Abstract of thesis entitled
“Evidence-based guidelines of fall prevention programme for hospitalized older patients”
Submitted by
Law Man Wai
for the degree of Master of Nursing
at The University of Hong Kong
in July 2013
Background: Falls are one of the most common and serious problems facing the elderly
and are known to be associated with significant mortality, morbidity, decreased functioning and
premature institutionalization. In Hong Kong, the prevalence of falls among community-
dwelling older adults is 19.3%. Moreover, the incidence of falls among older people in
institutions is almost three times the fall rates for the community-dwelling elderly. Institutional
falls are regarded as common adverse events in hospitalized older patients. Significant mortality,
morbidity and healthcare costs associated with institutional falls led institutions to recognize falls
as a high-priority safety risk for hospitalized patients. This demonstrated the significance of
providing the health care providers with an evidenced-based practice guideline of an effective
multifactorial fall prevention programme in order to prevent in-patient falls.
Objectives: The objectives of the study are to systematically review and present the best
evidence for the effectiveness of multifactorial fall prevention interventions in reducing falls in
hospitals, to translate the reviewed evidence and to develop evidence-based practice guidelines
for the multifactorial fall prevention programme as well as to develop a plan for implementing
and evaluating the multifactorial fall prevention programme.
Methods: The relevant literature was searched by several electronic databases. The
related literature was then retrieved, reviewed and synthesized. The quality assessment of the
studies was performed according to the methodological checklist for controlled trials designed by
the Scottish intercollegiate Guideline Network (SIGN). Evidenced-based practice guidelines for
the multifactorial fall prevention programme were then synthesized according to the findings of
the reviewed literature, while the implementation potential being assessed in terms of
transferability, feasibility and the cost-benefit ratio.
Results: Five studies were identified according to the inclusion and exclusion criteria set.
“Evidence-based guidelines of fall prevention programme for hospitalized older patients” were
formulated based on the review of the selected studies. Fourteen recommendations of the
evidence-based guidelines are formulated and graded according to the grading system of Scottish
Intercollegiate Guidelines Network (SIGN). The evidence-based recommendations can offer
nurses and other health care professionals the standards and strategies required for implementing
multifactorial fall risk assessment and multifactorial fall prevention interventions, including
environmental modifications, knowledge, medication reviews and exercise. A communication
plan for various parties in hospitals including a pilot test for determining the feasibility of the
innovation and an evaluation plan to determine the effectiveness of the fall prevention
programme were subsequently developed.
Conclusion: This study reviewed evidence for the effectiveness of the multifactorial fall
prevention programme in reducing the incidence of falls, translated the reviewed evidence and
developed evidence-based guidelines for a multifactorial fall prevention programme, which can
provide the health care practitioners with an evidence-based approach in fall risk assessment and
management so as to prevent in-patient falls.
Evidence-based guidelines of fall prevention programme for
hospitalized older patients
By
Law Man Wai
B. Nurs. H.K.U.
A thesis submitted in partial fulfilment of the requirements for
the Degree of Master of Nursing
at The University of Hong Kong
July 2013
Declaration
I declare that this thesis represents my own work, except where due acknowledgement is
made, and that it has not been previously included in a thesis, dissertation or report submitted to
this University or to any other institution for a degree, diploma or other qualification.
Signed ....................................................................................
Law Man Wai
Acknowledgements
I would like to express my gratitude to my supervisors, Professor Sophia Chan and Dr.
Janet Wong, for their continuous guidance, assistance and their suggestions for improvement
throughout my study. Their prompt responses and availability despite their busy schedules were
highly appreciated.
I would also like to thank Dr. Daniel Fong for providing us with tutorials for the
dissertation. His enthusiastic teaching in the tutorials was of great help in exploring this
complicated subject.
Finally, I would like to express my deep and sincere thanks to my parents, my fiancé, Mr.
Markus Chan, and to my colleagues, who have provided me with on-going love, encouragement
and understanding throughout this endeavor. Their unconditional support has led to the
successful completion of this dissertation.
Table of Contents
Declaration
Acknowledgements
Table of contents
Chapter 1
INTRODUCTION
Page
1.1
Background
1
1.2 Affirming the need 3
1.3 Objectives and significance 4
Chapter 2
CRITICAL APPRAISAL
2.1
Search and appraisal strategies
6
2.11 Criteria for considering studies for the review
2.12 Search strategies for the identification of studies
2.13 Appraisal strategies
2.2 Results 8
2.21 Study design
2.22 Demographic characteristics of participants
2.23 Sample size
2.24 Randomization
2.25 Blinding
2.26 Data collection
2.27 Applicability and generalizability
2.3 Summary and Synthesis 12
2.31 Results of the systematic review
2.32 Summary of the components of a multifactorial fall prevention programme
2.321 Multifactorial fall risk assessment
2.322 Exercise
2.323 Medication review
2.324 Environmental modifications
2.325 Knowledge
2.4 Implications for practice 17
Chapter 3
TRANSLATION AND APPLICATION
3.1
Implementation potential
19
3.11 Target audience
3.12 Target setting
3.13 Transferability of findings
3.14 Feasibility
3.141 Support from the administration level
3.142 Support from the individual level (nursing staff)
3.15 Cost/ Benefit ratio of the innovation
3.2 Evidence-based practice guideline/ protocol 28
Chapter 4
IMPLEMENTATION PLAN
4.1
Communication plan
32
4.11 Stakeholders in the fall prevention programme
4.12 Communication with the hospital administrators
4.13 Formation of the steering committee
4.14 Communication with frontline staff in the ward
4.15 Sustaining the change process of the innovation
4.2 Pilot study plan 36
4.21 Training workshop for the innovation
4.22 The pilot test
4.3 Evaluation plan 38
4.31 Intervention outcomes identification
4.311 Patient outcomes
4.312 Healthcare provider outcomes
4.313 System outcomes
4.32 Nature and number of clients to be involved
4.33 Data analysis
4.34 Basis for an effective change of practice
4.35 Summary and conclusion
Appendices 44
References 68
Appendices
Page
Appendix A Search flowchart for identification of studies 44
Appendix B Table of evidence for the reviewed studies 45
Appendix C Methodological checklist for controlled trials 47
Appendix D Grading system for level of evidence 49
Appendix E Tables of quality assessment of the reviewed studies 50
Appendix F Table of characteristics of the interventions of the reviewed studies 55
Appendix G MORSE Fall Scale (MFS) 56
Appendix H Reference Guide for the multifactorial fall prevention programme 57
Appendix I
Evidence-based guidelines of the multifactorial fall prevention
programme
58
1
CHAPTER 1 INTRODUCTION
1.1 Background
The existing literature contains many different definitions of the term “fall”, however,
there is a lack of consensus regarding a precise definition. According to the Prevention of Falls
Network Europe, a fall is defined as an unintentional event in which an individual comes to rest
on the floor, the ground or other lower level from a standing, sitting, or horizontal position
(Lamb, 2005). The direct consequences of a fall can vary from minor injuries such as bruising,
abrasions and lacerations, to severe soft tissue wounds and bone fractures (Kannus, Sievanen,
Palvanen, Jarvinen & Parkkari, 2005). Although less than 10% of falls result in bone fractures
(Kannus, Sievanen, Palvanen, Jarvinen & Parkkari, 2005), fall-associated fractures in the elderly
are a significant cause of morbidity and mortality (Zuckerman, 1996).
Falls are one of the most common and serious problems facing the elderly (Murphy,
Labonte, Klock & Houser, 2008) and are known to be associated with significant mortality,
morbidity, decreased functioning and premature institutionalization (Brown, 1999; Rubenstein,
Josephson & Robbins, 1994). Falls are the result of a complex interaction of various and diverse
risk factors, many of which can be avoided. Elderly persons are particularly vulnerable to falls
since they are more likely to experience multiple intrinsic risks like visual impairment, gait
dysfunction, muscle weakness, balance deficits, altered mental status, acute and chronic illnesses
and extrinsic risks such as the presence of environmental hazards (Rubenstein & Josephson,
2006).
Falls in the elderly are a rising concern in society. Prospective studies have reported that
approximately 30% to 60% of generally healthy older persons in communities fall once a year,
2
while nearly half of them suffer multiple falls (Rubenstein & Josephson, 2002). In Hong Kong,
the prevalence of falls among community-dwelling older adults is 19.3% (Chu, Chi & Chiu,
2007). Moreover, the incidence of falls among older people in institutions is almost three times
the fall rate of the community-dwelling elderly (McClure, Turner, Peel, Spinks, Eakin & Hughes,
2008). Institutional falls are regarded as common adverse events in hospitalized older patients
(Thomas & Brennan, 2000).
There is considerable mortality and morbidity in institutional falls. Mortality from falls is
the leading cause of death in Australia, accounting for 2% of all deaths in those aged 65 and over
(Australian Institute of Health and Welfare, 2002). Fall-related injuries can range from bruises
and minor injuries to severe wound and bone fractures (Kannus, Sievanen, Palvanen, Jarvinen &
Parkkari, 2005). Such injuries may lead to impaired rehabilitation and comorbidity (Bates,
Pruess, Souney & Platt, 1995). Moreover, patients with previous experience of falls are
frequently associated with higher anxiety and depression scores, fear of falling and loss of
confidence, which may contribute to reduced mobility and increased care dependence (Vellas,
Wayne & Romero, 1997). All these complications result in increased length of hospital stay and
lead to greater healthcare expenses (Heinrich, Rapp, Rissmann, Becker & Konig, 2010). In Hong
Kong, the estimated public healthcare cost of elderly fallers is US$71million more than the
figure attributed to non-fallers (Chu, Chi & Chiu, 2007). In addition, falls may also result in
anxiety or guilt among staff and litigation from patients’ families (Liddle & Gilleard, 1994;
Oliver, 2002). These undesirable fall-associated consequences show the significance of the
problem of in-hospital falls and emphasized the need for preventing falls among hospitalized
older adults.
3
1.2 Affirming the need
Significant mortality, morbidity and healthcare costs associated with falls led institutions
to recognize falls as a high-priority safety risk for hospitalized patients. Since nurses are in a
position and have the capacity to analyze and identify fall risks and hence to formulate plans for
fall prevention, falls and fall rates are considered to be an indicator of the quality of nursing and
hospital care (Boyle, 2004). In 2005, the National Patient Safety Goal established the need for
institutions to reduce the potential harm associated with falls. It suggested the need for initial
assessment of patients’ fall risks and the taking of action to address any identified risks.
Moreover, in 2007, the goal further reinforced the need for the implementation and evaluation of
the effectiveness of a fall reduction programme (Joint Commission on Accreditation of
Healthcare Organizations, 2007). Hence, the development of a fall prevention guideline to assist
health care specialists in fall risk assessment and management for hospitalized older patients
became an essential factor in health care settings (American Geriatrics Society, 2001). Health
care practitioners are assumed to utilize their clinical knowledge and make corresponding
judgments in applying the guidelines in the light of available evidence to help fall prevention and
reduction in institutions.
