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

Features of effective hospital fall prevention trials: an intervention component analysis

BACKGROUND

Falls in hospitals continue to burden patients, staff, and health systems. Prevention approaches are varied, as well as their success at preventing falls. Intervention component analysis (ICA) is useful in indicating important features associated with successful interventions in sets of trial with high heterogeneity.

METHODS

We conducted an ICA of systematically identified randomised controlled trials of interventions for preventing falls in older people in hospitals. Trial characteristics were extracted; inductive thematic analysis of published papers from included trials to seek triallists perspectives on drivers of success or failure of trials was conducted (ICA stage one) followed by a stratified thematic synthesis by trial outcomes, where trials were classified as positive or negative based on their falls rate or falls risk ratios (ICA stage two) and mapped to the presence of the theorised drivers of success or failure of the trials.

RESULTS

45 trials met the inclusion criteria. Inductive thematic analysis of 50 papers revealed three key drivers (themes), each with subthemes, of effective inpatient hospital fall prevention trials. Theme 1, integration with the local setting, was present in 79% of the positive trials and 67% of the negative trials (79% vs 62% engaging ward staff and 33% vs 43% engaging hospital management). Theme 2, responsive interventions, was present in 83% of the positive trials and 71% of the negative trials (29% vs 38% targeting patient risk assessments and 83% vs 57% tailoring to patient needs and abilities). Theme 3, patient and family involvement, featured in 83% of the positive trials and 52% of the negative trials (50% vs 19% through fall prevention awareness and 58% vs 48% through an active role in fall prevention).

CONCLUSION

Tailored fall prevention approaches and involving patient and family in fall prevention through increasing awareness, in addition to integration with the local intervention setting, appear to play a role in impacting the effectiveness of fall prevention interventions. These theories should be considered in the design of future fall prevention programs and trials and require further evaluation in high quality trials.

Using the Analytic Hierarchy Process to Measure Nurses' Decision-Making Regarding Fall Risks and Care Strategies for Fall Prevention

Background and Purpose: Visualizing the thought processes of nurses is useful in forming evidence to prevent falls. This study aimed to quantify nursing judgment by comparing the choices made by nurses with different experiences regarding fall prevention. Methods: Questionnaires were administered to participants with <9 and ≥10 years of nursing experience to examine their importance ratings regarding fall prevention using an analytic hierarchy process (AHP). Results: Compared with the group with <9 years of experience, the group with ≥10 years of experience viewed habitual behavior in unstable activity as the most important fall risk. They also viewed early detection and alleviation of symptoms that lead to fall risk due to side effects of drugs and diseases as an important nursing practice. Conclusion: Since differences in nursing judgment between experienced and inexperienced nurses were revealed, it is possible that nursing judgment can be measured using AHP.

Considerations across multiple stakeholder groups when implementing fall prevention programs in the acute hospital setting: a qualitative study

BACKGROUND

Falls in hospital remain a common and costly patient safety issue internationally. There is evidence that falls in hospitals can be prevented by multifactorial programs and by education for patients and staff, but these are often not routinely or effectively implemented in practice. Perspectives of multiple key stakeholder groups could inform implementation of fall prevention strategies.

METHODS

Clinicians of different disciplines, patients and their families were recruited from wards at two acute public hospitals. Semi-structured interviews and focus groups were conducted to gain a broad understanding of participants' perspectives about implementing fall prevention programs. Data were analysed using an inductive thematic approach.

RESULTS

Data from 50 participants revealed three key themes across the stakeholder groups shaping implementation of acute hospital fall prevention programs: (i) 'Fall prevention is a priority, but whose?' where participants agreed falls in hospital should be addressed but did not necessarily see themselves as responsible for this; (ii) 'Disempowered stakeholders' where participants expressed feeling frustrated and powerless with fall prevention in acute hospital settings; and (iii) 'Shared responsibility may be a solution' where participants were optimistic about the positive impact of collective action on effectively implementing fall prevention strategies.

CONCLUSION

Key stakeholder groups agree that hospital fall prevention is a priority, however, challenges related to role perception, competing priorities, workforce pressure and disempowerment mean fall prevention may often be neglected in practice. Improving shared responsibility for fall prevention implementation across disciplines, organisational levels and patients, family and staff may help overcome this.

A Stepped-Wedge Cluster-Randomized Controlled Trial of a Multi-interventional Approach for Fall Prevention

BACKGROUND AND OBJECTIVES

Falls are one of the most common adverse events at hospitals that may result in injury and even death. They are also associated with raised length of stay (LOS) and hospitalization costs. This experiment aimed to examine the effectiveness of multiple interventions in reducing inpatient fall rates and the consequent injuries.

METHODS

The present study was a stepped-wedge cluster-randomized controlled trial. It was done in 18 units in a public university hospital over 36 weeks. Patients included in this research were at risk of falls. Overall, 33 856 patients were admitted, of whom 4766 were considered high-risk patients. During the intervention phases, a series of preventive and control measures were considered, namely staff training; patient education; placement of nursing call bells; adequate lighting; supervision of high-risk patients during transmission and handovers; mobility device allocation; placement of call bell and safe guard in bathrooms; placing "fall alert" signs above patients' beds; nurses informing physicians timely about complications such as delirium and hypoxia; encouraging appropriate use of eyeglasses, hearing aids and footwear; keeping side rails up; and reassessing patients after each fall. The primary outcome was participant falls per 1000 patient-days. Secondary outcomes were fall-related injuries and LOS.

RESULTS

The results revealed a decrease in fall rate (n = 4 per 1000 patient-days vs 1.34 per 1000 patient-days, incidence rate ratio (IRR) = 0.19 [95% confidence interval (CI), 0.14-0.26]; P = .001) and injuries (n = 2.4 per 1000 patient-days vs 0.79 per 1000 patient-days, IRR = 0.22 [95% CI, 0.15-0.32]; P = .001) in exposed compared with unexposed phases. There was not a significant difference in LOS (exposed mean 10.63 days [95% CI, 10.26-10.97], unexposed mean 10.84 days [95% CI, 10.59-11.09], mean difference = -0.13 [95% CI, -0.53 to 0.27], P = .52).

