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.

The 6-PACK programme to decrease falls and fall-related injuries in acute hospitals : protocol for an economic evaluation alongside a cluster randomised controlled trial

Background Falls are a common hospital occurrence complicating the care of patients. From an economic perspective, the impact of in-hospital falls and related injuries is substantial. However, few studies have examined the economic implications of falls prevention interventions in an acute care setting. The 6-PACK programme is a targeted nurse delivered falls prevention programme designed specifically for acute hospital wards. It includes a risk assessment tool and six simple strategies that nurses apply to patients classified as high-risk by the tool.
Objective To examine the incremental cost-effectiveness of the 6-PACK programme for the prevention of falls and fall-related injuries, compared with usual care practice, from an acute hospital perspective.
Methods and design The 6-PACK project is a multicentre cluster randomised controlled trial (RCT) that includes 24 acute medical and surgical wards from six hospitals in Australia to investigate the efficacy of the 6-PACK programme. This economic evaluation will be conducted alongside the 6-PACK cluster RCT. Outcome and hospitalisation cost data will be prospectively collected on approximately 16 000 patients admitted to the participating wards during the 12-month trial period. The results of the economic evaluation will be expressed as ‘cost or saving per fall prevented’ and ‘cost or saving per fall-related injury prevented’ calculated from differences in mean costs and effects in the intervention and control groups, to generate an incremental cost-effectiveness ratio (ICER).
Discussion This economic evaluation will provide an opportunity to explore the cost-effectiveness of a targeted nurse delivered falls prevention programme for reducing in-hospital falls and fall-related injuries. This protocol provides a detailed statement of a planned economic evaluation conducted alongside a cluster RCT to investigate the efficacy of the 6-PACK programme to prevent falls and fall-related injuries.

In-hospital falls and fall-related injuries: a protocol for a cost of fall study

Background:
In-hospital falls are common and pose significant economic burden on the healthcare system. To date, few studies have quantified the additional cost of hospitalisation associated with an in-hospital fall or fall-related injury. The aim of this study is to determine  the additional length of stay and hospitalisation costs associated with in-hospital falls and fall-related injuries, from the acute hospital perspective.

Methods and design: 
A multisite prospective study will be conducted as part of a larger falls-prevention clinical trial—the 6-PACK project. This study will involve 12 acute medical and surgical wards from six hospitals across Australia. Patient and admission characteristics, outcome and hospitalisation cost data will be prospectively collected on approximately 15 000 patients during the 15-month study period. A review of all inhospital fall events will be conducted using a multimodal method (medical record review and daily verbal report from the nurse unit manager, triangulated with falls recorded in the hospital incident reporting and administrative database), to ensure complete case ascertainment. Hospital clinical costing data will be used to calculate patient-level hospitalisation costs incurred by a patient during their inpatient stay. Additional hospital and hospital resource utilisation costs attributable to inhospital falls and fall-related injuries will be calculated using linear regression modelling, adjusting for a prioridefined potential confounding factors.

Discussion:
This protocol provides the detailed statement of the planned analysis. The results from this study will be used to support healthcare planning, policy making and allocation of funding relating to falls prevention within acute hospitals.

Geriatric fall-related injuries.

Background: Falls are the leading cause of geriatric injury. Objectives: We aimed to study the anatomical distribution, severity, and outcome of geriatric fall-related injuries in order to give recommendations regarding their prevention. Methods: All injured patients with an age ≥ 60 years who were admitted to Al-Ain Hospital or died in the Emergency Department due to falls were prospectively studied over a four year period. Results: We studied 92 patients. Fifty six of them (60.9%) were females. The mean (standard deviation) of age was 72.2 (9.6) years. Seventy three (89%) of all incidents occurred at home. Eighty three patients (90.2%) fell on the same level. The median (range) ISS was 4 (1-16) and the median GCS (range) was 15 (12-15). The lower limb was the most common injured body region (63%). There were no statistical significant differences between males and females regarding age, ISS, and hospital stay (p = 0.85, p = 0.57, and p = 0.35 respectively). Conclusion: The majority of geriatric fall-related injuries were due to fall from the same level at home. Assessment of risk factors for falls including home hazards is essential for prevention of geriatric fall-related injuries.

