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BackgroundPoor translation of clinical practice guidelines (CPGs) into clinical practice is a barrier to the provision of consistent and high-quality evidence-based care. The objective was to systematically review the roles and effectiveness of knowledge brokers (KBs) for translating CPGs in health-related settings.MethodsMEDLINE, Embase, PsycINFO and CINAHL Plus were searched from 2014 to June 2022. Randomised controlled trials (RCTs), controlled and uncontrolled preintervention and postintervention studies involving KBs, either alone or as part of a multicomponent intervention, that reported quantitative postintervention changes in guideline implementation in a healthcare setting were included. A KB was defined as an intermediary who facilitated knowledge translation by acting in at least two of the following core roles: knowledge manager, linkage agent or capacity builder. Specific activities undertaken by KBs were deductively coded to the three core roles, then common activities were inductively grouped. Screening, data extraction, quality assessment and coding were performed independently by two authors.Results16 studies comprising 6 RCTs, 8 uncontrolled precomparisons–postcomparisons, 1 controlled precomparison–postcomparison and 1 interrupted time series were included. 14 studies (88%) were conducted in hospital settings. Knowledge manager roles included creating and distributing guideline material. Linkage agent roles involved engaging with internal and external stakeholders. Capacity builder roles involved audit and feedback and educating staff. KBs improved guideline adherence in 10 studies (63%), had mixed impact in 2 studies (13%) and no impact in 4 studies (25%). Half of the RCTs showed KBs had no impact on guideline adherence. KBs acted as knowledge managers in 15 (94%) studies, linkage agents in 11 (69%) studies and capacity builders in all studies.ConclusionKnowledge manager and capacity builder roles were more frequently studied than linkage agent roles. KBs had mixed impact on translating CPGs into practice. Further RCTs, including those in non-hospital settings, are required.PROSPERO registration numberCRD42022340365.

Background/Objectives Continuous positive airway pressure (CPAP) concomitant with weight loss is a recommended treatment approach for adults with moderate-severe obstructive sleep apnoea (OSA) and obesity. This requires multiple synchronous behaviour changes. The aim of this study was to examine the effectiveness of a 6-month lifestyle intervention and to determine whether the timing of starting a weight loss attempt affects weight change and trajectory after 12 months in adults newly diagnosed with moderate-severe OSA and treated at home with overnight CPAP. Methods Using a stepped-wedge design, participants were randomised to commence a six-month lifestyle intervention between one and six-months post-enrolment, with a 12-month overall follow-up. Adults (n = 60, 75% males, mean age 49.4 SD 10.74 years) newly diagnosed with moderate-severe OSA and above a healthy weight (mean BMI 34.1 SD 4.8) were recruited. Results After 12 months, exposure to the intervention (CPAP and lifestyle) resulted in a 3.7 (95% CI: 2.6 to 4.8, p p = 0.86). Conclusions The lifestyle intervention resulted in a modest reduction in body weight, while timing of commencement did not impact the degree of weight loss at 12 months. These findings support the recommendation of adjunctive weight-loss interventions within six-months of starting CPAP.

Exercise interventions can improve physical recovery and reduce falls in older adults following hospitalization. The aim of the study was to identify factors associated with exercise engagement after hospital discharge.This study was a secondary analysis of data collected as part of a randomized controlled trial. Participants were 60 years and older, discharged from 3 rehabilitation hospitals in Australia, and followed for 6 months after discharge. The primary outcome was level of engagement in exercise after discharge, measured using setting, type, frequency, and time. A secondary outcome was self-efficacy for exercise at 6-month follow-up. Data were gathered at baseline in hospital and at 6 months after discharge by telephone using structured surveys. Associations between exercise and participant characteristics were evaluated using logistic regression models.Participants' (n = 292) mean age was 78 (SD 8) years and 63% were female. There were 146 (50%) who exercised after hospitalization for a median (interquartile range) time of 60 (60-75) minutes per week. Characteristics that were significantly associated with post-discharge engagement in exercise were having higher levels of functional ability at discharge (adjusted odds ratio [AOR] 1.2, 95% CI 1.0, 1.4), living with a partner (AOR 2.9, 95% CI 1.7, 4.9), and engagement in exercise prior to hospital admission (AOR 1.7, 95% CI 1.0, 2.8). The mean self-efficacy for exercise score at 6 months post-discharge was 58.5/90 (SD 24.5). Characteristics that were significantly predictive of a higher mean self-efficacy score at 6 months after hospitalization were having a college or university education (adjusted β-coefficient [Adj β] 11.5, 95% CI 3.8, 19.0), exercise prior to hospital admission (Adj β 12.3, 95% CI 5.1, 19.5), living with a partner at discharge (Adj β 14.5, 95% CI 7.1, 21.9), and higher functional ability at discharge (Adj β 4.0, 95% CI 1.9, 6.1).Older adults have low levels of engagement in exercise that might impact their recovery after hospitalization. During exercise prescription, clinicians should prioritize older adults who live alone, who have lower functional ability, and no previous habit of exercising.