CONCLUSIONS

This multi-interventional trial showed a reduction in falls and fall rates with injury but without an overall effect on LOS. Further research is needed to understand the sustainability of multiple fall prevention strategies in hospitals and their long-term impacts.

Is telehealth an effective and feasible option for improving falls-related outcomes in community-dwelling adults with neurological conditions? A systematic review and meta-analysis

OBJECTIVE

To determine the effectiveness of telehealth interventions in reducing community falls risk or rates compared to equivalent in-person interventions in adults with neurological conditions.

DATA SOURCES

Eight electronic databases, trial registries and search engines were searched for the concepts 'falls', 'neurological conditions', and 'telehealth', limited to English language, from inception until August 2022.

REVIEW METHODS

Search for original research where the intervention was delivered via synchronous videoconferencing with the aim of reducing falls and falls-related outcomes. Screening and risk of bias assessment were completed by two independent researchers. Outcome data included falls rates, falls-related outcomes, safety, feasibility, and acceptability. Risk of bias was assessed using the ROB-2 and ROBINS-I tools. Quality of evidence was rated with the grading of recommendations, assessment, development and evaluation (GRADE) approach.

RESULTS

Seventeen studies with 581 participants were included; six were randomised controlled trials. Risk of bias ranged from low to high. Only one study (n = 76) reported falls and did not find differences between telehealth and in-person physiotherapy. There was low-quality evidence that telehealth interventions improve balance outcomes more than face-to-face interventions (pooled between-group mean difference 2.48 Berg Balance Scale units, 95%CI 0.77 to 4.20). Fear of falling was not different between intervention delivery modes.

CONCLUSION

Findings suggest that telehealth delivered falls prevention interventions are safe, feasible and acceptable in community-dwelling adults with neurological conditions, however, data related to effectiveness in reducing falls is limited. Low-quality evidence suggests that telehealth may deliver similar or better outcomes for standing balance in this population.PROSPERO Registration: (CRD42021240167).

Optimizing Post-Acute Care Patient Safety: A Scoping Review of Multifactorial Fall Prevention Interventions for Older Adults

Accidental falls are preventable adverse events for older post-acute care (PAC) patients. Yet, due to the functional and medical care needs of this population, there is little guidance to inform multidisciplinary prevention efforts. This scoping review aims to characterize the evidence for multifactorial PAC fall prevention interventions. Of the 33 included studies, common PAC intervention domains included implementing facility-based strategies (e.g., staff education), evaluating patient-specific fall risk factors (e.g., function), and developing an individualized risk profile and treatment plan that targets the patient's constellation of fall risk factors. However, there was variability across studies in how and to what extent the domains were addressed. While further research is warranted, health system efforts to prevent accidental falls in PAC should consider a patient-centered multifactorial approach that fosters a culture of safety, addresses individuals' fall risk, and champions a multidisciplinary team.

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.

Patients' thoughts on their falls in a rehabilitation hospital: a qualitative study of patients with stroke

BACKGROUND

Patients with stroke in rehabilitation wards are at an increased risk of falling. Although patients' participation in establishing medical safety is considered crucial, there is limited evidence on their perspectives of falls. This study aims to comprehensively elucidate the subjective falling experience of patients with stroke who have been admitted to rehabilitation wards.

METHODS

Twenty-three consecutive patients with stroke (44 to 90 years) who experienced a fall during hospitalisation were interviewed within 1 week after the fall, and thematic analysis was used to analyse the data.

RESULTS

Five themes surrounding fall events were extracted from the narratives: 'Psychological background before the action', 'Support for the action', 'Direct causes of the fall', 'Patients' awareness after the fall', and 'Changes in attitudes and behaviours after the fall'. 'Psychological background before the action' comprised hastiness or hesitation to call for help. Participants often took an action based on 'Support for the action' derived from their past experiences of moving safely, their confidence, and/or motivation to challenge themselves to move. 'Direct causes of the fall' consisted of unfamiliar actions, training fatigue, the surrounding environment, reduced physical function due to paralysis, lack of attention, overconfidence in their ability, and insufficient prediction of falls. 'Patients' awareness after the fall' consisted of re-affirming difficult movements, the need for rehabilitation, a reduced ability to move, an increased risk of falling, the need for attention while moving, a fear of falling, and a lack of lessons learned from falling. Finally, patients demonstrated 'Changes in attitudes and behaviours after the fall' such as embodying a positive attitude to cope with the risk of falling or behavioural changes to reduce the risk of falling.

CONCLUSIONS

Comprehensive information on patients' perspectives before and after the fall was elucidated, uncovering many aspects including the psychological background for why patients engaged in risky behaviours resulting in falls, presence of positive thinking, and behaviour after the fall. By incorporating the patients' views on fall incidences and their assessment, we can develop appropriate prevention strategies against falls.

Stroke Patients with Nearly Independent Transfer Ability are at High Risk of Falling

OBJECTIVES

To examine the relationship between patients' transfer ability and fall risk in stroke patients during hospitalization.

MATERIALS AND METHODS

We retrospectively enrolled 237 stroke patients who were transferred to a convalescent rehabilitation ward from acute wards in the same hospital. Using incident reports, we investigated their fall rates and activity status at the falls according to their transfer abilities, which were assessed with Functional Independence Measure (FIM) transfer scores. The bi-weekly time trend of fall rates in all patients and in three subgroups based on FIM transfer scores of 1-3, 4-5, and 6-7, and activity status at the falls, were investigated. In addition, changes of patients' transfer ability on admission, at the first fall, and at discharge were investigated among falling patients.

RESULTS

The fall rate was the greatest in patients with a FIM transfer score of 4 (14.3 times/1000 person-days). The majority of falls for patients with a FIM transfer score of 1 occurred at the activity status of "on the bed" and "sitting", while three quarters of patients with a FIM score of 7 had falls during "standing" and "walking". No longitudinal trend in fall rates was found overall; however, the fall rate trends differed depending on the FIM transfer score. The majority of the patients who fell required full assistance for transfers upon admission but required no assistance at discharge.

CONCLUSIONS

Fall risk differed among patients with various transfer abilities; the greatest risk was in those who needed minimal assistance for transfers.

