Divesting from a Scored Hospital Fall Risk Assessment Tool (FRAT): A Cluster Randomized Non-Inferiority Trial

Hospital falls clinical practice guidelines: a global analysis and systematic review

BACKGROUND

Hospital falls continue to be a persistent global issue with serious harmful consequences for patients and health services. Many clinical practice guidelines now exist for hospital falls, and there is a need to appraise recommendations.

METHOD

A systematic review and critical appraisal of the global literature was conducted, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Web of Science, Embase, CINAHL, MEDLINE, Epistemonikos, Infobase of Clinical Practice Guidelines, Cochrane CENTRAL and PEDro databases were searched from 1 January 1993 to 1 February 2024. The quality of guidelines was assessed by two independent reviewers using Appraisal of Guidelines for Research and Evaluation Global Rating Scale and Appraisal of Guidelines of Research and Evaluation Recommendation Excellence (AGREE-REX). Certainty of findings was rated using Grading of Recommendations Assessment, Development and Evaluation Confidence in Evidence from Reviews of Qualitative Research. Data were analysed using thematic synthesis.

RESULTS

2404 records were screened, 77 assessed for eligibility, and 20 hospital falls guidelines were included. Ten had high AGREE-REX quality scores. Key analytic themes were as follows: (i) there was mixed support for falls risk screening at hospital admission, but scored screening tools were no longer recommended; (ii) comprehensive falls assessment was recommended for older or frail patients; (iii) single and multifactorial falls interventions were consistently recommended; (iv) a large gap existed in patient engagement in guideline development and implementation; (v) barriers to implementation included ambiguities in how staff and patient falls education should be conducted, how delirium and dementia are managed to prevent falls, and documentation of hospital falls.

CONCLUSION

Evidence-based hospital falls guidelines are now available, yet systematic implementation across the hospital sector is more limited. There is a need to ensure an integrated and consistent approach to evidence-based falls prevention for a diverse range of hospital patients.

Evaluation of a concise fall risk stratification among older adults with cataracts in day surgery settings: A historically controlled study

AIM

This study aimed to evaluate the use of a concise fall risk stratification in assessing and predicting falls compared with the Morse Falls Scale among older adults with cataracts in day surgery settings.

METHODS

A historically controlled study conducted from July 2020 to June 2022 was used in a municipal ophthalmic hospital in China. The concise fall risk stratification which directly graded fall risk by multifactorial judgment was used during the intervention period, while the Morse Falls Scale which graded fall risk by scale scores was used during the control period. The fall risk levels, fall assessment time, fall rates, fall-related injuries, predictive validity, and patient satisfaction with day surgery care were extracted. Propensity score matching was performed to balance baselines.

RESULTS

After matching, 4132 patients were included in the final analysis. Compared with the control group, the intervention group had significantly higher assessment results for fall risk level, a significantly shorter (by 48.15%) fall assessment time, and higher patient satisfaction. There were no differences in fall rates and fall-related injuries. Compared with the Morse Falls Scale, the concise fall risk stratification had higher sensitivity and negative predictive validity, and lower specificity and positive predictive validity, while the area under curve did not differ significantly.

CONCLUSION

The use of the concise fall risk stratification reduced fall assessment time, improved patient satisfaction, and is unlikely to impact falls with an overall predictive performance comparable to that of the Morse Falls Scale for older cataract adults in day surgery settings.

Talking about falls: a qualitative exploration of spoken communication of patients' fall risks in hospitals and implications for multifactorial approaches to fall prevention

BACKGROUND

Inpatient falls are the most common safety incident reported by hospitals worldwide. Traditionally, responses have been guided by categorising patients' levels of fall risk, but multifactorial approaches are now recommended. These target individual, modifiable fall risk factors, requiring clear communication between multidisciplinary team members. Spoken communication is an important channel, but little is known about its form in this context. We aim to address this by exploring spoken communication between hospital staff about fall prevention and how this supports multifactorial fall prevention practice.

METHODS

Data were collected through semistructured qualitative interviews with 50 staff and ethnographic observations of fall prevention practices (251.25 hours) on orthopaedic and older person wards in four English hospitals. Findings were analysed using a framework approach.

