Breaking the cycle of recurrent fracture: implementing the first fracture liaison service (FLS) in British Columbia, Canada.

Fractures occurring with very little trauma are often caused by osteoporosis and can lead to disability. This study demonstrates that a coordinator working with an orthopaedic team can significantly increase the number of individuals receiving appropriate treatments during their after-fracture care to prevent future fractures from occurring. PURPOSE: Well-implemented Fracture Liaison Service (FLS) programs increase appropriate investigation and treatment for osteoporosis after low trauma fracture. This research evaluates the effectiveness of the first FLS program implemented in British Columbia (BC), Canada. METHODS: A controlled before-and-after study was conducted. The intervention was an FLS program implemented at an orthopaedic outpatient clinic at Peace Arch Hospital in BC. Eligible patients were those over the age of 50 years with a low trauma fracture of the hip, pelvis, vertebra, wrist or humerus. A nurse practitioner FLS coordinator identified, investigated and initiated treatment in patients based on their future fracture risk. The primary outcome was the percentage of all patients at high-risk to refracture, who achieved at least one of the following outcomes: (1) started on osteoporosis medication, (2) referred to an osteoporosis consultant or (3) assessed for treatment change if they were already on osteoporosis medication at the time of the fracture. Secondary outcomes included the rate of bone density testing, referral to fall prevention programs and change in health-related quality of life over 6 months. RESULTS: A total of 195 patients participated in the study (65 in the usual care group, 130 in the FLS group). Average age was 70.5 years (standard deviation 11.5), and 84% of participants were female. In the FLS group, 77.8% of high-risk patients achieved the primary outcome compared with 22.9% in the usual care group. CONCLUSION: In BC, the implementation of an FLS program improved investigation and treatment for osteoporosis after low trauma fracture.

Fall Prevention Mobile Clinic: A Novel Fall Prevention Program for Community-Dwelling Older Adults.

ABSTRACTCauses of falls in older adults are common, multifactorial, and can lead to significant injury. This before-and-after study evaluated the benefits of a Fall Prevention Mobile Clinic (FPMC) in reducing the risk of falling in older adults in British Columbia, Canada. Four hundred seventy-six participants (average age of 83.6 years) enrolled in the study and were followed for 12 months after attending the FPMC. At 12-month follow-up, the mean percentage uptake of fall prevention recommendations was 48.8 per cent (SD = 25.7%), the Timed Up and Go mobility measure improved from a median of 19.04 seconds to 17.45 seconds and the number of participants falling decreased from 64.8 per cent (in the 12 months before attending the clinic) to 55.6 per cent (in the 12 months after attending the clinic) (p = .012). After attending the FPMC, participants acted on recommendations, improved mobility and decreased their risk of future falls.

Recommendations for a core outcome set for measuring standing balance in adult populations: a consensus-based approach.

BACKGROUND: Standing balance is imperative for mobility and avoiding falls. Use of an excessive number of standing balance measures has limited the synthesis of balance intervention data and hampered consistent clinical practice. OBJECTIVE: To develop recommendations for a core outcome set (COS) of standing balance measures for research and practice among adults. METHODOLOGY: A combination of scoping reviews, literature appraisal, anonymous voting and face-to-face meetings with fourteen invited experts from a range of disciplines with international recognition in balance measurement and falls prevention. Consensus was sought over three rounds using pre-established criteria. DATA SOURCES: The scoping review identified 56 existing standing balance measures validated in adult populations with evidence of use in the past five years, and these were considered for inclusion in the COS. RESULTS: Fifteen measures were excluded after the first round of scoring and a further 36 after round two. Five measures were considered in round three. Two measures reached consensus for recommendation, and the expert panel recommended that at a minimum, either the Berg Balance Scale or Mini Balance Evaluation Systems Test be used when measuring standing balance in adult populations. LIMITATIONS: Inclusion of two measures in the COS may increase the feasibility of potential uptake, but poses challenges for data synthesis. Adoption of the standing balance COS does not constitute a comprehensive balance assessment for any population, and users should include additional validated measures as appropriate. CONCLUSIONS: The absence of a gold standard for measuring standing balance has contributed to the proliferation of outcome measures. These recommendations represent an important first step towards greater standardization in the assessment and measurement of this critical skill and will inform clinical research and practice internationally.

Agreement between video footage and fall incident reports on the circumstances of falls in long-term care.

OBJECTIVE: 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. DESIGN/SETTING/PARTICIPANTS: Video capture of 863 falls (by 309 individuals) over 6 years in common areas of 2 LTC facilities in British Columbia. MEASUREMENTS: 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. RESULTS: 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. CONCLUSION: 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.

Facilitators of and barriers to hip protector acceptance and adherence in long-term care facilities: a systematic review.

BACKGROUND: 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. PURPOSE: 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. METHODS: 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. RESULTS: 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). DISCUSSION: 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.