EFFECTIVENESS OF EDUCATIONAL INTERVENTIONS FOR FALL PREVENTION: A SYSTEMATIC REVIEW

ABSTRACT Objective: to assess the effectiveness of educational interventions for fall prevention implemented in hospitals, at homes and nursing homes. Method: this is a systematic review, carried out based on the guiding question: what is the effectiveness of isolated educational interventions for preventing falls in adults and the elderly developed in experimental studies? The search took place in the electronic databases: Scopus, PubMed/PMC, Web of Science, CINAHL, SciELO, Cochrane and EMBASE. The exposure factor was the educational intervention on preventing falls, and as outcomes: reducing fall rates, improving knowledge, awareness and adherence to preventive care for adult and elderly patients. Only randomized controlled trials, in all languages and published between 2011 and 2020 were included. Results: 1,474 articles were identified, of which 16 were included. Four studies did not show effectiveness related to fall prevention. As common characteristics, these studies were carried out with elderly patients and without one-to-one follow-up. The others were effective in reducing falls and/or improving knowledge and were mostly studies with personalized interventions, carried out by nurses and mediated by educational technologies. Conclusion: educational interventions are effective for preventing falls in the home, hospital and nursing homes. Studies have shown a reduction in fall rates, improved knowledge and engagement in prevention strategies.

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.

Barriers and Facilitators to Older Adults Participating in Fall-Prevention Strategies After Transitioning Home from Acute Hospitalization: A Scoping Review

PURPOSE

Approximately, 14% of older adults aged 65 years and over experience a fall within 1 month post-hospital discharge. Adequate self-management may minimize the impact of these falls; however, research is lacking on why some older adults engage in self-management to prevent falls while others do not.

METHODS

We conducted a scoping review to identify barriers and facilitators to older adults participating in fall-prevention strategies after transitioning home from acute hospitalization. Eligibility criteria were peer-reviewed journal articles published during 2009-2019 which were written in English and contained any of the following keywords or their synonyms: "fall-prevention," "older adults," "post-discharge" and "transition care." We systematically and selectively summarized the findings of these articles using the Joanna Briggs Institute guidelines and the PRISMA-ScR reporting guidelines. Seven bibliographic databases were searched: PubMed/MEDLINE, ERIC, CINAHL, Cochrane Library, Scopus, PsycINFO, and Web of Science. We used the Capability-Opportunity-Motivation-Behavior (COM-B) model of health behavior change as a framework to guide the content, thematic analysis, and descriptive results.

RESULTS

Seventeen articles were finally selected. The most frequently mentioned barriers and facilitators for each COM-B dimension differed. Motivation factors include such as older adults lacking inner drive and self-denial of being at risk for falls (barriers) and following-up with older adults and correcting inaccurate perceptions of falls and fall-prevention strategies (facilitators).

CONCLUSION

This scoping review revealed gaps and future research areas in fall prevention relative to behavioral changes. These findings may enable tailoring feasible fall-prevention interventions for older adults after transitioning home from acute hospitalization.

Interventions to prevent in-hospital falls in older people with cognitive impairment for further research: A mixed studies review

BACKGROUND

While advances in falls prevention in the adult population have occurred, the care requirements for older patients with cognitive impairment at risk of falling are less established.

OBJECTIVES

To identify interventions to prevent in-hospital falls in older patients with cognitive impairment for further research and describe the strategies used to implement those interventions.

DESIGN

A seven-stage mixed studies review was used.

METHODS

Seven electronic databases were searched. The SPIDER framework guided the review question and selection of search terms. The Mixed Methods Assessment Tool was used to appraise the quality of research studies, and the Quality Improvement Minimum Quality Data Set was used to appraise the quality of quality improvement projects. A convergent qualitative synthesis was used to analyse the extracted data. The adapted PRISMA guideline informed the procedures.

RESULTS

Ten projects (five quality improvements and five researches) were included. Five themes emerged from the synthesis: engaging with families in falls prevention, assessing falls risk to identify interventions, extending nursing observation through technology, conducting a medication review and initiating nonpharmacological delirium prevention interventions. Implementation was not well described and commonly focused on capital investment to initiate a falls prevention programme and education to introduce staff to the new techniques for practice.

CONCLUSIONS

Emerging research and quality improvement studies demonstrate that effective falls prevention with this vulnerable population is possible but requires further investigation before widespread practice recommendations can be made. Further research and quality improvement in this area should consider adoption of an implementation framework to address sustainability.

RELEVANCE TO CLINICAL PRACTICE

Reducing falls in older people with cognitive impairment requires nurses to work more closely with pharmacists, occupational therapists and social workers to develop strategies that work and are sustainable.

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.

A hospitalist's role in preventing patient falls

Despite decades of fall prevention efforts, patient falls remain a common cause of harm in hospitalized older adults. While fall prevention strategies have been historically championed by nurses, hospitalist physicians, nurse practitioners, and physician assistants play a vital role in the multidisciplinary care team in ensuring the safety of our patients. Multiple fall risk assessment tools exist, but no one tool has demonstrated excellence in predicting patient falls in the hospital. Any fall risk assessment tool should be complemented by a clinician's individualized evaluation of patient-specific, situational, and environmental risk factors. A particular emphasis on medication review is critical, as numerous medication classes can increase the risk of falls, and medications are a potentially modifiable risk factor. Multiple studies of individual and multicomponent nursing-based interventions have failed to demonstrate success in reducing falls or fall injuries. Promising strategies for fall prevention include tailoring interventions to patient risk factors and individualized patient education. In addition to nursing-based interventions, the hospitalist's role in fall prevention is to (1) identify and address potentially modifiable risk factors, (2) reinforce individualized education to patients, and (3) advise behavior choices that promote safe mobility. If a patient does sustain a fall, the hospitalist should partner with the multidisciplinary care team in post fall care to assess for injury, evaluate underlying causes of the fall, and determine plans for secondary prevention.

Design, delivery and evaluation of a simulation-based workshop for health professional students on falls prevention in acute care settings

AIMS AND OBJECTIVES

To describe the design, delivery and evaluation outcomes of a simulation-based educational workshop to teach a patient-centred falls prevention strategy to health professional students tasked with implementing the strategy during clinical placement.

