Elsevier

Applied Nursing Research

Volume 31, August 2016, Pages 52-59
Applied Nursing Research

Original Article
The effect of a translating research into practice intervention to promote use of evidence-based fall prevention interventions in hospitalized adults: A prospective pre–post implementation study in the U.S.

https://doi.org/10.1016/j.apnr.2015.12.004Get rights and content

Abstract

Background

Falls are a major public health problem internationally. Many hospitals have implemented fall risk assessment tools, but few have implemented interventions to mitigate patient-specific fall risks. Little research has been done to examine the effect of implementing evidence-based fall prevention interventions to mitigate patient-specific fall risk factors in hospitalized adults.

Objectives

To evaluate the impact of implementing, in 3 U.S. hospitals, evidence-based fall prevention interventions targeted to patient-specific fall risk factors (Targeted Risk Factor Fall Prevention Bundle). Fall rates, fall injury rates, types of fall injuries and adoption of the Targeted Risk Factor Fall Prevention Bundle were compared prior to and following implementation.

Design

A prospective pre–post implementation cohort design.

Setting

Thirteen adult medical-surgical units from three community hospitals in the Midwest region of the U.S.

Participants

Nurses who were employed at least 20 hours/week, provided direct patient care, and licensed as an RN (n = 157 pre; 140 post); and medical records of patients 21 years of age or older, who received care on the study unit for more than 24 hours during the designated data collection period (n = 390 pre and post).

Methods

A multi-faceted Translating Research Into Practice Intervention was used to implement the Targeted Risk Factor Fall Prevention Bundle composed of evidence-based fall prevention interventions designed to mitigate patient-specific fall risks. Dependent variables (fall rates, fall injury rates, fall injury type, use of Targeted Risk Factor Fall Prevention Bundle) were collected at baseline, and following completion of the 15 month implementation phase. Nurse questionnaires included the Stage of Adoption Scale, and the Use of Research Findings in Practice Scale to measure adoption of evidence-based fall prevention practices. A Medical Record Abstract Form was used to abstract data about use of targeted risk-specific fall prevention interventions. Number of falls, and number and types of fall injuries were collected for each study unit for 3 months pre- and post-implementation. Data were analyzed using multivariate analysis.

Results

Fall rates declined 22% (p = 0.09). Types of fall injuries changed from major and moderate to minor injuries. Fall injury rates did not decline. Use of fall prevention interventions improved significantly (p < 0.001) for mobility, toileting, cognition, and risk reduction for injury, but did not change for those targeting medications.

Conclusions

Using the Translating Research Into Practice intervention promoted use of many evidence-based fall prevention interventions to mitigate patient-specific fall risk factors in hospitalized adults.

Introduction

Falls are the most common reported patient safety incident in hospitals (Anonymous, 2011, Oliver, 2008a, Rubenstein, 2006), and are a major public health problem internationally (Caldevilla et al., 2013, Higaonna, 2015, Quigley and White, 2013, Shmueli et al., 2014). Up to 30% of falls result in injury including fractures, soft tissue trauma and death (Oliver, 2008a, Rubenstein, 2006). Additional consequences include prolonged hospital stay, discharge to long term care facilities, increased hospital costs, patient anxiety, and loss of confidence in mobility and activities of daily living (Boltz et al., 2014, Caldevilla et al., 2013, Oliver et al., 2004, Rubenstein, 2006, Tinetti and Kumar, 2010).