Within the context of the medical and geriatrics wards of a local hospital, a
multicomponent fall prevention programme is referred to as a set of interventions that address
more than one intervention domain or category and which are offered to all individuals in a
programme (American Geriatrics Society, 2001). This fall prevention programme is the one
currently used in my hospital cluster. However, patient falls are still the most prevalent type of
incidents occuring in my hospital cluster, particularly in medical and geriatrics wards (NTWC
Fall Prevention and Management Committee, 2010). This demonstrated the need for identifying
4
another effective evidence-based fall prevention programme in my cluster. Among different
approaches of fall prevention interventions, multifactorial fall prevention programmes refer to
interventions made up of a subset of interventions that are selected and offered to individuals in
order to address the specific fall risk factors identified through a multifactorial fall risk
assessment (American Geriatrics Society, 2001) have been suggested by various studies as being
effective in reducing fall rates of older persons in institutional settings (Chang, Morton,
Rubenstein, Mojica, Maglione, Suttorp, Roth & Shekelle, 2004; Milisen, Geeraerts & Dejaeger,
2009). However, no concise recommendations are available regarding any particular component
of the programme. In order to ensure a uniform and evidenced-based approach that can be
employed in clinical practice, the effectiveness of the multifactorial fall prevention interventions
in reducing fall rates and the number of fallers in health care settings will be examined in this
paper. Moreover, the essential components constituting an effective multifactorial fall prevention
programme will also be identified. The synthesized result can then be employed to formulate
evidence-based fall prevention guidelines that can help to reduce the incidence of falla in
hospitals.
1.3 Objectives and significance
With the health care issue identified and its significance demonstrated, the clinical
question formulated to guide the analysis of this paper will be:
In (P) older patients admitted to acute or sub-acute hospital care settings, how does (I) a
multifactorial fall prevention programme provided for older patients compare to (C) the usual
patient care and how does it affect (O) the rate of fall incidents in hospital care settings?
The objectives of the study are:
5
1. To systematically review and present the best evidence for the effectiveness of the
multifactorial fall prevention interventions in reducing fall rates and the number of fallers
in hospitals
2. To summarize and synthesize the evidence from the selected bibliography
3. To translate the reviewed evidence and to develop evidence-based practice guidelines for
the multifactorial fall prevention programme
4. To develop a plan for implementing and evaluating the implementation of the evidence-
based multifactorial fall prevention guidelines
It is well established that falls in the elderly are the result of multiple, coexisting intrinsic
and extrinsic risk factors, many of which can be prevented (Rubenstein & Josephson, 2006).
According to a recent study carried out in Hong Kong, effective fall prevention programmes in
Hong Kong might reduce falls and fall-associated health care service utilization by up to 30%.
Hence, HK$160 million in health care expenses could possibly be saved annually (Chu, Chi &
Chiu, 2007). This demonstrates the significance of providing the health care providers with
evidenced-based practice guidelines of an effective multifactorial fall prevention programme in
order to prevent in-patient falls.
6
CHAPTER 2 CRITICAL APPRAISAL
This chapter gives a review for the evidence on the effectiveness of a multifactorial fall
prevention programme for hospitalized older adults by describing the search strategies of the
related literature, the synthesized Table of Evidence, the quality assessment of the methodology
of selected studies and the summary and synthesis drawn from the findings of the relevant
literature.
2.1 Search and appraisal strategies
2.11 Criteria for considering studies for the review
The criteria set for considering studies for review are based on four major areas: types of
studies, types of participants, types of interventions and types of outcome measurement.
Types of studies: All randomized trials, including quasi-randomized trials were considered.
Types of participants: All trials with the mean age of participants over 65 years, of either sex and
who were in-patients in hospital, were considered. Trials involving participants admitted to
accident and emergency departments, outpatients departments or the community settings of
hospitals were excluded
Types of intervention: All trials with the intervention of any multifactorial fall prevention
programme (refer to the definition by the American Geriatrics Society, 2011) compared with
usual care or placebos were considered
Types of outcome measurement: All trials that reported data or statistics relating to the number
of falls, the rate of falls or the number of fallers (participants suffering at least one fall) were
7
considered. Trials that only reported the severity of falls, such as the number of injurious falls,
were excluded.
2.12 Search strategies for the identification of studies
The identification of the relevant literature was performed in two steps. Firstly, a search
was conducted on the electronic databases PubMed, MEDLINE and CINAHL, from April 2012
to September 2012. The keywords used were “falls”, “fallers”, “aged”, “older”, “elderly”,
“hospitals”, “institution”, “geriatric ward”, “acute ward”, “sub-acute ward”, “multifactorial”
“targeted risk factors” and “intervention”. The literature-searching flowchart is outlined in
Appendix A. One hundred and twenty-three studies were retrieved from PubMed, twenty-eight
studies were retrieved from MEDLINE and eighteen studies were retrieved from CINAHL. After
screening the headings and the abstracts of the papers obtained according to the criteria set for
considering studies for review, full text articles were obtained for those considered to be relevant
or considered to be unclearly identified. With the full text obtained, the studies that met the
criteria for studies to review were determined. Secondly, the reference lists of related systematic
reviews and eligible papers identified were examined for additional relevant papers. Finally, five
studies were identified and included in the systematic review. Data from the five selected studies
were extracted and summarized in the form of a “Table of Evidence” in Appendix B.
2.13 Appraisal strategies
The quality assessment of the included studies was performed according to the
methodological checklist for controlled trials designed by the Scottish Intercollegiate Guideline
Network (SIGN), 2011. The methodology checklist for controlled trials of SIGN is attached in
8
Appendix C. The internal validity of the included studies was critiqued according to ten factors
as follows:
1. Appropriateness and clarity of the research questions
2. Randomization method
3. Allocation concealment
4. Blinding of participants and outcome assessors
5. Similarity between the intervention group and the control group
6. Provision of treatment
7. Validity and reliability of the outcome measurement
8. Drop-out rate
9. Handling of attrition bias
10. Comparability of sites for study with multi-sites involved
The details of the quality assessment of each study are listed in Appendix E. The level of
evidence for each study was then graded according to the result of the quality assessment based
on the SIGN grading system as shown in Appendix D.
2.2 Results
According to the methodological checklist for controlled trials designed by the Scottish
intercollegiate Guideline Network (SIGN), five selected studies were appraised and are presented
in Appendix E. Moreover, a summary of the study characteristics and methodological issues
related to the included studies will be described in the following section.
9
2.21 Study design
Five studies (Haines, Bennell, Osborne & Hill, 2004; Healey, Monro, Cockram, Adams
& Heseltine, 2004; Stenvall et al., 2007; Cumming et al., 2008; Ang, Mordiffi & Wong, 2011)
are randomized controlled trials (RCT) which are level 1 according to the grading system of the
level of evidence of the Scottish Intercollegiate Guidelines Network. However, looking into the
conduction of the five studies, although they are randomized controlled trials, a certain level of
bias might have occurred in the study design. Therefore, the five studies were further graded as
“++”, “+” and “-” according to the level of bias encountered in each study.
2.22 Demographic characteristics of participants
In all five studies (Haines, Bennell, Osborne & Hill, 2004; Healey, Monro, Cockram,
Adams & Heseltine, 2004; Stenvall et al., 2007; Cumming et al., 2008; Ang, Mordiffi & Wong,
2011), the participants recruited were from both acute and sub-acute wards in hospital care
settings. A total of 9300 participants were included in the five selected studies and the mean age
of the participants in the five studies ranged from 70 to 82.
2.23 Sample size
Determining the sample size by performing a power calculation, four studies (Haines,
Bennell, Osborne & Hill, 2004; Healey, Monro, Cockram, Adams & Heseltine, 2004; Cumming
et al., 2008; Ang, Mordiffi & Wong, 2011) had quite a large sample size, ranging from 626 to
3999, while the study by Stenvall et al. (2007) had a relatively small study sample size of 199.
Stenvall et al. (2007) explained this in the discussion section and stated that, although the study
sample was quite small, it was calculated according to the result of a previous study.
10
2.24 Randomization
For the randomization method, two studies (Healey, Monro, Cockram, Adams &
Heseltine, 2004; Cumming et al., 2008) used cluster randomization, while the other three studies
(Haines, Bennell, Osborne & Hill, 2004; Stenvall et al., 2007; Ang, Mordiffi & Wong, 2011)
used individual randomization. Although the matched pairs of wards in the two studies (Healey,
Monro, Cockram, Adams & Heseltine, 2004; Cumming et al., 2008) shared similar demographic
characteristics, the natural variation between the two wards might still have had an effect on the
result. For example, there were fewer new patients admitted and a relatively longer length of stay
in the intervention wards. If falls were more likely to occur at the beginning of a hospital stay
due to the unfamiliar environment, fewer falls would be expected in the intervention wards.
During an enquiry into this aspect, Healey, Monro, Cockram, Adams & Heseltine (2004) stated
the possibility of a reduction in falls related to natural variation instead of to the effect of
interventions. However, they empathized the number of participants (3386) and the time period
of the study (12-month period) made this less likely. On the other hand, Cumming et al. (2008)
stated randomization of 24 wards would be likely to succeed in eliminating major systematic
differences between the intervention and control groups.
2.25 Blinding
When conducting a behavioural intervention, thefull blinding of participants and staff
involved in the outcome assessment is difficult. The inability to completely blind the participants
and staff involved in the outcome assessment is a difficulty encountered by four out of the five
studies included (Haines, Bennell, Osborne & Hill, 2004; Healey, Monro, Cockram, Adams &
Heseltine, 2004; Stenvall et al., 2007; Cumming et al., 2008). However, in study by Haines,
11
Bennell, Osborne & Hill (2004), although staff members who recorded falls were likely to be
aware of an individual’s allocation status, a staff survey was carried out at the time and indicated
that they were relatively unaware of the allocation status. In Ang, Mordiffi & Wong’s (2011)
study, the participants and staff involved in the outcome assessment could be blinded, since the
waiver of informed consent was approved in order to prevent the Hawthorne effect. It also stated
that the staff members who recorded falls were not aware of the individual’s allocation status
because they were not informed about the study methodology, including the interventions
received by the participants. In addition, the interventions were provided by trained research
nurses.
2.26 Data collection
Data collection methods were stated in all five studies (Haines, Bennell, Osborne & Hill,
2004; Healey, Monro, Cockram, Adams & Heseltine, 2004; Stenvall et al., 2007; Cumming et al.,
2008; Ang, Mordiffi & Wong, 2011). Data on falls in the five studies were derived either from
an incident reporting system or from a systematic fall reporting system. The system already
existed and was practiced by the staff in the health care settings before the studies were
introduced. The use of accident and incident reporting systems is also worldwide general practice
in hospitals.
2.27 Applicability and generalizability
Four studies (Haines, Bennell, Osborne & Hill, 2004; Healey, Monro, Cockram, Adams
& Heseltine, 2004; Stenvall et al., 2007; Cumming et al., 2008) out of five were carried out in
hospital wards in Western countries, while one study (Ang, Mordiffi & Wong, 2011) was
conducted in a hospital of an Asian country, Singapore. Singapore is a developed country with
12
similar health care settings to those of Hong Kong. Thus, this reinforces the applicability of the
results of the evidence synthesized from the systematic review to the targeted clinical health care
settings in Hong Kong.
A systematic review is an important step in the development of evidence-based practice
guidelines. This helps to present the best evidence for the effectiveness of the interventions. In
addition, critical appraisal of the studies selected in the systematic review is also essential in
synthesizing the best evidence for uniform and evidenced-based clinical practice guidelines in
hospital care settings.
2.3 Summary and synthesis
2.31 Results of the systematic review
From the results of the review, four studies (Haines, Bennell, Osborne & Hill, 2004;
Healey, Monro, Cockram, Adams & Heseltine, 2004; Stenvall et al., 2007; Ang, Mordiffi &
Wong, 2011) out of five demonstrated multifactorial fall prevention programmes to be effective
interventions, as these showed a significant reduction in the incidence of falls or in the number of
patients falling in the hospital settings, as well as in the relative risk of recorded falls in hospital
wards. All four studies showed a reduction in the number of falls after the intervention, but only
two studies (Haines, Bennell, Osborne & Hill, 2004; Ang, Mordiffi & Wong, 2011) had
statistically significant results with the P-value stated. Moreover, two studies (Haines, Bennell,
Osborne & Hill, 2004; Stenvall et al., 2007) showed a statistically significant reduction in the
number of patients falling in hospital settings in the intervention group. Two studies (Healey,
Monro, Cockram, Adams & Heseltine, 2004; Ang, Mordiffi & Wong, 2011) demonstrated a
13
statistically significant reduction in the relative risk of recorded falls in the intervention group in
hospital wards.
