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

Effect of Physical Activity on Static and Dynamic Postural Balance in Women Treated for Breast Cancer: A Systematic Review

BACKGROUND

Therapies against breast cancer (BC) frequently involve complications that impair patients' daily function and quality of life, the most common of which are motor coordination and balance disorders, increasing the risk of falls and injuries. In such cases, physical activity is recommended. Designed following the PRISMA guidelines, this study presents a systematic review of randomised and pilot clinical trials investigating the effect of physical exercises on postural balance in women treated for BC.

METHODS

Scientific databases (PubMed, EBSCO) and the online resources of grey publications were searched for trial reports published between January 2002 and February 2022. The inclusion criteria necessitated full-text, English-language reports from randomised clinical trials (RCTs) or pilot clinical trials (pilot CTs), whose authors used physical exercises to treat women with BC and the experimental and control groups consisted of at least 10 women. The methodological quality of the RCTs and pilot CTs were measured using the Physiotherapy Evidence Database (PEDro) scale and the Methodological Index for Non-Randomized Studies (MINORS), respectively. Data were extracted on the effect of exercise on the women's static and dynamic balance.

RESULTS

Seven reports, five RCTs and two pilot CTs involving a total of 575 women (aged 18-83 years) were included in the systematic review. Their training protocols utilised a variety of aerobic, strength, endurance, sensorimotor, Pilates exercises, and fitness exercises with elements of soccer. The experimental groups usually worked out in fitness or rehabilitation centres under the supervision of physiotherapists or trainers. Training sessions of 30-150 min were held 2 or 3 times a week for 1.5-24 months. Most trials reported that static and dynamic balance in the experimental groups improved significantly more compared with the control groups.

CONCLUSIONS

Physical exercises are able to improve static and dynamic postural balance in women treated for BC. However, as all evidence in support of this conclusion comes from only two pilot CT and five RCTs whose methodologies varied widely, more high quality research is needed to validate their findings and determine which exercise protocols are the most effective in improving postural control in women with BC.

Improving hospital falls screening and mitigation using a health professional education framework

OBJECTIVE

Although health professional education has the potential to mitigate hospital falls risk, the best methods to develop, deliver and evaluate health professional education remain unclear. This study applied evidence-based approaches to education design to improve falls risk mitigation.

DESIGN

Mixed methods using questionnaires to evaluate health professionals knowledge of evidence-based falls risk assessment and mitigation, followed by semi-structured interviews with individual health professionals.

SETTING

Five large Australian hospitals.

PARTICIPANTS

For each hospital, 10 clinical leaders from nursing and allied health professions were invited to participate in falls workshops.

METHODS

46 participants received a three-hour education program on the latest evidence in hospital falls risk assessment and how to implement evidence-based falls screening and management. This was based on the "4P" education model (Presage, Planning, Process and Product). They were taught practical skills to enable them to educate other health professionals.

RESULTS

The education workshop significantly changed participants' views about best practice guidelines for falls screening and prevention. Participants felt more confident in assessing falls risk and judging and implementing the best mitigation strategies. They were prepared and motivated to educate others about falls prevention and satisfied with the skills gained.

CONCLUSIONS

A high-quality education program grounded in a rigorous quality framework improved health professionals knowledge regarding evidence-based falls prevention. Use of evidence-based rationales for behaviour change promotes effective learning.

Fall prediction using decision tree analysis in acute care units

[Purpose] To present an accurate and straight-forward system of fall prediction by performing decision tree analysis using both the fall assessment sheet and Berg balance scale (BBS). [Participants and Methods] The participants in this retrospective study were inpatients from acute care units. We extracted the risk factors for falls from the fall assessment and performed a decision tree analysis using the extracted fall risk factors and BBS score. [Results] "History of more than one fall in the last 1 year", "Muscle weakness", "Use of a walking aid or wheelchair", "Requires assistance for transfer", "Use of Narcotics", "Dangerous behavior", and "High degree of self-reliance" were fall risk factors. The decision tree analysis extracted five fall risk factors, with an area under the curve of 0.7919. Patients with no history of falls and who did not require assistance for transfer or those with a BBS score ≥51 did not fall. [Conclusion] Decision tree-based fall prediction was useful and straightforward and revealed that patients with no history of falling and those who did not require assistance for transfer or had a BBS score ≥51 had a low risk of falling.

