Journal of Nursing Management, 2015, 23, 910–919
Improving falls risk screening and prevention using an e-learning approach MAREE JOHNSON R N , B A p p s S c i , M A p p S c i , P h D 1,2, LINDA KELLY R N , M N ( E d ) , D i p A p p S c i ( N u r s i n g ) 3, KATICA SIRIC R N , B N u r s , G D i p A c u t e C a r e , M C l i n L e a & C l i n S u p 4, DUONG THUY TRAN M I P H 5 and BRONWYN OVERS BPsych (Hons)
6
1
Professor, School of Nursing and Midwifery, University of Western Sydney, 2Director, Centre for Applied Nursing Research, South Western Sydney Local Health District, University of Western Sydney (Affiliated with the Ingham Institute, Liverpool NSW), Liverpool, 3Nurse Educator, Centre for Education and Workforce Development, Rozelle, 4Acting Patient Safety Co-ordinator, Concord Repatriation General Hospital, Sydney Local Health District, Sydney, 5Research Fellow, Centre for Health Research, School of Medicine, University of Western Sydney, Penrith, and 6Research Assistant, Mental Health Centre (Level 1), Faculty of Medicine, School of Psychiatry, Liverpool Hospital, Infant Child Adolescent Mental Health Service (ICAMHS) Research, University of New South Wales, Liverpool, NSW, Australia
Correspondence Maree Johnson School of Nursing and Midwifery University of Western Sydney and Centre for Applied Nursing Research South Western Sydney Local Health District & University of Western Sydney Locked Bag 7103 c/- 1 Campbell Street Liverpool 2170 NSW Australia E-mail: [email protected]
JOHNSON M., KELLY L., SIRIC K., TRAN D.T., OVERS B.
(2015) Journal of Nursing Management 23, 910–919. Improving falls risk screening and prevention using an e-learning approach Aim This study investigated the impact of an e-learning education programme for nurses on falls risk screening, falls prevention and post-falls management. Background Falls injury within older inpatients is a major patient safety concern. Method Using a pre–post design, observation of the patient and environment and patient health care record audits, were conducted following the introduction of a falls e-learning education programme. Results Audits of patient health care records (using the Falls Chart Audit Tool), together with observation of practice for 119 (pre) and 99 (post) patients, were undertaken. Initial risk screening was conducted using the Modified Ontario Stratify Scale for most patients (95%). Interventions such as a falls risk flag in the records/on beds, supervision when the patient is mobilising or in the bathroom, area clear of hazards, use of chair/bed alarms, and referral to allied health staff were significantly improved. Conclusions Initial risk screening of patients and improvements in preventive interventions were demonstrated. Implications for nursing management This falls e-learning programme represents a cost-effective method of increasing falls mitigation strategies within large organisations. The Falls Chart Audit Tool provides a valuable monitoring tool for managers. Falls risk screening when the patient’s condition changes, requires vigilance by managers or reminders within clinical information systems. Keywords: audit, education, falls, learning, nurses
Accepted for publication: 10 February 2014
Introduction Falls prevention and management is an ever-increasing priority for all health professionals (Myers 2003). A 910
fall is defined as ‘an event which results in a person coming to rest inadvertently on the ground, or floor or at a lower level’ (Reinsch et al. 1992, p. 5). A fall includes when a person inadvertently comes to rest on DOI: 10.1111/jonm.12234 ª 2014 John Wiley & Sons Ltd
Falls prevention education program
furniture, against a wall or other objects (Sydney South West Area Health Service 2009). Accidental falls in hospitals were the most frequently reported adverse events (21%) (NSW Department of Health & the Clinical Excellence Commission 2009) with the rates ranging from 2.2 falls per 1000 patient days in general acute medical wards to 20 falls per 1000 patient days in long-term care and rehabilitation units (Coussement et al. 2008, Hill et al. 2009). In Australia, hospitalisations due to falls in people aged 65 years and over increased by 10% between 2003/04 and 2005/06 (Bradley & Pointer 2009). In the United Kingdom, a large retrospective study found the mean standardised rate of falls of 4.8 per 1000 bed days in acute hospitals (Healy et al. 2008). The health and financial consequences of falls among inpatients are substantial, including increased mortality and morbidity, delayed recovery from hospitalisation, poorer health outcomes, increased length of stay and usage of health resources, and a higher risk of premature institutionalisation (Rubenstein 2006, Oliver et al. 2007, Bradley & Pointer 2009, Hill et al. 2009). Estimates of medical costs in 2000 for fatal and non-fatal falls within the United States of America were ‘$0.2 billion dollars for fatal and $19 billion dollars for non-fatal injuries; 63% ($12 billion) for hospitalisations, 21% ($4 billion) for emergency department visits, and 16% ($3 billion) on treatment in outpatient settings’ (Stevens et al. 2006, p. 290). It has been estimated that, given Australia’s ageing population and the current fall incidence, the falls related injuries and health costs in 2051 will increase by three times to $1375 million per year (Australian Council for Safety & Quality in Health Care 2009). The introduction of a state-wide policy on falls within our local health district prompted us to provide education to nurses and to undertake a falls audit of current practices within facilities with higher rates of falls.