BACKGROUND

Falls are among the most common and costly threat to patient safety. The Safe Recovery Programme (SRP) is an evidence-based, one-to-one communication approach with demonstrated efficacy at preventing falls in the postgraduate context. Simulation-based education (SBE) is commonly used to address issues of patient safety but has not been widely incorporated into falls prevention.

METHODS

This study was a Pre-Post-test intervention design. Health professional students were taught how to deliver the SRP in an SBE workshop. The workshop incorporated content delivery, role-play simulations and interactions with a simulated patient. Students completed surveys immediately before and after the workshop and after clinical placement. Linear and logistic regression analysis was undertaken to identify differences within each pairwise comparison at the three time points. Qualitative free text responses underwent content analysis.

RESULTS

There were 178 students trained. The educational design of the programme described in this paper was highly valued by students. Following the workshop, students' falls knowledge increased and they correctly identified evidence-based strategies except bedrail use and patient sitters. Following clinical placement, fewer SBE students correctly identified evidence surrounding bed alarm use. Students became more confident about falls communication post-SBE; however, this confidence decreased postclinical placement. Motivation to implement the SRP decreased between postworkshop and postclinical placement time points.

CONCLUSIONS

Falls research often includes educational components but previous studies have failed to adequately describe educational methods. Students learnt about best evidence falls prevention strategies using interactive educational methodologies with a workshop viewed by students as being well-designed and assisting their learning from theory to practice.While students valued the delivery of the SRP using SBE, confidence and motivation to implement falls strategies were not sustained following clinical placement. A programme of education including SBE can be used to support the delivery of falls-based education, but further research is needed to identify what factors may influence student's motivation and confidence to implement falls prevention strategies during clinical placement.

Improving Hospital Safety Culture for Falls Prevention Through Interdisciplinary Health Education

BACKGROUND

Falls are a serious public health problem, with an estimated 37.3 million falls a year requiring medical assistance. Improving hospital culture to address safety and falls prevention is a major organizational challenge that requires interdisciplinary teams and evidence-based education to change individual behaviors and improve outcomes.

METHODS

We collaborated with an interdisciplinary team of health practitioners at a critical access hospital to develop a health education program tailored to their internal assessment of falls and safety issues. The resulting program used the Five As behavior change model and evidence-based health education. Education session activities and posttests were used to measure participant outcomes, and the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture was distributed hospital-wide to measure patient safety culture pre- and postintervention.

RESULTS

Participants reported increased knowledge, attitudes, and motivations with attendance at education sessions. The AHRQ Hospital Survey showed positive improvements in 10 of the 11 composite categories, 4 of which were statistically significant.

CONCLUSION

The use of the Five As, along with an interdisciplinary health education approach, can improve individual hospital employee falls prevention knowledge, attitudes, and motivations. That individual-level change can improve patient safety culture at the organizational level.

Evidence on Fall and Injurious Fall Prevention Interventions in Acute Care Hospitals

Falls and injurious falls are a major safety concern for patient care in acute care hospitals. Inpatient falls and injurious falls can cause extra financial burden to patients, families, and healthcare facilities. This article provides clinical implications and recommendations for adult inpatient fall and injurious fall prevention through a brief review of factors associated with falls and injurious falls and current fall prevention practices in acute care hospitals.

Caring for the older person with cognitive impairment in hospital: Qualitative analysis of nursing personnel reflections on fall events

AIMS AND OBJECTIVES

To explore nurse and nursing assistant reflections on the care of older patients with cognitive impairment who have experienced a fall.

BACKGROUND

While there are evidence-based clinical guidelines for the prevention and management of falls and for the care of older people with cognitive impairment, the falls rates for older people with cognitive impairment are three times as high as those without.

DESIGN

Critical incident technique.

METHODS

Eleven registered and two enrolled nurses and four assistants in nursing working in one subacute and two acute wards within two hospitals of a tertiary level health service in south-east Queensland. Individual semistructured interviews focused on two past events when a patient with cognitive impairment had fallen in hospital: one when there was minimal harm and the second when there was significant harm. Thematic analysis was undertaken. The COREQ checklist was followed.

RESULTS

Three themes emerged from 23 reflective accounts of fall events: "direct observation is confounded by multiple observers" and "knowing the person has cognitive impairment is not enough," and "want to rely on the guideline but unsure how to enact it." While participants were aware of the falls prevention policy and techniques available to prevent falls, the implementation of these was challenging due to the complexity of care required by the older person with cognitive impairment.

CONCLUSIONS

Falls prevention for older people with cognitive impairment is complex and belies the simple application of policy.

RELEVANCE TO CLINICAL PRACTICE

To reduce falls, nurses can involve the family to support "knowing the patient" to enable prediction of impulsive actions; shift the focus of in-service from lectures to specific case presentations, with collaborative analysis on person-focused strategies to prevent falls in older people with cognitive impairment; and reconsider the sitter role from simple observer to assistant, focused on ambulation and supporting independence in activities of daily living.

[Effects of a fall intervention program for elderly patients with dementia based on person-centered care on care staff]

AIM

This study aimed to clarify the effects of a fall prevention intervention that focused on the characteristics of falls among elderly patients with dementia and was based on person-centered care in geriatric facilities on care staff.

METHODS

This study was conducted between May 2016 and January 2017, and the subjects were classified into two groups: the intervention group, consisting of members who had participated in a three-month education training program, and the control group, consisting of members who provided the usual care. The study period was nine months divided as follows: training period (three months), fall prevention practice (three months), and follow-up period (three months). The quality of care was measured using the Nursing Quality Indicator for Preventing Falls (NQIPFD), and the assessment scale of health care professionals' recognition of the successful Interdisciplinary Team Approach in Health Care Facilities for the Elderly was also used. In total, the care staff members were evaluated four times: once to obtain baseline values before training, and again after the training period, after the fall prevention practice, and after the follow-up period. The results were analyzed using an analysis of variance (fixed factors = group and time, random factor = subjects, and covariance = years of experience working at the geriatric facility and type of job).

RESULTS

There were 50 care staff subjects in the intervention group and 69 people in the control group. The results of the analysis of variance indicated that there was a significant difference in the NQIPFD between baseline 68.60 (±9.09) and follow-up 70.02 (±9.88) in the intervention group. With regard to the differences by intervention, the effect size of the dementia knowledge scale scores was 0.243 higher than the others, which was significant (p<0.01).

