Do hospital fall prevention programs work? A systematic review

Practices of falls risk assessment and prevention in acute hospital settings: a realist investigation

Background

Falls are the most common safety incident reported by acute hospitals. The National Institute of Health and Care Excellence recommends multifactorial falls risk assessment and tailored interventions, but implementation is variable.

Aim

To determine how and in what contexts multifactorial falls risk assessment and tailored interventions are used in acute National Health Service hospitals in England.

Design

Realist review and multisite case study. (1) Systematic searches to identify stakeholders' theories, tested using empirical data from primary studies. Review of falls prevention policies of acute Trusts. (2) Theory testing and refinement through observation, staff interviews (n = 50), patient and carer interviews (n = 31) and record review (n = 60).

Setting

Three Trusts, one orthopaedic and one older person ward in each.

Results

Seventy-eight studies were used for theory construction and 50 for theory testing. Four theories were explored. (1) Leadership: wards had falls link practitioners but authority to allocate resources for falls prevention resided with senior nurses. (2) Shared responsibility: a key falls prevention strategy was patient supervision. This fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared. (3) Facilitation: assessments were consistently documented but workload pressures could reduce this to a tick-box exercise. Assessment items varied. While individual patient risk factors were identified, patients were categorised as high or low risk to determine who should receive supervision. (4) Patient participation: nursing staff lacked time to explain to patients their falls risks or how to prevent themselves from falling, although other staff could do so. Sensitive communication could prevent patients taking actions that increase their risk of falling.

Limitations

Within the realist review, we completed synthesis for only two theories. We could not access patient records before observations, preventing assessment of whether care plans were enacted.

Conclusions

(1) Leadership: There should be a clear distinction between senior nurses' roles and falls link practitioners in relation to falls prevention; (2) shared responsibility: Trusts should consider how processes and systems, including the electronic health record, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses, and ensure items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling.

Future work

(1) Development and evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, multifactorial falls risk assessment and selection and delivery of tailored interventions; (2) mixed method and economic evaluations of patient supervision; (3) evaluation of engagement support workers, volunteers and/or carers to support falls prevention. Research should include those with cognitive impairment and patients who do not speak English.

Study registration

This study is registered as PROSPERO CRD42020184458.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129488) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Smartphones and Threshold-Based Monitoring Methods Effectively Detect Falls Remotely: A Systematic Review

In the US, at least one fall occurs in at least 28.7% of community-dwelling seniors 65 and older each year. Falls had medical costs of USD 51 billion in 2015 and are projected to reach USD 100 billion by 2030. This review aims to discuss the extent of smartphone (SP) usage in fall detection and prevention across a range of care settings. A computerized search was conducted on six electronic databases to investigate the use of remote sensing technology, wireless technology, and other related MeSH terms for detecting and preventing falls. After applying inclusion and exclusion criteria, 44 studies were included. Most of the studies targeted detecting falls, two focused on detecting and preventing falls, and one only looked at preventing falls. Accelerometers were employed in all the experiments for the detection and/or prevention of falls. The most frequent course of action following a fall event was an alarm to the guardian. Numerous studies investigated in this research used accelerometer data analysis, machine learning, and data from previous falls to devise a boundary and increase detection accuracy. SP was found to have potential as a fall detection system but is not widely implemented. Technology-based applications are being developed to protect at-risk individuals from falls, with the objective of providing more effective and efficient interventions than traditional means. Successful healthcare technology implementation requires cooperation between engineers, clinicians, and administrators.

Physical Activity and Fall Prevention in Geriatric Inpatients in an Acute Care Unit (AGIR Study): Protocol for a Usability Study

Background

Falls are one of the world’s top 10 risks associated with disability in people older than 60 years. They also represent more than two-thirds of adverse events in hospitals, mainly affecting patients older than 65 years. Physical activity is a central intervention in fall prevention for older people. Whatever the details of the prevention strategy that is adopted (ie, how a mono- or multifactorial intervention is evaluated, the category of person the intervention targets, and where it is used), it is important to ensure that the proposed intervention is feasible and usable for the patient and the health care team.

Objective

The primary objective is to study the usability of carrying out a physical activity intervention, including 3 types of exercises, in older patients hospitalized in a geriatric acute care unit and categorized according to 3 fall risk levels: low, moderate, and high. The secondary objectives are to determine the difficulty of the physical exercise for patients with different fall risk levels, to study the health care team’s perceptions of the intervention’s feasibility, and to study the benefits for patients.

Methods

This is an open-label, unicenter, nonrandomized, usability prospective clinical trial. The intervention tested is a daily physical activity program. It consists of 3 types of physical exercise: staying out of bed for at least 3 hours, performing balance exercises while standing for 2 minutes, and the Five Times Sit to Stand transfer exercise. These exercises are carried out under the supervision of the health care team. Fall risk in the patients is classified with the Brief Geriatric Assessment tool. The exercise program starts on the second day of hospitalization after inclusion in the study. Patient assessment continues until the last day of hospitalization or the 20th day of hospitalization, whichever is earlier. For each fall-risk group and each type of exercise, the intervention will be defined as usable if at least 80% of the participants complete 75% or more of the exercises (ie, the ratio between the number of days when the patient completes a type of exercise and the total number of hospitalization days). The perceived feasibility by the health care team is measured with 2 scales, measuring perceived difficulty and time spent with the patient. The intervention benefit is evaluated using the performance of the Five Times Sit to Stand test before and after the intervention.

Results

The first patient was recruited on March 16, 2015. The study enrolled 266 patients, including 75 with low fall risk, 105 with moderate risk, and 85 with high risk.

Conclusions

We have not yet analyzed the results, but our observations suggest that the usability of each type of exercise for a given patient will depend on their fall risk level.

Trial Registration

ClinicalTrials.gov NCT02393014; https://clinicaltrials.gov/ct2/show/NCT02393014

International Registered Report Identifier (IRRID)

DERR1-10.2196/32288

A Multicenter Cohort Study of Falls Among Patients Admitted to the ICU

OBJECTIVES

To determine the incidence of falls, risk factors, and adverse outcomes, among patients admitted to the ICU.

DESIGN

Retrospective cohort study.

SETTING

Seventeen ICUs in Alberta, Canada.

PATIENTS

Seventy-three thousand four hundred ninety-five consecutive adult patient admissions between January 1, 2014, and December 31, 2019.

MEASUREMENTS AND MAIN RESULTS

A mixed-effects negative binomial regression model was used to examine risk factors associated with falls. Linear and logistic regression models were used to evaluate adverse outcomes. Six hundred forty patients experienced 710 falls over 398,223 patient days (incidence rate of 1.78 falls per 1,000 patient days [95% CI, 1.65-1.91]). The daily incidence of falls increased during the ICU stay (e.g., day 1 vs day 7; 0.51 vs 2.43 falls per 1,000 patient days) and varied significantly between ICUs (range, 0.37-4.64 falls per 1,000 patient days). Male sex (incidence rate ratio [IRR], 1.37; 95% CI, 1.15-1.63), previous invasive mechanical ventilation (IRR, 1.82; 95% CI, 1.40-2.38), previous sedative and analgesic medication infusions (IRR, 1.60; 95% CI, 1.15-2.24), delirium (IRR, 3.85; 95% CI, 3.23-4.58), and patient mobilization (IRR, 1.26; 95% CI, 1.21-1.30) were risk factors for falling. Falls were associated with longer ICU (ratio of means [RM], 3.10; 95% CI, 2.86-3.36) and hospital (RM, 2.21; 95% CI, 2.01-2.42) stays, but lower odds of death in the ICU (odds ratio [OR], 0.09; 95% CI, 0.05-0.17) and hospital (OR, 0.21; 95% CI, 0.14-0.30).