Clinical guidelines on frailty

The paper represents clinical guidelines on frailty, developed by Russian Association of gerontologists and geriatricians. The guidelines are dedicated to geriatricians, internal medicine specialists, general practitioners, family doctors and other specialists, dealing with adult patients. The paper includes screening and diagnostic tools and treatment options for patients with frailty, along with prevention, rehabilitation and medical care organization in this cohort of patients.

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.

Evaluation of the "medication fall risk score"

PURPOSE

Results of a study evaluating the predictive validity of a fall screening tool in hospitalized patients are reported.

METHODS

Administrative claims data from two hospitals were analyzed to determine the discriminatory ability of the "medication fall risk score" (RxFS), a medication review fall-risk screening tool that is designed for use in conjunction with nurse-administered tools such as the Morse Fall Scale (MFS). Through analysis of data on administered medications and documented falls in a population of adults who underwent fall-risk screening at hospital admission over a 15-month period (n = 33,058), the predictive value of admission MFS scores, alone or in combination with retrospectively calculated RxFS-based risk scores, was assessed. Receiver operating characteristic (ROC) curve analysis and net reclassification improvement (NRI) analysis were used to evaluate improvements in risk prediction with the addition of RxFS data to the prediction model.

RESULTS

The area under the ROC curve for the predictive model for falls compromising both MFS and RxFS scores was computed as 0.8014, which was greater than the area under the ROC curve associated with use of the MFS alone (0.7823, p = 0.0030). Screening based on MFS scores alone had 81.25% sensitivity and 61.37% specificity. Combined use of RxFS and MFS scores resulted in 82.42% sensitivity and 66.65% specificity (NRI = 0.0587, p = 0.0003).

CONCLUSION

Reclassification of fall risk based on coadministration of the MFS and the RxFS tools resulted in a modest improvement in specificity without compromising sensitivity.

Falls screening and assessment tools used in acute mental health settings: a review of policies in England and Wales

Objectives

There is an urgent need to improve the care of older people at risk of falls or who experience falls in mental health settings. The aims of this study were to evaluate the individual falls risk assessment tools adopted by National Health Service (NHS) mental health trusts in England and healthcare boards in Wales, to evaluate the comprehensiveness of these tools and to review their predictive validity.

Methods

All NHS mental health trusts in England (n = 56) and healthcare boards in Wales (n = 6) were invited to supply their falls policies and other relevant documentation (e.g. local falls audits). In order to check the comprehensiveness of tools listed in policy documents, the risk variables of the tools adopted by the mental health trusts’ policies were compared with the 2004 National Institute for Health and Care Excellence (NICE) falls prevention guidelines. A comprehensive analytical literature review was undertaken to evaluate the predictive validity of the tools used in these settings.

Results

Falls policies were obtained from 46 mental health trusts. Thirty-five policies met the study inclusion criteria and were included in the analysis. The main falls assessment tools used were the St. Thomas’ Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY), Falls Risk Assessment Scale for the Elderly, Morse Falls Scale (MFS) and Falls Risk Assessment Tool (FRAT). On detailed examination, a number of different versions of the FRAT were evident; validated tools had inconsistent predictive validity and none of them had been validated in mental health settings.

Conclusions

Falls risk assessment is the most commonly used component of risk prevention strategies, but most policies included unvalidated tools and even well validated tool such as the STRATIFY and the MFS that are reported to have inconsistent predictive accuracy. This raises questions about operational usefulness, as none of these tools have been tested in acute mental health settings. The falls risk assessment tools from only four mental health trusts met all the recommendations of the NICE falls guidelines on multifactorial assessment for prevention of falls. The recent NICE (2013) guidance states that tools predicting risk using numeric scales should no longer be used; however, multifactorial risk assessment and interventions tailored to patient needs is recommended. Trusts will need to update their policies in response to this guidance.

Validating a multifactorial falls risk assessment

Reducing risk of falls has been identified as a national safety goal by The Joint Commission (TJC). The purpose was to determine if the total score on the multifactorial Falls Risk Assessment accurately identifies the risk of falls in a homebound client. In addition, the study examined if any individual item had a higher predictive power with the incidence of falls. One hundred clients (> 65 years old) who sustained an avoidable fall during a home care episode of care, plus 25 home care clients in the same age range and time period, who did not fall. A retrospective chart review, including Falls Risk Assessment (FRA) performed at start of care, demographic information, specific physical therapy (PT) evaluation, and visit notes if necessary to determine if the fall met the inclusion criteria. Scores for each individual area of the assessment were collected for statistical analysis. Data were analyzed by a biostatistician using simple linear regression, t-tests, and regression of variable combinations. The total score on the multifactorial risk assessment tool was shown to have a strong relationship with incidence of falls. The average scores of individuals who fell after assessment were significantly higher than those of individuals who did not fall. No single factors were found to be highly predictive. A single approach to decreasing falls is likely to be less effective than a multipronged approach. Caregivers and providers are advised to consider the entirety of the falls risk and direct comprehensive interventions to address the multiple factors that lead to falls.

