A New Resource from The World Health Organization:
Step Safely
I recently searched for resources and guidance to prevent falls on stairs, specific to the safety of older adults. Knowing that older adults are more likely — three times more likely — to experience fall-related accidents while descending steps, rather than climbing up steps (Elliott, et al., 2015), we have a responsibility to educate patients about strategies to exercise caution and reduce their risk. Falls among older adults that occur while navigating stairs also are associated with injuries (Blanchet and Edwards, 2018). Extensive research has been conducted that asserts the importance of caution when navigating stairs, and I have long included patient education about safety strategies to reduce the risk of falling while ascending and descending stairs. Through my research, I discovered a resource that was new to me, which I must share with you:
World Health Organization: Step Safely
Strategies for Preventing and Managing
Falls Across the Life Span
My knowledge of resources has been limited to older and vulnerable adults. So, I welcomed this resource to expand my knowledge. I knew that I must share this with you because this resource offers guidance across the life span.
The alarm is sounded at the start of their forward: “Every year more than 684,000 people die as a result of a fall, and an estimated 172 million more are left with short- or long-term disability – a shocking statistic that represents substantial human suffering: in comparison, 410,000 people died from Malaria in 2019” ( Step Safely, 2021, p. 9) … globally, falls result in more years lived with disability than transport injury, poisoning, drowning, and burns combined.” (Step Safely, p. 9).
Three populations at greatest risk for falls and fall-related injuries include: children and adolescents, workers, and older people. The global magnitude of falls in each of these populations is detailed in Section 1.
Section 2 provides key steps to assess fall situations for each population and by settings. It reviews emergency data, death statistics, and falls by facilities, at all levels, from local, to regional, to national. Analysis of this data enables understanding the types of falls and the prevention interventions most likely to be effective and cost-effective in each setting.
Then, recommendations are provided for interested and responsible stakeholders, such as groups, industries, and organizations, to join together for action — gathering resources and controls to improve safety, and setting policies and regulations.
Section 3 introduces interventions across the life span (children and adolescents, workers, and older people) to prevent falls and fall-related injuries in three sections: primary prevention of injury, secondary prevention to reduce the severity of injury, and tertiary prevention to decrease the frequency and severity of disability after an injury. The interventions are graded on levels of evidence to consider integrating the interventions into practice:
Strongly Recommended, A level, “excellent”. These interventions are consistently supported by several high-quality systematic reviews and/or randomized controlled trials and have a large benefit.
Recommended, B level, “good”. These interventions are supported by evidence from some robust studies including randomized trials and systematic reviews, and have a significant benefit.
Promising, C level, “satisfactory”. These interventions are supported by evidence from some robust studies, but there may be only few studies, or studies may have some risk of bias or conflicting evidence about the extent of the benefit of the intervention.
Prudent , D level, “poor” or “weak” evidence to support their use. These interventions are recommended as “prudent” as judged by experts to be advisable despite a lack of high-quality research to support their use, where the intervention had face validity and did not result in significant harm in reviewed studies.
(Step Safely, p. 19)
I invite you to review the recommended interventions and assigned evidence levels by populations you are interested in. I reviewed the recommendations for children and adolescents and older adults, because more is done to protect children from injuries when they fall compared to older adults. For example, for children, there is a recommendation to include corner protectors for sharp furniture corners as part of home safety to protect young children (Prudent level, lowest level) (Step Safely, p. 56). But, this recommendation is not included for older adults, which I have recommended for decades as an injury reduction strategy in homes, hospitals, and bathrooms.
