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Amy Kim Drahota, Derek Ward, Julie E. Udell, Dia Soilemezi, Reuben Ogollah, Bernard Higgins, Taraneh P. Dean, Martin Severs, Pilot cluster randomised controlled trial of flooring to reduce injuries from falls in wards for older people, Age and Ageing, Volume 42, Issue 5, September 2013, Pages 633–640, https://doi.org/10.1093/ageing/aft067
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Abstract
Background: falls disproportionately affect older people, who are at increased risk of falls and injury. This pilot study investigates shock-absorbing flooring for fall-related injuries in wards for frail older people.
Methods: we conducted a non-blinded cluster randomised trial in eight hospitals in England between April 2010 and August 2011. Each site allocated one bay as the ‘study area’, which was randomised via computer to intervention (8.3-mm thick Tarkett Omnisports EXCEL) or control (2-mm standard in situ flooring). Sites had an intervention period of 1 year. Anybody admitted to the study area was eligible. The primary outcome was the fall-related injury rate. Secondary outcomes were injury severity, fall rate and adverse events.
Results: during the intervention period, 226 participants were recruited to each group (219 and 223 were analysed in the intervention and control group, respectively). Of 35 falls (31 fallers) in the intervention group, 22.9% were injurious, compared with 42.4% of 33 falls (22 fallers) in the control group [injury incident rate ratio (IRR) = 0.58, 95% CI = 0.18–1.91]. There were no moderate or major injuries in the intervention group and six in the control group. The fall IRR was 1.07 (95% CI = 0.64–1.81). Staff at intervention sites raised concerns about pushing equipment, documenting one pulled back.
Conclusions: future research should assess shock-absorbing flooring with better ‘push/pull’ properties and explore increased faller risk. We estimate a future trial will need 33,480–52,840 person bed-days per arm.
Trial registration: ClinicalTrials.gov (ID: NCT00817869); UKCRN (ID: 5735).
Comments
Dear Editor,
We have read the article by Drahota and colleagues with great interest. The trial, which is evaluating the injury reducing potential of shock absorbing flooring, is both important and pioneering. The effectiveness of preventing injury, in the event of an accident, by reducing mechanical force is well known (De Haven 1942, Haddon 1980) and the principle has been widely applied in other fields of injury prevention, e.g. traffic and sports safety, with great success. As limited evidence-based methods are available to reduce the risk of falls in a nursing home setting, (Cameron, Gillespie et al. 2012) the shift of focus towards fall-injury prevention, rather than fall prevention, is an important step. One of the first fall-related injury prevention strategies within the healthcare sector was the use of hip protectors on patients who were especially prone to falling. With a shock absorbing material placed over the trochanter, hypothetically, the risk of injury was reduced in the event of a sideways fall. Whilst promising theoretical and clinical research was published, limited effect was seen in the following studies, most likely due to a low level of compliance as well as the protectors being uncomfortable to wear (Gillespie, Gillespie et al. 2010). These results, however, do not minimize the theoretical importance of shock absorbing materials in reducing the risk of fall-related injuries. Therefore, to eliminate the aspects of comfort and compliance, a natural step is to transfer the hip protectors from clothing to the flooring. Due to the high risk of falls and fall-related injuries in nursing homes, we are conducting a similar study to Drahota et al but in a nursing home setting. The flooring that we are evaluating (Kradal flooring) is, unlike the floor used in Drahota et als study, specially designed to be used in healthcare settings as a method to reduce fall-related injuries. Whilst the floor has been tested in a laboratory setting, our study is the first in a clinical setting. The study design is quasi experimental with patients living in areas with the intervention being compared to patients in identical wards, without the intervention flooring. As Drahota et al correctly point out there is a risk of bias in fall rate due to a tendency to move multiple fallers into areas with intervention flooring, a problem that we also have experienced. When it is perceived that the elderly fall softer, with no resulting injury, it is understandable that the staff chooses to move them. This is a source of uncertainty in evaluating the intervention's impact on fall rate in this type of trial and needs to be carefully monitored. We are looking forward to present our results as soon as our study reaches sufficient statistical power.
Corresponding author: Johanna Gustavsson, [email protected]
CAMERON, I.D., GILLESPIE, L.D., ROBERTSON, M.C., MURRAY, G.R., HILL, K.D., CUMMING, R.G. and KERSE, N., 2012. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane database of systematic reviews (Online), 12, pp. CD005465. DE HAVEN, H., 1942. Mechanical analysis of survival in falls from heights of fifty to one hundred and fifty feet. War Medicine, 2, pp. 586-96. GILLESPIE, W.J., GILLESPIE, L.D. and PARKER, M.J., 2010. Hip protectors for preventing hip fractures in older people. Cochrane database of systematic reviews (Online), (10)(10), pp. CD001255. HADDON, W.,Jr, 1980. Advances in the epidemiology of injuries as a basis for public policy. Public health reports (Washington, D.C.: 1974), 95(5), pp. 411-421.
Conflict of Interest:
None declared