Predicting falls using two instruments (the Hendrich Fall Risk Model and the Morse Fall Scale) in an acute care setting in Lebanon

AIMS AND OBJECTIVES

To assess the predictive value of two instruments (the Morse Fall Scale (MFS) and the Heindrich II Fall Risk Model (HFRM)] in a Middle Eastern country (Lebanon) and to evaluate the factors that are related to falls.

DESIGN

A prospective observational cross-sectional design was used.

BACKGROUND

Falls and fall-related injuries in the acute care settings contribute a substantial health and economic burden on patients and organisations. Preventing falls is a priority for most healthcare organisations. While the risk of falling cannot be eliminated, it can be significantly reduced through accurate assessment of patients' risk of falling.

METHODS

Data from 1815 inpatients at the American University of Beirut Medical Center (AUBMC) in Lebanon were evaluated using two instruments to predict falls: the MFS and the HFRM.

RESULTS

The incidence of falls was 2·7% in one year. The results indicate that while the instruments were significantly correlated, the HFRM was more sensitive in predicting falls than the MFS. The internal consistency of both scales was moderate, but inter-rater reliability was high. Patients using antiepileptic drugs and assistance devises had higher odds of falling.

CONCLUSIONS

Although both instruments were easy to use in a Middle Eastern country, the HFRM rather than the MFS is recommended for inpatients in an acute care setting as it had higher sensitivity and specificity.

RELEVANCE TO CLINICAL PRACTICE

It is recommended that while the HFRM had adequate sensitivity, it is not seamless, and as such, nurses should not rely entirely on it. Rather, nurses should use their expert clinical judgement, their ethical obligations and cultural considerations to implement a safer environment of care for the patient.

Validity of the Morse Fall Scale implemented in an electronic medical record system

AIMS AND OBJECTIVES

To examine the validity of the Morse Fall Scale by analysing the electronic medical records on fall risk during different phases of hospitalisation.

BACKGROUND

Regular monitoring on fall risk with a reliable and valid assessment tool is a key element in the fall prevention. In Korea, the Morse Fall Scale is currently being used in numerous medical institutions, yet it has not been comprehensively evaluated whether it is suitable and valid.

DESIGN

The study design was a retrospective case-control study.

METHODS

The participants included 151 fallers and 694 nonfallers. Data were extracted from a university hospital implementing Morse Fall Scale in the electronic medical records between October 2010 and June 2011. The nonfallers were selected by the stratified random sampling method among the patients who were in the hospital during the same period as the fallers. The Morse Fall Scale scores during three different time periods of hospital stay were used for analysis: the initial assessment score upon admission, the last and the maximum scores recorded from admission to the fall or discharge.

RESULTS

With the maximum Morse Fall Scale score and the best cut-off point of 51, validity indicators showed the highest performance: 0·72 for sensitivity, 0·91 for specificity, 0·63 for positive predictive value, 0·94 for negative predictive value, 0·63 for Youden Index and 0·77 for the area under the receiver operating characteristic curve.

CONCLUSION

The Morse Fall Scale showed relatively high predictive performance for the Korean population.

RELEVANCE TO CLINICAL PRACTICE

The study results recommend practice change in fall prevention. As the validity was highest when the patient was first classified into the high-risk group based on the Morse Fall Scale cut-off score 51, patients classified as high risk should be placed under special nursing interventions until the day of their discharge, regardless of change in the patient state.

A pragmatic study of the predictive values of the Morse falls score

BACKGROUND

inpatient falls are an important safety challenge, with around half causing physical injuries that compromise the recovery of older, frailer patients. Falls risk scores are in widespread use, but validation studies of their predictive values are few.

OBJECTIVES

to assess the predictive values of the Morse falls score (MFS) in an acute general hospital.

METHODS

age, admitting speciality, MFS, and any falls in the subsequent 7 days were collected in April 2011 through case note review and incident reporting systems.

