Abstract
Background Discharge from the hospital is a high risk transition period for older adults at risk of falls. Guidelines relevant to physical therapists for managing this risk are well documented, but commonly not implemented.
Purpose This project implemented an intervention to improve physical therapists' adherence to key guideline recommendations for managing risk of falls on discharge from one hospital.
Data Sources A pretest-posttest study design was undertaken and was underpinned by the Theoretical Domains Framework (TDF) to aid in the design of interventions to increase physical therapists' adherence to guideline recommendations and to identify barriers to these interventions.
Data Extraction A multifaceted intervention was implemented, including the establishment of a governance committee, education sessions, development of a “pathway” to guide practice, modification of an existing standardized assessment proforma, development of standardized processes and indicators for handover, increasing availability of educational handouts, audit and feedback processes, and allocation of dedicated staffing to oversee falls prevention within the physical therapy department.
Data Synthesis There were significant improvements in physical therapist behavior leading to key guideline recommendations being met, including: the proportion of patients who were identified to be at risk of falls (6.3% preintervention versus 94.8% postintervention) prior to discharge, an increase in documentation of clinical handover at discharge (68.6% preintervention versus 90.9% postintervention), and improvement in the quality of this documented clinical handover (34.9% of case notes met 5 criteria preintervention versus 92.9% postintervention).
Limitations The approach was resource intensive and consequently may be difficult to replicate at other sites.
Conclusions A multifaceted intervention underpinned by the TDF, designed to modify physical therapists' behavior to improve adherence to guideline recommendations for managing risk of falls on discharge from one hospital, was successful.
In Australia, best practice guidelines for the prevention of falls and harm from falls in older people1 and the National Safety and Quality Health Service Standards,2 which address the prevention of falls and harm from falls, exist. These 2 documents provide detailed evidence-based recommendations for health professionals working across acute, primary, and community settings for strategies to reduce risk and improve patient outcomes. However, despite the existence of these detailed guidelines and accreditation standards, falls continue to be a major public health issue for older Australians. In the general community, 1 in 3 people aged 65 years and over will fall one or more times per year,3 and these falls are the leading cause of injury in Australian hospitals, with up to 38% of all incidents reported in hospitals related to falls.4 The first 6 months following hospital discharge is also a particularly high-risk period,5,6 with reports of up to 40% of patients falling at least once and with more than half of these falls resulting in injury6 that will likely require rehospitalization or, at the least, medical intervention.
A single fall can have a devastating impact on an individual, including consequences such as: hip fracture, head injury, loss of confidence and independence, and ongoing disability, ultimately resulting in hospitalization, reduced quality of life, institutionalization, and even death.7–11 The impact on the broader community also is significant, with projections of a 3-fold increase in the total annual cost of fall-related injury in Australia by 2051 to just over US$734 million per annum.12 This is not an issue isolated to Australia, with this public health burden recognized as an international health priority.13
Although there is a growing body of literature focusing on strategies to prevent falls in the hospital2,14 and an extensive body of literature for the community setting,2,15 there has not been such a strong focus on reducing risk of falls during the transition between care settings, that is, when patients transfer from the hospital back into the community or to another facility. Recommendations for reducing risk for patients admitted to the hospital include identifying patient risk early in the admission, taking action to increase the proportion of patients who are at risk undergoing comprehensive assessment of risk of falls, referring patients who are at risk to appropriate services as part of the discharge process, and educating patients and their caregivers about this risk and possible prevention strategies.1,2 Yet, even though these strategies are well described, interventions targeting the successful implementation of these recommendations into clinical practice have not been extensively evaluated.
Acute care physical therapists are well positioned to identify and subsequently put management strategies in place for patients who are considered to be at risk of falls while in the hospital and on discharge. However, this opportunity may not be capitalized effectively at all hospitals. A study conducted at one South Australian acute care hospital investigated physical therapist management of patients with high risk of falls (admitted to the hospital after hip fracture).8,16,17 It was identified that less than 10% of patients had risk of falls documented in their assessment, and only 8% had a documented referral to a community service provider for falls prevention follow-up.
Consequently, the aim of the present study was to design and implement a strategy to modify physical therapists' behavior to improve their adherence to guideline recommendations relating to the identification and clinical handover of patients who are at risk of falls on discharge from the hospital.
Method
Study Design
The study design has been described in detail in a previous publication.18 In summary, the 4-step process described by French and colleagues19 for developing a theory-informed, multifaceted intervention to change clinical behavior provided the framework for the current study. In summary, barriers to and enablers of practice change were identified and underpinned the design of a multifaceted intervention targeting behavior change in physical therapists.
