Implementing Patient Falls Education in Hospitals: A Mixed-Methods Trial

Hospital falls clinical practice guidelines: a global analysis and systematic review

BACKGROUND

Hospital falls continue to be a persistent global issue with serious harmful consequences for patients and health services. Many clinical practice guidelines now exist for hospital falls, and there is a need to appraise recommendations.

METHOD

A systematic review and critical appraisal of the global literature was conducted, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Web of Science, Embase, CINAHL, MEDLINE, Epistemonikos, Infobase of Clinical Practice Guidelines, Cochrane CENTRAL and PEDro databases were searched from 1 January 1993 to 1 February 2024. The quality of guidelines was assessed by two independent reviewers using Appraisal of Guidelines for Research and Evaluation Global Rating Scale and Appraisal of Guidelines of Research and Evaluation Recommendation Excellence (AGREE-REX). Certainty of findings was rated using Grading of Recommendations Assessment, Development and Evaluation Confidence in Evidence from Reviews of Qualitative Research. Data were analysed using thematic synthesis.

RESULTS

2404 records were screened, 77 assessed for eligibility, and 20 hospital falls guidelines were included. Ten had high AGREE-REX quality scores. Key analytic themes were as follows: (i) there was mixed support for falls risk screening at hospital admission, but scored screening tools were no longer recommended; (ii) comprehensive falls assessment was recommended for older or frail patients; (iii) single and multifactorial falls interventions were consistently recommended; (iv) a large gap existed in patient engagement in guideline development and implementation; (v) barriers to implementation included ambiguities in how staff and patient falls education should be conducted, how delirium and dementia are managed to prevent falls, and documentation of hospital falls.

CONCLUSION

Evidence-based hospital falls guidelines are now available, yet systematic implementation across the hospital sector is more limited. There is a need to ensure an integrated and consistent approach to evidence-based falls prevention for a diverse range of hospital patients.

A stepped-wedge randomised controlled trial to assess efficacy and cost-effectiveness of a care-bundle to prevent falls in older hospitalised patients

BACKGROUND

Patient accidental falls in a hospital environment are a serious problem for patient safety, and for the additional costs due to associated medical interventions.

OBJECTIVE

The endpoints of this study were the assessment of the fall incidence in the hospital before and after the implementation of a multidisciplinary care-bundle, along with a cost-effectiveness evaluation.

DESIGN

A stepped-wedge trial was conducted between April 2015 and December 2016 in Bologna University Hospital.

METHODS

Incidence rates (IRs) of falls in both the control and intervention periods were calculated. A multilevel mixed-effects generalised linear model with logit link function, adjusted for age, sex, cluster cross-over timing and patients' clinical severity was used to estimate odds ratios (OR) of fall risk of patients of the intervention group respect to the controls.Intervention costs associated with the introduction of the care-bundle intervention were spread between patients per cluster-period-group of exposure. Incremental cost-effectiveness ratio was evaluated using total costs in the intervention and control groups.

RESULTS

IRs of falls in control and intervention periods were respectively 3.15 and 2.58 for 1,000 bed-days. After adjustment, the subjects receiving the intervention had a statistically significant reduced risk of falling with respect to those who did not (OR = 0.71, 95% confidence interval: 0.60-0.84). According to the cost-effectiveness analysis, the incremental cost per fall prevented was €873.92 considering all costs, and €1644.45 excluding costs related falls.

CONCLUSIONS

Care-bundle had a protective effect on patients, with a statistically significant reduction of the fall risk. This type of intervention appears cost-effective compared to routine practices.

Prevention of Falls in Parkinson's Disease: Guidelines and Gaps

Background

People living with Parkinson's disease (PD) have a high risk for falls.

Objective

To examine gaps in falls prevention targeting people with PD as part of the Task Force on Global Guidelines for Falls in Older Adults.

Methods

A Delphi consensus process was used to identify specific recommendations for falls in PD. The current narrative review was conducted as educational background with a view to identifying gaps in fall prevention.