CONCLUSIONS

We observed that among ICU patients, falls occur frequently, vary substantially between ICUs, and are associated with modifiable risk factors, longer ICU and hospital stays, and lower risk of death. Our study suggests that fall prevention strategies should be considered for critically ill patients admitted to ICU.

Fall Prevention Practices and Implementation Strategies: Examining Consistency Across Hospital Units

OBJECTIVE

Our study examines how consistently fall prevention practices and implementation strategies are used by U.S. hospitals.

METHODS

We conducted a cross-sectional, descriptive study of 60 general adult hospital units.We administered a survey measuring 5 domains of fall prevention practices: visibility and identification, bed modification, patient monitoring, patient safety, and education. We measured 4 domains of implementation strategies including quality management (e.g., providing data and support for quality improvement), planning (e.g., designating leadership), education (e.g., providing consultation and training), and restructuring (e.g., revising staff roles and modifying equipment).

RESULTS

Of 60 units, 43% were medical units and 57% were medical-surgical units. The hospital units varied in fall prevention practices, with practices such as keeping a patient's bed in a locked position (73% strongly agree) being used more consistently than other practices, such as scheduled toileting (15% strongly agree). Our study observed variation in fall prevention implementation strategies. For example, publicly posting fall rates (60% strongly agree) was more consistently used than having a multidisciplinary huddle after a fall event (12% strongly agree).

CONCLUSIONS

There is substantial variation in the implementation of fall prevention practices and implementation strategies across inpatient units. Our study found that resource-intensive practices (e.g., scheduled toileting) are less consistently used than less resource-intensive practices and that interdisciplinary approaches to fall prevention are limited. Future studies should examine how units tailor fall prevention practices based on patient risk factors and how units decide, based on their available resources, which implementation strategies should be used.

Exploring the Environment behind In-Patient Falls and Their Relation to Hospital Overcrowdedness-A Register-Based Observational Study

(1) Background: Inpatient falls are a serious threat to patients' safety and their extrinsic factors are, at present, insufficiently described. Additionally, hospital overcrowdedness is known for its malicious effects but its relation to the inpatient falls is currently underexplored. The aim of this study was to explore the distribution of falls and their extrinsic characteristics amongst a range of different clinics, and to explore the correlation and predictive ability of hospital overcrowding in relation to inpatient falls. (2) Methods: An observational, cross-sectional, registry-based study was conducted using retrospective data from an incidence registry of a hospital organization in Sweden during 2018. The registry provided data regarding the extrinsic factors of inpatient falls, including the clinics' overcrowdedness. Simple descriptive statistics, correlation analysis and simple linear regression analysis were used. (3) Results: Twelve clinics were included. A total of 870 inpatient falls were registered during 2018. Overcrowdedness and total amount of falls were positively and very strongly correlated (r = 0.875, p < 0.001). Overcrowdedness was a significant predictor of the total amount of inpatient falls (p < 0.001, α = 0.05). (4) Conclusions: The characteristics regarding inpatient falls vary among the clinics. Inpatient overcrowding might have a significant role in the prevalence of inpatient falls, but further high-evidence-level studies are required.

Fall prevention implementation strategies in use at 60 United States hospitals: a descriptive study

BACKGROUND

To guide fall prevention efforts, United States organisations, such as the Joint Commission and the Agency for Healthcare Research and Quality, have recommended organisational-level implementation strategies: leadership support, interdisciplinary falls committees, electronic health record tools, and staff, family and patient education. It is unclear whether hospitals adhere to such strategies or how these strategies are operationalised.

OBJECTIVE

To identify and describe the prevalence of specific hospital fall prevention implementation strategies.

METHODS

In 2017, we surveyed 80 US hospitals participating in the National Database of Nursing Quality Indicators who volunteered for the study. We conducted descriptive statistics by calculating percentages for categorical variables and the median and IQR for count variables.

RESULTS

A total of 60/80 (75%) of hospitals completed the survey. The majority of hospitals were not-for-profit (98%) and urban (90%); more than half were Magnet (53%), small (53%) and teaching (52%). Hospitals were more likely to use leadership strategies, such as updating fall policies in the past 3 years (98%) but less likely to reward staff (40%). Hospitals commonly used interdisciplinary falls committees (83%) but membership rarely included physicians. Hospitals lacked access to electronic health record tools, such as high-risk medication warnings (27%). Education strategies were commonly used; 100% of hospitals provided fall education at staff orientation, but only 22% educated all employees (not just nursing staff).

CONCLUSIONS

Our study is the first to our knowledge to examine which expert-recommended implementation strategies are being used and how they are being operationalised in US hospitals. Future studies are needed to document fall prevention implementation strategies in detail and to test which implementation strategies are most effective at reducing falls. Additionally, research is needed to evaluate the quality of implementation (eg, fidelity) of fall prevention interventions.

Publication and related bias in quantitative health services and delivery research: a multimethod study

Background

Bias in the publication and reporting of research findings (referred to as publication and related bias here) poses a major threat in evidence synthesis and evidence-based decision-making. Although this bias has been well documented in clinical research, little is known about its occurrence and magnitude in health services and delivery research.

Objectives

To obtain empirical evidence on publication and related bias in quantitative health services and delivery research; to examine current practice in detecting/mitigating this bias in health services and delivery research systematic reviews; and to explore stakeholders’ perception and experiences concerning such bias.

Methods

The project included five distinct but interrelated work packages. Work package 1 was a systematic review of empirical and methodological studies. Work package 2 involved a survey (meta-epidemiological study) of randomly selected systematic reviews of health services and delivery research topics (n = 200) to evaluate current practice in the assessment of publication and outcome reporting bias during evidence synthesis. Work package 3 included four case studies to explore the applicability of statistical methods for detecting such bias in health services and delivery research. In work package 4 we followed up four cohorts of health services and delivery research studies (total n = 300) to ascertain their publication status, and examined whether publication status was associated with statistical significance or perceived ‘positivity’ of study findings. Work package 5 involved key informant interviews with diverse health services and delivery research stakeholders (n = 24), and a focus group discussion with patient and service user representatives (n = 8).

Results

We identified only four studies that set out to investigate publication and related bias in health services and delivery research in work package 1. Three of these studies focused on health informatics research and one concerned health economics. All four studies reported evidence of the existence of this bias, but had methodological weaknesses. We also identified three health services and delivery research systematic reviews in which findings were compared between published and grey/unpublished literature. These reviews found that the quality and volume of evidence and effect estimates sometimes differed significantly between published and unpublished literature. Work package 2 showed low prevalence of considering/assessing publication (43%) and outcome reporting (17%) bias in health services and delivery research systematic reviews. The prevalence was lower among reviews of associations than among reviews of interventions. The case studies in work package 3 highlighted limitations in current methods for detecting these biases due to heterogeneity and potential confounders. Follow-up of health services and delivery research cohorts in work package 4 showed positive association between publication status and having statistically significant or positive findings. Diverse views concerning publication and related bias and insights into how features of health services and delivery research might influence its occurrence were uncovered through the interviews with health services and delivery research stakeholders and focus group discussion conducted in work package 5.

Conclusions

This study provided prima facie evidence on publication and related bias in quantitative health services and delivery research. This bias does appear to exist, but its prevalence and impact may vary depending on study characteristics, such as study design, and motivation for conducting the evaluation. Emphasis on methodological novelty and focus beyond summative assessments may mitigate/lessen the risk of such bias in health services and delivery research. Methodological and epistemological diversity in health services and delivery research and changing landscape in research publication need to be considered when interpreting the evidence. Collection of further empirical evidence and exploration of optimal health services and delivery research practice are required.

