Outcomes of a consult fall prevention screening clinic

OBJECTIVE: To report patient satisfaction and quality outcomes from a standardized, multicenter fall prevention screening clinic. DESIGN: Referrals were made to the fall prevention screening clinic, which was staffed by a physician, pharmacist, therapist, nurse, and the site coordinator. The fall prevention screening clinic staff utilized a team-meeting format with clearly delineated management options to determine the appropriate interventions based on various screening examinations. RESULTS: Primary care providers acknowledged pharmacy recommendations and >80% of the recommendations were followed. There was a reduction in reported falls (initial visit = 297 falls, follow-up visit = 141 falls, P = 0.0002) and in the number of recurrent fallers. There was a small (average difference = 1.8 secs) but significant (P = 0.025) decrease in the 8-foot Up-and-Go time, representing a functional improvement in walking speed. There was no significant change in the Fall Efficacy Scale, however. At least 80% of the patients reported that they were completely satisfied with their care. CONCLUSIONS: Patients who attended the fall prevention screening clinic demonstrated improved confidence during activities of daily living and reduced falls. They reported high satisfaction with the clinic format.     

Enhancing functional balance and mobility among older people living in long-term care facilities

This study of long-term care residents investigated whether a balance strategy training program (BSTP) developed for older people living in the community is effective in improving functional mobility and reducing falls when adapted to resident functional abilities. The BSTP was delivered twice weekly over 12 weeks. Outcome measures compared pre- and postintervention measured Timed Up and Go, Functional Reach, timed 5 sit-to-stand movements, and number of?falls in 12 weeks before intervention with 12-week follow-up period. Forty-seven residents participated, 26 of whom were cognitively impaired. There was a significant improvement in all functional balance and mobility measures, but this was clinically significant only in 5 sit-to-stand time. There was no reduction in falls, although this outcome was confounded by all fallers being acutely ill at the time of falling. These results suggest participation in a BSTP by residents of long-term care improves resident functional mobility and balance.     

Effects of a multifactorial falls prevention program for people with stroke returning home after rehabilitation: a randomized controlled trial

Batchelor FA, Hill KD, Mackintosh SF, Said CM, Whitehead CH. Effects of a multifactorial falls prevention program for people with stroke returning home after rehabilitation: a randomized controlled trial.ObjectivesTo determine whether a multifactorial falls prevention program reduces falls in people with stroke at risk of recurrent falls and whether this program leads to improvements in gait, balance, strength, and fall-related efficacy.DesignA single blind, multicenter, randomized controlled trial with 12-month follow-up.SettingParticipants were recruited after discharge from rehabilitation and followed up in the community.ParticipantsParticipants (N=156) were people with stroke at risk of recurrent falls being discharged home from rehabilitation.InterventionsTailored multifactorial falls prevention program and usual care (n=71) or control (usual care, n=85).Main Outcome MeasuresPrimary outcomes were rate of falls and proportion of fallers. Secondary outcomes included injurious falls, falls risk, participation, activity, leg strength, gait speed, balance, and falls efficacy.ResultsThere was no significant difference in fall rate (intervention: 1.89 falls/person-year, control: 1.76 falls/person-year, incidence rate ratio=1.10, P=.74) or the proportion of fallers between the groups (risk ratio=.83, 95% confidence interval=.60–1.14). There was no significant difference in injurious fall rate (intervention: .74 injurious falls/person-year, control: .49 injurious falls/person-year, incidence rate ratio=1.57, P=.25), and there were no significant differences between groups on any other secondary outcome.ConclusionsThis multifactorial falls prevention program was not effective in reducing falls in people with stroke who are at risk of falls nor was it more effective than usual care in improving gait, balance, and strength in people with stroke. Further research is required to identify effective interventions for this high-risk group.     

Physical exercise and fall prevention: A systematic review and meta-analysis of experimental studies included in Cochrane reviews

The aim of this systematic review (SR) and meta-analysis was to assess what type of exercise is associated with fall risk reduction among apparently healthy adults aged 50 and older. We conducted a SR by searching for randomized controlled trials (RCTs) included in Cochrane SRs published until October 2019. Five SRs that compared exercise versus any type of control included 32 RCTs. The outcomes examined were falls, fallers, fractures, and fear of falling. A random effects-based meta-analysis by type of exercise was performed. Almost all the interventions were effective for fall rate reduction, with a major effect for three-dimensional exercise, strength/resistance exercises, and mixed exercises. The number of fallers was reduced by three-dimensional exercise and mixed exercises. Fall-related fractures were generally reduced by all types of exercises considered all together, but none singly resulted in statistically effective fracture prevention. Fear of falling was slightly decreased with endurance exercises.     