Step 1: identifying the problem.
The setting was Flinders Medical Centre (FMC), a 588-bed acute teaching hospital located in South Australia. The initial focus of the project was the 28-bed Orthopaedic Ward, which admits an average of 5 to 10 new patients with hip fracture per week. During step 1, a detailed mapping of processes to clearly identify the problem, it was determined that key guideline recommendations for reducing risk of falls for older adults following hospital discharge were not being routinely implemented by physical therapists hospital-wide. Consequently, the target setting changed from the Orthopaedic Ward to include any patient who was admitted to the site and identified as being at risk of falls on hospital discharge either by their treating physical therapist or by an automatically computer-generated list that was produced on a daily basis as patients were admitted to the hospital's emergency department.
The key health professional group that was targeted in this study was hospital physical therapists (including physical therapist students) who were responsible for the assessment and management of older patients who were admitted to the hospital and who were at risk of falls on discharge. Another key group important to the study was the Southern Community Falls Prevention Team (SCFPT), who were a community-based team of allied health professionals responsible for the coordination of fall prevention services for older people living in southern metropolitan Adelaide identified as being at risk of falling. Although they were not the only community service provider responsible for fall prevention in this region, they were the primary point of contact and had links with all other relevant community service providers. In addition, hospital executives who had an interest in or were responsible for resource allocation relevant to falls prevention and any patients who were admitted to the site and who were considered to be at risk of falls on discharge were considered key target groups.
Following synthesis of information gathered through interviews with patients and key stakeholders, focus groups with physical therapists, medical record audits, and telephone interviews with patients, processes were able to be mapped. These processes were then compared with the Australian best practice guidelines for the prevention of falls and harm from falls in older people1 and the National Safety and Quality Health Service Standards,2 allowing for identification and clarification of key issues that needed to be addressed. Three key practices were identified that were not meeting recommendations for best practice care: (1) patients who were at risk of falling on hospital discharge were not routinely being identified, (2) documentation of high-quality clinical handover of information relating to patients who were identified as being at risk of falling on hospital discharge was not occurring routinely or consistently, and (3) patients were not involved in the process of identification of their risk of falls or planning for the management of this risk.
Step 2: assessing the problem.
The Theoretical Domains Framework (TDF) was applied retrospectively to data collected to allow for a thorough analysis of barriers to and enablers of practice change.20,21 The TDF is made up of 14 domains, and each barrier and enabler identified were linked to one or more relevant domains within the TDF. When considering intervention functions to overcome the identified barriers, factors such as feasibility, local relevance, and acceptability to the target setting were considered. For a detailed description of all identified barriers and enablers and which TDF domains they were linked to, see the earlier publication by Thomas and Mackintosh.18
Step 3: forming possible solutions.
A detailed description of the multifaceted intervention has been described in a previous publication.18 In summary, the multifaceted intervention consists of: (1) establishment of a project Governance Committee to review and provide feedback on proposed interventions; (2) education sessions delivered to physical therapists about guideline recommendations and the consequences of failing to meet these recommendations; (3) development of a “pathway” to assist physical therapists to meet guideline recommendations in identification and management of risk of falls; (4) modification of an existing standardized initial assessment proforma to include prompts to consider identification of risk of falls and document any identified risks and proposed actions; (5) development of standardized processes for producing high-quality handover (both paper and electronic) at discharge that would be available to relevant community agencies managing the risk of falls on an ongoing basis; (6) making widely available the booklet titled Don't Fall for It: Falls Can Be Prevented!,22 a consumer information resource produced by the Australian federal government and considered to be highly relevant and useful by both patients and physical therapists; (7) establishing a Physiotherapy Department Falls Committee responsible for ensuring ongoing sustainability of practice change through the conduct, review, and distribution of audit results, as well as identifying and mitigating potential risks and reinforcing positive behavior change with staff; (8) allocation of 0.2 full-time equivalent staff to oversee identification and referral processes on an ongoing basis; and (9) an audit-and-feedback process where numbers of patients identified as being at risk of falls on discharge, number of times handover was completed for these identified patients, and number of quality criteria that the handover met were collected, graphed, and distributed to all key stakeholders with whom the practice change was targeted. This process was done via email and verbally at a weekly staff meeting. Steps 1 through 3 ran over an 11-month period.
Step 4: evaluating the selected intervention.