CONCLUSIONS

The results showed that the participation of care staff in a fall intervention program to support elderly patients with dementia based on person-centered care significantly improved the NQIPFD and other measured factors. These findings suggest that the program fostered positive effects among the care staff.

Interventions for preventing falls in older people in care facilities and hospitals

BACKGROUND

Falls in care facilities and hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of a review first published in 2010 and updated in 2012.

OBJECTIVES

To assess the effects of interventions designed to reduce the incidence of falls in older people in care facilities and hospitals.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (August 2017); Cochrane Central Register of Controlled Trials (2017, Issue 8); and MEDLINE, Embase, CINAHL and trial registers to August 2017.

SELECTION CRITERIA

Randomised controlled trials of interventions for preventing falls in older people in residential or nursing care facilities, or hospitals.

DATA COLLECTION AND ANALYSIS

One review author screened abstracts; two review authors screened full-text articles for inclusion. Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We calculated rate ratios (RaR) with 95% confidence intervals (CIs) for rate of falls and risk ratios (RRs) and 95% CIs for outcomes such as risk of falling (number of people falling). We pooled results where appropriate. We used GRADE to assess the quality of evidence.

MAIN RESULTS

Thirty-five new trials (77,869 participants) were included in this update. Overall, we included 95 trials (138,164 participants), 71 (40,374 participants; mean age 84 years; 75% women) in care facilities and 24 (97,790 participants; mean age 78 years; 52% women) in hospitals. The majority of trials were at high risk of bias in one or more domains, mostly relating to lack of blinding. With few exceptions, the quality of evidence for individual interventions in either setting was generally rated as low or very low. Risk of fracture and adverse events were generally poorly reported and, where reported, the evidence was very low-quality, which means that we are uncertain of the estimates. Only the falls outcomes for the main comparisons are reported here.Care facilitiesSeventeen trials compared exercise with control (typically usual care alone). We are uncertain of the effect of exercise on rate of falls (RaR 0.93, 95% CI 0.72 to 1.20; 2002 participants, 10 studies; I² = 76%; very low-quality evidence). Exercise may make little or no difference to the risk of falling (RR 1.02, 95% CI 0.88 to 1.18; 2090 participants, 10 studies; I² = 23%; low-quality evidence).There is low-quality evidence that general medication review (tested in 12 trials) may make little or no difference to the rate of falls (RaR 0.93, 95% CI 0.64 to 1.35; 2409 participants, 6 studies; I² = 93%) or the risk of falling (RR 0.93, 95% CI 0.80 to 1.09; 5139 participants, 6 studies; I² = 48%).There is moderate-quality evidence that vitamin D supplementation (4512 participants, 4 studies) probably reduces the rate of falls (RaR 0.72, 95% CI 0.55 to 0.95; I² = 62%), but probably makes little or no difference to the risk of falling (RR 0.92, 95% CI 0.76 to 1.12; I² = 42%). The population included in these studies had low vitamin D levels.Multifactorial interventions were tested in 13 trials. We are uncertain of the effect of multifactorial interventions on the rate of falls (RaR 0.88, 95% CI 0.66 to 1.18; 3439 participants, 10 studies; I² = 84%; very low-quality evidence). They may make little or no difference to the risk of falling (RR 0.92, 95% CI 0.81 to 1.05; 3153 participants, 9 studies; I² = 42%; low-quality evidence).HospitalsThree trials tested the effect of additional physiotherapy (supervised exercises) in rehabilitation wards (subacute setting). The very low-quality evidence means we are uncertain of the effect of additional physiotherapy on the rate of falls (RaR 0.59, 95% CI 0.26 to 1.34; 215 participants, 2 studies; I² = 0%), or whether it reduces the risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 83 participants, 2 studies; I² = 0%).We are uncertain of the effects of bed and chair sensor alarms in hospitals, tested in two trials (28,649 participants) on rate of falls (RaR 0.60, 95% CI 0.27 to 1.34; I² = 0%; very low-quality evidence) or risk of falling (RR 0.93, 95% CI 0.38 to 2.24; I² = 0%; very low-quality evidence).Multifactorial interventions in hospitals may reduce rate of falls in hospitals (RaR 0.80, 95% CI 0.64 to 1.01; 44,664 participants, 5 studies; I² = 52%). A subgroup analysis by setting suggests the reduction may be more likely in a subacute setting (RaR 0.67, 95% CI 0.54 to 0.83; 3747 participants, 2 studies; I² = 0%; low-quality evidence). We are uncertain of the effect of multifactorial interventions on the risk of falling (RR 0.82, 95% CI 0.62 to 1.09; 39,889 participants; 3 studies; I² = 0%; very low-quality evidence).

AUTHORS' CONCLUSIONS

In care facilities: we are uncertain of the effect of exercise on rate of falls and it may make little or no difference to the risk of falling. General medication review may make little or no difference to the rate of falls or risk of falling. Vitamin D supplementation probably reduces the rate of falls but not risk of falling. We are uncertain of the effect of multifactorial interventions on the rate of falls; they may make little or no difference to the risk of falling.In hospitals: we are uncertain of the effect of additional physiotherapy on the rate of falls or whether it reduces the risk of falling. We are uncertain of the effect of providing bed sensor alarms on the rate of falls or risk of falling. Multifactorial interventions may reduce rate of falls, although subgroup analysis suggests this may apply mostly to a subacute setting; we are uncertain of the effect of these interventions on risk of falling.

Effectiveness of patient-centered interventions on falls in the acute care setting compared to usual care: a systematic review

BACKGROUND

Unintentional falls during hospitalization remain a concern for healthcare institutions globally despite implementation of various improvement strategies. Although the incidence of falls has been of heightened focus for many years and numerous studies have been done evaluating different approaches for fall prevention, fall rates remain high in acute care settings. Patient fall risk scales tend to address only particular intrinsic and extrinsic factors but do not adequately assess a patient's current fall risk status, subsequently warranting more patient-centered risk assessments and interventions.

OBJECTIVES

To evaluate the effectiveness of patient-centered interventions on falls in the acute care setting.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

All adult patients admitted to medical or surgical acute care units for any condition or illness.