While four studies showed multifactorial fall prevention intervention to be effective in
reducing in the incidence of falls of older adults in hospital care settings, the study by Cumming
et al. (2008) showed no significant reduction in the incidence of falls or in the number of fallers
after a multifactorial fall prevention programme was carried out, therefore, it was deemed to be
non-effective. The contradictory result of the study by Cumming et al. (2008) might be explained
by the relatively short length of stay, which was only 7 days, in contrast to the >20 day length of
stay in the other four studies (Haines, Bennell, Osborne & Hill, 2004; Healey, Monro, Cockram,
Adams & Heseltine, 2004; Stenvall et al., 2007; Ang, Mordiffi & Wong, 2011). This provided a
clue, in that it was likely that a multifactorial fall prevention programme needed more than a few
days to take effect. Another explanation given by Cumming et al. (2008) for the contradictory
result might be that the intervention team spent too little time on each ward (three months in one
ward) to effect any change in ward culture, resulting in the multifactorial fall prevention
interventions lacking effect.
Therefore, concluding from the results synthesized from the systematic review, a
multifactorial fall prevention programme provided for older patients is effective in reducing the
incidence of falls of older patients with relatively long lengths of stay (20 days or more) in acute
or sub-acute hospital care settings.
2.32 Summary of the components of a multifactorial fall prevention programme
After a multifactorial fall prevention programme is demonstrated to be effective in
reducing the incidence of falls in hospital care settings, the essential components constituting an
14
effective multifactorial fall prevention programme will then be identified. There is a striking
variety in the combinations of interventions in each multifactorial fall prevention programme.
Categories of fall prevention interventions listed by ProFaNE taxonomy (Lamb, Hauer & Becker,
2007) will be used for the analysis of the characteristics of the interventions involved. ProFaNE
taxonomy is designed for and is being widely used in research activity to characterize and
classify existing fall prevention interventions (Lamb, Hauer & Becker, 2007). ProFaNE
taxonomy classified the interventions of fall prevention programme into eight categories namely
exercise, medication, management of urinary incontinence, fluid or nutritional therapy,
psychological or environmental modifications, knowledge or education and other (Lamb, Hauer
& Becker, 2007).
With the interventions of each multifactorial fall prevention programme of the five
studies (Haines, Bennell, Osborne & Hill, 2004; Healey, Monro, Cockram, Adams & Heseltine,
2004; Stenvall et al., 2007; Cumming et al., 2008; Ang, Mordiffi & Wong, 2011) listed
according to the ProFaNE taxonomy in the table shown in Appendix F, it is easy to observe that,
despite the striking variability in the combinations of interventions in each multifactorial fall
prevention programme, they were mainly composed of four categories including exercise,
medication reviews, environmental modifications and knowledge.
2.321 Multifactorial fall risk assessment
A multifactorial fall prevention programme refers to a programme made up of a subset of
interventions that are selected and offered to individuals according to the specific risk factors
identified through a multifactorial fall risk assessment (American Geriatrics Society, 2001).
Hence, a multifactorial fall risk assessment is an essential component of an effective
15
multifactorial fall prevention programme, as it assists in identifying individualized fall
prevention interventions. All five of the selected studies (Haines, Bennell, Osborne & Hill, 2004;
Healey, Monro, Cockram, Adams & Heseltine, 2004; Stenvall et al., 2007; Cumming et al., 2008;
Ang, Mordiffi & Wong, 2011) included a multifactorial fall risk assessment in the multifactorial
fall prevention programme in order to determine the targeted interventions that patients received.
The purpose of a multifactorial fall risk assessment is to pair individual fall risk factors with
targeted interventions, eliminating the effect of the fall risk factors for the patients so as to
reduce the incidence of falls among hospitalized older adults.
2.322 Exercise
The exercise component was included in four studies (Haines, Bennell, Osborne & Hill,
2004; Stenvall et al., 2007; Cumming et al., 2008; Ang, Mordiffi & Wong, 2011). Gait, balance
and functional training is included in the exercise component of all these four studies (Haines,
Bennell, Osborne & Hill, 2004; Stenvall et al., 2007; Cumming et al., 2008; Ang, Mordiffi &
Wong, 2011). Gait training involves specific correction of the techniques and pace of walking
(for example, heel and toe raises, heel to toe walking, walking back and forwards and so on)
while balance training involves training in basic functional movement patterns and complex
movement patterns for dynamic activities (for example, foot eye coordination, walking in line
and standing on an unstable surface) (Lamb, Hauer & Becker, 2007). The exercise sessions in
three of the studies (Haines, Bennell, Osborne & Hill, 2004; Stenvall et al., 2007; Cumming et al.,
2008) were supervised by physiotherapy staff. 3D training (Tai Chi), which refers to constant
movement in a controlled way through three dimensions and supervised by physiotherapists, was
involved in the exercise component of study by Haines, Bennell, Osborne & Hill (2004).
16
2.323 Medication reviews
A medication review was included in three studies (Healey, Monro, Cockram, Adams &
Heseltine, 2004; Stenvall et al., 2007; Ang, Mordiffi & Wong, 2011). Assessment and
modification of the prescription of medication is an important component in a medication review
because the therapeutic or adverse effects of medication may increase the risk of patients falling.
For example, antidepressants or antipsychotics may cause drowsiness in patients and thus affect
their gait and balance. Therefore, recent changes in the medication regime, the therapeutic or
adverse effects of medication and the effect of poly-pharmacy will be considered in the
medication review.
2.324 Environmental modifications
Environmental modifications were involved in four studies (Haines, Bennell, Osborne &
Hill, 2004; Healey, Monro, Cockram, Adams & Heseltine, 2004; Stenvall et al., 2007; Cumming
et al., 2008). Environmental modifications include communication, information and signaling
aids, personal mobility aids and personal care and protection aids. Three studies (Haines, Bennell,
Osborne & Hill, 2004; Healey, Monro, Cockram, Adams & Heseltine, 2004; Cumming et al.,
2008) out of the four included communication, information and signaling aids. Aids for
communication, information and signaling included optical and hearing aids for improving the
communication ability of patients, signaling and indicating aids (for example, high risk alert
cards and identification bracelets) and alarm systems such as a nurse call bell or alarm. Personal
mobility aids were included in the study by Cumming et al. (2008). Physiotherapy staff
prescribed patients with walking aids after assessment and educated them in the use of such aids,
while nurses supervised who used the walking aids. Personal care and protection aids were
17
included in three studies (Haines, Bennell, Osborne & Hill, 2004; Healey, Monro, Cockram,
Adams & Heseltine, 2004; Cumming et al., 2008). Reviewing the need for bedrails, providing
bed height adjustment and assessing the footwear safety of patients are examples of personal care
and protection aids. Staff training on fall prevention is also a social environmental modification
included in a multifactorial fall prevention programme (Stenvall et al., 2007).
2.325 Knowledge
Patient education and knowledge training on fall prevention was included in four studies
(Haines, Bennell, Osborne & Hill, 2004; Stenvall et al., 2007; Cumming et al., 2008; Ang,
Mordiffi & Wong, 2011). Knowledge training intervention can be provided for patients in the
form of written materials, videos or lectures. Generally, analysis of the fall risk factors of
patients is performed and related education will then be provided for the patients. Educational
sessions with a duration of 30 minutes and related to an individual fall risk factor analysis and
safe mobility in wards were included in two studies (Haines, Bennell, Osborne & Hill, 2004;
Ang, Mordiffi & Wong, 2011).
2.4 Implications for practice
In conclusion from the summary and synthesis of the systematic review, a multifactorial
fall prevention programme is effective in reducing the incidence of falls or the number of falls by
older patients in acute or sub-acute hospital care settings with relatively long lengths of stay.
Moreover, a multifactorial fall risk assessment, exercise, medication reviews, environmental
modifications and knowledge are considered to be important components of an effective
multifactorial fall prevention programme.
18
The synthesized summary helped to inform my clinical practice on fall prevention. My
clinical setting is a medical and geriatrics ward in a local hospital, which is combined with an
acute unit with medical as a subspecialty and a sub-acute unit with geriatrics as a subspecialty at
the same time. The sub-acute unit in my ward consists of patients with relatively longer lengths
of stay according to the statistics from the ward records, the mean length of stay is 21days.
Moreover, these patients are generally at higher risk of in-hospital falls. They accounted for
approximately 70% of the fall incidence in the ward in 2011. Hence, in agreement with the result
of the summary and synthesis drawn from the identified studies, the target group of the
multifactorial fall prevention programme is the patients with geriatrics as a subspecialty in my
clinical settings. The following step in my dissertation will be to develop “Evidence-based
guidelines of fall prevention programme for hospitalized older patients”. The implementation
potential of the evidence-based guidelines developed will be discussed in chapter 3.
19
CHAPTER 3 TRANSLATION AND APPLICATION
In conclusion, from the summary and synthesis in chapter two, a multifactorial fall
prevention programme was affirmed to be effective in reducing the incidence of falls or the
number of fallers for older patients in hospital care settings. In this chapter, the implementation
potential and the content of an evidence-based multifactorial fall prevention programme for
hospitalized older patients will be discussed.
3.1 Implementation potential
Before the implementation of an evidence-based innovation, the target audience and
setting must first be clearly identified. The implementation potential of the innovation will then
be assessed according to several aspects: the transferability of the findings, feasibility and the
cost-benefit ratio of the innovation.
3.11 Target audience
According to the local statistics in my hospital cluster inpatient falls and fall-related
injuries mostly occurred in hospitalized patients aged 65 or above (NTWC Fall Prevention and
Management Committee, 2010). Moreover, summarizing from the Table of Evidence listed in
Appendix B, the mean age of the participants in the five studies ranged from 70 to 82. Thus, the
target audience is hospitalized patients aged 65 or above.
3.12 Target setting
My clinical setting is a medical and geriatrics ward combined with an acute unit (medical
as a subspecialty) and a sub-acute unit (geriatrics as a subspecialty). In the sub-acute unit in my
ward, patients have a relatively longer length of stay and are at higher risk of in-hospital falls.
20
Therefore, the target setting of the multifactorial fall prevention programme is the sub-acute unit
of a medical and geriatrics ward in a local hospital. The total number of available beds in the
sub-acute unit of the ward is 40. The ward is a mixed ward setting with both male and female
patients.
3.13 Transferability of the findings
The proposed target population and setting were developed from the summary and
synthesis obtained from the review of the five research studies included in the Table of Evidence.
The comparison of the characteristics of the target population in the reviewed literature and the
target setting is listed in table 1. The target population and target setting is similar to those in the
reviewed literature. Thus, it is likely that the multifactorial fall prevention programme fits into
the local nursing practice.
Table 1 Characteristics of the target population in the reviewed literature and the target
setting
Characteristics of
target population
Reviewed literatures Target setting
Age Mean age ranged from 70 to 82 Aged over 65 or above
Gender Both male and female patients included Both male and female patients
included
Ethnicity Western (Australia, United Kingdom,
Sweden); Asian (Singapore)
Asian (Hong Kong, China)
21
Hospital care
settings admitted
Included acute and sub-acute units in
both medical and surgical wards
Sub-acute unit of a medical
ward
Length of hospital
stay
Mean length of stay: >20days Mean length of stay: 21 days
My hospital cluster is committed to providing patient-oriented health care services and to
providing an environment that ensure patient safety (New Territories West Cluster, 2009). The
philosophy of care of my hospital cluster supports the importance of developing an effective
evidence-based fall prevention strategy for staff, in order to comply with minimizing the risk of
falls (NTWC Fall Prevention and Management Committee, 2012).
