Editor's view

In the article, the author discusses the challenges in the decision making and advance care planning on critical care admission of patients living with dementia. Also cited are the poor understanding of the public of critical care, the effectiveness of using natural language processing of unstructured records and machine learning to identify those at risk of subsequent falls, and the recommended fall prevention strategies like Tai Chi.

CHRONOFALLS: A multicentre nurse-led intervention in the chronoprevention of in-hospital falls in adults.

BACKGROUND: Falls are among the most common and serious adverse events for hospitalised patients. In-hospital falls pose a major medical and economic challenge for public health worldwide. Nevertheless, the issue is often addressed without regard to certain relevant variables such as the time of the fall. The aim of this study was to determine the effect of the implementation of a nurse-led intervention based on the temporal patterns of falls and their aetiology on the occurrence of falls. METHODS: A mixed-method research design was carried out in three phases: a) a longitudinal prospective study (audits, chronobiological analyses and implementation of a multicentre nurse-led intervention based on temporal patterns of falls); b) a retrospective study of fall records; and c) a qualitative study based on focus groups. The protocol was published in 2021. RESULTS: A difference was observed in the number of fall records before and after the chronopreventive intervention (retrospective: 64.4% vs. 35.6%; p < 0,001). According to the interrupted series analysis, considering the influence of the COVID-19 pandemic, a reduction in falls of 2.96% (95% CI 1.70%-4.17%) was observed. The concepts of falls, the COVID-19 pandemic and the causes of non-registration have emerged as categories for qualitative analysis. CONCLUSIONS: A multicentric nurse-led program based on tailored organisational, educational and behavioural chronopreventive measures seems to lead to a reduction in the number of in-hospital falls. The findings of the present study, highlighting the implementation of chronopreventive measures, can serve as a basis for future health policies. TRIAL REGISTRATION: The project was registered on the Clinical Trials Registry NCT04367298 (29/04/2020).

A fall in isolation: reflection on a complex case

This case review focuses on a male patient who had fallen and was found to be profoundly hypothermic, with an altered level of consciousness and evidence of seizure activity. With multiple time-critical features, this clinical presentation was made particularly challenging by the presence of several human factors. A reflective model that considered these human factors in the context of the COVID-19 pandemic, when this incident occurred, was employed. Reflecting on this incident revealed how some subconscious (intuitive) thinking led to a degree of unconscious bias compounded by availability heuristics and human factors present. This meant that the author encountered difficulty when trying to obtain peripheral vascular access and, although several alternative interventions were identified, the majority of these were unavailable at the time and some would require a change to standard clinical practice for many paramedics. The only intervention that could have been used earlier in the management of this patient was rectal diazepam, but the need for this was removed by the patient's seizure activity self-terminating. Given the increasing prevalence of falls, social isolation, mental health problems, alcohol and substance misuse, especially in the pandemic, this type of case was unlikely to be an isolated event, strengthening the argument that the range of clinical interventions available to paramedics should be increased.

Primary survey: Highlights from this issue

Byrne et al have explored this in more depth, completing a systematic review into the willingness and preparation of medical students in relation to disaster medicine. Tolhurst-Cleaver et al have reviewed UK guidelines on the management of this condition and found a significant degree of variability, often with variation between written and verbal accounts of practice. [...]we have another paper from Vassallo et al on a comparative analysis of major incident tools in children, an area that I’ve been interested in for many years.

Abstracts from international Emergency Medicine journals

Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an from each publication.

Effects of Aquatic Physical Exercise on Motor Risk Factors for Falls in Older People During the COVID-19 Pandemic: A Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to assess the effects of aquatic training on motor risk factors for falls in older people during the COVID-19 pandemic. METHODS: A randomized controlled trial was carried out with older people, divided into an aquatic training group (ATG) (n = 24) and a control group (CG) (n = 25). Muscle strength was assessed by the 5-Times Sit-to-Stand Test, mobility by the simple and dual-task Timed Up and Go Test, and postural stability through stabilometric data (force platform). The CG received monthly calls to monitor general health. The ATG carried out training lasting 16 weeks, with two 1-hour sessions per week. RESULTS: Both groups improved muscular strength and cognitive-motor tasks, and they performed a dual task with fewer errors in the secondary task after 16 weeks regardless of the pandemic and COVID-19 diagnosis. There was a significant decrease in the area of center of pressure displacement in the tandem posture with eyes closed in the CG. When analyzing participants who adhered at least 50% to the intervention, the ATG significantly reduced the number of steps on the Timed Up and Go Test performance. Both groups improved muscular strength and cognitive-motor tasks and increased the cognitive task cost. In the CG, there was a significant decrease in the mean amplitude of the anteroposterior center of pressure displacement in the feet together with eyes open. CONCLUSION: We found that aquatic physical exercise presented positive effects on some potentially modifiable motor risk factors for falls (mobility and muscle strength) regardless of the COVID-19 pandemic and COVID-19 diagnosis, especially among people who adhered to the intervention.

