Implementation fidelity of a nurse-led falls prevention program in acute hospitals during the 6-PACK trial

Renata T. Morello, Anna L. Barker, Darshini Rebecca Ayton, Fiona Landgren, Jeannette Kamar, Keith D. Hill, Caroline A. Brand, Catherine Sherrington, Rory Wolfe, Sheral Rifat, Johannes Stoelwinder

Research output: Contribution to journalArticleResearchpeer-review

1 Citation (Scopus)

Abstract

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).
Original languageEnglish
Article number383
JournalBMC Health Services Research
Volume17
Issue number1
DOIs
Publication statusPublished - 2 Jun 2017

Keywords

  • Complex health intervention
  • Falls prevention
  • Hospitals
  • Implementation fidelity
  • Injury prevention
  • Process evaluation
  • Program evaluation
  • Quality improvement

Cite this

@article{4ab55524bb0e4d648499921f31c49127,
title = "Implementation fidelity of a nurse-led falls prevention program in acute hospitals during the 6-PACK trial",
abstract = "BackgroundWhen 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.MethodsBased 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.ResultsAll 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.ConclusionsWhile 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 registrationThe 6-PACK cluster RCT is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000332921 (29 March 2011).",
keywords = "Complex health intervention, Falls prevention, Hospitals, Implementation fidelity, Injury prevention, Process evaluation, Program evaluation, Quality improvement",
author = "Morello, {Renata T.} and Barker, {Anna L.} and Ayton, {Darshini Rebecca} and Fiona Landgren and Jeannette Kamar and Hill, {Keith D.} and Brand, {Caroline A.} and Catherine Sherrington and Rory Wolfe and Sheral Rifat and Johannes Stoelwinder",
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language = "English",
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Implementation fidelity of a nurse-led falls prevention program in acute hospitals during the 6-PACK trial. / Morello, Renata T.; Barker, Anna L.; Ayton, Darshini Rebecca; Landgren, Fiona ; Kamar, Jeannette; Hill, Keith D.; Brand, Caroline A.; Sherrington, Catherine; Wolfe, Rory; Rifat, Sheral; Stoelwinder, Johannes .

In: BMC Health Services Research, Vol. 17, No. 1, 383, 02.06.2017.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Implementation fidelity of a nurse-led falls prevention program in acute hospitals during the 6-PACK trial

AU - Morello, Renata T.

AU - Barker, Anna L.

AU - Ayton, Darshini Rebecca

AU - Landgren, Fiona

AU - Kamar, Jeannette

AU - Hill, Keith D.

AU - Brand, Caroline A.

AU - Sherrington, Catherine

AU - Wolfe, Rory

AU - Rifat, Sheral

AU - Stoelwinder, Johannes

PY - 2017/6/2

Y1 - 2017/6/2

N2 - BackgroundWhen 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.MethodsBased 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.ResultsAll 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.ConclusionsWhile 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 registrationThe 6-PACK cluster RCT is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000332921 (29 March 2011).

AB - BackgroundWhen 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.MethodsBased 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.ResultsAll 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.ConclusionsWhile 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 registrationThe 6-PACK cluster RCT is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000332921 (29 March 2011).

KW - Complex health intervention

KW - Falls prevention

KW - Hospitals

KW - Implementation fidelity

KW - Injury prevention

KW - Process evaluation

KW - Program evaluation

KW - Quality improvement

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U2 - 10.1186/s12913-017-2315-z

DO - 10.1186/s12913-017-2315-z

M3 - Article

VL - 17

JO - BMC Health Services Research

JF - BMC Health Services Research

SN - 1472-6963

IS - 1

M1 - 383

ER -