4 Discussion
4.6 Future Directions
There is a significant research gap in the literature on falls prevention in stroke survivors. This, in part, is due to the fact that research in the past has focused mainly on reporting incidence and risk factors of falls in stroke survivors and less on specific contributing factors. There is a need for longitudinal studies examining the patterns of falls in stroke survivors across all settings. Specifically, an examination of falls in the LTC setting is needed. In addition, as stated before, the implementation of suggested mechanisms to improve safety is beyond the scope of this study. However, it would be interesting to observe if the implementation of these safety defenses has an impact on falls rates in stroke survivors within the three settings. As discussed earlier, the SFIM is a comprehensive and effective tool in identifying safety deficiencies at all levels of the Swiss cheese. However, due to some of its limitations (such as amount of time required to conduct investigations), further research should examine if other, more efficient tools exist for the identification of contributing factors for falls in stroke survivors.
Chapter 5
5
Conclusions
In Canada, there are approximately 50,000 new stroke cases each year, and in 2009 there were 315,000 stroke survivors living with the long-term effects of stroke (Goeree et al., 2005). In all stages of recovery after stroke, falls are a major potential adverse event (Batchelor et al., 2012), with advanced age further compounding the risk. The incidence of stroke survivors experiencing a fall at all levels of the continuum of care is higher than for other patient populations.
Using a systems approach to look at not only intrinsic and extrinsic factors related to the faller, but also everyone and everything surrounding the incident that are
considered potential safety barriers, allows for clear identification of the contributing factors to falls in stroke survivors. Identification of reasons stroke survivors fall enables for targeted intervention and prevention strategies, allowing for an increase in safety within the healthcare system and in the community.
Comprehensive investigations, using the SFIM data collection tool allowed for the identification of the multiple contributing factors involved in a falls incident. The investigation of 22 fall case studies across the stroke continuum of care uncovered over 750 contributing factors (an average of 34 CFs per case). Across-case analysis revealed similarities in contributing factors across all settings (with differing prevalence rates) and also contributors to falls unique to a particular setting.
Factors that were prevalent across all settings included disease-specific factors such as problems with balance, muscle weakness, medications, impulsivity, and poor judgements (in making unsafe decisions and carrying out unsafe acts). Other factors included issues with assistive devices and communication devices (such as call bells), lack of supervision, ineffective falls prevention strategies, and a reactive approach to falls safety. There was a failure to learn from past breakdowns in safety, and falls assessments and prevention strategies were inconsistently carried out. Findings also exposed
contributing factors to falls unique to a particular setting, such as cognition in the acute phase of stroke, when patients were highly medicated, agitated, and confused. Specific
factors related to the transition of care post-discharge from hospital were found to contribute to falls in the stroke population living at home. Specifically, it was found that stroke survivors were being sent home with minimal community services, little support for their informal caregivers, and without the proper assessments of their home
environments. Post-discharge, stroke survivors and their families were expected to take on the responsibility of safety with minimal support.
The implementation of safety recommendations (made in each case study report) has the potential to improve safety in each of the specific organizations. Identification of similar factors within other organizations involved with the care of stroke survivors has the potential to prevent falls and target fall prevention strategies. Future studies should aim at identifying contributing factors to falls in the stroke population residing in long- term care facilities.
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Appendices
Appendix A: UWO Research Ethics Board Approval
Use of Human Participants - Ethics Approval Notice
Principal Investigator :Dr. Alexsandra Zecevic
Review Number: 18538E Review Level: Delegated
Approved Local Adult Participants: 30
Approved Local Minor Participants: 0
Protocol Title: Improving safety and preventing falls in stroke survivors through the continuum of care
Department & Institution: Faculty of Health Sciences, University of Western Ontario
Sponsor: Ontario Stroke Strategy
Ethics Approval Date: November 04, 2011 Expiry Date: October 31, 2016
Documents Reviewed & Approved & Documents Received for Information:
Document Name
UWO Protocol
Comments Version Date
Letter of Information & Consent Stroke survivor/Faller - Version 2 Letter of Information & Consent
Advertisement
Other
Generic - Version 2 Telephone Script Re-contact Script
"Il1is is to notify you that The Uni versity of Western Ontario Research Ethi cs Board for Health Sciences Research Involving Human Subject s (HSREI3) whi ch is orga nized and operates according to the Tri-Council Policy Statement: Ethical Conduct of Resea rch Involving Humans and the HealU1 Canada/ICH Good Clinical Practice Practices: Consolidat ed Guidelin es; and U1e applicable Jaws and regulations of Ontario ha s reviewed and granted
approva l to the above referenced rcvision(s) or amendment(s) on the approva l date noted above. TI1e m embership of this RED also complies wiU1 the
membership requirements for REB's as defined in Division 5 of the Food .ind Drug Regulation s.