TYPES OF INTERVENTION(S)

Patient-centered intervention strategies to reduce falls compared to usual care.

TYPES OF STUDIES

Randomized control trials.

TYPES OF OUTCOMES

Primary outcome: fall rates or number of falls. Secondary outcome: fall-related injuries.

SEARCH STRATEGY

A comprehensive search strategy aimed to find relevant published and unpublished quantitative, English language studies from the inception of databases through July 30, 2016 was undertaken. Databases searched included: PubMed, CINAHL, Embase and Health Source: Nursing/Academic Edition. A search for unpublished studies was also performed using ProQuest Dissertations and Theses, the New York Academy of Medicine and the Virginia Henderson e-Repository.

METHODOLOGICAL QUALITY

Reviewers evaluated the included studies for methodological quality using the standardized critical appraisal instrument form from the Joanna Briggs Institute.

DATA EXTRACTION

Quantitative data were extracted from papers included in the review using the standardized data extraction form from the Joanna Briggs Institute.

DATA SYNTHESIS

Due to clinical and methodological heterogeneity among the included studies, a meta-analysis was not possible. The findings of this review have been presented in narrative form.

RESULTS

Five randomized control trials were included. Three studies demonstrated statistically significant reductions in fall rates (p < 0.04) while two studies showed no difference in fall rates between groups (p > 0.5). In the three studies that demonstrated reduced fall rates, personalized care plans and patient-centered education based on patients' fall risk results were utilized. Three studies measured the secondary outcome of fall-related injuries; however, results demonstrated no difference in fall-related injuries between groups (p > 0.5).

CONCLUSIONS

Evidence of this review indicates patient-centered interventions in addition to tailored patient education may have the potential to be effective in reducing falls and fall rates in acute care hospitals. There is limited high quality evidence demonstrating the effectiveness of patient-centered fall prevention interventions so novel solutions are urgently needed and warrant more rigorous, larger scale randomized trials for more robust estimates of effect.

Effectiveness of patient-centered interventions on falls in the acute care setting: a quantitative systematic review protocol

REVIEW OBJECTIVE

The quantitative objective of this review is to identify the effectiveness of patient-centered interventions on fall rates in adult patients in the acute care setting.

Conceptual definitions of indicators for the nursing outcome "Knowledge: Fall Prevention"

ABSTRACT Objective: to construct conceptual definitions for indicators of nursing outcome Knowledge: Fall Prevention, selected for evaluation of hospitalized patients with the nursing diagnosis Risk for falls. Method: integrative literature review performed in the LILACS, MEDLINE and Web of Science databases, comprising articles published in English, Spanish and Portuguese languages from 2005 to 2015. Results: the final sample of the study was composed of 17 articles. The conceptualizations were constructed for 14 indicators of nursing outcome Knowledge: Fall Prevention focused on hospitalized patients. Conclusion: the theoretical support of the Nursing Outcomes Classification (NOC), through the process of constructing the conceptual definitions of the indicators of its results, allows nurses to accurately implement this classification in clinical practice and to evaluate the effectiveness of their interventions through the change of the patients' status over time.

Testing the Predictive Validity of the Hendrich II Fall Risk Model

Cumulative data on patient fall risk have been compiled in electronic medical records systems, and it is possible to test the validity of fall-risk assessment tools using these data between the times of admission and occurrence of a fall. The Hendrich II Fall Risk Model scores assessed during three time points of hospital stays were extracted and used for testing the predictive validity: (a) upon admission, (b) when the maximum fall-risk score from admission to falling or discharge, and (c) immediately before falling or discharge. Predictive validity was examined using seven predictive indicators. In addition, logistic regression analysis was used to identify factors that significantly affect the occurrence of a fall. Among the different time points, the maximum fall-risk score assessed between admission and falling or discharge showed the best predictive performance. Confusion or disorientation and having a poor ability to rise from a sitting position were significant risk factors for a fall.

Impact of the CMS No-Pay Policy on Hospital-Acquired Fall Prevention Related Practice Patterns

Background and Objectives

In October 2008, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursing hospitals for costs related to patient falls. This study aimed to examine whether the CMS no-pay policy influenced four fall prevention practices: bed alarms, sitters, room changes, and physical restraints.

Research Design and Methods

Using electronic medical record data collected from four hospitals between 2005 and 2010, this secondary observational analysis examined the associations between the CMS no-pay policy and nursing interventions and medical orders related to fall prevention. Multivariable generalized linear mixed models with logit link function and accommodation for matching was used to assess the associations between the CMS no-pay policy and nursing interventions and medical orders.

Results

After the CMS policy change, nurses were more likely to perform one or more fall-related interventions (adjusted odds ratio (aOR): 1.667; 95% confidence interval (CI): 1.097–2.534). Of the four prevention practices, the use of bed alarms (aOR: 2.343; 95% CI: 1.409–3.897) increased significantly after the CMS policy change.

Discussion and Implications

The CMS no-pay policy increased utilization of fall prevention strategies despite little evidence that these measures prevent falls.

Identifying protective and risk factors for injurious falls in patients hospitalized for acute care: a retrospective case-control study

Background

Admitted patients who fall and injure themselves during an acute hospitalization incur increased costs, morbidity, and mortality, but little research has been conducted on identifying inpatients at high risk to injure themselves in a fall. Falls risk assessment tools have been unsuccessful due to their low positive predictive value when applied broadly to entire hospital populations. We aimed to identify variables associated with the risk of or protection against injurious fall in the inpatient setting. We also aimed to test the variables in the ABCs mnemonic (Age > 85, Bones-orthopedic conditions, anti-Coagulation and recent surgery) for correlation with injurious fall.

Methods

We performed a retrospective case-control study at an academic tertiary care center comparing admitted patients with injurious fall to admitted patients without fall. We collected data on the demographics, medical and fall history, outcomes, and discharge disposition of injured fallers and control patients. We performed multivariate analysis of potential risk factors for injurious fall with logistic regression to calculate adjusted odds ratios.

Results

We identified 117 injured fallers and 320 controls. There were no differences in age, anti-coagulation use or fragility fractures between cases and controls. In multivariate analysis, recent surgery (OR 0.46, p = 0.003) was protective; joint replacement (OR 5.58, P = 0.002), psychotropic agents (OR 2.23, p = 0.001), the male sex (OR 2.08, p = 0.003) and history of fall (OR 2.08, p = 0.02) were significantly associated with injurious fall.

