Introduction 1 2 3 4 5 6 7 11 12 13 14 15 16 10 17 20 21 21 22 23 25 26 27 Considering the lack of fall prevention studies in hospitals, especially after recent hip fracture surgery, this is an area of interest for study. The aim of this study was thus to evaluate if a postoperative multidisciplinary, multifactorial intervention program could reduce inpatient falls and fall-related injuries in patients with femoral neck fractures. Methods Recruitment and randomization 28 In Sweden different surgery methods are used depending on the displacement of the femoral neck fracture. In the present study patients with undisplaced fracture were operated on using internal fixation (IF) and patients with displaced fracture were operated on using hemiarthroplasty (HAP). If patients had severe rheumatoid arthritis, severe hip osteoarthritis, or pathological fracture they were excluded, by the surgeon on duty, because of the need for a different surgery method, such as total hip arthroplasty (THA). Patients with severe renal failure were excluded, by the anesthesiologist, because of their morbidity. Patients being bedridden before the fracture occurred were also excluded. 1 p p p 1 Patients were randomized, to postoperative care in a geriatric ward with a special intervention program or to conventional care in an orthopedic ward, in opaque sealed envelopes. The lots in the envelopes were sequentially numbered. All participants received this envelope while in the emergency room but the envelope was not opened until immediately before surgery to ensure that all patients received similar preoperative treatment. Persons not involved in the study performed these procedures.  n n n n Fig. 1 Flow chart for the randomized trial  Table 1 SD ADL   n n p Sociodemographic  Age, mean±SD 82.3 ± 6.6 82.0 ± 5.9 0.724  Females 74 74 0.546  Independent living before the fracture 66 60 0.677 Health and medical problems n 29 20 0.265  Dementia 28 36 0.145 n a 16 14 0.829 n 33 45 0.031 n 23 17 0.417 n 57 53 0.938 Medications on admission  Number of drugs, mean±SD 5.8 ± 3.8 5.9 ± 3.6 0.867  Antidepressants  29 45 0.009 Sensory impairments n 42 34 0.667 n 37 27 0.584 Functional performance before fracture n 56 52 0.948 n 23 16 0.334 n b 24 25 0.580 n 85 85 0.191 1 3 n 5 (1–7.75) 5 (0.25–7) 0.859 Assessments during hospitalization n 17.4 ± 8.2 15.7 ± 9.1 0.191 n 10.1 ± 10.8 12.5 ± 11.4 0.148 n 5.2 ± 3.6 4.5 ± 3.5 0.271 a b Intervention 29 30 2 Table 2 Main content of the postoperative program and differences between the two groups   Intervention group Control group Ward layout Single and double rooms Single, double, and four-bed rooms 24-bed ward, extra beds when needed 27-bed ward, extra beds when needed  The geriatric control ward was similar to the intervention ward Staffing 1.07 nurses/aides per bed 1.01 nurses per bed Two full-time physiotherapists Two full-time physiotherapists Two full-time occupational therapists 0.5 occupational therapist 0.2 dietician No dietician  The geriatric control ward had staffing similar to the intervention ward Staff education A 4-day course in caring, rehabilitation, teamwork, and medical knowledge including sessions about how to prevent, detect, and treat various postoperative complications such as postoperative delirium and falls No specific education before or during the project Teamwork Team included registered nurses (RN), licensed practical nurses (LPN), physiotherapists (PT), occupational therapists (OT), dietician, and geriatricians No corresponding teamwork at the orthopedic unit Close cooperation between orthopedic surgeons and geriatricians in the medical care of the patients The geriatric ward, where some of the control group patients were cared for, used teamwork similar to that in the intervention ward Individual care planning All team members assessed each patient as soon as possible, usually within 24 h, to be able to start the individual care planning Individual care planning was used in the orthopedic unit but not routinely as in the intervention ward Team planning of the patients’ individual rehabilitation process and goals twice a week At the geriatric rehabilitation unit there was weekly individual care planning Prevention and treatment of complications Investigation as far as possible regarding how and why they sustained the hip fracture, through analyzing external and internal fall risk factors No routine analysis of why the patients had fractured their hips An action to prevent new falls and fractures was implemented including global ratings of the patients’ fall risk every week during team meetings No attempt was made to systematically prevent further falls Calcium and vitamin D and other pharmacological treatments for osteoporosis were used when indicated No routine prescription of calcium and