Fall-related emergency department admission: fall environment and settings and related injury patterns in 6357 patients with special emphasis on the elderly

PRINCIPALS Throughout the world, falls are a major public health problem and a socioeconomic burden. Nevertheless there is little knowledge about how the injury types may be related to the aetiology and setting of the fall, especially in the elderly. We have therefore analysed all patients presenting with a fall to our Emergency Department (ED) over the past five years. METHODS Our retrospective data analysis comprised adult patients admitted to our Emergency Department between January 1, 2006, and December 31, 2010, in relation to a fall. RESULTS Of a total of 6357 patients 78% (n = 4957) patients were younger than 75 years. The main setting for falls was patients home (n = 2239, 35.3%). In contrast to the younger patients, the older population was predominantly female (56.3% versus 38.6%; P < 0.0001). Older patients were more likely to fall at home and suffer from medical conditions (all P < 0.0001). Injuries to the head (P < 0.0001) and to the lower extremity (P < 0.019) occurred predominantly in the older population. Age was the sole predictor for recurrent falls (OR 1.2, P < 0.0001). CONCLUSION Falls at home are the main class of falls for all age groups, particularly in the elderly. Fall prevention strategies must therefore target activities of daily living. Even though falls related to sports mostly take place in the younger cohort, a significant percentage of elderly patients present with falls related to sporting activity. Falls due to medical conditions were most likely to result in mild traumatic brain injury.

The reliability of information on work-related injuries available from hospitalisation data in Australia

Objective: To examine the reliability of work-related activity coding for injury-related hospitalisations in Australia. Method: A random sample of 4373 injury-related hospital separations from 1 July 2002 to 30 June 2004 were obtained from a stratified random sample of 50 hospitals across 4 states in Australia. From this sample, cases were identified as work-related if they contained an ICD-10-AM work-related activity code (U73) allocated by either: (i) the original coder; (ii) an independent auditor, blinded to the original code; or (iii) a research assistant, blinded to both the original and auditor codes, who reviewed narrative text extracted from the medical record. The concordance of activity coding and number of cases identified as work-related using each method were compared. Results: Of the 4373 cases sampled, 318 cases were identified as being work-related using any of the three methods for identification. The original coder identified 217 and the auditor identified 266 work-related cases (68.2% and 83.6% of the total cases identified, respectively). Around 10% of cases were only identified through the text description review. The original coder and auditor agreed on the assignment of work-relatedness for 68.9% of cases. Conclusions and Implications: The current best estimates of the frequency of hospital admissions for occupational injury underestimate the burden by around 32%. This is a substantial underestimate that has major implications for public policy, and highlights the need for further work on improving the quality and completeness of routine, administrative data sources for a more complete identification of work-related injuries.

Identifying work related injuries : comparison of methods for interrogating text fields

Background: Work-related injuries in Australia are estimated to cost around $57.5 billion annually, however there are currently insufficient surveillance data available to support an evidence-based public health response. Emergency departments (ED) in Australia are a potential source of information on work-related injuries though most ED’s do not have an ‘Activity Code’ to identify work-related cases with information about the presenting problem recorded in a short free text field. This study compared methods for interrogating text fields for identifying work-related injuries presenting at emergency departments to inform approaches to surveillance of work-related injury.---------- Methods: Three approaches were used to interrogate an injury description text field to classify cases as work-related: keyword search, index search, and content analytic text mining. Sensitivity and specificity were examined by comparing cases flagged by each approach to cases coded with an Activity code during triage. Methods to improve the sensitivity and/or specificity of each approach were explored by adjusting the classification techniques within each broad approach.---------- Results: The basic keyword search detected 58% of cases (Specificity 0.99), an index search detected 62% of cases (Specificity 0.87), and the content analytic text mining (using adjusted probabilities) approach detected 77% of cases (Specificity 0.95).---------- Conclusions The findings of this study provide strong support for continued development of text searching methods to obtain information from routine emergency department data, to improve the capacity for comprehensive injury surveillance.