FINDINGS

We observed staff engaging in 'multifactorial talk' to address patients' modifiable risk factors, especially during multidisciplinary meetings which were patient focused rather than risk type focused. Such communication coexisted with 'categorisation talk', which focused on patients' levels of fall risk and allocating nursing supervision to 'high risk' patients. Staff negotiated tensions between these different approaches through frequent 'hybrid talk', where, as well as categorising risks, they also discussed how to modify them.

CONCLUSION

To support hospitals in implementing multifactorial, multidisciplinary fall prevention, we recommend: (1) focusing on patients' individual risk factors and actions to address them (a 'why?' rather than a 'who' approach); (2) where not possible to avoid 'high risk' categorisations, employing 'hybrid' communication which emphasises actions to modify individual risk factors, as well as risk level; (3) challenging assumptions about generic interventions to identify what individual patients need; and (4) timing meetings to enable staff from different disciplines to participate.

Patient handling training interventions and musculoskeletal injuries in healthcare workers: Systematic review and meta-analysis

Workplace injuries are a serious issue for the health and social care industry, with the sector accounting for 20 % of all serious claims reported. The aim of this systematic review was to determine whether patient handling training interventions that included instruction on patient transfer techniques are effective in preventing musculoskeletal injuries in healthcare workers. Methods: Electronic databases MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO) and Health and Safety Science Abstracts (ProQuest) were searched for controlled trials from January 1996-August 2022. Risk of bias was evaluated using the PEDro scale and overall certainty of evidence assessed using the Grading of Recommendations, Assessment, Development and Evaluation for each meta-analysis. Results: A total of nine studies (3903 participants) were included. There is moderate certainty evidence that could not conclude whether patient handling training affects the 12-month incidence of lower back pain (OR = 0.83, 95 % CI [0.59, 1.16]). There is low certainty evidence that patient handing training does not prevent lower back pain in health professionals without pre-existing pain (MD = -0.06, 95 % CI [-0.63, 0.52]) but may reduce lower back pain in those with pre-existing pain (MD = -2.92, 95 % CI [-5.44, -0.41]). The results also suggest that there may be a positive effect of training incorporating risk assessment on musculoskeletal injury rates; however the evidence is of very low certainty. There is low certainty evidence from a single study that training may have a short-term effect on sickness absences.) Conclusions: There is a lack of evidence to support patient handling training when delivered to all healthcare staff. Training in its current form may be an ineffective strategy for reducing musculoskeletal injuries and pain. High quality disinvestment studies or trials incorporating risk assessment strategies are warranted. Practical Applications: This review suggests health service managers question the effectiveness of current patient handling training practices and consider evaluating current practices before allocating resources to meet employee risk reduction obligations.

Preventing hospital falls: feasibility of care workforce redesign to optimise patient falls education

OBJECTIVE

To examine the feasibility of using allied health assistants to deliver patient falls prevention education within 48 h after hospital admission.

DESIGN AND SETTING

Feasibility study with hospital patients randomly allocated to usual care or usual care plus additional patient falls prevention education delivered by supervised allied health assistants using an evidence-based scripted conversation and educational pamphlet.

PARTICIPANTS

(i) allied health assistants and (ii) patients admitted to participating hospital wards over a 20-week period.

OUTCOMES

(i) feasibility of allied health assistant delivery of patient education; (ii) hospital falls per 1,000 bed days; (iii) injurious falls; (iv) number of falls requiring transfer to an acute medical facility.

RESULTS

541 patients participated (median age 81 years); 270 control group and 271 experimental group. Allied health assistants (n = 12) delivered scripted education sessions to 254 patients in the experimental group, 97% within 24 h after admission. There were 32 falls in the control group and 22 in the experimental group. The falls rate was 8.07 falls per 1,000 bed days in the control group and 5.69 falls per 1,000 bed days for the experimental group (incidence rate ratio = 0.66 (95% CI 0.32, 1.36; P = 0.26)). There were 2.02 injurious falls per 1,000 bed days for the control group and 1.03 for the experimental group. Nine falls (7 control, 2 experimental) required transfer to an acute facility. No adverse events were attributable to the experimental group intervention.