vitamin D Active prevention, detection, and treatment of postoperative complications such as delirium, pain, and decubitus ulcers was systematic Assessments for postoperative complications were made with check-ups for, i.e., saturation, hemoglobin, nutrition, bladder and bowel function, home situation etc., but these check-ups were not carried out systematically as in the intervention group Oxygen-enriched air during the 1st postoperative day and longer if necessary until the measured oxygen saturation was stable  Urinary tract infections and other infections were screened for and treated  If a urinary catheter was used it should be discontinued within 24 h postoperatively  Regular screening for urinary retention, and prevention and treatment of constipation  Blood transfusion was prescribed if B-hemoglobin  <100 g/l and  <110 for those at risk of delirium or those already delirious  If the patient slept badly, the reason was investigated and the aim was then to treat the cause  Nutrition Food and liquid registration was systematically performed and protein-enriched meals were served to all patients during the first 4 postoperative days and longer if necessary A dietician was not available at the orthopedic unit Nutritional and protein drinks were served every day No routine nutrition registration or protein-enriched meals were available for the patients Rehabilitation Mobilization within the first 24 h after surgery Mobilization usually within the first 24 h The training included both specific exercise and other rehabilitation procedures delivered by a PT and OT, as well as basic daily ADL performance training, by caring staff. The patients should always do as much as they could by themselves before they were helped The PT on the ward mobilized the patients together with the caring staff. The PT aimed to meet the lucid patients every day. Functional retraining in ADL situations was not always given. The OT at the orthopedic unit only met the patients for consultation The rehabilitation was based on functional retraining with special focus on fall risk factors The geriatric control ward had both specific exercise and other rehabilitation procedures delivered by a PT and OT, similar to the intervention ward but did not systematically focus on fall risk factors Home visit by an OT and/or a PT No home visits were made by staff from the orthopedic unit n 2 The staffs on the intervention and control wards were not aware of the nature of the present study. Data collection Two registered nurses were employed and performed the assessments during hospitalization. 31 32 33 34 35 36 A geriatrician, unaware of study group allocation, analyzed all assessments and documentation, after the study was finished, for completion of the final diagnoses according to the same criteria for all patients. The Ethics Committee of the Faculty of Medicine at Umeå University approved the study (§ 00-137). Statistical analysis 22 t 2 2 37 p 1 2 p Results 3 Table 3 CI IRR   n n p Number of falls 18 60  Postoperative in-hospital days 2,860 3,685  Crude fall incidence rate (number of falls/1,000 days) 6.29 16.28  IRR (95% CI) a 1.00 (Ref.) 0.006 Number of fallers 12 26 0.007 Number of fallers with injuries due to falls 3 15 0.002 Number of fallers with fractures due to falls 0 4 0.055 Number of falls among people with dementia 1 34  IRR (95% CI) among people with dementia a 1.00 (Ref.) 0.013 n 1 11 0.006 a p p 3 2 p Fig. 2 Kaplan-Meir survival graph  p p p p p p p p p p p Discussion The present study shows that the number of falls and time lapse to first fall can be reduced during in-hospital rehabilitation after a femoral neck fracture. A multidisciplinary, multifactorial geriatric care program with systematic assessment and treatment of fall risk factors as well as active prevention, detection, and treatment of other postoperative complications resulted in fewer patients who fell, a lower total number of falls, and fewer injuries. 26 27 26 27 27 38 22 10 15 16 39 The investigation into why the patients had fractured their hip and why they fell may also have influenced the result, as well as the investigation and rehabilitation concerning external fall risk factors such as the use of walking aids, safe transfers, balance, and mobility. It seems that teamwork and individual care planning alone do not have the same effect on falls, as half the falls in the control group occurred in the geriatric control ward, a ward specializing in geriatric patients where teamwork, as well as individual care planning, is applied. 19 22 40 41 Conclusion A team applying comprehensive geriatric assessment and rehabilitation, including prevention, detection, and treatment of fall risk factors, can successfully prevent inpatient falls and injuries, even in patients with dementia.