Falls prevention in Australia

In November 2009, the following guidelines were endorsed by Australian Health Ministers for use by Australian health professionals – Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Hospitals, Residential Aged Care Facilities and Community Care 2009. As the first Australian national falls prevention guidelines to address the three main care settings, they provided a nationally consistent basis for falls prevention strategies and were designed to inform and assist health professionals reduce the risk and rate of falls in older people while providing care.

The guidelines were developed by the Australian Commission on Safety and Quality in Health Care (the Commission). The Commission was created by Australian Health Ministers in 2006 to lead and coordinate improvements in the safety and quality of health care nationally.

The focus of the Commission’s work since its inception has been on priorities for the health system where current, complex problems and community concerns could benefit from national consideration and action.

From the outset, the Commission’s remit ran across the healthcare system in Australia, including the public and private hospital sectors and primary care. This breadth of scope has been reflected in the selection of work programs and specific activities. Work in areas such as the Australian Charter of Healthcare Rights, clinical handover, medication safety, patient identification, open disclosure, falls prevention and hand hygiene has application not only in acute hospital settings but also in many other health settings. These include primary care, mental health, paediatrics, maternity care, allied health and diagnostics.

The Commission’s role is primarily as a coordinating and facilitating organisation. The Commission, prioritising through evidence and data, harnesses the experience, enthusiasm and commitment of government, consumers, clinicians, managers and other stakeholders to influence the health system and make changes to improve the safety and quality of health care in Australia.

One such safety area the Commission has focused on has been falls prevention. Falls in older people are a national safety and quality priority.

Falls are the single biggest reason for admission to hospital and presentations to the emergency department in people over 65 years of age1. Every year, approximately 30% of Australians older than 65 years fall, with 10% of these falls leading to injury2. Along with cognitive impairment and incontinence, falls are one of the major factors in precipitating admission to residential aged care facilities3.

The proportion of falls-related overnight admissions that do not go home is 80%, as opposed to 4.5% of other admissions4.

An increase in falling as people get older is associated with decreased muscle tone, strength and fitness as a result of physical inactivity. Medications can contribute to an increased risk of falling. Alcohol consumption can also lead to more falls, particularly if the alcohol interacts with certain medications. Impaired vision also contributes to falls.

In hospitals, fall rates of four to 12 per 1000 bed days have been described5. In the sub-acute or rehabilitation hospital setting, over 40% of patients with specific clinical problems, such as stroke, experience one or more falls during their admission5.Thus, incident rates vary between wards and departments in hospitals. Injuries result from approximately 30% of such falls6.

In residential aged care facilities, fall rates vary according to case mix, so that the fall and injury rates are likely to be very different for mobile people with dementia compared to very dependent people in high-level care. Fall rates in residential aged care facilities have been described as anything from four to 10 per 1000 resident bed days7 8, and there have also been descriptions of anything from one-to-five falls per resident per annum. This means up to 50% of residents experience one or more falls in a 12-month period9.

Non-injurious falls in particular tend to be under-reported and there is therefore a reporting bias.

The potential for falls multiplies once older people enter healthcare facilities. Even with high rates of falls, there may still be under reporting of events10.

In the community, prospective studies around the world have found fall rates in community-dwelling older people to be approximately 30%-40% each year. Depending on the population studied, anywhere between 22% and 60% of older people suffer injuries from falls; 10%-15% suffer serious injuries; 2%-6% suffer fractures; and 0.2%-1.5% suffer hip fractures11 12 13.

Approximately 22% of falls requiring hospitalisation in Australia occur in residential aged care facilities14.

For people aged 85 years and over, 20% of fall-related deaths occur in residential aged care facilities. It has been calculated that at least 91% of hip fractures are caused by falls15.

The hip and thigh are the most commonly injured areas requiring hospitalisation in both men and women sustaining falls16. Femur fractures from falls have decreased since 1999–2000 by 1.3% per year for men and 2.2% for women. Head injuries are also common, more so for men, and indicate that injury prevention mechanisms for the head should be considered, as well as for hips and thighs. Hip fractures are one of the most common reasons for hospital admission (in relation to injury), and most (91%) hip fractures are caused by falls17.

Hip fractures impose heavily on the Australian community due to increased death and morbidity, decreased independence, increased burden on family members and carers, increased costs due to rehabilitation, and increased admission into residential aged care facilities. Falls also result in wrist fractures; when people fall, they put their arms out to break the fall. Falls may lead to complications, including a fear of falling or a loss of confidence in walking, a longer stay in hospital or other facility, additional diagnostic procedures or surgery, and potential litigation18.

