JAN. Reducing serious fall-related injuries in acute hospitals: are low-low beds a critical success factor? JOURNAL OF ADVANCED NURSING

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1 JAN JOURNAL OF ADVANCED NURSING ORIGINAL RESEARCH Reducing serious fall-related injuries in acute hospitals: are low-low beds a critical success factor? Anna Barker, Jeannette Kamar, Tamara Tyndall & Keith Hill Accepted for publication 3 March 2012 Correspondence to: A.L. Barker: anna.barker@monash.edu.au and J. Kamar: jeanette.kamar@nh.org.au Anna Barker PhD BPhty MPhty Senior Research Fellow Centre of Research Excellence in Patient Safety, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia and Northern Clinical Research Centre, The Northern Hospital, Epping, Victoria, Australia Jeannette Kamar BAppSc (Nsg) GradCert (Psych Nurs) Injury Prevention/Falls Coordinator Injury Prevention Unit, The Northern Hospital, Epping, Victoria, Australia Tamara Tyndall BAppSc (Nsg) Injury Prevention Nurse Injury Prevention Unit, The Northern Hospital, Epping, Victoria, Australia Keith Hill BAppSc(Physio) PhD Professor/Head of School School of Physiotherapy, Curtin University, Perth, Western Australia and Preventive and Public Health Division, National Ageing Research Institute, Parkville, Victoria, Australia BARKER A., KAMAR J., TYNDALL T. & HILL K. (2013) Reducing serious fallrelated injuries in acute hospitals: are low-low beds a critical success factor? Journal of Advanced Nursing 69(1), doi: /j x Abstract Aim. This article is a report of a study of associations between occurrence of serious fall-related injuries and implementation of low-low beds at The Northern Hospital, Victoria, Australia. Background. A 9-year evaluation at The Northern Hospital found an important reduction in fall-related injuries after the 6-PACK falls prevention program was implemented. Low-low beds are a key component of the 6-PACK that aims to decrease fall-related injuries. Design. A retrospective cohort study. Methods. Retrospective audit of The Northern Hospital inpatients admitted between Changes in serious fall-related injuries throughout the period and associations with available low-low beds were analysed using Poisson regression. Results. During the observation of 356,158 inpatients, there were 3946 falls and 1005 fall-related injuries of which 60 (5Æ9%) were serious (55 fractures and five subdural haematomas). Serious fall-related injuries declined significantly throughout the period. When there was one low-low bed to nine or more standard beds there was no statistically significant decrease in serious fall-related injuries. An important reduction only occurred when there was one low-low bed to three standard beds. Conclusion. The 6-PACK program has been in place since 2002 at The Northern Hospital. Throughout this time serious fall-related injuries have decreased. There appears to be an association between serious fall-related injuries and the number of available low-low beds. Threshold numbers of these beds may be required to achieve optimal usability and effectiveness. A randomized controlled trial is required to give additional evidence for use of low-low beds for injury prevention in hospitals. Keywords: accidental falls, fracture, hospital, injury prevention, nursing 112 Ó 2012 Blackwell Publishing Ltd

2 JAN: ORIGINAL RESEARCH Introduction Serious fall-related injuries such as fractures and subdural haematomas in older hospitalized patients are costly to individuals and the healthcare system. They are associated with an increased risk of death, admission to residential aged care and deterioration in a person s capacity to perform activities of daily living (Murray et al. 2007). Past studies report 60% of falls in acute general medical and surgical wards result in injury (Barker et al. 2009a) and 6 9% result in serious injuries (Fonda et al. 2006, Galbraith et al. 2011). The changing demographics of ageing populations suggest that fall-related injury burden will escalate in coming decades (Moller 2005). Despite a substantial increase in falls prevention awareness and activity over the last decade, a recent Australian study found a doubling in the rates of reported fall-related injuries and no decrease in the rates of fall-related fractures in Victorian public hospitals between 1998 and 2008 (Brand & Sundararajan 2010). Effective injury prevention strategies are required if falls injury burden is to be at a minimum stabilized or more optimistically reduced. Background Falls from bed are common in hospital patients (Fonda et al. 2006, Bollini et al. 2010, De Paiva et al. 2010, Tzeng 2010) and can result in serious injuries such as fractures and subdural haematomas (Oliver et al. 2010). Therefore, if strategies can be implemented to reduce injuries acquired from falling out of bed there is likely to be a substantial reduction in overall fall-related injury burden in hospitals. Low-low beds have been increasingly implemented in hospitals in recent years, being considered a useful strategy for reducing fall-related injuries in hospitals and residential aged care facilities. Low-low beds can be lowered