CONCLUSIONS

It is feasible and of benefit to supplement usual care with patient education delivered by allied health assistants.

A stepped-wedge randomised controlled trial to assess efficacy and cost-effectiveness of a care-bundle to prevent falls in older hospitalised patients

BACKGROUND

Patient accidental falls in a hospital environment are a serious problem for patient safety, and for the additional costs due to associated medical interventions.

OBJECTIVE

The endpoints of this study were the assessment of the fall incidence in the hospital before and after the implementation of a multidisciplinary care-bundle, along with a cost-effectiveness evaluation.

DESIGN

A stepped-wedge trial was conducted between April 2015 and December 2016 in Bologna University Hospital.

METHODS

Incidence rates (IRs) of falls in both the control and intervention periods were calculated. A multilevel mixed-effects generalised linear model with logit link function, adjusted for age, sex, cluster cross-over timing and patients' clinical severity was used to estimate odds ratios (OR) of fall risk of patients of the intervention group respect to the controls.Intervention costs associated with the introduction of the care-bundle intervention were spread between patients per cluster-period-group of exposure. Incremental cost-effectiveness ratio was evaluated using total costs in the intervention and control groups.

RESULTS

IRs of falls in control and intervention periods were respectively 3.15 and 2.58 for 1,000 bed-days. After adjustment, the subjects receiving the intervention had a statistically significant reduced risk of falling with respect to those who did not (OR = 0.71, 95% confidence interval: 0.60-0.84). According to the cost-effectiveness analysis, the incremental cost per fall prevented was €873.92 considering all costs, and €1644.45 excluding costs related falls.

CONCLUSIONS

Care-bundle had a protective effect on patients, with a statistically significant reduction of the fall risk. This type of intervention appears cost-effective compared to routine practices.

Blind Spots in Hospital Fall Prevention: Falls in Stroke Patients Occurred Not Only in Those at a High Risk of Falling

OBJECTIVES

Although the standard falls prevention strategy is to identify and respond to patients with high-risk conditions, it remains unclear whether falls in patients with high fall risk account for most observed falls. In this study, fall risk and number of falls were calculated based on patients' motor and cognitive abilities, and the relationship between the two was examined.

DESIGN

We conducted a retrospective cohort study.

SETTING AND PARTICIPANTS

We included 2518 consecutive patients with stroke who were admitted to a rehabilitation hospital.

METHODS

Data on falls during hospitalization and biweekly assessed Functional Independence Measure scores were retrieved from the medical records. The average Functional Independence Measure scores for the motor and cognitive items were obtained and categorized as complete dependence, modified dependence, and independence. The fall rate (falls/1000 person-days) and number of observed falls in each combined condition were investigated.

RESULTS

Modified dependence on motor ability and complete dependence on cognitive ability had the highest risk of falls, with a fall rate of 10.8/1000 person-days and 51 fall observations, which accounted for 4.3% of all falls. Independent motor and cognitive ability had the lowest risk of falls, a fall rate of 2.6/1000 person-days and 146 observed falls, accounting for 12.4% of all falls, which was 2.8 times higher than the number of falls observed in the highest risk of falls condition.

CONCLUSIONS AND IMPLICATIONS

The combined motor-cognitive ability with the highest risk of falls in stroke inpatients did not have the highest number of observed falls. Rather, the combined motor-cognitive ability with the lowest risk of falls tended to have a high number of observed falls. A different strategy is needed to reduce the total number of falls.

Investigation and analysis of high risk factors of falls in hospitalised patients after vascular surgery

AIM

To analyse the risk factors for falls in vascular patients and methods to mitigate fall risk in hospitalised patients receiving vascular surgery.

DESIGN

This study is a multicentre, retrospective study.

METHODS

A total of 112 inpatients that underwent vascular surgery in five hospitals in Shanxi Province from April 2018 to April 2022 were selected. They were divided into two groups according to whether they had fallen or not; 56 patients who fell were taken as the observation group and 56 patients who did not fall were taken as the control group. The risk factors of falls were analysed by univariate and logistic regression.

