Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39499.546030.BE (Published 03 April 2008) Cite this as: BMJ 2008;336:758All rapid responses
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Sir
We congratulate Professor Cummings and colleagues on an excellently designed study [1] well-powered to detect any resulting changes in falls rates. But do their findings mean acute hospitals should abandon multi- faceted interventions as ineffective? Evidence is indeed limited, with most studies based on rehabilitation units [2] and only one other large cluster RCT in an acute setting. [3] This showed a significant reduction in falls after the introduction of multi-faceted interventions, as did two large acute hospital studies of before-and-after design.[4 5] So what explains the disparity in the results? It is hard to fault the quality of design in this study, so unpacking the “black box” of the intervention is crucial in understanding the null result.
Firstly, as the authors point out, control wards in their study may have introduced some or all of the interventions too - hopefully control ward patients were also provided with ‘appropriate walking aids’. Osmosis is particularly likely given the study duration of three years, and interventions based on guidance issued in 1998. [6] It is harder to effect a difference if good practice is already embedded.
Secondly, the intervention was focussed on all admitted patients; concentrating efforts on the patients most vulnerable to falling [3] might have been more effective.
Thirdly, the actual interventions applied may be critical. These are not clearly described, but other than exercise (never shown in any falls prevention study to be effective within one week) appear to centre on good practice suggestions to ward staff related to medication and delirium. The effect on team dynamics of a research nurse who completes an assessment and hands over implementation might result in less ownership of interventions; the authors rightly comment that falls prevention programmes ‘led by ward staff themselves’ may be more effective. Most importantly, we do not know whether the suggested interventions were actually carried out and adhered to, or whether there was instead a focus on documentation.
It is premature to say this study suggests multi-faceted interventions in acute hospitals are ineffective especially in view of other large, long-duration and positive (if non-randomised)[4,5] studies. It is likely to depend on the relevance of the interventions to an acute hospital population – and in acute settings seeking and treating medical causes of falls may be of particular value [3] - and most importantly, whether interventions are implemented, rather than just recommended. [7] Yours faithfully,
David Oliver
Frances Healey
1. Cumming RG, Sherrington C, Lord SR et al. Cluster randomised trial of a targeted multi-factorial intervention to prevent falls among older people in hospital BMJ on line 10 March 2008
2 Coussement J, De Paepe L, Schwendimann R et al. Interventions for preventing falls in acute- and chronic- care hospitals: a systematic review and meta-analysis JAGS 2008 56:29-36
3 Healey F, Monro A, Cockram A et al. Using targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial. Age & Ageing 2004;33:390-5.
4 Fonda D, Cook J, Sandler V, Bailey M. Sustained reduction in serious fall-related injuries in older people in hospital. Med J Aust 2006;184:379 -82.
5 Von Renteln-Kruse W, Krause T. Incidence of in-hospital falls in geriatric patients before and after the introduction of an interdisciplinary team-based fall-prevention intervention. Am Geriatr Soc 2007; 55:2068–2074.
6 Shanley C. Putting your best foot forward: preventing and managing falls in aged care facilities. Sydney: Centre for Education and Research on Ageing, 1998.
7. Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SE. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. BMJ, Jan 2008; 336: 130 - 133
Competing interests: None declared
Competing interests: No competing interests
Sir, In Cumming et al cluster randomised trial it was not mentioned whether these patients were assessed by a doctor. The “multifactorial” intervention in the trial was through a nurse and a physiotherapist for a median time of a week. If the administrative and paper work time (let us say 5 hours weekly) is taken into consideration, this means that in the trial each patient had 12 minutes daily of physiotherapy and a similar period from the nurse.
Medical input is crucial in the assessment of the causes and risk factors for falls. A previous systematic review and meta-analysis found that interventions that actively provide treatments may be more effective than those that provide only knowledge and referral (1).
Also it is not expected that a one week programme (which is the median stay of patients) and without medical input would be effective in preventing such a complex entity like falls. Another systematic review concluded that interventions to prevent falls in older adults are effective in reducing both the risk of falling and the monthly rate of falling and the most effective intervention was a multifactorial falls risk assessment and management programme (2).
The limited evidence in falls research is clouded by variable methodological quality in different studies. To represent the findings of this trial it is fair to say that a nurse and a physiotherapist targeted multifactorial falls prevention programme, without medical input, was not effective among older people in hospital wards with median length of stay of seven days.
(1)Gates S, Fisher JD, Cooke MW, Carter YH, Lamb SE. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. BMJ 2008; 336:130-3.
(2) Chang JT, Morton SC, Rubenstein ZL et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 2004; 328:680.
Competing interests: None declared
Competing interests: No competing interests
Cummings et al 2008 [1] have presented a rigorous evaluation of an unsuccessful falls prevention strategy for the hospital setting. From a methodological perspective, this study has negated difficulties in conducting and analysing falls prevention trials in hospitals using cluster randomisation designs previously identified [2]. Collecting falls data from nurses in addition to incident reports and medical charts is a strength, though inconsistency in what nurses believe constitutes a fall and should be reported remains a potential source of variability that has received little investigation. Given the generous amount of staffing provided in addition to usual care on intervention wards, this study casts doubts on the likely effectiveness of similar strategies that increase resources available to perform tasks that may have already been undertaken to a greater or lesser extent as a part of usual care. With this in mind, it is arguable that the strategies themselves provided in this study were not necessarily ineffective, rather the provision of resources in addition to usual care to provide them was.