An educational video to promote multi-factorial approaches for fall and injury prevention in long-term care facilities.

BACKGROUND: Older adults living in long term care (LTC) settings are vulnerable to fall-related injuries. There is a need to develop and implement evidence-based approaches to address fall injury prevention in LTC. Knowledge translation (KT) interventions to support the uptake of evidence-based approaches to fall injury prevention in LTC need to be responsive to the learning needs of LTC staff and use mediums, such as videos, that are accessible and easy-to-use. This article describes the development of two unique educational videos to promote fall injury prevention in long-term care (LTC) settings. These videos are unique from other fall prevention videos in that they include video footage of real life falls captured in the LTC setting. METHODS: Two educational videos were developed (2012-2013) to support the uptake of findings from a study exploring the causes of falls based on video footage captured in LTC facilities. The videos were developed by: (1) conducting learning needs assessment in LTC settings via six focus groups (2) liaising with LTC settings to identify learning priorities through unstructured conversations; and (3) aligning the content with principles of adult learning theory. RESULTS: The videos included footage of falls, interviews with older adults and fall injury prevention experts. The videos present evidence-based fall injury prevention recommendations aligned to the needs of LTC staff and: (1) highlight recommendations deemed by LTC staff as most urgent (learner-centered learning); (2) highlight negative impacts of falls on older adults (encourage meaning-making); and, (3) prompt LTC staff to reflect on fall injury prevention practices (encourage critical reflection). CONCLUSIONS: Educational videos are an important tool available to researchers seeking to translate evidence-based recommendations into LTC settings. Additional research is needed to determine their impact on practice.

Concept mapping applied to the intersection between older adults' outdoor walking and the built and social environments.

OBJECTIVE: For older adults, the ability to navigate walking routes in the outdoor environment allows them to remain active and socially engaged, facilitating community participation and independence. In order to enhance outdoor walking, it is important to understand the interaction of older adults within their local environments and the influence of broader stakeholder priorities that impact these environments. Thus, we aimed to synthesize perspectives from stakeholders to identify elements of the built and social environments that influence older adults' ability to walk outdoors. METHOD: We applied a concept mapping approach with the input of diverse stakeholders (N=75) from British Columbia, Canada in 2012. RESULTS: A seven-cluster map best represented areas that influence older adults' outdoor walking. Priority areas identified included sidewalks, crosswalks, and neighborhood features. CONCLUSION: Individual perceptions and elements of the built and social environments intersect to influence walking behaviors, although targeted studies that address this area are needed.

What does it mean to transform knowledge into action in falls prevention research? Perspectives from the Canadian Institutes of Health Research.

INTRODUCTION: The concept of knowledge translation as defined by the Canadian Institutes for Health Research and the Knowledge to Action Cycle, described by Graham et al (Graham et al., 2006), are used to make a case for the importance of using a conceptual model to describe moving knowledge into action in the area of falls prevention. METHOD: There is a large body of research in the area of falls prevention. It would seem that in many areas it is clear what is needed to prevent falls and further syntheses can determine where the evidence is sufficiently robust to warrant its implementation as well as where the gaps are that require further basic research. CONCLUSION: The phases of the action cycle highlight seven areas that should be paid attention to in order to maximize chances of successful implementation.

When evidence is not enough: the challenge of implementing fall prevention strategies.

PROBLEM: As the evidence-based movement has advanced in public health, changes in public health practices have lagged far behind creating a science to service gap. For example, science has produced effective falls prevention interventions for older adults. It now is clearer WHAT needs to be done to reduce injury and death related to falls. However, issues have arisen regarding HOW to assure the full and effective uses of evidence-based programs in practice. SUMMARY: Lessons learned from the science and practice of implementation provide guidance for how to change practices by developing new competencies, how to change organizations to support evidence-based practices, and how to change public health systems to align system functions with desired practices. The combination of practice, organization, and system change likely will produce the public health benefits that are the promise of evidence-based falls prevention interventions. IMPACT ON PUBLIC HEALTH: For the past several decades, the emphasis has been solely on evidence-based interventions. Public health will benefit from giving equal emphasis to evidence-based implementation. IMPACT ON INDUSTRY: We now have over two decades of research on the effectiveness of fall prevention interventions. The quality of this research is judged by a number of credible international organizations, including the Cochrane Collaboration (http://www.cochrane.org/), the American and British Geriatrics Societies, and the Campbell Collaboration (http://www.campbellcollaboration.org/). These international bodies were formed to ponder and answer questions related to the quality and relevance of research. These developments are a good first step. However, while knowing WHAT to do (an evidence-based intervention) is critical, we also need to know HOW to effectively implement the evidence. Implementation, organization change, and system change methods produce the conditions that allow and support the full and effective use of evidence-based interventions. It is time to focus on utilization of implementation knowledge in public health. Without this focus the vast amount on new evidence being generated on the prevention of falls and related injuries among older adults will have little impact on their health and safety.

