Knowledge translation for falls prevention: the view from Canada

Influencing factors of interprofessional collaboration in multifactorial fall prevention interventions: a qualitative systematic review

BACKGROUND

With the ageing population worldwide, falls are becoming a severe and growing health problem. Interprofessional multifactorial fall prevention interventions (FPIs) have effectively prevented falls in community-dwelling older adults. However, the implementation of FPIs often fails due to a lack of interprofessional collaboration. Therefore, gaining insight into the influencing factors of interprofessional collaboration in multifactorial FPI's for older adults living in the community is essential. Consequently, our aim was to provide an overview of factors influencing interprofessional collaboration in multifactorial FPIs for community-dwelling older adults.

METHODS

This qualitative systematic literature research was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Pubmed, CINAHL, and Embase electronic databases have been systematically searched for eligible articles, with a qualitative design. The quality was appraised using the Checklist for Qualitative Research by the Joann Briggs Institute. The findings were inductively synthesized using a meta-aggregative approach. Confidence in the synthesized findings was established using the ConQual methodology.

RESULTS

Five articles were included. Analysis of the included studies resulted in 31 influencing factors for interprofessional collaboration, which were labelled as findings. These findings were summarized in ten categories and combined into five synthesized findings. Results showed that communication, role clarity, information sharing, organization, and interprofessional aim influence interprofessional collaboration in multifactorial FPIs.

CONCLUSIONS

This review provides a comprehensive summary of findings on interprofessional collaboration, specifically in the context of multifactorial FPIs. Knowledge in this area is considerably relevant given the multifactorial nature of falls, which demands an integrated, multidomain approach, including both health and social care. The results can be utilized as a fundament for developing effective implementation strategies aiming to improve interprofessional collaboration between health and social care professionals working in multifactorial FPIs in the community.

Effectiveness of complex falls prevention interventions in residential aged care settings: a systematic review

OBJECTIVE

The objective of this review was to synthesize the best available evidence for the effectiveness of complex falls prevention interventions delivered at two or more of the following levels: resident, facility or organization, on fall rates in the residential aged care (RAC) population.

INTRODUCTION

Preventing falls in the high risk RAC population is a common global goal with acknowledged complexity. Previous meta-analyses have not specifically addressed complexity, described as falls prevention intervention delivery at multiple levels of a RAC organization, to determine its effect on fall outcomes.

INCLUSION CRITERIA

The current review considered studies that included participants who were aged 65 years and over residing in long-term care settings providing 24-hour supervision and/or care assistance.Studies that evaluated complex falls prevention interventions delivered by single discipline or multidisciplinary teams across at least two or all of the following levels: residents, RAC facility and RAC organization were eligible. Experimental study designs including randomized controlled trials, controlled clinical trials and quasi-experimental trials that reported on measures related to fall incidence were considered, namely, rate of falls (expressed as the number of falls per 1000 occupied bed days), the number of participants who became fallers (expressed as the number of participants who fell once or more) and the rate of injurious falls (expressed as the number of falls with injury per 1000 occupied bed days).

METHODS

A three-step search strategy was undertaken, commencing with an initial scoping search of MEDLINE and CINAHL databases prior to an extensive search of all relevant published literature, clinical trial registries and gray literature. Two independent reviewers assessed selected studies for methodological validity using the standardized critical appraisal instrument from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Data were extracted from the selected studies using the standardized data extraction tool from JBI SUMARI. Quantitative data were pooled in statistical meta-analysis for rate of falls, the number of participants who became fallers and the rate of injurious falls. Meta-analysis was conducted using a random-effect model with heterogeneity assessed using the standard Chi-squared and I index. Where statistical pooling was not possible, study findings were presented in narrative form.