Results

A recent Cochrane review recommended exercises and structured physical activities for PD; however, the types of exercises and activities to recommend and PD subgroups likely to benefit require further consideration. Freezing of gait, reduced gait speed, and a prior history of falls are risk factors for falls in PD and should be incorporated in assessments to identify fall risk and target interventions. Multimodal and multi-domain fall prevention interventions may be beneficial. With advanced or complex PD, balance and strength training should be administered under supervision. Medications, particularly cholinesterase inhibitors, show promise for falls prevention. Identifying how to engage people with PD, their families, and health professionals in falls education and implementation remains a challenge. Barriers to the prevention of falls occur at individual, environmental, policy, and health system levels.

Conclusion

Effective mitigation of fall risk requires specific targeting and strategies to reduce this debilitating and common problem in PD. While exercise is recommended, the types and modalities of exercise and how to combine them as interventions for different PD subgroups (cognitive impairment, freezing, advanced disease) need further study.

Fall risk in older adults hospitalized with tumours: Contributing factors and prediction model

AIM

Rates vary widely across hospitals globally and typically range from 3 to 11 falls per 1000 bed days and as 7-11 in Affiliated Hospital of Nantong University. This study determined to explore contributing factors and poor prognosis of fall in elderly tumour patients in China.

DESIGN

A cross-sectional study.

METHODS

161 older adults were invited to participate in this study and completed a self-reported questionnaire, took blood tests, and received the exam of musculoskeletal ultrasound.

RESULTS

Among 161 patients, falls occurred in 41 cases, accounting for 24.8%. 51.6% of older adults suffered from intermediate-to-high risk of falls. Fall history, reduced self-care ability, sleep disturbance, hearing impairment, hyperkyphosis, chronic disease, platelet count, and the thickness of left muscle rectus femoris (LF-MLT), and left cross-sectional area (LF-CSA) were all contributing factors of fall, and higher risk of fall indicating lower quality of life. A fall prediction model was established in this study based on above contributing factors with good prediction efficiency (AUC = 0.920).

PATIENT OR PUBLIC CONTRIBUTION

The patient volunteers participated in this study and provided valuable data for the final analysis and the acquisition of conclusion.

Creating an Implementation Enhancement Plan for a Digital Patient Fall Prevention Platform Using the CFIR-ERIC Approach: A Qualitative Study

(1) Background: Inpatient falls are a major cause of hospital-acquired complications (HAC) and inpatient harm. Interventions to prevent falls exist, but it is unclear which are most effective and what implementation strategies best support their use. This study uses existing implementation theory to develop an implementation enhancement plan to improve the uptake of a digital fall prevention workflow. (2) Methods: A qualitative approach using focus groups/interview included 12 participants across four inpatient wards, from a newly built, 300-bed rural referral hospital. Interviews were coded to the Consolidated Framework for Implementation Research (CFIR) and then converted to barrier and enabler statements using consensus agreement. Barriers and enablers were mapped to the Expert Recommendations for Implementing Change (ERIC) tool to develop an implementation enhancement plan. (3) Results: The most prevalent CFIR enablers included: relative advantage (n = 12), access to knowledge and information (n = 11), leadership engagement (n = 9), patient needs and resources (n = 8), cosmopolitanism (n = 5), knowledge and beliefs about the intervention (n = 5), self-efficacy (n = 5) and formally appointed internal implementation leaders (n = 5). Commonly mentioned CFIR barriers included: access to knowledge and information (n = 11), available resources (n = 8), compatibility (n = 8), patient needs and resources (n = 8), design quality and packaging (n = 10), adaptability (n = 7) and executing (n = 7). After mapping the CFIR enablers and barriers to the ERIC tool, six clusters of interventions were revealed: train and educate stakeholders, utilize financial strategies, adapt and tailor to context, engage consumers, use evaluative and iterative strategies and develop stakeholder interrelations. (4) Conclusions: The enablers and barriers identified are similar to those described in the literature. Given there is close agreement between the ERIC consensus framework recommendations and the evidence, this approach will likely assist in enhancing the implementation of Rauland's Concentric Care fall prevention platform and other similar workflow technologies that have the potential to disrupt team and organisational routines. The results of this study will provide a blueprint to enhance implementation that will be tested for effectiveness at a later stage.