Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses

OBJECTIVES: To evaluate the evidence for strategies to prevent falls or fractures in residents in care homes and hospital inpatients and to investigate the effect of dementia and cognitive impairment. DESIGN: Systematic review and meta-analyses of studies grouped by intervention and setting (hospital or care home). Meta-regression to investigate the effects of dementia and of study quality and design. DATA SOURCES: Medline, CINAHL, Embase, PsychInfo, Cochrane Database, Clinical Trials Register, and hand searching of references from reviews and guidelines to January 2005. RESULTS: 1207 references were identified, including 115 systematic reviews, expert reviews, or guidelines. Of the 92 full papers inspected, 43 were included. Meta-analysis for multifaceted interventions in hospital (13 studies) showed a rate ratio of 0.82 (95% confidence interval 0.68 to 0.997) for falls but no significant effect on the number of fallers or fractures. For hip protectors in care homes (11 studies) the rate ratio for hip fractures was 0.67 (0.46 to 0.98), but there was no significant effect on falls and not enough studies on fallers. For all other interventions (multifaceted interventions in care homes; removal of physical restraints in either setting; fall alarm devices in either setting; exercise in care homes; calcium/vitamin D in care homes; changes in the physical environment in either setting; medication review in hospital) meta-analysis was either unsuitable because of insufficient studies or showed no significant effect on falls, fallers, or fractures, despite strongly positive results in some individual studies. Meta-regression showed no significant association between effect size and prevalence of dementia or cognitive impairment. CONCLUSION: There is some evidence that multifaceted interventions in hospital reduce the number of falls and that use of hip protectors in care homes prevents hip fractures. There is insufficient evidence, however, for the effectiveness of other single interventions in hospitals or care homes or multifaceted interventions in care homes.

Comparative performance of UK PFI and non-PFI hospitals

Since the first PFI hospital was established in 1994, many debates centred on the value for money and risk transfer in PFIs. Little concern is shown with PFI hospitals’ performance in delivering healthcare. Exploratory research was carried out to compare PFI with non‐PFI hospital performance. Five performance indicators were analysed to compare differences between PFI and non‐PFI hospitals, namely the length of waiting, the length of stay, MRSA infection rate, C difficile infection rate and patient experience. Data was collected from various government bodies. The results show that only some indexes measuring patient experience emerge statistically significant. This leads to a conclusion that PFI hospitals may not perform better than non‐PFI hospitals but they are not worse than non‐PFI hospitals in the delivery of services. However, future research needs to pay attention to reliability and validity of data sets currently available to undertake comparison.

Haldane's Mackindergarten: a radical experiment in British military education

This article critically evaluates a course that was conceived and run at the LSE by Sir Halford Mackinder for officers of the Britsh Army between 1907 and 1932.There is an examination of the nature of the syllabus,the aims and objectives of this course.An explanation is also given as to why the army cut it seven years before the outbreak of the Second World War.

Military doctrine, command philosophy and the generation of fighting power: genesis and theory

Military doctrine is one of the conceptual components of war. Its raison d’être is that of a force multiplier. It enables a smaller force to take on and defeat a larger force in battle. This article’s departure point is the aphorism of Sir Julian Corbett, who described doctrine as ‘the soul of warfare’. The second dimension to creating a force multiplier effect is forging doctrine with an appropriate command philosophy. The challenge for commanders is how, in unique circumstances, to formulate, disseminate and apply an appropriate doctrine and combine it with a relevant command philosophy. This can only be achieved by policy-makers and senior commanders successfully answering the Clausewitzian question: what kind of conflict are they involved in? Once an answer has been provided, a synthesis of these two factors can be developed and applied. Doctrine has implications for all three levels of war. Tactically, doctrine does two things: first, it helps to create a tempo of operations; second, it develops a transitory quality that will produce operational effect, and ultimately facilitate the pursuit of strategic objectives. Its function is to provide both training and instruction. At the operational level instruction and understanding are critical functions. Third, at the strategic level it provides understanding and direction. Using John Gooch’s six components of doctrine, it will be argued that there is a lacunae in the theory of doctrine as these components can manifest themselves in very different ways at the three levels of war. They can in turn affect the transitory quality of tactical operations. Doctrine is pivotal to success in war. Without doctrine and the appropriate command philosophy military operations cannot be successfully concluded against an active and determined foe.

‘Warsaw Pact Military Doctrines in the 70s and 80s: Findings in the East German Archives’

This article draws on Warsaw Treaty Organisation and East German military archives to demonstrate that the WTO's military exercises until the mid-1990s always envisaged an offensive strategy with the aim of reaching the Channel in a few days. Only gradually did this change under Gorbachev and to include also defensive strategies, very much against the opposition of East Germany.