RESULTS

Twelve studies were included in this review with seven being eligible for meta-analysis. Complex falls prevention interventions delivered at multiple levels in RAC populations did not show a significant effect in reducing fall rates (MD = -1.29; 95% CI [-3.01, 0.43]), or the proportion of residents who fell (OR = 0.76; 95% CI [0.42, 1.38]). However, a sensitivity analysis suggested complex falls prevention interventions delivered with additional resources at multiple levels had a significant positive effect in reducing fall rates (MD = -2.26; 95% CI [-3.72, -0.80]).

CONCLUSIONS

Complex falls prevention interventions delivered at multiple levels in the RAC population may reduce fall rates when additional staffing, expertise or resources are provided. Organizations may need to determine how resources can be allocated to best address falls prevention management. Future research should continue to investigate which combinations of multifactorial interventions are effective.

Falls in long-term care institutions for elderly people: protocol validation

ABSTRACT Objectives: To validate the content of a fall management risk protocol in long-term institutions for elderly people. Methods: Methodological, quanti-qualitative study using the Delphi technique. The tool, based on the literature, was sent electronically to obtain consensus among the 14 experts that meet the defined inclusion criteria. Results: The 27 indicators of the protocol are organized in three dimensions: prepare for the institutionalization (IRA=.88); manage the risk of falls throughout the institutionalization (IRA=.9); and lead the communication and formation (IRA=1), with a CVI=.91. Two rounds were performed to get a consensus superior to 80% in every item. Conclusion: The values obtained in the reliability test (>0.8) show that the protocol can be used to meet the intended goal. The next step is the clinic validation of the protocol with residents of long-term care institutions for elderly people.

Delivering the aims of the Collaborations for Leadership in Applied Health Research and Care: understanding their strategies and contributions

Background

In 2008, the National Institute for Health Research (NIHR) in England established nine Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) to develop partnerships between universities and local NHS organisations focused on improving patient outcomes through the conduct and application of applied health research.

Objectives

The study explored how effectively the CLAHRCs supported the ‘translation’ of research into patient benefit, and developed ways of doing applied research that maximised its chances of being useful to the service and the capacity of the NHS to respond. It focused on three issues: (1) how the NHS influenced the CLAHRCs, and vice versa; (2) how effective multistakeholder and multidisciplinary research and implementation teams were built in the CLAHRCs; (3) how the CLAHRCs supported the use of research knowledge to change commissioning and clinical behaviour for patient benefit.

Methods

The study adopted an adaptive and emergent approach and incorporated a formative evaluation. An initial phase mapped the landscape of all nine CLAHRCs and the context within which they were established, using document analysis, workshops and interviews, and a literature review. This mapping exercise identified the three research questions that were explored in phase 2 through a stakeholder survey of six CLAHRCs, in-depth case studies of two CLAHRCs, validation interviews with all nine CLAHRCs and the NIHR, and document review.

Results

(1) The local remit and the requirement for matched NHS funding enhanced NHS influence on the CLAHRCs. The CLAHRCs achieved positive change among those most directly involved, but the larger issue of whether or not the CLAHRCs can influence others in and across the NHS remains unresolved. (2) The CLAHRCs succeeded in engaging different stakeholder groups, and explored what encouraged specific groups to become involved. Being responsive to people’s concerns and demonstrating ‘quick wins’ were both important. (3) There was some evidence that academics were becoming more interested in needs-driven research, and that commissioners were seeing the CLAHRCs as a useful source of support. A growing number of completed projects had demonstrated an impact on clinical practice.

Conclusions

The CLAHRCs have included NHS decision-makers in research and researchers in service decision-making, and encouraged research-informed practice. All the CLAHRCs (as collaborations) adopted relationship models. However, as the complexities of the challenges they faced became clearer, it became obvious that a focus on multidisciplinary relationships was necessary, but not sufficient on its own. Attention also has to be paid to the systems within and through which these relationships operate.