Objective The purpose of this study was to examine the impact of increasing allied health staffing levels on patient and health service outcomes across 1) all Geriatric Evaluation and Management patients, and 2) Geriatric Evaluation and Management patients discharged to home in the community. Design Quasi-experimental, pre-post intervention study. Setting Two sub-acute hospital units in an Australian, tertiary health service. Subjects Data related to patients admitted to the study units, who were classified as Geriatric Evaluation and Management patients. Interventions Comparison of therapy time across two units with a differential in staffing allocation over a six-month trial period. Main measures Primary outcomes: length of stay, readmission rate, and improvement on the Functional Independence Measure. Secondary outcomes: total cost of admission per patient and number of allied health sessions. Results Data were analysed for 214 patients (mean age = 79.9, standard deviation (SD) = 9.4 years, mean Functional Independence Measure (FIM = 64.9, SD = 21.2) admitted to the intervention unit, and 199 patients (mean age = 81.3, SD = 8.5, mean FIM = 64.2, SD = 24.0) admitted to the control unit. The overall difference in staffing allocation between the control and intervention units for the trial period was 21%. There was no statistically significant difference between units in subacute length of stay (Adj Coef = -0.10 days, 95%CI = -0.39 to 0.19), rate of readmission (OR = 1.0, 95%CI = 0.5 to 2.0) or change in function (Coef = 1.42 FIM change score, 95%CI = -2.4 to 5.3). Conclusions Increasing allied health staffing allocation to a unit over six-months did not impact change in function or length of stay for patients admitted for Geriatric Evaluation and Management.

Home care clients with dementia/cognitive impairment are typically functionally dependent and physically inactive. We pilot-tested a co-designed physical exercise program for its feasibility, safety, adherence and potential for benefits on physical activity, physical function, healthcare use and falls. Trained community care support workers delivered a 12-week home exercise program to clients with dementia/cognitive impairment, once weekly for 15 min during care shifts, supplemented by carers’ supervision of exercises for 30 min, three times weekly. A physiotherapist provided fortnightly phone support to ensure safety and exercise progression. Baseline and Week 12 assessments using validated scales for physical activity, physical function, daily living independence, falls efficacy, quality of life, self-reported healthcare use, falls and sleep quality were undertaken. Differences were examined with regression analyses. Care support workers (n = 26) and client/carer dyads (n = 26 and 80.8% culturally and linguistically diverse) participated. Participants recorded adverse events/falls and exercises in dairies. Fifteen dyads completed the program. No falls/adverse events occurred with the exercises. The adherence rates against targets for exercise time completed and days in which exercise were undertaken for support workers were 137%/79.6%, and for client/carer dyads were 82%/104.8%, respectively. Physical activity participation, physical function and falls efficacy significantly improved at Week 12 compared to baseline. The feasibility, safety and adherence of the co-designed physical exercise program were demonstrated. Strategies to minimise dropouts in future effectiveness studies are required.

This study examined the potential for effect of a six-week gait aid training program for people with dementia on spatiotemporal gait outcomes, perception of use, and falls with gait aid use. The program utilised four 30-min physiotherapy home visits, scheduled at weeks 1/2/3/6, and was enhanced by carer-supervised practice. Falls and the physiotherapist’s clinical judgement of participants achieving safe gait aid use during and after the program were described. Perception ratings at each visit were measured using Likert scales which, along with the spatiotemporal outcomes using the gait aid (Time-Up-and-Go-Test, 4-m-walk-test, Figure-of-8-Walk-Test with/without a cognitive task) at weeks 1 and 6, and at weeks 6 and 12 (6-week post-program), were examined with ordinal logistic regression analyses. Twenty-four community-dwelling older people with dementia and their carers participated. Twenty-one (87.5%) older people achieved safe gait aid use. Twenty falls occurred, and only one faller was using their gait aid when they fell. Walking speed, step length, and cadence significantly improved when walking with the gait aid at week 6 compared with week 1. No significant improvements in spatiotemporal outcomes were retained at week 12. Physiotherapists were more likely to agree that gait aid use had improved walking safety among older people with dementia with subsequent training visits. Larger studies of the gait aid training program are needed for this clinical group.

There are groups in our community who may be more vulnerable to contracting, transmitting, or experiencing negative health impacts of COVID-19 than the general community. They may also have greater difficulty accessing, accepting, and acting upon COVID-19 public health information. Our aim was to understand if vulnerable communities and those who express "COVID-risk" behavioural intentions seek and respond differently to COVID-19 public health information.This observational, cross-sectional study recruited adults aged over 18 years from the Australian general community and six community groups (people with disabilities and their caregivers, Aboriginal and Torres Strait Islanders, aged care workers, street-based sex workers, refugees and asylum seekers, and the deaf and hard of hearing). We investigated attitudes and beliefs about COVID-19 public health messages. We identified factors associated with the respondent's perception of the ease of finding information and understanding it, and its relevance to them. We also examined latent classes that were developed based on attitudes to public health measures and vulnerable group categories, along with demographic variables.We received 1444 responses (n = 1121 general community; n ≥50 for each vulnerable group). The vulnerable groups examined found COVID-19 public health messages as easy, if not easier, to find and understand than the general community. Four latent classes were identified: COVID-safe mask wearers (10% of sample), COVID-safe test takers (56%), COVID-risk isolators (19%) and COVID-risk visitors (15%). The COVID-risk classes (34% of sample) were less likely to consider COVID-19 information easy to find, understandable, and relevant.Additional public health messaging strategies may be needed for targeting people with "COVID-risk" beliefs and attitudes who appear across the community (general and vulnerable groups) rather than just targeting specific cultural or other groupings that we think may be vulnerable. COVID-risk classes identified through this study were not defined by demographic characteristics or cultural groupings, but were spread across vulnerable communities and the general community. Different approaches for tailoring and delivery of specific public health information for these groups are needed.