RESULTS

a total of 467 inpatients were included in the study; 51% were aged 75+ years; 56% had an MFS ≥25; 23% had an MFS ≥55; 28 fell. An MFS ≥25 was not significantly better than chance in the total sample or in any subgroups considered (YI: -0.01 to 0.15). An MFS ≥55 was significantly better than chance for the total sample (YI: 0.39), patients ≥75 years (YI: 0.31) and geriatrician-led wards (YI 0.37), although either sensitivity or specificity fell below 70% in each of these groups. Other subgroups did not demonstrate significantly better accuracy than chance, but may have been affected by type II error.

CONCLUSIONS

using MFS ≥25 cannot be clinically justified, while using MFS ≥55 would be contingent on an effective intervention that was ethically acceptable to withhold from the patients with an MFS < 55, despite >40% of falls occurring in that group. Given similar limitations of alternative falls risk scores, hospitals should consider directly assessing and acting on individual patients' specific modifiable risk factors for falls.

Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review and meta-analysis

Background

Falls are a serious problem for hospitalized patients, reducing the duration and quality of life. It is estimated that over 84% of all adverse events in hospitalized patients are related to falls. Some fall risk assessment tools have been developed and tested in environments other than those for which they were developed with serious validity discrepancies. The aim of this review is to determine the accuracy of instruments for detecting fall risk and predicting falls in acute hospitalized patients.

Methods

Systematic review and meta-analysis. Main databases, related websites and grey literature were searched. Two blinded reviewers evaluated title and abstracts of the selected articles and, if they met inclusion criteria, methodological quality was assessed in a new blinded process. Meta-analyses of diagnostic ORs (DOR) and likelihood (LH) coefficients were performed with the random effects method. Forest plots were calculated for sensitivity and specificity, DOR and LH. Additionally, summary ROC (SROC) curves were calculated for every analysis.

Results

Fourteen studies were selected for the review. The meta-analysis was performed with the Morse (MFS), STRATIFY and Hendrich II Fall Risk Model scales. The STRATIFY tool provided greater diagnostic validity, with a DOR value of 7.64 (4.86 - 12.00). A meta-regression was performed to assess the effect of average patient age over 65 years and the performance or otherwise of risk reassessments during the patient’s stay. The reassessment showed a significant reduction in the DOR on the MFS (rDOR 0.75, 95% CI: 0.64 - 0.89, p = 0.017).

Conclusions

The STRATIFY scale was found to be the best tool for assessing the risk of falls by hospitalized acutely-ill adults. However, the behaviour of these instruments varies considerably depending on the population and the environment, and so their operation should be tested prior to implementation. Further studies are needed to investigate the effect of the reassessment of these instruments with respect to hospitalized adult patients, and to consider the real compliance by healthcare personnel with procedures related to patient safety, and in particular concerning the prevention of falls.

Lower limb power rehabilitation (LLPR) using interactive video game for improvement of balance function in older people

Declined balance functions have adverse effects on elderly population. Lower limbs muscle power training is currently an emerging concept in rehabilitation on individuals with decreased balance and mobility. In this prospective, controlled study, we used a human-computer interactive video-game-based rehabilitation device (LLPR) for training of lower limb muscle power in the elderly. Forty (aged >65 years) individuals were recruited from the community. Twenty participants in the exercise group received 30-min training, twice a week, using the LLPR system. The LLPR system allows participants to perform fast speed sit-to-stand (STS) movements. Twenty age-matched participants in the control group performed slow speed STS movements, as well as strengthening and balance exercises, with the same frequency and duration. The results were compared after 12 sessions (6 weeks) of training. The mechanical and time parameters during STS movement were measured using the LLPR system. Modified falls efficacy scale (MFES), Tinetti Performance-Oriented Mobility Assessment (POMA), function reach test, five times sit to stand (FTSS) and Timed Up and Go (TUG) were administered to participants as clinical assessments. Results showed that in the exercise group, all the mechanical and time parameters showed significant improvement. In control group, only the maximal vertical ground reaction force (MVGRF) improved significantly. For clinical assessments (balance, mobility, and self-confidence), exercise group showed significantly better scores. The STS movements in video-game-based training mimic real life situations which may help to transfer the training effects into daily activities. The effectiveness of lower limb muscle training is worthy of further investigation.

Fall prediction according to nurses' clinical judgment: differences between medical, surgical, and geriatric wards

OBJECTIVES

To assess the value of nurses' clinical judgment (NCJ) in predicting hospital inpatient falls.

DESIGN

Prospective multicenter study.

