RECOMENDACIONES

The majority of the literature concerning falls in any clinical environment has focused on prevention strategies, including single trials and systematic reviews such as a Cochrane Review (Cameron et al., 2010). There is still much debate regarding the best approach to managing the problem of hospital-based falls, primarily as there is insufficient data, certainly in comparison to community-based studies (Gillespie et al., 2009; NPSA, 2007). However, growing interest in researching the area has meant that there are now guidelines as to what constitutes best practice. NHS organisations have already begun to adopt effective measures of reducing falls rates (RCP, 2011) and this will inevitably continue to develop as the evidence-base is strengthened by studies investigating specific components of what is considered to be a complex area (Cameron et al., 2010; Campbell and Robertson, 2009;

Gillespie et al., 2009; Oliver, 2008; Kannus et al., 2006). This section will initially set the broad context of prevention strategies within an in-patient setting before focusing on specific studies more relevant to the underpinning themes of this study.

2.7.1 Falls prevention: Cochrane Review (2010)

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Previous Cochrane Reviews have focused on interventions preventing falls in older people living in the community (Gillespie et al., 2009) and exercise for improving balance in older people (Howe et al., 2007). The Cochrane Library published a review (Cameron et al., 2010) that evaluated randomised controlled trials (RCT) of interventions for preventing falls in older people in nursing care facilities and hospitals. The review aimed to inform best practice and to provide direction for future research. It differed from an earlier Cochrane Review as it recognised that patient characteristics and the environment influenced the types of interventions implemented by professionals with different skill mixes in different clinical settings. This was substantiated further by the review as data concerning nursing care facilities were separated from hospital-based studies.

Numerous outcome measures were used in the review, including number of falls, number of fallers, severity of falls, fractures/deaths, and complications of the interventions.

Interventions were classified according to a taxonomy developed by the Prevention of Falls Network Europe (ProFaNe), which detailed categories and sub-categories of types of interventions, such as exercises, medication, surgery, environmental/assistive technology etc. 41 studies were included, with eleven of these being based in hospital settings. Seven trials tested the effect of a single intervention and four trials tested a multifactorial intervention i.e. those comprised of several components, often including exercise, education, review of medication and environmental risk modification (Cameron et al., 2010).

The first key finding of the Cochrane Review was that the effectiveness of supervised exercise within a sub-acute setting to reduce falls or reduce falls risk was inconsistent (Cameron et al., 2010), partly due to the differences between the patients recruited for the three hospital studies reviewed (Barreca et al., 2004; Donald et al., 2000; Jarvis et al., 2007). However, the collective data of these three studies showed a significant reduction in the risk of falling (risk ratio 0.44, 95% confidence interval 0.20 to 0.97: I2 = 0%). Barreca et al. (2004) demonstrated similar falls rates between the control (n = 3) and intervention ( n = 3) groups; Donald et al. (2000) found reduced falls rates between control (n = 17) and intervention (n = 5) participants; falls rates could not be determined in Jarvis et al. (2007).

Other single interventions, such as medication targeting (vitamin D supplementation), psychological interventions and environmental/assistive technology studies, demonstrated no significant difference in risk of falling or reduction of fallers in a hospital setting. There was a significant increase in the rate of falling on carpet flooring (Donald et al., 2000), and

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one study reported a non-significant increase in the risk of falling in an intervention group (27 intervention versus 21 control; hazard ratio of 1.3 = 95% confidence interval: 0.8 to 2.4) wearing a blue identification bracelet (Mayo et al., 1994). The findings from four hospital multifactorial studies showed various significant reductions in rate of falls and risk of falling:

Cumming et al. (2008) found 9.26 falls per 1000 bed days (intervention group) and 9.20 falls per 1000 bed days (control group), p = 0.96, 381 total falls; Stenvall et al. (2007) found 6.29 falls per 1000 bed days (intervention group, 18 total falls) and 16.28 falls per 1000 days (control group, 60 total falls), p = 0.006; Haines et al. (2004) found 30% fewer falls in the intervention group (n = 105) compared to the control group (n = 149), relative risk 0.78 (95%

confidence interval 0.56 to 1.06); Healey et al. (2004) found their intervention group (n = 180) had fewer falls than the control group (n = 319) six months following the introduction of the intervention (risk ratio 0.71, 95% confidence interval 0.55-0.90, p = 0.006). However, the number of reported fractures could not be analysed due to insufficient data, and the pooled data of the studies were not necessarily applicable to hospital settings where there were short lengths of stay. The review stated that it was difficult to interpret multifactorial interventions due to the complexities of having different component elements.

The adverse effects of implementing falls prevention strategies were briefly explained in the review. It was noted that interventions may, paradoxically, increase the risk of falls and injuries. Frail older people might be less likely to benefit from participating in exercise programmes (Faber et al., 2006). There was a balance between encouraging patients to be more involved in interventions and monitoring the subsequent risks inherently involved with increased activity (NPSA, 2007). The review suggested that there was a potential need to increase additional resources if hospitals implemented prevention programmes.

The Cochrane Review of interventions to reduce falls in hospitals and nursing care facilities (Cameron et al., 2010) was an invaluable addition to the growing evidence-base underpinning falls in acute care settings. The methodological quality of the review was high due to a robust approach towards searching for key literature, data analysis and inter-rater reliability. Part of the strength of this review came from the exclusive use of RCTs only. This ensured that the studies reviewed by Cameron et al. (2010) were good quality and added marked value to the field of in-patient falls prevention, yet by the same virtue excluded other studies which have made important contributions to the evidence-base.