Hospitals have instituted fall risk assessment scales to identify patients at risk for falls followed by implementation of general fall prevention interventions (e.g., putting signs on the door for those at risk) (Caldevilla et al., 2013, Oliver, 2008b). Although fall prevention interventions should be customized to the individual’s identified risk factors (Anonymous, 2011, Cameron et al., 2012), hospitals have not yet promoted use of fall prevention interventions targeted to patient-specific risks (e.g., ambulation or refer to physical therapy for unsteady gait) (Coussement et al., 2008, Hempel et al., 2013, Oliver et al., 2010). Because falls are complex and risks for falls are multifactorial, beneficial effects of fall reduction interventions may increase when interventions target patient-specific fall risk factors (Anonymous, 2011, Cameron et al., 2012, Coussement et al., 2008, Tinetti, 2003). Few studies however have examined the effect of implementing evidence-based fall prevention interventions to mitigate patient-specific fall risk factors in hospitalized adults (Dykes et al., 2010).

The purpose of this 18 month study was to implement evidence-based fall prevention interventions targeted to patient-specific fall risk factors (Targeted Risk Factor Fall Prevention Bundle) and evaluate the impact on reducing falls and fall related injuries. A multifaceted Translating Research Into Practice intervention was used to promote uptake and use of the Targeted Risk Factor Fall Prevention Bundle in 13 adult medical surgical units in three community hospitals in the U.S. Specific aims of the study were to (1) compare fall rates, fall injury rates, and types of fall injuries prior to and following implementation of the evidence-based Targeted Risk Factor Fall Prevention Bundle, and (2) evaluate adoption of the evidence-based Targeted Risk Factor Fall Prevention Bundle.

Section snippets

Fall Prevention Conceptual Framework

The conceptual framework used in this study was informed by a taxonomy that classifies types of fall prevention interventions (Cameron et al., 2012, Hook and Winchel, 2006, McCarter-Bayer et al., 2005). Interventions are conceptualized as Universal Fall Precautions (e.g., reducing environmental risks for falls such as patient room and hall free of clutter), General Fall Prevention Interventions (e.g., bedside table, call light and other personnel items within reach) and Targeted Individual

Methods

A prospective, pre–post cohort implementation design using a participatory partnership research approach was used for this study. We chose a participatory partnership approach to foster engagement, ownership of the study, as well as use of findings to improve quality of care (Cornwall and Jewkes, 1995, Gold and Taylor, 2007, Green et al., 2001).

Results

Demographics of the nurses and study units did not differ significantly between pre- and post-implementation. Patients on the study units were 65 years of age or older (X¯ = 65.6; SD = 2.8), and the majority (68%) were in the moderate or major severity of illness category. The average RN skill mix was 75% and the mean RN hours per patient days was 6.8 (SD = 0.81). The majority of nurses were white (> 90%), female (> 90%), between 30 and 40 years of age, and with an average of over eight years work

Discussion

The Translating Research Into Practice intervention used in this study was effective in promoting use of fall prevention interventions that target patient-specific fall risk factors. Increased use included fall prevention interventions for history of previous falls, mobility, elimination, cognition/mental status, and risk for injury from a fall. Targeted risk factor fall prevention interventions were designed to mitigate patient-specific risks factors for falls, which goes beyond general fall

Limitations

The study findings are not generalizable to other types of healthcare settings, such as ambulatory and long-term care agencies. Given the pre–post design of the study, it is difficult to rule out effects from other factors in the environment occurring simultaneously with this study. Lastly, although medical records are used by regulatory agencies to measure care delivery, some of the fall prevention interventions may have been implemented, but not documented.

Conclusions

The Translating Research Into Practice intervention improved use of fall prevention interventions targeted to patient-specific fall risk factors. The study also demonstrated improvement in reduction of fall rates and types of fall injuries. To make significant gains in reducing falls in hospitals, clinicians must do more than arriving at a fall risk score with subsequent implementation of general fall reduction interventions; they need to know each patient’s risk factors for falls and implement

References (83)

  • National voluntary consensus standards for nursing-sensitive care: an initial performance measure set: a consensus report

    (2004)
  • Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons

  • E.A. Balas

    Computerized knowledge management in diabetes care

    Medical Care

    (2004)
  • S.A. Birken et al.