to floor level, reducing the harm which a patient suffers if they fall from the bed. However, despite increasing use and promotion of lowlow beds there is little evidence to support their effectiveness for reducing fall-related injuries. A recent cluster randomized trial by Haines et al. investigated the efficacy of a policy to introduce low-low beds for the prevention of fall-related injuries in hospitals (Haines et al. 2010). The study included 10,937 inpatients, 711 falls and 283 fall-related injuries, of which 23 were serious. The rate of falls, fall-related injuries and fall-related fractures did not differ between intervention and control wards after the introduction of the low-low beds (Haines et al. 2010). The authors report that participating hospitals had some difficulty in using the low-low beds as described in the research protocol. These included difficulty moving and positioning the beds and Low-low beds and serious fall-related injuries ensuring that the beds were allocated to patients at the highest risk of falls. The authors hypothesized three reasons for noeffect in their study. First, the low-low beds provided a false sense of security to hospital staff, resulting in decreased supervision of high falls-risk patients using these beds. Second, the low-low beds may only be able to prevent a small proportion of the overall number of falls on a ward; thus, even if the beds were allocated to the most appropriate patients and were being used correctly, the number needed to treat to prevent one fall with this intervention may still have been high. Third, as the rates of falls and fall-related injuries reduced in both the intervention and control wards a Hawthorne effect may have been present. The authors concluded that additional studies are required to determine the effect of low-low beds on serious fall-related injuries (Haines et al. 2010). In contrast to the findings of no-effect in the study by Haines et al., a report of a 3-year quality improvement project in a large acute hospital found a decrease in fallrelated injuries after implementation of a falls prevention program that included toileting schedules, low-low beds and bed alarms (Fonda et al. 2006). It must be acknowledged that this study was a longitudinal study (not a randomized trial) but the results do provide some proof of concept that a program including use of low-low beds may have an impact on reducing fall-related injuries. A recently published 9-year evaluation at The Northern Hospital (TNH) found a statistically significant reduction in fall-related injuries after a targeted multifactorial falls prevention programme the 6-PACK was implemented (Barker et al. 2009a). The programme included development and implementation of a new falls risk assessment process as part of the nursing care plan and six nursing interventions. A large scale cluster randomized controlled trial is currently being undertaken to give higher evidence of the 6-PACK effectiveness for reducing fall-related injuries and to examine its transferability to hospitals external to where it was developed (Barker et al. 2011). A key component of the 6-PACK programme was the implementation of low-low beds on high-falls risk wards. Low-low beds were introduced as a strategy to reduce the use of bed rails. Traditionally, staff used bed rails to deter patients from attempting to get out of bed independently. However, the use of bed rails has been discouraged due to evidence of increased patient injuries with their use (Capezuti et al. 1996, Todd et al. 1997, Hanger et al. 1999). The other 6-PACK interventions for high-falls risk patients (classification of risk based on the TNH- STRATIFY) (Barker et al. 2010), are placement of a fallsalert sign above the patient s bed; supervision of patients while in the bathroom; ensuring that the patient s walking aid is in reach at all times; establishment of a toileting regime; and Ó 2012 Blackwell Publishing Ltd 113

3 A. Barker et al. use of bed/chair alarm when patients are positioned in a chair or bed. It is thought that the low-low beds have played a major role in the reduction of fall-related injuries at TNH as described in the 9-year evaluation (Barker et al. 2009a). This prior study did not, however, investigate the associations between availability of low-low beds and fall-related injury rates. To address the low-low bed falls-related injury prevention evidence-practice gap, the aim of this study was to investigate changes in serious fall-related injuries and associations with implementation of low-low beds, over 11 years at TNH. The study Aim The aim of this study was to report the association between occurrence of serious fall-related injuries and implementation of low-low beds at The Northern Hospital, Victoria, Australia (TNH). Design A retrospective cohort study. Sample The sample consisted of 356,158 patients who were admitted to TNH, an acute hospital located in Melbourne, Australia between January 1999 December 2009 (Table 1). The hospital s bed capacity increased from during the study period. Low-low bed implementation The 6-PACK falls prevention programme was implemented at