How to reduce falls

Effectiveness of bedrails in preventing falls among hospitalized older adults: a systematic review

BACKGROUND

Falls are a major problem today affecting adults of any age, but the elderly are a population that is more susceptible to falls. Falls are the leading cause of injury or death among older adults. Hospitalized older people are particularly vulnerable to falls. Falls cause direct injuries (minor injuries, severe wounds of the soft tissues and bone fractures) to patients and increased length of stay. The prevention of falls is commonly considered an indicator of the quality of care. Therefore, health institutions and professionals treat the identification and implementation of strategies to prevent or minimize their effects as a high priority. Fall prevention interventions involving physical restraints are still common and considered a primary preventative measure, despite controversy in their use. One of the most frequently used restraint interventions is bedrails. The question of the effectiveness of bedrails in preventing falls cuts across all societies and cultures and has with significant implications for the clinical practice of nurses.

OBJECTIVES

The objective of this review was to identify the effectiveness of the use of bedrails in preventing falls among hospitalized older adults when compared with no use of bedrails or any type of physical restraints.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

The current review considered studies that included hospitalized adults (female and male), 65 years and over with any clinical condition in a non-intensive care unit (ICU).

TYPES OF INTERVENTION(S)

The current review considered studies that evaluated the use of bedrails as a restraint to prevent falls among older adults in non-ICUs compared to no use of bedrails or any type of physical restraints, for example, bedrails versus no bedrails, and bedrails versus no wrist or ankle ties.

TYPES OF STUDIES

The current review considered any randomized controlled trials (RCTs). In the absence of RCTs, other research designs such as non-RCTs, before and after studies, cohort studies, case-control studies, descriptive studies, case series/reports and expert-opinion were considered.

OUTCOMES

The current review considered studies that included primary outcomes (number of patients who fell or the number of falls per patient) and secondary outcomes (number of head trauma, bone fractures or soft tissue injuries).

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished articles. A three-step search strategy was utilized in 13 databases. Articles published in Portuguese, English and Spanish beginning from 1980 were considered for inclusion.

METHODOLOGICAL QUALITY

Assessment of methodological quality was not conducted as no articles were identified that met the inclusion criteria.

DATA EXTRACTION AND DATA SYNTHESIS

Data extraction and synthesis was not performed, because no articles were included in this systematic review.

RESULTS

The search identified a total of 875 potentially relevant articles. Sixteen articles were identified through the reference lists of all identified articles. One hundred and thirteen full-text papers were assessed by two independent reviewers to determine eligibility. However, 11 articles were not found (despite all the efforts), and 102 articles did not meet the inclusion criteria.

CONCLUSION

There is no scientific evidence comparing the use of bedrails in preventing falls among hospitalized older adults to no use of bedrails or any type of physical restraints.

Fall incidence and fall prevention practices at acute care hospitals in Singapore: a retrospective audit

OBJECTIVE

To investigate the incidence of falls and explore fall prevention practices at acute care hospitals in Singapore.

DESIGN

A retrospective audit to collect baseline data on (1) incidence of falls (patient fall rates and fall injury rates) and (2) fall prevention practices, was conducted in five acute care hospitals in Singapore from December 2004 to March 2005.

STUDY PARTICIPANTS

Medical record data (n = 6000) of patients admitted into the medical, surgical and geriatric units in the five hospitals.

OUTCOME MEASURES

Fall incidence was obtained from the hospital's fall databases and incident reports for the period of June 2003 to May 2004. In total, 6000 medical records from five hospitals were randomly selected, retrieved and reviewed to determine whether falls, fall assessments and interventions were being initiated and documented.

RESULTS

The number of fallers for all hospitals was 825. Analysis showed that patient fall rates ranged from 0.68 to 1.44 per 1000 patient days, and the proportion of falls associated with injury ranged from 27.4% to 71.7%. The use of a fall risk assessment tool by nurses was recorded in 77% of all the nursing records.

CONCLUSION

This study has laid the foundation for further research for fall prevention in Singapore by describing current fall rates, fall-associated injury rates and the status of fall prevention practices in acute care settings. The results will be used to inform the development of a tailored multifaceted strategy to facilitate the implementation of Fall Prevention Clinical Practice Guidelines to reduce the burden of falls and fall injuries in hospitals in Singapore.