Falls prevention interventions Knowledge of falls risk factors is increasing (Pynoos et al. 2006, Rubenstein 2006). In the past two decades, numerous research studies targeting falls reduction and prevention using various study designs and interventions (both single and multifactorial) have been conducted (Rubenstein 2006, Oliver et al. 2007, Gates et al. 2008, Australian Council for Safety & Quality in Health Care 2009, Hill et al. 2009). Recommended strategies for falls prevention include, but are not limited to, risk factor assessment followed by ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 910–919
interventions targeted at each identified risk factor, patient exercise, patient education, pharmaceutical supplementation and medication review and/or adjustment, use of hip protector, fall alarm devices and environmental modification (Rubenstein 2006, Oliver et al. 2007). However, falls prevention studies have revealed inconsistent evidence of effectiveness. For inpatients or institutionalised persons, a number of systematic reviews found limited effects of falls interventions on the rates of falls or fallers (Oliver et al. 2007, Coussement et al. 2008, Stern & Jayasekara 2009). For community-dwelling people, a number of meta-analyses found some effectiveness of fall prevention programmes: 10% reduction of falling risk (Chang et al. 2004). Hill-Westmoreland et al. (2002) have reported a 4% reduction of the fall rate and Campbell and Robertson (2007) as high as a 27% decrease of the fall rate. Exercise programmes for older people in the community could reduce falls by 17% (Sherrington et al. 2008). However, a recent systematic review reported limited effects of fall prevention (Gates et al. 2008). Nevertheless, interpreting these findings requires caution due to methodological variations among review studies. Some reviews included only randomised controlled trials (Chang et al. 2004, Costello & Edelstein 2008, Stern & Jayasekara 2009) but some included study designs of lower levels of evidence such as quasiexperimental designs, case control or observational cohort studies (Hill-Westmoreland et al. 2002, Oliver et al. 2007, Coussement et al. 2008, Gates et al. 2008). The common issues raised by these systematic reviews and meta-analyses were the great variability in the components of interventions, heterogeneity of methodological quality and study populations, and insufficient data on fall rates and injuries (Oliver et al. 2007, Gates et al. 2008). Ward-based falls prevention by nursing staff and structured multifactorial interventions were recommended as potentially effective fall prevention strategies in hospital settings (Lightbody et al. 2002, Oliver et al. 2007, Cumming et al. 2008, Stern & Jayasekara 2009).
Nurses and falls preventions Patient safety is fundamental to quality nursing care and should be addressed in all aspects of care (International Council of Nurses 2002). Nurses, as frontline health professionals, play a critical role in promoting patient safety and preventing falls in particular. Nursing interventions should include identification of patients at risk of falls, a detailed nursing care plan, and implementation and evaluation of falls prevention 911
M. Johnson et al.
strategies. An earlier study demonstrated no clear relationship between nursing assessment of patient’s fall risk and communicating risk, and planning tailored interventions (Dykes et al. 2009). Although the education of nurses does occur as part of multidisciplinary approaches (Stenvall et al. 2007, Banez et al. 2008), we were unable to locate specific education programmes focusing on nurses and changes in falls risk assessment and preventative interventions. The documentation of nursing interventions relating to falls is central to ensuring continuity of the interventions as well as providing evidence of care being delivered. One study conducted in Singapore found documentation of toileting rounds in 60% of records of non-fallers and 76% in fallers and documentation of environmental modifications in 84% for non-fallers and 92% for fallers (Koh et al. 2007). Although specific interventions were not explored these results inform this study which will examine documentation of interventions. Finally, Dykes et al. (2009) suggested that the patient and family should be involved as an active member in the fall prevention team. The need for family involvement is consistent with the findings of a study (Johnson et al. 2011), which revealed that in a majority of falls incidents reported to the Incident Information Management System (IIMS) nurses were not physically present when the patients fell. An increase in patient and family involvement in falls prevention was recommended (Johnson et al. 2011).