Previous work by Haines et al 2004 [3] has inadvertently been misrepresented by the authors, particularly the statement “…the intervention (in Haines et al 2004) was effective only among people with hospital stays over 45 days”. Re-examination of this dataset including only those who stayed less than 45 days revealed that of 247 intervention group patients, 29 fell a total of 48 times (rate 9.13 falls per/1000 days) whereas of 259 control group patients, 41 fell a total of 56 times (rate 10.29 falls per/1000 days). Thus patients in the control group had a 35% higher risk of being a faller and a 13% higher rate of falls, magnitudes that I would argue as being of clinical importance. The distribution of falls for all patients over time brackets was: between 0 and 10 days - 41:45 (intervention:control), 10 to 20 days - 23:32, 20 to 30 days - 13:22, 30 to 40 days - 17:9, >40 days -11:41. The statement by the authors may have arisen due to a misinterpretation of the Nelson- Aalen cumulative hazard plot presented. Even though the cumulative hazard curves only noticeably separate after day 45, there were small separations preceding this which due to the magnitude of the Y-axis are difficult to detect by the naked eye.
[1] Cumming R, Sherrington C, Lord S, Simpson J, Vogler C, Cameron I, Naganathan V. Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ 2008; 0: bmj.39499.546030.BEv1 [2] Haines T, Hill K. Difficulties encountered in hospital falls prevention research. Age & Ageing. 2005;34:311 [3] Haines T, Bennell K, Osborne R, Hill K. Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial. British Medical Journal 2004;328:676-679.
Competing interests: None declared
Competing interests: No competing interests
The fact that an intervention of about 7 days duration was ineffective in improving fall resistance should not be a surprise. All falls have a mechanical cause that accelerates the centre of mass in way the subject is unable to counter effectively to maintain balance. There are indications that the hip ab-adductor muscles play a major role in controlling the pelvis during balance perturbing events, and that improving strength and endurance in these muscles could improve fall resistance (Walmsley & Brodie, 2007). However, strength gains take several weeks to manifest, and the early gains are largely an expression of improved neuro-motor coordination. As a consequence, patients would be no better able to combat the mechanical events that trigger falls after a short intervention, even though it included some strength training.
Refs Walmsley, A., & Brodie, M. A. (2007). A modified Tai-Chi video intervention reduces fall risk. Paper presented at the Biomechanics of the Lower Limb in Health, Disease and Rehabilitation.
Competing interests: None declared
Competing interests: No competing interests
Prior to this study (1), there is insufficient evidence(2) for the effectiveness of other single interventions in hospitals or care homes or multifaceted interventions in care homes. The results of the study questioned on interventions to prevent falls in elderly people during hospital admissions. However, statistical analysis does not favour interventions but the results should be viewed cautiously. I hope the research groups working in this area should take positive message of developing better interventions for preventing falls.
References:
1.Robert G Cumming, Catherine Sherrington, Stephen R Lord, Judy M Simpson, Constance Vogler, Ian D Cameron, Vasi Naganathan for the Prevention of Older People’s Injury Falls Prevention in Hospitals Research Group. Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ 2008; 0: bmj.39499.546030.BEv1
2.Oliver D, Connelly JB, Victor CR, Shaw FE, Whitehead A, Genc Y, Vanoli A, Martin FC, Gosney MA. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ 2007;334(7584):82 (13 January)
Competing interests: None declared
Competing interests: No competing interests
An trend for In-Patient Falls Reduction
The recent paper by Cummings (1) did not demonstrate a reduction in falls in older people on a short stay ward despite targeted multidisciplinary and faceted interventions. The author concludes that innovative approaches to falls reduction in this cohort of high-risk older people are required. We report our initial findings of the use of new low beds and other falls prevention initiatives as part of our trusts service redesign in a PFI initiative and input from the Trusts Falls Group. To decrease the number of in-patient falls in the trust several iniatives have been undertaken. 1. The trusts Falls Risk Assessment guidelines, which also encompasses the trusts bed rail policy, was re-launched in June 2007 at a Falls Awareness Day for the staff. 2. Core care plans for older patients at risk of falls have been trailed on a small number of medical wards alongside education sessions for the ward staff on falls. 3. From February 2007 the use of low beds in the redeveloped clinical areas of the trust became standard. The use of low low beds has been established in the other clinical areas. 4. A senior champion for Falls within the trust supported the Falls group and expanded the membership to include input from the risk department, facilities and governance. This has enabled the regular review of appropriate IR1 falls data and allowed targeted changes in practice at ward level. 5. Introduction of regular Lead and Senior Nurse meetings with updates related to falls and discussion of the success or otherwise of preventative initiatives.
Initial analysis of the number of reported falls in the trust in the last year suggests a trend towards a reduction in the number of in-patient falls across the trust. Reviewing the reported injuries as a result of a recorded fall the number of falls that resulted in a fracture was reduced from 5 per quarter for the 1st half of 2007 to 2 per quarter for the second half, though these numbers are small and may not represent a significant change in falls outcome. However, the number of other injuries sustained also suggests a trend downwards. This data is from reported falls within the trust and therefore may be subject to reporting error. These changes were part of service development within the trust thus we cannot ascribe any specific causal associations regarding the trend towards a decrease in the number of in-patient falls across the trust. The changes do however seem to suggest a temporal relationship between the introduction of low and low low beds and the relaunch and raised awareness of falls risk assessments and interventions across the trust. This would suggest that the use of such initiatives warrants further research. Dr Jane Youde and Frances Grant (on behalf of Derby Hospital NHS Foundation Trust Falls Group)
1. Cumming RG, Sherrington C, Lord SR, Simpson JM, Vogler C, Cameron ID, Naganthan V Cluster randomisation trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ 2008;336:758-760
Competing interests: None declared
Competing interests: No competing interests