Study registration

This study is registered as PROSPERO CRD42016052333 and CRD42016052366.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 33. See the NIHR Journals Library website for further project information.

Risk Factors for Falls among Hospitalized Trauma Patients

Inpatient falls lead to an injury in 30 per cent of cases and serious injury in 5 per cent. Increasing staffing and implementing fall prevention programs can be expensive and require a significant use of resources. We hypothesized that trauma patients have unique risk factors to sustain a fall while hospitalized. This is a retrospective cohort study from 2005 to 2010 of all trauma patients admitted to an urban Level I trauma center. Patients who fell while hospitalized were compared with patients who did not fall to identify risk factors for sustaining an inpatient fall. There were 16,540 trauma patients admitted during the study period and 128 (0.8%) fell while hospitalized. Independent risk factors for a trauma patient to fall while hospitalized included older age (odds ratio [OR], 1.02 [1.01 to 1.03], P < 0.001), male gender (OR, 1.6 [1.0 to 2.4], P = 0.03), blunt mechanism (OR, 5.1 [1.6 to 16.3], P = 0.006), Glasgow Coma Score at admission (OR, 0.59 [0.35 to 0.97], P = 0.04), intensive care unit admission (OR, 2.3 [1.4 to 3.7], P = 0.001), and need for mechanical ventilation (OR, 2.2 [1.2 to 3.9], P = 0.01). Trauma patients who fell while hospitalized sustained an injury in 17 per cent of cases and a serious injury in 5 per cent. Inpatient falls in hospitalized trauma patients are uncommon. Risk factors include older age, male gender, blunt mechanism, lower Glasgow Coma Score, and the need for intensive care unit admission or mechanical ventilation. Trauma patients with these risk factors may require higher staffing ratios and should be enrolled in a formal fall prevention program.

Fall-related injuries for three ages groups - Analysis of Swedish registry data 1999-2013

INTRODUCTION

The objective of this study was to analyze which factors (including factors pertaining to the individual, the household, and the local area) increase the risk of fall injuries for the three age groups with the highest risk for fall injuries in Sweden.

METHOD

The study combined longitudinal data covering the period 1999-2013 from several different official registries from Statistics Sweden as well as from the Swedish health care system and fitted the models to data using mixed model regressions.

RESULTS

Three age groups had a markedly heightened risk for fall injuries: 1-3-year olds, 12-14 year olds, and the elderly (65+). The home was the most common location for fall injuries, as about 40% of all fall injuries occur in the home. Only for the elderly strong predictors for fall injuries were found, and these were: age, single household, and special housing.

CONCLUSIONS

There is preventive potential in the special residences for the elderly and disabled. People living in these special residences make up a strongly selected group that needs extra safe environments. Our findings indicate that their needs are currently not meet. Practical applications: Design of special residences for the elderly and disabled should aim at reducing the consequences of falling.

Hospital falls prevention with patient education: a scoping review

BACKGROUND

Hospital falls remain a frequent and debilitating problem worldwide. Most hospital falls prevention strategies have targeted clinician education, environmental modifications, assistive devices, hospital systems and medication reviews. The role that patients can play in preventing falls whilst in hospital has received less attention. This critical review scopes patient falls education interventions for hospitals. The quality of the educational designs under-pinning patient falls education programmes was also evaluated. The outcomes of patient-centred falls prevention programs were considered for a range of hospital settings and diagnoses.

METHODS

The Arksey and O'Malley (2005) framework for scoping reviews was adapted using Joanna Briggs Institute and PRISMA-ScR guidelines. Eight databases, including grey literature, were searched from January 2008 until February 2020. Two reviewers independently screened the articles and data were extracted and summarised thematically. The quality of falls prevention education programs for patients was also appraised using a modified quality metric tool.

RESULTS

Forty-three articles were included in the final analysis. The interventions included: (i) direct face-to-face patient education about falls risks and mitigation; (ii) educational tools; (iii) patient-focussed consumer materials such as pamphlets, brochures and handouts; and (iv) hospital systems, policies and procedures to assist patients to prevent falls. The included studies assessed falls or education related outcomes before and after patient falls prevention education. Few studies reported incorporating education design principles or educational theories. When reported, most educational programs were of low to moderate quality from an educational design perspective.

CONCLUSIONS

There is emerging evidence that hospital falls prevention interventions that incorporate patient education can reduce falls and associated injuries such as bruising, lacerations or fractures. The design, mode of delivery and quality of educational design influence outcomes. Well-designed education programs can improve knowledge and self-perception of risk, empowering patients to reduce their risk of falling whilst in hospital.

Clinical features of fallers among inpatient subacute stroke: an observational cohort study

BACKGROUND AND PURPOSE

The aim of this study is to observe the differences between fallers, common fallers, and non-fallers in stroke patients compared with the global ability in a rehabilitation setting.

MATERIALS AND METHODS

An observational and prospective study has been carried out. A total of 476 subacute stroke patients have been observed. The main outcome measures were assessed using the Canadian Neurological Scale (CNS), Barthel Index (BI), Functional Ambulatory Category (FAC), and Trunk Control Test (TCT) at admission to the rehabilitation unit and after 90 days of the rehabilitation treatment (nearly 3 h for day for 5 days for week) at the discharge with intermediate evaluations after the first and second months.

RESULTS

Out of 397 patients, 109 reported 1 or more falls (27.5%), of whom 67 fell 1 time (fallers) in the hospital (16.9%) and 42 fell 2 or more times (common fallers) (10.6%). For fallers, BI and FAC scores had a significant effect (p = 0.003 for both). Common fallers had statistically significant differences in BI (p = 0.002), FAC (p = 0.012), and TCT scores (0.023) compared with non-fallers.

CONCLUSIONS

The severity of stroke may directly increase the risk of fall, and also indirectly, lengthening the hospitalization. Our study seems to suggest that patients with BI scores of between 21 and 30 on admission are more prone to fall in the first period of hospitalization, whereas in the second month, those with scores of between 11 and 20 on admission have a higher risk of falls. In the third month, patients with BI scores below 10 on admission are more susceptible to falls.

Impact of Fall Prevention on Nurses and Care of Fall Risk Patients

Purpose of the Study

Falls are common events for hospitalized older adults, resulting in negative outcomes both for patients and hospitals. The Center for Medicare and Medicaid (CMS) has placed pressure on hospital administrators by identifying falls as a "never event", resulting in a zero falls goal for many hospitals. Staff nurses are responsible for providing direct care to patients and for meeting the hospital no falls goal. Little is known about the impact of "zero falls" on nurses, patients and the organization.

Design and Methods

A qualitative study, using Grounded Dimensional Analysis (GDA) was conducted to explore nurses' experiences with fall prevention in hospital settings and the impact of those experiences on how nurses provide care to fall risk patients. Twenty-seven registered nurses and certified nursing assistants participated in in-depth interviews. Open, axial and selective coding was used to analyze data. A conceptual model which illustrates the impact of intense messaging from nursing administration to prevent patient falls on nurses, actions nurses take to address the message and the consequences to nurses, older adult patients and to the organization was developed.

Results

Intense messaging from hospital administration to achieve zero falls resulted in nurses developing a fear of falls, protecting self and unit, and restricting fall risk patients as a way to stop messages and meet the hospital goal.

Implications

Results of this study identify unintended consequences of fall prevention message on nurses and older adult patients. Further research is needed understand how nurse care for fall risk patients.