TNH in The main elements of the 6-PACK programme, except the number of available low-low beds, have remained essentially the same from 2002 until present. A detailed description of the 6-PACK programme, implementation strategy and outcomes is described elsewhere (Barker et al. 2009a). The 6-PACK intervention of interest in this study is the low-low beds. The majority of the low-low beds purchased by TNH were FLOORCAREÒ beds with TNH-6PACK features from Maxi-Care Promotions. The beds were specially designed for use in hospitals and include an electronic hand control for bed height, knee break and back rest similar to standard hospital beds and also include tilt and reverse Trendelenburg functions which are often utilized for neuro-surgical patients when head-up or down-tilt is a postoperative order. They can be lowered to floor level and raised to a maximum bed height of 70 cm. Low-low beds were acquired at three stages throughout the observation period. In 1999 there were five low-low beds on the high falls risk wards, in 2004 this increased to 13 and in 2007 there were 45 (Table 2). The low-low beds were located on the high falls risk wards which were medical and surgical units that local audit identified as the wards with the highest falls rates (Barker et al. 2009a). Ward assistants were available to locate and change standard beds to low-low beds at the request of nursing staff. As part of the 6-PACK falls prevention programme nursing staff were required to record the falls risk score and selected prevention strategies including a low-low bed strategy for their patients each shift on the patient care plan. This was to facilitate clear and up-to-date communication of patients falls risk and management between members of the care team. Staff from the TNH injury prevention unit provided ward staff with training on the use of the low-low beds. This included an explanation of the features of the low-low beds, instructions for care and use of the bed and practical demonstrations. Staff were advised to lower the bed to floor level at all times when a high-fall risk patient was positioned Table 1 Patients demographics Patients admitted (N) 24,624 25,654 26,006 26,298 27,817 32,022 34,711 35,694 38,269 41,587 43,476 Female (%) Occupied bed days Hospital-wide 80,407 89,116 80,036 82,183 86,801 93, ,943 95, , , ,700 High falls risk wards41,498 43,607 43,731 43,787 48,654 45,812 53,899 55,251 61,709 67,181 64,714 Mean age (years) Hospital-wide 49Æ90 49Æ95 46Æ30 45Æ53 46Æ27 47Æ33 46Æ83 46Æ59 47Æ29 47Æ23 47Æ43 High falls risk wards 64Æ75 63Æ74 60Æ14 60Æ93 59Æ20 59Æ22 59Æ59 60Æ37 61Æ40 61Æ73 61Æ66 Mean length of stay (days) Hospital-wide 3Æ46 3Æ45 3Æ37 3Æ30 3Æ24 2Æ93 2Æ89 2Æ90 2Æ95 2Æ98 2Æ85 High falls risk wards 5Æ09 5Æ40 6Æ53 6Æ33 5Æ84 5Æ78 5Æ77 6Æ10 5Æ69 5Æ71 5Æ Ó 2012 Blackwell Publishing Ltd

4 JAN: ORIGINAL RESEARCH Low-low beds and serious fall-related injuries Table 2 Patient falls and fall-related injuries during the observation period Falls (N) Hospital-wide High falls risk wards Fall-related injuries (N) Hospital-wide High falls risk wards Serious fall-related injuries (N) Hospital-wide High falls risk wards Falls (rate*) Hospital-wide 2Æ71 2Æ69 3Æ96 3Æ65 3Æ63 3Æ63 3Æ71 4Æ21 3Æ55 4Æ06 4Æ31 High falls risk wards 4Æ63 5Æ23 6Æ43 6Æ14 5Æ86 6Æ70 6Æ44 6Æ68 5Æ79 7Æ00 7Æ66 Fall-related injuries (rate*) Hospital-wide 1Æ55 1Æ39 1Æ65 1Æ31 0Æ98 0Æ61 0Æ65 0Æ71 0Æ68 0Æ63 0Æ68 High falls risk wards 2Æ80 2Æ73 2Æ47 2Æ33 1Æ99 1Æ16 1Æ11 1Æ16 1Æ20 1Æ10 1Æ21 Serious fall-related injury (rate*) Hospital-wide 0Æ09 0Æ09 0Æ07 0Æ07 0Æ07 0Æ05 0Æ06 0Æ06 0Æ04 0Æ03 0Æ02 High falls risk wards 0Æ17 0Æ18 0Æ14 0Æ14 0Æ12 0Æ11 0Æ11 0Æ11 0Æ06 0Æ06 0Æ03 Number of high falls risk wards Beds on high-risk wards (N) Low-low beds (N) Standard to low-low bed ratio *Rate per 1000 occupied bed days. On high fall risk wards. in the bed unsupervised. The importance of raising the bed when assisting or supervising patients getting in or out of bed to facilitate patient independence and to reduce the required staff physical assistance and subsequent risk of staff injury, was highlighted to staff. Information was also provided on how low-low beds might reduce falls-related injuries and how patients should be prioritized for use of these beds. For example, patients with cognitive impairment who nursing staff assess as being likely to try to get out of bed on their own and be at risk of falling when attempting this were highlighted as patients most likely to benefit from a low-low bed. However, staff were also informed that they would need to use their own judgment as to which patients should be positioned in a low-low bed. If a low-low bed was not available and the staff considered that it would be beneficial for a patient, they were advised to use a standard hospital bed and lower it to the lowest level when the patient was positioned in bed unattended and not to use the bed rails. After the low-low beds were implemented on wards the injury prevention staff conducted regular ward walk-rounds where they observed the use of low-low beds and provided reminders to staff about their safe and effective use. Specifically, staff