Fall-related injuries exert an enormous health burden on older adults in long-term care (LTC). Softer landing surfaces, such as those provided by low-stiffness "compliant" flooring, may prevent ...fall-related injuries by decreasing the forces applied to the body during fall impact. Our primary objective was to assess the clinical effectiveness of compliant flooring at preventing serious fall-related injuries among LTC residents.
The Flooring for Injury Prevention (FLIP) Study was a 4-year, randomized superiority trial in 150 single-occupancy resident rooms at a single Canadian LTC site. In April 2013, resident rooms were block randomized (1:1) to installation of intervention compliant flooring (2.54 cm SmartCells) or rigid control flooring (2.54 cm plywood) covered with identical hospital-grade vinyl. The primary outcome was serious fall-related injury over 4 years that required an emergency department visit or hospital admission and a treatment procedure or diagnostic evaluation in hospital. Secondary outcomes included minor fall-related injury, any fall-related injury, falls, and fracture. Outcomes were ascertained by blinded assessors between September 1, 2013 and August 31, 2017 and analyzed by intention to treat. Adverse outcomes were not assessed. During follow-up, 184 residents occupied 74 intervention rooms, and 173 residents occupied 76 control rooms. Residents were 64.3% female with mean (SD) baseline age 81.7 (9.5) years (range 51.1 to 104.6 years), body mass index 25.9 (7.7) kg/m2, and follow-up 1.64 (1.39) years. 1,907 falls were reported; 23 intervention residents experienced 38 serious injuries (from 29 falls in 22 rooms), while 23 control residents experienced 47 serious injuries (from 34 falls in 23 rooms). Compliant flooring did not affect odds of ≥1 serious fall-related injury (12.5% intervention versus 13.3% control, odds ratio OR: 0.98, 95% CI: 0.52 to 1.84, p = 0.950) or ≥2 serious fall-related injuries (5.4% versus 7.5%, OR: 0.74, 95% CI: 0.31 to 1.75, p = 0.500). Compliant flooring did not affect rate of serious fall-related injuries (0.362 versus 0.422 per 1,000 bed nights, rate ratio RR: 1.04, 95% CI: 0.45 to 2.39, p = 0.925; 0.038 versus 0.053 per fall, RR: 0.81, 95% CI: 0.38 to 1.71, p = 0.560), rate of falls with ≥1 serious fall-related injury (0.276 versus 0.303 per 1,000 bed nights, RR: 0.97, 95% CI: 0.52 to 1.79, p = 0.920), or time to first serious fall-related injury (0.237 versus 0.257, hazard ratio HR: 0.92, 95% CI: 0.52 to 1.62, p = 0.760). Compliant flooring did not affect any secondary outcome in this study. Study limitations included the following: findings were specific to 2.54 cm SmartCells compliant flooring installed in LTC resident rooms, standard fall and injury prevention interventions were in use throughout the study and may have influenced the observed effect of compliant flooring, and challenges with concussion detection in LTC residents may have prevented estimation of the effect of compliant flooring on fall-related concussions.
In contrast to results from previous retrospective and nonrandomized studies, this study found that compliant flooring underneath hospital-grade vinyl was not effective at preventing serious fall-related injuries in LTC. Future studies are needed to identify effective methods for preventing fall-related injuries in LTC.
ClinicalTrials.gov: NCT01618786.
The Flooring for Injury Prevention Mackey, Dawn C; Lachance, Chantelle C; Wang, Peiwei T ...
