Colón-Emeric Cathleen S, Corazzini Kirsten, McConnell Eleanor S, Pan Wei, Toles Mark, Hall Rasheeda, Cary Michael P, Batchelor-Murphy Melissa, Yap Tracey, Anderson Amber L, Burd Andrew, Amarasekara Sathya, Anderson Ruth A
Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina.
Durham VA Geriatric Research Education and Clinical Center, Durham, North Carolina.
JAMA Intern Med. 2017 Nov 1;177(11):1634-1641. doi: 10.1001/jamainternmed.2017.5073.
New approaches are needed to enhance implementation of complex interventions for geriatric syndromes such as falls.
To test whether a complexity science-based staff training intervention (CONNECT) promoting high-quality staff interactions improves the impact of an evidence-based falls quality improvement program (FALLS).
DESIGN, SETTING, AND PARTICIPANTS: Cluster-randomized trial in 24 nursing homes receiving either CONNECT followed by FALLS (intervention), or FALLS alone (control). Nursing home staff in all positions were asked to complete surveys at baseline, 3, 6, and 9 months. Medical records of residents with at least 1 fall in the 6-month pre- and postintervention windows (n = 1794) were abstracted for fall risk reduction measures, falls, and injurious falls.
CONNECT taught staff to improve their connections with coworkers, increase information flow, and use cognitive diversity in problem solving. Intervention components included 2 classroom sessions, relationship mapping, and self-monitoring. FALLS provided instruction in the Agency for Healthcare Research and Quality's Falls Management Program.
Primary outcomes were (1) mean number of fall risk reduction activities documented within 30 days of falls and (2) median fall rates among residents with at least 1 fall during the study period. In addition, validated scales measured staff communication quality, frequency, timeliness, and safety climate.
Surveys were completed by 1545 staff members, representing 734 (37%) and 811 (44%) of eligible staff in intervention and control facilities, respectively; 511 (33%) respondents were hands-on care workers. Neither the CONNECT nor the FALLS-only facilities improved the mean count of fall risk reduction activities following FALLS (3.3 [1.6] vs 3.2 [1.5] of 10); furthermore, adjusted median recurrent fall rates did not differ between the groups (4.06 [interquartile range {IQR}, 2.03-8.11] vs 4.06 [IQR, 2.04-8.11] falls/resident/y). A modest improvement in staff communication measures was observed overall (mean, 0.03 [SE, 0.01] points on a 5-point scale; P = .03) and for communication timeliness (mean, 0.8 [SE, 0.03] points on a 5-point scale; P = .02). There was wide variation across facilities in intervention penetration.
An intervention targeting gaps in staff communication and coordination did not improve the impact of a falls quality improvement program. New approaches to implementing evidence-based care for complex conditions in the nursing home are urgently needed.
clinicaltrials.gov Identifier: NCT00636675.
需要新的方法来加强对老年综合征（如跌倒）复杂干预措施的实施。
测试一种基于复杂性科学的促进高质量员工互动的员工培训干预措施（CONNECT）是否能提高基于证据的跌倒质量改进计划（FALLS）的效果。
设计、地点和参与者：对24家疗养院进行整群随机试验，这些疗养院要么先接受CONNECT再接受FALLS（干预组），要么只接受FALLS（对照组）。所有职位的疗养院工作人员被要求在基线、3个月、6个月和9个月时完成调查。对干预前后6个月内至少发生1次跌倒的居民（n = 1794）的医疗记录进行摘要，以获取跌倒风险降低措施、跌倒和伤害性跌倒的信息。
CONNECT培训员工改善与同事的联系、增加信息流通并在解决问题时利用认知多样性。干预内容包括2次课堂教学、关系映射和自我监测。FALLS提供了医疗保健研究与质量局跌倒管理计划的指导。
主要结局为（1）跌倒后30天内记录的跌倒风险降低活动的平均数量，以及（2）研究期间至少发生1次跌倒的居民的跌倒中位数发生率。此外，使用经过验证的量表测量员工沟通质量、频率、及时性和安全氛围。
1545名工作人员完成了调查，分别占干预组和对照组符合条件工作人员的734名（37%）和811名（44%）；511名（33%）受访者为直接护理人员。接受CONNECT干预的设施和仅接受FALLS干预的设施在FALLS实施后均未改善跌倒风险降低活动的平均计数（10项活动中分别为3.3 [1.6] 项和3.2 [1.5] 项）；此外，两组调整后的跌倒复发率中位数没有差异（4.06 [四分位间距{IQR}，2.03 - 8.11] 次/居民/年 vs 4.06 [IQR，2.04 - 8.11] 次/居民/年）。总体而言，工作人员沟通措施有适度改善（5分制平均提高0.03 [标准误，0.01] 分；P = 0.03），沟通及时性方面也有改善（5分制平均提高0.8 [标准误，0.03] 分；P = 0.02）。各设施在干预实施程度上存在很大差异。
针对员工沟通和协调差距的干预措施并未改善跌倒质量改进计划的效果。迫切需要新的方法来在疗养院实施针对复杂情况的循证护理。
clinicaltrials.gov标识符：NCT00636675。
