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Age and Ageing Advance Access originally published online on May 5, 2006
Age and Ageing 2006 35(5):520-523; doi:10.1093/ageing/afl020
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© The Author 2006. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Research Letter

Hip protector use amongst older hospital inpatients: compliance and functional consequences

SIR—Hip protectors are special undergarments with protective material inserted over the hip areas that either absorb or deflect the forces transmitted to the hip when a fall on the hip occurs. The effectiveness of hip protector garments in preventing fractured neck of femur injuries is currently unclear [1–3]. Falls are particularly prevalent in the subacute hospital setting, and approximately 2% of in-hospital falls have been found to result in fracture [4]. No randomised controlled trials of hip protectors being deployed as a single intervention in hospitals have demonstrated the effectiveness of this intervention. Such a trial would require potentially prohibitively large numbers to be sufficiently powered to detect an effect. However, owing to the high morbidity, mortality and economic costs of fractures, this setting remains a viable target for hip protector use and research.

A commonly cited problem in hip protector research is reluctance by participants to wear hip protectors [1, 5–13]. Recent studies and reviews have reported a range of contributory factors to reduced compliance with hip protector use, which are intrinsic to the protector (e.g. undergarments not fashionable), extrinsic to the protector (e.g. nurse encouragement to wear the protectors) and patient related (e.g. agitation) [5, 14, 15]. Measures of compliance have varied between studies.

Beyond the primary intended effect of hip protectors, there are many potential secondary effects that require investigation. On the positive side, the use of hip protectors has previously been reported to increase the self-efficacy of community-dwelling women who wear them [16]. On the negative side, however, hip protector use has been associated with skin irritation and abrasion [3, 17], discomfort [18] and even hip fracture [19].


   Methods
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Results
 Discussion
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 Funding
 References
 
Research design
Multiple snapshot cross-sectional survey.

Aims
To evaluate the compliance of patients recommended for the use of hip protectors in wearing them in the subacute setting and to determine whether patients wearing this equipment have greater functional dependency with toileting activities while doing so.

Subjects and setting
Patients included in this evaluation were those participating in the intervention arm of a randomised controlled trial of a multifactorial falls prevention program at the Peter James Centre, a metropolitan subacute hospital in Melbourne, Australia [4].

Intervention
The hip protector intervention consisted of provision of two pairs of SAFEHIP (Abena-Sanicare, Moorabbin, Victoria, Australia) hip protector pants and one pair of removable hip protector shields. Intervention group patients recommended for this intervention were encouraged to wear hip protectors throughout the day and night by nursing staff and an information sheet was provided with the hip protectors. Hip protector garments were washed regularly, and patients who required additional hip protector garments because of incontinence were provided with them to ensure that they were not without a clean pair to be worn.

Measures
Patient’s compliance with wearing hip protectors was recorded through unannounced surveys conducted by the investigator and research physiotherapist every 5 weeks during the study period. The information collected was the following:

  1. Were the hip protectors being worn (at the time of the survey)?
  2. Self-report or nursing staff report of how many hours over the past 24 h had the hip protectors been worn.
  3. If the hip protectors had been removed for 1 h or more over the past 24 h, why were they removed?
  4. If the hip protectors had been removed for 1 h or more over the past 24 h, was there a particular time of day that they were not worn and
  5. What were the nursing staff ratings of patient’s toileting, using the modified Functional Independence Measure (FIM) [20], when the patient was and was not wearing the hip protectors?

The FIM is an ordinal scale measuring burden of care on 18 items, each scored between 1 (fully dependent) and 7 (fully independent with no aids). Only one item (FIM toileting) was assessed and reported for this study.

Procedure
Patients admitted to the subacute wards of the Peter James Centre were approached for participation. Only patients who were randomly allocated to the intervention group and recommended for the hip protector intervention were eligible to be surveyed. Please see Appendix 1 in the supplementary data on the journal website for criteria for recommendation of this intervention (http://www.ageing.oxfordjournals.org). These criteria were listed in the Peter James Centre Falls Risk Assessment Tool, the validity of which has been described elsewhere [21]. Participants may also have received any of the three other interventions (risk alert card, education or exercise) as required.

The survey was administered on five weekdays of the survey week. Survey weeks were conducted every 5 weeks during the randomised controlled trial. During a survey week, every intervention group participant recommended for hip protectors who was currently in the hospital was surveyed. Patients were not made aware of the duration or the timing of surveys so that patient’s awareness of the survey process would have minimal impact on the compliance data recorded [5]. For questions (i)–(iv) of the survey, if the patient was unable to answer the questions (e.g. because of communication impairment), the patient’s primary care nurse was interviewed. The primary care nurse was interviewed for question (v) in all cases.

