Terry P. Haines

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.

The stepped wedge cluster randomised trial : rationale, design, analysis, and reporting

The stepped wedge cluster randomised trial is a novel research study design that is increasingly being used in the evaluation of service delivery type interventions. The design involves random and sequential crossover of clusters from control to intervention until all clusters are exposed. It is a pragmatic study design which can reconcile the need for robust evaluations with political or logistical constraints. While not exclusively for the evaluation of service delivery interventions, it is particularly suited to evaluations that do not rely on individual patient recruitment. As in all cluster trials, stepped wedge trials with individual recruitment and without concealment of allocation (or blinding of the intervention) are at risk of selection biases. In a stepped wedge design more clusters are exposed to the intervention towards the end of the study than in its early stages. This implies that the effect of the intervention might be confounded with any underlying temporal trend. A result that initially might seem suggestive of an effect of the intervention may therefore transpire to be the result of a positive underlying temporal trend. Sample size calculations and analysis must make allowance for both the clustered nature of the design and the confounding effect of time. The stepped wedge cluster randomised trial is an alternative to traditional parallel cluster studies, in which the intervention is delivered in only half the clusters with the remainder functioning as controls. When the clusters are relatively homogeneous (that is, the intra-cluster correlation is small), parallel studies tend to deliver better statistical performance than a stepped wedge trial. However, if substantial cluster-level effects are present (that is, larger intra-cluster correlations) or the clusters are large, the stepped wedge design will be more powerful than a parallel design, even one in which the intervention is preceded by a period of baseline control observations.

Patient Education to Prevent Falls Among Older Hospital Inpatients: A Randomized Controlled Trial

BACKGROUND Falls are a common adverse event during hospitalization of older adults, and few interventions have been shown to prevent them. METHODS This study was a 3-group randomized trial to evaluate the efficacy of 2 forms of multimedia patient education compared with usual care for the prevention of in-hospital falls. Older hospital patients (n = 1206) admitted to a mixture of acute (orthopedic, respiratory, and medical) and subacute (geriatric and neurorehabilitation) hospital wards at 2 Australian hospitals were recruited between January 2008 and April 2009. The interventions were a multimedia patient education program based on the health-belief model combined with trained health professional follow-up (complete program), multi-media patient education materials alone (materials only), and usual care (control). Falls data were collected by blinded research assistants by reviewing hospital incident reports, hand searching medical records, and conducting weekly patient interviews. RESULTS Rates of falls per 1000 patient-days did not differ significantly between groups (control, 9.27; materials only, 8.61; and complete program, 7.63). However, there was a significant interaction between the intervention and presence of cognitive impairment. Falls were less frequent among cognitively intact patients in the complete program group (4.01 per 1000 patient-days) than among cognitively intact patients in the materials-only group (8.18 per 1000 patient-days) (adjusted hazard ratio, 0.51; 95% confidence interval, 0.28-0.93]) and control group (8.72 per 1000 patient-days) (adjusted hazard ratio, 0.43; 95% confidence interval, 0.24-0.78). CONCLUSION Multimedia patient education with trained health professional follow-up reduced falls among patients with intact cognitive function admitted to a range of hospital wards. Trial Registration anzctr.org.au Identifier: ACTRN12608000015347.

The relationship between quality of life and disability across the lifespan for people with spinal cord injury

Study design:Prospective cross-sectional survey.Objectives:To compare quality of life (QOL) for people with spinal cord injury (SCI) and their able-bodied peers and to investigate the relationship between QOL and disability (impairments, activity limitations and participation restrictions) across the lifespan, for people with SCI.Setting:A community outreach service for people with SCI in Queensland, Australia.Methods:A random sample of 270 individuals who sustained SCI during the past 60 years was surveyed using a guided telephone interview format. The sample was drawn from the archival records of a statewide rehabilitation service. QOL was measured using the World Health Organization Quality of Life Assessment Instrument-Bref, impairment was measured according to the American Spinal Injury Association classification and the Secondary Condition Surveillance Instrument, activity limitations using the motor subscale of the Functional Independence Measure and participation restrictions using the Community Integration Measure. Lifespan was considered in terms of age and time since injury. Correlation and regression analyses were employed to determine the relationship between QOL and components of disability across the lifespan.Results:QOL was significantly poorer for people with SCI compared to the Australian norm. It was found to be associated with secondary impairments, activity limitations and participation restrictions but not with neurological level, age or time since injury. The single most important predictor of QOL was secondary impairments whereas the second most important predictor was participation.Conclusion:To optimize QOL across the lifespan, rehabilitation services must maintain their focus on functional attainment and minimizing secondary conditions, although at the same time enabling participation.

Can simulation replace part of clinical time? Two parallel randomised controlled trials

Medical Education 2012

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.

Two perspectives of proxy reporting of health-related quality of life using the Euroqol-5D, an investigation of agreement.