Background: Delay in dietetic service provision for upper gastrointestinal cancer exacerbates disease-related malnutrition and consequently increases morbidity and mortality. Dietetic services are usually referral-based and provided face-to-face in inpatient or outpatient settings, which can delay the commencement of nutrition care. The aim of this study was to provide intensive dietetic intervention close to the time of diagnosis for upper gastrointestinal cancer and assess the effect on quality-adjusted life years. Methods: A three-arm randomised controlled trial of adults newly diagnosed with upper gastrointestinal cancer was performed. A behavioural-based, individually tailored, symptom-directed nutrition intervention was provided in addition to usual care, delivered by a dietitian using a telephone (synchronously) or a mobile application (asynchronously) for 18 weeks, compared with a usual care control group. Data were collected at baseline, three, six, and twelve months post-randomisation. The primary outcome was quality-adjusted life years (EQ-5D-5L quality of life assessment tool). Data were analysed using linear mixed models. Results: One hundred and eleven participants were randomised. Quality-adjusted life years were not different in the intervention groups compared with control (telephone: mean (95% CI) 0.04 (0.43, 2.3), p = 0.998; App: −0.08 (−0.18, 0.02), p = 0.135) after adjustment for baseline, nutrition risk status, age, and gender. Survival was similar between groups over 12 months. The asynchronous mobile app group had a greater number of withdrawals compared with the telephone group. Conclusion: Early and intensive nutrition counselling, delivered at home, during anticancer treatment did not change quality-adjusted life years or survival over 12 months compared with usual care. Behavioural counselling alone was unable to achieve nutritional adequacy. Dietetic services delivered asynchronously using a mobile app had low acceptance for patients undergoing anticancer treatment. Trial Registration: 27 January 2017 Australian and New Zealand Clinical Trial Registry, ACTRN12617000152325.

Objectives: Effective public policy to prevent falls among independent community-dwelling older adults is needed to address this global public health issue. This paper aimed to identify gaps and opportunities for improvement of future policies to increase their likelihood of success.Methods: A systematic scoping review was conducted to identify policies published between 2005–2020. Policy quality was assessed using a novel framework and content criteria adapted from the World Health Organization’s guideline for Developing policies to prevent injuries and violence and the New Zealand Government’s Policy Quality Framework.Results: A total of 107 articles were identified from 14 countries. Content evaluation of 25 policies revealed that only 54% of policies met the WHO criteria, and only 59% of policies met the NZ criteria. Areas for improvement included quantified objectives, prioritised interventions, budget, ministerial approval, and monitoring and evaluation.Conclusion: The findings suggest deficiencies in a substantial number of policies may contribute to a disconnect between policy intent and implementation. A clear and evidence-based model falls prevention policy is warranted to enhance future government efforts to reduce the global burden of falls.

Residents of Residential Age Care Facilities (RACFs) have particularly high rates of Emergency Department (ED) visits, with up to 55% being potentially avoidable (e.g. not resulting in a hospital admission). This is concerning as ED visits by RACF residents are associated with negative outcomes including longer hospital stays, iatrogenic illness, complications and mortality. Limited English proficiency (LEP) has significant negative impacts on the healthcare quality and outcomes for older people but has not been studied as a factor in ED visits from RACFs. This study aimed to examine if RACF residents with LEP have a lower rate of hospital admission via the ED compared to non-LEP controls and identify any associated factors. We hypothesised that LEP-related communication difficulties would reduce the ability to manage minor health issues in the RACF, leading to a lower proportion of LEP ED transfers being admitted. We used a parallel mixed-methods design, comprising a quantitative matched cohort study of ED visit data from two Local Hospital Networks (LHNs) in South-East Melbourne, Australia and secondary thematic analysis of 25 interviews with LEP residents, family carers and staff from two RACFs in the same region. We found no differences in the proportion of hospital ED transfers that led to admission (LHN1, 87.1% LEP, 85.6% non-LEP controls, p = 0.57; LHN2, 76.0% LEP, 76.9% non-LEP controls, p = 0.41) and no direct qualitative evidence suggesting that resident LEP affected decisions to transfer residents to ED, despite communication difficulties being reported during the transfer process. These results may be due to the high level of family carer involvement in residents' care identified in the qualitative study. However, additional research using different measures of LEP is recommended to further explore a broader range of cultural and linguistic factors in both rates of ED presentations and the decision-making processes underpinning resident transfers to ED.

Objective To assess the impacts of changing a model of care and employing general practitioners (GPs) within residential aged care facilities (RACFs) on costs to the aged care provider (ACP) and state and federal governments of Australia. Methods This study was a cost analysis of a prospective, stepped-wedge, cluster randomised trial. All financial data from the ACP for every RACF involved, before and after implementation of the new model were obtained. Costs of hospital transfers, admissions, ambulance usage and GP consultations were calculated. Costs of new infrastructure, recruiting and training new staff were accounted for. Costs were standardised to 2019 Australian Dollars per occupied bed day (OBD). Results Implementation of the new model of care resulted in overall cost savings of $9.7 per OBD to the ACP, with increased salary costs offset by increased federal government subsidies and Medicare claims income. Costs to the federal government increased by $19.6 per OBD, driven by increases in subsides. Costs savings of $3.0 per OBD to state governments were seen, driven by decreased costs of hospital transfers. Conclusions Implementation of a model of care including GPs employed at RACFs had a mixed impact on costs depending on perspective, with overall savings to the ACP and state government perspective.