Initial Validation of the Toulouse St. Louis University Mini Falls Assessment in Older Adults

BACKGROUND/OBJECTIVES

Falls are one of the most prevalent health issues facing older adults. This study examines the validity of the Toulouse-St. Louis University Mini Falls Assessment (TSLUMFA). Objectives were to validate the TSLUMFA by testing if it differentiates between prior non fallers (n=80) and fallers (n=23), and predicts future falls as well as or better than the gold standard Tinetti Gait and Balance Instrument (TGBI). Examine if the subset of FRAIL Scale items on the TSLUMFA distinguishes between previous non fallers (n=75) and fallers (n=20), and predicts future falls as well as or better than the TGBI. Identify TSLUMFA cut offs scores for fall risk.

DESIGN

Prospective validation study.

SETTING

Participants were ambulatory patients presenting to the SLU Geriatrics Clinic.

PARTICIPANTS

103 ambulatory older adults.

MEASUREMENTS

Fall risk was assessed using the three assessments. Outcome measures were previous falls and follow up falls.

RESULTS

TSLUMFA, FRAIL, and TGBI differentiated between previous fallers and non fallers. A TSLUMFA score <23 stratified patients as moderate risk (Sensitivity=0.806 Specificity=0.776) and a score <21 stratified patients as high risk (Sensitivity=0.929 Specificity=0.897). 78% of patients (n=80) participated in follow up and 20% (n=16) of these patients fell during follow up. TSLUMFA and TGBI absolute scores were lower among patients who fell during the follow up period versus non fallers but the observed differences were not statistically significant (TSLUMFA P=0.123 and TGBI P=0.074).

CONCLUSION

This study validated the TSLUMFA and FRAIL. No test predicted falls with statistical significance (most likely due to the low follow up participation) but a positive trend was seen. Clinical recommendations from this study are to use the FRAIL as an initial fall screen and patients scoring > 3 should be analyzed by TSLUMFA. The TSLUMFA's advantage is that it pinpoints areas that will directly benefit from therapy to reduce falls.

Validation and inter-rater reliability of a three item falls risk screening tool

Background

Falls screening tools are routinely used in hospital settings and the psychometric properties of tools should be examined in the setting in which they are used. The aim of this study was to explore the concurrent and predictive validity of the Austin Health Falls Risk Screening Tool (AHFRST), compared with The Northern Hospital Modified St Thomas’s Risk Assessment Tool (TNH-STRATIFY), and the inter-rater reliability of the AHFRST.

Methods

A research physiotherapist used the AHFRST and TNH-STRATIFY to classify 130 participants admitted to Austin Health (five acute wards, n = 115 two subacute wards n = 15; median length of stay 6 days IQR 3–12) as ‘High’ or ‘Low’ falls risk. The AHFRST was also completed by nursing staff on patient admission. Falls data was collected from the hospital incident reporting system.

Results

Six falls occurred during the study period (fall rate of 4.6 falls per 1000 bed days). There was substantial agreement between the AHFRST and the TNH-STRATIFY (Kappa = 0.68, 95% CI 0.52–0.78). Both tools had poor predictive validity, with low specificity (AHFRST 46.0%, 95% CI 37.0–55.1; TNH-STRATIFY 34.7%, 95% CI 26.4–43.7) and positive predictive values (AHFRST 5.6%, 95% CI 1.6–13.8; TNH-STRATIFY 6.9%, 95% CI 2.6–14.4). The AHFRST showed moderate inter-rater reliability (Kappa = 0.54, 95% CI = 0.36–0.67, p < 0.001) although 18 patients did not have the AHFRST completed by nursing staff.

Conclusions

There was an acceptable level of agreement between the 3 item AHFRST classification of falls risk and the longer, 9 item TNH-STRATIFY classification. However, both tools demonstrated limited predictive validity in the Austin Health population. The results highlight the importance of evaluating the validity of falls screening tools, and the clinical utility of these tools should be reconsidered.

A battery-less and wireless wearable sensor system for identifying bed and chair exits in a pilot trial in hospitalized older people

Falls in hospitals are common, therefore strategies to minimize the impact of these events in older patients and needs to be examined. In this pilot study, we investigate a movement monitoring sensor system for identifying bed and chair exits using a wireless wearable sensor worn by hospitalized older patients. We developed a movement monitoring sensor system that recognizes bed and chair exits. The system consists of a machine learning based activity classifier and a bed and chair exit recognition process based on an activity score function. Twenty-six patients, aged 71 to 93 years old, hospitalized in the Geriatric Evaluation and Management Unit participated in the supervised trials. They wore over their attire a battery-less, lightweight and wireless sensor and performed scripted activities such as getting off the bed and chair. We investigated the system performance in recognizing bed and chair exits in hospital rooms where RFID antennas and readers were in place. The system’s acceptability was measured using two surveys with 0–10 likert scales. The first survey measured the change in user perception of the system before and after a trial; the second survey, conducted only at the end of each trial, measured user acceptance of the system based on a multifactor sensor acceptance model. The performance of the system indicated an overall recall of 81.4%, precision of 66.8% and F-score of 72.4% for joint bed and chair exit recognition. Patients demonstrated improved perception of the system after use with overall score change from 7.8 to 9.0 and high acceptance of the system with score ≥ 6.7 for all acceptance factors. The present pilot study suggests the use of wireless wearable sensors is feasible for detecting bed and chair exits in a hospital environment.

Risk factors for falls in older patients with cancer

Objectives

A rising number of patients with cancer are older adults (65 years of age and older), and this proportion will increase to 70% by the year 2020. Falls are a common condition in older adults. We sought to assess the prevalence and risk factors for falls in older patients with cancer.

Methods

This is a single-site, retrospective cohort study. Patients who were receiving cancer care underwent a comprehensive geriatric assessments, including cognitive, functional, nutritional, physical, falls in the prior 6 months and comorbidity assessment. Vitamin D and bone densitometry were performed.

Analysis

Descriptive statistics and multivariable logistic regression.

Results

A total of 304 patients aged 65 or above were enrolled in this study. The mean age was 78.4±6.9 years. They had haematological, gastrointestinal, urological, breast, lung and gynaecological cancers. A total of 215 patients with available information about falls within the past 6 months were included for final analysis. Seventy-seven (35.8%) patients had at least one fall in the preceding 6 months. Functional impairment (p=0.048), frailty (p<0.001), dementia (p=0.021), major depression (p=0.010) and low social support (p=0.045) were significantly associated with the fall status in the univariate analysis. Multivariate logistic regression analysis identified frailty and functional impairment to be independent risk factors for falls.

Conclusions

Falls are common in older patients with cancer and lead to adverse clinical outcomes. Major depression, functional impairment, frailty, dementia and low social support were risk factors for falls. Heightened awareness and targeted interventions can prevent falls in older patients with cancer.

Activity Monitoring and Heart Rate Variability as Indicators of Fall Risk: Proof-of-Concept for Application of Wearable Sensors in the Acute Care Setting

Growing concern for falls in acute care settings could be addressed with objective evaluation of fall risk. The current proof-of-concept study evaluated the feasibility of using a chest-worn sensor during hospitalization to determine fall risk. Physical activity and heart rate variability (HRV) of 31 volunteers admitted to a 29-bed adult inpatient unit were recorded using a single chest-worn sensor. Sensor data during the first 24-hour recording were analyzed. Participants were stratified using the Hendrich II fall risk assessment into high and low fall risk groups. Univariate analysis revealed age, daytime activity, nighttime side lying posture, and HRV were significantly different between groups. Results suggest feasibility of wearable technology to consciously monitor physical activity, sleep postures, and HRV as potential markers of fall risk in the acute care setting. Further study is warranted to confirm the results and examine the efficacy of the proposed wearable technology to manage falls in hospitals. [Journal of Gerontological Nursing, 43(7), 53-62.].