Context of the falls prevention The current falls rates across our local health services ranged from 2 to 11 per 1000 occupied bed days (2009–2011). The Falls Policy of Sydney South West Area Health Service (2009) was introduced into all health facilities to minimise falls incidents. This policy required initial screening for patient fall risk factors using the Modified Ontario Stratify Scale (Oliver et al. 1997, Papaioannou et al. 2004) by nurses, and the management of the identified fall risk factors using a protocol designed by the Clinical Excellence Commission (2012) and the Best Practice Guidelines for Falls Prevention (Australian Council for Safety & Quality in HealthCare 2009). To assist nurses to engage with the Falls Policy directions in terms of falls prevention and management and post-fall management, nurse educators and researchers worked together to develop an on-line e-learning education programme (Johnson et al. 2012) and a supporting Falls Management Flip Chart. The effectiveness of the education programme and the Falls Management Flip Chart on nurses’ 912
knowledge, self-reported behaviours in relation to falls management, and falls incidents has been reported elsewhere (Johnson et al. 2014) and complements these findings. This paper reports on the changes effected by the education programme and support material (Falls Management Flip Chart) on nursing practice in screening and assessment for fall risks, implementation of falls prevention strategies and postfall management of patients.
Method This study used a pre–post test design within two hospitals and was undertaken between February 2010 and December 2011. A review of the patient health care records using an audit tool (Appendix S1), in addition to the observation of the patient and environment and nursing activities, was completed prior to nurses undertaking an on-line education programme. This study was approved by the Human Research and Ethics Committee of the Concord Repatriation General Hospital, South Western Sydney Area Health Service, as a quality assurance project approval No. CH62/6/2010-054.
Sample and setting Two subacute metropolitan Sydney hospitals specialising predominantly in aged care, one with 92 inpatient beds (four wards) (hospital 1) and another 96 bed hospital (one ward 36 beds) (hospital 2), participated in the study. Each hospital was selected for the presence of a high intake of elderly patients (65 years or older) and a high rate of falls per occupied bed days (>4 per 1000 occupied bed days). Participating wards employed varying categories of staff including registered and enrolled nurses and assistants-in-nursing (AIN) with limited staff turnover. The proportion of staff within the varying categories differed between the two hospitals; 47% registered nurses (RNs), 20% enrolled nurses (ENs), 29% AINs (hospital 1, n = 63); 65% RNs, 27% enrolled nurses, 8% AINs (hospital 2, n = 37). Different patients and patient health care records were included in the pre-test and post-test due to the length of time between the data collection points. The participating wards used the Modified Ontario Stratify Scale (hereafter referred to as the STRATIFY) with Sydney scoring (Oliver et al. 1997, Papaioannou et al. 2004) to screen the admitted patients for falls risks. The falls risk is considered to be low if the STRATIFY score is between 0 and 5, medium (6–16) and high (17–30) (Hunter New England Area Health ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 910–919
Falls prevention education program
Service 2012). The falls risk score is related to the subsequent falls management approach. For one hospital a random selection (using a random numbers chart) of 60 patients (and their records) (out of 92) was chosen, while in the second hospital (36 bed ward) all patients and their related records (65 years or older) admitted to the ward throughout the data collection period were included until a total of 60 patients was achieved. Sixty records were selected to adequately measure likely differences in a timely manner. For the second hospital there was a proportion of patients aged 7 days
Pre n = 111, %
Post n = 89, %
v2
P
95.80 85.71
94.95 83.84
0.09 0.15
0.51 0.70
94.12
89.90
1.34
0.25
58.82
70.71
3.32
0.07
1.68
10.10
7.37
0.01
36.13
62.63
15.19
Improving falls risk screening and prevention using an e-learning approach MAREE JOHNSON R N , B A p p s S c i , M A p p S c i , P h D 1,2, LINDA KELLY R N , M N ( E d ) , D i p A p p S c i ( N u r s i n g ) 3, KATICA SIRIC R N , B N u r s , G D i p A c u t e C a r e , M C l i n L e a & C l i n S u p 4, DUONG THUY TRAN M I P H 5 and BRONWYN OVERS BPsych (Hons)
6
1