Recently hospitalized older people are at risk of falls and face barriers to undertaking fall prevention strategies after they return home from hospital. The authors examined the effects of tailored education delivered by physiotherapists on the knowledge (capability) and the motivation of older people to engage in fall prevention after hospital discharge. Utilizing data gathered from a recent trial, data was analyzed from 390 people who were 60 years and over without impaired cognition (>7/10 abbreviated mental test score) and discharged from three Australian hospitals. Motivation and capability were measured at baseline in the hospital and at 6-months after hospital discharge by blinded assistants using structured surveys. Bivariate analysis using generalized linear modeling explored the impact of education on the capability and motivation. Engagement in fall prevention strategies was entered as an independent variable during analysis to determine associations with capability and motivation. The education significantly improved capability [−0.4, 95% CI (−0.7, −0.2), p < 0.01] and motivation [−0.8, 95% CI (−1.1, −0.5), p < 0.01] compared with social-control at the time of hospital discharge. In contrast, social-control participants gained capability and motivation over the 6-months, and no significant differences were found between groups in capability [0.001, 95% CI (−0.2, 0.2), p = 0.9] and motivation [−0.01, 95% CI (−0.3, 0.3), p = 0.9] at follow-up. Tailored fall prevention education is recommended around hospital discharge. Participants still needed to overcome barriers to falls prevention engagement post hospitalization. Thus, tailored education along with direct clinical services such as physiotherapy and social supports is warranted for older people to avoid falls and regain function following hospitalization.

Activin A is a potent negative regulator of muscle mass elevated in critical illness. It is unclear whether muscle strength and physical function in critically ill humans are associated with elevated activin A levels.The objective of this study was to investigate the relationship between serum activin A levels, muscle strength, and physical function at discharge from the intensive care unit (ICU) and hospital.Thirty-six participants were recruited from two tertiary ICUs in Melbourne, Australia. Participants were included if they were mechanically ventilated for48 h and expected to have a total ICU stay of5 days. The primary outcome measure was the Six-Minute Walk Test distance at hospital discharge. Secondary outcome measures included handgrip strength, Medical Research Council Sum Score, Physical Function ICU Test Scored, Six-Minute Walk Test, and Timed Up and Go Test assessed throughout the hospital admission. Total serum activin A levels were measured daily in the ICU.High peak activin A was associated with worse Six-Minute Walk Test distance at hospital discharge (linear regression coefficient, 95% confidence interval, p-value: -91.3, -154.2 to -28.4, p = 0.007, respectively). Peak activin A concentration was not associated with the secondary outcome measures.Higher peak activin A may be associated with the functional decline of critically ill patients. Further research is indicated to examine its potential as a therapeutic target and a prospective predictor for muscle wasting in critical illness.ACTRN12615000047594.

Disinvestment is the removal or reduction of previously provided practices or services, and has typically been undertaken where a practice or service has been clearly shown to be ineffective, inefficient and/or harmful. However, practices and services that have uncertain evidence of effectiveness, efficiency and safety can also be considered as candidates for disinvestment. Disinvestment from these practices and services is risky as they may yet prove to be beneficial if further evidence becomes available. A novel research approach has previously been described for this situation, allowing disinvestment to take place while simultaneously generating evidence previously missing from consideration. In this paper, we describe how this approach can be expanded to situations where three or more conditions are of relevance, and describe the protocol for a trial examining the reduction and elimination of use of mobilisation alarms on hospital wards to prevent patient falls. Our approach utilises a 3-group, concurrent, non-inferiority, stepped wedge, randomised design with an embedded parallel, cluster randomised design. Eighteen hospital wards with high rates of alarm use (≥3%) will be paired within their health service and randomly allocated to a calendar month when they will transition to a “Reduced” (

Low-frequency ultrasonic debridement (LFUD) is a technology that uses sound waves conducted through saline mist to debride wound tissue. Whilst this technology purportedly reduces wound-healing times, the airborne mist generated is potentially problematic. Theoretically, the saline mist could carry an increased number of microbes into the surrounding environment, posing an infection control risk to the patient, clinician, and clinical environment. This research aimed to establish the degree and extent to which there is microbial spread during the use of, and following the use of, LFUD. The total number of colony forming units was identified for use of LFUD without the suction attachment (control) and with the suction attachment (intervention).This was a prospective, observational study with repeated measures across each treatment (before, during, and after). Quota sampling in a 2 × 2 × 2 factorial design was undertaken so that half of the 24 treatments were conducted at each health service (Monash Health vs Peninsula Health), in different treatment environments (inpatient vs outpatient), and half were conducted with and without suction. The use of suction was not randomized but was determined at the treating clinician's discretion. Patients treated in the inpatient environment lay on their beds, whereas patients in the outpatient environment sat in a treatment chair.There was higher microbial count during treatment (P .001) with a higher microbial count associated with lower ultrasound amplitude (P = .028), lower saline flow rate (P = .010), no suction attachment (P = .001), and a larger wound area (P = .002). All were independently associated with greater microorganism aerosolization. There was no correlation between the type of handpiece selected, the presence of wound infection, and the treatment time or treatment environment.This research has assisted in developing guidelines for cleaning of equipment and environments following treatment, as well as around the use of personal protective equipment required to protect the staff member and the patient during the use of LFUD. Additionally, recommendations have been made regarding the specific LFUD settings to reduce the risk of cross-infection to the clinic environment. These include selecting a higher ultrasound amplitude and saline flow rate as well as the use of suction where clinically possible.