According to the statistical record of my ward, 2000 patients were admitted to the sub-
acute unit of the ward in 2011, and 95% of the admitted patients were aged 65 or above.
Therefore, it is estimated that 1900 (2000 X 95%) patients would benefit from the fall prevention
programme. Due to the prolonged life expectancy of people in Hong Kong, our health care
system is facing the problem of an aging population. In general, it is estimated that the number of
patients admitted to the geriatrics unit of hospitals will constantly increase. Therefore, the
number of patients admitted to the sub-unit of my ward is expected to grow in the near future and
the number of patients who would benefit from the implementation of a multifactorial fall
prevention programme would be more than previously estimated. Hence, the multifactorial fall
prevention programme will be beneficial to a sufficiently large number of clients in my ward.
The time required for the preparation, implementation and evaluation of the innovation is
listed in Table 2. A total of three months is needed for the preparation of the fall prevention
22
programme before implementation. The length of the follow-up to the fall prevention
programmes in the reviewed studies ranged from 9 to 36 months. In my hospital cluster, the
statistics show that the in-patient fall rates are usually higher in winter. Therefore, considering
this seasonal cycle, it is recommended that the period of implementation and evaluation to be not
less than 12 months. Thus, approximately 15 months will be needed for the preparation,
implementation and evaluation of the innovation, which is an acceptable length of time.
Table 2 Timeline for the preparation, implementation and evaluation of the innovation
23
In conclusion, the findings of the reviewed literature are transferable to the target setting
and it is worth implementing the findings in the target setting.
3.14 Feasibility
The support from both the individual level (nursing staffs and aligned health care
specialist) and the administration level is vital to the success of the implementation of an
innovation. Thus, the feasibility of the implementation of the multifactorial fall prevention
programme in the target setting is assessed according to these two aspects.
3.141 Support from the administration level
My hospital cluster is committed to providing an environment and resources to ensure
patient safety and to establish an evidence-based system for fall prevention (NTWC Fall
Prevention and Management Committee, 2012). All staff members are responsible for taking
initiatives to minimize the risk of patients falling and for complying with the fall prevention
Commencement
Date
Duration
Equipment and training materials preparations + Nursing
staff training
1st march, 2013 1 month
Pilot study 1st April, 2013 1 month
Evaluation and modification of the pilot study 1st May, 2013 1 month
Period of implementation and evaluation of the innovation 1st June, 2013 12 months
Total: 15 months
24
policies. Moreover, patient fall is the most prevalent type of incident in the medical and
geriatrics wards in my hospital cluster (NTWC Fall Prevention and Management Committee,
2012). Therefore, the Department Operations Manager (DOM) of the Medical and Geriatrics
department and the ward manager of the target setting are willing to support an evidence-based
fall prevention programme in order to minimize the risk of patient falls.
Apart from the nursing department, the support and cooperation of other departments are
also necessary for the implementation of the fall prevention programme. Exercise sessions in the
fall prevention programme require supervision by physiotherapists, while the medication review
in the fall prevention programme needs support from medical officers. However, implementation
of the innovation is unlikely to generate conflict between the two departments because. Firstly,
with regard to the physiotherapists, a referral system for fall prevention assessment and exercise
has already been incorporated into the current multicomponent fall prevention programme. Thus,
the implementation of the innovation will not increase their workload, but will ensure better
utilization of the referral system. Medication screening is the daily routine practice for medical
officers, therefore, the implementation of the innovation will not increase their workload. The
implementation of the multifactorial fall prevention programme could increase collaboration and
communication among the three parties involved, thus providing a better and more systematic
utilization of the existing services to help to prevent the incidence of patient falls.
Equipment and facilities required for the innovation, such as mobility aids, signaling aids,
alarm systems and fall prevention education leaflets are readily available in the target setting.
Additional materials such as multifactorial fall assessment forms, cue cards introducing the
newly introduced multifactorial fall prevention programme and evaluation forms for nursing
staff to provide comments and feedback can be easily arranged at an affordable price.
25
3.142 Support from the individual level (nursing staff)
Regarding the implementation of multifactorial fall prevention programme, nurses have
the autonomy to implement and terminate the programme according to the evidence-based
guidelines. A multicomponent fall prevention programme is currently practiced by nursing staff
in the target setting. Nurses already have fundamental knowledge about and skills for fall
prevention. Fall risk screening and assessment is currently routine nursing care. The
implementation of the innovation will provide nurses with more effective fall risk assessment to
identify fall risk factors of individual patients and to tackle the specific risk factors accordingly.
It is expected that this will not greatly increase the workload in the daily practice of the nursing
staff. Thus, the implementation of the innovation will not interfere with their current duties. The
potential barrier to the implementation of the multifactorial fall prevention programme may be
weak incentive for nurses to change current practices. Nurses and other health professionals have
weak incentives for change, because they perceive many barriers to change related to their lack
of knowledge about the change and the significance of the change (Koh, Hafizah, Lee, Loo &
Muthu, 2009). Hence, this problem can be addressed through preparing a one-hour training
workshop for the staff, educating them about the new multifactorial fall prevention programme
before the implementation of the innovation. Moreover, using a simplified multifactorial fall
assessment tool and integrating the assessment process into the normal nursing outline may also
help to increase the incentive for change.
In current practice, the fall incidents have to be reported through a computerized Adverse
Incident Reporting System (AIRS) by completing the “Patient Fall Incident Reporting Form”.
Hence, a clinical evaluation tool is already available for the evaluation of the innovation.
26
3.15 Cost/Benefit ratio of the innovation
The cost/benefit ratio of the innovation is another factor affecting the implementation
potential. With the current multicomponent fall prevention programme used in my hospital
cluster, the fall incident is still prevalent in the medical and geriatrics departments. This results in
an increased length of hospital stays and leads to greater hospital expenses (Heinrich, Rapp,
Rissmann, Becker & Konig, 2010). This reveals the need for a new and effective fall prevention
programme to help to minimize the risk of patient falls. Summarizing from the findings of
chapter two, a multifactorial fall prevention programme is effective in reducing the incidence of
fall for older patients in acute or sub-acute hospital care settings. This determines the worthiness
of the implementation of the innovation in the target setting.
Material and non-material costs have to be considered before the implementation of the
innovation. Considering the material cost of the implementation of the innovation, basic
information on the target setting and the resources needed annually for the implementation of the
programme are listed in Table 3 and Table 4a, respectively. Fall related injuries range from
minor wounds to severe injuries like fractures (Kannus, Sievanen, Palvanen, Jarvinen & Parkkari,
2005). These result in the increased length of hospital stays (Heinrich, Rapp, Rissmann, Becker
& Konig, 2010). According to a study on health service utilization after falls in Hong Kong, the
length of a hospital stay, even for fallers with no major injuries, would increase by at least one
day (Chu, Chi & Chiu, 2007). Therefore, according to the findings from the Table of Evidence,
assuming that 30% of fall incidents can be prevented by the implementation of the multifactorial
fall prevention programme, the annual expenses saved related to the reduced incidence of fall
will be at least $186 561, as stated in Table 4b. The cost-benefit ratio of the innovation is less
than 0.08 (14750/186561).
27
Table 3 Basic information on the target setting
Total number of nursing staff in the target setting 30
Total number of target patients admitted to the target setting 1900 (per year)
Fall rates in the target setting ~10%
Number of fall incidents in target setting 1900 X 10%= ~190
Unit cost per day of hospital stay $3273
Table 4a Annual material cost needed for implementation of the programme
Resources needed Annual cost
Nursing training $130/hour X 1 hour X 30 staff
= $3900
Pocket guide and evaluation forms for nurses $5/ staff X 30 staff= $150
Printed materials (Multifactorial fall risk assessment forms,
Fall prevention education leaflets)
$3/patient X 1900 patients=
$5700
Maintenance cost of available resources (Mobility aids,
Signaling aids, Alarm systems)
$5000
Total= $14750
28
Table 4b Annual expenses saved after the implementation of the programme
Annual expenses saved
Extra length of hospital stay related to in-patient
fall
$3273 X 1 Day X (190 X30%)= $186561
Regarding the non-material costs of implementation of the programme, staff morale may
be affected at the beginning because of the weak incentives for nurses for to change their current
practice. However, with the training workshop provided for the staff, addressing the significance
of the change and explaining the use of the new guidelines of the multifactorial fall prevention
programme, the effect on staff morale will be minimal. On the other hand, falls may result in
anxiety or guilt among staff and in litigation from patients’ families (Liddle & Gilleard, 1994;
Oliver, 2002). Moreover, there will be a decreased workload on post-fall management and
documentation of the effective fall prevention programme reducing the incidence of falls. Thus,
staff morale may be improved after the implementation of the innovation.
In conclusion, after considering the transferability, feasibility and the cost-benefit ratio of
the innovation, the implementation of the innovation in the proposed target setting is
recommended.
3.2 Evidence-based practice guideline/protocol
“Evidence-based guidelines of fall prevention programme for hospitalized older patients”
are formulated based on the review of the selected studies as stated in chapter two.
29
These guidelines are written to offer nurses and other health care professionals the
standard required for multifactorial fall prevention strategies. The target population covered is
patients aged 65 or above who are admitted to the sub-acute unit of a general ward. The
objectives of the evidence-based guidelines are to:
Formulate clinical practice instructions for implementing the multifactorial fall
prevention programme based on best available evidence
Summarize strategies for identifying fall risk factors for patients and for
preventing the occurrence of in-patient falls
The multifactorial fall prevention programme will be implemented step-by-step for
eligible patients admitted to the target setting, as listed in the Reference Guide in Appendix H.
Step 1: Perform fall risk screening and multifactorial fall risk assessment using the
MORSE Fall Scale (MFS) (Morse, 1997) in Appendix G upon admission and at intervals in
order to identify patients with a high risk of falling and to identify the specific risk factors for
falls of individual patients. (Refer to Appendix I---Step 1)
Step 2: Patients with a MORSE Fall Score ≥45 are identified as patients with a high fall
risk. Multifactorial fall prevention intervention---environmental modifications will be
implemented for them firstly. For patients with a MORSE Fall Score <45, basic nursing care
such as orientation of the patient to the ward environment and responding to a patient’s call as
soon as possible will be provided, and they will be reassessed for the risk of falling weekly and
whenever their condition changes. (Refer to Appendix I---Step 2)
30
Step 3: Patients with a score >0 in Risk factor “History of falling” or “Mental status”, are
identified as in need of receiving multifactorial fall prevention intervention---knowledge. (Refer
to Appendix I---Step 3)
Step 4: Patients with a score >0 in Risk factor “Secondary diagnosis” or “Intravenous
therapy/Saline lock” are identified as in need of receiving multifactorial fall prevention
intervention---medication review. (Refer to Appendix I---Step 4)
Step 5: Patients with a score >0 in Risk factor “Ambulatory aid” or “Gait” are identified
as in need of receiving multifactorial fall prevention intervention---exercise. (Refer to Appendix
I---Step 5)
Recommendations in the evidence-based guidelines of the multifactorial fall prevention
programme are formulated based on the findings of the selected studies listed in the Table of
Evidence. The grading system of the Scottish Intercollegiate Guidelines Network in Appendix D
was adopted to state the level of evidence of the studies and hence the grading of the
recommendations. The evidence-based recommendations on multifactorial fall risk assessment
and multifactorial fall prevention interventions including environmental modifications,
knowledge, medication review and exercise are listed in detail in Appendix I with evidence
supporting the recommendations stated.
