The Flooring for Injury Prevention (FLIP) Study of compliant flooring for the prevention of fall-related injuries in long-term care: A randomized trial

Abstract

Background Fall-related injuries exert an enormous health burden on older adults in long-term care (LTC). Softer landing surfaces, such as those provided by low-stiffness “compliant” flooring, may prevent fall-related injuries by decreasing the forces applied to the body during fall impact. Our primary objective was to assess the clinical effectiveness of compliant flooring at preventing serious fall-related injuries among LTC residents. Methods and findings The Flooring for Injury Prevention (FLIP) Study was a 4-year, randomized superiority trial in 150 single-occupancy resident rooms at a single Canadian LTC site. In April 2013, resident rooms were block randomized (1:1) to installation of intervention compliant flooring (2.54 cm SmartCells) or rigid control flooring (2.54 cm plywood) covered with identical hospital-grade vinyl. The primary outcome was serious fall-related injury over 4 years that required an emergency department visit or hospital admission and a treatment procedure or diagnostic evaluation in hospital. Secondary outcomes included minor fall-related injury, any fall-related injury, falls, and fracture. Outcomes were ascertained by blinded assessors between September 1, 2013 and August 31, 2017 and analyzed by intention to treat. Adverse outcomes were not assessed. During follow-up, 184 residents occupied 74 intervention rooms, and 173 residents occupied 76 control rooms. Residents were 64.3% female with mean (SD) baseline age 81.7 (9.5) years (range 51.1 to 104.6 years), body mass index 25.9 (7.7) kg/m 2 , and follow-up 1.64 (1.39) years. 1,907 falls were reported; 23 intervention residents experienced 38 serious injuries (from 29 falls in 22 rooms), while 23 control residents experienced 47 serious injuries (from 34 falls in 23 rooms). Compliant flooring did not affect odds of ≥1 serious fall-related injury (12.5% intervention versus 13.3% control, odds ratio [OR]: 0.98, 95% CI: 0.52 to 1.84, p = 0.950) or ≥2 serious fall-related injuries (5.4% versus 7.5%, OR: 0.74, 95% CI: 0.31 to 1.75, p = 0.500). Compliant flooring did not affect rate of serious fall-related injuries (0.362 versus 0.422 per 1,000 bed nights, rate ratio [RR]: 1.04, 95% CI: 0.45 to 2.39, p = 0.925; 0.038 versus 0.053 per fall, RR: 0.81, 95% CI: 0.38 to 1.71, p = 0.560), rate of falls with ≥1 serious fall-related injury (0.276 versus 0.303 per 1,000 bed nights, RR: 0.97, 95% CI: 0.52 to 1.79, p = 0.920), or time to first serious fall-related injury (0.237 versus 0.257, hazard ratio [HR]: 0.92, 95% CI: 0.52 to 1.62, p = 0.760). Compliant flooring did not affect any secondary outcome in this study. Study limitations included the following: findings were specific to 2.54 cm SmartCells compliant flooring installed in LTC resident rooms, standard fall and injury prevention interventions were in us...

The Effect of Fall Biomechanics on Risk for Hip Fracture in Older Adults: A Cohort Study of Video-Captured Falls in Long-Term Care

“…Although previous studies did not specify whether they defined "fall direction" as the initial fall direction or landing configuration, our results for landing configuration are in agreement with those reported by Greenspan and colleagues, (13) who found that sideways falls had 5.7-fold higher odds for hip fracture than falls in other directions; by Nevitt and Cummings, (39) who reported that sideways or straight-down falls had 3.3-fold higher odds for fracture; and by Hwang and colleagues, (29) who found that, when compared to forward falls, both backward and sideways falls created over 10-fold higher risk for hip fracture. Future studies should separately consider and report outcomes for initial fall direction and landing direction.…”

“…We previously reported that hand impact did not affect the risk for head impact during falls by residents of LTC. (22,33) Others have reported that arresting the fall with the hands associated with reduced risk for hip fracture among communitydwelling individuals, (14,39) but had no effect on hip fracture risk for older adults residing in nursing homes. (13) The discrepancy may be due to differences between LTC and community-based populations in factors such as upper limb strength and flexibility.…”

“…Previous case-control studies in older adults have found that risk for hip fracture in a fall depends at least as much on the biomechanics of the fall, as it does on bone density. (12,39) In particular, although a one standard deviation (1SD) decline in bone density increased fracture risk twofold to threefold, (12) falling sideways increased fracture risk sixfold, (13) and landing on the hip increased fracture risk 30-fold. (14) Furthermore, hip fractures were less common when the person landed on their hand, or grabbed or hit an object to break the fall.…”

“…(14) Furthermore, hip fractures were less common when the person landed on their hand, or grabbed or hit an object to break the fall. (39) However, a major limitation of these studies is their reliance on interviews or questionnaires completed by the faller and witnesses (if any) to determine a narrow range of fall characteristics (fall direction, fall height, and contact sites). Recalling the circumstances of falls is challenging, especially for older adults with cognitive impairment.…”

Implementation of a Multifactorial Fall Intervention Model in Hospital: a Longitudinal Before-and-after Controlled Study From 2015 to 2018

“…In particular, the exploration of fall prevention measures has attracted a large number of investigators. (11,12) Related research has also yielded many meaningful results, such as the progress of a series of fall assessment tools and the improvement of fall prevention measures for use in hospitals. (13)(14)(15)(16)(17)(18)(19) Correspondingly, the importance of interventions when falls occur and after falls are often overlooked.…”