Use of routinely collected data in reporting falls in hospitals in a local health district in New South Wales, Australia

OBJECTIVE

To examine the quality of the two routinely collected sets of data, the Incident Information Management System (IIMS) and the health information exchange (HIE) in hospitals in New South Wales, Australia.

METHOD

IIMS records indicating a fall and its location were examined. HIE data were examined using International Classification of Diseases (ICD)-10-AM codes W00-W19 and an indicator, 'onset of the condition' for falls in hospital. If onset of the condition was not recorded, ICD-10-AM code for place of occurrence (Y92.22 = Health service area) immediately following ICD-10-AM code for the fall was used. Comprehensive criteria were applied to exclude records of earlier documented falls. IIMS and HIE data were linked. Characteristics of falls that were recorded in one data set but not in the other were determined.

RESULTS

Between January 2010 and December 2014, 8647 falls in hospitals were recorded in IIMS, 2169 were recorded in HIE and 9338 were recorded in either data set (rate of 3.2 falls per 1000 bed days). IIMS captured 93% and HIE captured 23% of these falls. Of the falls recorded in HIE, 677 (31%) were not recorded in IIMS. These were more likely to be subsequent falls, by patients who were female, younger than 65 years, who underwent a non-allied health procedure or had length of stay less than 1 week.

CONCLUSIONS

IIMS captured the vast majority of falls in hospitals but failed to report one-third of falls recorded in HIE.

Patient education to prevent falls in subacute care

Objective: To evaluate the effectiveness of a patient education programme for preventing falls in the subacute hospital setting.

Design: Randomized controlled trial, subgroup analysis.

Participants: Patients of a metropolitan subacute/aged rehabilitation hospital who were recommended for a patient education intervention for the prevention of falls when enrolled in a larger randomized controlled trial of a falls prevention programme.

Methods: Participants in both the control and intervention groups who were recommended for the education programme intervention were followed for the duration of their hospital stay to determine if falls occurred. Only participants in the intervention group who were recommended for this intervention actually received it. In addition, these participants completed an evaluation survey at the completion of their education programme.

Results: Intervention group participants in this subgroup analysis had a significantly lower incidence of falls than their control group counterparts (control: 16.0 falls/1000 participant-days, intervention: 8.2 falls/1000 participant-days, log-rank test: P = 0.007). However the difference in the proportion of fallers was not significant (relative risk 1.21, 95% confidence interval 0.68 to 2.14).

Conclusion: Patient education is an important part of a multiple intervention falls prevention approach for the subacute hospital setting.

Preventing falls and stump injuries in lower limb amputees during inpatient rehabilitation: completion of the audit cycle

Objectives: To study the factors contributing to falls among recent lower limb amputees, and to reduce the number of falls during inpatient rehabilitation and resulting injuries.

Design: Retrospective, followed by prospective, cohort study, then a follow-up study conducted after interventions.

Setting: Twenty-bedded inpatient rehabilitation unit for amputees.

Subjects: Lower limb amputees.

Interventions: Patient education, environmental modifications and application of a bivalve plaster of Paris stump protector to patients who were aged 70 or over, or cognitively impaired.

Main outcome measures: Numbers of falls and other accidents, and resulting injuries.

Results: In phase 1 of the study, a retrospective audit of incident forms that had been completed on lower limb amputees who had an accident during their inpatient rehabilitation, between 1 April 1996 and 31 Ocotber 1998, was carried out. This showed that approximately a third of admissions (32%) were complicated by an accident. Most accidents were falls. In phase 2, a prospective study of 113 patients admitted to the unit was undertaken. Patients who fell were significantly older than those who did not. In phase 3, 62 consecutive patients were studied. There were 37 accidents in total, of which 35 were falls. Compared with the phase 2 study, there was no reduction in the proportion of patients who had a fall or other accident in phase 3, but significantly fewer falls resulted in any injury (p/0.05).

Conclusions: Although the interventions employed did not reduce the proportion of patients who had falls or other accidents, significantly fewer falls resulted in injuries.

Nurses' Perceptions of Implementing Fall Prevention Interventions to Mitigate Patient-Specific Fall Risk Factors

Evidence-based (EB) fall prevention interventions to mitigate patient-specific fall risk factors are readily available but not routinely used in practice. Few studies have examined nurses' perceptions about both the use of these EB interventions and implementation strategies designed to promote their adoption. This article reports qualitative findings of nurses' perceptions about use of EB fall prevention interventions to mitigate patient-specific fall risks, and implementation strategies to promote use of these interventions. The findings revealed five major themes: before-study fall prevention practices, use of EB fall prevention interventions tailored to patient-specific fall risk factors, beneficial implementation strategies, overall impact on approach to fall prevention, and challenges These findings are useful to guide nurses' engagement and use of EB fall prevention practices tailored to patient-specific fall risk factors.

Effectiveness of a Batteryless and Wireless Wearable Sensor System for Identifying Bed and Chair Exits in Healthy Older People

Aging populations are increasing worldwide and strategies to minimize the impact of falls on older people need to be examined. Falls in hospitals are common and current hospital technological implementations use localized sensors on beds and chairs to alert caregivers of unsupervised patient ambulations; however, such systems have high false alarm rates. We investigate the recognition of bed and chair exits in real-time using a wireless wearable sensor worn by healthy older volunteers. Fourteen healthy older participants joined in supervised trials. They wore a batteryless, lightweight and wireless sensor over their attire and performed a set of broadly scripted activities. We developed a movement monitoring approach for the recognition of bed and chair exits based on a machine learning activity predictor. We investigated the effectiveness of our approach in generating bed and chair exit alerts in two possible clinical deployments (Room 1 and Room 2). The system obtained recall results above 93% (Room 2) and 94% (Room 1) for bed and chair exits, respectively. Precision was >78% and 67%, respectively, while F-score was >84% and 77% for bed and chair exits, respectively. This system has potential for real-time monitoring but further research in the final target population of older people is necessary.

Using process improvement methodology to address the complex issue of falls in the inpatient setting

Falls in the acute care hospital are a significant patient safety issue. The purpose of this article was to describe the use of process improvement methodology to address inpatient falls on 5 units. This initiative focused on a proactive approach to falls, identification of high-risk patients, and a complete assessment of patients at risk. During the project timeframe, the mean total fall rate decreased from 3.7 to 2.8 total falls per 1000 patient days.

Effectiveness of individualized fall prevention program in geriatric rehabilitation hospital setting: a cluster randomized trial

BACKGROUND AND AIMS

There is no conclusive evidence that hospital fall prevention programs can reduce the number of falls. We aimed to investigate the effect of a targeted individualized falls prevention program in a geriatric rehabilitation hospital.

METHODS

This was a two-stage cluster-controlled trial carried out in five geriatric rehabilitation wards. Participants were 752 patients with mean age 83.2 years. The intervention was a two-phase targeted intervention falls prevention program. The intervention included an assessment of patient's risk by a risk assessment tool and an individual management that includes medical, behavioral, cognitive and environmental modifications. Patients with moderate risk received additionally orientation guidance, and mobility restriction. Patients determined as high risk were additionally placed under permanent personal supervision. Outcome measures were falls during hospital stay.

