Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial
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《英国医生杂志》
1 University of Melbourne School of Physiotherapy, Parkville, Victoria 3052, Australia, 2 Centre for Rheumatic Disease, Royal Melbourne Hospital and the University of Melbourne, Parkville, 3 National Ageing Research Institute and Melbourne Extended Care and Rehabilitation Service, Parkville
Correspondence to: K Hill k.hill@nari.unimelb.edu.au
Abstract
Falls are a common occurrence among elderly inpatients in subacute hospitals and are generally reported to affect between 13% and 32% of admitted patients.1 2 In stroke rehabilitation units, falls have been reported in up to 47% of patients.3 Patients who fall incur physical injuries (up to 70% of falls result in injuries, 1-10% result in fractures),4 5 psychological effects,6 and have longer lengths of hospital stay.5 Inpatient falls therefore result in substantial morbidity and additional healthcare costs and are a viable target for interventions.
Interventions to reduce in hospital falls have received little attention. Only three randomised controlled trials have been published.7-9 Two investigated single interventions (bed alarms9 and alert bracelets8) in conjunction with usual care compared with usual care alone. The third investigated two interventions (additional exercise and type of flooring) in a two by two design in conjunction with usual care.7 None of these studies showed a significant reduction in fall rates, though all the studies were relatively small (between 54 and 134 participants). Previous studies based in hospitals with historical controls and randomised controlled trials in community settings have reduced fall rates by using targeted multiple intervention strategies.10 11 We evaluated the effectiveness of a targeted multiple intervention falls prevention programme in reducing the rate of falls, the proportion of patients who fall, and the rate of injuries related to falls in a subacute hospital.
Methods
Baseline characteristics
We approached 1040 patients, of whom 626 (60%) consented to participate. Figure 2 shows recruitment of participants and recommendations of the falls prevention programme intervention. No participants withdrew from the trial during the study period, and there were no adverse events attributable to the intervention. Baseline characteristics of participants in each group were similar (table 2).
Table 2 Characteristics of participant and completion rates of the PJC-FRAT by hospital staff. Figures are numbers (percentages) unless stated otherwise
Analysis of falls, fallers, and injuries related to falls
Compared with the control group, the intervention group had 30% fewer falls (149 v 105) and a lower proportion of participants who experienced one or more falls (71 v 54), relative risk 0.78 (95% confidence interval 0.56 to 1.06). Thirty five participants in the intervention group fell once compared with 49 in the control group. Both groups had 10 participants who fell twice and three who fell three times, but the intervention group had only six participants who fell four or more times compared with nine in the control group.
The Nelson-Aalen cumulative hazard estimate for both groups was similar until about day 45, when the fall rate in the control group marginally increased and the rate in the intervention group suddenly reduced (fig 3). Both the log rank test (P = 0.004) and Peto extension (P = 0.045) showed significantly fewer falls in the intervention group.
Fig 3 Nelson-Aalen cumulative hazard estimates of the control and intervention groups
Table 3 shows the definitions and distributions of injuries related to falls between the two groups. The incidence of falls with injury was 28% lower in the intervention group (23 v 32, log rank test, P = 0.20). Two participants from each group incurred a fracture related to a fall. One participant fractured the neck of the femur while wearing hip protectors.
Table 3 Classification and distribution of falls that led to injury (fall rated by worst injury sustained)
Hospital staff survey of participant group allocation
Hospital staff correctly identified the group allocation of 90 out of 172 participants they were caring for ( = 3% chance corrected agreement).
Discussion
Mion L, Gregor S, Buettner M, Chwirchak D, Lee O, Paras W. Falls in the rehabilitation setting: incidence and characteristics. Rehabil Nurs 1989;14: 17-22.
Vlahov D, Myers A, Al-Ibrahim M. Epidemiology of falls among patients in a rehabilitation hospital. Arch Phys Med Rehabil 1990;71: 8-12.
Rapport LJ, Webster JS, Flemming KL, Lindberg JW, Godlewski MC, Brees JE, et al. Predictors of falls among right-hemisphere stroke patients in the rehabilitation setting. Arch Phys Med Rehabil 1993;74: 621-6.
Brandis S. A collaborative occupational therapy and nursing approach to falls prevention in hospital inpatients. J Qual Clin Pract 1999;19: 215-20.
Grenier-Sennelier C, Lombard I, Jeny-Loeper C, Maillet-Gouret M, Minvielle E. Designing adverse event prevention programs using quality management methods: the case of falls in hospital. Int J Qual Health Care 2002;14: 419-26.
Liddle J, Gilleard C. The emotional consequences of falls for older people and their families. Clin Rehabil 1995;9: 110-4.