SETTING

Six Belgian hospitals.

PARTICIPANTS

Two thousand four hundred seventy participants (mean age 67.6 ± 18.3; female, 55.7%) on four surgical (n = 812, 32.9%), eight geriatric (n = 666, 27.0%), and four general medical wards (n = 992, 40.1%) were included upon admission. All participants were hospitalized for at least 48 hours.

MEASUREMENTS

Within 24 hours after admission, nurses gave their judgment on the question "Do you think your patient is at high risk for falling?" Nurses were not trained in assessing fall risk. Falls were documented on a standardized incident report form.

RESULTS

During hospitalization, 143 (5.8%) participants experienced one or more falls, accounting for 202 falls and corresponding to an overall rate of 7.9 falls per 1,000 patient days. NCJ of participant's risk of falling had high sensitivity (78-92%) with high negative predictive value (94-100%) but low positive predictive value (4-17%). Although false-negative rates were low (8-22%) for all departments and age groups, false-positive rates were high (55-74%), except on surgical and general medical wards and in participants younger than 75.

CONCLUSION

This analysis, based on multicenter data and a large sample size, suggests that NCJ can be recommended on surgical and general medical wards and in individuals younger than 75, but on geriatric wards and in participants aged 75 and older, NCJ overestimates risk of falling and is thus not recommended because expensive comprehensive fall-prevention measures would be implemented in a large number of individuals who do not need it.

A NOVEL MEASUREMENT SYSTEM FOR QUANTITATIVE ASSESSMENT OF AGE-RELATED SENSORI-MOTOR DEGRADATION

Early identification of individuals with impaired balancing ability could lead to timely interventions and reduce the hazard of age-related falls. Numerous methods for researching the prevention of falls and age-related sensori-motor degradation have been proposed and tested. Most are either too expensive for practitioners or too physically demanding to use with seniors. A simple, reliable technique is desired. The aim of this research is to develop a practical and quantitative solution for assessment of age-related degradation of human sensori-motor function, which could in turn serve as a means of fall prevention among seniors. A novel testing apparatus, the dynamic balance testing platform, was developed. The design includes artificial neural network (ANN) technology to address the nonlinearity and redundancy in the neural network that controls sensori-motor functions. A total of 62 male subjects aged from 18 to 84 years were tested using the proposed method. Results showed that (1) the new device did reflect the sensori-motor degradation related to age, (2) reliable evaluation of sensori-motor function need not be complicated, time consuming, or costly, and (3) the developed equipment powered with ANN technology holds great potentials for predicting fall possibility. Overall, this study validated a strategy of fall prevention with a potential for prevalent use in the healthcare industry.

Effectiveness of a fall awareness and education program in acute care

The impact of a patient fall can have serious consequences for the patient, the family, and the healthcare institution. More than half of patient falls are considered preventable. This article reflects the outcomes of a quasi-experimental study to determine the effectiveness of a fall awareness and education program in an acute care setting. Staff development educators working in acute care settings may find the strategies useful in addressing the issue of falls in their own institutions.

Diagnostic accuracy of three types of fall risk methods for predicting falls in nursing homes

AIMS

To determine the diagnostic accuracy of three different methods for identifying individuals at high risk of falling. The St- Thomas Risk Assessment tool (STRATIFY- modified for nursing homes), staff judgment of fall risk, and previous falls remembered by the staff were evaluated. We also examined whether a combination of two of the methods would increase accuracy.

MATERIALS AND METHODS

A prospective observational cohort study was carried out for 18 months. One thousand one hundred and forty-eight participants were included and assessed for fall risk. Falls among these residents were recorded from the date of inclusion to the date of death, transfer, or end of observation time. Diagnostic accuracy was evaluated in terms of sensitivity, specificity, predictive values and likelihood ratios, as well as Kaplan-Meier estimates and the Cox proportional hazard model, with time to the first fall as the dependent variable. Sensitivity, specificity, predictive value and likelihood ratios were calculated for falls within 30, 90 and 180 days of assessment for fall risk.