Background:Proxy-reporting has been proposed as an alternative to self-report of health-related quality of life (HRQoL) for patients with poor cognition. There are 2 possible perspectives from which to complete a proxy-report, answer as the patient would (proxy-patient) or from the proxys own perspective (proxy-proxy). Most research has not differentiated between perspectives. Agreement between patient and proxy-reports from either perspective has not been investigated using the Euroqol-5D (EQ-5D) among elderly hospital patients undergoing rehabilitation. Objectives:Identify agreement levels between proxy-patient and patient self-report as well as proxy-proxy and patient self-report of the EQ-5D and investigate interaction effects of timing (admission vs. discharge) and basic cognition (intact vs. not intact). Research Design:Repeated measures, inter-rater agreement investigation of clinician proxy-report, and patient self-report incorporating; proxy-patient reports (perspective A) and proxy-proxy reports (perspective B). Subjects:Geriatric rehabilitation patients (n = 272) and their proxies (treating physiotherapists n = 29). Measures:EQ-5D for HRQoL and Mini Mental State Examination for cognition. Results:One hundred fifty (89%) proxy-patient and 130 (98%) proxy-proxy datasets were complete, 51 perspective A and 52 perspective B patients did not have basic cognition intact. Proxy-patient assessments had strong agreement with self-report at discharge across all cognition levels (kappa = 0.76–0.95), but at admission had stronger agreement among patients with better cognition (kappa = 0.70–0.86) than patients with lower cognition (kappa = 0.47–0.76). At admission and discharge proxy-proxy assessments generally had moderate agreement with self-report among patients with poor cognition on most domains with proxies giving lower scores than patients (kappa = 0.23–0.81), this is in contrast to proxy-proxy assessments and patients with better cognition (kappa = 0.55–0.95). Conclusions:Clinician (physiotherapist) proxy-reports among this population generally had good agreement with patient self-report though this was affected by proxy perspective, patient cognition, and timing.

Adherence to and efficacy of home exercise programs to prevent falls: A systematic review and meta-analysis of the impact of exercise program characteristics

OBJECTIVE To determine whether adherence to home exercise interventions for the prevention of falls in older adults relates to home exercise program characteristics and intervention efficacy. METHODS In Australia (2011) a systematic literature search of four databases was conducted. Randomized controlled trials were included. Random-effects meta-analysis of participant adherence rates was performed. Meta-regression analyses were used to determine the relationship between intervention program characteristics, intervention efficacy and adherence. RESULTS Twenty-three studies met the inclusion criteria. The pooled estimate of participants who were fully adherent was 21% (95% Confidence Interval: 15%-29%, range: 0%-68%). Higher levels of full adherence were found in interventions containing balance or walking exercise, moderate home visit support, physiotherapist led delivery and no flexibility training. Higher levels of partial adherence were found in interventions containing home visit or telephone support, a participant health service recruitment approach and no group exercise training. Neither full nor partial adherence to prescribed home exercise program dosages was associated with intervention efficacy. CONCLUSION Adherence to home exercise for the prevention of falls in older adults is low and may be affected by home exercise program characteristics. There is an absence of evidence to link adherence to intervention efficacy.

Patient education to prevent falls in subacute care

Objective: To evaluate the effectiveness of a patient education programme for preventing falls in the subacute hospital setting. Design: Randomized controlled trial, subgroup analysis. Participants: Patients of a metropolitan subacute/aged rehabilitation hospital who were recommended for a patient education intervention for the prevention of falls when enrolled in a larger randomized controlled trial of a falls prevention programme. Methods: Participants in both the control and intervention groups who were recommended for the education programme intervention were followed for the duration of their hospital stay to determine if falls occurred. Only participants in the intervention group who were recommended for this intervention actually received it. In addition, these participants completed an evaluation survey at the completion of their education programme. Results: Intervention group participants in this subgroup analysis had a significantly lower incidence of falls than their control group counterparts (control: 16.0 falls/1000 participant-days, intervention: 8.2 falls/1000 participant-days, log-rank test: P = 0.007). However the difference in the proportion of fallers was not significant (relative risk 1.21, 95% confidence interval 0.68 to 2.14). Conclusion: Patient education is an important part of a multiple intervention falls prevention approach for the subacute hospital setting.

A protocol for evidence-based targeting and evaluation of statewide strategies for preventing falls among community-dwelling older people in Victoria, Australia

Background Falls are a significant threat to the safety, health and independence of older citizens. Despite the now substantial evidence about effective falls prevention interventions, translation into falls reductions has not yet been fully realised. While the hip fracture rate is decreasing, the number and rate of fall-related hospital admissions among older people is increasing. The challenge now is to deliver the most effective interventions efficiently at a population level, and for these interventions to be taken up by older people. Objective To support the development, and evaluation of, effective falls prevention policy and practice in the state of Victoria, Australia. Methods The RE-AIM model (Reach, Efficacy, Adoption, Implementation, Maintenance) was used to identify strategies for an effective programme. Research objectives were developed to support the strategies. These include: (1) identification of subgroups of older people most frequently admitted to hospital for falls; (2) examining the acceptability of established falls interventions; (3) identification of factors that encourage and support relevant lifestyle changes; (4) identifying opportunities to incorporate confirmed interventions in existing programmes and services; (5) developing guidelines for sustainability. The research results will subsequently guide strategy details for the falls prevention plan. RE-AIM will provide the framework for the evaluation structure. Outcome measures Measures to monitor the implementation of the selected interventions will be determined for each intervention, based on the five key factors of the RE-AIM model. The overall effect of the falls prevention plan will be monitored by time series analysis of fall-related hospital admission rates for community-dwelling older people.