Background: Injurious falls in hospitals and care homes are a life-limiting and costly international issue. Shock-absorbing flooring may offer part of the solution; however, evidence is required to inform decision-making.
Objectives: The objectives were to assess the clinical effectiveness and cost-effectiveness of shock-absorbing flooring for fall-related injury prevention among older adults in care settings.
Review methods: A systematic review was conducted of experimental, observational, qualitative and economic studies evaluating flooring in care settings targeting older adults and/or staff. Studies identified by a scoping review (inception to May 2016) were screened, and the search of MEDLINE, AgeLine and Scopus (to September 2019) was updated, alongside other sources. Two independent reviewers assessed risk of bias in duplicate (using Cochrane's Risk of Bias 2.0 tool, the Risk Of Bias In Non-randomized Studies - of Interventions tool, or the Joanna Briggs Institute's qualitative tool).
Results: Of the 22 included studies, 20 assessed the outcomes (three randomised controlled trials; and seven observational, five qualitative and five economic studies) on novel floors (n = 12), sports floors (n = 5), carpet (n = 5) and wooden subfloors (n = 1). Quantitative data related to 11,857 patient/resident falls (nine studies) and 163 staff injuries (one study). Qualitative studies included patients/residents (n = 20), visitors (n = 8) and staff (n = 119). Hospital-based randomised controlled trial data were too imprecise; however, very low-quality evidence indicated that novel/sports flooring reduced injurious falls from three per 1000 patients per day on vinyl with concrete subfloors to two per 1000 patients per day (rate ratio 0.55, 95% confidence interval 0.36 to 0.84; two studies), without increasing falls rates (two studies). One care home-based randomised controlled trial found that a novel underlay produces similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to those of a plywood underlay with vinyl overlays and concrete subfloors. Very low-quality data demonstrated that, compared with rigid floors, novel/sports flooring reduced the number of falls resulting in injury in care homes (26.4% vs. 33.0%; risk ratio 0.80, 95% confidence interval 0.70 to 0.91; three studies) and hospitals (27.1% vs. 42.4%; risk ratio 0.64, 95% confidence interval 0.44 to 0.93; two studies). Fracture and head injury outcomes were imprecise; however, hip fractures reduced from 30 per 1000 falls on concrete to 18 per 1000 falls on wooden subfloors in care homes (odds ratio 0.59, 95% confidence interval 0.45 to 0.78; one study; very low-quality evidence). Four low-quality economic studies concluded that shock-absorbing flooring reduced costs and improved outcomes (three studies), or increased costs and improved outcomes (one study). One, more robust, study estimated that shock-absorbing flooring resulted in fewer quality-adjusted life-years and lower costs, if the number of falls increased on shock-absorbing floors, but that shock-absorbing flooring would be a dominant economic strategy if the number of falls remained the same. Staff found moving wheeled equipment more difficult on shock-absorbing floors, leading to workplace adaptations. Staff injuries were observed; however, very low-quality evidence suggests that these are no less frequent on rigid floors.
Limitations: Evidence favouring shock-absorbing flooring is of very low quality; thus, much uncertainty remains.
Conclusions: Robust evidence is lacking in hospitals and indicates that one novel floor may not be effective in care homes. Very low-quality evidence indicates that shock-absorbing floors may be beneficial; however, wider workplace implications need to be addressed. Work is required to establish a core outcome set, and future research needs to more comprehensively deal with confounding and the paucity of hospital-based studies, and better plan for workplace adaptations in the study design.
Study registration: This study is registered as PROSPERO CRD42019118834.
Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 5. See the NIHR Journals Library website for further project information.
Keywords: ACCIDENTAL FALLS; FLOORS AND FLOOR COVERINGS; FRACTURES, BONE; HOSPITALS; LONG-TERM CARE.
Aim: The aim of this study was to summarise what is known about shock-absorbing flooring for reducing injurious falls in hospitals and care homes.
Background: Falls and fall-related injuries are a major problem for older adults in both hospitals and care homes. Shock-absorbing flooring (such as carpet, sports floors or specially designed floors) provides a more cushioned surface and is one potential solution to help reduce the impact forces from a fall.
Methods: From literature searches, we identified relevant studies on shock-absorbing flooring use in hospitals and care homes. We gathered data on the quality of the studies’ methods, what and who the studies involved, and the study findings. Members of the public were involved throughout the project. They helped improve the clarity of the reporting and collaborated in meetings to help guide the study team.
Findings: One high-quality study in a care home found that vinyl overlay with novel shock-absorbing underlay was no better at reducing injuries than vinyl overlay with plywood underlay on concrete subfloors. We found very low-quality evidence that shock-absorbing flooring may reduce injuries in hospitals and care homes, without increasing falls; if this were true, then economic evidence suggested that shock-absorbing flooring would be the best-value option for patients (lower cost and improved outcomes). There was insufficient evidence to determine the effects of shock-absorbing flooring on fractures or head injuries, although wooden subfloors resulted in fewer hip fractures than concrete subfloors. Shock-absorbing flooring made it harder for staff to move equipment such as beds and trolleys, and led to staff changing how they work.
Implications: The evidence suggests that one type of shock-absorbing floor may not work in care homes, compared with rigid flooring; however, gaps still exist in the knowledge. The evidence in favour of shock-absorbing flooring was of very low quality, meaning it is uncertain. There is a lack of robust evidence in hospitals, which often have concrete subfloors and different population characteristics. If planning to install shock-absorbing flooring, it is important to consider the wider impacts on the workplace and how best to manage these.