Intentional Rounding versus Standard of Care for Patients Hospitalised in Internal Medicine Wards: Results from a Cluster-Randomised Nation-Based Study.

The aim of the study was to explore the effects of Intentional Rounding, a regular-based proactive patient monitoring, on falls and pressure ulcers in internal medicine units. This is a cluster-randomised controlled study, where units were assigned (1:1) to Intentional Rounding (intervention group) or Standard of Care (control group). The primary outcome was the cumulative incidence of falls and new pressure ulcers. These events were considered separately as secondary endpoints, together with the number of bell calls and the evaluation of patient satisfaction. Primary analyses were carried out on the modified intention-to-treat population (hospitalisation of at least 10 days). Recruitment occurred between October 2019 and March 2020, at which time the study was prematurely closed due to the COVID-19 pandemic. Enrolment totalled 1822 patients at 26 sites; 779 patients were included in the modified intention-to-treat analysis. The intervention group had a lower risk of falls (adjusted incidence rate ratio 0.14; 95% confidence interval, 0.02-0.78; p = 0.03). There were no statistical differences in new pressure ulcers or the cumulative incidence of both adverse events. Mean bell calls for each patient were 15.4 ± 24.1 in the intervention group and 13.7 ± 20.5 in the control group (p = 0.38). Additionally, patient satisfaction in the intervention group was almost at the maximum level. Our study supports the usefulness of Intentional Rounding in a complex and vulnerable population such as that hospitalised in internal medicine units.

A Case Management Program at Home to Reduce Fall Risk in Older Adults (the MAGIC Study): Protocol for a Single-Blind Randomized Controlled Trial.

BACKGROUND: Individual case management programs may be particularly effective in reducing fall risk as they can better identify barriers and facilitators to health recommendations. OBJECTIVE: This paper describes the protocol for a single-blind, parallel-group randomized controlled trial that aims to investigate the effectiveness and cost-effectiveness of a home-based multifactorial program targeting fall risk factors among people aged 60 years and over who have fallen at least twice in the past 12 months (the MAGIC trial). METHODS: Older people with a history of at least 2 falls in the last year will be divided into 2 groups. The intervention group will receive case management at home for reducing the risk of falls, including a multidimensional assessment, explanation of fall risk factors, and elaboration and monitoring of an individualized intervention plan based on the identified fall risk factors, personal preferences, and available resources. The control group will be monitored once a month. Assessments (clinical data, fall risk awareness, physical and mental factors, safety at home, feet and shoes, and risk and rate of falls) will be carried out at baseline, after 16 weeks of the intervention, and at the posttrial 6-week and 1-year follow-up. After 16 weeks of the intervention, satisfaction and adherence to the intervention will also be assessed. Economic health will be evaluated for the period up to the posttrial 1-year follow-up. RESULTS: Data collection started in April 2021, and we expected to end recruitment in December 2021. This case management program will address multifactorial assessments using validated tools and the implementation of individualized intervention plans focused on reducing fall risk factors. CONCLUSIONS: This trial may provide reliable and valuable information about the effectiveness of case management for increasing fall risk awareness and reducing fall risk in older people. TRIAL REGISTRATION: Brazilian Clinical Trials Registry (ReBec) RBR-3t85fd; https://ensaiosclinicos.gov.br/rg/RBR-3t85fd. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34796.

The effects of social isolation due to COVID-19 on the fear of movement, falling, and physical activity in older people.

OBJECTIVE: This study investigates the interaction between fear of movement, fall risk, and physical activity levels in ageing individuals who experienced social isolation during the COVID-19 pandemic. METHODS: In this descriptive and cross-sectional study, 254 eligible participants used an online background survey. Individuals' fear of movement was evaluated by the kinesiophobia causes scale, fall risk by the falls efficacy scale, and physical activity levels by the physical activity scale for the ageing. RESULTS: The fear of movement had a significant positive interaction on fall risk (ß = 0.471, R2  = 0.495, p < 0.001). The fall risk had a negative effect on physical activity (ß = -1.686, R2  = 0.161, p < 0.001). The fear of movement and fall risk explained 15.6% of the change in physical activity levels of ageing individuals (p < 0.001). CONCLUSIONS: These results showed a significant interaction between physical activity levels and fear of movement, with a high fall risk in ageing individuals during the pandemic period.