Spiritual care at the end of life in long-term care

BACKGROUND: There is growing attention given to the spiritual needs of dying patients and long-term care (LTC) facilities are common settings in which patients receive care as they approach death. OBJECTIVES: To describe the sources of support, the structure and processes of spiritual care in LTC, and examine the relationship between these components and family ratings of overall care. RESEARCH DESIGN: After-death interviews of family members of decedents. SUBJECTS: Family members of 284 decedent residents from a stratified sample of 100 residential care/assisted living facilities and nursing homes in Florida, Maryland, New Jersey, and North Carolina. MEASURES:: Interview items included sources of spiritual support, processes of spiritual care, and the impression of overall care (4 = very good, 3 = good, 2 = fair, 1 = poor) for decedents. Facility-level data included demographics, counseling by clergy, on-site religious services, hospice services, and hospice unit. RESULTS: Most decedents (87%) received assistance with their spiritual needs and those who received spiritual care were perceived by family members to have had better overall care (3.59 vs. 3.25, P = 0.002). Family ratings of care ratings were higher for those who received spiritual support or care from facility staff when compared with those who did not (3.76 vs. 3.49, P < 0.001) and better care was associated with the facilitation of individual devotional activities (3.87 vs. 3.53, P = 0.001). CONCLUSIONS: Spiritual support and care are associated with better overall care at the end of life for LTC residents, and interventions to improve this type of care may best target interactions between residents and facility staff.     

A pilot study of falls risk and vestibular dysfunction in older fallers presenting to hospital emergency departments

PURPOSE: To compare falls risk in older fallers and non-fallers, with an emphasis on dizziness and signs of vestibular dysfunction. METHOD: The fallers had presented to the Emergency Department of the Royal Melbourne Hospital, Australia following a fall and were discharged directly home (n = 20) (75% female, mean age 78 years). The non-fallers were an age and gender matched group, who had not fallen in the past 12 months (n = 20). All clients received a home-based assessment, which involved a comprehensive assessment of falls risk. RESULTS: Over three-quarters of the fallers took four or more medications, had balance impairments, and used a gait aid in the community. The fallers had a significantly higher falls risk score (P < 0.001), demonstrated significantly poorer balance (P < 0.001) and walked significantly more slowly (P < 0.001) than the non-fallers. There was no significant difference between the groups in their reports of dizziness (P = 0.68), although static balance testing (CTSIB condition 5) suggested a greater degree of underlying vestibular dysfunction in the group of fallers (P < 0.001). CONCLUSION: Older people discharged home from the ED following a fall are at high risk of falling in the future and have a greater level of vestibular dysfunction based on simple clinical testing. Additional clinically applicable tests of vestibular function are required to further investigate the relationship between vestibular dysfunction and falling in older people.     

Predicting which patient will fall again… and again

In order to compare the characteristics, preventive interventions and outcomes of single and multiple fallers, a retrospective cross-sectional study was conducted in a 680-bed acute-care hospital in Western Australia Fifty patients falling more than once (multiple fallers) were randomly selected from all patients reported to have fallen between 1 July 1989 and 31 December 1989, and age–sex matched with 50 patients falling once in the trial period (single fallers) In total, 382 in-patients were reported to have sustained 578 falls in the 6-month trial period Fifty-two per cent of these falls involved multiple fallers An analysis of the 100 single and multiple fallers showed that single fallers were more likely to have fallen from their bed, be discharged home from hospital, and be clinically deteriorating at the time of the fall Multiple fallers were more likely to be transferred to a long-term nursing facility after discharge from hospital, suffer blindness/poor vision, be sedated post fall, be ordered to be restrained following a fall, and be hospitalized for longer periods There was also a tendency for multiple fallers to repeat the type and location of the fall on successive falls Stepwise logistic regression showed that falling from the bed on the first fall predicted remaining a single faller Being ordered to be restrained following the first fall and hospitalized for longer periods predicted the patient would fall repeatedly Further analytical research incorporating an expanded number of independent variables is needed to allow confident assertions of causality To test the effectiveness of preventive measures, a prospective longitudinal study is required.     

Fall prevention in a Swiss acute care hospital setting Reducing multiple falls

Preventing in-hospital falls is an important goal in avoiding poor patient outcomes. In this quasi-experimental study, the authors evaluated the effectiveness of a nurse-led fall prevention program in a 300-bed Swiss hospital. Four hundred and nine patients (internal medicine) were included: intervention group (n = 198), usual-care group (n = 211). The program consisted of training nurses in the use of the Morse Fall Scale, and the implementation of 15 selected preventive interventions. In the intervention group, the proportion of patients at risk for falls was higher (p = .048), and fewer patients with multiple falls were observed (p = .009). The intervention program showed an effect in preventing multiple falls, but not first falls. The prolonged mean time to a first fall in a subgroup of fallers in the intervention group may indicate an increased awareness of the nurses and the appropriateness of the interventions used.     