Additionally, falls may result in caregiver stress, and fear of litigation for clinical and administrative staff.

In addition to injuries, the effects of falls are costly to the individual — in terms of function and quality of life — and to the community.

Recent research across all settings identifies that in the face of an ageing population, if nothing more is done to prevent falls by 2051:

• The total estimated health cost attributable to fall-related injury will increase almost three fold from $498.2 million in 2001 to $1,375 million per year in 2051.


• In hospitals there will be 886,000 additional bed days per year or the equivalent of 2,500 additional beds


• permanently allocated to fall injury treatment.


• 3,320 additional residential aged care facility places will be required.

To maintain the current health costs, there will need to be a 66% reduction in the incidence of falls by 205119.

The clear message from this extensive data is that preventing falls and minimising their harmful effects is critical. The rate, intensity and cost of falls identify them as a key national safety and quality issue and, therefore, a focus for the Australian Commission on Safety and Quality in Health Care.

Three separate guidelines were developed that address the three main care settings: the community, hospitals and residential aged care facilities. Although there are common elements across the three guidelines, some information and recommendations are specific to each setting. Collectively, the guidelines, Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Hospitals, Residential Aged Care Facilities and Community Care 2009, are referred to as the Falls Prevention Guidelines.

The Commission agreed to develop national falls prevention guidelines in late 2007. To guide and provide advice to the project, a multidisciplinary expert panel (the Falls Guidelines Review Expert Advisory Group) was established in 2008.

The panel included specialists in the areas of falls prevention research, health economics, measurement and monitoring, quality improvement, change management and policy, as well as healthcare professions from fields including geriatric medicine, allied health and nursing.

Whenever necessary, the expert panel accessed resources outside its membership. Each chapter was reviewed by an expert in the subject matter. Three Australian falls prevention experts were appointed to review each separate guideline from an Australian, and setting-specific, perspective. In addition, three international falls prevention experts were appointed to review each separate guideline from an international, and setting specific, perspective.

A review consultation process was undertaken and involved a call for submissions, an online survey, multiple nationwide workshops (in all state and territory capitals and a number of regional centres), teleconferences, and targeted interviews with key stakeholders. An extensive range of useful, high-quality responses to these processes assisted in the development of the guidelines (and subsequent implementation process), as well as to identify other areas of action.

In addition, specialist groups provided invaluable feedback on previous guidelines and draft versions of the new guidelines. They included the National Injury Prevention Working Group, the Australian Association of Gerontology, the Royal Australian College of General Practitioners and the Continence Foundation of Australia.

Key messages identified in the 2009 Falls Prevention Guidelines are:

• Many falls can be prevented;


• Fall and injury prevention need to be addressed at both point of care and from a multidisciplinary perspective;


• Managing many of the risk factors for falls (e.g. delirium or balance problems) will have wider benefits beyond merely falls prevention;


• Engaging older people is an integral part of preventing falls and minimising harm from falls;


• Best practice in fall and injury prevention includes implementing standard falls prevention strategies, identifying fall risk and implementing targeted individualised strategies that are resourced adequately, and monitored and reviewed regularly;


• The consequences of falls resulting in minor or no injury are often neglected, but factors such as fear of falling and reduced activity level can profoundly affect function and quality of life, and increase the risk of seriously harmful falls;


• The most effective approach to falls prevention is likely to be one that includes all staff in healthcare facilities engaged in a multifactorial falls prevention program; and


• At a strategic level, there will be a time lag between investment in a falls prevention program and improvements in outcome measures.

Older people themselves are at the centre of the Falls Prevention Guidelines. Their participation, to the full extent of their desire and ability, encourages shared responsibility in health care, better assures care quality and focuses accountability.

Any fall needs to be considered in the context of the care provided relative to best practice for the individual within the specific environment. Some falls may continue to occur even when best practice is followed. In such cases, there remains a need for vigilant monitoring, review of the care plan, and implementation of actions to minimise injury risk.

The Commission’s suite of publications includes the three volumes of the Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Hospitals, Residential Aged Care Facilities and Community Care 2009. Each guideline tailors information specifically for the care setting.

Short versions, or guidebooks, of each Falls Prevention Guideline, have been designed for front line health professionals providing care for older residents and those at risk of falling. They contain the critical information from the guidelines needed to reduce the risk of falling by older patients or residents and the harm experienced from falls. Included in the guidebook are key recommendations, good practice points, information on assessing for risk factors and providing interventions, points of interest and case studies.