RESULTS

There was no significant difference between the observation and the control groups in male patients and the incidence of falls without family members. In the observation group, the percentage of patients aged ≥65 years old, with a history of falls and/or fractures, long-term medications and a history of osteoporosis was higher than in the control group and showed a statistically significant difference. Multivariate logistic regression analysis showed that advanced age, a history of falls and fractures, long-term medications and a history of osteoporosis were independent risk factors for falls, and the differences were statistically significant.

CONCLUSION

Older age, a history of falls and/or fractures, continuous medication for more than 3 months and a history of osteoporosis are the risk factors for falls in hospitalised patients undergoing vascular surgery.

Nurses' perspectives on inpatient falls in a large academic hospital in South Africa

BACKGROUND

Falls risk assessment tools, including the Morse Falls Scale, have been used for years, and yet falls remain key adverse events in hospitals. Nurses are key role players in falls prevention and can champion patient safety.

OBJECTIVES

The aim of the study was to explore ward nurses' attitudes, knowledge and practices regarding the use of falls risk assessment tools, institutional falls policy and falls prevention.

METHODS

A survey design was used. All permanent ward nurses were eligible to participate, and a convenience sample was used.

RESULTS

Nurses endorsed the Morse Falls Scale, recommended by institutional policy, as effective in reducing falls and indicated that incident reporting measured progress on monitoring fall events. Falls prevention training was scanty; however, nurses were keen for further education of falls.

CONCLUSION

Effective falls risk management needs to extend beyond promulgating policy and actively address nursing and patient education.Contribution: This study adds to the sparse literature regarding nursing practice and falls prevention in a developing country. Recommendations for change have been made.

Fall risk stratification of community-living older people. Commentary on the world guidelines for fall prevention and management

The Task Force on Global Guidelines for Falls in Older Adults has put forward a fall risk stratification tool for community-dwelling older adults. This tool takes the form of a flowchart and is based on expert opinion and evidence. It divides the population into three risk categories and recommends specific preventive interventions or treatments for each category. In this commentary, we share our insights on the design, validation, usability and potential impact of this fall risk stratification tool with the aim of guiding future research.

Falls risk perception measures in hospital: a COSMIN systematic review

Falls prevention in hospital continues to be a research priority because of the poor health outcomes and financial burdens that can arise. Recently updated World Guidelines for Falls Prevention and Management strongly recommend evaluating patients' concerns about falling as part of a multifactorial assessment. The aim of this systematic review was to evaluate the quality of falls risk perception measures for adults in a hospital setting. This review was conducted using the Consensus-based Standards for the selection of health Measurement Instruments guidelines and provides a comprehensive summary of these instruments, including psychometric properties, feasibility and clinical recommendations for their use. The review followed a prospectively registered protocol, in which a total of ten databases were searched between the years 2002 and 2022. Studies were included if the instruments measured falls risk perception and/or other psychological falls constructs, if they were conducted in a hospital setting and if the target population contained hospital inpatients. A total of 18 studies met the inclusion criteria, encompassing 20 falls risk perception measures. These falls risk perception instruments were grouped into five falls-related constructs: Balance Confidence, Falls Efficacy/Concern, Fear of Falling, Self-Awareness and Behaviour/Intention. Two of the patient reported outcome measures (PROMs) received Class A recommendations (Falls Risk Perception Questionnaire and the Spinal Cord Injury-Falls Concern Scale); however, this rating is only applicable for the populations/context described in the studies. Thirteen PROMs received Class B recommendations, solidifying the need for further validation studies of these PROMs.

Nurses' experiences of using falls alarms in subacute care: A qualitative study

Bed and chair alarms have been included in many multifaceted falls prevention interventions. None of the randomised trials of falls alarms as sole interventions have showed significant effect on falls or falls with injury. Further, use of bed and chair alarms did not change patients' fear of falling, length of hospital stay, functional status, discharge destination or health related quality of life. The aim of this study was to explore nurses' experiences of using bed and chair alarms. A qualitative descriptive study using semi-structured interviews with a purposive sample of 12 nurses was conducted on a 32-bed Geriatric Evaluation and Management ward in Melbourne, Australia. Participants were interviewed between 27 January and 12 March 2021.Transcribed audio-recordings of interviews were analysed using inductive thematic analysis. NVIVO 12.6 was used to manage the study data. Three major themes and four subthemes were constructed from the data: i) negative impacts of falls alarms (subthemes: noisy technology, imperfect technology), ii) juggling the safety-risk conflict, and iii) negotiating falls alarm use (subthemes: nurse decision making and falls alarm overuse). Nurses' experience of using falls alarms was predominantly negative and there was tension between falls alarms having limited impact on patient safety and risks associated with their use. Nurses described a need to support nurse decision making related to falls alarms use in practice and policy, and a desire to be empowered to manage falls risk in other ways.

