Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2102 (Published 11 May 2010) Cite this as: BMJ 2010;340:c2102
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Falls Prevention in the Inpatient Setting
The authors read with great interest the recent articles on the
prevention of falls in the community (1,2). Falls prevention is an issue
of significant concern to orthopaedic surgeons. Falls among the elderly
population lead to fragility fractures, constituting a significant
proportion of our workload. Hip fractures are a leading cause of morbidity
and mortality in the elderly population. These injuries can initiate a
general decline in overall health, resulting in a mortality of 33% at 1
year (3). Similarly, falls in the inpatient population can result in
negative outcomes such as injury, prolonged hospitalisation and delayed
rehabilitation, in addition to carrying a significant associated economic
burden (4). Thus, it is imperative that we develop preventative strategies
to minimise the healthcare consequences of falls in the elderly.
The value of a community fall prevention programme has been
highlighted by reduced fall rates and improved clinical outcomes (2). It
has however been highlighted that a major obstacle in community fall
preventive programmes is their difficulty in reaching the target
population1. We recently examined the impact of a newly introduced
multidisciplinary falls prevention programme on the incidence of inpatient
falls and fall-related injuries in an elective orthopaedic hospital over a
two year period. We found that following the implementation of this
strategy there was a 39% reduction in fall incidence and a 75% reduction
in major injuries sustained from falls. We eliminated the incidence of hip
fractures and significantly reduced associated health-related costs.
Fall prevention strategies among the elderly population, whether in
the hospital setting or in the community, minimise the poor outcomes
associated with fragility fractures. As an orthopaedic community, we
strongly support such multidisciplinary interventions targeting those at
greatest risk.
John G Galbraith orthopaedic registrar, Department of Trauma and
Orthopaedic Surgery, Cork University Hospital / St Mary’s Orthopaedic
Hospital, Cork, Ireland. johng442@hotmail.com
Joseph S Butler SpR in trauma and orthopaedic surgery, Department of
Trauma and Orthopaedic Surgery, Cork University Hospital / St Mary’s
Orthopaedic Hospital, Cork, Ireland.
James A Harty consultant orthopaedic surgeon, Department of Trauma
and Orthopaedic Surgery, Cork University Hospital / St Mary’s Orthopaedic
Hospital, Cork, Ireland.
1. Clemson L. Prevention of falls in the community. BMJ. 2010 May
11;340:c2244.
2. Logan PA, Coupland CA, Gladman JR, Sahota O, Stoner-Hobbs V,
Robertson K, Tomlinson V, Ward M, Sach T, Avery AJ. Community falls
prevention for people who call an emergency ambulance after a fall:
randomised controlled trial. BMJ. 2010 May 11;340:c2102.
3. Roche JJ, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and
postoperative complications on mortality after hip fracture in elderly
people: prospective observational cohort study. BMJ. 2005 Dec
10;331(7529):1374.
4. Alexander BH, Rivara FP, Wolf ME. The cost and frequency of
hospitalization for fall-related injuries in older adults. Am J Public
Health. 1992 Jul;82(7):1020-3.
Competing interests:
None declared
Competing interests: No competing interests
Falls prevention trial in 999 callers: paving the way for a definitive trial of referral by the ambulance service
Pip Logan and colleagues demonstrate reductions in the rate of self
reported falls and 999 calls following treatment by a community-based
falls service in a population who had been left at the scene by an
emergency ambulance crew after being attended for a fall. Older patients
who have fallen are frequently left at home by ambulance services although
crews are not generally formally trained to assess these patients for non-
conveyance and practice is highly variable [1].
Although the National Service Framework for Older People [2] advocates
referral of older people who fall by ambulance crews to community based
care, evidence of effectiveness is lacking. In terms of the MRC Framework
for the development and evaluation of complex interventions [3], Logan’s
study further builds the case made in earlier exploratory work [4] for a
multi-centre trial of an intervention in which patients who have fallen
are assessed and referred by attending ambulance crews to community-based
falls services direct from the scene of the fall. It is not certain that
Logan’s results will be repeated in other sites, especially with the
formalisation of the assessment and referral process by ambulance crews.
Indeed, previous studies in this setting have found that change in
practice is very difficult [5] to achieve and new pathways of care have
been underused. Furthermore, the safety of non-conveyance decisions by
paramedics has not been established [6].
The SAFER 2 trial evaluates a complex intervention comprising: training;
protocols and referral pathway for paramedics to refer patients meeting
appropriate criteria to falls services who provide treatment consistent
with NICE guidance [7] for the multi-disciplinary assessment and treatment
of older people who have suffered a fall. This NIHR HTA funded cluster
randomised trial, with randomisation by ambulance station, is in its set
up phase in three ambulance services and corresponding falls services in
North East London, South Wales and Nottingham. As suggested by Logan and
colleagues, the trial includes a range of outcomes, consistent with the
PROFANE guidance [8], and will assess safety, costs and effects of the new
model of care.
Ambulance services, under existing pressures to divert patients from acute
care [9] and to meet stringent response time based performance targets,
are keen to develop alternative pathways of care for older people who have
fallen. We have the opportunity to provide robust evidence about the
clinical and cost effectiveness of this intervention. The challenge
facing SAFER 2 researchers and partners is to align the research,
clinical, operational and commissioning agendas so that the trial can test
a consistent intervention across trial sites, whilst keeping the control
arm “clean”. So it is essential that, at least within trial sites,
referral pathways for patients attended by paramedics are delayed and that
usual care is provided until the safety, costs and benefits of this
potentially useful health technology are clear.
1. Snooks HA, Halter M, Close JCT, Cheung WY, Moore F, Roberts
SE.Qual Saf Health Care 2006;15:390-392 Emergency care of older people
who fall: a missed opportunity
2. National Service Framework for Older People. Department of Health 2001
http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicati...
3. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M.
Developing and evaluating complex interventions: the new Medical Research
Council guidance BMJ 2008;337:a1655
4. Halter M, Close JCT, Snooks H, Porsz S, Cheung WY. Fit to be left: can
ambulance staff use an assessment tool to decide if an older person who
has fallen can be safely left at home? Report for the Department of
Health Research Programme to Support Implementation of the National
Service Framework for Older People. London Ambulance Service NHS Trust
November 2005.
5. Mary Halter, Susan Vernon, Helen Snooks, et al. Complexity of the
decision making process of ambulance staff for assessment and referral of
older people who have fallen: a qualitative study Emerg Med J published
online May 14, 2010
6. Snooks H, Kearsley N, Dale J, Halter M, Redhead J, Cheung W
(2004).Towards primary care for non-serious 999 callers: results of a
controlled study of 'Treat and Refer' protocols for ambulance crews. Qual
Saf Health Care 13(6):435-43.
7. National Institute of Clinical Excellence. The assessment and
prevention of falls in older people. Clinical Guideline CG21; November
2004 http://www.nice.org.uk/CG021
8. Lamb S, Jørstad-Stein EC, Hauer K, Becker C. (2005) On behalf of the
Prevention of Falls Network Europe and Outcomes Consensus Group. J Am
Geriatr Soc 53 1618–23
9. Taking healthcare to the patient: Transforming NHS ambulance services.
Department of Health, 2005
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
Competing interests:
None declared
Competing interests: No competing interests