Falls prevention training for community health workers: strategies and actions for independent living (SAIL)

This article describes a quasi-experimental study on falls prevention for clients of home support services in British Columbia, Canada. The study tested a nurse-designed multifactorial intervention, delivered by community health workers. The intervention consisted of 1 day of falls surveillance and prevention training for 51 community health workers, followed by 6 months of evidence-based interventions with their clients (n = 70) using a pretested Checklist and Action Plan. Study findings showed a 43% reduction (chi2 = 8.742, p < .01) in falls and a 44% reduction (chi2 = 5.739, p < .05) for fallers (those who fell once or more) from the 6-month preintervention period to postintervention. The proportion of falls resulting in any injury did not decrease; however, fractures were reduced from seven in the 6-month preintervention period to one following the intervention. The results indicate this intervention is an effective and inexpensive falls prevention strategy for frail recipients of home support services.     

Evaluation of a falls prevention programme in an acute tertiary care hospital

Aims and objectives. To evaluate a systematic, coordinated approach to limit the severity and minimize the number of falls in an acute care hospital. Background. Patient falls are a significant cause of preventable injury and death, particularly in older patients. Best practice principles mandate that hospitals identify those patients at risk of falling and implement interventions to prevent or minimize them. Methods. A before and after design was used for the study. All patients admitted to three medical wards and a geriatric evaluation management unit were enrolled over a six‐month period. Patients’ risk of falling was assessed using a falls risk assessment tool and appropriate interventions implemented using a falls care plan. Data related to the number and severity of falls were obtained from the Australian Incident Monitoring System database used at the study site. Results. In this study, 1357 patient admissions were included. According to their risk category, 37% of patients (n = 496) were grouped as low risk (score = 1–10), 58% (n = 774) medium risk (score = 11–20) and 5% (n = 63) high risk (score = 21–33) for falls. The incidence of falls (per average occupied bed day) was eight per 1000 bed days for the study period. Compared with the same months in 2002/2003, there was a significant reduction in falls from 0·95 to 0·80 (95% CI for the difference ?0·14 to ?0·16, P < 0·001). Conclusion. We evaluated a systematic, coordinated approach to falls management that included a falls risk assessment tool and falls care plan in the acute care setting. Although a significant reduction in falls was found in this study, it could not be attributed to any specific interventions. Relevance to clinical practice. Preventing falls where possible is essential. Assessment of risk and use of appropriate interventions can reduce the incidence of falls.     

The incidence of falls in intensive care survivors

Background

Falling among adults in acute care is an important problem with falls rates in tertiary hospitals ranging from 2% to 5%. Factors that increase the risk of falling, such as advanced age, altered mental status, medications that act on the central nervous system and poor mobility, often characterise individuals who survive a prolonged intensive care unit (ICU) admission.

Purpose

To measure the incidence of falls and describe the characteristics of fallers among intensive care survivors.

Methods

A comprehensive retrospective chart review was undertaken of 190 adults who were intubated and ventilated for ≥168 h and survived their acute care stay. Using a standardised form, several variables were extracted including falls during hospitalisation and risk factors such as age, severity of illness, and length of stay in intensive care and hospital.

Findings

Thirty-two (17%, 95% confidence interval 11.5–22.2%) patients fell at least once on the in-patient wards following their ICU stay. Compared with non-fallers, fallers were younger (53.2 ± 17.9 vs. 44.1 ± 18.3 years; p = 0.009) and had a shorter duration of inotropic support in ICU (84 ± 112 vs. 56 ± 100 h; p = 0.040). The majority of fallers were aged less than 65 years (84%). Both fallers and non-fallers had similar APACHE II scores (20 ± 8 vs. 21 ± 7; p = 0.673), length of stay in intensive care (14.2 ± 8.7 vs. 14.0 ± 9.7 days; p = 0.667) and hospital length of stay (43.9 ± 33.1 vs. 41.0 ± 38.8 days; p = 0.533).

Conclusion

Falling during hospitalisation is common in intensive care survivors. Compared with non-fallers, fallers were younger and required inotropes for a shorter duration. Those who survive a prolonged admission to an ICU may benefit from specific assessment of balance and falls risk by the multidisciplinary team.     

Care outcomes in long-term care facilities in British Columbia, Canada. Does ownership matter?