An implementation guide for hospitals and residential aged care facilities has been designed to assist facilities implement the Falls Prevention Guidelines. Providing practical, step by step implementation advice based on a sound methodology, the guides assist implementation of a falls reduction strategy.

Falls fact sheets have been designed to deliver the key messages from the Falls Prevention Guidelines. They describe the roles allied health professionals, nurses, doctors and support staff have to play in reducing falls. In addition, a consumer fact sheet provides falls reduction messages for residents.

The guidelines and associated materials can be found on the Commission website at: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/FallsGuidelines

Copies of the guidelines and support materials can be obtained from the Queensland Government Bookshop online at: https://www.bookshop.qld.gov.au/home.aspx or on 13 13 04.

The Falls Prevention Guidelines will be reviewed again in 2014.

Graham Bedford

Policy Team Manager
Australian Commission on Safety and Quality in Health Care
Graham Bedford has been Policy Team Manager at the Australian Commission on Safety and Quality in Health Care since 2007. He is a BA, holds legal qualifications and was admitted as a solicitor in 1992. He currently manages the Medication Safety, Falls Prevention and Open Disclosure Programs. Previous roles included Director, Policy Research and Evaluation at the Australian Public Service Commission and work as an industrial relations advocate.

References

1. AIHW (Australian Institute of Health and Welfare) (2008). A Picture of Osteoporosis in Australia, Australian Institute of Health and Welfare, Australian Government, Canberra.

2. Pointer S, Harrison J and Bradley C (2003). National Injury Prevention Plan Priorities for 2004 and Beyond: discussion paper, Australian Institute of Health and Welfare, Canberra.

3. AIHW (Australian Institute of Health and Welfare) (2008). Movement from Hospital to Residential Aged Care, Australian Government, Canberra.

4. AIHW (Australian Institute of Health and Welfare) (2007). Older Australians in Hospital, Australian Government, Canberra.

5. Oliver D, Hopper A, Seed P. Do hospital fall prevention programs work? A systematic review. Journal of the American Geriatrics Society 2000; 48(12): 1679 89.

6. Oliver D (2004). Prevention of falls in hospital inpatients: agendas for research and practice. Age and Ageing 33(4):328–330.

7. Rubenstein L, Josephson K and Osterweil D (1996). Falls and fall prevention in the nursing home. Clinics in Geriatric Medicine 12(4):881–902.

8. 17 Morse J (1996). Preventing Patient Falls, Sage Publications, Thousand Oaks, California.

9. NARI (National Ageing Research Institute) (2004). An Analysis of Research on Preventing Falls and Falls Injury in Older People: Community, Residential Care and Hospital Settings (2004 update), Australian Government Department of Health and Ageing, Injury Prevention Section, Canberra.

10. Sutton J, Standen P and Wallace A (1994). Incidence and documentation of patient accidents in hospital. Nursing Times 90(33):29–35.

11. Cripps R and Carman J (2001). Falls by the elderly in Australia: trends and data for 1998, Injury Research and Statistics Series, Australian Institute of Health and Welfare, Adelaide.

12. New South Wales Health (1994). The epidemiology of falls in older people in NSW, New South Wales Health, Sydney.

13. Gibson M, Andreas R, Isaacs B, Radebaugh T and Worm-Petersen J (1987). The prevention of falls in later life. A report of the Kellogg International Work Group on the Prevention of Falls by the Elderly. Danish Medical Bulletin 34 (suppl. 4):1–24.

14. AIHW (Australian Institute of Health and Welfare) (2008). Hospitalisations Due to Falls by Older People, Australia 2005–06, Australian Government, Canberra.

15. AIHW (Australian Institute of Health and Welfare) (2008). Hospitalisations Due to Falls by Older People, Australia 2005–06, Australian Government, Canberra.

16. AIHW (Australian Institute of Health and Welfare) (2008). Hospitalisations Due to Falls by Older People, Australia 2005–06, Australian Government, Canberra.

17. AIHW (Australian Institute of Health and Welfare) (2008). A Picture of Osteoporosis in Australia, Australian Institute of Health and Welfare, Australian Government, Canberra.

18. NARI (National Ageing Research Institute) (2004). An Analysis of Research on Preventing Falls and Falls Injury in Older People: Community, Residential Care and Hospital Settings (2004 update), Australian Government Department of Health and Ageing, Injury Prevention Section, Canberra.

19. DoHA (Australian Government Department of Health and Ageing) (2003). Projected Costs of Fall Related Injury to Older Persons Due to Demographic Change in Australia, Department of Health and Ageing, Australian Government, Canberra.