PLoS medicine,
06/2019, Letnik:
16, Številka:
6
Journal Article
Recenzirano
Fall-related injuries exert an enormous health burden on older adults in long-term care (LTC). Softer landing surfaces, such as those provided by low-stiffness "compliant" flooring, may prevent ...fall-related injuries by decreasing the forces applied to the body during fall impact. Our primary objective was to assess the clinical effectiveness of compliant flooring at preventing serious fall-related injuries among LTC residents. The Flooring for Injury Prevention (FLIP) Study was a 4-year, randomized superiority trial in 150 single-occupancy resident rooms at a single Canadian LTC site. In April 2013, resident rooms were block randomized (1:1) to installation of intervention compliant flooring (2.54 cm SmartCells) or rigid control flooring (2.54 cm plywood) covered with identical hospital-grade vinyl. The primary outcome was serious fall-related injury over 4 years that required an emergency department visit or hospital admission and a treatment procedure or diagnostic evaluation in hospital. Secondary outcomes included minor fall-related injury, any fall-related injury, falls, and fracture. Outcomes were ascertained by blinded assessors between September 1, 2013 and August 31, 2017 and analyzed by intention to treat. Adverse outcomes were not assessed. During follow-up, 184 residents occupied 74 intervention rooms, and 173 residents occupied 76 control rooms. Residents were 64.3% female with mean (SD) baseline age 81.7 (9.5) years (range 51.1 to 104.6 years), body mass index 25.9 (7.7) kg/m.sup.2, and follow-up 1.64 (1.39) years. 1,907 falls were reported; 23 intervention residents experienced 38 serious injuries (from 29 falls in 22 rooms), while 23 control residents experienced 47 serious injuries (from 34 falls in 23 rooms). Compliant flooring did not affect odds of greater than or equal to1 serious fall-related injury (12.5% intervention versus 13.3% control, odds ratio OR: 0.98, 95% CI: 0.52 to 1.84, p = 0.950) or greater than or equal to2 serious fall-related injuries (5.4% versus 7.5%, OR: 0.74, 95% CI: 0.31 to 1.75, p = 0.500). Compliant flooring did not affect rate of serious fall-related injuries (0.362 versus 0.422 per 1,000 bed nights, rate ratio RR: 1.04, 95% CI: 0.45 to 2.39, p = 0.925; 0.038 versus 0.053 per fall, RR: 0.81, 95% CI: 0.38 to 1.71, p = 0.560), rate of falls with greater than or equal to1 serious fall-related injury (0.276 versus 0.303 per 1,000 bed nights, RR: 0.97, 95% CI: 0.52 to 1.79, p = 0.920), or time to first serious fall-related injury (0.237 versus 0.257, hazard ratio HR: 0.92, 95% CI: 0.52 to 1.62, p = 0.760). Compliant flooring did not affect any secondary outcome in this study. Study limitations included the following: findings were specific to 2.54 cm SmartCells compliant flooring installed in LTC resident rooms, standard fall and injury prevention interventions were in use throughout the study and may have influenced the observed effect of compliant flooring, and challenges with concussion detection in LTC residents may have prevented estimation of the effect of compliant flooring on fall-related concussions. In contrast to results from previous retrospective and nonrandomized studies, this study found that compliant flooring underneath hospital-grade vinyl was not effective at preventing serious fall-related injuries in LTC. Future studies are needed to identify effective methods for preventing fall-related injuries in LTC.
Summary Background Falls in elderly people are a major health burden, especially in the long-term care environment. Yet little objective evidence is available for how and why falls occur in this ...population. We aimed to provide such evidence by analysing real-life falls in long-term care captured on video. Methods We did this observational study between April 20, 2007, and June 23, 2010, in two long-term care facilities in British Columbia, Canada. Digital video cameras were installed in common areas (dining rooms, lounges, hallways). When a fall occurred, facility staff completed an incident report and contacted our teams so that we could collect video footage. A team reviewed each fall video with a validated questionnaire that probed the cause of imbalance and activity at the time of falling. We then tested whether differences existed in the proportion of participants falling due to the various causes, and while engaging in various activities, with generalised linear models, repeated measures logistic regression, and log-linear Poisson regression. Findings We captured 227 falls from 130 individuals (mean age 78 years, SD 10). The most frequent cause of falling was incorrect weight shifting, which accounted for 41% (93 of 227) of falls, followed by trip or stumble (48, 21%), hit or bump (25, 11%), loss of support (25, 11%), and collapse (24, 11%). Slipping accounted for only 3% (six) of falls. The three activities associated with the highest proportion of falls were forward walking (54 of 227 falls, 24%), standing quietly (29 falls, 13%), and sitting down (28 falls, 12%). Compared with previous reports from the long-term care setting, we identified a higher occurrence of falls during standing and transferring, a lower occurrence during walking, and a larger proportion due to centre-of-mass perturbations than base-of-support perturbations. Interpretation By providing insight into the sequences of events that most commonly lead to falls, our results should lead to more valid and effective approaches for balance assessment and fall prevention in long-term care. Funding Canadian Institutes for Health Research.
