6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trialBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.h6781 (Published 26 January 2016) Cite this as: BMJ 2016;352:h6781
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Re: 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial
Congratulations indeed to the 6 Pack team for such an important study that tells us clearly that nursing interventions alone however well-meant and thought out just don’t do what we would hope. As disappointing as this may first appear to the many frontline nurses and nurse leaders who have wholeheartedly and valiantly tried to make improvements to the care of this most vulnerable patient group it’s time now for us all to move on and embrace the evidence for multiprofessional interventions as described in NICE https://www.nice.org.uk/Guidance/CG161
This may not be as daunting as it sounds. When did the care and management of elderly people with complex needs ever depend on a single profession? we've been doing just that for decades! Time now to reenergise and look at innovative and novel quality improvement initiatives that include all professional groups.
Competing interests: No competing interests
Are we allocating hospital resources to fall prevention interventions that are completely ineffective?
Barker and colleagues are to be commended for their large rigorous trial that seems to have comprehensively demonstrated the ineffectiveness of the 6-PACK intervention(s). In this case, it would seem that taking a falls risk screening tool and 6 individual intervention components (that have no randomised trial evidence of effectiveness on their own in preventing fall injuries) and combining them into a single multi-faceted intervention was ultimately ineffective in reducing falls in 6 acute hospitals. Is this response a commendation made in jest? Not at all. From my viewpoint, I consider this a seminal contribution to this field for (at least) three reasons.
First, the quality of the study and its reporting are a credit to the investigators and institutions involved. The evaluation of intervention implementation, in addition to other robust design features, enables us to rest assured that the intervention was successfully implemented, it just didn't prevent falls as the investigators had expected based on their pilot data. I think this is precisely why rigorous multi-site randomised trials are invaluable, albeit surprisingly uncommon, in this field. The academic integrity of plainly reporting a negative finding is meritorious, and credit is also due to the BMJ for publishing this negative finding.
Second, this study should serve as a call to reinvigorate genuine debate over resource allocation for fall prevention activities in hospital settings. The authors report that “components of the 6-PACK programme are commonplace in some hospitals” and I don’t doubt this. In fact, I think it is fair to say we have a long (and growing) list of ‘fall prevention’ interventions consuming precious and finite hospital resources internationally that continue to lack any robust evidence of effect in reducing falls and fall-related injuries. My mind boggles to think about what we could do with the hospital resources we currently invest (or perhaps squander is the term I am looking for) in inpatient ‘fall prevention’ interventions that do not actually prevent falls and fall-related injuries.
Third, this study indirectly raises questions about the role of hospital accreditation standards and associated quality and safety processes in the implementation of costly and ineffective fall prevention activities in acute hospital settings. The authors of the present study have correctly highlighted the dearth of evidence supporting fall prevention activities in acute hospital settings. Despite a concerted effort to prevent falls, they have provided yet another example of a seemingly good approach that was ultimately ineffective in preventing falls even though they increased the implementation of the targeted intervention activities. Yet, I suspect that for clinicians and hospital administrators alike, if an external assessor of quality and safety evaluating our facilities asked about fall prevention activities, we may have no hesitation in bringing out a list comprising a falls risk assessment and a series of six falls prevention interventions that lack evidence of effectiveness in acute hospital settings. We ought to consider how much of our ‘fall prevention’ activity is driven by a desire to be doing something (even if futile) rather than acknowledging that in the cupboard of interventions for preventing falls in hospital there is a surprising bare shelf labelled ‘interventions that have some kind of randomised trial evidence indicating effectiveness in reducing fall-related injuries in acute hospitals’.
Perhaps in our hospitals we should be more readily considering careful and closely monitored disinvestment (with robust evaluation) from ‘fall prevention’ interventions that currently lack evidence of effect? It would seem that low-low beds, and use of bed-alarms may feature prominently on any list of dis-investment prospects for hospitals due to the valuable reporting of negative findings from prior studies in the field[2 3], in addition to findings from the present study. This way, we may have hope of reducing allocation of resources to futile fall prevention interventions, while identifying some interventions that we can’t do without (that are effective), and re-allocating resources saved to effective interventions (or development of effective approaches for inpatient fall prevention). I am sure this is easier said than done.
1. Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. BMJ 2016;352 doi: 10.1136/bmj.h6781.
2. Shorr RI, Chandler AM, Mion LC, et al. Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients: A Cluster Randomized Trial. Annals of internal medicine 2012;157(10):692-99 doi: 10.7326/0003-4819-157-10-201211200-00005.
3. Haines TP, Bell RA, Varghese PN. Pragmatic, cluster randomized trial of a policy to introduce low-low beds to hospital wards for the prevention of falls and fall injuries. Journal of the American Geriatrics Society 2010;58(3):435-41 doi: 10.1111/j.1532-5415.2010.02735.x|.
Competing interests: I have past and current research collaborations with several investigators from this study, but was not involved in the conduct of this trial.