Hospital fall risk assessment tools: a critique of the literature

There are numerous fall risk assessment tools developed for use by nurses in hospitals; however, few of them have established validity and reliability. This article will examine the current state of knowledge in regard to fall risk assessment tools through review and critique of the literature on the topic. Recommendations for future research on fall risk assessment tools will be made and a conceptual framework detailing the relationship between the variables involved in assessing the accuracy of fall risk assessment tools will be presented.

Fall risk assessment: a prospective investigation of nurses' clinical judgement and risk assessment tools in predicting patient falls

A prospective cohort study was used to determine the reliability and validity of two fall risk assessment tools and nurses' clinical judgement in predicting patient falls. The study wards comprised two aged care and rehabilitation wards within a 570 bed acute care tertiary teaching hospital in Western Australia. Instrument testing included test-retest reliability and calculations of sensitivity, specificity, positive predictive value, negative predictive value and accuracy. The test retest reliability of all methods was good. In this setting, the three methods of assessing fall risk showed good sensitivity but poor specificity. Also, all methods had limited accuracy, and overall, exhibited an inability to adequately discriminate between patient populations at risk of falling and those not at risk of falling. Consequently, neither nurses' clinical judgement nor the fall risk assessment tools could be recommended for assessing fall risk in this clinical setting.

Enhancing the safety of hospitalization by reducing patient falls

The iatrogenic nature of hospitalization places patients at risk of falling, injury, and death. In this article, the major principles of providing protective and preventive interventions are outlined. The principles are the establishment of a multifaceted fall prevention program that targets fall interventions according to each etiologic factor; the recognition that fall protective and prevention interventions are distinct and serve a different function; the use of the fall monitoring system comprehensively; the creation of a clinical nurse specialist position, responsible for fall intervention; and a conscious and individualized approach to fall prevention. The process and problems of the varying nature of providing fall protection and fall prevention are discussed; for example, use of a side rail as a protective strategy may be successful with one patient but considered a hazard when used with a different patient.

Insights obtained from an evaluation of a falls prevention program set in a rural hospital

An evaluation of a Falls Prevention Program that took place in a 29-bed rural hospital in New South Wales is described. The aim of the project was to ascertain the overall effectiveness of the Program and to explore the usefulness of the assessment criteria in predicting falls. The sample consisted of 111 participants, representing all patients 65 years and over who were admitted to the general ward of the hospital between January and December 1997. The Falls Prevention Program had reduced the incidence of falls and was found to be effective for those patients requiring minimal assistance with walking. However, it was less effective for those using pick-up frames or forearm support frames. The patients who fell were more likely to be in the high risk category and it was concluded that while the assessment criteria was useful in predicting falls, the Falls Prevention Program could only limit the number of falls but not prevent them altogether. Age, mental status and mobility of patients in combination with time and location of falls suggested a pattern that was possibly peculiar to this rural hospital, which has implications for funding and staffing.

The efficacy of an educational program to improve direct caregiver knowledge regarding fall prevention

One hundred seventy-one (N = 171) direct caregivers were tested to determine their baseline knowledge about patient falls and fall prevention and to determine the impact of a fall prevention education program on their knowledge. Following the pretesting of participants for baseline knowledge a 20-minute educational videotape was viewed. Identical posttesting of knowledge followed. Mean posttest scores (M = 14.01) were significantly higher (t = 17.883; p < 0.001) than the pretest scores, supporting the effectiveness of the educational program in increasing direct caregivers' knowledge related to fall prevention.

Do hospital fall prevention programs work? A systematic review

OBJECTIVES

To analyze published hospital fall prevention programs to determine whether there is any effect on fall rates. To review the methodological quality of those programs and the range of interventions used. To provide directions for further research.

DESIGN

Systematic review of published hospital fall prevention programs. Meta-analysis.

METHODS

Keyword searches of Medline, CINAHL, monographs, and secondary references. All papers were included that described fall rates before and during intervention. Risk ratios and 95% Confidence Intervals (95% CI) were estimated and random effects meta-analysis employed. Begg's test was applied to detect possible publication bias. Separate meta-analysis regressions were performed to determine whether individual components of multifaceted interventions were effective.