Professor, School of Nursing and Midwifery, University of Western Sydney, 2Director, Centre for Applied Nursing Research, South Western Sydney Local Health District, University of Western Sydney (Affiliated with the Ingham Institute, Liverpool NSW), Liverpool, 3Nurse Educator, Centre for Education and Workforce Development, Rozelle, 4Acting Patient Safety Co-ordinator, Concord Repatriation General Hospital, Sydney Local Health District, Sydney, 5Research Fellow, Centre for Health Research, School of Medicine, University of Western Sydney, Penrith, and 6Research Assistant, Mental Health Centre (Level 1), Faculty of Medicine, School of Psychiatry, Liverpool Hospital, Infant Child Adolescent Mental Health Service (ICAMHS) Research, University of New South Wales, Liverpool, NSW, Australia
Correspondence Maree Johnson School of Nursing and Midwifery University of Western Sydney and Centre for Applied Nursing Research South Western Sydney Local Health District & University of Western Sydney Locked Bag 7103 c/- 1 Campbell Street Liverpool 2170 NSW Australia E-mail: [email protected]
JOHNSON M., KELLY L., SIRIC K., TRAN D.T., OVERS B.
(2015) Journal of Nursing Management 23, 910–919. Improving falls risk screening and prevention using an e-learning approach Aim This study investigated the impact of an e-learning education programme for nurses on falls risk screening, falls prevention and post-falls management. Background Falls injury within older inpatients is a major patient safety concern. Method Using a pre–post design, observation of the patient and environment and patient health care record audits, were conducted following the introduction of a falls e-learning education programme. Results Audits of patient health care records (using the Falls Chart Audit Tool), together with observation of practice for 119 (pre) and 99 (post) patients, were undertaken. Initial risk screening was conducted using the Modified Ontario Stratify Scale for most patients (95%). Interventions such as a falls risk flag in the records/on beds, supervision when the patient is mobilising or in the bathroom, area clear of hazards, use of chair/bed alarms, and referral to allied health staff were significantly improved. Conclusions Initial risk screening of patients and improvements in preventive interventions were demonstrated. Implications for nursing management This falls e-learning programme represents a cost-effective method of increasing falls mitigation strategies within large organisations. The Falls Chart Audit Tool provides a valuable monitoring tool for managers. Falls risk screening when the patient’s condition changes, requires vigilance by managers or reminders within clinical information systems. Keywords: audit, education, falls, learning, nurses
Accepted for publication: 10 February 2014
Introduction Falls prevention and management is an ever-increasing priority for all health professionals (Myers 2003). A 910
fall is defined as ‘an event which results in a person coming to rest inadvertently on the ground, or floor or at a lower level’ (Reinsch et al. 1992, p. 5). A fall includes when a person inadvertently comes to rest on DOI: 10.1111/jonm.12234 ª 2014 John Wiley & Sons Ltd
Falls prevention education program
furniture, against a wall or other objects (Sydney South West Area Health Service 2009). Accidental falls in hospitals were the most frequently reported adverse events (21%) (NSW Department of Health & the Clinical Excellence Commission 2009) with the rates ranging from 2.2 falls per 1000 patient days in general acute medical wards to 20 falls per 1000 patient days in long-term care and rehabilitation units (Coussement et al. 2008, Hill et al. 2009). In Australia, hospitalisations due to falls in people aged 65 years and over increased by 10% between 2003/04 and 2005/06 (Bradley & Pointer 2009). In the United Kingdom, a large retrospective study found the mean standardised rate of falls of 4.8 per 1000 bed days in acute hospitals (Healy et al. 2008). The health and financial consequences of falls among inpatients are substantial, including increased mortality and morbidity, delayed recovery from hospitalisation, poorer health outcomes, increased length of stay and usage of health resources, and a higher risk of premature institutionalisation (Rubenstein 2006, Oliver et al. 2007, Bradley & Pointer 2009, Hill et al. 2009). Estimates of medical costs in 2000 for fatal and non-fatal falls within the United States of America were ‘$0.2 billion dollars for fatal and $19 billion dollars for non-fatal injuries; 63% ($12 billion) for hospitalisations, 21% ($4 billion) for emergency department visits, and 16% ($3 billion) on treatment in outpatient settings’ (Stevens et al. 2006, p. 290). It has been estimated that, given Australia’s ageing population and the current fall incidence, the falls related injuries and health costs in 2051 will increase by three times to $1375 million per year (Australian Council for Safety & Quality in Health Care 2009). The introduction of a state-wide policy on falls within our local health district prompted us to provide education to nurses and to undertake a falls audit of current practices within facilities with higher rates of falls.