Preimplementation data were captured up to 2 years prior to the implementation of the practice change strategies (the interventions). The first postimplementation data were captured approximately 6 weeks following initial implementation of the interventions, and the final data were captured just over 12 months following implementation of the interventions.
Medical record audit.
Potential participant records were identified via a database kept by the FMC Orthopaedic Department of all patients admitted to the site for surgery for hip fracture. This group was originally chosen to audit for their known high risk of falls on discharge and because this was where the original evidence practice gap for this project was identified. After it was identified that the problem was occurring hospital-wide, the audit was expanded to include the electronic discharge summaries of patients who had been admitted to the site and who had subsequently been identified as being at risk of falls on discharge by their treating physical therapist. Records of these patients were kept in an electronic database managed by the falls prevention physical therapist. Before implementation of change strategies, the electronic discharge summary was the only mechanism for the SCFPT to gather patient information, including reason for referral.
Using a time-series approach, data were collected at 3 separate time points both before and after implementation of the behavior change strategies. An audit tool was developed for both the case note and electronic discharge summary audits. Before implementation of change strategies, this tool captured basic demographic data; type, frequency, and intensity of physical therapy provided; identification, assessment, or implementation of fall prevention strategies; and handover quality. After implementation of change strategies, the audit tool was modified slightly to ensure that it also captured process indicators to identify whether behavior change had occurred.
Telephone follow-up of patients identified as being at risk of falls on discharge.
Potential participants were identified via the database of patients referred to the SCFPT. Patients appeared in this database if they were identified as being at risk of falls by the triage nurse in the emergency department or if their treating physical therapist identified them as being at risk of falls and chose to refer them to the SCFPT. Eligible participants were sent a letter of offer to participate within 2 weeks of discharge from FMC.
Telephone interviews were conducted within 5 weeks of the patient being discharged from FMC by a research assistant using an interview guide (eAppendix) and a standardized data collection form. Three separate attempts to contact the eligible participant were made; patients who could not be reached after the third attempt were dropped from the study. The 5-week time lag from discharge to telephone call was to allow the SCFPT time to receive and act on the referral from FMC. Two rounds of interviews were conducted both before and after implementation of behavior change strategies.
Outcome Measures
Primary outcomes included the proportion of patients who had risk of falls documented in their medical records and a clearly documented clinical handover from their treating physical therapist at discharge. Secondary outcomes were the proportion of documented handovers by the physical therapist at discharge that met a standardized set of criteria for handover quality and the level of patient awareness about their identified risk of falls and proposed management strategies for this risk.
Data Analysis
Data were analyzed using IBM SPSS for Windows version 20.0 (IBM Corp, Armonk, New York). Comparisons between groups for patient demographics and process indicators before and after intervention were conducted using independent-samples t tests or independent group chi-square tests as appropriate, depending on the nature and distribution of the data.
Role of the Funding Source
Lead author Dr Thomas was supported through an Australian National Health and Medical Research Council (NHMRC) Translating Research Into Practice (TRIP) Fellowship (Grant ID: GNT1035256) for the duration of this study. The fellowship provided training and support in the methodological approach for translational research.
Results
Medical Record Audits
Patient case notes.
A total of 159 case notes were audited prior to implementation of the intervention, and 154 case notes were audited during the follow-up postimplementation phase. There were no significant differences between patients audited before and after implementation of the intervention for age, sex, length of hospital stay, reason for admission, premorbid accommodation, or discharge destination (Tab. 1). All patients whose case notes were audited had been admitted to the site with a diagnosis of hip fracture and were considered to be at high risk of future falls on hospital discharge, regardless of whether the reason for admission was fall related.
Demographic Data for Audited Patient Case Notes Before and After Implementation of Practice Change Strategies
The proportion of patients identified as being at risk of falls on discharge via documentation in the case notes increased by 88.5%, from 6.3% before implementation to 94.8% after implementation of the intervention (Tab. 2, χ2=241.65, P<.001). This finding was largely accounted for by improved quality of documentation of risk of falls on the physical therapy initial assessment proforma, which had been modified as one of the practice change strategies. The proportion of patients who had clinical handover documented at discharge by their treating physical therapist also significantly increased from 68.6% before intervention to 90.9% after intervention (χ2=22.68, P<.001), with 63.8% increased use of the electronic discharge summary after implementation of the intervention. Also of significance was the improvement in the quality of clinical handover documentation, where a score of 5 indicated high-quality clinical handover measured against a standardized set of criteria for handover quality (ISBAR [Identify, Situation, Background, Assessment, and Recommendation]).23 A score of 5 was achieved in only 34.9% of case notes audited before intervention, with this number increasing to 92.9% after intervention (χ2=117.04, P<.001). There was statistically significant improvement in the proportion of case notes with documented discharge risk of falls and subsequent implementation of practice change strategies. Before intervention, this documentation was not observed in any case notes and had improved 21.4% on the initial assessment proforma (χ2=54.26, P<.001) and 18.7% on the clinical handover (χ2=35.19, P<.001).