To generate evidence of the effectiveness of hip protectors to minimize risk of hip fracture at the time of falling among residents of long-term care (LTC) by contrasting rates of hip fractures ...between falls with and without hip protectors.
A 12-month, retrospective cohort study. We retrospectively reviewed fall incident reports recorded during the 12 months prior to baseline in participating homes.
A population-based sample comprising all residents from 14 LTC homes owned and operated by a single regional health authority, who experienced at least 1 recorded fall during the 12-month study.
At baseline, the pooled mean (standard deviation) age of residents in participating homes was 82.7 (11.3) years and 68% were female. Hip protectors were worn in 2108 of 3520 (60%) recorded falls. Propensity to wear hip protectors was associated with male sex, cognitive impairment, wandering behavior, cardiac dysrhythmia, use of a cane or walker, use of anti-anxiety medication, and presence of urinary and bowel incontinence. The incidence of hip fracture was 0.33 per 100 falls in falls with hip protectors compared with 0.92 per 100 falls in falls without hip protectors, representing an unadjusted relative risk (RR) of hip fracture of 0.36 (95% confidence interval 0.14-0.90, P = .029) between protected and unprotected falls. After adjusting for propensity to wear hip protectors, the RR of hip fracture was 0.38 (95% confidence interval 0.14-0.99, P = .048) during protected vs unprotected falls.
Hip protectors were worn in 60% of falls, and the risk of hip fracture was reduced by nearly 3-fold by wearing a hip protector at the time of falling. Given that most clinical trials have failed to attain a similar level of adherence, our findings support the need for future research on the benefits of dissemination and implementation strategies to maximize adherence with hip protectors in LTC.
Hip protectors represent an attractive strategy for reducing hip fractures among high-risk fallers in long-term care facilities. However, clinical studies yield conflicting results regarding their ...clinical value. This is mainly due to poor acceptance and adherence among users in wearing these devices. As a result, there is an urgent need to identify potential barriers and facilitators to initial acceptance and continued adherence with hip protector use.
The objective of this systematic review is to synthesize available research evidence to identify factors that influence acceptance and adherence among older adults living in long-term care facilities.
A key word search was conducted for studies published in English between 2000 and 2013 that employed quantitative, qualitative, or mixed-methods research designs. Two independent reviewers evaluated each article for inclusion, with a third reviewer when needed to resolve discrepancies.
Twenty-eight articles met our inclusion criteria, and facilitators and barriers were clustered into 4 socio-ecological levels: system (eg, facility commitment, staff shortages), caregiver (eg, belief in the efficacy of protectors, negative perceptions), resident (eg, clinical risk factors for falls and related fractures, acute illness), and product (eg, soft shell, discomfort).
The outcomes provide decision makers, health professionals, and caregivers with a greater awareness of strategies to improve compliance with the use of hip protectors. Furthermore, researchers can use this information to design clinical trials that yield high acceptance and adherence.
If worn during a fall, hip protectors substantially reduce risk for hip fracture. However, a major barrier to their clinical efficacy is poor user adherence. In long-term care, adherence likely ...depends on how committed care providers are to hip protectors, but empirical evidence is lacking due to the absence of a psychometrically valid assessment tool.
