A failed fall prevention study in an acute care setting: lessons from the swamp

Designing and implementing fall intervention studies in acute care settings presents researchers with a number of challenges. To date, there are no fall prevention interventions that have unequivocal empirical support in these settings. Based on the best available evidence a multistrategy fall prevention program was implemented using a pretest–post-test design over a 12-month period. The results indicated no reduction in the fall rate. Contrary to the expected result, the fall rate increased post the implementation of the multistrategy fall prevention program. To assist other researchers understand the contextual and methodological barriers to conducting fall prevention research in acute care settings, this paper discusses the difficulties experienced in this study.

Older persons' perception of risk of falling : implications for fall-prevention campaigns

Objectives. We examined older people's attitudes about falls and implications for the design of fall-prevention awareness campaigns.

Methods. We assessed data from (1) computer-assisted telephone surveys conducted in 2002 with Australians 60 years and older in Northern Rivers, New South Wales (site of a previous fall-prevention program; n=1601), and Wide Bay, Queensland (comparison community; n=1601), and (2) 8 focus groups (n=73).

Results. Participants from the previous intervention site were less likely than were comparison participants to agree that falls are not preventable (odds ratio [OR]=0.76; 95% confidence interval [Cl]=0.65, 0.90) and more likely to rate the prevention of falls a high priority (OR=1.31; 95% CI=1.09, 1.57). There was no difference between the groups for self-perceived risk of falls; more than 60% rated their risk as low. Those with a low perceived risk were more likely to be men, younger, partnered, and privately insured, and to report better health and no history of falls. Focus group data indicated that older people preferred messages that emphasized health and independence rather than falls.

Conclusions. Although older people accepted traditional fall-prevention messages, most viewed them as not personally relevant. Messages that promote health and independence may be more effective.

Fall incidence and fall prevention practices at acute care hospitals in Singapore : a retrospective audit

Objective To investigate the incidence of falls and explore fall prevention practices at acute care hospitals in Singapore.

Design A retrospective audit to collect baseline data on (1) incidence of falls (patient fall rates and fall injury rates) and (2) fall prevention practices, was conducted in five acute care hospitals in Singapore from December 2004 to March 2005.

Study participants Medical record data (n = 6000) of patients admitted into the medical, surgical and geriatric units in the five hospitals.

Outcome measures Fall incidence was obtained from the hospital's fall databases and incident reports for the period of June 2003 to May 2004. In total, 6000 medical records from five hospitals were randomly selected, retrieved and reviewed to determine whether falls, fall assessments and interventions were being initiated and documented.

Results The number of fallers for all hospitals was 825. Analysis showed that patient fall rates ranged from 0.68 to 1.44 per 1000 patient days, and the proportion of falls associated with injury ranged from 27.4% to 71.7%. The use of a fall risk assessment tool by nurses was recorded in 77% of all the nursing records.

Conclusion This study has laid the foundation for further research for fall prevention in Singapore by describing current fall rates, fall-associated injury rates and the status of fall prevention practices in acute care settings. The results will be used to inform the development of a tailored multifaceted strategy to facilitate the implementation of Fall Prevention Clinical Practice Guidelines to reduce the burden of falls and fall injuries in hospitals in Singapore.

Nurses' perceived barriers to the implementation of a Fall Prevention Clinical Practice Guideline in Singapore hospitals

Background

Theories of behavior change indicate that an analysis of barriers to change is helpful when trying to influence professional practice. The aim of this study was to assess the perceived barriers to practice change by eliciting nurses' opinions with regard to barriers to, and facilitators of, implementation of a Fall Prevention clinical practice guideline in five acute care hospitals in Singapore.
Methods

Nurses were surveyed to identify their perceptions regarding barriers to implementation of clinical practice guidelines in their practice setting. The validated questionnaire, 'Barriers and facilitators assessment instrument', was administered to nurses (n = 1830) working in the medical, surgical, geriatric units, at five acute care hospitals in Singapore.
Results

An 80.2% response rate was achieved. The greatest barriers to implementation of clinical practice guidelines reported included: knowledge and motivation, availability of support staff, access to facilities, health status of patients, and, education of staff and patients.
Conclusion

Numerous barriers to the use of the Fall Prevention Clinical Practice Guideline have been identified. This study has laid the foundation for further research into implementation of clinical practice guidelines in Singapore by identifying barriers to change in acute care settings.