OBJECTIVES: This study investigated whether for-profit (FP) versus not-for-profit (NP) ownership of long-term care facilities resulted in a difference in hospital admission and mortality rates among facility residents in British Columbia, Canada. RESEARCH DESIGN: This retrospective cohort study used administrative data on all residents of British Columbia long-term care facilities between April 1, 1996, and August 1, 1999 (n = 43,065). Hospitalizations were examined for 6 diagnoses (falls, pneumonia, anemia, dehydration, urinary tract infection, and decubitus ulcers and/or gangrene), which are considered to be reflective of facility quality of care. In addition to FP versus NP status, facilities were divided into ownership subgroups to investigate outcomes by differences in governance and operational structures. RESULTS: We found that, overall, FP facilities demonstrated higher adjusted hospitalization rates for pneumonia, anemia, and dehydration and no difference for falls, urinary tract infections, or DCU/gangrene. FP facilities demonstrated higher adjusted hospitalization rates compared with NP facilities attached to a hospital, amalgamated to a regional health authority, or that were multisite. This effect was not present when comparing FP facilities to NP single-site facilities. There was no difference in mortality rates in FP versus NP facilities. CONCLUSIONS: The higher adjusted hospitalization rates in FP versus NP facilities is consistent with previous research from U.S. authors. However, the superior performance by the NP sector is driven by NP-owned facilities connected to a hospital or health authority, or that had more than one site of operation.     

Effectiveness of an automatic manual wheelchair braking system in the prevention of falls

The purpose of this study was to evaluate the effectiveness of an automatic manual wheelchair braking system in the reduction of falls for patients at high risk of falls while transferring to and from a manual wheelchair. The study design was a normative survey carried out through the use of a written questionnaire sent to 60 skilled nursing facilities to collect data from the medical charts, which identified patients at high risk for falls who used an automatic wheelchair braking system. The facilities participating in the study identified a frequency of falls of high-risk patients while transferring to and from the wheelchair ranging from 2 to 10 per year, with a median fall rate per facility of 4 falls. One year after the installation of the automatic wheelchair braking system, participating facilities demonstrated a reduction of zero to three falls during transfers by high-risk patients, with a median fall rate of zero falls. This represents a statistically significant reduction of 78% in the fall rate of high-risk patients while transferring to and from the wheelchair, t (18) = 6.39, p < .0001. Incident reports of falls to and from manual wheelchairs were reviewed retrospectively for a 1-year period. This study suggests that high-risk fallers transferring to or from manual wheelchairs sustained significantly fewer falls when the Steddy Mate automatic braking system for manual wheelchairs was installed. The application of the automatic braking system allows clients, families/caregivers, and facility personnel an increased safety factor for the reduction of falls from the wheelchair.     

Beyond the 'tick and flick': facilitating best practice falls prevention through an action research approach

Aims and objectives. To examine residential aged care facility staff views on using falls risk assessment tools and the implications for developing falls prevention practices in the context of an action research project. Background. Falls risk assessments play an important role in care planning by identifying and monitoring aged care facility residents most at risk of falls. Yet while such assessments are recommended in falls prevention best practice guidelines, there is little published research that examines staff procedures and views related to conducting falls risk assessments. Design. Falls risk assessments were undertaken in the context of an action research project. Method. Twelve staff members from two residential aged care facilities (RACFs) in Tasmania formed a single Falls Action Research Group, which met 22 times over a year, providing the study’s qualitative data. During this time, key group members assessed 178 residents using a new falls risk assessment tool (FROP‐Resi). Results. According to group members, facilities evolved from a ‘tick‐and‐flick’ approach to falls risk assessment to a more individualised, face‐to‐face assessment process. Group members perceived the process to be more meaningful and enjoyable for staff involved in the assessment process resulting in higher quality of assessments and leading to improved levels of falls awareness among staff, residents and family caregivers. Conclusions. An action research process is useful for facilitating a new approach to falls risk assessments, engaging aged care facility staff with falls prevention and prompting improvements in falls prevention practices. Relevance to clinical practice. RACFs need to provide opportunities for staff to meet regularly to discuss practice, identify issues and take action. By doing so, staff can engage meaningfully with best practice activities such as optimising falls risk assessment processes.     

Improving resident outcomes with GAPN organization level interventions

This research tested the effectiveness of the second tier of interventions in a two-tiered nursing intervention model designed to improve quality of care for residents in long-term care facilities (LTCFs). The first tier of the model called for gerontological advanced practice nurses (GAPNs) to provide direct care and to teach staff to implement care protocols for residents with incontinence, pressure ulcers, depression, and aggression. Results of the first-tier study indicated significant improvement in resident outcomes in incontinence, pressure ulcers, and aggression. In the second tier, GAPNs added a set of organization-level (OL) interventions including membership on the LTCF quality assurance committee and collaborating with staff on problem-solving teams. Analysis following the addition of OL interventions revealed significant improvement in both depression scores and in the trajectory of depression in residents of the LTCF where OL interventions were used.     

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.