Ethics
This research was approved by the Human Research Ethics Committee of the Peter James Centre, and all participants provided written informed consent.

Statistical analysis
Please see Appendix 2 in the supplementary data on the journal website (http://www.ageing.oxfordjournals.org).


   Results
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Discussion
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 References
 
A total of 89 (29%) intervention group participants were recommended for the hip protector intervention. The hip protector survey was completed on 203 occasions by 46 individual study participants (maximum of five survey occasions per patient per survey week), with nine participants surveyed during two separate survey weeks. The hip protectors were being worn at the time of the survey on 57% of occasions (115 of 203 survey occasions). The surveyed patient had worn the hip protectors for ≥12 h over the preceding 24 h on 57% of occasions (115 of 203 survey occasions), whereas they were worn for all 24 h on 18% of occasions (37 of 203 survey occasions) and not at all on 42% of occasions (86 of 203 survey occasions). Hip protectors were not worn at night on 82% of occasions (166 of 203 survey occasions). Please see Appendix 3 in the supplementary data on the journal website (http://www.ageing.oxfordjournals.org) for reasons provided for patients not wearing hip protectors.

Modified FIM scores were recorded for 36 patients (using first survey occasions only) as the toileting assessment, whereas wearing hip protectors could not be assessed on people who refused to wear the hip protectors. The median (inter-quartile range) score for FIM toileting scores when not wearing hip protectors was 4.5 (3–6). When wearing hip protectors, the median FIM toileting score was 4 (3–6). There was a reduction by one modified FIM score level in 10 patients and by two levels in one patient. This difference was significant (Signed rank test: P = 0.001).

Those who had the survey completed had a longer length of stay and were more likely to have had a stroke precipitate admission (Table 1, P < 0.05).


View this table:
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  		Table 1.. Characteristics of patients in the intervention group recommendation for the hip protectors (at some point during inpatient stay) and separated by those who were recommended but were not surveyed and those who were surveyed (one or more times)

 


   Discussion
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This investigation indicates that compliance with hip protector use by subacute hospital inpatients is consistent with the reported compliance rates from recent reviews of this area over a number of settings [1, 5]. Most patients were reluctant to wear hip protectors at night, with several reasons identified for not wearing the hip protectors, such as primarily discomfort, immobility at night time and incontinence. Also, the use of hip protectors was associated with increased functional dependency in this patient group when completing toileting activities. This may mean that higher level of staff assistance is required for some patients with hip protectors in toileting tasks.

The method of collecting compliance data in this investigation could be criticised because not all eligible patients were surveyed; some were surveyed twice, and of those who were surveyed, the survey was conducted at different times since study entry. However, the pragmatic nature of the clinical trial within which this investigation was nested made it difficult to use alternate approaches. The use of diaries can potentially influence compliance with hip protectors [5] and as such may not produce a valid reflection of compliance in the ‘real world’. Participants who were surveyed twice were so done because their period of recommendation for hip protectors while in hospital overlapped two survey periods. Thus, the compliance of participants with longer lengths of stay may have been over-represented by the surveying strategy. This study also did not investigate ‘initial acceptance’ [5, 22] of hip protectors or whether hip protectors were being worn at the time of participant falls.

This research indicates that the use of hip protectors could potentially be successfully integrated into routine hospital care; however, more work is required to establish a means for promoting compliance (particularly at night), to identify staff-time costs and to identify the clinical effectiveness of this intervention in the hospital setting. Research investigating whether the patients at highest risk of injurious falls are more or less likely to wear the protectors and whether hip protectors are in place at the time of falls is warranted.


   Key points
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  • Approximately half of the patients at high risk of falls wore hip protectors for at least 12 h per day.
  • Hip protector use was associated with reduced patient independence with going to the toilet.
  • Hip protectors were rarely worn at night, and several patients reported that the hip protectors were uncomfortable to wear in bed.


   Funding
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This research was funded by the Victorian Department of Human Services (Aged Care Division), and hip protectors were provided at a discounted purchase price by Abena-Sanicare Pty. Neither party had any role in the design, execution, analysis and interpretation of data or writing of the study.