The evidence-based recommendations on different components of the multifactorial fall
prevention programme offer nurses and other health care professionals the standard and
strategies required for implementing the “Evidence-based guidelines of fall prevention
programme for hospitalized older patients”. The plan for implementing and evaluating the
31
evidence-based guidelines of the multifactorial fall prevention programme will be discussed in
chapter four.
32
CHAPTER 4 IMPLEMENTATION PLAN
The following chapter will illustrate the communication plan for various parties in the
hospital, the pilot test for determining the feasibility of the innovation and the evaluation plan of
the innovation.
4.1 Communication plan
A communication plan is essential to disseminate the objectives and significance of the
innovation and the contents of the fall prevention programme to different stakeholders in the
hospital, in order to promote the implementation of the innovation.
4.11 Stakeholders in the fall prevention programme
Stakeholders in the fall prevention programme, including the hospital administrators,
ward link nurse for fall prevention, frontline nursing staff/ registered nurses (RNs), medical
officers and physiotherapists, are those affected by the innovation and those responsible for
anticipating the results of the innovation. The hospital administrators, including the Department
Operations Manager (DOM) of the Medical and Geriatrics (M&G) department and the ward
manager of the target setting, need to be informed in advance in order to obtain approval and
resources for the implementation of the innovation. Ward link nurses play an important role in
introducing the innovation to the RNs and monitoring the implementation of the innovation. The
RNs, medical officers and physiotherapists are key members in carrying out the proposed fall
prevention programme.
33
The timeline for the communication plan of the innovation is listed in Table 5, as follows:
Table 5 Timeline for the communication plan of the innovation
Time (Week)
Phase
1 2 3 4 5 6 7 8
Communication with the ward manager
Communication with the DOM
Formation of the steering committee
(Recruitment of committee members)
Communication with the frontline nursing staff
Communication with medical officers and
physiotherapists in the ward
Consolidation of the comments gathered and finalization
of the innovation
4.12 Communication with the hospital administrators
Since the ward manager is the most crucial gatekeeper, obtaining support from the ward
manger can facilitate communication with the DOM. In order to initiate the change, the current
fall prevention programme used in the M&G Department and recent department fall rates are
first reviewed. These will indicate the need for change. Afterwards, evidence from the literature
will be listed to demonstrate the significance and objectives of the innovation. After a clear
vision of the necessity for change has been shown, the details of the multifactorial fall prevention
programme, the feasibility and the cost/benefit ratio of the programme will be explained to the
administrators. In order to get approval from them, the significance of the innovation, as well as
34
how the proposed programme will be introduced to the ward routine with minimal disturbance
and interference will be highlighted in the discussion. The fall prevention programme will be
modified according to the comments arising. Moreover, the approval for the formation of the
steering committee will be obtained at the same time.
4.13 Formation of the steering committee
After obtaining the approval and support from the DOM and the ward manager, the
steering committee will be established within two weeks. The steering committee includes the
Assistant Consultant (AC) and a medical officer from the target ward, the ward link nurse for fall
prevention, the author of the proposed innovation and a physiotherapist in charge of the target
ward. In the committee meeting, the significance, objectives and contents of the proposed
multifactorial fall prevention programme will be presented and the proposed fall prevention
programme will be modified according to the suggestions of the committee members. Moreover,
the essential function of the steering committee will be stated in the meeting as follows:
Table 6 Essential function of the steering committee members
Steering committee members Essential function stated
Assistant Consultant Act as adviser
Medical officer Disseminate the fall prevention programme to their colleagues in
the target ward Physiotherapist
Ward link nurse for fall prevention Disseminate the fall prevention programme to the nursing staff
in the target ward
Assess the nurses’ compliance with the fall prevention
programme so as to sustain the change afterward
Author of the innovation
35
4.14 Communication with frontline staff in the ward
The ward link nurse for fall prevention and the author of the innovation will take turns to
present the proposed fall prevention programme twice a week after the handover session from
the morning to the afternoon shift. The briefing sessions will be provided for three weeks. The
attendance of all RNs will be ensured by means of their signatures. The content of the briefing
includes the significance and objectives of the multifactorial fall prevention programme, the
proposed programme, how the programme can be incorporated into the daily ward routine with
minimal disturbance and so on. Moreover, question and answer sessions will be arranged to
clarify any misunderstandings or to answer enquiries from the nursing colleagues. The comments
and suggestions from the nursing staff will then be consolidated within one week and these can
help to finalize the proposed programme. The detailed content of the multifactorial fall
prevention programme will then be delivered to all frontline staff in the ward via the hospital
intranet.
4.15 Sustaining the change process of the innovation
After initiating and guiding the change process of the innovation, it is important to ensure
that the facilitation of the innovation is adequate in order to sustain the change process. Firstly,
nurses’ compliance with the proposed fall prevention programme can be assessed by auditing the
multifactorial fall prevention assessment form. Secondly, the patient outcomes can be monitored
by the patient fall incident reports. Thirdly, comments from the frontline medical, nursing and
other health care staff will be discussed in regular meetings of the steering committee, enabling
on-going revisions and amendments to be made to the programme. Moreover, an evaluation will
be conducted after the pilot test.
36
4.2 Pilot study plan
A pilot study is a small-scale, preliminary study conducted before a full-scale trial in
order to determine the feasibility of the proposed innovation and to evaluate if revisions are
needed before the large-scale trial (Hulley, 2007).
The objectives of the pilot study of the multifactorial fall prevention programme are to
evaluate the effectiveness of the training workshop, to assess the staff’s compliance with the
innovation, to evaluate the preliminary effectiveness of the innovation and to test the feasibility
of implementing the innovation.
The timeline of the pilot study plan is listed in Table 6 as follows:
Table 7 Timeline of the pilot study plan
Time (Week)
Phase
1 2 3 4 5 6 7 8 9 10 11 12
Preparatory period for the pilot test
Training workshop for the innovation
Evaluation and amendment of the training workshop
Pilot test period
Pilot test of the innovation
Evaluation period of the pilot test
Data collection and analysis
Discussion and final review of the innovation
37
4.21 Training workshop for the innovation
The ward link nurse and the author of the innovation will provide a one-hour training
workshop on the multifactorial fall prevention programme for the nursing staff. The training
workshops will be arranged in two identical sessions after the morning shift over three
consecutive weeks in an interview room on the ward. All the information in the workshop will be
presented via power-point slide show. A pocket guide will be provided for each member of the
nursing staff. The pocket guide includes the detailed flow of the multifactorial fall prevention
programme, the multifactorial fall risk assessment form, evidence-based guidelines and the
reference guide for the programme. The contents of the pocket guide will be explained in detail
during the workshop. In addition, case scenarios will be provided individually to each member of
the nursing staff to assess if the nursing staff can identify the patient’s fall risk factors by using
the fall risk assessment form correctly and thus implement the fall prevention programme
properly. Furthermore, questionnaires will be provided for the nursing staff to indicate their self-
perceived confidence level in implementing the fall prevention programme after the workshop
and to comment on the appropriateness of the training material, the format and the duration of
the workshop. Hence, with the assessment of staff performance in the case scenarios and the
information gathered from the questionnaires, the effectiveness of the training workshop can be
reviewed. One week will be used for the evaluation and amendment of the training workshop, if
required, before the pilot test starts.
4.22 The pilot test
The pilot test will last for four weeks to ensure that the 30 nursing staff members in the
ward will have enough chances to practice the innovation. All target patients in the target setting
38
will be invited to join the pilot test and an information leaflet on the multifactorial fall prevention
programme will be provided for them.
During the pilot test period, the multifactorial fall risk assessment form will be audited by
the ward link nurse and the author of the proposed innovation in order to assess staff compliance
with the innovation. Auditing of the results will be summarized by the link nurse and the author
of the innovation after the pilot test period. Moreover, the fall rate during the pilot test period
will be collected and compared with the monthly fall rates in the target setting so as to evaluate
the preliminary effectiveness of the innovation. Furthermore, in order to test the flow and the
feasibility of the programme, an evaluation form will be presented to all nursing staff for them to
rate their satisfaction level with the programme, to express their opinions about the flow of the
programme and to voice any problems or difficulties encountered during the pilot test period. All
the information mentioned above will be gathered and consolidated by the ward link nurse and
the author of the innovation within two weeks after the pilot test. Afterwards, the results will be
discussed in the steering committee meeting. The multifactorial fall prevention programme and
the evidence-based guidelines will be reviewed once again in light of the evaluation results of the
pilot test. Therefore, the final amendments will be made within two weeks in order to prepare for
the upcoming full–scale implementation of the innovation.
4.3 Evaluation plan
The evaluation plan is used to determine if the innovation is effective in the target setting.
Outcomes to be achieved should be identified first, since these will affect the procedures and
methods of data collection and analysis for evaluating the effectiveness of the innovation.
39
4.31 Intervention outcomes identification
The identified outcomes of a clinical innovation can generally be classified into three
aspects, including patient outcomes, healthcare provider outcomes and system outcomes.
4.311 Patient outcomes
Reducing the fall incidence of elderly patients in the target setting is the main clinical
benefits of the multifactorial fall prevention programme. The incidence of falls is defined as the
number of falls per patient admitted, expressed as a percentage. The system for reporting the fall
incidents is consistent with the current practice. All fall incidents will be reported through the
computerized Adverse Incident Reporting System by completing the “Patient Fall Incident
Reporting Form” within 24 hours after the incident. Data collection of the fall incidents and the
total number of patients admitted will be performed at the end of every month during the
implementation of the programme. Thus, monthly fall rates in the target setting during the
implementation of the innovation can be determined. Based on the identified literature studies,
the period of implementation of the innovation is set to be 12 months. The reduction of the
incidence of falls in the target setting will be evaluated at 6 months and 12 months after the
innovation starts, so as to determine the intermediate and overall effects of the innovation.
4.312 Healthcare provider outcomes
For the healthcare provider outcomes, the nursing staff’s satisfaction levels and
confidence levels in applying the evidence-based guidelines for the fall prevention programme
will be used in determining the effectiveness of the innovation. Since the fall prevention
programme is mainly delivered by the nursing staff, their satisfaction level with the programme
is highly important in determining whether or not the innovation can be sustained. Moreover,
40
confidence in performing the fall prevention programme is also important. With confidence, the
nursing staff will demonstrate competency in fall risk assessment and fall prevention
interventions. An evaluation form will be provided for the nursing staff after the implementation
period of the innovation for them to self-rate their satisfaction and confidence level in applying
the programme. The result will be compared with those collected during the pilot study period.
In this manner, any change of attitude in the nursing staff towards the fall prevention programme
after the implementation of the innovation can be indicated.
4.313 System outcomes
In determining whether or not the fall prevention programme can be sustained, the
cost/benefit ratio of the programme is an important concern for the administration sector. The
cost of implementing the programme will be marked down accurately according to the items
listed in Table 7 throughout the preparatory and implementation period of the programme. Thus,
with the number of fall incidents reduced during the implementation period being collected at the
same time, the cost/benefit ratio of the programme can be evaluated according to the method
used in section 3.15.
Table 8 Costs of the multifactorial fall prevention programme
Resources Annual cost ($)
Nursing training
Pocket guides and evaluation forms for nurses
Printed materials (Multifactorial fall risk assessment forms, Fall prevention education
leaflets)
Maintenance cost of available resources (Mobility aids, Signaling aids, Alarm system)
Total cost=
41
4.32 Nature and number of clients to be involved
The evaluation study will be conducted using a pre-post design. The incidence of falls
during the one-year implementation period will be compared with a similar period prior to the
implementation of the intervention for a retrospective data analysis.
