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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