BACKGROUND Increased accessibility to the internet and mobile devices has seen a rapid expansion in electronic health (eHealth) behavior change interventions delivered to patients with cancer and survivors using synchronous, asynchronous, and combined delivery methods. Characterizing effective delivery methods of eHealth interventions is required to enable improved design and implementation of evidence-based health behavior change interventions. OBJECTIVE This study aims to systematically review the literature and synthesize evidence on the success of eHealth behavior change interventions in patients with cancer and survivors delivered by synchronous, asynchronous, or combined methods compared with a control group. Engagement with the intervention, behavior change, and health outcomes, including quality of life, fatigue, depression, and anxiety, were examined. METHODS A search of Scopus, Ovid MEDLINE, Excerpta Medica dataBASE, Cumulative Index to Nursing and Allied Health Literature Plus, PsycINFO, Cochrane CENTRAL, and PubMed was conducted for studies published between March 2007 and March 2019. We looked for randomized controlled trials (RCTs) examining interventions delivered to adult cancer survivors via eHealth methods with a measure of health behavior change. Random-effects meta-analysis was performed to examine whether the method of eHealth delivery impacted the level of engagement, behavior change, and health outcomes. RESULTS A total of 24 RCTs were included predominantly examining dietary and physical activity behavior change interventions. There were 11 studies that used a synchronous approach and 11 studies that used an asynchronous approach, whereas 2 studies used a combined delivery method. Use of eHealth interventions improved exercise behavior (standardized mean difference [SMD] 0.34, 95% CI 0.21-0.48), diet behavior (SMD 0.44, 95% CI 0.18-0.70), fatigue (SMD 0.21, 95% CI −0.08 to 0.50; SMD change 0.22, 95% CI 0.09-0.35), anxiety (SMD 1.21, 95% CI: 0.36-2.07; SMD change 0.15, 95% CI −0.09 to 0.40), depression (SMD 0.15, 95% CI 0.00-0.30), and quality of life (SMD 0.12, 95% CI −0.10 to 0.34; SMD change 0.14, 95% CI 0.04-0.24). The mode of delivery did not influence the amount of dietary and physical activity behavior change observed. CONCLUSIONS Physical activity and dietary behavior change eHealth interventions delivered to patients with cancer or survivors have a small to moderate impact on behavior change and a small to very small benefit to quality of life, fatigue, depression, and anxiety. There is insufficient evidence to determine whether asynchronous or synchronous delivery modes yield superior results. Three-arm RCTs comparing delivery modes with a control with robust engagement reporting are required to determine the most successful delivery method for promoting behavior change and ultimately favorable health outcomes.

Management of diabetes-related foot ulcers often involves debridement of devitalized tissue, but evidence regarding the most effective debridement method is limited.A systematic review was conducted to determine the effectiveness of nonsurgical sharp debridement (NSSD) versus low-frequency ultrasonic debridement (LFUD) for diabetes-related foot ulceration in adults.Published studies (earliest date available to April 2017) comparing healing outcomes of LFUD- and NSSD-treated foot ulcers in adults were considered. The quality of publications that met inclusion criteria were assessed using the PEDro scale, and a meta-analysis was undertaken to compare percentage healed and percentage of ulcer size reduction.Of the 259 publications identified, 4 met the inclusion criteria but 2 of the 4 did not contain sufficient patient outcomes details for meta-analysis, leaving a sample size of 173 patients. Outcome data for the 2 studies included percentage of ulcers healed between the 2 debridement methods. This difference was not significant (RR = 0.92; 95% CI = 0.76-1.11). The risk of bias for both studies was low.No difference in healing outcomes between NSSD and LFUD debridement of diabetic foot ulcers was found. Well-designed, controlled clinical studies are needed to address the current paucity of studies examining the efficacy and comparative effectiveness of debridement methods.

Background Older people are at high risk of falls after hospital discharge. The study aimed to evaluate the effect of providing individualized falls prevention education in addition to usual care on falls rates in older people after hospital discharge compared to providing a social intervention in addition to usual care. Methods A randomized clinical trial at three hospitals in Western Australia: participants followed for 6 months after discharge. Baseline and outcomes measured by assessors masked to group allocation. Participants: aged 60 years and over, admitted for rehabilitation. Eligibility included: cognitively able to undertake education (Abbreviated mental test score >7/10). Intervention: tailored education comprising patient video and workbook, structured discussion and goal setting led by trained therapist. Main outcomes: falls in the 6 months after discharge; proportion of participants sustaining one or more falls. Results There were 382 (194 intervention; 188 control) participants (mean age 77.7 [SD 8.7] years). There were 378 falls (fall rate per 1,000 patient-days, 5.9 intervention; 5.9 control) reported by 164 (42.9%) participants in the 6 months following hospital discharge; 188 (49.7%) of these falls were injurious. There were no significant differences in falls rates between intervention and control groups: (adjusted IRR, 1.09; 95% CI [0.78 to 1.52]) or the proportion of participants who fell once or more (adjusted OR, 1.37; 95% CI [0.90 to 2.07]). Conclusions Providing individualized falls prevention education prior to discharge did not reduce falls at home after discharge. Further research is warranted to investigate how to reduce falls during this high-risk transition period.

Depression is common in older people and symptoms of depression are known to substantially increase during hospitalization. There is little known about predictors of depressive symptoms in older adults or impact of common interventions during hospitalization. This study aimed to describe the magnitude of depressive symptoms, shift of depressive symptoms and the impact of the symptoms of depression among older hospital patients during hospital admission and identify whether exposure to falls prevention education affected symptoms of depression. Participants (n=1206) were older adults admitted within two Australian hospitals, the majority of participants completed the Geriatric Depression Scale - Short Form (GDS) at admission (n=1168). Participants' mean age was 74.7 (±SD 11) years and 47% (n=551) were male. At admission 53% (619 out of 1168) of participants had symptoms of clinical depression and symptoms remained at the same level at discharge for 55% (543 out of 987). Those exposed to the low intensity education program had higher GDS scores at discharge than those in the control group (low intensity vs control n=652, adjusted regression coefficient (95% CI)=0.24 (0.02, 0.45), p=0.03). The only factor other than admission level of depression that affected depressive symptoms change was if the participant was worried about falling. Older patients frequently present with symptoms of clinical depression on admission to hospital. Future research should consider these factors, whether these are modifiable and whether treatment may influence outcomes.

