This study examined fall rates, consequent injuries and characteristics of hospitalized patients before and after the implementation of an interdisciplinary falls prevention program. The frequencies of falls, consequent injuries, and clinical patient characteristics varied between the departments of internal medicine, geriatrics and surgery. Following the implementation of the IFP, no reduction of in-patient fall rates and no reduction in consequent injuries were observed within individual departments or in the hospital. During the observation period, the mean length of hospital stay decreased slightly, while the mean nursing care time per patient day increased: both trends may reflect a higher workload for healthcare staff. Additionally, one in three patients was 80 years and older, and in those patients who fell while hospitalized, the prevalence of risk factors for falls increased significantly from 1999 to 2003. These may reflect altered patient characteristics, which lead to proneness to falling.
In this general urban hospital setting, overall fall rates per 1,000 patient days (e.g., 8.9 falls) were higher compared to other studies reporting rates between 2.7 and 4.1 falls per 1,000 patient days [8
]. Fall related injuries were seen in 33.6% (3.9% major) of our patients, a proportion that was similar to others reported in the literature [10
]. It appears that irrespective of fall rates, the percentage of patients with consequent injuries remain relatively stable.
Since falls and consequent injuries affect patient safety and may damage a hospital's reputation, various falls prevention programs have been implemented [26
]. Recently, a 30% and a 28% reduction of falls and subsequent injuries in a sub-acute hospital setting were reported from a randomized controlled trial [32
]. These effects were attributed to a targeted multiple intervention program. Another intervention program in elderly patients in a community hospital resulted in a 21% reduction of falls at 6 months postintervention, while no effect was noted for fall related injuries [33
]. A falls prevention program in a rehabilitation hospital setting (quasi-experimental study) reported reductions of falls by 15.3%, fewer fallers by 29.7%, and fewer patients with fall related injuries by 51.1% within a 1 year period [34
]. Unfortunately, the benefit of the program did not remain significant after correcting for length of stay. In addition, after the implementation of a nurse led falls prevention program in a large general district hospital, fall related injuries were reduced by 25% over a 5-years period, while the number of falls did not change [28
]. In another prospective observational study, the intervention effects of ward based quality cycle teams in a rehabilitation hospital resulted in a significant reduction of fall rates per 1,000 patient days comparing 3 years of pre-intervention with 3 years post intervention [35
]. In most of these former studies, patients have benefited from falls prevention programs within 6 and 12 months in terms of fewer falls and related injuries [26
], but only two non-experimental studies [28
] reported positive effects exceeding one year. In the current study neither a sustained reduction of falls nor a decrease in consequent injuries was observed within the 3 years after the implementation of the IFP. This raises questions about whether the interventions of the program was not effective, adherence to the intervention protocol was poor and if the altered patient characteristics may have neutralized intervention effects.
Our study examined the effects of the IFP falls prevention program in daily clinical practice rather than under rigorous research conditions as it was done in other more successful falls prevention studies [32
]. The IFP consists of the elements reported in intervention studies and falls prevention programs which resulted in reduced fall rates and reduced injury rates. The design of the intervention protocol of the IFP used best available evidence for hospital settings [27
] and showed positive results in an earlier study [29
]. In view of adherence to the protocol, it's assumed from the audits of the falls prevention committee that the physicians and nurses may not consistently practice the IFP. This argument is supported from a study in an acute care metropolitan hospital, with 43% non-adherence with the fall prevention protocol [37
]. In another study, compliance with the program deteriorated over time and after 5 years fall rates increased back to the level before the program was implemented [38
More specifically, in our study data were not available on how often the intervention protocol was followed including screening patients risk for falls and examination of those patients at risk for falls as well as the type of subsequent interventions was applied. This was not the case in another study too [33
In view of altered patient characteristics it remains unclear if the observed increases in age and decreases of length of stay during the course of the study had an impact on the effectiveness of the program. The relatively high and stable fall rates before and after the IFP may be viewed with regard to a quotation of Bernard Isaacs that "a unit where nobody falls is a unit where nobody moves" [39
]. This higher rate may reflect our hospital practice of early remobilization and forced ambulation of the patients in order to reach functional autonomy for hospital discharge as soon as possible. Positive effects of the hospital falls prevention program immediately after implementation may have been caused by an increased initial awareness of nurses rather than by the specific interventions for patients at risk for falling [27
]. In addition, the IFP was mandated in three different hospital departments each with numerous health care professionals. This approach could be inappropriate for some units since multi-factorial interdisciplinary interventions are often time consuming which may limit their practicability in a busy acute hospital setting.
If clinicians adherence to the intervention protocol was inconsistent, it remains unclear if this can be explained by a lack of commitment on the part of the physicians and the nurses, by insufficient knowledge about which patients were at risk for falling, or whether the high priority given to the acute care treatment of patients contributed to the multifactorial falls risk modification protocol being neglected. The clinicians may not have been adequately prepared and facilitated to integrate the intervention protocol into their daily routine and, therefore, no sustained change of the clinical practice was established. Translating evidence from research into practice remains a challenge. An appropriate approach such as action research [41
] should be considered. Action research is basically a self-reflective enquiry undertaken by participants (e.g., clinicians, researchers in hospital settings) in order to improve the rationality and justification of their own practices, their understanding of those practices, and the situations in which the practices are performed [42
]. This type of approach may support future attempts to improve interdisciplinary falls prevention practice.
The following limitations of this study have to be considered. First, due to its serial survey design, characteristics of patients and the hospital organization were not controlled. Second, the fall risk profile of those patients who did not fall was not obtained, therefore it was unclear to what extend this population was at risk for falling. Third, adherence to the intervention protocol was not observed or recorded.
The audits may not have been sufficient to ensure sustained adherence to such a complex program because the commitment and clinical expertise of the individual nurses and physicians varied, and may also have been influenced by staffing, patient severity, and communication skills within the interdisciplinary team.