Exploring Hospital Inpatients' Awareness of Their Falls Risk: A Qualitative Exploratory Study

Patient falls in hospital may lead to physical, psychological, social and financial impacts. Understanding patients' perceptions of their fall risk will help to direct fall prevention strategies and understand patient behaviours. The aim of this study was to explore the perceptions and experiences that influence a patient's understanding of their fall risk in regional Australian hospitals. Semi-structured, individual interviews were conducted in wards across three Australian hospitals. Participants were aged 40 years and over, able to communicate in English and were mobile prior to hospital admission. Participants were excluded from the study if they returned a Standardised Mini-Mental State Examination (SMMSE) score of less than 18 when assessed by the researcher. A total of 18 participants with an average age of 69.8 years (SD ± 12.7, range 41 to 84 years) from three regional Victorian hospitals were interviewed for this study. Data were analysed using a reflexive thematic analysis identifying three major themes; (1) Environment (extrinsic) (2) Individual (intrinsic), and (3) Outcomes, as well as eight minor themes. Participants recognised the hazardous nature of a hospital and their personal responsibilities in staying safe. Falls education needs to be consistently delivered, with the focus on empowering the patient to help them adjust to changes in their clinical condition, whether temporary or permanent.

Interprofessional education to implement patient falls education in hospitals: Lessons learned

AIM

The aim of this study was to design, deliver and evaluate an interprofessional education programme for healthcare professionals on how to implement a modified version of the safe recovery programme to prevent falls in hospitalized patients.

DESIGN

Mixed methods design incorporating pre- and post education surveys and individual semi-structured interviews.

METHODS

Thirty-four health professional participants attended a 1-h face-to-face or Zoom® interprofessional education session to learn how to deliver an evidence-based patient falls prevention education strategy, the modified Safe Recovery Programme.

RESULTS

A 1-hour education session was insufficient to build full confidence to deliver the Safe Recovery Programme. There was no statistically significant change in participant views on interprofessional collaboration. Participants recommended prior consultation and preparation before delivery of IPE, with additional opportunities for discussion and feedback during implementation with patients. The findings highlight the importance of interprofessional education for evidence-based interventions in hospitals. Health professionals value education that is timely, interactive, realistic and engaging.

Adult Inpatients’ Perceptions of Their Fall Risk: A Scoping Review

Patient falls in hospitals continue to be a global concern due to the poor health outcomes and costs that can occur. A large number of falls in hospitals are unwitnessed and mostly occur due to patient behaviours and not seeking assistance. Understanding these patient behaviours may help to direct fall prevention strategies, with evidence suggesting the need to integrate patients’ perspectives into fall management. The aim of this scoping review was to explore the extent of the literature about patients’ perceptions and experiences of their fall risk in hospital and/or of falling in hospital. This review was conducted using a five-stage methodological framework recommended by Arksey and O’Malley. A total of nine databases were searched using key search terms such as “fall*”, “perception” and “hospital.” International peer-reviewed and grey literature were searched between the years 2011 and 2021. A total of 41 articles, ranging in study design, met the inclusion criteria. After reporting on the article demographics and fall perception constructs and measures, the qualitative and quantitative findings were organised into five domains: Fall Risk Perception Measures, Patients’ Perceptions of Fall Risk, Patients’ Perceptions of Falling in Hospital, Patients’ Fear of Falling and Barriers to Fall Prevention in Hospital. Approximately two-thirds of study participants did not accurately identify their fall risk compared to that defined by a health professional. This demonstrates the importance of partnering with patients and obtaining their insights on their perceived fall risk, as this may help to inform fall management and care. This review identified further areas for research that may help to inform fall prevention in a hospital setting, including the need for further research into fall risk perception measures.