Reliability of HOME FAST BRAZIL-Self-Reported Version for Community-Dwelling Older Adults.

Objective: Verify the intra- and inter-rater reliability of the HOME FAST BRAZIL-Self-reported version and correlate household environmental risks with the history of falls by community-dwelling older adults. Method: Cross sectional study with 50 community-dwelling older adults who were screened by the cut-off point of the Mini Mental State Exam and replied to the HOME FAST BRAZIL-Self-reported version using two evaluators, on three occasions. The reliability analysis was determined by the Intra-class Correlation Coefficient (ICC), considering ICC > 0.70 as adequate. To test the correlations, the Spearman test was used. Results: The mean age of the participants was 73.2 ± 5.8 years. The inter- rater reliability of HOME FAST BRAZIL-Self-reported version was ICC 0.83 (IC95%, 0.70-0.90) and the Intra- reliability ICC 0.85 (IC95%, 0.74-0.91). A risk of falls was verified in 88% of the sample and four environmental risks presented significant correlations with the history of falls. Conclusions: The HOME FAST BRAZIL-Self-reported version presented adequate reliability for the evaluation of household environmental risks for community-dwelling older adults. Risks such as inadequate armchairs/ sofas, the absence of anti-slip mats in the shower recess, the presence of pets and inadequate beds require attention in the evaluation of household risks, due to their correlation with the occurrence of falls.

Association Between Fatigue and Falls Risk Among the Elderly Aged Over 75 Years in China: The Chain Mediating Role of Falls Efficacy and Lower Limb Function.

Background: Although fatigue has been shown to be strongly associated with falls risk, very few studies have focused on its mechanism involved in community-dwelling older subjects. The purpose of this study was to explore the relationship between fatigue and falls risk and its internal mechanism by constructing a chain mediation model. Methods: A cross-sectional study design was adopted. A convenience sample of 270 older adults was recruited from July to October 2021 in an urban community, in Beijing, China. The participants completed the 14-item Fatigue Scale (FS-14), Falls Efficacy Scale International (FES-I), the Short Physical Performance Battery (SPPB) and Fall-Risk Self-Assessment Questionnaire (FRQ) to measure fatigue, falls efficacy, lower limb function and falls risk. The theory of unpleasant symptoms was used as a conceptual framework. Structural equation modeling (SEM) was utilized to test the hypothetical model. Results: The overall fit of final model was found to be satisfactory: χ2/df = 1.61, CFI = 0.971, TLI = 0.962, RMSEA = 0.049 (95% CI 0.030/0.066) and SRMR = 0.023. Fatigue had a direct effect on falls risk (ß = 0.559, S.E. = 0.089, 95% CI 0.380/0.731), and it also had indirect effects on falls risk (ß = 0.303, S.E. = 0.072, 95% CI 0.173/0.460) through mediating factors. Falls efficacy and lower limb function were the main mediating variables, and there was a chain mediating effect (ß = 0.015, S.E. = 0.010, 95% CI 0.003/0.046). Conclusions: Our study suggests that fatigue can influence falls risk among the elderly in China. There are many mediating paths between fatigue and falls risk. These results may help healthcare professionals to better understand the inherent relationship between fatigue and fall risk that may benefit older adults.

Prevalence, Circumstances, and Risk Factors of Falls Among Community Dwelling Members of University of the Third Age.

Objective: Study aimed to identify the prevalence of falls and associated contributory factors among older Malaysians. Methods: A cross sectional study among community dwelling older adults aged 50 years and above. Self-administered questionnaires on history of falls in the previous 12 months, physical assessment and computerized and clinical measures of balance were assessed on a single occasion. Results: Forty nine (31.0%) participants fell, with 4.4% reported having multiple falls within the previous 12 months. Slips were the most prevalent cause of falls, accounting for 49% of falls. More than half (54.5%) of falls occurred in the afternoon while participants walked inside the home (32.7%), outside home (30.6%), and 36.7% were in community areas. More than half of respondents were identified as having turning instability. Step Test, turn sway, depression, physical activity level and edge contrast sensitivity were significantly worse for fallers (p < 0.05). Multiple logistic regression analysis showed that turning performance, visual acuity and back pain were significantly associated with falls risk, accounting for 72% of the variance of risk factors for falls among studied population. Conclusion: Falls are common among community dwelling older Malaysians. The findings provide information of falls and falls risk factors among community dwelling older adults in Malaysia. Future intervention studies should target locally identified falls risk factors. This study has highlighted the importance of instability during turning as an important fall risk factor.