RESULTS

In both stages of the trial, intervention and control wards were almost similar at baseline for individual patient characteristics. Overall, 37 falls occurred during the study. No significant difference was found in fall rates during follow-up between intervention and control wards: 1.306 falls per 1000 bed days in the intervention groups and 1.763-1.826 falls per 1000 bed days in the control groups. The adjusted hazard ratio for falls in the intervention groups was 1.36 (95 % confidence interval 0.89-1.77) (P = 0.08) in the first stage and 1.27 (95 % confidence interval 0.92-1.67) (P = 0.12) in the second stage.

CONCLUSION

These results suggest that in a geriatric rehabilitation hospital a targeted individualized intervention falls prevention program is not effective in reducing falls.

The Falls In Care Home study: a feasibility randomized controlled trial of the use of a risk assessment and decision support tool to prevent falls in care homes

Objective:

To explore the feasibility of implementing and evaluating the Guide to Action Care Home fall prevention intervention.

Design:

Two-centre, cluster feasibility randomized controlled trial and process evaluation.

Setting:

Purposive sample of six diverse old age/learning disability, long stay care homes in Nottinghamshire, UK.

Subjects:

Residents aged over 50 years, who had fallen at least once in the past year, not bed-bound, hoist-dependent or terminally ill.

Interventions:

Intervention homes (n = 3) received Guide to Action Care Home fall prevention intervention training and support. Control homes (n = 3) received usual care.

Outcomes:

Recruitment, attrition, baseline and six-month outcome completion, contamination and intervention fidelity, compliance, tolerability, acceptance and impact.

Results:

A total of 81 of 145 (56%) care homes expressed participatory interest. Six of 22 letter respondent homes (27%) participated. The expected resident recruitment target was achieved by 76% (52/68). Ten (19%) residents did not complete follow-up (seven died, three moved). In intervention homes 36/114 (32%) staff attended training. Two of three (75%) care homes received protocol compliant training. Staff valued the training, but advised greater management involvement to improve intervention implementation. Fall risks were assessed, actioned and recorded in care records. Of 115 recorded falls, 533/570 (93%) of details were complete. Six-month resident fall rates were 1.9 and 4.0 per year for intervention and control homes, respectively.

Conclusions:

The Guide to Action Care Home is implementable under trial conditions. Recruitment and follow-up rates indicate that a definitive trial can be completed. Falls (primary outcome) can be ascertained reliably from care records.

Respective and combined effects of impairments in sensorimotor systems and cognition on gait performance: a population-based cross-sectional study

Background

Respective and combined effects of impairments in sensorimotor systems and cognition on gait performance have not been fully studied. This study aims to describe the respective effects of impairments in muscle strength, distance vision, lower-limb proprioception and cognition on the Timed Up & Go (TUG) scores (i.e., performed TUG [pTUG], imagined TUG [iTUG] and the time difference between these two tests [delta TUG]) in older community-dwellers; and to examine their combined effects on TUG scores.

Methods

Based on a cross-sectional design, 1792 community-dwellers (70.2±4.8 years; 53.6% female) were recruited. Gait performance was assessed using pTUG, iTUG and delta TUG. Participants were divided into healthy individuals and 15 subgroups of individuals according to the presence of impairment in one or more subsystems involved in gait control (i.e., muscle strength and/or distance vision and/or lower-limb proprioception and/or cognition [episodic memory and executive performance]). Impairment in muscle strength, distance vision and lower-limb proprioception was defined as being in the lowest tertile of performance. Impairment in cognition was defined as abnormal episodic memory and executive tests.

Results

A total of 191 (10.7%) exhibited impairment in muscle strength, 188 (10.5%) in distance vision, 302 (16.9%) in lower-limb proprioception, and 42 (2.3%) in cognition. Linear regressions showed that cognitive impairment as well as dual combinations of impairments were associated with increased pTUG (P<0.02). Impairment in lower-limb proprioception was associated with decreased iTUG (P=0.015). All combinations of impairments, except those including muscle strength and the combinations of the 4 subsystems, were associated with increased delta TUG (P<0.04).

Conclusion

Cognitive integrity is central for efficient gait control and stability, whereas lower-limb proprioception seems to be central for gait imagery.

Intervention to Prevent Falls on the Medical Service in a Teaching Hospital

Objective.

To evaluate an intervention to prevent falls at a hospital.

Design.

A quasi-experimental intervention with historical and contemporaneous control groups.

Setting and Participants.

Nursing staff and patients in the medicine service (comprising 2 intervention floors and 2 control floors) at an academic hospital.

Intervention.

Nursing staff were educated regarding fall prevention during the period from April through December 2005. Data on implemented prevention strategies were collected on control and intervention floors. Mean monthly fall rates were compared over time and between intervention and control floors, using repeated-measures analysis of variance.

Results.

Postintervention fall knowledge test scores for the nursing staff were greater than preintervention test scores (mean postintervention test score, 91%; mean preintervention test score, 72%;P< .001). Use of prevention strategies was greater on intervention floors than it was on control floors, including patient education via pamphlets (46% vs 15%;P< .001), use of toileting schedules (36% vs 25%;P= .016), and discussion of high-risk medications (51% vs 30%;P< .001). The mean fall rate for the first 5 months of the intervention was 43% less than that for the 9-month preintervention period for intervention floors (3.81 falls per 1,000 patient-days vs 6.64 falls per 1,000 patient-days;P= .043). Comparisons of mean rates for the overall 9-month intervention period versus the 9-month preintervention period showed a 23% difference in the fall rate for intervention floors, but this did not reach statistical significance (5.09 falls per 1,000 patient-days vs 6.64 falls per 1,000 patient-days;P= .182).

Conclusion.

The nursing staffs knowledge and use of prevention strategies increased. Fall rates decreased for 5 months after the educational intervention, but the reduction was not sustained.

Development and pilot study of a bed-exit alarm based on a body-worn accelerometer

BACKGROUND

Falls are a major problem in hospitals and nursing homes. The consequences of falls can be severe, both for the individual and for the caring institution.

OBJECTIVE

The aim of the work presented here is to reduce the number of falls on a geriatric ward by monitoring patients more closely. To achieve this goal, a bed-exit alarm that reliably detects an attempt to get up has been constructed.

MATERIALS AND METHODS

A requirements analysis revealed the nurses' and physicians' needs and preferences. Based on the gathered information, an incremental design process generated different prototypes. These were tested for the reliability of their ability to detect attempts to get up in both laboratory settings and with geriatric patients. Based on the result of these tests, a scalable technical solution has been developed and proven its reliability in a 1-year, randomized controlled pilot clinical trial on a geriatric ward.

RESULTS

The developed system is unobtrusive and easy to deploy. It has been tested in laboratory settings, usability tests and a 1-year randomized clinical trial with 98 patients. This paper focuses on the technical development of the system. We present different prototypes, the experiments and the pilot study used to evaluate their performance. Last but not least, we discuss the lessons learned so far.

CONCLUSION

The developed bed-exit alarm is able to reliably detect patients' attempts to get up. The results of the clinical trial show that the system is able to reduce the number of falls on a geriatric ward. Next steps are the design of a specialized sensor node that is easier to use and can be applied on an even larger scale due to its reduced cost. A multicenter trial with a larger number of patients is required to confirm the results of this pilot study.

Inpatient falls: defining the problem and identifying possible solutions. Part I: an evidence-based review

In this 2 part series, analysis of the risk stratification tools that are available, definition for the scope of the problem, and potential solutions through a review of the literature are presented. A systematic review was used to identify articles for risk stratification and interventions. Three risk stratification systems are discussed, St Thomas's Risk Assessment Tool in Falling Elderly Inpatients, Morse Fall Scale, and the Hendrich Fall Risk Model. Of these scoring systems, the Hendrich Fall Risk Model is the easiest to use and score. Predominantly, multifactorial interventions are used to prevent patient falls. Education and rehabilitation are common themes in studies with statistically significant results. The second article presents a guide to implementing a quality improvement project around hospital falls. A 10-step approach to Plan-Do-Study-Act (PDSA) cycles is described. Specific examples of problems and analysis are easily applicable to any institution. Furthermore, the sustainability of interventions and targeting new areas for improvement is discussed. Although specific to falls in the hospitalized patient, the goal is to present a stepwise approach which is broadly applicable to other areas requiring quality improvement.