Adherence to nutrition supplements among patients with a fall-related lower limb fracture

Background The purpose of this study was to provide a detailed evaluation of adherence to nutrition supplements by patients with a lower limb fracture. Methods These descriptive data are from 49 nutritionally“ at-risk” patients aged 70+ years admitted to the hospital after a fall-related lower limb fracture and allocated to receive supplementation as part of a randomized, controlled trial. Supplementation commenced on day 7 and continued for 42 days. Prescribed volumes aimed to meet 45% of individually estimated theoretical energy requirements to meet the shortfall between literature estimates of energy intake and requirements. The supplement was administered by nursing staff on medication rounds in the acute or residential care settings and supervised through thrice-weekly home visits postdischarge. Results Median daily percent of the prescribed volume of nutrition supplement consumed averaged over the 42 days was 67% (interquartile range [IQR], 31–89, n = 49). There was no difference in adherence for gender, accommodation, cognition, or whether the supplement was self-administered or supervised. Twenty-three participants took some supplement every day, and a further 12 missed <5 days. For these 35 “nonrefusers,” adherence was 82% (IQR, 65–93), and they lost on average 0.7% (SD, 4.0%) of baseline weight over the 6 weeks of supplementation compared with a loss of 5.5% (SD, 5.4%) in the “refusers” (n = 14, 29%), p = .003. Conclusions We achieved better volume and energy consumption than previous studies of hip fracture patients but still failed to meet target supplement volumes prescribed to meet 45% of theoretical energy requirements. Clinicians should consider alternative methods of feeding such as a nasogastric tube, particularly in those patients where adherence to oral nutrition supplements is poor and dietary intake alone is insufficient to meet estimated energy requirements.

Reducing road related injuries for young adolescents : an investigation of truancy as a risk factor

Truancy is recognised as an indicator of engagement in high-risk behaviours for adolescents. Injuries from road related risk behaviours continue to be a leading cause of death and disability for early adolescents (13-14 years). The aim of this research is to determine the extent to which truancy relates to increased risk of road related injuries for early adolescents. Four hundred and twenty-seven Year 9 students (13-14 years) from five high schools in Queensland, Australia, completed a questionnaire about their perceptions of risk and recent injury experience. Self-reported injuries were assessed by the Extended Adolescent Injury Checklist (E-AIC). Injuries resulting from motorcycle use, bicycle use, vehicle use (as passenger or driver), and as a pedestrian were measured for the preceding three months. Students were also asked to indicate whether they sought medical attention for their injuries. Truancy rates were assessed from self-reported skipping class or wagging school over the same three month period. The findings explore the relationship between early adolescent truancy and road related injuries. The relationship between road related injuries and truancy was analysed separately for males and females. Results of this study revealed that road related injuries and reports of associated medical treatment are higher for young people who engage in truancy when compared with non-truant adolescents. The results of this study contribute knowledge about truancy as a risk factor for engagement in road related risks. The findings have the potential to enhance school policies and injury prevention programs if emphasis is placed on increasing school attendance as a safety measure to decrease road related injuries for young adolescents.

Consumer product-related injuries in Queensland children : A snapshot of current problem areas for potential action

This report presents a snapshot from work which was funded by the Queensland Injury Prevention Council in 2010-11 titled “Feasibility of Using Health Data Sources to Inform Product Safety Surveillance in Queensland children”. The project provided an evaluation of the current available evidence-base for identification and surveillance of product-related injuries in children in Queensland and Australia. A comprehensive 300 page report was produced (available at: http://eprints.qut.edu.au/46518/) and a series of recommendations were made which proposed: improvements in the product safety data system, increased utilisation of health data for proactive and reactive surveillance, enhanced collaboration between the health sector and the product safety sector, and improved ability of health data to meet the needs of product safety surveillance. At the conclusion of the project, a Consumer Product Injury Research Advisory group (CPIRAG) was established as a working party to the Queensland Injury Prevention Council (QIPC), to prioritise and advance these recommendations and to work collaboratively with key stakeholders to promote the role of injury data to support product safety policy decisions at the Queensland and national level. This group continues to meet monthly and is comprised of the organisations represented on the second page of this report. One of the key priorities of the CPIRAG group for 2012 was to produce a snapshot report to highlight problem areas for potential action arising out of the larger report. Subsequent funding to write this snapshot report was provided by the Institute for Health and Biomedical Innovation, Injury Prevention and Rehabilitation Domain at QUT in 2012. This work was undertaken by Dr Kirsten McKenzie and researchers from QUT's Centre for Accident Research and Road Safety - Queensland. This snapshot report provides an evidence base for potential further action on a range of children’s products that are significantly represented in injury data. Further information regarding injury hazards, safety advice and regulatory responses are available on the Office of Fair Trading (OFT) Queensland website and the Product Safety Australia websites. Links to these resources are provided for each product reviewed.