Impact of the 2020 New Zealand COVID-19 lockdown on participants in a community-based, peer-led fall prevention program.

OBJECTIVES: To explore the impacts of the 2020 New Zealand COVID-19 lockdown on peer-led Steady as You Go (SAYGO) fall prevention exercise classes and members, and to develop recommendations for mitigating impacts during future lockdowns. METHODS: Semi-structured phone interviews were conducted with 20 SAYGO program participants and managers following the first COVID-19 lockdown in New Zealand. Interviews were audio-recorded, transcribed verbatim and analysed using the General Inductive Approach. RESULTS: Participants were between 67 and 88 years of age, predominantly female (90%) and NZ European (80%), with one participant identifying as NZ Maori. Three themes were constructed from the analysis: Personal Function and Well-Being, Class Functioning and Logistics, and Future Strategies for Classes During Prospective Lockdowns. Participants used a range of strategies to stay connected with each other and continue the SAYGO exercises at home. Most participants and peer-leaders reported that they maintained physical function during lockdown, although some had feelings of psychological distress and social isolation. Contact systems and resource distribution varied substantially between groups. Classes resumed post-lockdown with only minor modifications and slightly decreased attendance. CONCLUSIONS: Overall, members of this peer-led model of fall prevention classes demonstrated resilience during the COVID-19 lockdown, despite some challenges. We propose three recommendations to address the challenges of maintaining existing peer-led exercise classes in the context of prospective lockdowns: (1) develop a comprehensive contact detail register and plans for each group; (2) delivery of modified exercise classes remotely over lockdown; and (3) implementation of a nationwide IT education and resource program for older adults.

[What factors contributed to the higher incidence rate of in-hospital falls at the time of Covid 19? A paradigm shift?]

The COVID-19 pandemic has put a strain on all health systems as there has been a growing rapidity in the demand for health care from COVID 19 positive patients in hospitals around the world. With the intensification of the pandemic, determining in real time the consequent needs for health resources (beds, personnel, equipment) has in fact become the fundamental priority for many countries to ensure health services consistent with the health needs expressed by the population. In Italy, the demand has often been satisfied with the conversion of existing beds and the remodeling of the healthcare offer or where the available resources allow it also with the opening of new beds dedicated to pandemic assistance. This work analyzes the falls detected at the time of COVID in patients and hospitalized in direct hospital beds (600 beds) of a Local Health Authority of Lazio (ASL ROMA 2). Although the data on the incidence of falls recorded in the three centers were equal to 2.21 every 1000 days of beds occupied and that the data recorded are lower than those reported in the literature, it is also true that the increase in average hospital stay and the reduction in the rotation rate of beds had an impact on the still low occupancy rates compared to the literature data. The COVID-19 pandemic has put a strain on all health systems as there has been a growing rapidity in the demand for health care from COVID 19 positive patients in hospitals around the world. With the intensification of the pandemic, determining in real time the consequent needs for health resources (beds, personnel, equipment) has in fact become the fundamental priority for many countries to ensure health services consistent with the health needs expressed by the population. In Italy, the demand has often been satisfied with the conversion of existing beds and the remodeling of the healthcare offer or where the available resources allow it also with the opening of new beds dedicated to pandemic assistance. This work analyzes the falls detected at the time of COVID in patients and hospitalized in direct hospital beds (600 beds) of a Local Health Authority of Lazio (ASL ROMA 2). Although the data on the incidence of falls recorded in the three centers were equal to 2.21 every 1000 days of beds occupied and that the data recorded are lower than those reported in the literature, it is also true that the increase in average hospital stay and the reduction in the rotation rate of beds had an impact on the still low occupancy rates compared to the literature data. In fact, the scientific literature shows that in England and Wales, whose national health service is very similar to the Italian one, the falls of patients in hospitals with optimal bed occupancy rates and optimal average hospitalization rates (equal to 4.5 days in general medicine, 3.5 days in general surgery, 3 days in orthopedics) represent the first sentinel event in terms of incidence and frequency, albeit with a very variable damage detection. The average falls is 6.63 falls per 1,000 bed-occupied days, which equates to approximately 1,700 falls per year in an 800-bed hospital with an optimal occupancy rate. Regarding damage, the literature documents that physical injuries and fractures occur in 30-50% of events and fractures occur in 1-3% of cases. The data collected in ASL ROMA 2 have documented that despite the increase in staff dedicated to assistance by 15 - 30%, an increase due to the application of COVID pathways and to the activities of compression of the risk of circulation of the virus among hospitalized patients , the rate of falls has nevertheless increased by 13.5% despite the persistence of standards of quality and safety of patients in care activities, debunking the paradigm that falls can be caused by an undersizing of the care staff and by the possible overcrowding of the emergency departments - urgency.