Terry P. Haines1,*, Keith D. Hill2, Kim L. Bennell3 and Richard H. Osborne3

1 School of Health and Rehabilitation Sciences, The University of Queensland and Princess Alexandra Hospital, Woolloongabba, Queensland, Australia Email: terrence_haines{at}health.qld.gov.au
2 National Ageing Research Institute, Public Health Division, Parkville, Victoria, Australia
3 The University of Melbourne, Centre for Health Exercise and Sports Medicine, AFV Centre for Rheumatic Disease, Parkville, Victoria, Australia

* To whom correspondence should be addressed


   References
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 Funding
 References
 

  1. Parker J, Gillespie L, Gillespie W. Hip protectors for preventing hip fractures in the elderly (Cochrane Review). Chichester, UK: John Wiley & Sons Ltd, 2005.
  2. O’Halloran PD, Cran GW, Beringer TR et al. A cluster randomised controlled trial to evaluate a policy of making hip protectors available to residents of nursing homes. Age Ageing 2004; 33: 582–8.[Abstract/Free Full Text]
  3. Kannus P, Parkkari J, Niemi S et al. Prevention of hip fracture in elderly people with use of a hip protector. N Engl J Med 2000; 343: 1506–13.[Abstract/Free Full Text]
  4. Haines T, Bennell K, Osborne R, Hill K. Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial. Br Med J 2004; 328: 676–9.[Abstract/Free Full Text]
  5. van Schoor N, Deville W, Bouter L, Lips P. Acceptance and compliance with external hip protectors: a systematic review of the literature. Osteoporosis Int 2002; 13: 917–24.[CrossRef][Web of Science][Medline]
  6. Cameron ID, Quine S. External hip protectors: likely non-compliance among high risk elderly people living in the community. Arch Gerontol Geriatr 1994; 19: 273–81.[CrossRef][Web of Science][Medline]
  7. Chan DK, Hillier G, Coore M et al. Effectiveness and acceptability of a newly designed hip protector: a pilot study. Arch Gerontol Geriatr 2000; 30: 25–34.[CrossRef][Web of Science][Medline]
  8. Fan CW, Tan KM, Coakley D, Walsh JB. Compliance of external hip protector use amongst elderly day hospital attenders. Ir J Med Sci 2005; 174: 49–54.[Web of Science][Medline]
  9. Hopper A, Oliver D, Parsons M. Compliance with hip protectors in patients discharged with a community rehabilitation team. Age Ageing 1999; 28: S85.
  10. Kurrle SE, Cameron ID, Quine S. Predictors of adherence with the recommended use of hip protectors. J Gerontol 2004; 59: M958–61.[Web of Science]
  11. McAughey J, McAdoo M. Acceptability of hip protectors was 35% at six months in the community. Br Med J 2002; 324: 1454.[CrossRef][Medline]
  12. Thompson P, Jones C, Villar T. Rate of adherence is 42% at three months in residential homes. Br Med J 2002; 324: 1454.[CrossRef][Web of Science][Medline]
  13. Tracey M, Villar A, Hill P, Inskip H, Thompson P, Cooper C. Will elderly rest home residents wear hip protectors? Age Ageing 1998; 27: 195–8.[Abstract/Free Full Text]
  14. Jantti PO, Aho HJ, Maki-Jokela PL, Heikinheimo RJ. Hip protectors and hip fractures. Age Ageing 1998; 27: 758–9.[Free Full Text]
  15. Harada A, Mizuno M, Takemura M, Tokuda H, Okuizumi H, Niino N. Hip fracture prevention trial using hip protectors in Japanese nursing homes. Osteoporos Int 2001; 12: 215–21.[CrossRef][Web of Science][Medline]
  16. Cameron ID, Stafford B, Cumming RG et al. Hip protectors improve falls self-efficacy. Age Ageing 2000; 29: 57–62.[Abstract/Free Full Text]
  17. Ekman A, Mallmin H, Michaelsson K, Ljunghall S. External hip protectors to prevent osteoporotic hip fractures. Lancet 1997; 350: 563–4.[Web of Science][Medline]
  18. Woo J, Sum C, Chung L, Ho L. Efficacy of a specially designed hip protector for hip fracture prevention and compliance with use in elderly Hong Kong Chinese. Clin Rehabil 2003; 17: 203–5.[Abstract/Free Full Text]
  19. Cameron I, Kurrle S. External hip protectors. J Am Geriatr Soc 1997; 45: 1158.[Web of Science][Medline]
  20. Linacre J, Heinemann A, Wright B, Granger C, Hamilton B. The structure and stability of the Functional Independence Measure. Arch Phys Med Rehabil 1994; 75: 127–32.[Web of Science][Medline]
  21. Haines T, Bennell K, Osborne R, Hill K. A new instrument for targeting falls prevention interventions was accurate and clinically applicable in a hospital setting. J Clin Epidemiol 2005; 59: 168–75.[CrossRef][Web of Science]
  22. Cryer C, Knox A, Stevenson E. Factors associated with the initial acceptance of hip protectors amongst older people in residential care. Age Ageing 2006; 35: 72–84.[Free Full Text]

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