Abstract of thesis entitled. Evidence-based guidelines of fall prevention programme for hospitalized older patients. Submitted by.

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1 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 communitydwelling 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

2 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

3 provide the health care practitioners with an evidence-based approach in fall risk assessment and management so as to prevent in-patient falls.

4 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

5 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

6 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.

7 Table of Contents Declaration Acknowledgements Table of contents Chapter 1 INTRODUCTION Page 1.1 Background Affirming the need Objectives and significance 4 Chapter 2 CRITICAL APPRAISAL 2.1 Search and appraisal strategies Criteria for considering studies for the review 2.12 Search strategies for the identification of studies 2.13 Appraisal strategies 2.2 Results 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 Results of the systematic review 2.32 Summary of the components of a multifactorial fall prevention programme Multifactorial fall risk assessment Exercise Medication review Environmental modifications Knowledge 2.4 Implications for practice 17

8 Chapter 3 TRANSLATION AND APPLICATION 3.1 Implementation potential Target audience 3.12 Target setting 3.13 Transferability of findings 3.14 Feasibility Support from the administration level 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 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 Training workshop for the innovation 4.22 The pilot test 4.3 Evaluation plan Intervention outcomes identification Patient outcomes Healthcare provider outcomes 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

9 Appendices 44 References 68

10 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

11 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, 1

12 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. 2

13 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 3

14 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: 4

15 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 evidencebased 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. 5

16 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 6

17 considered. Trials that only reported the severity of falls, such as the number of injurious falls, were excluded 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 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 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), The methodology checklist for controlled trials of SIGN is attached in 7

18 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. 8

19 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 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 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. 9

20 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 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, 10

21 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 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 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 11

22 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 12

23 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 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 13

24 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 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 14

25 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 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). 15

26 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 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 16

27 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) 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. 17

28 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 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. 18

29 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 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 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. 19

30 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 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) 20

31 Hospital care Included acute and sub-acute units in Sub-acute unit of a medical settings admitted Length of hospital stay both medical and surgical wards Mean length of stay: >20days ward 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 subacute 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 21

32 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 22

33 Commencement Duration Date Equipment and training materials preparations + Nursing 1 st march, month staff training Pilot study 1 st April, month Evaluation and modification of the pilot study 1 st May, month Period of implementation and evaluation of the innovation 1 st June, months Total: 15 months 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 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 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 23

34 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. 24

35 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. 25

36 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 $ , as stated in Table 4b. The cost-benefit ratio of the innovation is less than 0.08 (14750/186561). 26