were reminded to lower the low-low beds to floor level when high-risk patients were positioned in their bed and unattended. Data collection Data were collected between January 1999 December Patients suffering serious fall-related injuries during the observation period were identified through audit of the hospital incident reporting data base. The medical records of these patients were then audited by a Registered Nurse to verify the fall event and injury and to extract patient demographic, clinical and fall information. The primary outcome was the rate of in-hospital serious fall-related injuries per 1000 occupied bed days. A serious fall-related injury was defined as a fracture or subdural haematoma confirmed by radiological investigation. The definition of a fall used was an event which results in a person coming to rest inadvertently on the ground or floor or other lower level (World Health Organization 2009). It is mandatory that all patient falls be reported on the hospital computerbased incident reporting system RiskmanTM (Software Design & Enhancement, Victoria). Hospital-wide occupied bed day data were extracted from hospital administrative datasets. Ó 2012 Blackwell Publishing Ltd 115

5 A. Barker et al. Ethical considerations This study was considered a quality improvement activity conducted by TNH staff that involved no patient contact outside usual care and so ethical approval was not obtained. Data analysis Rate changes in falls, fall-related injuries and serious fallrelated injuries throughout the observation were analysed using Poisson regression with yearly falls, fall-related injuries or serious fall-related injury counts as the dependent variable, the year of observation the single explanatory variable and occupied bed days as the exposure variable. Serious fallrelated injury counts were aggregated by year rather than month as they are rare events and therefore larger groupings permitted more precise estimates of change. Associations between the ratio of standard beds to low-low beds and changes in rates of serious fall-related injuries were also explored using Poisson regression. This model was the same as the first model except that the ratio of standard beds to low-low beds was the single explanatory variable and this was entered as a dummy categorical variable so that each ratio was compared with the baseline ratio. There were four low-low bed categories representing the four different standard to low-low bed ratios present in the observation period on the high-risk wards (Table 2). Linearity assumptions between the time variable (year) and the outcome (rate of serious fall-related injuries) were tested using standard methods. To ensure that Poisson models were the best fit to the data, negative binomial models that adjust for data clustering [a common property of hospital fall data (Barker et al. 2009b)] were first estimated and the overdispersion parameter alpha and associated P values computed. If the P values for alpha were not statistically significant (>0Æ05) the Poisson model was considered appropriate as data were not over-dispersed. Associations were reported as incidence rate ratios (IRRs) and 95% confidence intervals based on the Poisson distribution were calculated. P 0Æ05 was considered to be statistically significant. Descriptive statistics were used to profile serious fall-related injuries. Changes in the number of annual admissions, age and length of stay throughout the observation period were explored using linear regression models with the demographic variable listed as the outcome variable and year as the single explanatory variable. All analyses were conducted using STATA MP version 11.0 (Stata Corp., College Station, TX, USA). Results The average patient age (hospital-wide and high falls risk wards) and high-risk ward length of stay did not change throughout the study observation period (linear regression P > 0Æ05). Throughout the 11-year observation period, the average patient age on the high falls risk wards was between 59 and 65 years and between 52% and 57% of patients admitted to these wards were women (Table 1). Throughout the 11-year observation period, the annual number of admissions increased and the hospital-wide average length of stay decreased (linear regression P < 0Æ001) (Table 1). During the observation of 356,158 inpatients, there were 3946 falls and 1005 fall-related injuries of which 60 (5Æ9%) were serious (55 fractures and 5 subdural haematomas). Serious fall-related injuries are rare events with a hospitalwide maximum of eight in 2000 and minimum of two in 2009 (Table 2). The Alpha for both negative binomial models was non-significant (P =0Æ500) indicating data were not over-dispersed and that Poisson models would be most appropriate. The rate of falls increased throughout the period [Poisson regression Incidence rate ratio (IRR) = 1Æ03; 95% CI: 1Æ02 1Æ04; P < 0Æ001]. The rate of falls injuries (Poisson regression IRR = 0Æ90; 95% CI: 0Æ88 0Æ92; P < 0Æ001) and serious fall-related injuries (Poisson regression IRR = 0Æ88, 95% CI: 0Æ82 0Æ96, P =0Æ003) both declined significantly throughout the period. This indicates that the percent change in the rate of serious falls-related injuries decreased 12% each year of observation (Table 2). Table 3 Associations between available low-low beds and serious fall-related injuries. Incidence rate ratio (95% confidence interval) P* 1 low-low bed to 19 standard beds ( ) Reference 1 low-low bed to 25 standard beds ( ) 0Æ75 (0Æ37 1Æ51) 0Æ417 1 low-low bed to 9 standard beds ( ) 0Æ72 (0Æ36 1Æ42) 0Æ343 1 low-low bed to 3 standard beds ( ) 0Æ34 (0Æ16 0Æ70) 0Æ004 *Based on the Poisson regression model. 116 Ó 2012 Blackwell Publishing Ltd