Of course, there were recommendations for soft-fall surfaces in playgrounds and playing fields (Promising level, C), but no recommendations for soft-fall surfaces for older adults. In fact, floor mats to protect older adults from injury when falling from beds were absent, which is very disappointing. Floor mats are a standard of care in long term care settings, the Department of Veterans Affairs inpatient settings, and in more and more hospitals in the US. The only injury prevention intervention for older adults included in this resource is, surprisingly, hip protectors, which are not widely used, rather met with resistance. The only country that I am familiar with that uses hip protectors is Canada, where for years, a national social marketing strategy has been deployed. I am not aware of their success. However, Canada’s Case Study 7 is showcased (Step Safely, p. 108). Still, floor mats should have been included, and rated as Recommended, B level, based on a program of biomechanical research that floor mats absorb trauma and reduce the severity of impact (Bowers, et al., 2008). Everyone knows that if a person falls onto a floor mat, padded carpet, soft flooring, that impact severity is less than falling onto unprotected flooring, such as concrete or tile.
I’ll share one more interesting finding, which raised concern as an expert in fall prevention. WHO recommends Vitamin D for fall prevention for older adults (p. 88). However, in 2018, the United States Preventive Services Task Force changed their recommendations for screening for fall risk, specifically multifactorial assessment and supplemental Vitamin D. Based on review of the evidence, Vitamin D has no benefit in fall prevention. Vitamin D is no longer recommended for fall prevention. Rather, Vitamin D is still prescribed as part of osteopenia and osteoporosis treatment, reducing fracture risk.
When protecting older adults from falls and injuries, this report does caution older adults living independently in the community because of evidence that they are “most likely to fall in and near their own homes, where falls on stairs and in bathrooms are associated with high risk of injury” (Step Safely, p. 35).
Section 4, the last section, addresses fall management, aimed at helping countries ensure good fall-injury management systems across the spectrum of care: pre-hospital, hospital, surgery, rehabilitation, post-care, and prevention of future falls. These spectrums of care must be interconnected to maximize each patient’s survival, recovery, and rehabilitation, to reach maximum function and independence of those injured, and reduce repeat falls and further injuries.
Again, I hope you will take time, with your falls committee, to review this international resource. Read the case studies from countries all around the world as they, like us, commit to reduce risk of falls, protect populations from fall-related injuries, maximize injury rescue and implement treatment programs to restore maximum function and quality of life.
I concur with Etienne Krug, MD, MPH, Director, Social Determinants of Health, WHO, that “The view that falls are an inevitable part of life, particularly as we age, can create fatalism and complacency when it comes to how we respond to the problem. But there is growing evidence and awareness – upon which this resource is based – that many falls are preventable and that prevention efforts are effective. There is nothing to stop us strengthening these efforts with immediate effect” (Step Safely, p. vii).
Thank you for reading my message. I welcome your comments.
Pat Quigley
03/11/22
References:
Blanchet R, & Edwards N. (2018). A need to improve the assessment of environmental hazards for falls on stairs and in bathrooms: Results of a scoping review. BMC Geriatr. 18(1):272.
Bowers, B., Lloyd, J., Lee, W., Powell-Cope, G., & Baptiste, A. (2008). Biomechanical evaluation of injury severity associated with patient falls from bed. Rehabilitation Nursing, 33(6), 253–259.
Elliott, DB., Foster, RJ, Whitaker, D, et al. (2015). Analysis of lower limb movement to determine the effect of manipulating the appearance of stairs to improve safety: a linked series of laboratory-based, repeated measures studies. Public Health Res. 3(8). https://www.ncbi.nlm.nih.gov/books/NBK305246/
Step safely: Strategies for preventing and managing fall across the life-course. Geneva: World Health Organization; 2021. Licence: CCBY-NC-SA 3.0.IGO. https://www.who.int/teams/social-determinants-of-health/safety-and-mobility/step-safely
Dr. Patricia Quigley is a Nurse Consultant, Nurse Scientist, Former Associate Director and VISN 8 Patient Safety Center of Inquiry. She is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation, and her contributions to patient safety, nursing and rehabilitation are evident at a national level, with emphasis on clinical practice innovations designed to promote elders’ independence and safety. She is nationally known for her program of research in patient safety, particularly in fall prevention. The falls program research agenda continues to drive research efforts across health services and rehabilitation researchers.