Introduction: Simulated learning environments (SLEs) are used worldwide in health professional education, including physiotherapy, to train certain attributes and skills. To date, no randomized controlled trial (RCT) has evaluated whether education in SLEs can partly replace time in the clinical environment for physiotherapy cardiorespiratory practice. Methods: Two independent single-blind multi-institutional RCTs were conducted in parallel using a noninferiority design. Participants were volunteer physiotherapy students (RCT 1, n = 176; RCT 2, n = 173) entering acute care cardiorespiratory physiotherapy clinical placements. Two SLE models were investigated as follows: RCT 1, 1 week in SLE before 3 weeks of clinical immersion; RCT 2, 2 weeks of interspersed SLE/clinical immersion (equivalent to 1 SLE week) within the 4-week clinical placement. Students in each RCT were stratified on academic grade and randomly allocated to an SLE plus clinical immersion or clinical immersion control group. The primary outcome was competency to practice measured in 2 clinical examinations using the Assessment of Physiotherapy Practice. Secondary outcomes were student perception of experience and clinical educator and patient rating of student performance. Results: There were no significant differences in student competency between the SLE and control groups in either RCT, although students in the interspersed group (RCT 2) achieved a higher score in 5 of 7 Assessment of Physiotherapy Practice standards (all P < 0.05). Students rated the SLE experience positively. Clinical educators and patients reported comparability between groups. Conclusions: An SLE can replace clinical time in cardiorespiratory physiotherapy practice. Part education in the SLE satisfied clinical competency requirements, and all stakeholders were satisfied.

The aim of this study was to determine if the addition of daily ward interview data improves the capture of hospital quality and safety indicators compared with incident reporting systems alone. An additional aim was to determine the potential characteristics influencing under-reporting of hospital quality and safety indicators in incident reporting systems.A prospective, observational study was performed at two tertiary metropolitan public hospitals. Research assistants from allied health backgrounds met daily with the nurse in charge of the ward and discussed the occurrence of any falls, pressure injuries and rapid response medical team calls. Data were collected from four general medical wards, four surgical wards, an orthopaedic, neurosciences, plastics, respiratory, renal, sub-acute and acute medical assessment unit.An estimated total of 303 falls, 221 pressure injuries and 884 rapid response medical team calls occurred between 15 wards across two hospitals, over a period of 6 months. Hospital incident reporting systems underestimated falls by 30.0%, pressure injuries by 59.3% and rapid response medical team calls by 17.0%. The use of ward interview data collection in addition to hospital incident reporting systems improved data capture of falls by 23.8% (n = 72), pressure injuries by 21.7% (n = 48) and rapid response medical team calls by 12.7% (n = 112). Falls events were significantly less likely to be reported if they occurred on a Monday (P = 0.04) and pressure injuries significantly more likely to be reported if they occurred on a Wednesday (P = 0.01).Hospital quality and safety indicators (falls, pressure injuries and rapid response medical team calls) were under-reported in incident reporting systems, with variability in under-reporting between wards and the day of event occurrence. The use of ward interview data collection in addition to hospital incident reporting systems improved reporting of hospital quality and safety indicators.

The extent to which best practice for falls prevention is being routinely delivered by health care providers for community-dwelling older adults is unclear. We investigated falls prevention practice among Hospital Admission Risk Programs (HARP) that provide and coordinate specialized health care for people at high risk of hospitalization.Cross-sectional survey of all HARP services in Victoria, excluding one paediatric programme (n = 34). The questionnaire focused upon medication review and exercise prescription, as these are the evidence-based falls interventions with a good fit with HARP services.Completed questionnaires were received from 24 programmes (70.6%) that service 15,250 older clients (60+ years). All except one programme screened for medicine use; however, a lower proportion (65% of those that screen) target falls risk medications. Among the 17 programmes responding to the exercise prescription question, all routinely include strengthening exercises, and almost all (n = 15) include flexibility, endurance training and movement of the centre of gravity. A lesser proportion (71%) includes reducing the need for upper limb support. The majority of services (88%) undertake falls risk assessments, and all of these either make referral appointments for clients or refer to other services that make referral appointments for clients. Follow-up of appointments and the resulting recommendations was high.Screening for falls risk medications could be improved and staff training in exercise prescription for balance challenge in this high-risk group may be needed. Although evidence-based falls prevention practice within Victorian HARP services appears strong, the effect on falls risk may not be as high as that achieved in randomized trials.

Footwear selection is important among older adults. Little is known about factors that influence footwear selection among older women. If older women are to wear better footwear that reduces their risk of falls and foot abnormalities, then a better understanding of the factors underlying footwear choice is needed. This study aims to identify factors that drive footwear selection and use among older community-dwelling women with no history of falls.A cross-sectional survey using a structured, open-ended questionnaire was conducted by telephone interview. The participants were 24 women, 60 to 80 years old, with no history of falls or requirement for gait aids. The responses to open-ended questions were coded and quantified under a qualitative description paradigm.The main themes identified about footwear selection were aesthetics and comfort. Aesthetics was by far the main factor influencing footwear choice. Wearing safe footwear was not identified as a consideration when purchasing footwear.This study indicates that older women are driven primarily by aesthetics and comfort in their footwear selection. These footwear drivers have implications for health-care providers when delivering fall and foot health education.