6 JAN: ORIGINAL RESEARCH When there was one low-low bed to nine or more standard beds on high falls risk wards there was no statistically significant decrease in serious fall-related injuries (Poisson regression IRR >0Æ72, P > 0Æ343). A statistically significant reduction only occurred when the ratio was one low-low bed to three standard beds (Poisson regression IRR = 0Æ34, 95% CI: 0Æ16 0Æ70; P = 0Æ004) (Table 3). The results indicate that the expected serious fall-related injury rate with a ratio of one low-low bed to three standard beds is approximately one third of the expected rate for the reference group (one lowlow bed to 19 standard beds). The majority of serious fall-related injuries were fractures (92%). Fractures to the femur were the most common injury sustained (70%) and falls in the patient s bedroom were also the most common location for serious fall-related injuries to occur (60%). Patients suffering a serious fall-related injury were more commonly women (62%) and aged 80 years and older (67%) (Table 4). Discussion Although the problem of falls in hospital inpatients is a key focus for clinicians, healthcare providers and stakeholders, Table 4 Characteristics of fallers sustaining serious injury and circumstances of falls resulting in serious injury. (N = 60) % Fracture Base of skull 1 2 Femur Ankle 1 2 Elbow 1 2 Humerus 4 6 Wrist 3 5 Ribs 2 3 Spine 1 2 Subdural haematoma 5 8 Fall location Bathroom Bedroom Other Female Age Low-low beds and serious fall-related injuries in-hospital falls continue to be a major source of personal and healthcare burden in Australia and internationally. The quest for innovative and effective strategies to reduce this burden is high on the public health agenda. Low-low beds have been suggested as one such strategy. Our study provides preliminary evidence that low-low beds may be a key component of in-hospital falls programmes to reduce serious fall-related injuries. An important finding, however, was that threshold numbers of these beds may be required to achieve optimal usability and effectiveness. The observed decline in serious fall-related injuries without a decline in falls warrants discussion. The finding of reduced fall-related injuries, although not specifically serious fallrelated injuries, was discussed in detail in the 9-year evaluation study of the 6-PACK (Barker et al. 2009a). The factors identified in this evaluation relating to falls injuries also apply to the findings of this study of serious fall-related injuries. Specifically, increased fall reporting with improved falls prevention practice and awareness and that the 6-PACK interventions may only reduce falls injuries and not the number of falls, were proposed as potential explanations of the finding of a decline in serious fall-related injuries but not falls. The latter is intuitive: a low-low bed will not stop a fall from occurring. A confused patient may still roll out of a lowlow bed and this will be classified and reported as a fall by nursing staff as it meets the fall definition used at TNH, but because of the low bed height the risk of injury is markedly reduced. Despite the increasing use and promotion of low-low beds as an effective strategy to reduce harm to patients who fall while attempting to get out of bed, there is limited evidence of their benefit. In contrast to the findings of the current study, a large scale pragmatic cluster randomized controlled trial conducted by Haines et al. found a Queensland Health policy to introduce low-low beds did not appear to reduce fallrelated injuries (Haines et al. 2010). There are several factors which may explain the different results between the Haines and current study. First, the current study found that serious falls-related injuries did not reduce until a substantial number of low-low beds were available. The Haines trial had a ratio of one low-low bed to every 12 standard beds, whereas the present study only identified an important significant reduction when the ratio was 1:3. This relationship is intuitive when the dynamic and transient nature of the hospital ward and workforce is considered. Flow of patients throughout the hospital ward is constant. In an acute hospital length of stay is short currently less than 3 days in this study population and patients can transfer between beds throughout their admission highlighting the high number of bed transitions. In this environment, nurses have high workloads managing Ó 2012 Blackwell Publishing Ltd 117