Conclusion

In this study, the variables in the ABCs parameters were among the variables not useful for identifying inpatients at risk of injuring themselves in a fall, while other non-ABCs variables demonstrated a significant association with injurious fall. Recent surgery was a protective factor, and practices around the care of surgical patients could be extrapolated to reduce the in-hospital fall rates.

Decreasing Falls in Acute Care Medical Patients: An Integrative Review

Falls in acute care medical patients are a complex problem impacted by the constantly changing risk factors affecting this population. This integrative literature review analyzes current evidence to determine factors that continue to make falls a top patient safety problem within the medical unit microsystem. The goal of this review is to develop an evidence-based structure to guide process improvement and effective use of organization resources.

Functional Measures for Fall Risk in the Acute Care Setting: A Review

This review explores the evidence pertaining to the use of functional ability measures for fall risk in the acute care setting. We included studies from six bibliographic databases that investigated fall risk functional ability measures in hospitalized older adults (≥55 years). We utilized the following search terms: acute care, subacute care, critical care, inpatient, fall, and fall prevention. Nineteen articles met the inclusion criteria. Timed "Up and Go" (TUG) was identified as a feasible fall risk functional ability measure for clinicians; it demonstrated clinical performance of fair sensitivity (56%-68%) and good specificity (74%-80%). Clinical performance of other measures (Berg Balance Scale and Functional Reach test) was not as favorable as the TUG. Functional ability measures are underutilized in the acute care setting, potentially due to limited knowledge and training on administration. Combining functional measures with subjective screening tools may optimize performance and accuracy of identifying fall risk identification.

Establishing the effectiveness, cost-effectiveness and student experience of a Simulation-based education Training program On the Prevention of Falls (STOP-Falls) among hospitalised inpatients: a protocol for a randomised controlled trial

INTRODUCTION

Simulation-based education (SBE) is now commonly used across health professional disciplines to teach a range of skills. The evidence base supporting the effectiveness of this approach for improving patient health outcomes is relatively narrow, focused mainly on the development of procedural skills. However, there are other simulation approaches used to support non-procedure specific skills that are in need of further investigation. This cluster, cross-over randomised controlled trial with a concurrent economic evaluation (cost per fall prevented) trial will evaluate the effectiveness, cost-effectiveness and student experience of health professional students undertaking simulation training for the prevention of falls among hospitalised inpatients. This research will target the students within the established undergraduate student placements of Monash University medicine, nursing and allied health across Peninsula Health acute and subacute inpatient wards.

METHODS AND ANALYSIS

The intervention will train the students in how to provide the Safe Recovery program, the only single intervention approach demonstrated to reduce falls in hospitals. This will involve redevelopment of the Safe Recovery program into a one-to-many participant SBE program, so that groups of students learn the communication skills and falls prevention knowledge necessary for delivery of the program. The primary outcome of this research will be patient falls across participating inpatient wards, with secondary outcomes including student satisfaction with the SBE and knowledge gain, ward-level practice change and cost of acute/rehabilitation care for each patient measured using clinical costing data.

ETHICS AND DISSEMINATION

The Human Research Ethics Committees of Peninsula Health (LRR/15/PH/11) and Monash University (CF15/3523-2015001384) have approved this research. The participant information and consent forms provide information on privacy, storage of results and dissemination. Registration of this trial has been completed with the Australian and New Zealand Clinical Trials Registry: ACTRN12615000817549. This study protocol has been prepared according to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist.

TRIAL REGISTRATION NUMBER

ACTRN12615000817549; Pre-results.

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.

Patient perceptions and experiences with falls during hospitalization and after discharge

AIMS

The aim of this study was to describe hospitalized older adults' (> 60years) perceptions about (1) their fall risks while hospitalized; (2) fall prevention interventions received while hospitalized; and (3) fall prevention discharge instructions.

BACKGROUND

Little is known about hospitalized older adults' perceptions regarding fall prevention interventions received during hospitalization and fall prevention discharge instructions.

METHODS

This is a prospective, exploratory study using qualitative methods.

RESULTS

This paper reports qualitative findings of patients' perspectives on fall prevention interventions during hospitalization and at discharge. Eight major themes supported by multiple minor themes emerged: overall perceptions of falling; overall perceptions of fall prevention interventions while hospitalized; "telling" fall prevention; "doing" fall prevention; effectiveness of fall prevention strategies; personal fall prevention strategies; fall-related discharge instructions; and most effective fall-related discharge instructions.

CONCLUSIONS

Findings suggest healthcare providers need to more fully engage patients and families in understanding fall prevention interventions and factors contributing to falls during hospitalization and at discharge.

6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial

OBJECTIVE

To evaluate the effect of the 6-PACK programme on falls and fall injuries in acute wards.

DESIGN

Cluster randomised controlled trial.

SETTING

Six Australian hospitals.

PARTICIPANTS

All patients admitted to 24 acute wards during the trial period.

INTERVENTIONS

Participating wards were randomly assigned to receive either the nurse led 6-PACK programme or usual care over 12 months. The 6-PACK programme included a fall risk tool and individualised use of one or more of six interventions: "falls alert" sign, supervision of patients in the bathroom, ensuring patients' walking aids are within reach, a toileting regimen, use of a low-low bed, and use of a bed/chair alarm.

MAIN OUTCOME MEASURES

The co-primary outcomes were falls and fall injuries per 1000 occupied bed days.

RESULTS

During the trial, 46 245 admissions to 16 medical and eight surgical wards occurred. As many people were admitted more than once, this represented 31 411 individual patients. Patients' characteristics and length of stay were similar for intervention and control wards. Use of 6-PACK programme components was higher on intervention wards than on control wards (incidence rate ratio 3.05, 95% confidence interval 2.14 to 4.34; P<0.001). In all, 1831 falls and 613 fall injuries occurred, and the rates of falls (incidence rate ratio 1.04, 0.78 to 1.37; P=0.796) and fall injuries (0.96, 0.72 to 1.27; P=0.766) were similar in intervention and control wards.