RESULTS

A total of 21 papers met the criteria (18 from North America), although only 10 contained sufficient data to allow calculation of confidence intervals. A rate ratio of <1 indicates a reduction in the fall rate, resulting from an intervention. Three were randomized controlled trials (pooled rate ratio 1.0 (CI 0.60, 1.68)), seven prospective studies with historical control (0.76 (CI 0.65, 0.88)). Pooled effect rate ratio from these 10 studies was 0.79 (CI 0.69, 0.89). The remaining 11 studies were prospective studies with historical control describing fall rates only. Individual components of interventions showed no significant benefit.

DISCUSSION

The pooled effect of about 25% reduction in the fall rate may be a result of intervention but may also be biased by studies that used historical controls not allowing for historical trends in the fall rate before and during the intervention. The randomized controlled trials apparent lack of effect might be due to a change in practice when patients and controls were in the same unit at the same time during a study. Studies did not analyze compliance with the intervention or opportunity costs resulting from the intervention. Research and clinical programs in hospital fall prevention should pay more attention to study design and the nature of interventions.

Comparison of three instruments in predicting accidental falls in selected inpatients in a general teaching hospital

Accidental patient falls are becoming a major cause of concern for hospitalized inpatients. It is well known that patients who fall once during their hospital stay are more likely to fall again and that fall rates tend to be higher in hospitalized elderly individuals. Concerned health care team personnel recognize that many accidental patient falls may be predicted and, thus, prevented. The best tool to predict falls has not been determined yet. The purpose of this study was to compare the abilities of the Morse Fall Scale (MFS), the Functional Reach (FR) test, and the nurses' clinical judgment in predicting those inpatients on a rehabilitation unit and a geriatric medical ward who were most likely to fall. A total of 98 patients were screened in a 3-month period, with each patient undergoing all three instruments the same day. The results showed that the two objective standardized tests (i.e., MFS, FR) were time consuming and often inconvenient and were no better at prediction than the clinical judgments made by the primary nurses.

Falls in a psychiatric unit

The purposes of this descriptive study were to document the prevalence of previously identified risk factors for falls in a group of acutely ill psychiatric patients, to determine if patients who fell differed from nonfallers with respect to risk factors, and to describe the circumstances surrounding falls that occurred on an inpatient unit. All patients admitted to an acute psychiatric unit during a 7-month period were entered into the study (N = 197). Twice a day, nurses who worked on the unit completed a fall-risk factors checklist for each patient. When a fall occurred, an additional instrument designed to measure circumstances associated with the fall was completed. The most frequently occurring risk factors were clinical diagnoses of depression and confusion or disorientation. Seventeen patients fell during their hospitalization. Compared with nonfallers, patients who fell were more likely to have a previous history of falls, generalized weakness, confusion or disorientation, difficulty with mobility or walking, elimination problems, and temperature elevation. Analysis of circumstances surrounding falls showed that the majority of falls occurred when patients were attempting to get out of bed, walk to the bathroom at night, or change from a sitting to a standing position. Findings from this research can be used to identify psychiatric patients who are at risk for falls during their hospitalization.

A fall prevention educational program for community dwelling seniors

The purpose of this research was to assess participants' responses to a fall prevention educational program. Fourteen persons volunteered to participate in the study conducted at a large senior center. Descriptive statistics were used to characterize the sample and to assess subjects' awareness about falls, attitudes about fall risk, fall prevention behaviors, and incidence of falls before the fall prevention program and again at one month and three months after the program. Forty-six percent of the sample had fallen in the previous year. In general, subjects' perceptions that their risk of falling was lower than others of the same age and sex increased following the fall prevention program. Additionally, subjects were somewhat more concerned about falling after attendance at the fall prevention program. Most of the participants completed the home safety checklist; however, very few subjects made changes at home to reduce the risk of falling or did the recommended muscle strengthening exercises. Suggestions for community fall prevention programs are offered based upon the pilot results.

Clinical nursing judgment related to reducing the incidence of falls by elderly patients

The incidence of falls among elderly patients has been and continues to be a major challenge for nurses. Falls add physical injury and mental stress to patients' existing health problems, are a deterrent to rehabilitation, and increase healthcare costs. This study describes the variables that nurses identify as influencing their clinical decision making and the nursing behaviors associated with preventing patient falls. The study was grounded in the theory that discretionary nursing behaviors are related to nursing expertise, and the study was guided by the assumption that such behaviors are proactive and anticipatory. An analysis of interviews of registered nurses (n = 14) working on a geriatric rehabilitation unit in a medical center in Ohio focused on the zones of association and the contextual meanings of language used by the nurses when discussing patient falls. Four themes emerged: the reasons for patient falls, identifying patients who are likely to fall, preventing falls, and nurses' feelings when patients fall.

