As a physiotherapist who works in the public health sector with a particular interest in falls prevention, I find the failure of our health services to reduce the rate of falls for our patients and clients an ongoing bitter pill to swallow. 

Most of us are aware of evidence that, with the right targeted strategies, we can reduce falls rates. 

Indeed, physiotherapists can stand tall given the overwhelming evidence of our potential for impact in this area, particularly in community settings. 

It can be frustrating and disheartening, therefore, when we can’t see tangible differences for the communities we care for. 

Whatever we are doing, there is obviously room for improvement.

The world guidelines for falls prevention and management for older adults

In 2022, the world guidelines for falls prevention and management for older adults were published in Age and Ageing (Montero-Odasso et al 2022). 

Authors included esteemed Australian falls prevention researchers of whom we should all be very proud. 

This release was a significant moment for clinicians and researchers with an interest in falls prevention as these were the first ever world guidelines on this topic. 

The most recent Australian guidelines at that time dated back to 2009 (we eagerly await the newest Australian guidelines, due to be released this year) and so a collation of the overall body of literature on falls prevention was gratefully received.

Following the release of the world guidelines, I had the pleasure of analysing both my physiotherapy department’s and overall health service’s performance against the world guidelines and to address any gaps in our processes and performance that I uncovered. 

I did this in the hope that a systematic approach to assessing against the world guidelines and incorporating them into routine practice might help us to reduce the previously unbending falls rate per 1000 bed days at our health service.

The world guidelines are extensive and cover recommendations for hospital and ambulatory settings and for different specific conditions that are associated with an increased risk of falls. 

They contain an algorithm that describes the recommended path for an older person who enters the pathway either through opportunistic case finding (for example, during a routine check-up) or when they receive healthcare for a fall or related injury. 

Depending on whether there has been a fall in the past 12 months, how severe the fall was and whether gait and balance are impaired, the person is considered to be at low risk, intermediate risk or high risk of falls. 

The recommended interventions begin with education on physical activity for low risk patients and then gradually become more extensive and tailored as risk increases.

Falls prevention gap analysis of health service performance

Eastern Health has services across the largest geographical area of any metropolitan health service in Victoria. 

We provide a range of services, from emergency, surgical and medical care to palliative care, residential care and ambulatory services. 

More than 240 physiotherapists work at Eastern Health across more than six sites.

Given that outer eastern Melbourne has a higher proportion of older people compared with statewide and nationwide averages and the significant risk of falls for the population we serve, timely and effective implementation of the world guidelines was important.

The process that I undertook to conduct the gap analysis and implementation work is shown in Figure 1. 

The first task was to review and understand the world guidelines. 

Even this step was shared with colleagues to ensure early investment in the process. 

We identified recommendations that were more specific to physiotherapy (eg, recommendations for balance assessment, gait speed assessment and balance interventions) and those that were more broadly related to Eastern Health. 

Then came wide consultation with clinicians, managers and local experts (including our falls working group) to determine whether we had evidence of adherence to each recommendation. 

Following this, we were generating ideas to address any identified gaps and then putting those ideas into action via projects that followed the Eastern Health quality improvement methodology, guideline reviews and documentation or tool reviews.

The tool that I used to record the findings of the gap analysis for both Eastern Health broadly and physiotherapy was a simple Excel spreadsheet. 

The spreadsheet had tabs for each of the main sections of the world guidelines (eg, general recommendations, hospital recommendations and specific conditions) and columns for the recommendation, the subsection of the guideline that it was lifted from, the strength of the recommendation (the authors used a modified GRADE approach) and a description of the required state to meet the recommendation. 

I then put the current state into a final column, according to my knowledge and with input from various experts and clinicians with whom I consulted. 

I used a traffic light system to keep track of whether the recommendation was already in practice at Eastern Health (green), was not already in practice but we had a plan to address it (amber) or needed a plan or consultation to progress (red).

Outcomes of gap analysis

In the physiotherapy-specific gap analysis we identified many areas of current-state adherence to the world guidelines, including offering an objective assessment of gait where there have been previous falls. 

Further, we felt confident that older adults who sustain a hip fracture are offered an individualised and progressive exercise
program. 

We have an existing routinely audited guideline that ensures that we follow the Hip Fracture Clinical Care Standard. 

Gaps that we identified included routine assessment of balance (including assessment of gait speed for predicting falls risk) and the provision of appropriately challenging exercise interventions to prevent future falls.

Strategies to address identified physiotherapy-specific gaps have all been in the form of project work. 

A wide-reaching quality project using the Eastern Health quality improvement methodology (which closely resembles the Institute for Healthcare Improvement methodology) has been completed to increase the uptake of balance and gait assessment in all settings. 

Measured walkways and tools containing normative values to improve ease and utility of gait speed assessment in the acute and subacute settings have been implemented. 

In the subacute setting, routine assessment of gait speed and/or use of the de Morton Mobility Index on admission and discharge is also now undertaken as a minimum. 

The next step in this important work is to address the gap in provision of appropriately challenging exercise interventions to prevent future falls. 

Our residential aged care physiotherapists are also engaged in this process and are working collaboratively with the Monash University My Therapy Rehabilitation project team to promote exercise training and improve the frequency of offers to participate in physical activity at Murrenda, Eastern Health’s residential care facility.

This gap analysis and implementation has been extensive but further work is still needed to fully explore and address gaps in our processes and practice. 

Some strategies that we have found effective so far include:

• take the time to understand the current situation at your health service
• share the load among your team (which also helps to translate evidence to practice more quickly)
• find mutual wins for team members, such as addressing goals to lead or participate in auditing or project work
• use the resources you have and outsource where appropriate.

Our hope (and the ultimate test of this gap analysis and implementation) is that this systematic approach to implementing the world guidelines will see us have a greater systemic impact on the falls rate at our health service. 

At the time of writing, there is no significant difference in the overall rate of falls at Eastern Health but with work still to come, we are hopeful that this change will happen over coming months and years. 

The authors of the world guidelines wrote that their initiative does not conclude with the writing of the guidelines and the same tireless focus is also necessary for those of us translating evidence-based falls prevention recommendations into routine practice.

Melanie Haley will present this month’s eTalk, ‘Real world implementation of the world guidelines for falls prevention and management for older adults’. Click here to find out more.

>> Melanie Haley MACP is an APA Gerontological Physiotherapist with a Master of Gerontology degree. She works as a clinical lead Grade 4 physiotherapist in aged and complex care for Eastern Health in Melbourne.

Reference: Montero-Odasso, M. et al. ‘World guidelines for falls prevention and management for older adults: a global initiative.’ Age and Ageing, 51(9), 2022, afac205.