We conducted a cross-sectional survey in a convenience sample of 529 paid care providers. We developed the 15-item C-HiP Index to measure commitment, comprised of three subscales: affective, cognitive and behavioural. Responses were subjected to hierarchical factor analysis and internal consistency testing. Eleven experts rated the relevance and clarity of items on 4-point Likert scales. We performed simple linear regression to determine whether C-HiP Index scores were positively related to the question, "Do you think of yourself as a champion of hip protectors", rated on a 5-point Likert scale. We examined whether the C-HiP Index could differentiate respondents: (i) who were aware of a protected fall causing hip fracture from those who were unaware; (ii) who agreed in the existence of a champion of hip protectors within their home from those who didn't.
Hierarchical factor analysis yielded two lower-order factors and a single higher-order factor, representing the overarching concept of commitment to hip protectors. Items from affective and cognitive subscales loaded highest on the first lower-order factor, while items from the behavioural subscale loaded highest on the second. We eliminated one item due to low factor matrix coefficients, and poor expert evaluation. The C-HiP Index had a Cronbach's alpha of 0.96. A one-unit increase in championing was associated with a 5.2-point (p < 0.01) increase in C-HiP Index score. Median C-HiP Index scores were 4.3-points lower (p < 0.01) among respondents aware of a protected fall causing hip fracture, and 7.0-points higher (p < 0.01) among respondents who agreed in the existence of a champion of hip protectors within their home.
We offer evidence of the psychometric properties of the C-HiP Index. The development of a valid and reliable assessment tool is crucial to understanding the factors that govern adherence to hip protectors in long-term care.
Incident reports guide fall prevention efforts in long-term care (LTC) facilities, often based on descriptions of how falls occurred. The validity of these reports is poorly understood. We examined ...agreement on fall characteristics between fall incident reports and analysis of video footage of real-life falls in LTC.
Video capture of 863 falls (by 309 individuals) over 6 years in common areas of 2 LTC facilities in British Columbia.
We reviewed each fall video with a previously validated questionnaire to determine the cause of imbalance leading to the fall, activity at the time of falling, and use of mobility aids. These data were compared with corresponding information recorded by staff on fall incident reports.
There was agreement between video analysis and incident reports on the cause of imbalance in 45.5% of falls (kappa = 0.25), on activity at time of falling in 45.1% of falls (kappa = 0.22), and on use of mobility aids in 79.5% of falls (kappa = 0.59). When compared with video analysis, incident reports overreported falls due to slips, and falling while rising and while using a wheelchair or walker. Incident reports also underreported falls due to hit/bump and loss-of-support, and falling while standing and sitting down.
In more than 50% of falls, we found discrepancies between fall incident reports and analysis of video footage on the cause of imbalance and activity while falling. Emerging technologies incorporating video capture or wearable sensors should improve our ability to understand the mechanisms and improve the prevention of falls in LTC.
If worn, certain models of hip protectors are highly effective at preventing hip fractures from falls in residents of long-term care, but modest acceptance and adherence have limited the ...effectiveness of hip protectors. Residents of long-term care are more likely to accept the initial offer of hip protectors and to adhere to recommendations concerning the use of hip protectors when staff are committed to supporting the application of hip protectors. Yet, we know very little about the nature of and factors associated with staff commitment to hip protectors in long-term care.
To identify factors associated with staff commitment to hip protectors in long-term care.
A cross-sectional survey.
Thirteen long-term care homes (total beds = 1816) from a single regional health district in British Columbia, Canada.
A convenience sample of 535 paid staff who worked most of their time (>50% of work hours) at a participating long-term care home, for at least one month, and for at least 8 h per week. We excluded six (1.1%) respondents who were unaware of hip protectors. Of the remaining 529 respondents, 90% were female and 55% were health care assistants.