As mentioned in the last chapter, summarizing from the Table of Evidence listed in
Appendix B, the target clients to be involved are hospitalized patients aged 65 or above who
have been admitted to the sub-acute (geriatrics as a subspecialty) unit in an M&G ward. The total
number of available beds in the sub-acute unit of the ward is 40, and it is a mixed ward with both
male and female patients. According to the statistical record of the target setting in 2011, the
total number of target patients admitted to the target setting was 1900 in 2011.
Online software from Lenth (2006-2009) is used for the sample size calculation of the
study. The fall rate in the target setting is 10%, according to the statistical record for 2011, while
the estimated effect size of the multifactorial fall prevention programme is 30%, based on the
findings from the Table of Evidence. Hence, with 80% statistical power and the level of
significance set to be 0.05, the calculated sample size needed for the study is 716. Therefore, a
sufficient number of clients can be recruited in the target setting.
4.33 Data analysis
Descriptive statistics will be used to describe the socio-demographic data of the patients
involved, such as age, medical history, diagnosis on admission, fall history and so on. These data
can be obtained from the nursing admission assessment form. The main outcome to be analyzed
is the incidence of fall (fall rate) after the implementation of the multifactorial fall prevention
programme. The evaluation objective is to determine if the fall rate is reduced following the
42
implementation of the innovation. Significance testing will be the method of analysis used. For
comparing the fall rate after the implementation of the innovation with the one before the
innovation, a two-tailed z-test for testing one proportion will be applied for analyzing the
findings.
4.34 Basis for an effective change of practice
Determining whether or not the multifactorial fall prevention programme is effective
depends on if the identified outcomes can be achieved. The primary outcome of the innovation is
definitely the patient outcome identified, which is a 30% reduction in the incidence of falls in the
target setting after the implementation of the innovation. It is the ultimate purpose of the fall
prevention programme.
In addition, the healthcare provider and system outcomes identified are also important in
determining the effectiveness of the innovation. The implementation of the innovation can only
be sustained if the service provider can implement the innovation with good levels of satisfaction
and confidence. For administrative section of the hospital, the cost-benefit ratio will determine if
the implementation of the innovation is worth continuing. Therefore, with all the identified
patient, healthcare provider and system outcomes achieved, the programme can be considered to
be effective. Hence, the implementation of the programme can be sustained or even be extended
to other similar clinical settings in the future.
4.35 Conclusion
This study reviewed evidence for the effectiveness of the multifactorial fall prevention
programme in reducing the incidence of falls, translated the reviewed evidence and developed
evidence-based guidelines for the multifactorial fall prevention programme. Moreover, an
43
implementation plan and evaluation plan were developed to ensure the effective implementation
of the guidelines. Hence, the developed “Evidence-based guidelines of fall prevention
programme for hospitalized older adults” in this study can provide the health care practitioners
with an evidence-based approach for fall risk assessment and management so as to prevent in-
patient falls.
44
Appendix A: Search flowchart for identification of studies
PubMed MEDLINE CINAHL
1. Falls OR Fallers 36703 4462 2688
2. Aged OR Older OR Elderly 3778482 376018 98345
3. Hospitals OR Institutions OR Geriatric ward OR
Acute ward OR Sub-acute ward 391127 41392 22988
4. Intervention OR Programme OR Multifactorial OR
Targeted risk factor 382433 43355 23321
1 AND 2 AND 3 AND 4 178 30 18
Limit to published in the last ten years 123 28 17
45
Appendix B: Table of Evidence of the reviewed studies
Bibliographic
citation
Study Type Patient
characteristics
Interventions Comparison Length of
Follow Up
Outcome Measures Effect Size
1. Haines,
Bennell,
Osborne &
Hill, 2004
Randomized
controlled
trial
(1++)*
Patients from
sub-acute
hospital wards
(Mean age=80
years)
Targeted fall risk prevention programme
based on identified falls risk:
-Fall risk alert card with information
brochure
-Supervised exercise programme
-Education programme at bedside
-Hip protectors
-Usual care
(n=310)
Usual care
(n=316)
Until
participants
were
discharged
from
hospital
(10 months)
Primary:
1.Number of falls
2.Number of participants falling
Secondary:
3.Number of participants sustaining
injury
1. -44 (p=0.045)
2. -17 (p=0.05)
3. -9 (p=0.20)
2. Healey,
Monro,
Cockram,
Adams &
Heseltine,
2004
Randomized
controlled
trial
(1+)*
Patients from
elderly care
acute and sub-
acute hospital
wards
(Mean age=81
years)
Use of care plan with screening of fall
risk factors and targeted interventions for
identified risks:
-Eyesight examination
-Medication review
-Postural blood pressure check
-Ward test urine examination
-Mobility examination
-Environmental check
Usual care
(n=776 prior to intervention; n=749
during the intervention)
Usual care
(n=956 prior
to
intervention;
n=905 during
the
intervention)
6 months
prior to
intervention
+ 6 months
during the
intervention
Primary:
1.Number of falls
2.Fall rates per 1000 occupied bed
days
Secondary:
3.Relative risk of recorded falls
1. 180 in the
intervention group
during intervention
versus 319 in the
control group
during intervention
2. 11.38 in the
intervention group
during intervention
versus 19.92 in the
control group
during intervention
3. –0.33 (p=0.006)
3. Stenvall,
Olofsson,
Lundstrom,
Englund,
Borssen,
Svensson,
Nyberg &
Gustafson,
2007
Randomized
controlled
trial
(1+)*
Patients from
orthopedic and
geriatric
hospital wards
(Mean age=82
years)
Comprehensive geriatric assessment and
rehabilitation including:
-Individual care planning
-Medication review
-Environmental modification
-Supervised functional retraining
-Nutritional supplementation and
monitoring
(n=102)
Usual care
(n=97)
Until
participants
were
discharged
from
hospital
(32 months)
Primary:
1.Number of falls
2.Fall rates per 1000 occupied bed
days
3.Number of participants falling
Secondary:
4.Incident rate ratio
5.Number of participants sustaining
injury
6.Number of participants sustaining
fracture
1. -42
2.-9.99
3. -14 (p=0.007)
4. -0.62 (p=0.006)
5.-12 (p=0.002)
6.-4 (p=0.055)
46
4. Cumming,
Sherrington,
Lord, Simpson,
Vogler,
Cameron &
Naganathan,
2008
Randomized
controlled
trial
(1+)*
Patients from
acute and sub-
acute hospital
wards
(Mean age=79
years)
Use of risk assessment of falls and
targeted multifactorial intervention
including:
-Staff and patient education
-Drug review
-Modification of bedside and ward
environments
-An excise programme
-Alarms for selected patients
(n=2047)
Usual care
(n=1952)
Until
participants
were
discharged
from
hospital
(36 months)
Primary:
1.Fall rates per 1000 occupied bed
days
Secondary:
2.Incidence rate ratio for falls
3.Incidence rate ratio for injurious
falls
1. Intervention 9.26
versus Control 9.2
(P=0.96)
2. 1.02 (P=0.92)
3. 1.12 (95% CI
0.71 to 1.77)
5. Ang,
Mordiffi &
Wong, 2011
Randomized
controlled
trial
(1++)*
Patients from
medical
hospital wards
(mean age= 70
years)
Standard fall prevention interventions
plus Fall risk assessment using Hendrich
II Falls Risk Model in order to provide
interventions and educational session
according to participants’ risk factors
including
-Mental and emotional status
-Altered elimination
-Symptoms of dizziness
-Known categories of medications
increasing risk
-Unsteady gait and balance
(n=910)
Usual care
(n=912)
Until
participants
were
discharged
from
hospital
(9 months)
Primary:
1.Number of falls
Secondary:
2.Relative risk estimate
3. Estimated hazard ratio (%)
1. Intervention
4/910 versus
Control 14/912
(P=0.018)
2. -0.29 (P=0.031)
3. -0.29 (P=0.019)
1. Haines, T. p., Bennell, K.L., Osborne, R.H., & Hill, K. D. (2004). Effectiveness of targeted falls prevention programme in subacute
hospital setting: randomized controlled trial. BMJ, 328 (7441), 676-679.
2. Healey, F., Monro, A., Cockram, A., Adam, V., & Heseltine, D. (2004). Using targeted risk factor reduction to prevent falls in older in-
patients: a randomized controlled trial. Age and Ageing, 33 (4), 390-395.
3. Stenvall, M., Olofsson, B., Lundstrom, M., Englund, U., Borssen, B., Svensson, O., Nyberg, L., & Gustafson, Y. (2007). A
multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture. Osteoporosis
International, 18 (2), 167-175.
4. Cumming, R. G., Sherrington, C., Lord, S. R., Simpson, J. M., Vogler, C., Cameron I. D., & Naganathan, V. (2008). Clustered randomized
trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ, 336 (7647), 758-760.
5. Ang, E., Mordiffi, S. Z., & Wong, H. B. (2011). Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in
an acute care hospital: a randomized controlled trial. Journal of Advanced Nursing, 67 (9), 1984-1992.
47
Appendix C: Methodological checklist for controlled trials designed by the Scottish
Intercollegiate Guideline Network (SIGN), 2011
(Scottish Intercollegiate Guidelines Network, 2011a)
METHODOLOGY CHECKLIST 2: RANDOMISED CONTROLLED TRIALS
Study identification (Include author, title, year of publication, journal title, pages)
Guideline topic: Key Question No:
Before completing this checklist, consider:
Is the paper a randomized controlled trial or a controlled clinical trial? If in doubt, check the study
design algorithm available from SIGN and make sure you have the correct checklist. If it is a controlled
clinical trial questions 1.2, 1.3, and 1.4 are not relevant, and the study cannot be rated higher than 1+
Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention Comparison
Outcome). IF NO REJECT (give reason below). IF YES complete the checklist.
Reason for rejection: Reason for rejection: 1. Paper not relevant to key question □ 2. Other reason □ (please specify):
Checklist completed by:
Section 1: Internal validity
In a well conducted RCT study… In this study this criterion is:
1.1 The study addresses an appropriate and clearly focused question.
Well covered Adequately addressed Poorly addressed
Not addressed Not reported Not applicable
1.2 The assignment of subjects to treatment groups is randomised
Well covered Adequately addressed Poorly addressed
Not addressed Not reported Not applicable
1.3 An adequate concealment method is used Well covered Adequately addressed Poorly addressed
Not addressed Not reported Not applicable
1.4 Subjects and investigators are kept ‘blind’ about treatment allocation
Well covered Adequately addressed Poorly addressed
Not addressed Not reported Not applicable
1.5 The treatment and control groups are similar at the start of the trial
Well covered Adequately addressed Poorly addressed
Not addressed Not reported Not applicable
1.6 The only difference between groups is the treatment under investigation
Well covered Adequately addressed Poorly addressed
Not addressed Not reported Not applicable
1.7 All relevant outcomes are measured in a standard, valid and reliable way
Well covered Adequately addressed Poorly addressed
Not addressed Not reported Not applicable
1.8 What percentage of the individuals or clusters recruited into each treatment arm of the study dropped out before the study was completed?
1.9 All the subjects are analysed in the groups to which they were randomly allocated (often referred to as intention to treat analysis)
Well covered Adequately addressed
Not addressed Not reported Not applicable
48
Poorly addressed
1.10 Where the study is carried out at more than one site, results are comparable for all sites
Well covered Adequately addressed Poorly addressed
Not addressed Not reported Not applicable
Section 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimise bias?