Characteristics and associated factors in patient falls, and effectiveness of the lower height of beds for the prevention of bed falls in an acute geriatric hospital

OBJECTIVES

Whereas several studies about patient falls have provided data for long-term healthcare institutions, less information is available for acute care centres. The objective was to analyze the characteristics of the patient falls and associated factors, and the effectiveness of the lower beds' height to reduce the frequency and the harms of the patient falls in an acute geriatric hospital.

METHODS

A descriptive and retrospective study using a mandatory safety incident report, the IHI Global Trigger Tool, and the claims related to patient falls between 2007 and 2011 in a 200-bed university-associated geriatric hospital.

RESULTS

The falls rate was 5.4 falls per 1000 patient days (1.3% of falls led to fractures) and there was exitus in 6 patients (0.6%). Nearly half of the falls ocurred during the night shift (42.4%). By wards, falls were more frequent in acute geriatric wards (42.9%). A 7.5% of patients had a fall before admission. 3 (0.2%) claims due to possible clinical negligence were found. A reduction (28.3%) of bed falls with the lower height of the bed and a 1.88 times less falls with harm (RR 0.53; CI 95% 0.83-0.34) (p=0.006) was observed.

CONCLUSION

The prevention of patient falls is an important task in geriatric units with a potential reduction of harms and costs, some measures such as the lower height of the bed showed a significant reduction of the falls.

Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness

OBJECTIVES

To systematically document the implementation, components, comparators, adherence, and effectiveness of published fall prevention approaches in U.S. acute care hospitals.

DESIGN

Systematic review. Studies were identified through existing reviews, searching five electronic databases, screening reference lists, and contacting topic experts for studies published through August 2011.

SETTING

U.S. acute care hospitals.

PARTICIPANTS

Studies reporting in-hospital falls for intervention groups and concurrent (e.g., controlled trials) or historic comparators (e.g., before-after studies).

INTERVENTION

Fall prevention interventions.

MEASUREMENTS

Incidence rate ratios (IRR, ratio of fall rate postintervention or treatment group to the fall rate preintervention or control group) and ratings of study details.

RESULTS

Fifty-nine studies met inclusion criteria. Implementation strategies were sparsely documented (17% not at all) and included staff education, establishing committees, seeking leadership support, and occasionally continuous quality improvement techniques. Most interventions (81%) included multiple components (e.g., risk assessments (often not validated), visual risk alerts, patient education, care rounds, bed-exit alarms, and postfall evaluations). Fifty-four percent did not report on fall prevention measures applied in the comparison group, and 39% neither reported fidelity data nor described adherence strategies such as regular audits and feedback to ensure completion of care processes. Only 45% of concurrent and 15% of historic control studies reported sufficient data to compare fall rates. The pooled postintervention incidence rate ratio (IRR) was 0.77 (95% confidence interval = 0.52-1.12, P = .17; eight studies; I(2) : 94%). Meta-regressions showed no systematic association between implementation intensity, intervention complexity, comparator information, or adherence levels and IRR.

CONCLUSION

Promising approaches exist, but better reporting of outcomes, implementation, adherence, intervention components, and comparison group information is necessary to establish evidence on how hospitals can successfully prevent falls.

Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial

BACKGROUND

Bed alarm systems intended to prevent hospital falls have not been formally evaluated.

OBJECTIVE

To investigate whether an intervention aimed at increasing bed alarm use decreases hospital falls and related events.

DESIGN

Pair-matched, cluster randomized trial over 18 months. Nursing units were allocated by computer-generated randomization on the basis of baseline fall rates. Patients and outcome assessors were blinded to unit assignment; outcome assessors may have become unblinded. (ClinicalTrials.gov registration number: NCT00183053)

SETTING

16 nursing units in an urban community hospital.

PATIENTS

27 672 inpatients in general medical, surgical, and specialty units.

INTERVENTION

Education, training, and technical support to promote use of a standard bed alarm system (intervention units); bed alarms available but not formally promoted or supported (control units).

MEASUREMENTS

Pre-post difference in change in falls per 1000 patient-days (primary end point); number of patients who fell, fall-related injuries, and number of patients restrained (secondary end points).

RESULTS

Prevalence of alarm use was 64.41 days per 1000 patient-days on intervention units and 1.79 days per 1000 patient-days on control units (P = 0.004). There was no difference in change in fall rates per 1000 patient-days (risk ratio, 1.09 [95% CI, 0.85 to 1.53]; difference, 0.41 [CI, -1.05 to 2.47], which corresponds to a greater difference in falls in control vs. intervention units) or in the number of patients who fell, injurious fall rates, or the number of patients physically restrained on intervention units compared with control units.

LIMITATION

The study was conducted at a single site and was slightly underpowered compared with the initial design.

CONCLUSION

An intervention designed to increase bed alarm use in an urban hospital increased alarm use but had no statistically or clinically significant effect on fall-related events or physical restraint use.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Potentially inappropriate prescribing of benzodiazepines for older adults and risk of falls during a hospital stay: a descriptive study

BACKGROUND

Falls have been identified as a potential adverse event associated with the administration of psychotropic medications to older patients.

OBJECTIVE

The objective of this exploratory study was to examine the association between potentially inappropriate prescribing of benzodiazepines, as defined by the Beers criteria, by older adults (at least 65 years of age) and the risk of having a fall during acute inpatient care.

METHODS

This 1-year retrospective cross-sectional study of discharges from a tertiary care hospital in Halifax, Nova Scotia, used pharmacy data to identify the prescription of benzodiazepines listed in the updated Beers criteria as being associated with an increased risk of falls. These data were linked with information on in-hospital falls from occurrence report forms.

RESULTS

For 5831 (58.1%) of the 10 044 discharges, the patient had received a prescription for at least one benzodiazepine during the hospital stay. A total of 574 falls were reported (for 374 patients), and 226 (39.4%) of the falls resulted in an injury. According to the Beers criteria, for 936 (9.3%) of the discharges, the patient had received a prescription for at least one potentially inappropriate benzodiazepine. However, there was no statistically significant difference between patients with a prescription for a potentially inappropriate benzodiazepine and those receiving an appropriate or no benzodiazepine in terms of occurrence of falls (4.5% versus 3.8%, p = 0.30) or fall-related injuries (2.6% versus 1.8%, p = 0.08). The median length of stay was about 3 days longer for the former group (9 versus 6 days, p < 0.001).

CONCLUSIONS

The findings from the current study do not support use of the Beers criteria related to benzodiazepines alone for identifying patients at risk of falls or injuries.

Falls on an inpatient rehabilitation unit: risk assessment and prevention

PURPOSE

To determine the relationship between admission diagnosis and admission score on Functional Independence Measure (FIM) to the likelihood that a patient will fall. To measure the effectiveness of a multifactorial program to reduce falls.

METHOD

The Quality Improvement Team put in place a multifactorial program to reduce the incidence of falls on an inpatient rehabilitation unit. The authors reviewed the records of all patients admitted to the rehabilitation unit between January 2006 and December 2009 to determine if the program resulted in a reduced rate of falls. The authors also reviewed the data to evaluate if admission score on the FIM and the diagnosis or impairment group of the patient are related to the risk of fall.