Falls prevention interventions Knowledge of falls risk factors is increasing (Pynoos et al. 2006, Rubenstein 2006). In the past two decades, numerous research studies targeting falls reduction and prevention using various study designs and interventions (both single and multifactorial) have been conducted (Rubenstein 2006, Oliver et al. 2007, Gates et al. 2008, Australian Council for Safety & Quality in Health Care 2009, Hill et al. 2009). Recommended strategies for falls prevention include, but are not limited to, risk factor assessment followed by ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 910–919
interventions targeted at each identified risk factor, patient exercise, patient education, pharmaceutical supplementation and medication review and/or adjustment, use of hip protector, fall alarm devices and environmental modification (Rubenstein 2006, Oliver et al. 2007). However, falls prevention studies have revealed inconsistent evidence of effectiveness. For inpatients or institutionalised persons, a number of systematic reviews found limited effects of falls interventions on the rates of falls or fallers (Oliver et al. 2007, Coussement et al. 2008, Stern & Jayasekara 2009). For community-dwelling people, a number of meta-analyses found some effectiveness of fall prevention programmes: 10% reduction of falling risk (Chang et al. 2004). Hill-Westmoreland et al. (2002) have reported a 4% reduction of the fall rate and Campbell and Robertson (2007) as high as a 27% decrease of the fall rate. Exercise programmes for older people in the community could reduce falls by 17% (Sherrington et al. 2008). However, a recent systematic review reported limited effects of fall prevention (Gates et al. 2008). Nevertheless, interpreting these findings requires caution due to methodological variations among review studies. Some reviews included only randomised controlled trials (Chang et al. 2004, Costello & Edelstein 2008, Stern & Jayasekara 2009) but some included study designs of lower levels of evidence such as quasiexperimental designs, case control or observational cohort studies (Hill-Westmoreland et al. 2002, Oliver et al. 2007, Coussement et al. 2008, Gates et al. 2008). The common issues raised by these systematic reviews and meta-analyses were the great variability in the components of interventions, heterogeneity of methodological quality and study populations, and insufficient data on fall rates and injuries (Oliver et al. 2007, Gates et al. 2008). Ward-based falls prevention by nursing staff and structured multifactorial interventions were recommended as potentially effective fall prevention strategies in hospital settings (Lightbody et al. 2002, Oliver et al. 2007, Cumming et al. 2008, Stern & Jayasekara 2009).
Nurses and falls preventions Patient safety is fundamental to quality nursing care and should be addressed in all aspects of care (International Council of Nurses 2002). Nurses, as frontline health professionals, play a critical role in promoting patient safety and preventing falls in particular. Nursing interventions should include identification of patients at risk of falls, a detailed nursing care plan, and implementation and evaluation of falls prevention 911
M. Johnson et al.
strategies. An earlier study demonstrated no clear relationship between nursing assessment of patient’s fall risk and communicating risk, and planning tailored interventions (Dykes et al. 2009). Although the education of nurses does occur as part of multidisciplinary approaches (Stenvall et al. 2007, Banez et al. 2008), we were unable to locate specific education programmes focusing on nurses and changes in falls risk assessment and preventative interventions. The documentation of nursing interventions relating to falls is central to ensuring continuity of the interventions as well as providing evidence of care being delivered. One study conducted in Singapore found documentation of toileting rounds in 60% of records of non-fallers and 76% in fallers and documentation of environmental modifications in 84% for non-fallers and 92% for fallers (Koh et al. 2007). Although specific interventions were not explored these results inform this study which will examine documentation of interventions. Finally, Dykes et al. (2009) suggested that the patient and family should be involved as an active member in the fall prevention team. The need for family involvement is consistent with the findings of a study (Johnson et al. 2011), which revealed that in a majority of falls incidents reported to the Incident Information Management System (IIMS) nurses were not physically present when the patients fell. An increase in patient and family involvement in falls prevention was recommended (Johnson et al. 2011).