Respondents completed the Commitment to Hip Protectors Index to indicate their commitment to hip protectors. We used Bayesian Model Averaging logistic regression to model staff commitment as a function of personal variables, experiences with hip protectors, intraorganizational communication and influence, and organizational context.
Staff commitment was negatively related to organizational tenure >20 years (posterior probability = 97%; logistic regression coefficient = −0.28; 95% confidence interval = −0.48, −0.08), and awareness of a padded hip fracture (100%; −0.57; −0.69, −0.44). Staff commitment was positively related to the existence of a champion of hip protectors within the home (100%; 0.24; 0.17, 0.31), perceived quality of intraorganizational communication (100%; 0.04; 0.02, 0.05), extent of mutual respect between residents and staff and perceived contribution to quality of life of the residents they serve (100%; 0.10; 0.05, 0.15), and frequency of transformational leadership practices by respondents’ primary supervisors (100%; 0.01; 0.01, 0.02).
We provide novel insight into the factors governing staff commitment to hip protectors in long-term care. Targeting of these factors could improve acceptance and adherence with hip protectors, thereby contributing to enhanced effectiveness of hip protectors to prevent hip fractures in long-term care.
Les objectifs de cette étude en trois phases étaient (1) de caractériser les opportunités existantes dans les programmes de loisirs pour les locataires résidant avec aide à la vie autonome (AVA)* et ...(2) de recueillir les perceptions sur les facteurs qui influent sur la planification et la prestation des programmes. Au cours d'une collaboration d'un an, nous avons utilisé un cadre de l'application des connaissances intégrées qui a ciblé 51 sites AVA subventionnés par l'État de deux autorités de la santé en Colombie-Britannique. Nous avons effectué une revue des activités, une enquête auprès du personnel et des symposia interactifs pour identifier les facteurs qui ont permis ou restreint les programmes de loisirs. D'après les informations obtenues, nous avons déterminé que tous les sites AVA livraient programmes de loisirs. Bien que les possibilités d'exercice et de l'activité physique ont été perçus comme ayant une grande importance, la plupart des activités étaient de nature sociale. Le personnel a signalé leur confiance dans la prestation de ce type de programmation et a estimé qu'il répondait aux besoins holistiques des locataires, y compris leur bien-être mental, favorisant un sentiment d'appartenance à la communauté. Futures pistes pour augmenter l'activité physique pour les locataires AVA devraient aborder les caractéristiques de l'individu, du site, et de l’organisation. The objectives of this three-phased investigation were to (1) characterize existing recreational programming opportunities for tenants residing in assisted living (AL) and (2) gather perceptions on factors influencing activity program planning and delivery. Using an integrated knowledge translation framework during a one-year collaboration, we targeted 51 publicly funded AL sites from two health authorities in British Columbia. We conducted an activity calendar review, staff survey, and interactive symposia to identify factors that enabled or restricted recreational programming. From the information obtained, we determined that all AL sites delivered recreational programming. Although exercise and physical activity opportunities were perceived as having high importance, most activities were social. Staff reported confidence in delivering this type of programming and believed it met the holistic needs of tenants, including their mental well-being, and fostered a sense of community. Future avenues for increasing physical activity of AL tenants should address individual, site, and organizational characteristics.
Epinephrine injection is an effective, simple, and economical method of endoscopic hemostasis for bleeding peptic ulcers. We measured catecholamine levels in 18 patients with actively bleeding ulcers ...(8 gastric ulcers and 10 duodenal ulcers) treated by endoscopic injection. Injection of epinephrine (1:10,000 IU) was given until bleeding from the ulcers stopped. Catecholamine levels were assayed by high-pressure liquid chromatography. Immediately after the injection the plasma level of epinephrine rose by four to five times above the basal level and returned to the baseline in 20 minutes. Norepinephrine levels were not significantly raised in these patients. No cardiovascular complications were seen. Although adverse cardiac events have not been recorded, it seems prudent to monitor these patients closely during and immediately after epinephrine injection.
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