7 A. Barker et al. patients acute care needs, transfers and discharge planning. Consequently, sourcing of non-critical equipment such lowlow beds may be low on a nurse s patient care priority list. In addition, the high movement of patients through beds may place a logistical challenge to moving the low-low beds to patients most in need. In the case of this study every fourth bed available in high fall risk wards was a low-low bed. As such, the logistical challenge of allocating a low-low bed to a patient most in need is expected to be lower at TNH than in the Haines study where there were fewer low-low beds available. Aside from the above-explained benefits of increased availability of beds for improving access to this injury prevention resource there are likely to also be flow-on utility effects. The ratio of one low-low bed to each three standard beds at TNH means that nurses have a high exposure to low-low beds. It is likely that most nurses will have at least one of their patients positioned in a low-low bed each shift. This is likely to promote staff familiarity with the beds which is likely to improve their effectiveness. If a lowlow bed is not lowered to floor level when a high fall risk patient is positioned in bed unattended then it will be of no greater benefit than a standard bed for reducing fall-related injuries. Thus, the human factors of the correct use of beds is critical to their effectiveness. Further to this point, a second factor that may explain the difference in results between the current and Haines study results is the staff education, audit and feedback processes in place at TNH. Injury prevention staff regularly conducted ward walk-rounds where they observed the use of low-low beds and provided reminders and feedback to staff on their performance with low-low bed use. These strategies are increasingly being recognized as vital ingredients to achieving implementation effectiveness with health service interventions (Scott 2009). They are also valuable in the current nursing workforce climate where there are increasing numbers of agency or new staff who may not yet have had opportunity to attend formal scheduled training sessions. The Haines study provided wards with manuals on the use of low-low beds and site representatives were able to contact researchers to report concerns surrounding the use of the low-low beds. They did not report conducting face-toface training with practical demonstrations or site visits for the purpose of audit, feedback and reminders. The presence of structured and supported face-to-face implementation and review associated with the implementation of low-low beds may have been a factor in the observed reduction in fallrelated injuries in the present study. The final factor that may explain the difference in results between the current and Haines studies is the observation period. The Haines study use a 6-month observation period whereas in the current study this was 11 years. Prior falls prevention studies that have used observation periods of only a few months and found no effect have considered an important factor in the lack of effect to be that achieving change in practice takes time (Cumming et al. 2008). The observation period in the Haines study may have been too short to capture practice change with respect to the effective use of the low-low beds. It should also be noted that other falls prevention activities included in the 6-PACK programme other than the low-low beds may have contributed to the reduction in serious fallrelated injuries. The 6-PACK programme consists of risk assessment of all patients and selection and application of one or more targeted interventions for patients classified as high risk by nurses. The number of available low-low beds on high falls risk wards has increased over the last 10 years at TNH although the five other 6-PACK interventions and implementation strategies have remained relatively constant. It is thought that the low-low beds have played a major role in the reduction of serious fall-related injuries at TNH but without high level evidence such as that obtained from a randomized controlled trial we cannot say for sure that that was the reason of the reduction observed. It could have been attributable to any of the 6-PACK interventions or a combination of them. It should be noted that throughout the implementation of the 6-PACK programme at TNH it was also promoted to staff that if no low-low bed was available and the patient was in a standard bed the bed rails should never be used to keep restless/high falls risk patients in bed. It is plausible that a declining use of bed rails contributed to the declining trends in serious fall-related injuries observed. A randomized controlled trial that compares the effectiveness of a policy to reduce the use of bed rails and lowering standard beds to their lowest height versus using low-low beds when restless/high falls risk patients are positioned in bed unsupervised would be a useful study to undertake. No other important injury prevention activities or shifts in patient case mix have been identified that may have contributed to the reductions in serious fall-related injuries at TNH. It is important to note that the rarity of fall-related injuries and particularly serious fall-related injuries creates noise or fluctuations in the data that can obscure temporal trends and true shifts in the occurrence of these events. Simple monitoring of raw counts of these events on a month by month basis may trigger an unnecessary review of events and system changes when counts appear to increase. This issue of tampering with effective patient safety systems is discussed in detail in a review of statistical process for monitoring hospital adverse events (Barker et al. 2009b). It appears that for rare events such as serious fall-related injuries, analysis should involve consideration of rates rather than raw counts 118 Ó 2012 Blackwell Publishing Ltd