RESULTS

FIM score is inversely related to the rate of falls. Patients with admission diagnosis of stroke, brain injury, amputation, neurologic disorders (Parkinson's disease, multiple sclerosis, Guillain-Barre, myopathy, peripheral neuropathy), and spinal cord injury are at higher risk for fall than patients whose admission diagnosis related to orthopedic, cardiac, pulmonary disorders, prolonged stay on medical or surgical units, or trauma without spinal cord injury or head injury. There was a significant reduction in the rate of falls from 14.9% to 7.3% of patients admitted to the IRF.

DISCUSSION

Patients with low FIM scores, disorders of the central and peripheral nervous system, and amputations are at high risk of fall. Compliance with recommended guidelines can reduce the rate of fall and improve patient safety.

CONCLUSION

The rate of falls on an IRF will be determined in part by the case mix and functional levels of the patients on the unit. Strict adherence to appropriate nursing protocols can reduce the rate of falls.

Cost analysis of a falls-prevention program in an orthopaedic setting

BACKGROUND

Falls by orthopaedic patients may lead to negative outcomes such as injury, prolonged hospitalization, delayed rehabilitation, and increased costs.

QUESTIONS/PURPOSES

We examined the impact of a multidisciplinary Falls-prevention Program (FPP) on the incidence of inpatient falls and fall-related injuries in an orthopaedic hospital during a 6-year period.

METHODS

Patient data and fall incident report data were reviewed to identify risk factors associated with falls and fall-related injuries. A cost analysis was performed to calculate costs incurred as a result of falls.

RESULTS

A total of 415 falls occurred during a 5-year period preintervention. The fall rate preintervention was significantly higher than the fall rate postintervention (3.49 versus 2.68 per 1000 bed days). Eighty-five falls occurred in the 12 months preintervention. A total of 15.29% (13 of 85) of falls resulted in minor injuries, and 9.42% (eight of 85) resulted in major injuries. The total cost incurred during this period as a result of falls was $117,754.12. Of this, 95.5% resulted from patients who sustained a hip fracture (n = 4). The total cost of implementing the FPP was $15,694.46. In the 12 months postintervention, 52 falls occurred. Twenty-five percent (13 of 52) of falls resulted in minor injuries, and 5.76% (two of 52) resulted in major injuries (no hip fractures). The total costs accrued during this period as a result of falls was $811.70.

CONCLUSIONS

After implementation of a FPP, there were significant decreases in fall incidence, fall-related morbidity, and consequent costs.

LEVEL OF EVIDENCE

Level III, economic and decision analyses. See the Guidelines for Authors for a complete description of levels of evidence.

An inpatient fall prevention initiative in a tertiary care hospital

BACKGROUND

In response to increasing inpatient fall rates, which reached 3.9 falls per 1000 inpatient-days in the last quarter of 2005, Staten Island University Hospital, a 714-bed, tertiary care hospital (Staten Island, New York), implemented a fall prevention initiative (FPI). The initiative was intended to decrease inpatient falls and associated injury by institutionalizing staff safety awareness; accountability, and critical thinking; eradicating historically acceptable system failures; and mandating a critical evaluation of safety precautions and application of fall prevention protocol.

METHODS

The intervention included two phases (1) a review phase, in which existing fall prevention efforts were evaluated, and (2) the FPI implementation phase, in which systems were implemented to ensure fall risk assessments, fall incident investigations, identifying and confronting problem issues, planning and adherence to corrective action, and accountability for missed preventive opportunities. For all 1,098,471 inpatient-days of persons aged 18 years and older, with an admission lasting at least one day, between April 2006 and March 2010, data were collected for inpatient falls and fall-associated injuries per 1000 inpatient-days.

RESULTS

Four-year inpatient fall rates decreased by 63.9% (p < .0001); the greatest reduction (72.3%) occurred between the first quarter (Q1) 2005 and Q4 2009. Minor and moderate fall-related injuries significantly decreased by 54.4% and 64.0%, respectively. Two falls with major injury occurred during the study.

CONCLUSIONS

The FPI was associated with a significant reduction in fall and fall-related injury rates. The results suggest that increasing commitment to continuous quality improvement through enhanced safety awareness and accountability contributed to the initiative's success and led to a change of normative behavior and a culture of safety.

Fall Prevention in Hospitals

This article summarizes research and draws overall conclusions from the body of literature on fall prevention interventions to provide nurse administrators with a basis for developing evidence-based fall prevention programs in the hospital setting. Data are obtained from published studies. Thirteen articles are retrieved that focused on fall interventions in the hospital setting. An analysis is performed based on levels of evidence using an integrative review process. Multifactoral fall prevention intervention programs that included fall-risk assessments, door/bed/patient fall-risk alerts, environmental and equipment modifications, staff and patient safety education, medication management targeted to specific types, and additional assistance with transfer and toileting demonstrate reduction in both falls and fall injuries in hospitalized patients. Hospitals need to reduce falls by using multifactoral fall prevention programs using evidence-based interventions to reduce falls and injuries.

Testing the sensitivity, specificity and feasibility of four falls risk assessment tools in a clinical setting

AIM

This paper reports on a study undertaken to test the sensitivity, specificity and feasibility of four fall risk assessment tools.

BACKGROUND

Falls risk assessment tools have been developed based on literature and findings from empirical studies, but the instruments often lack further testing in the clinical setting.

METHOD

Four falls risk assessment tools were tested simultaneously in this study. The data was collected in May-June 2006. All assessment tools were completed on a total of 1546 patients. Descriptive statistics were used for data analysis.

RESULTS

The use of the instruments was moderately consistent among registered nurses, but the education provided did not entirely eliminate problems with accuracy. The sensitivity of the instruments was 57.1-100% and specificity was 24.9-69.3%.

CONCLUSION

The sensitivity and specificity of the instruments are important factors to consider when choosing an instrument. However, the strategies to educate staff and to intervene appropriately are equally important for an organization undertaking a proactive stance in mitigating the risk of falls.

IMPLICATIONS FOR NURSING MANAGEMENT

It is important for managers to test instruments in their own organizations and specific populations. It is also critical to carefully assess that the chosen instrument is easy and accurate in use.

Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial

AIM

This article is a report of a randomized controlled trial to examine the effectiveness of a targeted multiple intervention strategy in reducing the number of patient falls in an acute care hospital.

BACKGROUND

Prevention of patient falls remains a challenge that has eluded healthcare institutions. The effectiveness of targeted multiple fall prevention interventions in reducing the incidences of falling has not been established.

METHODS

Patients who scored 5 and above on the Hendrich II Fall Risk Model, a fall assessment tool, were recruited in 2006. Patients who were randomized to the intervention group received targeted multiple interventions. Both the research groups received the standard fall prevention interventions from the ward nurses. The rates of fall incidences for both groups were reported with 95% CI, calculated using Wilson method and compared using the Chi-square test. The relative risk was estimated and 95% CI was calculated using the methods described by Armitage and Berry. The times to first fall events were constructed using the Kaplan-Meier method. The hazard ratio was reported at 95% CI and the comparison was made using the log-rank test.

RESULTS

There were 912 and 910 participants in the control and intervention groups, respectively. The fall incidence rates were 1·5% (95% CI: 0·9-2·6) and 0·4% (95% CI: 0·2-1·1) in the control and intervention groups, respectively. The relative risk estimate of 0·29 (95% CI: 0·1-0·87) favours the intervention group.

CONCLUSION

This study showed that targeted multiple interventions were effective in reducing the incidences of falls in patients in the acute care setting.