Introduction This project concerns the identification of the smallest worthwhile effect (SWE) of exercise-based programmes to prevent falls in older people. The SWE is the smallest effect that justifies the costs, risks and inconveniences of an intervention and is used to inform the design and interpretation of systematic reviews and randomised clinical trials. Methods and analysis This study will comprise two different methodological approaches: the benefit-harm trade-off method and the discrete choice experiment to estimate the SWE of exercise interventions to prevent falls in older people. In the benefit-harm trade-off method, hypothetical scenarios with the benefits, costs, risks and inconveniences associated with the intervention will be presented to each participant. Then, assuming a treatment effect of certain magnitude, the participant will be asked if he or she would choose to have the intervention. The size of the hypothetical benefit will be varied up and down until it is possible to identify the SWE for which the participant would choose to have the intervention. In the discrete choice experiment, the same attributes (benefits, costs, risks and inconveniences) with varying levels will be presented as choice sets, and participants will be asked to choose between these choice sets. With this approach, we will determine the probability that a person will consider the effects of an intervention to be worthwhile, given the particular costs, risks and inconveniences. For each of the two approaches, participants will be interviewed in person and on different occasions. A subsample of the total cohort will participate in both interviews. Ethics and dissemination This project has received Ethics Approval from the University of Sydney Human Ethics Committee (Protocol number: 14404). Findings will be disseminated through conference presentations, seminars and peer-reviewed scientific journals.

To identify the level of uptake of occupational therapists' home environmental audit recommendations by older community dwellers and the factors that contribute to adherence.Cohort nested within an RCT that compared two models of care for fall prevention located in Brisbane, Australia.Community-dwelling older people60 at risk of falls (n = 80).An environmental audit and recommendations by an occupational therapist.Of the recommendations made, 55% were completed by 6 months. Increasing number of comorbidities was a significant predictor of adherence with recommendations. Recommendations requiring external providers were more likely to be completed than those relying on the client or family member.Occupational therapists need to consider a wide range of intrinsic and extrinsic factors, which may contribute to adherence with home modifications.

Little scrutiny has been applied to how 'cost per fall' values have been calculated and applied. This paper presents discourse discussing how the cost of fall statistic could potentially be misleading when applied to inpatient health or residential care settings and provides estimates of the cost of falls and cost of falls per person.Burden of disease was estimated using a decision tree approach. Data informing the decision tree were drawn from a retrospective audit of 545 falls in a residential care facility, a visual observation study of 46 residents from the same facility and a cohort study of 186 residents from nine different facilities in Australia. Acute care and transportation costs were extracted from the retrospective audit using incident reports and care note review. The distribution of falls per person and associations between falls, fractures and change in resident mobility were extracted from the cohort study. The association between resident mobility and the amount of time required to perform toileting, transfer and dressing activities was extracted from the visual observational study.The minimum 'cost per fall' was estimated to be $AUD 841 and the maximum was $AUD 1024. The 'cost of falls per person' estimate was $AUD 1887 (2008 base year).This cost per fall estimate was substantially lower than three previous internationally derived estimates possibly as a consequence of how fall data were collected and modelled in these studies. Cost of falls per person may be a preferable statistic for future use.

To explore the climate of safety towards falls prevention among frontline hospital staff.Falls represent a serious threat to patient safety in hospitals. A positive safety climate is vital in healthcare organisations to promote safe care and reduce patient harm, yet little is known about the safety climate towards falls prevention among frontline staff in the hospital setting.An observational descriptive study.Frontline staff working in five acute and subacute wards at two metropolitan hospitals in Australia were sampled. Safety climate towards falls prevention was measured using the Patient Safety Climate in Healthcare Organizations survey. The item-specific, dimension-specific and overall percentage of problematic responses were calculated, based on the frequency of responses inconsistent with a positive safety climate. Higher percentage of problematic responses values reflects a weaker safety climate.The overall percentage of problematic responses towards falls prevention was 15%. Dimensions that were most inconsistent with a positive safety climate included 'provision of safe care' (percentage of problematic responses 42·1%) and 'unit recognition and support for safety efforts' (percentage of problematic responses 26·9%). The overall and dimension-specific percentage of problematic responses scores did not vary by hospital, or between nursing and allied health disciplines.The study provides important insights into the safety climate towards falls prevention among frontline hospital staff. Further research is required to improve the problematic areas of safety climate towards falls prevention, to promote and deliver safe patient care by hospital healthcare teams.Identifying problematic areas in the safety climate towards falls prevention is a first step in guiding the development of targeted strategies to promote a positive atmosphere towards preventing falls and reducing patient harm in the hospital setting.

Patient preference for interventions aimed at preventing in-hospital falls has not previously been investigated. This study aims to contrast the amount patients are willing to pay to prevent falls through six intervention approaches.This was a cross-sectional willingness-to-pay (WTP), contingent valuation survey conducted among hospital inpatients (n = 125) during their first week on a geriatric rehabilitation unit in Queensland, Australia. Contingent valuation scenarios were constructed for six falls prevention interventions: a falls consultation, an exercise programme, a face-to-face education programme, a booklet and video education programme, hip protectors and a targeted, multifactorial intervention programme. The benefit to participants in terms of reduction in risk of falls was held constant (30% risk reduction) within each scenario.Participants valued the targeted, multifactorial intervention programme the highest [mean WTP (95% CI): $(AUD)268 ($240, $296)], followed by the falls consultation [$215 ($196, $234)], exercise [$174 ($156, $191)], face-to-face education [$164 ($146, $182)], hip protector [$74 ($62, $87)] and booklet and video education interventions [$68 ($57, $80)]. A 'cost of provision' bias was identified, which adversely affected the valuation of the booklet and video education intervention.There may be considerable indirect and intangible costs associated with interventions to prevent falls in hospitals that can substantially affect patient preferences. These costs could substantially influence the ability of these interventions to generate a net benefit in a cost-benefit analysis.