Difference in Key Process Indicators Before and After Implementation of Practice Change Strategies Case Note Audita
Electronic discharge summary.
A total of 50 patient electronic discharge summaries were audited both before and after implementation of the intervention. All patients whose electronic discharge summaries were audited had been referred to the SCFPT for follow-up to manage discharge risk of falls. This audit measured the level of uptake of practice change strategies in other high-risk patient groups outside of patients who were admitted for hip fracture. There were no significant difference in the baseline characteristics for age, sex, length of hospital stay, or reason for admission for the preimplementation and postimplementation groups (Tab. 3).
Demographics of Patients and Difference in Key Process Indicators Before and After Implementation of Practice Change Strategies for Audit of Electronic Discharge Summariesa
The proportion of electronic discharge summaries that had clinical handover documented by the treating physical therapist significantly improved from 8% before intervention to 64% after intervention (Tab. 3, absolute difference=56%, χ2=31.64, P<.001). Whether the patient was aware of his or her referral to the SCFPT or his or her plan for management of discharge risk of falls was clearly documented in 34% of the discharge summaries after intervention compared with none of the discharge summaries (0%) before intervention. This was also a significant change (χ2=18.14, P<.001).
Telephone Interviews With Patients
Before intervention, 66 telephone interviews were attempted, with 47 interviews completed (Fig. 1). After intervention, 65 telephone interviews were attempted, with 36 interviews completed (Fig. 2). Patients interviewed did not differ before and after implementation on age or sex; however, there were significant differences in the mean time following discharge that the interview occurred (preimplementation mean of 4.3 weeks versus postimplementation mean of 5.9 weeks; t=−7.46, P<.0001) and the mean duration of the interview (postimplementation interviews lasted, on average, 4.12 minutes longer than preimplementation interviews; t=−6.67, P<.001) (Tab. 4).
Flow of patient eligibility for telephone interview before implementation of intervention. TCP=transitional care package, RA=research assistant.
Flow of patient eligibility for telephone interview after implementation of intervention. TCP=transitional care package.
Demographic Data of Patients Who Participated in a Telephone Interview Both Before and After Implementation of Change Strategies
After implementation, there was significant increase in the proportions of patients who recalled discussion with a health professional about discharge risk of falls (15/47 [32%] versus 23/36 [64%]; χ2=7.16, P=.007). No other significant differences were found before implementation compared with after implementation for participants' responses to questions asked during the telephone call interviews (eTable).
Discussion
This project was successful in developing and implementing an intervention to modify the clinical behavior of physical therapists to ensure key guideline recommendations for managing risk of falls on discharge from one hospital were being met. Patients who are at risk of falling on discharge from this hospital are now routinely being identified through more consistent and higher-quality documentation in both medical records and electronic discharge summaries.
The improvement in the quality of discharge documentation has 2 potential positive sequential effects. First, agencies responsible for managing risk of falls in the community may be able to deliver more targeted interventions, in a more timely fashion, to those patients who are most at risk because they have received detailed information about a patient's potential risk of falls. It is important to note that prior to the intervention implemented in this study, the only means for community agencies to access information about a patient's in-hospital stay and reason for referral to their services was via the discharge summary, which was rarely completed. Second, if a patient is readmitted to the acute setting, physical therapists will be alerted to the patient's risk of falls based on the information in the previous discharge summary.
Although there was evidence of improved involvement of the patient in identifying his or her risk of falls and educating the patient on strategies that would be put into place on discharge to mitigate this risk, further work at the target site is needed. From this study, it is difficult to tell the actual level of patient involvement in identification of risk of falls because results relied on the physical therapist remembering to document whether the patient had been involved or on patient recall in a telephone interview after discharge. In some instances, there was a delay of up to 9 weeks from discharge to telephone interview. There is growing recognition of the importance of involving patients in decision making about their own health care and the positive influence it can have on health outcomes.1 This is an area that warrants further investigation to understand how patients can be effectively involved in the identification and management of their own risk of falls, in a manner that is meaningful to them.