Recommendations for research

Future research should compare areas with an Academic Health Science Network (AHSN) and a CLAHRC with areas with just an AHSN, to understand the difference CLAHRCs make. There should be work on understanding implementation, such as the balancing of rigour and relevance in intervention studies; systemic barriers to and facilitators of implementation; and tailoring improvement interventions. There is also a need to better understand the factors that support the explicit use of research evidence across the NHS, and the processes and mechanisms that support the sustainability and scale-up of implementation projects. Research should place emphasis on examining the role of patient and public involvement in CLAHRCs and of the relation between CLAHRCs and NHS commissioners.

Funding

The NIHR Health Services and Delivery Research programme.

Implementation of evidence-based falls prevention in clinical services for high-risk clients

RATIONALE, AIMS AND OBJECTIVES

The extent to which best practice for falls prevention is being routinely delivered by health care providers for community-dwelling older adults is unclear. We investigated falls prevention practice among Hospital Admission Risk Programs (HARP) that provide and coordinate specialized health care for people at high risk of hospitalization.

METHOD

Cross-sectional survey of all HARP services in Victoria, excluding one paediatric programme (n = 34). The questionnaire focused upon medication review and exercise prescription, as these are the evidence-based falls interventions with a good fit with HARP services.

RESULTS

Completed questionnaires were received from 24 programmes (70.6%) that service 15,250 older clients (60+ years). All except one programme screened for medicine use; however, a lower proportion (65% of those that screen) target falls risk medications. Among the 17 programmes responding to the exercise prescription question, all routinely include strengthening exercises, and almost all (n = 15) include flexibility, endurance training and movement of the centre of gravity. A lesser proportion (71%) includes reducing the need for upper limb support. The majority of services (88%) undertake falls risk assessments, and all of these either make referral appointments for clients or refer to other services that make referral appointments for clients. Follow-up of appointments and the resulting recommendations was high.

CONCLUSION

Screening for falls risk medications could be improved and staff training in exercise prescription for balance challenge in this high-risk group may be needed. Although evidence-based falls prevention practice within Victorian HARP services appears strong, the effect on falls risk may not be as high as that achieved in randomized trials.

Integrating proven falls prevention interventions into government programs

OBJECTIVE

To identify Department of Health programs with high potential to integrate evidence-based interventions to prevent falls among older people.

METHODS

Broad consultation within the Department followed by structured decision making. This work was informed by an analysis of Victorian hospital separations data and a Cochrane Systematic Review to identify relevant target groups and interventions. Ranking of the integration potential of interventions for a broad range of Department program areas was achieved through a facilitated workshop. A short list of program areas was then developed and scored, using pre-defined criteria, for their match with the interventions.

RESULTS

The ranked order of interventions, from most to least suitable for integration, were: multifactorial risk assessment and intervention; multi-component group exercise; medication review; occupational therapy-based home safety; home-based exercise; and first eye cataract surgery. Four of six program areas had a strong match (a score of ≥75% of the maximum score) with one or more of three interventions. Two program areas (Primary Care Partnerships, and Home and Community Care) had strong matches with three interventions (group- and home-based exercise; occupational therapy-based home safety) and were selected as priority areas. The Hospital Admissions Risk Program had strong and good matches respectively with home-based exercise and medication review, and was also selected.

CONCLUSIONS

Our systematic methods identified Department programs with strong potential for integration of proven falls prevention interventions.

IMPLICATIONS

Matching departmental programs and evidence-based interventions for integration may lead to more efficient resource allocation for falls prevention in Victoria.

Preventing falls among seniors: the way forward

There is a growing body of research about the etiology and prevention of falls. However, the persistently high incidence of falls among seniors calls for renewed efforts to develop, test, implement, and scale-up fall prevention strategies for older adults. This paper considers advances in the field and describes three priority areas for generating research and translating knowledge on fall prevention. Clinical practice guidelines, systems change approaches and environmental risk factors are discussed. Recommendations include transcending our health sector view of the fall prevention problem, supporting comparative research on system-oriented approaches to fall prevention, and examining ways to sustain and scale-up fall prevention efforts.