Implementation fidelity of a nurse-led falls prevention program in acute hospitals during the 6-PACK trial
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Background: When tested in a randomized controlled trial (RCT) of 31,411 patients, the nurse-led 6-PACK falls prevention program did not reduce falls. Poor implementation fidelity (i.e., program not implemented as intended) may explain this result. Despite repeated calls for the examination of implementation fidelity as an essential component of evaluating interventions designed to improve the delivery of care, it has been neglected in prior falls prevention studies. This study examined implementation fidelity of the 6-PACK program during a large multi-site RCT. Methods: Based on the 6-PACK implementation framework and intervention description, implementation fidelity was examined by quantifying adherence to program components and organizational support. Adherence indicators were: 1) falls-risk tool completion; and for patients classified as high-risk, provision of 2) a ‘Falls alert’ sign; and 3) at least one additional 6-PACK intervention. Organizational support indicators were: 1) provision of resources (executive sponsorship, site clinical leaders and equipment); 2) implementation activities (modification of patient care plans; training; implementation tailoring; audits, reminders and feedback; and provision of data); and 3) program acceptability. Data were collected from daily bedside observation, medical records, resource utilization diaries and nurse surveys. Results: All seven intervention components were delivered on the 12 intervention wards. Program adherence data were collected from 103,398 observations and medical record audits. The falls-risk tool was completed each day for 75% of patients. Of the 38% of patients classified as high-risk, 79% had a ‘Falls alert’ sign and 63% were provided with at least one additional 6-PACK intervention, as recommended. All hospitals provided the recommended resources and undertook the nine outlined program implementation activities. Most of the nurses surveyed considered program components important for falls prevention. Conclusions: While implementation fidelity was variable across wards, overall it was found to be acceptable during the RCT. Implementation failure is unlikely to be a key factor for the observed lack of program effectiveness in the 6-PACK trial. Trial registration: The 6-PACK cluster RCT is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000332921 (29 March 2011).
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Acceptability of the 6-PACK falls prevention program: A pre-implementation study in hospitals participating in a cluster randomized controlled trialBarker, A.; Morello, R.; Ayton, D.; Hill, Keith; Brand, C.; Livingston, P.; Botti, M. (2017)There is limited evidence to support the effectiveness of falls prevention interventions in the acute hospital setting. The 6-PACK falls prevention program includes a fall-risk tool; 'falls alert' signs; supervision of ...
Barker, A.; Morello, R.; Wolfe, R.; Brand, C.; Haines, T.; Hill, Keith; Brauer, S.; Botti, M.; Cumming, R.; Livingston, P.; Sherrington, C.; Zavarsek, S.; Lindley, R.; Kamar, J. (2016)Objective: To evaluate the effect of the 6-PACK programme on falls and fall injuries in acute wards. Design: Cluster randomised controlled trial. Setting: Six Australian hospitals. Participants: All patients admitted to ...
Barriers and enablers to the implementation of the 6-PACK falls prevention program: A preimplementation study in hospitals participating in a cluster randomised controlled trialAyton, D.; Barker, A.; Morello, R.; Brand, C.; Talevski, J.; Landgren, F.; Melhem, M.; Bian, E.; Brauer, S.; Hill, Keith; Livingston, P.; Botti, M. (2017)Evidence for effective falls prevention interventions in acute wards is limited. One reason for this may be suboptimal program implementation. This study aimed to identify perceived barriers and enablers of the implementation ...