NRC is taking a positive approach to the future

Adrian Ashurst, Consultant Editor of NRC, outlines an exciting future for Nursing and Residential Care.

Frequency and characteristics of falls in people living with and without multiple sclerosis during the COVID-19 pandemic: A cross-sectional online survey.

BACKGROUND: Public health responses to Coronavirus Disease 2019 (COVID-19) including lockdowns may negatively impact physical and mental functioning in clinical populations. People living with multiple sclerosis (MS) may be more susceptible to physical function deterioration while practicing social distancing. Recent reports have suggested that about 50% of people with MS (pwMS) decreased their leisure physical activity during COVID-19, and upwards of 30% reported decreased physical fitness levels. However, the impact of social distancing on adverse health-related outcomes such as falls has not received much scrutiny. Therefore, we explored the frequency and characteristics of falls experienced by people living with and without MS during the COVID-19 pandemic. METHODS: Two-hundred and thirty-nine individuals, including 106 pwMS (median age: 59 years) and 133 people living without MS (median age: 66 years) were recruited for this cross-sectional study. A snowball sampling strategy was used for online recruitment. Participants completed a customized falls questionnaire and the number of falls experienced (if any) during COVID-19 was recorded. Fall-related characteristics such as the timing, locations, activities undertaken before falling and consequences, as well as self-reported physical activity were also recorded. RESULTS: Overall, participants reported 232 falls (1.67 falls/person in pwMS and 0.41 falls/person in non-MS participants). People living with MS (pwMS) had a significantly higher frequency of falls (58.5% vs 21.8%; p< 0.001) and recurrent falls (45.3% vs 9.8%; p< 0.001) compared to non-MS participants. Additionally, pwMS reported a significantly higher proportion of in-home falls (83.9% vs 54.2%; p = 0.004), as well as a higher proportion of overall injuries (44.3% vs 12.5%, p< 0.001), fractures (5.7% vs 0.8%, p = 0.048), and healthcare utilization (9.4% vs 1.6%, p = 0.007) compared to non-MS participants. A similar proportion of pwMS (49.1%) and non-MS participants (52.2%) reported lower physical activity levels during COVID-19. CONCLUSION: This cross-sectional study revealed that pwMS remain at high risk of falls and fall-related outcomes during COVID-19. The high number of falls experienced by pwMS is of clinical concern considering the current strain on the healthcare system. Findings from this study highlight the importance of monitoring falls and the potential for telerehabilitation in persons with MS during COVID-19.

Identifying patterns in unplanned hospital admissions during the COVID-19 pandemic: a single-centre retrospective study.

BACKGROUND: Countries with a high prevalence of COVID-19 have identified a reduction in crude hospital admission rates for non-COVID-19 conditions during the pandemic. There remains a paucity of such data from lower prevalence countries, including Australia. AIMS: To describe the patterns of unplanned hospital daily admission rates during the COVID-19 pandemic in a major Australian metropolitan hospital, with a focus on acute medical presentations including acute coronary syndrome (ACS), stroke and falls. METHODS: This single-centre retrospective analysis analysed hospital admission episodes between 1 March and 30 April 2020 (COVID-19-era) and compared this to a historical cohort during the same period between 2017 and 2019 (pre-COVID-19). Information collected included total admission rates and patient characteristics for ACS, stroke and falls patients. RESULTS: A total of 12 278 unplanned admissions was identified across the study period. The daily admission rate was lower in the COVID-19-era compared with pre-COVID-19 (46.59 vs 51.56 days, P < 0.001). There was also a reduced average daily admission rate for falls (7.79 vs 9.95 days, P < 0.001); however, similar admission rates for ACS (1.52 vs 1.49 days, P = 0.83) and stroke (1.56 vs 1.76 days, P = 0.33). CONCLUSIONS: Public health interventions have been effective in reducing domestic cases of COVID-19 in Australia. At our tertiary metropolitan hospital, we have observed a significant reduction in unplanned hospital admission rates during the COVID-19-era, particularly for falls. Public health messaging needs to focus on educating the public how to seek medical care safely and promptly in the context of the ongoing COVID-19 crisis.