8 JAN: ORIGINAL RESEARCH What is already known about this topic Injuries such as fractures and subdural haematomas sustained by patients who fall while in hospital are costly to individuals and the healthcare system. Falls from bed are common in hospital and can result in serious injury and in a small proportion lead to fractures and subdural haematomas. Low-low beds can be lowered to floor level, reducing the harm which a patient suffers if they fall from the bed. What this paper adds Low-low beds have been increasingly implemented in hospitals in recent years, being considered a useful strategy for reducing fall-related injuries. Despite their increasing use and promotion, there is little evidence to support their effectiveness for reducing fall-related injuries. To address the low-low bed falls-related injury prevention evidence-practice gap, the aim of this study was to investigate changes in serious fall-related injuries and associations with implementation of low-low beds, over an 11-year period at an acute Australian hospital. Implications for practice and/or policy There appears to be an association between serious fallrelated injuries and the number of available of low-low beds. Threshold numbers of these beds may be required to achieve optimal usability and effectiveness. and use statistical tools to enable true variation to be differentiated from random noise. Limitations Limitations of this study include the methodology used. It was not a randomized controlled trial and thus, some observed effects may have been because of factors other than the low-low beds, for example, changes in the hospital population, policy and environment. Although the magnitude and direct effect of these other changes cannot be quantified, this study used robust analyses on a large sample and with a long observation period. The chosen methodology addressed a specific question: are changes in the rates of serious fall-related injuries associated with the availability of lowlow beds? This real-world study suggests that there is an association and provides meaningful insights into the numbers of beds and implementation strategies likely to achieve optimal effects. Despite these strengths, this was a singlecentre study therefore the generalization of the findings to other patient groups or settings needs to be explored. A potential methodological limitation is that only one source of data (incident reports) was used to ascertain the primary outcome (falls). Previous studies have shown under-reporting is evident when just one data source is used in hospital-based falls prevention studies rather than combining incident reports with record review and patient self-report (Hill et al. 2010). It is likely, however, that falls resulting in serious injuries are the ones most likely to be reported, so the effect of under-reporting in this study is considered to be low. Conclusion The 6-PACK programme has been in place since 2002 at TNH and throughout this time serious fall-related injuries have decreased. There appears to be an association between serious fall-related injuries and the number of available of low-low beds. Threshold numbers of these beds may be required to achieve optimal usability and effectiveness. Several factors were identified that were likely to have driven this improved outcome. They were, provision of small group training and audit and feedback through regular ward walkrounds by injury prevention unit staff. A randomized controlled trial is required to strengthen evidence for use of low-low beds in this high-risk population. In addition, in the context of increasing implementation of patient safety interventions in the hospital setting, the effectiveness of simple single interventions such as low-low beds should be compared with more complex multifaceted fall-related injury prevention interventions. Finally, the climate of rising healthcare costs demands that the cost-effectiveness of interventions also be determined. Acknowledgements The 6-PACK Program Development, Injury Prevention Unit, The Northern Hospital, Northern Health, Melbourne, Australia. Funding Low-low beds and serious fall-related injuries This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Ó 2012 Blackwell Publishing Ltd 119