Code ++, +, or -
2.2 Taking into account clinical considerations, your evaluation of the methodology used, and the statistical power of the study, are you certain that the overall effect is due to the study intervention?
2.3 Are the results of this study directly applicable to the patient group targeted by this guideline?
2.4 Notes. Summarise the authors conclusions. Add any comments on your own
assessment of the study, and the extent to which it answers your question.
49
Appendix D: Grading system of level of evidence designed by the Scottish Intercollegiate
Guideline Network (SIGN), 2011
(Scottish Intercollegiate Guidelines Network, 2011b)
ANNEX B: KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS
LEVELS OF EVIDENCE
1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++ High quality systematic reviews of case control or cohort or studies High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+ Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3 Non-analytic studies, e.g. case reports, case series
4 Expert opinion
GRADES OF RECOMMENDATIONS
At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good practice points
Recommended best practice based on the clinical experience of the guideline development group
50
Appendix E: Tables of quality assessment of the reviewed studies (1)
Bibliographic citation 1. Haines, Bennell, Osborne & Hill, 2004
Internal validity Comments Description
1.Appropriateness and clarity of the
research questions
Well-covered Objective stated: To evaluate the
effectiveness of a targeted multiple
intervention falls prevention
programme in reducing the rate of
falls, the proportion of patients who
fall in a sub-acute hospital
2.Randomization method Well-covered Individual participants randomized
from random number table
3.Allocation concealment Adequately addressed Researcher revealed allocation after
receiving consent
4.Blinding of subjects and outcome
assessor
Not applicable Not possible to blind the participants
due to the research design
Staff recorded falls likely to be
aware of individual’s allocation
status (Staff survey indicated they
were relatively unaware of
allocation status)
5.Similarity between the treatment
group and control group
Well-covered Baseline characteristics between
intervention group and control group
were recorded and authors stated
baseline characteristics in each
group were similar
6.Treatment under investigation Well-covered There is no additional treatment
received by patients
7.Validity and reliability of the
outcome measurement
Well-covered The primary outcome measures
(number of falls and number of
participants falling) were clearly
stated in the study
Data on falls derived from incident
reports
8.Drop-out rate Not reported
9.Handling of attrition bias Well-covered Intention-to-treat analysis was
applied
10.Comparability of sites for study
with multi-sites involved
Not applicable There are three sub-acute hospitals
wards in one hospital in Australia
involved
Overall assessment of the study
Level of evidence ++
Certainty of overall effect due to the
study intervention
Significant reduction in number of falls
High quality research design with a very low risk of bias
Applicability of the result to the
targeted patient group
Yes, the result is applicable to hospitalized older adults (targeted patient
group set)
51
Appendix E: Tables of quality assessment of the reviewed studies (2)
Bibliographic citation 2. Healey, Monro, Cockram, Adams & Heseltine, 2004
Internal validity Comments Description
1.Appropriateness and clarity of the
research questions
Well-covered Objective stated: To test the efficacy
of a targeted risk factor reduction
care plan in reducing risk of falling
while in hospital
2.Randomization method Adequately addressed Cluster randomization by lottery of
four matched pairs of hospital acute
and sub-acute wards
3.Allocation concealment Poorly addressed Lottery witnessed by six health
professionals
Lottery method are not clearly stated
4.Blinding of subjects and outcome
assessors
Not applicable Not possible to blind the participants
due to the research design
Staff recorded falls likely to be
aware of their ward’s allocation
status
5.Similarity between the treatment
group and control group
Adequately addressed Baseline characteristics between
intervention group and control group
were recorded
Authors stated the possibility of
reduction in falls related to natural
variation instead of intervention
effect (but the number of
participants: 3386 and time periods:
12 months involved in the study
make this less likely)
6.Treatment under investigation Well-covered There is no additional treatment
received by patients
7.Validity and reliability of the
outcome measurement
Well-covered The primary outcome measures
(number of falls, fall rates and
relative risk of recorded falls) were
clearly stated in the study
Data on falls derived from incident
reports
8.Drop-out rate Not reported
9.Handling of attrition bias Well-covered Intention-to-treat analysis was
applied
10.Comparability of sites for study
with multi-sites involved
Not applicable There are eight elderly care acute
and sub-acute wards in one hospital
in United Kingdom involved
Overall assessment of the study
Level of evidence +
Certainty of overall effect due to the
study intervention
Significant relative reduction in incident rate of falls
Baseline relative risk of falls are not similar between intervention and
control wards
Well conducted research design with a certain risk of bias
Applicability of the result to the
targeted patient group
Yes, the result is applicable to hospitalized older adults (targeted patient
group set)
52
Appendix E: Tables of quality assessment of the reviewed studies (3)
Bibliographic citation 3. Stenvall, Olofsson, Lundstrom, Englund, Borssen, Svensson, Nyberg
& Gustafson, 2007
Internal validity Comments Description
1.Appropriateness and clarity of the
research questions
Well-covered Objective stated: To evaluate if a
postoperative multidisciplinary
multifactorial intervention could
reduce in-patient falls and fall-
related injuries after a femoral neck
fracture
2.Randomization method Poorly addressed Individual randomization with
process not described
Randomization stratified according
to surgery methods
3.Allocation concealment Adequately addressed Allocation concealed in opaque
envelop until before surgery
4.Blinding of subjects and outcome
assessors
Not applicable Not possible to blind the participants
due to the research design
Staff recorded falls likely to be
aware of their ward’s allocation
status
5.Similarity between the treatment
group and control group
Adequately addressed Baseline characteristics between
intervention group and control group
were recorded
Authors stated the difference of
basic characteristics between the
intervention and control groups had
no significant effects
6.Treatment under investigation Well-covered There is no additional treatment
received by patients
7.Validity and reliability of the
outcome measurement
Well-covered The primary outcome measures
(number of falls and number of
participants falling) were clearly
stated in the study
Data on falls derived from
systematic registration of falls in the
medical and nursing records
8.Drop-out rate 6.53%
9.Handling of attrition bias Well-covered Intention-to-treat analysis was
applied
10.Comparability of sites for study
with multi-sites involved
Not applicable There are an orthopedic ward and a
geriatric ward in one hospital in
Sweden involved
Overall assessment of the study
Level of evidence +
Certainty of overall effect due to the
study intervention
Significant relative reduction in number of fallers
Well conducted research design with a certain risk of bias
Applicability of the result to the
targeted patient group
Yes, the result is applicable to hospitalized older adults (targeted patient
group set)
53
Appendix E: Tables of quality assessment of the reviewed studies (4)
Bibliographic citation 4. Cumming, Sherrington, Lord, Simpson, Vogler, Cameron & Naganathan,
2008
Internal validity Comments Description
1.Appropriateness and clarity of the
research questions
Well-covered Objective stated: To determine the
efficacy of a targeted multifactorial
falls prevention programme in
elderly care wards with relatively
short length of stay
2.Randomization method Adequately addressed Cluster randomization of twelve
matched pairs of hospital wards with
sealed opaque envelopes
3.Allocation concealment Well-covered Randomization involved sealed
opaque envelopes supervised by a
study investigator unaware of ward
characteristics
4.Blinding of subjects and outcome
assessors
Not applicable Not possible to blind the participants
due to the research design
Staff recorded falls likely to be
aware of their ward’s allocation
status
5.Similarity between the treatment
group and control group
Adequately addressed Baseline characteristics between
intervention group and control group
were recorded
Authors stated randomization of 24
wards seems to be successful in
eliminating major systematic
differences between intervention and
control groups
6.Treatment under investigation Well-covered There is no additional treatment
received by patients
7.Validity and reliability of the
outcome measurement
Well-covered The primary outcome measures
(incident rate ratio for falls and
number of participants falling) were
clearly stated in the study
Data on falls derived from incident
reports
8.Drop-out rate No losses
9.Handling of attrition bias Well-covered Intention-to-treat analysis was
applied
10.Comparability of sites for study
with multi-sites involved
Adequately covered There are twenty-four elderly care
wards in twelve hospitals in
Australia involved
Overall assessment of the study
Level of evidence +
Certainty of overall effect due to the
study intervention
No significant reduction in incident rate ratio or relative risk of fall shown
Well conducted research design with a certain risk of bias
Applicability of the result to the
targeted patient group
The result is applicable to hospitalized older adults with a relatively short
length of stay
54
Appendix E: Tables of quality assessment of the reviewed studies (5)
Bibliographic citation 5. Ang, Mordiffi & Wong, 2011
Internal validity Comments Description
1.Appropriateness and clarity of the
research questions
Well-covered Objective stated: To examine the
effectiveness of a targeted multiple
intervention strategy in reducing the
number of patient falls in an acute
care hospital
2.Randomization method Well-covered Individual randomization using
block randomization with the aid of
a computer program and stratified by
ward
3.Allocation concealment Well-covered Sealed, opaque, serially numbered
envelopes were produced from the
randomization sequence separately
for each stratum
4.Blinding of subjects and outcome
assessors
Adequately addressed Waiver of informed consent was
approved to keep the participants
blinded
Staff recorded falls were not aware
of individual’s allocation status
5.Similarity between the treatment
group and control group
Well-covered Baseline characteristics between
intervention group and control group
were recorded
Authors stated the baseline
characteristics for intervention and
control groups were homogenous for
the mean age, race, current condition
and fall assessment score
6.Treatment under investigation Well-covered There is no additional treatment
received by patients
7.Validity and reliability of the
outcome measurement
Well-covered The primary outcome measures
(number of falls and relative risk
estimate) were clearly stated in the
study
Data on falls derived from incident
reports
8.Drop-out rate No losses
9.Handling of attrition bias Well-covered Intention-to-treat analysis was
applied
10.Comparability of sites for study
with multi-sites involved
Not applicable There are eight medical wards in one
hospital in Singapore involved
Overall assessment of the study
Level of evidence ++
Certainty of overall effect due to the
study intervention
Significant reduction in fall incident rates and the relative risk estimate in
the intervention group
High quality research design with very low risk of bias
Applicability of the result to the
targeted patient group
Yes, the result is applicable to hospitalized older adults (targeted patient
group set)
55
Appendix F: Table of characteristics of the interventions of the reviewed studies ProFaNE
category
Exercises Medication Management of
urinary
incontinence
Fluid or
nutritional
therapy
Psychological Environment
modifications
Knowledge/Education Others
1. Haines,
Bennell,
Osborne &
Hill, 2004
+
(Tai Chi
combined with
functional
training)
+
(Communication aid
+ Protection aids-Hip
protector)
+
(Twice weekly individual
sessions of 30min)
2. Healey,
Monro,
Cockram,
Adams &
Heseltine, 2004
+ +
(Communication aid
+ personal care and
protection aid-
bedrails and bed
height control)
+
(eyesight +
postural BP
assessment)
3. Stenvall,
Olofsson,
Lundstrom,
Englund,
Borssen,
Svensson,
Nyberg &
Gustafson,
2007
+
(Functional
training)
+ +
(Staff training)
+
(Fall risk factors analysis)
+
Prevention
and treatment
of
postoperative
complications
5. Ang,
Mordiffi &
Wong, 2011
+
(Gait and
balance
training)
+ + +
(30 min educational session
once)
4. Cumming,
Sherrington,
Lord, Simpson,
Vogler,
Cameron &
Naganathan,
2008 (Ref,)
+
(Balance and
functional
training)
+
(Communication aid
+ personal mobility
aid + personal care
and protection aid)
+
(Patient education on safe
mobility in ward)
56
Appendix G: MORSE Fall Scale (MFS)
(Morse, 1997)
The MORSE Fall Scale consists of six risk factors that have been shown to have predictive
validity and inter-rater reliability. The MORSE Fall Scale has been well validated and used in
various hospital settings.