Can social dancing prevent falls in older adults? a protocol of the Dance, Aging, Cognition,Economics (DAnCE) fall prevention randomised controlled trial

Background:  Falls are one of the most common health problems among older people and pose a major economic burden on health care systems. Exercise is an accepted stand-alone fall prevention strategy particularly if it is balance training or regular participation in Tai chi. Dance shares the ‘holistic’ approach of practices such as Tai chi. It is a complex sensorimotor rhythmic activity integrating multiple physical, cognitive and social elements. Small-scale randomised controlled trials have indicated that diverse dance styles can improve measures of balance and mobility in older people, but none of these studies has examined the effect of dance on falls or cognition. This study aims to determine whether participation in social dancing: i) reduces the number of falls; and ii) improves cognitive functions associated with fall risk in older people.

Methods/design: A single-blind, cluster randomised controlled trial of 12 months duration will be conducted. Approximately 450 participants will be recruited from 24 self-care retirement villages that house at least 60 residents each in Sydney, Australia. Village residents without cognitive impairment and obtain medical clearance will be eligible. After comprehensive baseline measurements including physiological and cognitive tests and self-completed questionnaires, villages will be randomised to intervention sites (ballroom or folk dance) or to a wait-listed control using a computer randomisation method that minimises imbalances between villages based on two baseline fall risk measures. Main outcome measures are falls, prospectively measured, and the Trail Making cognitive function test. Cost-effectiveness and cost-utility analyses will be performed.

Discussion: This study offers a novel approach to balance training for older people. As a community-based approach to fall prevention, dance offers older people an opportunity for greater social engagement, thereby making a major contribution to healthy ageing. Providing diversity in exercise programs targeting seniors recognises the heterogeneity of multicultural populations and may further increase the number of taking part in exercise.

Reducing fall risk in the elderly: risk factors and fall prevention, a systematic review

Falls in the elderly are a major source of injury resulting in disability and hospitalization. They have a significant impact on individual basis (loss of quality of live, nursing home admissions) and social basis (healthcare costs). Even though falls in the elderly are common there are some well studied risk factors. Special emphasis should be put on sarcopenia/frailty, polypharmacy, multimorbidity, vitamin D status and home hazards. There are several well evaluated fall prevention approaches that either target a single fall risk factor or focus on multiple risk factors. It has to be kept in mind that not all fall prevention strategies are useful for all patients as for example dietary substitution of vitamin D is only recommended in people with increased risk for a vitamin D deficiency. Home hazard reduction strategies are more effective when combined with other fall prevention approaches such as for example exercise programs. In conclusion elderly patients should routinely be screened for relevant risk factors and if need an indiviudally targeted fall prevention program compiled.

Fall prevention among older adults: a quantitative and qualitative study

The purpose of this study was to investigate the effect of a fall prevention program on older adults as well as to explore the perceptions of older adults have on fall risk and the fall prevention program. This research was completed in Newfoundland and Labrador, Canada with participants above the age of 65. The 10-week fall prevention program focused on balance, strength, and flexibility and was followed by focus groups with the control and intervention groups. Pre and post-test measures (postural sway, TUG test, foam and dome test, ABC Scale, ESE Scale, FES Scale, SAFFE) were completed to determine if the fall prevention program decreased fall risk. The results of the quantitative portion of the study did not produce significant results however the qualitative portion was very informative. Five themes emerged from the focus group data: risk factor awareness, confidence, connectedness, quality of life, and program promotion. This research highlights the importance of fall prevention programs for older adults, not only to keep them healthy, but also for the personal and social benefits they facilitate.

Impact of a fall prevention program in the Internal Medicine wards of a tertiary care university hospital

Objective: To determine whether a falls prevention program reduces the incidence of falls within a hospital. Materials and methods: Each patient admitted to the Internal Medicine ward was classiied into a risk category (high, medium, low) according to the scale of J.H. Downton, and then various general and speciic measures were applied by risk group. Interventions included appointments, teaching materials, and training of medical staff and family. Furthermore, a registration system was developed that allowed adverse event fe edback to the program and identiicat ion of the causes of the fall. The SPSS version 20.0 was used for the data analysis. Descriptive analysis was used for quantitative variables, and qualitative variables were expressed as proportions. To compare the rate of pre- and post-program implementation falls, x 2 was used, with a  = 0.05 determining a signiicant statistical value. Results: Since the implementation of the program, the rate of falls per 1000 days/patient decreased from 1.9 in 2007 to 0.67 in the period 2008-2013, representing a decrease of the rate of falls of up to 70%, with a statistically signiicant difference (P=.02). Conclusions: The implementation of a falls prevention program is an effective tool and reduces the rate and complications associated with them.