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There was insufficient data to evaluate the impact of particular aspects of interventions as it was established that there is too much variation in the literature regarding type, targeting, intensity and duration of falls prevention programmes. Strategies commonly applied in clinical settings, such as supervision of patients and alarm systems, have not been thoroughly researched in RCTs although have formed the basis of several studies (Haines et al., 2010; ACSQHC, 2009; Tzeng and Yin, 2008; Jackson and Gleason, 2004).

Conclusions could also not by drawn regarding interventions that targeted environmental risks in nursing facilities and hospitals, despite the evidence that has suggested that this should form part of an overall prevention strategy (ICSI, 2010; NPSA, 2007; Drahota et al., 2007).

2.7.2 Falls prevention: Oliver et al. (2006) and Coussement et al. (2008)

In addition to the Cochrane Review, two other recent systematic reviews on the prevention of in-patient falls have been published (Oliver et al., 2006; Coussement et al., 2008). The review by Oliver et al. (2006) aimed to evaluate the strategies to prevent falls and fractures in hospitals and care homes, and to investigate the effect of cognitive impairment on preventing falls. Thirteen studies were reviewed that focused on hospital settings, including three RCTs, two cluster randomised trials, and eight prospective studies. These included interventions such as risk (factor) assessment, care planning, education programmes and exercise etc.

Despite the variation in these studies in terms of type of interventions, settings and populations, the review found that there was evidence to support the use of multifactorial interventions to produce modest reductions (up to 18%) in falls rates (risk ratio 0.82, 95%

confidence interval 0.68-0.997, I2 = 80%, p = 0.72); this could not be comparable to fractures (p = 0.87) or fallers (p = 0.18). Similar to the Cochrane Review (Cameron et al., 2010), there were insufficient studies available to draw conclusions on interventions that were commonly applied in hospital settings e.g. fall alarms, environmental changes, or medication review as a single intervention. Many of the single interventions formed part of multifactorial approaches. The reviewers commented that the use of RCTs as the primary source of clinical evidence was not always appropriate in hospital settings where interventions are complex and consent is difficult to obtain (Oliver et al., 2006).

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A systematic review and meta-analysis by Coussement et al. (2008) included eight studies - six RCTs and two controlled trials; the latter two studies were excluded from the 2010 Cochrane Review. The clinical settings included in the review were long-stay (more than 1.5 years) and rehabilitation units (mean length of stay 36.9 days - similar to the two rehabilitation wards that participated in this PhD study). The authors highlighted the two most common approaches to falls prevention - the use of single interventions and multifactorial interventions. Initially, three of the studies reported a 30-49% reduction in number of falls (reduce rate of falls 0.82 (95% confidence interval 0.65 to 1.03), although when this was recalculated after adjusting for clustering, this became non-significant. No studies reported a significant reduction in the number of fallers in either the single or pooled intervention groups.

Coussement et al. (2008) concluded that there was no high methodological evidence to support the effectiveness of falls prevention programmes in hospital settings. More studies were required to determine whether targeting an individual’s risk factors could reduce the number of falls, particularly for more short-term hospital settings. The authors suggested a better link with community-based services so as to begin prevention programmes prior to hospitalisation. This was due to the differences being witnessed from only day 45 of admission. A better approach of identifying patients at risk is to target the individuals that have already fallen by performing a thorough post-fall assessment or to highlight the most common reversible/modifiable risk factors upon admission (Coussement et al., 2008).

All of the above systematic reviews used robust methods for the identification and analysis of relevant literature. Outcome measures were similar between the three reviews, and included number of falls, fractures, fallers and falls risk. In addition, the Cochrane Review included injurious falls and complications of the interventions as secondary measures (Cameron et al., 2010). Many studies were excluded from the three systematic reviews described above due to having what was considered to be low methodological quality.

However, it was acknowledged that many other studies existed that could form the basis of future directions of research, particularly those that included interventions commonly used in clinical practice (Cameron et al., 2010). The three reviews recognised the insufficiency of evidence to make any definite conclusions on the effectiveness of falls prevention programmes. The current evidence does suggest potential improvements can be achieved if multifactorial programmes are implemented more than single interventions, although more studies are needed to verify or dispute this.

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2.7.3 Falls prevention: other studies

Other studies which have focused on in-patient falls prevention include the assessment of falls risk (Kato et al., 2008; Williams et al., 2007; Hathaway et al., 2001); targeting key risk factors (Williams et al., 2007; Hathaway et al., 2001); assistive technology, such as sensors and alarms (Jackson and Gleason, 2004); exercise programmes (Haines et al., 2009;

Haines et al., 2007; Steadman et al., 2003); staff education and professional consultations (Kato et al., 2008); bedrails (Healey et al., 2009; NPSA, 2007); the height of patients’ beds (Haines et al., 2010; Tzeng and Yin, 2008); patient education (Haines et al., 2006); and different types of flooring (Drahota et al., 2007).

All of the above studies (and many more) shaped the design, methods and outcomes of this study by forming part of the initial process of identifying the problem in each cycle.