Donald I, Shuttleworth H. Preventing falls on an elderly care rehabilitation ward. Clin Rehabil 2000;14: 178-85.
Mayo N, Gloutney L, Levy R. A randomised trial of identification bracelets to prevent falls among patients in a rehabilitation hospital. Arch Phys Med Rehabil 1994;75: 1302-8.
Tideiksaar R, Feiner C, Maby J. Falls prevention: The efficacy of a bed alarm system in an acute care setting. Mount Sinai J Med 1993;60: 522-7.
Oliver D, Hopper A, Seed P. Do hospital fall prevention programs work? A systematic review. J Am Geriatr Soc 2000;48: 1679-89.
Gillespie L, Gillespie W, Robertson M, Lamb S, Cumming R, Rowe B. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev 2003;(4): CD000340 .
Fleiss J. Statistical methods for rates and proportions. 2nd ed. New York: John Wiley, 1981.
Perell K, Nelson A, Goldman R, Luther S, Prieto-Lewis N, Rubenstein L. Fall risk assessment measures: an analytic review. J Gerontol A Biol Sci Med Sci 2001;56: M761-6.
Wolf S, Barnhart H, Kutner N, McNeely E, Coogler C, Xu T, et al. Reducing frailty and falls in older persons: an investigation of tai chi and computerized balance training. J Am Geriatr Soc 1996;44: 489-97.
Victorian Department of Human Services. Victorian admitted episode dataset. Melbourne: Victorian Department of Human Services—Australia, 2002.
Folstein M, Folstein S, McHugh P. Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12: 189-98.
Nelson W. Theory and applications of hazard plotting for censored failure data. Technometrics 1972;14: 945-65.
Pepe M, Cai J. Some graphical displays and marginal regression analyses for recurrent failure times and time dependent covariates. J Am Stat Assoc 1993;88: 811-20.
Grambsch P, Therneau T. Proportional hazards tests and diagnostics based on weighted residuals. Biometrika 1994;81: 515-26.
Peto R, Peto J. Asymptotically efficient rank invariant test procedures (with discussion). J R Stat Soc A 1972;135: 185-206.
Altman D. Practical statistics for medical research. 1st ed. Melbourne: Chapman and Hall, 1993.
Wolf S, Kutner N, Green R, McNeely E. The Atlanta FICSIT study: Two exercise interventions to reduce frailty in elders. J Am Geriatr Soc 1993;41: 329-32.(Terry P Haines, PhD candi)
Correspondence to: K Hill k.hill@nari.unimelb.edu.au
Abstract
Falls are a common occurrence among elderly inpatients in subacute hospitals and are generally reported to affect between 13% and 32% of admitted patients.1 2 In stroke rehabilitation units, falls have been reported in up to 47% of patients.3 Patients who fall incur physical injuries (up to 70% of falls result in injuries, 1-10% result in fractures),4 5 psychological effects,6 and have longer lengths of hospital stay.5 Inpatient falls therefore result in substantial morbidity and additional healthcare costs and are a viable target for interventions.
Interventions to reduce in hospital falls have received little attention. Only three randomised controlled trials have been published.7-9 Two investigated single interventions (bed alarms9 and alert bracelets8) in conjunction with usual care compared with usual care alone. The third investigated two interventions (additional exercise and type of flooring) in a two by two design in conjunction with usual care.7 None of these studies showed a significant reduction in fall rates, though all the studies were relatively small (between 54 and 134 participants). Previous studies based in hospitals with historical controls and randomised controlled trials in community settings have reduced fall rates by using targeted multiple intervention strategies.10 11 We evaluated the effectiveness of a targeted multiple intervention falls prevention programme in reducing the rate of falls, the proportion of patients who fall, and the rate of injuries related to falls in a subacute hospital.
Methods
Baseline characteristics
We approached 1040 patients, of whom 626 (60%) consented to participate. Figure 2 shows recruitment of participants and recommendations of the falls prevention programme intervention. No participants withdrew from the trial during the study period, and there were no adverse events attributable to the intervention. Baseline characteristics of participants in each group were similar (table 2).
Table 2 Characteristics of participant and completion rates of the PJC-FRAT by hospital staff. Figures are numbers (percentages) unless stated otherwise
Analysis of falls, fallers, and injuries related to falls
Compared with the control group, the intervention group had 30% fewer falls (149 v 105) and a lower proportion of participants who experienced one or more falls (71 v 54), relative risk 0.78 (95% confidence interval 0.56 to 1.06). Thirty five participants in the intervention group fell once compared with 49 in the control group. Both groups had 10 participants who fell twice and three who fell three times, but the intervention group had only six participants who fell four or more times compared with nine in the control group.