This study successfully trialed a relatively new approach for designing an implementation intervention through use of the TDF to inform behavior change.21 Previously, the TDF had primarily been used to inform behavior change in the medical profession, but it had not yet been trialed to inform an intervention to improve management of risk of falls.24–27 A literature review revealed that many previous studies attempting to improve management of risk of falls in an acute hospital setting had failed to embed any kind of framework or systematic approach into their methodology.28–32 If these studies reported a successful intervention, it is difficult for future researchers or health professionals to replicate their methodology where a framework or systematic approach was lacking. It is hoped that the results of this study will encourage increased use of evidence-based frameworks, such as the TDF, in the future.
This study had a secondary outcome: it highlighted that the health system is a particularly fluid environment. This finding contributes to the complexity of managing successful practice change in health care professionals. Within the life span of this project, the community falls prevention team (SCFPT) underwent budget cuts and restructuring, the FMC Falls Committee was disbanded, the Australian federal government ceased funding the publication of the booklet titled Don't Fall for It: Falls Can Be Prevented!,22 and documentation in the medical records was transitioning from a paper-based system to an electronic system. These are all significant externally driven changes for a health care professional to be dealing with on a daily basis, let alone engaging in and driving internal practice change strategies to bridge evidence practice gaps. Given all of these changes, the question remains: If the timing of this project had fallen 6 months or even 12 months later, would the same success have been achieved? Until local and national governments and policy makers acknowledge the importance of translational research for improving patient outcomes and efficiency in health care practice, ultimately saving money, behavior change in health professionals will continue to be a difficult task to achieve.
Another unique aspect of this study was its success in developing an intervention to improve management of risk of falls across care settings. Previous studies have targeted their interventions at one setting only: acute care,14 residential care,14 or the community setting.15 In the current study, there were 2 main factors that contributed to the success of modifying behavior across care settings. One factor was the strong engagement and early adoption of this project from the community fall prevention team, and the second factor was the timing of the project, with accreditation based on the National Safety and Quality Health Service Standards.2 Of the 10 accreditation standards, one was dedicated entirely to the prevention of falls and harm from falls. This standard greatly enhanced engagement with the project at an organizational level, as management identified early that the project would provide evidence for meeting several criteria within this standard.
Limitations
The methodological approach undertaken in this study was time-intensive. The project leader received external funding to cover her salary for 0.5 full-time equivalents over 2 years to allow for the study to be designed and implemented. It is unlikely within the current South Australian health care climate that a researcher or clinician would receive this kind of funding from within an organization to implement such a practice change strategy. Consequently, the likelihood of this project being replicated at other sites remains questionable. Without dedicated funding, time, and training, this type of practice change may not be possible in the future. A previous study also has shown lack of access to appropriate resources, lack of time, and lack of funding to be barriers when dealing with implementation of clinical guidelines into clinical practice.33
Another limitation of this study was the lack of data to address whether the project was sustainable. Although accreditation was seen as a positive influence that enabled the project to gain immediate traction, once accreditation was complete, interest in upholding the new means of managing risk of falls may have waned. The FMC Falls Committee, which was providing ongoing governance for project interventions and was seen as a vital component to ensuring project sustainability, has been disbanded. In addition, the project leader, who was the primary change champion of the intervention, went on extended leave following project completion. It is likely that losing these 2 critical components for initial project success may result in poor sustainability of the practice change.
Use of the TDF to provide a framework to develop a multifaceted intervention to encourage change in physical therapists' behavior was successful in improving identification and documentation of risk of falls in one acute care setting. However, the approach was resource intensive and, consequently, may be difficult to replicate at other sites.
Footnotes
Both authors provided concept/idea/research design, writing, and fund procurement. Dr Thomas provided data collection, data analysis, and project management. Dr Mackintosh provided consultation (including review of manuscript before submission).
Ethical approval for this study was obtained from the Southern Adelaide Clinical Human Research Ethics Committee (Research Application Number: 229.12) and the University of South Australia Human Research Ethics Committee (Protocol Number: 0000030397).
Lead author Dr Thomas was supported through an Australian National Health and Medical Research Council (NHMRC) Translating Research Into Practice (TRIP) Fellowship (Grant ID: GNT1035256) for the duration of this study. The fellowship provided training and support in the methodological approach for translational research.
- Received April 13, 2015.
- Accepted November 10, 2015.
- © 2016 American Physical Therapy Association
References
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