The fall descriptions and health characteristics of older adults with hip fracture : a mixed methods study

Background: In light of the multifactorial etiology of fall-related hip fracture, knowledge of fall circumstances may be especially valuable when placed in the context of the health of the person who falls. We aimed to investigate the circumstances surrounding fall-related hip fractures and to describe fall circumstances in relation to participants' health and functional characteristics. Methods: The fall circumstances of 125 individuals (age >= 50 years) with hip fracture were investigated using semi-structured interviews. Data concerning participants' health (comorbidities and medications) and function (self-reported performance of mobility, balance, personal activities of daily living and physical activity, previous falls and hand grip strength) were collected via medical records, questionnaires and dynamometry. Using a mixed methods design, both data sets were analysed separately and then merged in order to provide a comprehensive description of fall events and identify eventual patterns in the data. Results: Fall circumstances were described as i) Activity at the time of the fall: Positional change (n = 24, 19%); Standing (n = 16, 13%); Walking (n = 71, 57%); Balance challenging (n = 14, 11%) and ii) Nature of the fall: Environmental (n = 32, 26%); Physiological (n = 35, 28%); Activity-related indoor (n = 8, 6%) and outdoor (n = 8, 6%); Trips and slips on snow (n = 20, 16%) and in snow-free conditions (n = 12, 10%) and Unknown (n = 10, 8%). We observed the following patterns regarding fall circumstances and participants' health: those who fell i) during positional change had the poorest functional status; ii) due to environmental reasons (indoors) had moderate physical function, but high levels of comorbidity and fall risk increasing medications; iii) in snow-free environments (outdoors) appeared to have a poorer health and functional status than other outdoor groups. Conclusions: Our findings indicate that patterns exist in relation to the falls circumstances and health characteristics of people with hip fracture which build upon that previously reported. These patterns, when verified, can provide useful information as to the ways in which fall prevention strategies can be tailored to individuals of varying levels of health and function who are at risk for falls and hip fracture.

Fall risk management intervention : a feasibility and validation study

A fall risk management intervention was undertaken by staff caring for older people in nursing homes. Its acceptability and usefulness was tested. 'High risk times' and 'at risk' individuals were found, thereby identfying times when staff should be vigilant, and specific residents to be targeted with fall prevention strategies.

The 6-PACK programme to decrease fall-related injuries in acute hospitals: protocol for a cluster randomised controlled trial

Background and aims In-hospital fall-related injuries are a source of personal harm, preventable hospitalisation costs, and access block through increased length of stay. Despite increased fall prevention awareness and activity over the last decade, rates of reported fall-related fractures in hospitals appear not to have decreased. This cluster randomised controlled trial (RCT) aims to determine the efficacy of the 6-PACK programme for preventing fall-related injuries, and its generalisability to other acute hospitals.

Methods 24 acute medical and surgical wards from six to eight hospitals throughout Australia will be recruited for the study. Wards will be matched by type and fall-related injury rates, then randomly allocated to the 6-PACK intervention (12 wards) or usual care control group (12 wards). The 6-PACK programme includes a nine-item fall risk assessment and six nursing interventions: ‘falls alert’ sign; supervision of patients in the bathroom; ensuring patient’s walking aids are within reach; establishment of a toileting regime; use of a low-low bed; and use of bed/chair alarm. Intervention wards will be supported by a structured implementation strategy. The primary outcomes are fall and fall-related injury rates 12 months following 6-PACK implementation.

Discussion This study will involve approximately 16 000 patients, and as such is planned to be the largest hospital fall prevention RCT to be undertaken and the first to be powered for the important outcome of fall-related injuries. If effective, there is potential to implement the programme widely as part of daily patient care in acute hospital wards where fall-related injuries are a problem.