Inpatient rehabilitation of patients following stroke can be resource intensive, with optimal models of service delivery unclear. This study investigates the dose-response curves between physiotherapy service delivery variables and balance and function clinical outcomes.This was a multi-centre (15 sites), prospective, cohort study involving patients (n = 288) admitted for rehabilitation following stroke conducted across two states in Australia. Physiotherapy department resource provision variables were collected and examined for association with change in patient function and balance outcomes (Functional Independence Measure, step test, functional reach test) measured at admission and discharge from inpatient care.A greater amount of log-transformed physiotherapy department resource provision was associated with greater improvement in the functional independence measure [Regression coefficient (95% CI): 4.05 (1.15, 6.95)] and functional reach test [46.43 (17.03, 75.84)], while physiotherapist time provided to patients was associated with greater improvement for the step test [0.15 (0.03, 0.28)], and functional reach [0.35 (0.19, 0.52)].Receiving a higher rate of physiotherapist input is an important factor in attaining a greater amount of recovery in function and balance outcomes; however, the improvement by patients who received the greatest amount of input was highly variable.

To compare three different methods of falls reporting and examine the characteristics of the data missing from the hospital incident reporting system.Fourteen-month prospective observational study nested within a randomized controlled trial.Rehabilitation, stroke, medical, surgical, and orthopedic wards in Perth and Brisbane, Australia.Fallers (n=153) who were part of a larger trial (1,206 participants, mean age 75.1 + or - 11.0).Three falls events reporting measures: participants' self-report of fall events, fall events reported in participants' case notes, and falls events reported through the hospital reporting systems.The three reporting systems identified 245 falls events in total. Participants' case notes captured 226 (92.2%) falls events, hospital incident reporting systems captured 185 (75.5%) falls events, and participant self-report captured 147 (60.2%) falls events. Falls events were significantly less likely to be recorded in hospital reporting systems when a participant sustained a subsequent fall, (P=.01) or when the fall occurred in the morning shift (P=.01) or afternoon shift (P=.01).Falls data missing from hospital incident report systems are not missing completely at random and therefore will introduce bias in some analyses if the factor investigated is related to whether the data is missing. Multimodal approaches to collecting falls data are preferable to relying on a single source alone.

To evaluate the efficacy of a policy to introduce low-low beds for the prevention of falls and fall injuries on wards that had not previously accessed low-low beds.This was a pragmatic, matched, cluster randomized trial with wards paired according to rate of falls. Intervention and control wards were observed for a 6-month period after implementation of the low-low beds on the intervention wards. Data from a 6-month period before this were also collected and included in analyses to ensure comparability between intervention and control group wards.Public hospitals located in Queensland, Australia.Patients of 18 public hospital wards.Provision of one low-low bed for every 12 on a hospital ward, with written guidance for identifying patients at greatest risk of falls.Falls and fall injuries in the hospital measured using a computerized incident reporting system.There were 10,937 admissions to control and intervention wards combined during the pre-intervention period. There was no significant difference in the rate of falls per 1,000 occupied bed days between intervention and control group wards after the introduction of the low-low beds (generalized estimating equation coefficient=0.23, 95% confidence interval=-0.18-0.65, P=.28). The rate of bed falls, falls resulting in injury, and falls resulting in fracture also did not differ between groups. Some difficulties were encountered in intervention group wards in using the low-low beds as directed.A policy for the introduction of low-low beds did not appear to reduce falls or falls with injury, although larger studies would be required to determine their effect on fall-related fractures.

To compare the effectiveness of a digital video disc (DVD) with that of a written workbook delivering falls prevention education to older hospital patients on self-perceived risk of falls, perception of falls epidemiology, knowledge of prevention strategies, and motivation and confidence to engage in self-protective strategies. To compare the effect of receiving either education approach versus no education on patients' perception of falls epidemiology.Randomized trial (DVD vs workbook) with additional quasi-experimental control group.Geriatric, medical, and orthopedic wards in Perth and Brisbane, Australia.One hundred (n=51 DVD, n=49 workbook) hospital inpatients aged 60 and older receiving an intervention (mean age 75.3+/-10.1) and 122 in the control group (mean age 79.3+/-8.3).Participants randomly assigned to receive identical educational material on falls prevention delivered on a DVD or in a workbook. Control group received usual care.Custom-designed survey addressing elements of the Health Belief Model of health behavior change.Participants randomized to DVD delivery had a higher self-perceived risk of falling (P=.04) and higher levels of confidence (P=.03) and motivation (P=.04) to engage in self-protective strategies than participants who received the workbook. A higher proportion of participants who received either form of the education provided "desired" responses than of control group participants across all knowledge items (P.001).Delivery of falls prevention education on a DVD compared to a written workbook is more likely to achieve important changes in parameters likely to affect successful uptake of falls prevention messages in the hospital setting.

To investigate agreement between hospital staff on what constitutes a fall and should be recorded on an incident report, to identify factors that influence whether a scenario is classified as a fall, and to examine the effect of providing a definition of a fall on interrater agreement.Two interrater agreement trials with pre-postintervention design.Seven hospitals.Four hundred forty-six hospital staff (nursing 76%, physiotherapy 14%, occupational therapy, 6%) working on participating wards over a 24-hour period.Fourteen video scenarios were played before participants, who were asked whether they would classify each scenario as a fall and whether they would complete an incident report in that scenario. A definition of a fall was then provided and the video scenarios replayed. Two definitions were investigated; the World Health Organization definition and a custom definition.Consensus was not evident in five of the 14 scenarios examined. Falls onto surfaces higher than the ground were less likely to be recorded on incident reports. Hospital and ward type influenced whether a scenario was classified as a fall. Overall agreement in classifying scenarios as a fall was only marginally greater after provision of the definition in both phases, although neither had an effect on whether staff would complete an incident report.Disagreement between hospital staff in what constitutes a fall may contribute to inconsistent research findings in this field and is not meaningfully improved through provision of a definition.