CONNECT for Quality: A Study to Reduce Falls in Nursing Homes

NCT00636675 | Completed Results DMC

• 3 other identifiers: Pro000187455R01NR0031782R56NR003178-09
• Study Type: interventional
• Target: 1,726
• Locations: 1 country
• Sites: 1

Brief Summary

Clinical trials have identified interventions that reduce adverse outcomes such as falls in nursing home (NH) residents but attempts to translate these into practice quality improvement (QI) techniques have not been successful. Using a complexity science framework, our previous study showed that low connection, information flow, and cognitive diversity among NH staff explains quality of care for complex problems such as falls. Our pilot of "Connect," a multi-component intervention that encourages staff to engage in network-building and use simple strategies to make new connections with others, enhance information flow, and use cognitive diversity, suggests that staff can improve the density and quality of their interactions. This 5-year study uses a prospective, cluster-randomized, outcome assessment blinded design, with NHs (n=16) randomized to either Connect and a falls QI program (Connect + Falls) or QI alone (Falls). About 800 residents and 576 staff will participate. Specific aims are to, in nursing homes: 1) Compare the impact of the Connect intervention plus a falls reduction QI intervention (Connect+Falls) to a falls reduction QI intervention (Falls) on fall risk reduction indicators (orthostatic blood pressure, sensory impairment, footwear appropriateness, gait; assistive device; toileting needs, environment, and psychotropic medication); 2) Compare the impact of Connect+Falls to Falls alone on fall rates and injurious falls, and determine whether these are mediated by the change in fall risk reduction indicators; 3) Compare the impact of Connect+Falls to Falls alone on complexity science measures (communication, participation in decision making, local interactions, safety climate, staff perceptions of quality) and determine whether these mediate the impact on fall risk reduction indicators and fall rates and injurious falls. Cross-sectional observations of complexity science measures are taken at baseline, at 3 months, at 6 months, and at 9 months. Resident fall risk reduction indicators, fall rates, and injurious falls are measured for the 6 months prior to the first intervention and the 6 months after the final intervention is completed. Analysis will use a 3-level mixed model to account for the complex nesting of patients and staff within nursing homes, and to control for covariates associated with fall risk, including baseline facility fall rates and staff turnover rates.

Conditions

Accidental Falls

Keywords

Accidental falls

Outcome Measures

Primary Outcomes (1)

• Fall Related Process Measures

  Mean of the total number of fall risk reduction indicators (steps staff have taken to reduce fall risk) that were documented in residents with high fall risk. These included orthostatic blood pressure measurement/intervention; sensory impairment evaluation/intervention; footwear; exercise/assistive device intervention; toileting schedule; environmental modification; psychoactive medication reduction; and vitamin D supplements. Note that this measure is NOT related to staff but rather residents in the nursing home, therefore the numbers are different from participant flow. The residents were not considered enrolled participants in the study.

  6 months post intervention

Secondary Outcomes (2)

• Fall Rates

  6 months post intervention

• Change in Weighted Average of Staff Interaction Scales

  baseline to post intervention, an average of 6 months

Study Arms (2)

Fall QI

EXPERIMENTAL

Falls QI includes quality improvement training about falls to be implement by indigenous nursing home staff with support of study personnel.

Behavioral: Falls QI

Connect & Falls QI

EXPERIMENTAL

Connect is delivered, followed by Falls. Behavioral intervention to improve staff interaction for better care planning and execution. Connect will be delivered, followed by the Falls quality improvement intervention.

Behavioral: Connect

Interventions

Falls QI BEHAVIORAL

Falls uses the Falls Management Program (AHRQ); it is familiar to nursing homes, uses minimal researcher time, is adaptable, and simulates real word quality improvement practices. Falls is delivered over 3 months. Components include: 1. In-House Falls Coordinator training on content and falls processes. 2. Case-based modules about fall prevention and tailored for various team members. 3. Academic Detailing in which researcher consults with staff regarding challenging residents with falls. 4. Audit and Feedback. Discussions about comparison of nursing home's current practice on fall-related process and outcome measures, and how it compares with the median and the 90th percentile of peer NHs. 5. Toolbox: Handbook of useful measures and worksheets.

