This is the first large randomised trial to show that the incidence of falls in elderly patients in hospital can be significantly reduced. The targeted multiple intervention programme we used led to a 30% reduction. A reduction of this magnitude is important not only for individual patients and their families but also for hospital management in dealing with the associated costs and additional care needed because of falls.4-6
Falls prevention programmes in subacute hospitals have been based on the little evidence available from the hospital setting or by transferring results from other settings. This study provides valuable evidence for healthcare administrators and practitioners to reduce falls in subacute hospitals, where falls are a common and dangerous occurrence.
In contrast to earlier studies,7-9
we have shown that this programme had a significant effect in reducing falls, which may be because of the targeted multiple intervention strategy, where each intervention intentionally addressed one or more of various risk factors for falls. There may also have been some unintended benefits, such as increased surveillance while participants were taking part in the exercise or education programmes. Targeting of interventions also meant that falls prevention strategies could be tailored to individual participants. The observed relative benefit of the intervention programme became pronounced after 45 days in hospital (), indicating that the programme may have had a cumulative effect over time and be of greatest benefit to those who have more complex presentations that necessitate greater lengths of stay in hospital.
Compared with the control group, 22% fewer participants in the intervention group fell and there were 28% fewer falls with injuries. The proportion of participants who were fallers in the control group (22.5%, 71 fallers of 316 participants in group) was less than the projected proportion used for the power analysis (30%). Our study was insufficiently powered to detect a difference in hip fractures (focus of the hip protector intervention) because they do not occur often (fractures have been reported to occur in less than 10% of hospital falls).5
We focused on falls, fallers, and injury related to falls as separate end points. Examining falls is important as each individual fall potentially leads to negative outcomes (physical and psychological) for participants and places additional demands on hospital resources. Thus measuring a reduction in both falls and falls with physical injury indicates improved safety for participants and less drain on hospital resources due to falls. In examining fallers, participants are the unit of analysis rather than events (falls). A reduction in fallers indicates improved delivery of health care through a greater proportion of patients being treated without incurring falls and their potential consequences.
Limitations and problems
The inability to completely blind all staff and participants is a difficulty commonly encountered by researchers in the hospital setting. This may have influenced the recording of the incidence of falls or altered elements of usual care such as provision of regular physiotherapy. By randomising individual participants, variances between hospital wards in these recording behaviours should not have influenced the results. The staff blinding survey also indicated that hospital staff were relatively unaware of the allocation of participants. Lastly, attendances at the usual care physiotherapy sessions () were similar between groups, suggesting that the provision of usual care was unaffected.
Some ethical dilemmas were present in this study. Firstly, we approached family members or carers of participants with cognitive impairment to provide consent. Although this challenges autonomy, it is important to be able to recruit participants with cognitive impairment into research that may benefit this population. Participants were not forced to participate in any intervention and were free to withdraw from the study at any stage, thus preserving a large degree of participant autonomy. Secondly, though the falls risk alert card may violate participant privacy and cause distress to participants and their families, we used a falls alert symbol identifiable by hospital staff rather than a sign with words to minimise this risk. During the study no official complaints or requests to remove falls risk alert cards were received.
The intervention programme could potentially be incorporated into the usual care of acute, other subacute, and residential facilities for elderly people. The principle underlying the PJC-FRAT—that hospital staff recommend falls prevention interventions based on their clinical judgment—can also be incorporated into these settings. Modifications to the exercise programme in the acute setting may be required to cater for participants with drips, drains, or other attachments. The description of the nature of falls provided in the written educational material could be modified and based on data on falls from local facilities.
Our results may be generalisable to other subacute settings. Although we recruited only 60% of eligible patients, their characteristics were consistent with those of the consecutive sample of 122 patients used in the validation of the PJC-FRAT, which suggests our sample was reasonably representative. Many participants in this study had diagnoses of dementia or stroke and were recommended for the falls prevention interventions, indicating that the programme could be implemented on wards that deal specifically with patients with these diagnoses. However, generalising the findings to acute hospitals may be problematic as the reduction in falls rates occurred after 45 days, a period after which few acute patients would still be in hospital.
In this study, usual care at the centre was compared with usual care plus the targeted falls prevention programme. Subsequently, we could not investigate many falls prevention interventions, such as review of sedative medication prescription, using this approach as such interventions were already incorporated into usual care. These interventions, along with evaluation of the relative effectiveness of individual interventions from this programme and the cost effectiveness of targeted multiple intervention strategies, are worthy of further investigation.
What is already known on this topic
Although several randomised controlled trials in community settings support the use of targeted multiple intervention programmes in reducing falls, there is little evidence of their effectiveness in hospitals
The three published trials that investigated falls prevention interventions in the hospital setting were underpowered and did not show a significant reduction in falls
What this study adds
A targeted multiple intervention falls prevention programme in addition to usual care compared with usual care alone reduced the incidence rate of falls by 30% in a subacute hospital setting
There was also a trend towards a reduction in the proportion of participants who were “fallers” and the incidence rate of fall related injuries
A targeted programme in addition to usual care leads to safer stays in hospitals for patients