Falls and fall prevention programmes in developing countries: environmental scan for the adaptation of the Canadian Falls prevention curriculum for developing countries.

PROBLEM: Falls in older persons in developing countries are poorly understood, and falls prevention and health promotion programmes for this population are largely lacking. METHODS: A systematic review was carried out of relevant literature on falls and prevention programmes, and falls prevention education, and a scan undertaken of health promotion programmes for older persons in a representative country - South Africa. RESULTS: Studies on the risk and prevalence of falls are largely retrospective and hospital-based, with varied methodology, including study period, sampling method and sample size. Falls prevalence is based largely on self-reports in studies on general trauma in all age groups. Falls incidence varies from 10.1% to 54%. No reports could be traced on sustained falls prevention or health promotion programmes. CONCLUSION: Scant research has been conducted and little preventive education offered on falls in older persons. Adaptation of the Canadian Falls Prevention Curriculum for developing countries will help to fill gaps in knowledge and practice. IMPACT ON INDUSTRY: With rapid increase in the populations of older persons in developing countries, research on age related disorders such as falls is required to guide policy and management of falls.

Evaluation of an evidence-based education program for health professionals: the Canadian Falls Prevention Curriculum© (CFPC).

INTRODUCTION: A staged, mixed methods approach was applied to the development and evaluation of an evidence-based education program for health care professionals and community leaders on how to design, implement and evaluate a fall prevention program. Stages included pre-development, development, pilot testing and impact on practice. The goal of the evaluation was to determine if the Canadian Falls Prevention Curriculum met the needs of the target audience and had an impact on learning and practice. METHODS: Methods included a needs assessment, systematic reviews, pre-post tests of learning, follow-up surveys and interviews, and descriptive reports of stakeholder involvement. The needs assessment and systematic review of existing programs indicated that there was a demand for a comprehensive, evidence-based curriculum on fall prevention and that no similar curricula existed. Pre-post test findings showed significant increases in learning and follow-up surveys showed a positive impact on practice. IMPACT ON INDUSTRY: Evidence shows that the most effective fall prevention efforts are those that address the multifactorial nature of fall risk, with proven interventions provided by trained clinicians. The Canadian Falls Prevention Curriculum provides evidence-based training for clinicians and community leaders using a public health approach to fall prevention that includes instruction on how to define the problem, assess the risk, examine best practices, implement the program, and conduct evaluation of the program's effectiveness.

Current approaches to fall risk assessment in nursing homes.

Although falls are the most frequently reported adverse events in nursing homes (NH), fall risk assessment is not standardized or regulated. The purpose of this study was to examine the types of fall risk assessment tools (FRATs) used in NH to identify which are used and the domains they include. Participating facilities completed a survey and were requested to submit a copy of their FRAT. A content analysis of the 137 surveys and 54 FRATs revealed that there was little consistency among the NH in terms of the type of FRAT used, and most of the FRATs submitted were not evidence-based. Improved and validated FRATs are needed to aid NH staff in evaluating NH residents who are at risk for falls.

A public health approach to fall prevention among older persons in Canada.

In 2008 to 2009, there were 53,545 fall-related hospitalizations among Canadian seniors, accounting for 85% of all injury-related hospitalizations and 7% of all hospitalizations for those aged 65 years and older. The estimated cost of fall-related injuries to the Canadian health care system in 2004 was more than $2 billion among a population of 4.1 million seniors. This article describes highlights of how policy makers, researchers, and practitioners are applying a public health approach to the issue of seniors' falls in Canada, including the successes, challenges, and recommendations for the future.

Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings.

OBJECTIVE: to conduct a systematic review of published studies that test the validity and reliability of fall-risk assessment tools for use among older adults in community, home-support, long-term and acute care settings. METHODS: searches were conducted in EbscoHost and MEDLINE for published studies in the English language between January 1980 and July 2004, where the primary or secondary purpose was to test the predictive value of one or more fall assessment tools on a population primarily 65 years and older. The tool must have had as its primary outcome falls, fall-related injury or gait/balance. Only studies that used prospective validation were considered. FINDINGS: thirty-four articles testing 38 different tools met the inclusion criteria. The community setting represents the largest number of studies (14) and tools (23) tested, followed by acute (12 studies and 8 tools), long-term care (LTC) (6 studies and 10 tools) and home-support (4 studies and 4 tools). Eleven of the 38 tools are multifactorial assessment tools (MAT) that cover a wide range of fall-risk factors, and 27 are functional mobility assessment tools (FMA) that involve measures of physical activity related to gait, strength or balance. CONCLUSION: fall-risk assessment tools exist that show moderate to good validity and reliability in most health service delivery areas. However, few tools were tested more than once or in more than one setting. Therefore, no single tool can be recommended for implementation in all settings or for all subpopulations within each setting.