Fall Prevention Among Older People in Hospital Settings

Question: Discuss about the Report of Fall Prevention Among Older People in Hospital Settings. Answer: Introduction Falls have been a common cause of morbidity and mortality in people of all ages. However, their risk increases with age. Hospitalization further increases the risk of falls due to the unacquainted environment, ailments, and treatments. It has been found that nearly 30% of the falls cause injury. These cause unrest to the patients, clinicians, and the health care system as a single fall may built up the fear of falling and initiate a downhill trend of reduced mobility. This leads to further loss of function and increased risk of falls. It also increases the hospital costs and length of stay. In severe cases, there may be a risk of institutionalization of the patient and legitimate complaint with following lawsuit against the hospital. Thus, clinical governance and practice improvement in relation to fall prevention among older people in hospital settings is extremely essential. The following summary table gives and overview of the published literature in this field followed by its critical appraisal. Summary table Sl.no. Author/s, year, Country Aims Sample/setting Design/methods Main findings Strengths and limitations of the study Article 1 Cameron et al., 2012, Australia To evaluate the effectiveness of interventions designed for reducing falls by older people in care facilities and hospitals. The Cochrane database 2012;MEDLINE, EMBASE, and CINAHL (all to March 2012); ongoing trial registers (to August 2012), and reference lists of articles were searched. 43 trials (30,373 participants) in care facilities and 17 (29,972 participants) in hospitals were studied. Review of randomized controlled trials of interventions to reduce falls in older people in residential or nursing care facilities or hospitals. For exercise interventions the results were inconsistent. Vitamin D supplementation decreased the rate of falls but not the risk of falling. Multifactorial interventions in care facilities and hospitals suggested a decrease in the rate of falls and risk of falling. Additional physiotherapy did not significantly reduce rate of falls but achieved a significant reduction in risk of falling. Carpet flooring significantly increased the rate of falls compared with vinyl flooring and potentially increased the risk of falling. Training and education of nurses and patients significantly decreased the risk of falling. Strengths: Two review authors independently assessed the risk of bias and extracted data. A rate ratio was used to compare the rate of falls between intervention and control groups. Risk ratio (RR) was used to assess the risk of falling in each group. Results were pooled where appropriate. Limitations: No conclusive results obtained. More trials are needed to confirm the effectiveness of multifactorial interventions in acute and subacute hospital settings. Article 2 Haines TP et al. 2011 Australia To identify single intervention strategies that prevent falls across a mixture of hospital wards Participants were older adults admitted to acute and sub-acute wards of the Princess Alexandra Hospital, Brisbane, Australia, and the acute and sub-acute wards of Swan Districts Hospital, Perth, Australia. 3-group randomized control trial. There were two intervention groups and one control group. One intervention group was given complete patient education by providing written, video-based materials and 1- to-1 follow-up with a health professional trained to provide this program at the patients bedside. The second intervention group was provided with materials only. The rate of falls was significantly lower among participants with intact cognitive function and allocated to the complete program group compared with the rate among similar participants allocated to the control and materials-only groups, and the proportion of these patients who became fallers was lower in the complete program group than in the control group. Strengths: Appropriate randomization and blinding. Limitations: Patients who were too ill to provide informed consent or those who had previously participated in the trial were excluded. Article 3 Dykes PC et al. 2010 US To investigate whether a fall prevention tool kit (FPTK) using health information technology (HIT) decreases patient falls in hospitals 4 urban US hospitals in units that received usual care (4 units and 5104 patients) or the intervention (4 units and 5160 patients) Cluster randomized study conducted January 1, 2009, through June 30, 2009, comparing patient fall rates The number of patients with falls differed between control (n = 87) and intervention (n = 67) units. Site-adjusted fall rates were significantly higher in control units than in intervention units. The FPTK was found to be particularly effective with patients aged 65 years or older. No significant effect was noted in fall-related injuries. Strengths: This is the first fall prevention clinical trial that provides evidence for using a specific HIT intervention to reduce falls in short-stay hospitals Limitations: It was conducted in 4 hospitals within a single health care system. The intervention was not blinded and the reporting of falls was biased. The FPTK was not effective with younger patients. The sample size was small. Article 4 Gates et al. 2008 England To evaluate the effectiveness of multifactorial assessment and intervention programs to prevent falls and injuries among older adults recruited to trials in primary care, community, or emergency care settings. Six electronic databases (Medline, Embase, CENTRAL, CINAHL, PsycINFO, Social Science Citation Index) to 22 March 2007, reference lists of included studies, and previous reviews. Systematic review of randomised and quasi randomised controlled trials, and meta-analysis. Eligible studies were randomised or quasi-randomised trials (n=19) that evaluated interventions to prevent falls that were based in emergency departments, primary care, or the community that assessed multiple risk factors for falling and provided or arranged for treatments to address these risk factors. No clear overall effect was found on the number of fallers during follow-up in 