9 A. Barker et al. Conflict of interest No conflict of interest has been declared by the authors. Author contributions All authors meet at least one of the following criteria (recommended by the ICMJE: and have agreed on the final version: substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content. References Barker A., Kamar J., Morton A. & Berlowitz D. (2009a) Bridging the gap between research and practice: review of a targeted hospital inpatient fall prevention programme. Quality & Safety in Health Care 18, Barker A., Morton A., Gatton M., Tong E. & Clements A. (2009b) Sequential monitoring of hospital adverse events when control charts fail: the example of fall injuries in hospitals. Quality & Safety in Health Care 18, Barker A., Kamar J., Graco M., Lawlor V. & Hill K. (2010) Adding value to the STRATIFY falls risk assessment in acute hospitals. Journal of Advanced Nursing 67, Barker A., Brand C., Haines T., Hill K., Brauer S., Jolley D., Botti M., Cumming R., Livingston P.M., Sherrington C., Zavarsek S., Morello R. & Kamar J. (2011) The 6-PACK programme to decrease fall-related injuries in acute hospitals: protocol for a cluster randomised controlled trial. Injury Prevention 17, e5. Bollini G., Lolli A., Cattin P., Zampieri P. & Lamberti M. (2010) Falls of patients in hospital: testing of a notification system and statistical monitoring. Prof Inferm 63, Brand C.A. & Sundararajan V. (2010) A 10-year cohort study of the burden and risk of in-hospital falls and fractures using routinely collected hospital data. Quality & Safety in Health Care 19, 1 7. Capezuti E., Evans L., Strumpf N. & Maislin G. (1996) Physical restraint use and falls in nursing home residents. Journal of the American Geriatrics Society 44, Cumming R.G., Sherrington C., Lord S.R., Simpson J.M., Vogler C., Cameron I.D. & Naganathan V. (2008) Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ 336, De Paiva M.C., De Paiva S.A., Berti H.W. & Campana A.O. (2010) Characterization of patient falls according to the notification in adverse event reports. Revista da Escola de Enfermagem da USP 44, Fonda D., Cook J., Sandler V. & Bailey M. (2006) Sustained reduction in serious fall-related injuries in older people in hospital. Medical Journal of Australia 184, Galbraith J., Butler J., Memon A., Dolan M. & Harty J. (2011) Cost analysis of a falls-prevention program in an orthopaedic setting. Clinical Orthopaedics and Related Research 469, Haines T.P., Bell R.A. & Varghese P.N. (2010) Pragmatic, cluster randomized trial of a policy to introduce low-low beds to hospital wards for the prevention of falls and fall injuries. Journal of the American Geriatrics Society 58, Hanger H.C., Ball M.C. & Wood L.A. (1999) An analysis of falls in the hospital: can we do without bedrails? Journal of the American Geriatrics Society 47, Hill A.M., Hoffmann T., Hill K., Oliver D., Beer C., Mcphail S., Brauer S. & Haines T.P. (2010) Measuring falls events in acute hospitals-a comparison of three reporting methods to identify missing data in the hospital reporting system. Journal of the American Geriatrics Society 58, Moller J. (2005) Current costing models: are they suitable for allocating health resources? The example of fall injury prevention in Australia. Accident Analysis and Prevention 37, Murray G.R., Cameron I.D. & Cumming R.G. (2007) The consequences of falls in acute and subacute hospitals in Australia that cause proximal femoral fractures. Journal of the American Geriatrics Society 55, Oliver D., Healey F. & Haines T.P. (2010) Preventing falls and fallrelated injuries in hospitals. Clinics in Geriatric Medicine 26, Scott I. (2009) What are the most effective strategies for improving quality and safety of health care? Internal Medicine Journal 39, Todd J.F., Ruhl C.E. & Gross T.P. (1997) Injury and death associated with hospital bed side-rails: reports to the US Food and Drug Administration from 1985 to American Journal of Public Health 87, Tzeng H.M. (2010) Understanding the prevalence of inpatient falls associated with toileting in adult acute care settings. Journal of Nursing Care Quality 25, World Health Organization (2009) Violence and injury prevention and disability (VIP). Retrieved from injury_prevention/other_injury/falls/en/index.html on 26 June Ó 2012 Blackwell Publishing Ltd

10 JAN: ORIGINAL RESEARCH Low-low beds and serious fall-related injuries The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers. For further information, please visit JAN on the Wiley Online Library website: Reasons to publish your work in JAN: High-impact forum: the world s most cited nursing journal, with an Impact Factor of 1Æ477 ranked 11th of 95 in the 2011 ISI Journal Citation Reports (Social Science Nursing). Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries worldwide (including over 3,500 in developing countries with free or low cost access). Fast and easy online submission: online submission at Positive publishing experience: rapid double-blind peer review with constructive feedback. Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication. Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley Online Library, as well as the option to deposit the article in your own or your funding agency s preferred archive (e.g. PubMed). Ó 2012 Blackwell Publishing Ltd 121