Shock-absorbing flooring for fall-related injury prevention in older adults and staff in hospitals and care homes: the SAFEST systematic review

Abstract

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.

Shock-absorbing effect of flooring-adopted mechanical metamaterial technology and its influence on the gait and balance of older adults

“…According to the Shock-Absorbing Flooring Effectiveness SysTematic (SAFEST) review, some studies found shock-absorbent floors to dominate standard floors, which indicate lower costs and better outcomes. One study estimated that shock-absorbing floors increased both the cost and quality-adjusted life year; however, the quality of these studies is not high 25. The shock-absorbing flooring interventions have the potential to be cost-effective compared with standard flooring, while further research is required to determine whether shock-absorbing flooring is likely to increase the fall rate 26.…”

“…One study estimated that shock-absorbing floors increased both the cost and quality-adjusted life year; however, the quality of these studies is not high. 25 The shock-absorbing flooring interventions have the potential to be cost-effective compared with standard flooring, while further research is required to determine whether shock-absorbing flooring is likely to increase the fall rate. 26 Since reliable shock-absorbing performance and ease of mass production are important in terms of cost, the MM-flooring has a manufacturing style that is relatively easy to mass produce since the cushioning material is made of elastomer and manufactured in units of 500×500 mm area.…”

Compliant sports floors and fall-related injuries: evidence from a residential care setting and updated meta-analysis for all patient care settings

“…Adding our estimates to a recent meta-analysis that compared the effectiveness of sports floors with that of novel shockabsorbing floors, 19 the combined state of the clinical evidence suggests that compliant floors can reduce the risk of injury.…”

“…Thus, they may provide similar injury-reducing effects at a lower cost, which has important implications for practice. However, the meta-analysis only contained two small-scale evaluations of sports floors, 19…”

“…Sports floors with some compliant qualities (eg, 8.3 mm thick Tarkett Omnisports Excel) are cheaper alternatives 15 that—according to a recent systematic review and meta-analysis of compliant flooring interventions 19 —may have comparable clinical effectiveness. Thus, they may provide similar injury-reducing effects at a lower cost, which has important implications for practice.…”