Context of the falls prevention The current falls rates across our local health services ranged from 2 to 11 per 1000 occupied bed days (2009–2011). The Falls Policy of Sydney South West Area Health Service (2009) was introduced into all health facilities to minimise falls incidents. This policy required initial screening for patient fall risk factors using the Modified Ontario Stratify Scale (Oliver et al. 1997, Papaioannou et al. 2004) by nurses, and the management of the identified fall risk factors using a protocol designed by the Clinical Excellence Commission (2012) and the Best Practice Guidelines for Falls Prevention (Australian Council for Safety & Quality in HealthCare 2009). To assist nurses to engage with the Falls Policy directions in terms of falls prevention and management and post-fall management, nurse educators and researchers worked together to develop an on-line e-learning education programme (Johnson et al. 2012) and a supporting Falls Management Flip Chart. The effectiveness of the education programme and the Falls Management Flip Chart on nurses’ 912
knowledge, self-reported behaviours in relation to falls management, and falls incidents has been reported elsewhere (Johnson et al. 2014) and complements these findings. This paper reports on the changes effected by the education programme and support material (Falls Management Flip Chart) on nursing practice in screening and assessment for fall risks, implementation of falls prevention strategies and postfall management of patients.
Method This study used a pre–post test design within two hospitals and was undertaken between February 2010 and December 2011. A review of the patient health care records using an audit tool (Appendix S1), in addition to the observation of the patient and environment and nursing activities, was completed prior to nurses undertaking an on-line education programme. This study was approved by the Human Research and Ethics Committee of the Concord Repatriation General Hospital, South Western Sydney Area Health Service, as a quality assurance project approval No. CH62/6/2010-054.
Sample and setting Two subacute metropolitan Sydney hospitals specialising predominantly in aged care, one with 92 inpatient beds (four wards) (hospital 1) and another 96 bed hospital (one ward 36 beds) (hospital 2), participated in the study. Each hospital was selected for the presence of a high intake of elderly patients (65 years or older) and a high rate of falls per occupied bed days (>4 per 1000 occupied bed days). Participating wards employed varying categories of staff including registered and enrolled nurses and assistants-in-nursing (AIN) with limited staff turnover. The proportion of staff within the varying categories differed between the two hospitals; 47% registered nurses (RNs), 20% enrolled nurses (ENs), 29% AINs (hospital 1, n = 63); 65% RNs, 27% enrolled nurses, 8% AINs (hospital 2, n = 37). Different patients and patient health care records were included in the pre-test and post-test due to the length of time between the data collection points. The participating wards used the Modified Ontario Stratify Scale (hereafter referred to as the STRATIFY) with Sydney scoring (Oliver et al. 1997, Papaioannou et al. 2004) to screen the admitted patients for falls risks. The falls risk is considered to be low if the STRATIFY score is between 0 and 5, medium (6–16) and high (17–30) (Hunter New England Area Health ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 910–919
Falls prevention education program
Service 2012). The falls risk score is related to the subsequent falls management approach. For one hospital a random selection (using a random numbers chart) of 60 patients (and their records) (out of 92) was chosen, while in the second hospital (36 bed ward) all patients and their related records (65 years or older) admitted to the ward throughout the data collection period were included until a total of 60 patients was achieved. Sixty records were selected to adequately measure likely differences in a timely manner. For the second hospital there was a proportion of patients aged 7 days
Pre n = 111, %
Post n = 89, %
v2
P
95.80 85.71
94.95 83.84
0.09 0.15
0.51 0.70
94.12
89.90
1.34
0.25
58.82
70.71
3.32
0.07
1.68
10.10
7.37
0.01
36.13
62.63
15.19