Agitation: measurement, management, and intervention research

Strategies for controlling and managing agitation of patients in long-term care populations has been identified as a research priority. Unfortunately, there is a paucity of literature on empirically tested therapeutic interventions for agitation. This manuscript summarizes the literature related to the measurement, management, and interventions for agitation and identifies a nursing research agenda for conducting research in this area. Nonpharmacological and nonrestraint interventions are highlighted and categorized by (1) alterations in care given, (2) environmental adaptations, and (3) behavioral approaches. Future research areas identified by the authors focus on additional types of environmental, interpersonal, and behavioral interventions as well as theoretical predictors of agitation; the influence and role of nursing personnel and caregiver; and the legal and ethical issues involved in caring for patients who manifest agitation.

Hospital falls: development of a predictive model for clinical practice

A retrospective case-control study related to falls was conducted at an 1,120-bed acute care tertiary hospital. The case (fall) sample consisted of 102 falls and 236 control (nonfall) charts during a 1-month period. An instrument developed by Hendrich (1988) was modified for use in the study. Demographic data and risk factors were recorded. Descriptive statistics included risk factor percentages for each sample and the corresponding univariate relative risks. Logistic regression was used to develop a multivariate risk factor model with seven risk factors. The significant risk factors were recent history of falls, depression, altered elimination patterns, dizziness or vertigo, primary cancer diagnosis, confusion, and altered mobility. The adjusted relative risks were converted to risk points to be used to assess a patient's level of fall risk. Within the data set, a sensitivity of 77% (79 of 102) and specificity of 72% (169 of 236) were calculated. The model was cross-validated in a 1987 data set with a sensitivity of 83% (59 of 71) and specificity of 66% (106 of 161).

Use of physical restraints. 2: Alternatives

The first article in this two-part series considered the consequences of physical restraints. This article considers the alternatives to physical restraints and argues that their use in daily nursing practice raises the quality of care provided to elderly patients.

An interdisciplinary approach to mobility and safety education for caregivers and stroke patients

A cerebrovascular accident (CVA), or stroke, often results not only in hemiplegia, but also in cognitive and perceptual impairments as well. The hemiplegia causes obvious problems with mobility, while cognitive and perceptual impairments might interfere with and delay progress in therapy. Physiotherapists and occupational therapists have extensive knowledge and training regarding the intricacies of movement and mobility. Unfortunately, little emphasis is given to these areas in most nursing programs; yet nurses spend the most time with hospitalized clients, providing 24-hour care. As stroke patients tend to learn by repetition, a consistent rehabilitation program is essential, especially with respect to mobility and safety education. It is important for the rehabilitation nurse to be knowledgeable regarding mobility techniques to prevent back injury to the caregiver and to reduce the degree of risk of injury to the patient.

A RETROSPECTIVE STUDY OF PATIENT FALLS IN A PSYCHIATRIC HOSPITAL

1. While falls on medical-surgical units are the focus of extensive research, falls on inpatient psychiatric units are an understudied critical event. 2. The purposes of this study were to identify the variables associated with psychiatric patient falls and to use that information to assess risk and, therefore, prevent falls in this population. 3. The psychiatric patient at risk for falling is described as a woman with a prior history of falls; less than 65 years of age; experiencing anxiety and agitation; and receiving a sedative, a tranquilizer, and a laxative. Additionally, this patient is more likely to fall in a community area.

Individual evaluation of accident risks at nursing homes

The purpose of the study was to find a practical applicable method for estimating risk of accidents among nursing home patients by localizing specified risk factors and recording accidents during a period of one year. During 1987-January-15 to 1988-January-14, a total of 153 accidents happened to 23 men and 76 women among 335 admitted patients. The strongest accident predictors suggested by a logistic regression procedure were: impaired balance, walking with device or human assistance, drugs influencing the central nervous system, dizziness and poor night-time sleep. The conclusion is reached that it will probably be possible to reduce accidents in the institutionalized elderly by education of staff, identification of risk patients, individual nursing planning and measurements.