Fall QI

Connect BEHAVIORAL

Connect, delivered over 12 weeks, helps nursing home staff learn interactions that increase exchange of new information, number and quality of connections among staff, and improve problem-solving about patient care. Protocols: 1. In-class learning sessions introduce interaction strategies. 2. Relationship map protocols assist staff to examine existing interaction patterns and agree on goals for improvement. Individuals develop their own relationship maps and use them to practice new horizontal and vertical connections and self-monitoring their own interactions. 3. Researcher facilitates authentic learning which occurs when learners directly and independently apply concepts. In-house staff volunteers and are facilitated to assume a mentoring role.

Connect & Falls QI

Eligibility Criteria

• Age: 65 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Older Adult (65+)

You may qualify if:

• Eligible residents will be long-term care residents at least 65 years of age who have resided in the NH at least 6 months and are likely to survive at least 6 months. Residents must be potentially at risk for falls, which we define as ambulatory or transfer-independent as recorded on the Minimum Data Set.

You may not qualify if:

• None.

Sponsors & Collaborators

• Duke University: lead
• The Carolinas Center for Medical Excellence: collaborator
• National Institute of Nursing Research (NINR): collaborator

Study Sites (1)

Duke University School of Nursing

Durham, North Carolina, 27710, United States

Location

Related Publications (26)

• Jordon M, Lanham HJ, Anderson RA, McDaniel RR Jr. Implications of complex adaptive systems theory for interpreting research about health care organizations. J Eval Clin Pract. 2010 Feb;16(1):228-31. doi: 10.1111/j.1365-2753.2009.01359.x.

  PMID: 20367840 BACKGROUND

• McDaniel RR Jr, Lanham HJ, Anderson RA. Implications of complex adaptive systems theory for the design of research on health care organizations. Health Care Manage Rev. 2009 Apr-Jun;34(2):191-9. doi: 10.1097/HMR.0b013e31819c8b38.

  PMID: 19322050 BACKGROUND

• Colon-Emeric CS, McConnell E, Pinheiro SO, Corazzini K, Porter K, Earp KM, Landerman L, Beales J, Lipscomb J, Hancock K, Anderson RA. CONNECT for better fall prevention in nursing homes: results from a pilot intervention study. J Am Geriatr Soc. 2013 Dec;61(12):2150-2159. doi: 10.1111/jgs.12550. Epub 2013 Nov 26.

  PMID: 24279686 BACKGROUND

• Anderson RA, Toles MP, Corazzini K, McDaniel RR, Colon-Emeric C. Local interaction strategies and capacity for better care in nursing homes: a multiple case study. BMC Health Serv Res. 2014 Jun 5;14:244. doi: 10.1186/1472-6963-14-244.

  PMID: 24903706 BACKGROUND

• Hall RK, Landerman LR, O'Hare AM, Anderson RA, Colon-Emeric CS. Chronic kidney disease and recurrent falls in nursing home residents: a retrospective cohort study. Geriatr Nurs. 2015 Mar-Apr;36(2):136-41. doi: 10.1016/j.gerinurse.2014.12.012. Epub 2015 Jan 20.

  PMID: 25616732 BACKGROUND

• Marcum ZA, Gurwitz JH, Colon-Emeric C, Hanlon JT. Pills and ills: methodological problems in pharmacological research. J Am Geriatr Soc. 2015 Apr;63(4):829-30. doi: 10.1111/jgs.13371. No abstract available.

  PMID: 25900504 BACKGROUND

• Mewshaw J, Bailey DE Jr, Porter KA, Anderson AL, Anderson RA, Burd AL, Colon-Emeric C, Corazzini KN. A novel program for ABSN students to generate interest in geriatrics and geriatric nursing research. J Nurs Educ Pract. 2017 Jun;7(6):95-99. doi: 10.5430/jnep.v7n6p95. Epub 2017 Feb 5.