The Nelson-Aalen cumulative hazard estimate for both groups was similar until about day 45, when the fall rate in the control group marginally increased and the rate in the intervention group suddenly reduced (fig 3). Both the log rank test (P = 0.004) and Peto extension (P = 0.045) showed significantly fewer falls in the intervention group.
Fig 3 Nelson-Aalen cumulative hazard estimates of the control and intervention groups
Table 3 shows the definitions and distributions of injuries related to falls between the two groups. The incidence of falls with injury was 28% lower in the intervention group (23 v 32, log rank test, P = 0.20). Two participants from each group incurred a fracture related to a fall. One participant fractured the neck of the femur while wearing hip protectors.
Table 3 Classification and distribution of falls that led to injury (fall rated by worst injury sustained)
Hospital staff survey of participant group allocation
Hospital staff correctly identified the group allocation of 90 out of 172 participants they were caring for ( = 3% chance corrected agreement).
Discussion
Mion L, Gregor S, Buettner M, Chwirchak D, Lee O, Paras W. Falls in the rehabilitation setting: incidence and characteristics. Rehabil Nurs 1989;14: 17-22.
Vlahov D, Myers A, Al-Ibrahim M. Epidemiology of falls among patients in a rehabilitation hospital. Arch Phys Med Rehabil 1990;71: 8-12.
Rapport LJ, Webster JS, Flemming KL, Lindberg JW, Godlewski MC, Brees JE, et al. Predictors of falls among right-hemisphere stroke patients in the rehabilitation setting. Arch Phys Med Rehabil 1993;74: 621-6.
Brandis S. A collaborative occupational therapy and nursing approach to falls prevention in hospital inpatients. J Qual Clin Pract 1999;19: 215-20.
Grenier-Sennelier C, Lombard I, Jeny-Loeper C, Maillet-Gouret M, Minvielle E. Designing adverse event prevention programs using quality management methods: the case of falls in hospital. Int J Qual Health Care 2002;14: 419-26.
Liddle J, Gilleard C. The emotional consequences of falls for older people and their families. Clin Rehabil 1995;9: 110-4.
Donald I, Shuttleworth H. Preventing falls on an elderly care rehabilitation ward. Clin Rehabil 2000;14: 178-85.
Mayo N, Gloutney L, Levy R. A randomised trial of identification bracelets to prevent falls among patients in a rehabilitation hospital. Arch Phys Med Rehabil 1994;75: 1302-8.
Tideiksaar R, Feiner C, Maby J. Falls prevention: The efficacy of a bed alarm system in an acute care setting. Mount Sinai J Med 1993;60: 522-7.
Oliver D, Hopper A, Seed P. Do hospital fall prevention programs work? A systematic review. J Am Geriatr Soc 2000;48: 1679-89.
Gillespie L, Gillespie W, Robertson M, Lamb S, Cumming R, Rowe B. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev 2003;(4): CD000340 .
Fleiss J. Statistical methods for rates and proportions. 2nd ed. New York: John Wiley, 1981.
Perell K, Nelson A, Goldman R, Luther S, Prieto-Lewis N, Rubenstein L. Fall risk assessment measures: an analytic review. J Gerontol A Biol Sci Med Sci 2001;56: M761-6.
Wolf S, Barnhart H, Kutner N, McNeely E, Coogler C, Xu T, et al. Reducing frailty and falls in older persons: an investigation of tai chi and computerized balance training. J Am Geriatr Soc 1996;44: 489-97.
Victorian Department of Human Services. Victorian admitted episode dataset. Melbourne: Victorian Department of Human Services—Australia, 2002.
Folstein M, Folstein S, McHugh P. Mini-mental state: A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12: 189-98.
Nelson W. Theory and applications of hazard plotting for censored failure data. Technometrics 1972;14: 945-65.
Pepe M, Cai J. Some graphical displays and marginal regression analyses for recurrent failure times and time dependent covariates. J Am Stat Assoc 1993;88: 811-20.
Grambsch P, Therneau T. Proportional hazards tests and diagnostics based on weighted residuals. Biometrika 1994;81: 515-26.
Peto R, Peto J. Asymptotically efficient rank invariant test procedures (with discussion). J R Stat Soc A 1972;135: 185-206.
Altman D. Practical statistics for medical research. 1st ed. Melbourne: Chapman and Hall, 1993.
Wolf S, Kutner N, Green R, McNeely E. The Atlanta FICSIT study: Two exercise interventions to reduce frailty in elders. J Am Geriatr Soc 1993;41: 329-32.(Terry P Haines, PhD candi)