Iatrogenesis in the elderly. Contributors to falls

Persons who are susceptible to falls can be identified before a fall occurs. A risk prediction tool must be evaluated for its usefulness; if a tool is not feasible, elderly persons who have fallen once are at high risk of falling again. Once high risk has been identified, strategies must be planned to prevent subsequent falls. One of the most important strategies is to communicate to all staff which patients are at high risk and the general circumstances surrounding any patient fall. Few interventions have been shown through rigorous clinical studies to be effective. Passive interventions, such as alarms, are usually more reliable than active interventions that staff must administer. Interventions must be individualized, based on the patient's deficits.

Using research-based interventions to decrease patient falls

The purpose of this study was to decrease patient falls by applying relevant interventions found in the nursing research literature. Clinical nurse specialists assisted staff with the application of selected research-based patient fall program interventions on two adult medical-surgical specialty units in a tertiary care facility. The fall rate on these two units decreased during the study year, while the all-hospital patient fall rate increased. To encourage comparison of fall data among institutions, a standard method for calculating fall rate is presented.

The development of the RISK tool for fall prevention

The authors tailored a 26-item risk assessment tool (RAT) for falls based on a literature review and an analysis of causative factors of falls that had occurred over a 3-month period at the Olin E. Teague VA Medical Center, an 1,100-bed acute medical-surgical, psychiatric, and extended care facility in Temple, TX. The RAT was completed by nursing staff on 10 patient units (four medical, four surgical, and two nursing home units) for all admissions during the period. A 25% sample of the completed RATs was randomly selected (n = 208). Pearson's correlation coefficient was used to identify factors that would most likely predict falls from the RATs of the randomly selected group and of the patients who fell (n = 78). Only 4 of the 26 items were statistically related to falls. Based on findings from this study, the RAT was shortened to the four items and called the RISK (Reassessment Is Safe "Kare") tool.

Why do they fall? Monitoring risk factors in nursing homes

A pilot study identified 40 falls involving 29 patients from incident reports in a nursing home. About one fourth of the fallers fell more than once and accounted for about one fourth of the falls. The majority of research studies on falls were conducted in hospital settings on a one-time basis. Studies are needed in nursing homes to monitor risk factors on a continuous basis to design remedial nursing interventions. Age, male gender, mental impairment, and short stay were risk factors identified in this study. The association of dementia with falls is especially significant because of the increasing numbers of dementia patients in nursing homes. This pinpoints the need for special surveillance of these patients.

Prediction and prevention of patient falls

Falls are a major cause of injury in hospitalized patients. To date, the focus of research has been on developing risk profiles to predict fallers and developing interventions to prevent falls. This paper presents and critiques these efforts. The authors conclude that (a) no high-risk profiles have yet been developed with adequate sensitivity and specificity to be useful as predictive instruments; (b) current fall interventions are rarely research-based; and (c) the few intervention studies conducted to date seem to reduce falls primarily through consciousness raising rather than specific changes in practice.

Falls in the rehabilitation setting: incidence and characteristics

A prospective six-month study was conducted to determine a high-risk index for medical rehabilitation patients who fall. Variables studied for all patients included demographics, medical conditions, associated symptoms, orthostatic blood pressure measurements, physical function, posture control, proprioception, use of physical restraints, and medications, A detailed examination of the fall events was also conducted. Of the 143 patients studied, 46 (32%) fell at least once, making a total of 84 falls. Impaired ability to follow directions, impaired judgment, impaired proprioception, presence of physical restraints, use of major tranquilizers, use of sedatives, and presence of psychiatric diagnosis were all individually associated with patients who fell. Males fell more than females. Logistic regression identified altered proprioception as the only major predictor of falling. Of those who fell, only 26% called for assistance prior to the fall. Sixty-eight percent of the falls were from wheelchairs. Importantly, no patients had serious injury or morbidity from the falls.

Tying down the elderly. A review of the literature on physical restraint

The apparently widespread practice of physical restraint of the elderly has received little systematic research, despite reported clinical awareness of its iatrogenic effects on frail elders. Prevalence rates in various settings range between 6% and 86%, with cognitive impairment an important risk factor for restraint. Despite strongly held beliefs, efficacy of restraints for safeguarding patients from injury has not been demonstrated clinically. This paper reviews the current status of knowledge regarding physical restraint use with the elderly and suggests a research agenda and implications for ethical practice.