    Uncovering middle managers’ role in healthcare innovation implementation

    Implementation Science

    (2012)
  • M. Boltz

    Activity restriction vs. self-direction: hospitalised older adults’ response to fear of falling

    International Journal of Older People Nursing

    (2014)
  • E.H. Bradley

    Translating research into clinical practice: making change happen

    Journal of American Geriatrics Society

    (2004)
  • E.H. Bradley

    Patterns of diffusion of evidence-based clinical programmes: a case study of the Hospital Elder Life Program

    Quality & Safety in Health Care

    (2006)
  • M.N. Caldevilla

    Evaluation and cross-cultural adaptation of the Hendrich II Fall Risk Model to Portuguese

    Scandinavian Journal of Caring Sciences

    (2013)
  • I.D. Cameron

    Interventions for preventing falls in older people in care facilities and hospitals

    Cochrane Database of Systematic Reviews

    (2012)
  • D.L. Carroll et al.

    An electronic fall prevention toolkit: effect on documentation quality

    Nursing Research

    (2012)
  • Centers for Medicare & Medicaid Services: CMS.gov.
  • J. Coussement

    Interventions for preventing falls in acute‐and chronic‐care hospitals: a systematic review and meta‐analysis

    Journal of the American Geriatrics Society

    (2008)
  • R.G. Cumming

    Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital

    BMJ

    (2008)
  • M. Dobbins

    A description of a knowledge broker role implemented as part of a randomized controlled trial evaluating three knowledge translation strategies

    Implementation Science

    (2009)
  • M. Dobbins

    A randomized controlled trial evaluating the impact of knowledge translation and exchange strategies

    Implementation Science

    (2009)
  • E.J. Dogherty

    Following a natural experiment of guideline adaptation and early implementation: a mixed-methods study of facilitation

    Implementation Science

    (2012)
  • D. Dougherty et al.

    The “3 T’s” road map to transform US health care: the “how” of high-quality care

    JAMA

    (2008)
  • P.C. Dykes

    Fall prevention in acute care hospitals: a randomized trial

    JAMA

    (2010)
  • A.P. Farmer

    Printed educational materials: effects on professional practice and health care outcomes

    Cochrane Database of Systematic Reviews

    (2008)
  • P.H. Feldman et al.

    Conducting translation research in the home care setting: lessons from a just-in-time reminder study

    Worldviews on Evidence-Based Nursing

    (2004)
  • P.H. Feldman

    Just-in-time evidence-based e-mail “reminders” in home health care: impact on patient outcomes

    Health Services Research

    (2005)
  • I.D. Fischer

    Patterns and predictors of inpatient falls and fall-related injuries in a large academic hospital

    Infection Control and Hospital Epidemiology

    (2005)
  • G. Flodgren

    Local opinion leaders: effects on professional practice and health care outcomes

    Cochrane Database of Systematic Reviews

    (2011)
  • L. Forsetlund

    Continuing education meetings and workshops: effects on professional practice and health care outcomes

    Cochrane Database of Systematic Reviews

    (2009)
  • W. Gifford

    Managerial leadership for nurses’ use of research evidence: an integrative review of the literature

    Worldviews on Evidence-Based Nursing

    (2007)
  • W. Gifford

    Developing team leadership to facilitate guideline utilization: planning and evaluating a 3-month intervention strategy

    Journal of Nursing Management

    (2011)
  • M. Gold et al.

    Moving research into practice: lessons from the US Agency for Healthcare Research and Quality’s IDSRN program

    Implementation Science

    (2007)
  • L. Green et al.

    Partnerships and coalitions for community-based research

    Public Health Reports

    (2001)
  • J. Grimshaw

    Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966-1998

    Journal of General Internal Medicine

    (2006)
  • J.T. Hanlon

    Falls in African American and white community-dwelling elderly residents

    Journals of Gerontology. Series A, Biological Sciences and Medical Sciences

    (2002)
  • F. Healey

    Using targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial

    Age and Ageing

    (2004)
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