: knowledge gaps and suggestions

Fall incidents are a leading safety concern in the hospital industry. Whereas roughening the floor surface can reduce fall risks, there remains unanswered controversies between achieving and maintaining hygienic cleaning efficiencies and adequately addressing conditions of flooring safety. Thus, the current study critically overviews the status of research and accepted practices on hospital flooring safety and healthy controls. Salient literature was identified by searching keywords and phrases within the databases of PubMed, Web of Science, MEDLINE, Scopus and ScienceDirect to find answers for the major questions on hospital floorings. A comprehensive review analysis identified that underlying causes of hospital fall incidents and flooring-attributable infectious illnesses mainly comprised floor types and materials, cleaning chemicals, materials and methods, maintenance and slip-resistance properties. Findings from this study suggest several major actions to advance hospital flooring safety and health research and practice.

Effects of Compliant Flooring on Dynamic Balance and Gait Characteristics of Community-dwelling Older Persons

BACKGROUND

Compliant flooring while providing the impact force attenuation in the event of falls, its low stiffness characteristic might impair balance and gait which consequently resulted in an increase in the risk of falling.

OBJECTIVE

To investigate the effects of compliant flooring on dynamic balance and gait performance of older adults under challenging conditions.

DESIGN AND PARTICIPANTS

A cross-sectional designed with repeated measured. Thirty five community-dwelling older adults (mean age 74.91 ± 6.51 yrs) participated in this study.

MEASUREMENT

Modified Dynamic Gait Index (mDGI) and Timed Up and Go (TUG) were used to assess dynamic balance. Spatio-temporal gait parameters were measured under comfortable and maximal speed. All tests were administered on the vinyl and compliant flooring in random order.

RESULTS

The time taken to complete TUG and the mDGI scores were similar between the two flooring types (p ≥ 0.05). Overall, gait characteristics were comparable when walking on the compliant and vinyl flooring for both speeds except for swing time, step time, and cadence.

CONCLUSION

The present study demonstrated that compliant flooring did not significantly affect dynamic balance and had minimal effects on gait characteristics. The compliant flooring appears to be safe for installing in self-ambulating older adult's home.

A quasi-experimental evaluation of compliant flooring in a residential care setting

BACKGROUND

Fall injuries affect the lives of older people to a substantial degree. This quasi-experimental observational study investigates the potential fall injury reducing effect of a compliant flooring in a residential care setting.

METHODS

The allocation of the compliant flooring was non-random. Data on fall-events and individual characteristics were collected in a residential care unit during a period of 68 months. The primary outcome was the fall injury rate per fall, and a logistic regression analysis was used to test for the effect of complaint flooring. Falls per 1000 bed days was the secondary outcome, used to measure the difference in fall risk on compliant flooring versus regular flooring.

RESULTS

The event dataset is an unbalanced panel with repeated observations on 114 individuals, with 70% women. The mean age was 84.9 years of age, the average Body Mass Index (BMI) was 24.7, and there was a mean of 6.57 (SD: 15.28) falls per individual. The unadjusted effect estimate showed a non-significant relative risk injury reduction of 29% per fall (RR 0.71 [95% CI: 0.46-1.09]) compared to regular flooring. Re-estimating, excluding identified outliers, showed an injury risk reduction of 63% (RR 0.37 [95% CI: 0.25-0.54]). Falls per 1000 bed days showed that individuals living in apartments with compliant flooring had a fall rate of 5.3 per 1000 bed days compared to a fall rate of 8.4 per 1000 bed days among individuals living in regular apartments. This corresponds to an incidence rate ratio (IRR) of 0.63 (95% exact Poisson CI: 0.50-0.80).

CONCLUSION

The results of this non-randomized study indicate that compliant flooring has the potential to reduce the risk of fall injury without increasing the fall risk among older people in a Swedish residential care setting.

A Scoping Literature Review of Dementia-Friendly Hospital Design

Purpose

We report the findings of a knowledge synthesis research project on the topic of dementia-friendly acute care (D-FAC) design. This exploratory project systematically mapped what is known about D-FAC physical design in hospitals. We discuss our challenges in locating reportable evidence and the implications of such design for maximizing independent function while ensuring safety and harm reduction in older people living with dementia.