MORSE Fall Scale
Risk Factor Scale Score History of falling No 0
Yes 25
Mental status Oriented to own ability 0
Overestimates/ Forgets limitation 15
Secondary diagnosis No 0
Yes 15
Intravenous therapy/ Saline lock No 0
Yes 20
Ambulatory aid None/ On bed rest/ Nurse assists 0
Crutches/ Cane/ Walker 15
Furniture 30
Gait Normal/ On bed rest/ Immobile 0
Weak (Uses touch for balance) 10
Impaired (Unsteady, difficulty rising to
stand)
20
Total Score:
Cut-off Score and risk level recommended
Risk level MFS Score
Not at Risk <45
High Risk ≥45
Cut-off Score: ≥45 Sensitivity 78%, Specificity 83%
57
Appendix H: Reference Guide for the multifactorial fall prevention programme
MORSE Fall Scale
Risk Factor Scale Score History of falling (History of fall in past 3 months)
No 0
Yes 25
Mental status (Are you able to go to toilet
alone?)
Oriented to own ability 0
Overestimates/ Forgets
limitation
15
Secondary diagnosis (More than 1 active diagnosis)
No 0
Yes 15
Intravenous therapy/
Saline lock
No 0
Yes 20
Ambulatory aid (According to usual practice of
patient)
None/ On bed rest/ Nurse
assists
0
Crutches/ Cane/ Walker 15
Furniture 30
Gait (observe patient get up and
walk)
Normal/ On bed rest/ Immobile 0
Weak (Uses touch for balance) 10
Impaired (Unsteady, difficulty
rising to stand)
20
Total
Score:
STEP 1: Perform fall risk screening and multifactorial fall risk assessment using the MORSE Fall
Scale (MFS) (Morse, 1997) upon admission and at intervals to identify patients with high fall risks
and to identify the specific risk factors of fall for individual patients.
STEP 2: Patients with MORSE Fall Score ≥45 are identified as patients with a
high fall risk. Multifactorial fall prevention intervention---environmental
modifications will be implemented for them first.
For patients with MORSE Fall Score <45, basic nursing care (such as orientating
the patient to the ward environment and responding to a patient’s call as soon as
possible) will be provided and the patient will be reassessed for the risk of falling
weekly and whenever his or her condition changes.
STEP 3: Patients with a score >0 in
Risk factor “History of falling” or
“Mental status” are identified as
needing to receive multifactorial fall
prevention intervention--knowledge.
STEP 4: Patients with a score >0 in
Risk factor “Secondary diagnosis” or
“Intravenous therapy/Saline lock” are
identified as needing to receive
multifactorial fall prevention
intervention---medication review.
STEP 5: Patients with a score >0 in
Risk factor “Ambulatory aid” or “Gait”
are identified as needing to receive
multifactorial fall prevention
intervention---exercise.
58
Appendix I: Evidence-based guidelines of the multifactorial fall prevention programme---
Step 1
STEP 1: Perform fall risk screening and multifactorial fall risk assessment using the
MORSE Fall Scale (MFS) (Morse, 1997) in Appendix G upon admission
and at intervals to identify patients with high risk of falls and to identify
the specific risk factors for falling for individual patients.
Recommendations for fall risk screening and multifactorial fall risk assessment (Refer to
Recommendations 1a-1c)
1a. Fall risk screening and multifactorial fall risk assessment have to be
performed by hospital frontline staff (nurses or medical officers) with
appropriate skills and training. [Grade of recommendation: A]
Hospital staff including nursing and medical staff, use their clinical judgment
and experience to perform fall risk assessment to identify patients at risk of
falling and focus the intervention on patients at high risk (Haines, Bennell,
Osborne & Hill, 2004 [1++]; Healey, Monro, Cockram, Adams & Heseltine,
2004 [1+]).
59
1b. Fall risk screening and multifactorial fall risk assessment have to be
performed at the earliest patient encounter (within 24 hours after
admission). [Grade of recommendation: A]
Fall risk assessment is a key component of the fall prevention programme and
patients have to be assessed as soon as possible after admission (Haines, Bennell,
Osborne & Hill, 2004 [1++]). Patients were assessed within 24 hours of
admission and recommended interventions would then be initiated (Stenvall et
al., 2007 [1+]; Cumming et al., 2008 [1+]).
1c. Multifactorial fall risk assessment should be followed by targeted multiple
interventions tailored to the identified fall risk factors. [Grade of
recommendation: A]
After identifying a patient’s individual fall risk factors, targeted multiple
interventions based on the patient’s risk factors were initiated to remove or
reduce the fall risk factors so as to reduce the individual’s risk of falling (Haines,
Bennell, Osborne & Hill, 2004 [1++]; Healey, Monro, Cockram, Adams &
Heseltine, 2004 [1+]; Stenvall et al., 2007 [1+]; Cumming et al., 2008 [1+]; Ang,
Mordiffi & Wong, 2011 [1++]).
60
Appendix I: Evidence-based guidelines of the multifactorial fall prevention programme---
Step 2
STEP 2: For patients with a MORSE Fall Score ≥45, they are identified as patients
with a high fall risk. Multifactorial fall prevention intervention---
environmental modifications will be implemented for them first.
For patients with a MORSE Fall Score <45, basic nursing care (such as
orientating patient to the ward environment and responding to a patient’s
call as soon as possible) will be provided and they will be reassessed for the
risk of falling weekly and whenever his or her condition changes.
Recommendations for multifactorial fall prevention intervention---environmental
modifications (Refer to Recommendations 2a-2c)
2a. Fall hazard signage for signaling and indicating patients with a risk of falling
should be used to alert frontline staff. [Grade of recommendation: A]
Fall risk alert cards are important to alert not only nursing staff but also
multidisciplinary health care providers in the ward to be aware of patients’ risk of
falling (Haines, Bennell, Osborne & Hill, 2004 [1++], Ang, Mordiffi & Wong,
2011 [1++]).
61
2b. Environmental assessment of the ward environment should be performed to
provide patients with a safe environment that is free from hazards. [Grade of
recommendation: A]
Examples of environmental safety assessments includes providing call bells
within reach, assessing a patient’s ability to use them, reviewing the need for
bedrails, keeping the bed at an appropriate level for the individual patient and
ensuring adequate lighting. A safe environment in hospital care settings that is
free from hazards is important for the prevention of falls, especially for elderly
patients (Healey, Monro, Cockram, Adams & Heseltine, 2004 [1+]; Cumming et
al., 2008 [1+]).
2c. Assessment of a patient’s personal care and protection aids is an
environmental modification for fall prevention. [Grade of recommendation:
A]
Examples of the safety assessment of a patient’s personal care and protection aids
includes checking patients for properly fitting clothes, checking proper footwear
of patients and advising accordingly and checking if patients are wearing
appropriate optical and hearing aids. Nurses must assess the personal care and
protection aids of patients to remove the possible fall risk factors of patients
(Haines, Bennell, Osborne & Hill, 2004 [1++]; Healey, Monro, Cockram, Adams
& Heseltine, 2004 [1+]; Cumming et al., 2008 [1+]).
62
Appendix I: Evidence-based guidelines of the multifactorial fall prevention programme---
Step 3
STEP 3: Patients with a score >0 in Risk factor “History of falling” or “Mental
status” are identified as in need of receiving multifactorial fall prevention
intervention---knowledge.
Recommendations for multifactorial fall prevention intervention---knowledge (Refer to
Recommendations 3a-3c)
3a. General education on fall prevention can be provided for patients and their
relatives verbally/face-to-face with the provision of an education pamphlet.
[Grade of recommendation: A]
General knowledge training that covers the nature of hospital falls, how
participants can prevent fall and orientation with the ward environment and
routines can increase a patient’s awareness of the risk of falling (Haines, Bennell,
Osborne & Hill, 2004 [1++]; Cumming et al., 2008 [1+]).
3b. Educational session related to analysis of individual patient’s fall risk factors
can be provided to increase the patient’s awareness of specific risks of falling
during hospitalization. [Grade of recommendation: A]
Educational session on targeted multiple interventions according to the
participants’ specific fall risk factors was used to increase the participants’
63
awareness of their specific fall risk factors and to provide strategies to reduce the
specific risk (Ang, Mordiffi & Wong, 2011 [1++]).
3c. Patient education on fall prevention should be conducted in a language that
the patient can comprehend. [Grade of recommendation: A]
Patient education on fall prevention is unlikely to be effective if patient cannot
fully understand the communication. For patients with communication problems,
education on fall prevention was also given to the relatives of the patients (Ang,
Mordiffi & Wong, 2011 [1++]).
64
Appendix I: Evidence-based guidelines of the multifactorial fall prevention programme---
Step 4
STEP 4: Patients with a score >0 in Risk factor “Secondary diagnosis” or
“Intravenous therapy/Saline lock” are identified as in need of receiving
multifactorial fall prevention intervention---medication review.
Recommendations for multifactorial fall prevention intervention---medication review
(Refer to Recommendation 4a-4b)
4a. Check for any prescription of diuretics, anti-hypertensives, sedatives, anti-
depressants, etc. and advising patients of related therapeutic or adverse
effects accordingly can the minimize risk of falling. [Grade of
recommendation: A]
A medication review is an important component of the fall prevention programme
because the therapeutic or adverse effects of medication may increase the risk of
patients falling (Healey, Monro, Cockram, Adams & Heseltine, 2004 [1+];
Stenvall et al., 2007 [1+]; Ang, Mordiffi & Wong, 2011 [1++]).
65
4b. Medical officers should review and revise the patient’s medications and
reduce the total number of medications if indicated because polypharmacy is
associated with an increased risk of falling. [Grade of recommendation: A]
Assessment and modification of prescription by medical officers is an important
feature of a fall prevention programme because the use of more than three or four
medications a day is related to an increased risk of falling (Healey, Monro,
Cockram, Adams & Heseltine, 2004 [1+]).
66
Appendix I: Evidence-based guidelines of the multifactorial fall prevention programme---
Step 5
STEP 5: Patients with score >0 in Risk factor “Ambulatory aid” or “Gait” are
identified as in need of receiving multifactorial fall prevention
intervention---exercise.
Recommendations for multifactorial fall prevention intervention---exercise (Refer to
Recommendations 5a-5c)
5a. Exercise that targets gait, balance and functional training is recommended
for patients with balance and gait deficits as an effective intervention to
reduce the risk of falling. [Grade of recommendation: A]
Exercises designed to enhance balance and functional abilities should be offered
to patients with balance and gait deficits to reduce the risk of falling (Haines,
Bennell, Osborne & Hill, 2004 [1++]; Stenvall et al., 2007 [1+]; Cumming et al.,
2008 [1+]; Ang, Mordiffi & Wong, 2011 [1++]).
5b. Physiotherapists should prescribe individual exercise programmes for
patients and supervise patients who are exercising. [Grade of
recommendation: A]
Exercise programmes should be tailored to meet the individual abilities of patients
and be supervised by qualified health professionals (Haines, Bennell, Osborne &
Hill, 2004 [1++]; Cumming et al., 2008 [1+]).
67
5c. Physiotherapists are referred to for the mobility assessment of patients.
Appropriate ambulatory aids are prescribed and instructions on the use of
the aids are provided to patients accordingly after assessment. [Grade of
recommendation: A]
To ensure safe mobility in the ward, physiotherapy staff prescribed patients with
appropriate walking aids after assessment and educated them in the use of the aids
(Cumming et al., 2008 [1+]).
68
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