The quik fix study : a randomised controlled trial of brief interventions for young people with alcohol-related injuries and illnesses accessing emergency department and crisis support care

Background: Alcohol is a major preventable cause of injury, disability and death in young people. Large numbers of young people with alcohol-related injuries and medical conditions present to hospital emergency departments (EDs). Access to brief, efficacious, accessible and cost effective treatment is an international health priority within this age group. While there is growing evidence for the efficacy of brief motivational interviewing (MI) for reducing alcohol use in young people, there is significant scope to increase its impact, and determine if it is the most efficacious and cost effective type of brief intervention available. The efficacy of personality-targeted interventions (PIs) for alcohol misuse delivered individually to young people is yet to be determined or compared to MI, despite growing evidence for school-based PIs. This study protocol describes a randomized controlled trial comparing the efficacy and cost-effectiveness of telephone-delivered MI, PI and an Assessment Feedback/Information (AF/I) only control for reducing alcohol use and related harm in young people. Methods/design: Participants will be 390 young people aged 16 to 25 years presenting to a crisis support service or ED with alcohol-related injuries and illnesses (including severe alcohol intoxication). This single blinded superiority trial randomized young people to (i) 2 sessions of MI; (ii) 2 sessions of a new PI or (iii) a 1 session AF/I only control. Participants are reassessed at 1, 3, 6 and 12 months on the primary outcomes of alcohol use and related problems and secondary outcomes of mental health symptoms, functioning, severity of problematic alcohol use, alcohol injuries, alcohol-related knowledge, coping self-efficacy to resist using alcohol, and cost effectiveness. Discussion: This study will identify the most efficacious and cost-effective telephone-delivered brief intervention for reducing alcohol misuse and related problems in young people presenting to crisis support services or EDs. We expect efficacy will be greatest for PI, followed by MI, and then AF/I at 1, 3, 6 and 12 months on the primary and secondary outcome variables. Telephone-delivered brief interventions could provide a youth-friendly, accessible, efficacious, cost-effective and easily disseminated treatment for addressing the significant public health issue of alcohol misuse and related harm in young people. Trial registration: This trial is registered with the Australian and New Zealand Clinical Trials Registry ACTRN12613000108718.

Infant product-related injuries: comparing specialised injury surveillance and routine emergency department data

- Objective To explore the potential for using a basic text search of routine emergency department data to identify product-related injury in infants and to compare the patterns from routine ED data and specialised injury surveillance data. - Methods Data was sourced from the Emergency Department Information System (EDIS) and the Queensland Injury Surveillance Unit (QISU) for all injured infants between 2009 and 2011. A basic text search was developed to identify the top five infant products in QISU. Sensitivity, specificity, and positive predictive value were calculated and a refined search was used with EDIS. Results were manually reviewed to assess validity. Descriptive analysis was conducted to examine patterns between datasets. - Results The basic text search for all products showed high sensitivity and specificity, and most searches showed high positive predictive value. EDIS patterns were similar to QISU patterns with strikingly similar month-of-age injury peaks, admission proportions and types of injuries. - Conclusions This study demonstrated a capacity to identify a sample of valid cases of product-related injuries for specified products using simple text searching of routine ED data. - Implications As the capacity for large datasets grows and the capability to reliably mine text improves, opportunities for expanded sources of injury surveillance data increase. This will ultimately assist stakeholders such as consumer product safety regulators and child safety advocates to appropriately target prevention initiatives.

Development and evaluation of training in culturally specific screening and brief intervention for hospital patients with alcohol-related injuries

Objective To evaluate health practitioners’ confidence and knowledge of alcohol screening, brief intervention and referral after training in a culturally adapted intervention on alcohol misuse and well-being issues for trauma patients. Design Mixed methods, involving semi-structured interviews at baseline and a post-workshop questionnaire. Setting: Targeted acute care within a remote area major tertiary referral hospital. Participants Ten key informants and 69 questionnaire respondents from relevant community services and hospital-based health care professionals. Intervention Screening and brief intervention training workshops and resources for 59 hospital staff. Main outcome measures Self-reported staff knowledge of alcohol screening, brief intervention and referral, and satisfaction with workshop content and format. Results After training, 44% of participants reported being motivated to implement alcohol screening and intervention. Satisfaction with training was high, and most participants reported that their knowledge of screening and brief intervention was improved. Conclusion Targeted educational interventions can improve the knowledge and confidence of inpatient staff who manage patients at high risk of alcohol use disorder. Further research is needed to determine the duration of the effect and influence on practice behaviour. Ongoing integrated training, linked with systemic support and established quality improvement processes, is required to facilitate sustained change and widespread dissemination.