Design and Methods

Exploratory iterative design utilizing scoping literature review methodology.

Results

A total of 28 primary studies plus expert reviewers' narratives on the impact of design and architectural features on independent function of hospitalized older people with dementia were included and evaluated. Items were mapped to key design elements to describe a D-FAC environment. This scoping review project confirms the limited nature of available acute care design evidence on maximizing function.

Implications

Physical design influences the usability and activity undertaken in a health care space and ultimately affects patient outcomes. Achieving safe quality hospital care for older people living with dementia is particularly challenging. Evidence of design principle effectiveness is needed that can be applied to general medical and surgical units where the bulk of older persons with and without dementia are treated.

Low-Impact Flooring: Does It Reduce Fall-Related Injuries?

OBJECTIVES

To compare fall rates and injuries from falls on low-impact flooring (LIF) compared with a standard vinyl flooring.

DESIGN

Prospective, observational, nonrandomized controlled study.

SETTING

Subacute Older Persons Health ward (N = 20 beds).

PARTICIPANTS

Older inpatients.

INTERVENTION

Three different types of LIF.

MEASUREMENTS

All falls in the ward were prospectively monitored using incident reporting, noting location and consequences of each fall. Fall rates (per 1000 bed days) and injuries, were compared between bedroom falls on LIF against those occurring on standard vinyl flooring (controls).

RESULTS

Over 31 months, there were 278 bedroom falls (from 178 fallers). The bedroom fall rate (falls per 1000 bed days occupied) did not differ between the LIF and control groups (median 15 [IQR 8-18] versus 17 [IQR 9-23], respectively; P = .47). However, fall-related injuries were significantly less frequent when they occurred on LIFs (22% of falls versus 34% of falls on control flooring; P = .02). Fractures occurred in 0.7% of falls in the LIF cohort versus 2.3% in the control cohort. Rolling resistance when moving heavier equipment, such as beds or hoists, was an issue for staff on LIF.

CONCLUSIONS

LIF significantly reduced fall-related injuries compared with a standard vinyl flooring, whereas they did not alter the overall risk of falling.

Compliant flooring to prevent fall-related injuries in older adults: A scoping review of biomechanical efficacy, clinical effectiveness, cost-effectiveness, and workplace safety

Background

Compliant flooring, broadly defined as flooring systems or floor coverings with some level of shock absorbency, may reduce the incidence and severity of fall-related injuries in older adults; however, a lack of synthesized evidence may be limiting widespread uptake.

Methods

Informed by the Arksey and O’Malley framework and guided by a Research Advisory Panel of knowledge users, we conducted a scoping review to answer: what is presented about the biomechanical efficacy, clinical effectiveness, cost-effectiveness, and workplace safety associated with compliant flooring systems that aim to prevent fall-related injuries in healthcare settings? We searched academic and grey literature databases. Any record that discussed a compliant flooring system and at least one of biomechanical efficacy, clinical effectiveness, cost-effectiveness, or workplace safety was eligible for inclusion. Two independent reviewers screened and abstracted records, charted data, and summarized results.

Results

After screening 3611 titles and abstracts and 166 full-text articles, we included 84 records plus 56 companion (supplementary) reports. Biomechanical efficacy records (n = 50) demonstrate compliant flooring can reduce fall-related impact forces with minimal effects on standing and walking balance. Clinical effectiveness records (n = 20) suggest that compliant flooring may reduce injuries, but may increase risk for falls. Preliminary evidence suggests that compliant flooring may be a cost-effective strategy (n = 12), but may also result in increased physical demands for healthcare workers (n = 17).

Conclusions

In summary, compliant flooring is a promising strategy for preventing fall-related injuries from a biomechanical perspective. Additional research is warranted to confirm whether compliant flooring (i) prevents fall-related injuries in real-world settings, (ii) is a cost-effective intervention strategy, and (iii) can be installed without negatively impacting workplace safety. Avenues for future research are provided, which will help to determine whether compliant flooring is recommended in healthcare environments.

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.