  PMID: 28435479 BACKGROUND

• Utley-Smith Q, Colon-Emeric CS, Lekan-Rutledge D, Ammarell N, Bailey D, Corazzini K, Piven ML, Anderson RA. The Nature of Staff - Family Interactions in Nursing Homes: Staff Perceptions. J Aging Stud. 2009 Aug;23(3):168-177. doi: 10.1016/j.jaging.2007.11.003.

  PMID: 19649311 RESULT

• Colon-Emeric CS, Lekan D, Utley-Smith Q, Ammarell N, Bailey D, Corazzini K, Piven ML, Anderson RA. Barriers to and facilitators of clinical practice guideline use in nursing homes. J Am Geriatr Soc. 2007 Sep;55(9):1404-9. doi: 10.1111/j.1532-5415.2007.01297.x.

  PMID: 17767682 RESULT

• Piven ML, Ammarell N, Lekan-Rutledge D, Utley-Smith Q, Corazzini KN, Colon-Emeric CS, Bailey D, Anderson RA. Paying attention: A leap toward quality care. Director. 2007 Winter;15(1):58-60, 62-3. No abstract available.

  PMID: 17710200 RESULT

• Corazzini KN, Lekan-Rutledge D, Utley-Smith Q, Piven ML, Colon-Emeric CS, Bailey D, Ammarell N, Anderson RA. "The Golden Rule": Only a starting point for quality care. Director. 2005;14(1):255-293.

  PMID: 17334452 RESULT

• Utley-Smith Q, Bailey D, Ammarell N, Corazzini K, Colon-Emeric CS, Lekan-Rutledge D, Piven ML, Anderson RA. Exit interview-consultation for research validation and dissemination. West J Nurs Res. 2006 Dec;28(8):955-73. doi: 10.1177/0193945905282301.

  PMID: 17099107 RESULT

• Piven ML, Ammarell N, Bailey D, Corazzini K, Colon-Emeric CS, Lekan-Rutledge D, Utley-Smith Q, Anderson RA. MDS coordinator relationships and nursing home care processes. West J Nurs Res. 2006 Apr;28(3):294-309. doi: 10.1177/0193945905284710.

  PMID: 16585806 RESULT

• Colon-Emeric CS, Ammarell N, Bailey D, Corazzini K, Lekan-Rutledge D, Piven ML, Utley-Smith Q, Anderson RA. Patterns of medical and nursing staff communication in nursing homes: implications and insights from complexity science. Qual Health Res. 2006 Feb;16(2):173-88. doi: 10.1177/1049732305284734.

  PMID: 16394208 RESULT

• Anderson RA, Ammarell N, Bailey D Jr, Colon-Emeric C, Corazzini KN, Lillie M, Piven ML, Utley-Smith Q, McDaniel RR Jr. Nurse assistant mental models, sensemaking, care actions, and consequences for nursing home residents. Qual Health Res. 2005 Oct;15(8):1006-21. doi: 10.1177/1049732305280773.

  PMID: 16221876 RESULT

• Anderson RA, Ammarell N, Bailey DE, Colon-Emeric C, Corazzini K, Lekan-Rutledge D, Piven ML, Utley-Smith Q. The power of relationship for high-quality long-term care. J Nurs Care Qual. 2005 Apr-Jun;20(2):103-6. doi: 10.1097/00001786-200504000-00003. No abstract available.

  PMID: 15839289 RESULT

• Anderson RA, Crabtree BF, Steele DJ, McDaniel RR Jr. Case study research: the view from complexity science. Qual Health Res. 2005 May;15(5):669-85. doi: 10.1177/1049732305275208.

  PMID: 15802542 RESULT

• Colon-Emeric CS, Plowman D, Bailey D, Corazzini K, Utley-Smith Q, Ammarell N, Toles M, Anderson R. Regulation and mindful resident care in nursing homes. Qual Health Res. 2010 Sep;20(9):1283-94. doi: 10.1177/1049732310369337. Epub 2010 May 17.

  PMID: 20479137 RESULT

• Toles M, Anderson RA. State of the science: relationship-oriented management practices in nursing homes. Nurs Outlook. 2011 Jul-Aug;59(4):221-7. doi: 10.1016/j.outlook.2011.05.001.

