David Oliver

Preventing Falls and Fall-Related Injuries in Hospitals

Falls are a widespread concern in hospitals settings, with whole hospital rates of between 3 and 5 falls per 1000 bed-days representing around a million inpatient falls occurring in the United States each year. Between 1% and 3% of falls in hospitals result in fracture, but even minor injuries can cause distress and delay rehabilitation. Risk factors most consistently found in the inpatient population include a history of falling, muscle weakness, agitation and confusion, urinary incontinence or frequency, sedative medication, and postural hypotension. Based on systematic reviews, recent research, and clinical and ethical considerations, the most appropriate approach to fall prevention in the hospital environment includes multifactorial interventions with multiprofessional input. There is also some evidence that delirium avoidance programs, reducing sedative and hypnotic medication, in-depth patient education, and sustained exercise programs may reduce falls as single interventions. There is no convincing evidence that hip protectors, movement alarms, or low-low beds reduce falls or injury in the hospital setting. International approaches to developing and maintaining a fall prevention program suggest that commitment of management and a range of clinical and support staff is crucial to success.

Measuring falls events in acute hospitals - A comparison of three reporting methods to identify missing data in the hospital reporting system

OBJECTIVES: To compare three different methods of falls reporting and examine the characteristics of the data missing from the hospital incident reporting system.

Falls After Discharge From Hospital: Is There a Gap Between Older Peoples’ Knowledge About Falls Prevention Strategies and the Research Evidence?

PURPOSEnThe aim of this study was to examine whether older people are prepared to engage in appropriate falls prevention strategies after discharge from hospital.nnnDESIGN AND METHODSnWe used a semi-structured interview to survey older patients about to be discharged from hospital and examined their knowledge regarding falls prevention strategies to utilize in the post-discharge period. The study was part of a prospective cohort study, nested within a larger, randomized controlled trial. Participants (n = 333) were asked to suggest strategies to reduce their falls risk at home after discharge, and their responses were compared with current reported research evidence for falls prevention interventions.nnnRESULTSnParticipants strategies (n = 629) were classified into 7 categories: behavioral, support while mobilizing, approach to movement, physical environment, visual, medical, and activities or exercise. Although exercise has been identified as an effective falls risk reduction strategy, only 2.9% of participants suggested engaging in exercises. Falls prevention was most often conceptualized by participants as requiring 1 (35.4%) or 2 (40.8%) strategies for avoiding an accidental event, rather than engaging in sustained multiple risk reduction behaviors.nnnIMPLICATIONSnResults demonstrate that older patients have low levels of knowledge about appropriate falls prevention strategies that could be used after discharge in spite of their increased falls risk during this period. Findings suggest that health care workers should design and deliver falls prevention education programs specifically targeted to older people who are to be discharged from hospital.

Evaluation of the Sustained Effect of Inpatient Falls Prevention Education and Predictors of Falls After Hospital Discharge—Follow-up to a Randomized Controlled Trial

BACKGROUNDnThis study aimed to determine (i) risk factors for postdischarge falls and (ii) the effect of inpatient falls prevention education on rates of falls after discharge.nnnMETHODSnParticipants (n = 343) were a prospective cohort nested within a randomized controlled trial (n = 1,206) of falls prevention patient education in hospital compared with usual care. Participants were followed up for 6 months after discharge and falls recorded via a falls diary and monthly telephone calls. Potential falls risk factors were assessed at point of discharge and at 6 months postdischarge using a telephone survey.nnnRESULTSnThere were 276 falls among 138 (40.2%) participants in the 6 months following discharge (4.52/1,000 person days) of which 150 were injurious falls (2.46/1,000 person days). Pairwise comparisons found no significant differences between groups in rates of falls after adjustment for confounding variables. Independent risk factors for all falls outcomes were male gender, history of falls prior to hospital admission, fall during hospital admission, depressed mood at discharge, using a walking aid at discharge, and receiving assistance with activities of daily living at 6 months following discharge. Receiving assistance with activities of daily living significantly reduced the risk of falls and injurious falls for high risk patients.nnnCONCLUSIONSnOlder patients are at increased risk of falls and falls injuries following discharge. Education that effectively reduced inpatient falls appears to have no ongoing protective effect after discharge. Independent risk factors for falls in this population differ from both hospital and general community settings.

Community matrons – an exploratory study of patients’ views and experiences

AIMnThe aim of the study was to explore patients views and experiences of the community matron role in one primary care provider organization.nnnBACKGROUNDnCommunity matrons manage the needs of people living with long-term conditions in the community and aim to improve patient self-management and education, and enhance co-ordination between in primary and social care.nnnMETHODSnA purposive sample of 14 service users (ten women, four men; aged 45-89u2003years) with a range of chronic conditions took part in interviews in 2007. A grounded theory approach was the framework for data collection and analysis.nnnFINDINGSnThe role of the community matron appeared to have a positive impact on patient care mainly in three areas: access, patient advocacy and psychosocial support. Patients thought that they had easier access to healthcare services and that the community matron acted as an advocate by helping them to understand medical jargon and supporting them at hospital appointments, thereby providing a link to secondary care. Some patient perceptions differed from those about other primary care staff.nnnCONCLUSIONnThere is evidence that community matrons may have a beneficial effect on patients perceptions of their care, psycho-social support, access to services and advocacy. The impact of this role on the patient experience needs to be taken into account when evaluating this nursing role and services, as benefits may not be captured by relying solely on quantitative evaluations of hospital readmission rates.