18 studies. Only one study gave accurate data on the number of falls per person year of follow-up. Evidence that multifactorial fall prevention programmes in primary care, community, or emergency care settings are effective in reducing the number of fallers or fall related injuries is limited. Strengths: NA Limitations: No studies reported quantitative data on health related quality of life or physical activity. Data was insufficient to assess fall and injury rates. The overall quality of the evidence was not high. Most of the trials were small and many had methodological drawbacks leaving them open to bias due to either insecure allocation concealment, lack of blinding of outcome assessment, high losses to follow-up, and poor reporting. Article 5 Cumming et al. 2008 Australia To determine the efficacy of a targeted multifactorial falls prevention programme in elderly care wards with relatively short lengths of stay. 24 elderly care wards in 12 hospitals in Sydney, Australia. 3999 patients, mean age 79 years, with a median hospital stay of seven days. Cluster randomised trial. A nurse and physiotherapist each worked for 25 hours a week for three months in all intervention wards. They provided a targeted multifactorial intervention that included a risk assessment of falls, staff and patient education, drug review, modification of bedside and ward environments, an exercise programme, and alarms for selected patients. Intervention and control wards were similar at baseline for previous rates of falls and individual patient characteristics. In all, 381 falls occurred during the study. No difference was found in fall rates during follow up between intervention and control wards. A targeted multifactorial falls prevention programme was not effective among older people in hospital wards with relatively short lengths of stay. Strengths: Large sample size, which resulted in fairly narrow confidence intervals. Limitations: Relatively short average length of stay (7 days). data were not collected blind to intervention status. Some falls prevention activities were already occurring in control (and intervention) wards before the start of the study. Critical appraisal of literature Critical appraisal of literature helps us to assess the reliability of the sample, methods and design used for the study. It is used to analyze the relevance and results of published papers so that we can decide if the information is believable and useful. Various tools have been developed for the critical appraisal of published literature. One commonly used one is the Critical Appraisal Skills Programme (CASP) tools and checklist (Anon, n.d.). Article 1 and 4 are review articles taking data from previous studies. So, for these systematic reviews tool by CASP may be used (Anon, n.d.). Article1was unable to address the focused question the need for more trials was ascertained as no conclusions were drawn from the existing trials. In article 4 also the aim could not be achieved as no clear overall effect was found in the studies chosen. Article 2, 3, 5 are randomized control trials. So, for these randomized control trial tool by CASP may be used (Anon, n.d.). Article 2 was able to reach conclusions pertaining to its aim as the study methodology was planned and appropriate randomization and blinding. Article 3 also justified the aim of the study though it was having some limitations. Lack of blinding however ascertains biasness in the results. Article 5 did not aim correctly for reaching any definitive conclusion as they aimed at the follow up (7 days) of patients with a short length of stay and there was no blinding. Findings Article 1 states that exercise interventions, physiotherapy, carpet flooring did not produce ay consistent results. However, vitamin D supplementation, multifactorial interventions, training and education of nurses and patients significantly affected the rate of falls and risk of falling. Article 2 added to the knowledge by stating that the rate of falls decreases significantly when the complete program (including written, video-based materials and 1- to-1 follow-up with a health professional) as compared with the rate among similar participants when only materials were used. Article 3 adds the role of FPTK in patients aged 65 years or older. No significant effect was noted in fall-related injuries. Article 4 reviewed that no clear overall effect was found on the number of fallers during follow-up. Limited evidence was found in relation to multifactorial fall prevention programs were found to be effective in primary care, community, or emergency care settings in reducing the number o f fallers or fall related injuries. Article 5 also gave no conclusive results for multifactorial interventions applied in the hospitals to prevent falls. Thus, the overall findings indicate that though multifactorial approaches for prevention of falls in hospitals have been studied but due to their limitations they have not been able to give any conclusive results. So, further research, and training and education of nurses about this aspect of nursing is needed. References Anon, CASP checklist for randomized control trials. Available at: https://media.wix.com/ugd/dded87_40b9ff0bf53840478331915a8ed8b2fb.pdf [Accessed July 30, 2016a]. Anon, CASP checklist for systematic reviews. Available at: https://media.wix.com/ugd/dded87_a02ff2e3445f4952992d5a96ca562576.pdf [Accessed July 30, 2016b]. Anon, Critical Appraisal Skills Programme (CASP). Critical Appraisal Skills Programme (CASP). Available at: https://www.casp-uk.net/ [Accessed July 30, 2016c]. Cameron, I.D. et al., 2012. Interventions for preventing falls in older people in care facilities and hospitals. The Cochrane Database of Systematic Reviews, 12, p.CD005465. Cumming, R.G. et al., 2008. Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ, 336(7647), pp.758760. Dykes PC et al., 2010. Fall prevention in acute care hospitals: A randomized trial. JAMA, 304(17), pp.19121918. Gates, S. et al., 2008. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. BMJ, 336(7636), pp.130133. Haines TP et al., 2011. Patient education to prevent falls among older hospital inpatients: A randomized controlled trial. Archives of Internal Medicine, 171(6), pp.516524.