  PMID: 21757079 RESULT

• Colon-Emeric CS, Pinheiro SO, Anderson RA, Porter K, McConnell E, Corazzini K, Hancock K, Lipscomb J, Beales J, Simpson KM. Connecting the learners: improving uptake of a nursing home educational program by focusing on staff interactions. Gerontologist. 2014 Jun;54(3):446-59. doi: 10.1093/geront/gnt043. Epub 2013 May 23.

  PMID: 23704219 RESULT

• Ausserhofer D, Anderson RA, Colon-Emeric C, Schwendimann R. First evidence on the validity and reliability of the Safety Organizing Scale-Nursing Home version (SOS-NH). J Am Med Dir Assoc. 2013 Aug;14(8):616-22. doi: 10.1016/j.jamda.2013.03.016. Epub 2013 May 14.

  PMID: 23684122 RESULT

• Simpson KM, Porter K, McConnell ES, Colon-Emeric C, Daily KA, Stalzer A, Anderson RA. Tool for evaluating research implementation challenges: a sense-making protocol for addressing implementation challenges in complex research settings. Implement Sci. 2013 Jan 2;8:2. doi: 10.1186/1748-5908-8-2.

  PMID: 23281623 RESULT

• Anderson RA, Corazzini K, Porter K, Daily K, McDaniel RR Jr, Colon-Emeric C. CONNECT for quality: protocol of a cluster randomized controlled trial to improve fall prevention in nursing homes. Implement Sci. 2012 Feb 29;7:11. doi: 10.1186/1748-5908-7-11.

  PMID: 22376375 RESULT

• Colon-Emeric C, Toles M, Cary MP Jr, Batchelor-Murphy M, Yap T, Song Y, Hall R, Anderson A, Burd A, Anderson RA. Sustaining complex interventions in long-term care: a qualitative study of direct care staff and managers. Implement Sci. 2016 Jul 16;11:94. doi: 10.1186/s13012-016-0454-y.

  PMID: 27422011 RESULT

• Colon-Emeric CS, Corazzini K, McConnell E, Pan W, Toles M, Hall R, Batchelor-Murphy M, Yap TL, Anderson AL, Burd A, Anderson RA. Study of Individualization and Bias in Nursing Home Fall Prevention Practices. J Am Geriatr Soc. 2017 Apr;65(4):815-821. doi: 10.1111/jgs.14675. Epub 2017 Feb 10.

  PMID: 28186618 RESULT

• Colon-Emeric CS, Corazzini K, McConnell ES, Pan W, Toles M, Hall R, Cary MP Jr, Batchelor-Murphy M, Yap T, Anderson AL, Burd A, Amarasekara S, Anderson RA. Effect of Promoting High-Quality Staff Interactions on Fall Prevention in Nursing Homes: A Cluster-Randomized Trial. JAMA Intern Med. 2017 Nov 1;177(11):1634-1641. doi: 10.1001/jamainternmed.2017.5073.

  PMID: 28973516 DERIVED

Limitations and Caveats

While randomized, the relatively small number of nursing homes (N = 24) likely resulted in imbalances in facility, staff, and resident-level factors by chance alone. We were limited to one geographic region.

Results Point of Contact

• Title: Ruth A. Anderson
• Organization: University of North Carolina Chapel HIll

rutha@email.unc.edu

919-966-8785

Study Officials

• Ruth A Anderson, RN, PhD

  Duke University School of Nursing

  PRINCIPAL INVESTIGATOR

• Cathleen S Colon-Emeric, MD, MHSc

  Duke University

  PRINCIPAL INVESTIGATOR

Publication Agreements

• PI is Sponsor Employee: No
• Restrictive Agreement: No

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: March 9, 2008
• First Posted: March 14, 2008
• Study Start: September 1, 2009
• Primary Completion: January 1, 2016
• Study Completion: January 1, 2016
• Last Updated: December 11, 2018
• Results First Posted: December 11, 2018

Record last verified: 2018-11

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)