Interventions to reduce falls in hospitals: a systematic review and meta-analysis

BACKGROUND

Falls remain a common and debilitating problem in hospitals worldwide. The aim of this study was to investigate the effects of falls prevention interventions on falls rates and the risk of falling in hospital.

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

Hospitalised adults.

INTERVENTION

Prevention methods included staff and patient education, environmental modifications, assistive devices, policies and systems, rehabilitation, medication management and management of cognitive impairment. We evaluated single and multi-factorial approaches.

OUTCOME MEASURES

Falls rate ratios (rate ratio: RaR) and falls risk, as defined by the odds of being a faller in the intervention compared to control group (odds ratio: OR).

RESULTS

There were 43 studies that satisfied the systematic review criteria and 23 were included in meta-analyses. There was marked heterogeneity in intervention methods and study designs. The only intervention that yielded a significant result in the meta-analysis was education, with a reduction in falls rates (RaR = 0.70 [0.51-0.96], P = 0.03) and the odds of falling (OR = 0.62 [0.47-0.83], P = 0.001). The patient and staff education studies in the meta-analysis were of high quality on the GRADE tool. Individual trials in the systematic review showed evidence for clinician education, some multi-factorial interventions, select rehabilitation therapies, and systems, with low to moderate risk of bias.

CONCLUSION

Patient and staff education can reduce hospital falls. Multi-factorial interventions had a tendency towards producing a positive impact. Chair alarms, bed alarms, wearable sensors and use of scored risk assessment tools were not associated with significant fall reductions.

Healthcare professional perspectives on barriers and enablers to falls prevention education: A qualitative study

In hospitals, patient falls prevention education is frequently delivered by nurses and allied health professionals. Hospital falls rates remain high globally, despite the many systems and approaches that attempt to mitigate falling. The aim of this study was to investigate health professional views on the enablers and barriers to providing patient falls education in hospitals. Four focus groups with 23 nursing and allied health professionals were conducted at 3 hospitals. Three researchers independently coded the data and findings were analysed thematically with a descriptive qualitative approach to identify and develop themes according to barriers and enablers. Barriers included (i) limited interprofessional communication about patient falls; (ii) sub-optimal systems for falls education for patients and health professionals, and (iii) perceived patient-related barriers to falls education. Enablers to providing patient falls education included: (i) implementing strategies to increase patient empowerment; (ii) ensuring that health professionals had access to effective modes of patient education; and (iii) facilitating interprofessional collaboration. Health professionals identified the need to overcome organisational, patient and clinician-related barriers to falls education. Fostering collective responsibility amongst health professionals for evidence-based falls prevention was also highlighted.

Clinical prediction models for hospital falls: a scoping review protocol

INTRODUCTION

Falls remain one of the most prevalent adverse events in hospitals and are associated with substantial negative health impacts and costs. Approaches to assess patients' fall risk have been implemented in hospitals internationally, ranging from brief screening questions to multifactorial risk assessments and complex prediction models, despite a lack of clear evidence of effect in reducing falls in acute hospital environments. The increasing digitisation of hospital systems provides new opportunities to understand and predict falls using routinely recorded data, with potential to integrate fall prediction models into real-time or near-real-time computerised decision support for clinical teams seeking to mitigate fall risk. However, the use of non-traditional approaches to fall risk prediction, including machine learning using integrated electronic medical records, has not yet been reviewed relative to more traditional fall prediction models. This scoping review will summarise methodologies used to develop existing hospital fall prediction models, including reporting quality assessment.

METHODS AND ANALYSIS

This scoping review will follow the Arksey and O'Malley framework and its recent advances, and will be reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews recommendations. Four electronic databases (CINAHL via EBSCOhost, PubMed, IEEE Xplore and Embase) will be initially searched for studies up to 12 November 2020, and searches may be updated prior to final reporting. Additional studies will be identified by reference list review and citation analysis of included studies. No restriction will be placed on the date or language of identified studies. Screening of search results and extraction of data will be performed by two independent reviewers. Reporting quality will be assessed by the adherence to the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study. Findings will be disseminated through peer-reviewed publication and scientific conferences.