Evaluation of the effect of patient education on rates of falls in older hospital patients: Description of a randomised controlled trial

BackgroundAccidental falls by older patients in hospital are one of the most commonly reported adverse events. Falls after discharge are also common. These falls have enormous physical, psychological and social consequences for older patients, including serious physical injury and reduced quality of life, and are also a source of substantial cost to health systems worldwide. There have been a limited number of randomised controlled trials, mainly using multifactorial interventions, aiming to prevent older people falling whilst inpatients. Trials to date have produced conflicting results and recent meta-analyses highlight that there is still insufficient evidence to clearly identify which interventions may reduce the rate of falls, and falls related injuries, in this population.Methods and designA prospective randomised controlled trial (n = 1206) is being conducted at two hospitals in Australia. Patients are eligible to be included in the trial if they are over 60 years of age and they, or their family or guardian, give written consent. Participants are randomised into three groups. The control group continues to receive usual care. Both intervention groups receive a specifically designed patient education intervention on minimising falls in addition to usual care. The education is delivered by Digital Video Disc (DVD) and written workbook and aims to promote falls prevention activities by participants. One of the intervention groups also receives follow up education training visits by a health professional. Blinded assessors conduct baseline and discharge assessments and follow up participants for 6 months after discharge. The primary outcome measure is falls by participants in hospital. Secondary outcome measures include falls at home after discharge, knowledge of falls prevention strategies and motivation to engage in falls prevention activities after discharge. All analyses will be based on intention to treat principle.DiscussionThis trial will examine the effect of a single intervention (specifically designed patient education) on rates of falls in older patients in hospital and after discharge. The results will provide robust recommendations for clinicians and researchers about the role of patient education in this population. The study has the potential to identify a new intervention that may reduce rates of falls in older hospital patients and could be readily duplicated and applied in a wide range of clinical settings.Trial RegistrationACTRN12608000015347

21st century health services for an ageing population: 10 challenges for general practice.

![][1] nnWhen Queen Elizabeth II was crowned in 1952, life expectancy was 66 years for males and 71 years for females. By 2001, these figures were 77 and 81 respectively. Average life expectancy at 70 is already 17 years for males and 19 years for females. Old age is often caricatured as a time of ill-health, loneliness, unhappiness, and dependence, but life satisfaction peaks in the 70s and most over-80s rate their health as being good or excellent and say they do not live with life-limiting long-term conditions (LTCs). Most over 65s are neither disabled nor dependent.1nnDespite this good news, ageing does pose significant challenges to health and social care systems, which need to change to meet radically different patterns of demand. I believe there are at least 10 key challenges for general practice in providing care for an ageing population. Several are well-illustrated by articles in this welcome themed issue of the BJGP .nnIn England, people over 65 years comprise 46% of spend in acute care, 37% in primary care, 60% in social care, 60% of admissions, and 70% of bed days in hospital. Many older patients have complex needs or use multiple services. There is major unwarranted variation between primary care trusts in rates of emergency hospital admission or bed utilisation in over 65s; and in a range of disease-specific processes and outcomes.2 We need to focus more on older people with multiple morbidities, whose care should be more prominent in plans for service redesign.nnOlder patients often get a poor deal in the NHS and other systems relative to other age-groups.3 Common age-related conditions receive lower priority and older people receive generally lower quality of care than those in midlife with the same diseases. Frailer old people who present with so-called ‘non-specific’ or …nn [1]: /embed/graphic-1.gif

Readmission rates reflect how well whole health and social care systems function

These articles on readmission are based on a flawed premise—that readmissions are a marker of the quality of care in acute hospitals.1 2 3 Of course, patients are sometimes sent home unwell and prematurely, or with complications caused by hospital admission. But readmissions usually occur because4:

Leadership is not management

I am one of those doctors who has undergone formal leadership training—having masters degrees in health management and health leadership and experience as clinical director and lead clinician in two trusts, as well as a senior role in my specialty society. So I wouldn’t be in the …

Over-claiming the evidence for telehealth and telecare?

It would seem that the emperor has few clothes.1 Telehealth and telecare have been relentlessly plugged in the Health Service Journal for the past year or so in a succession of features, some accompanied by the sector manufacturing the technology. At no point did the journal have an open, balanced BMJ style head to head debate so that the sceptics could have their say and restore balance to the …