CONCLUSIONS

Positive changes in falls prevention practice occurred following the introduction of the 6-PACK programme. However, no difference was seen in falls or fall injuries between groups. High quality evidence showing the effectiveness of falls prevention interventions in acute wards remains absent. Novel solutions to the problem of in-hospital falls are urgently needed.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12611000332921.

Educators' perspectives about how older hospital patients can engage in a falls prevention education programme: a qualitative process evaluation

OBJECTIVES

Falls are the most frequent adverse event reported in hospitals. Patient and staff education delivered by trained educators significantly reduced falls and injurious falls in an older rehabilitation population. The purpose of the study was to explore the educators' perspectives of delivering the education and to conceptualise how the programme worked to prevent falls among older patients who received the education.

DESIGN

A qualitative exploratory study.

METHODS

Data were gathered from three sources: conducting a focus group and an interview (n=10 educators), written educator notes and reflective researcher field notes based on interactions with the educators during the primary study. The educators delivered the programme on eight rehabilitation wards for periods of between 10 and 40 weeks. They provided older patients with individualised education to engage in falls prevention and provided staff with education to support patient actions. Data were thematically analysed and presented using a conceptual framework.

RESULTS

Falls prevention education led to mutual understanding between staff and patients which assisted patients to engage in falls prevention behaviours. Mutual understanding was derived from the following observations: the educators perceived that they could facilitate an effective three-way interaction between staff actions, patient actions and the ward environment which led to behaviour change on the wards. This included engaging with staff and patients, and assisting them to reconcile differing perspectives about falls prevention behaviours.

CONCLUSIONS

Individualised falls prevention education effectively provides patients who receive it with the capability and motivation to develop and undertake behavioural strategies that reduce their falls, if supported by staff and the ward environment.

Fall rates in hospital rehabilitation units after individualised patient and staff education programmes: a pragmatic, stepped-wedge, cluster-randomised controlled trial

BACKGROUND

Falls are the most frequent adverse events that are reported in hospitals. We examined the effectiveness of individualised falls-prevention education for patients, supported by training and feedback for staff, delivered as a ward-level programme.

METHODS

Eight rehabilitation units in general hospitals in Australia participated in this stepped-wedge, cluster-randomised study, undertaken during a 50 week period. Units were randomly assigned to intervention or control groups by use of computer-generated, random allocation sequences. We included patients admitted to the unit during the study with a Mini-Mental State Examination (MMSE) score of more than 23/30 to receive individualised education that was based on principles of changes in health behaviour from a trained health professional, in addition to usual care. We provided information about patients' goals, feedback about the ward environment, and perceived barriers to engagement in falls-prevention strategies to staff who were trained to support the uptake of strategies by patients. The coprimary outcome measures were patient rate of falls per 1000 patient-days and the proportion of patients who were fallers. All analyses were by intention to treat. This trial is registered with the Australian New Zealand Clinical Trials registry, number ACTRN12612000877886).

FINDINGS

Between Jan 13, and Dec 27, 2013, 3606 patients were admitted to the eight units (n=1983 control period; n=1623 intervention period). There were fewer falls (n=196, 7·80/1000 patient-days vs n=380, 13·78/1000 patient-days, adjusted rate ratio 0·60 [robust 95% CI 0·42-0·94], p=0·003), injurious falls (n=66, 2·63/1000 patient-days vs 131, 4·75/1000 patient-days, 0·65 [robust 95% CI 0·42-0·88], p=0·006), and fallers (n=136 [8·38%] vs n=248 [12·51%] adjusted odds ratio 0·55 [robust 95% CI 0·38 to 0·81], p=0·003) in the intervention compared with the control group. There was no significant difference in length of stay (intervention median 11 days [IQR 7-19], control 10 days [6-18]).

INTERPRETATION

Individualised patient education programmes combined with training and feedback to staff added to usual care reduces the rates of falls and injurious falls in older patients in rehabilitation hospital-units.

FUNDING

State Health Research Advisory Council, Department of Health, Government of Western Australia.

Effectiveness of team training on fall prevention

A longitudinal, repeated-measures design with intervention and comparison groups was used to evaluate the effect of a training curriculum based on TeamSTEPPS with video vignettes focusing on fall prevention. Questionnaires, behavioral observations, and fall data were collected over 9 months from both groups located at separate hospitals. The intervention group questionnaire scores improved on all measures except teamwork perception, while observations revealed an improvement in communication compared with the control group. Furthermore, a 60% fall reduction rate was reported in the intervention group. Team training may be a promising intervention to reduce falls.

Fall prevention in high-risk patients

In the oncology population, disease process and treatment factors place patients at risk for falls. Fall bundles provide a framework for developing comprehensive fall programs in oncology. Small sample size of interventional studies and focus on ambulatory and geriatric populations limit the applicability of results. Additional research is needed.

Nursing care mapping for patients at risk of falls in the Nursing Interventions Classification

Objective: Identifying the prescribed nursing care for hospitalized patients at risk of falls and comparing them with the interventions of the Nursing Interventions Classifications (NIC). Method: A cross-sectional study carried out in a university hospital in southern Brazil. It was a retrospective data collection in the nursing records system. The sample consisted of 174 adult patients admitted to medical and surgical units with the Nursing Diagnosis of Risk for falls. The prescribed care were compared with the NIC interventions by the cross-mapping method. Results: The most prevalent care were the following: keeping the bed rails, guiding patients/family regarding the risks and prevention of falls, keeping the bell within reach of patients, and maintaining patients’ belongings nearby, mapped in the interventions Environmental Management: safety and Fall Prevention. Conclusion: The treatment prescribed in clinical practice was corroborated by the NIC reference.


Risk factors for falls in hospitalized adult patients: an integrative review

Objective: Identifying risk factors for the occurrence of falls in hospitalized adult patients. Method: Integrative review carried out in the databases of LILACS, SciELO, MEDLINE and Web of Science, including articles published between 1989 and 2012. Results: Seventy-one articles were included in the final sample. Risk factors for falls presented in this review were related to patients (intrinsic), the hospital setting and the working process of health professionals, especially in nursing (extrinsic). Conclusion: The systematic screening of risk factors for falls was identified as a contributing factor to the reduction of this injury, helping the non-occurrence of this event that, despite being preventable, can have serious consequences including death.