The ethics approval for U1is study shall rema in va lid until the expiry date noted above assumin g timely and acceptable responses to U1c HSREB's periodic
requests for su"•eillance and monitorin g information. If you require an updat ed approval notice prior to U1at time you mu st request it using th e UWO Updat ed Approva l Request Fonn.
Members of the HSREB who are named as investigators in research studies, or declare a conflict of interest, do not participate in discu ssion related to, nor
vote on, such studi es when they are presented to the HSREB.
The Chair of the HSREB is Dr. Joseph Gilbert.·me UWO HSREB is registered with the U.S. Depa11ment of Health & Human Services under the !RB registration number IRB 00000940.
I
This is an o.Dicia l document. Please retain the original inyour files .
Tlie University of Western Ontario
Office of Resea rch Ethi cs
Suppor t Services Buildin g Room 5150 •London, Onta rio • CAN ADA - N6G 1G9
Appendix B: Lawson Approval
LAWSON HEALTH RESEARCH INSTITUTE FINAL APPROVAL NOTICE
RESEARCH OFFICE REVIEW NO.: R-11-598
PROJECT TITLE: Improving safety and preventing falls in stroke survivors through the continuum of care.
PRINCIPAL INVESTIGATOR: Dr. Aleksandra Zecevic DATE OF REVIEW BY CRIC: January 23, 2012 Health Sciences REB#: 18538E
Please be advised that the above project was reviewed by the Clinical Research Impact Committee and the project:
Was Approved
PLEASE INFORM THE APPROPRIATE NURSING UNITS, LABORATORIES, ETC. BEFORE STARTING THIS PROTOCOL. THE RESEARCH OFFICE NUMBER MUST BE USED WHEN COMMUNICATING WITH THESE AREAS.
Dr. David Hill V.P. Research
Lawson Health Research Institute
All future correspondence concerning this study should include the Research Office Review Number and should be directed to Sherry Paiva, CRIC Liaison, LHSC, Rm. C210, Nurses Residence, South Street Hospital.
November 28, 2011 Dr. A. Zecevic
Dear Aleksandra:
Re: Improving safety and preventing falls in stroke survivors through the continuum of care - REB# 18538
We wish to acknowledge receipt and thank you for your responses to the Parkwood CRIC review queries. We are, therefore, pleased to provide you with this Parkwood Hospital Clinical Research Impact Committee Letter of Approval.
This approval has been forwarded to the Lawson Health Research Institute Administrative Office, who will issue the final approval as projects may not be started until this final approval is received.
Yours sincerely,
Dalton Wolfe, PhD
Chair, Parkwood Hospital Clinical Research Impact Committee cc ARGC Administration Office
Lawson Administration Office
Aging, Rehabilitation, and Geriatric Care Research Centre Lawson Health Research Institute - Parkwood Hospital 801 Commissioners Rd. E., London, Ontario N6C 5J1
Tel: (519)685-4292 ext. 42957/42983 ● Fax (519)685-4060 ● email: [email protected] Administrative Assistant – [email protected]
Appendix D: Letter of Information-Stroke Survivor Improving safety and preventing falls in stroke survivors
through the continuum of care Principal Investigator: Aleksandra Zecevic, PhD Faculty of Health Sciences, University of Western Ontario
Co-Investigator:
Mona Madady, MSc candidate
Health and Rehabilitation Sciences Graduate Program University of Western Ontario
LETTER OF INFORMATION – Stroke survivor/Faller
The pronouns ‘you’ and ‘your’ refer to the research participant and not the person reading this letter.
This letter contains information to help you decide whether or not to participate in this research project. It is important for you to know why the data is being collected and the research is being conducted, and what we are asking you to agree to. Please take the time to read this carefully and feel free to ask questions if anything is unclear.
Researchers from the University of Western Ontario and community partners from University Hospital, Parkwood hospital, Dearness home, and the Ontario Stroke Strategy are engaged in ongoing research to better understand how to prevent falls in stroke survivors. IF during the next six months of your post-stroke recovery you experience one or multiple falls or near falls, we would like to talk to you in detail about what happened.
Whether the fall occurs in an acute care hospital, in a rehabilitation hospital, at home or somewhere else, an investigator trained in the Systemic Falls Investigative Method will be assigned to investigate this event. The investigator will interview you and others involved to collect detailed information about things that contributed to your fall.
Interviews might be audio taped and the location of the fall might be photographed. We are asking for your permission to collect and use the information from your interview and health record for research purposes. This investigation is done to better understand causes of falling and to improve the safety of all stroke survivors. The procedure is similar to the usual follow-up after a fall in a hospital with the exception that the information being collected will be de-identified (your name or identity will not be
revealed) and entered into a Systemic Falls Investigative Method Database (from herein called Falls Database).
If you agree to participate, data relating to your health history and current care will be