RESULTS

Five hundred and seventy (49.6%) of the 1148 residents had one or more falls during the observation period. One thousand one hundred had more than 30 days of observation, 987 more than 90 days, and 867 more than 180 days. For falls within 30 days of assessment for fall risk, sensitivity varied from 65% to 72%, specificity from 69% to 75%, positive predictive value from 31% to 35% and negative predictive value from 91% to 92%. Sensitivity and negative predictive value decreased for falls within 90 days and decreased further for falls within 180 days, whereas specificity and positive predictive value increased for all three assessment methods. Staff judgment of fall risk was the single method having the highest sensitivity but the lowest specificity. A combination of either two of them increased sensitivity to more than 80%, but decreased specificity. The positive Likelihood ratio varied from 2.24 to 2.70 and the negative Likelihood ratio from 0.41 to 0.49 for falls within 30 days. The relative risk of sustaining a fall was 2.4, 2.9 and 3.0 times higher for those assessed to be at high risk of falls compared with those assessed to be at low risk, according to STRATIFY, staff judgment of fall risk and previous falls remembered by the staff, respectively.

CONCLUSIONS

The diagnostic accuracy of the three methods did not differ markedly. However, staff judgment had the highest sensitivity and the lowest specificity after 30, 90 and 180 days. A combination of either two of the methods showed the highest sensitivity but the lowest specificity.

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

AIM

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR NURSING MANAGEMENT

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

Physical activity benefits and needs in adults with intellectual disabilities: systematic review of the literature

Regular physical activity is vital for adult individuals with intellectual disabilities. The purpose of this review was to assess critically the evidence on effectiveness of physical activity interventions for adults with intellectual disability. An electronic database search was conducted. Research was then assessed for methodological rigor, and strength of the evidence was determined. Eleven clinical studies met inclusion criteria. Interventions studied included a variety of physical activity modes. Critical review revealed moderate to strong evidence that physical activity positively affected balance, muscle strength, and quality of life in individuals with intellectual disability. The authors also found that the research in this area needs to be translated into practice, specifically the development of physical activity programs that are adaptable to the needs of individuals with intellectual disability.

Designing a falls prevention strategy that works

In implementing an evidence-based falls prevention strategy in acute care, planners are frequently pressed to meet organizational targets while allowing staff flexibility to match interventions with patient population needs and clinical realities. We describe the process of how one hospital creatively used evidence, systems change, staff engagement, expert consultation, policy and protocols, staff and patient education, marketing, and celebration to design and implement a falls prevention strategy on 60 clinical units that reduced annual fall rates by 20%.

World Health Organization fracture risk assessment tool in the assessment of fractures after falls in hospital

Background

Falls are very common accidents in a hospital. Various risk factors and risk assessment tools are used to predict falls. However, outcomes of falls such as bone fractures have not been considered in these risk assessment tools, and the performance of risk assessment tools in a Japanese hospital setting is not clear.

Methods

This was a retrospective single-institution study of 20,320 inpatients aged from 40 to 90 years who were admitted to a tertiary-care university hospital during the period from April 2006 to March 2009. Possible risk factors for falls and fractures including STRATIFY score and FRAX™ score and information on falls and their outcome were obtained from the hospital information system. The datasets were divided randomly into a development dataset and a test dataset. The chi-square test, logistic regression analysis and survival analysis were used to identify risk factors for falls and fractures after falls.

Results

Fallers accounted for 3.1% of the patients in the development dataset and 3.5% of the patients in the test dataset, and 2.6% and 2.9% of the fallers in those datasets suffered peripheral fractures. Sensitivity and specificity of the STRATIFY score to predict falls were not optimal. Most of the known risk factors for falls had no power to predict fractures after falls. Multiple logistic analysis and multivariate Cox's regression analysis with time-dependent covariates revealed that FRAX™ score was significantly associated with fractures after falls.

Conclusions

Risk assessment tools for falls are not appropriate for predicting fractures after falls. FRAX™ might be a useful tool for that purpose. The performance of STRATIFY to predict falls in a Japanese hospital setting was similar to that in previous studies.

Four-item fall risk screening tool for subacute and residential aged care: The first step in fall prevention

AIM

To report the reliability, accuracy and compliance of a brief fall risk screening tool in subacute and residential aged care.

METHOD

A 9-item tool, developed by expert and literature review, was administered to 291 persons admitted to subacute and residential aged care at Peninsula Health (PH) Victoria, Australia. Items were analysed for their ability to predict falls and the four strongest incorporated into a screening tool. Reliability was assessed on six nurses.

RESULTS

Most predictive items were recent falls (0.82), psychological status (0.55), medications (0.46) and cognition (0.41) chi(2) (4, n= 291) = 89.89, P < 0.0001. The final 4-item tool (PH-FRAT) provides 80% accuracy (sensitivity(ER) 70.2%, specificity(ER) 68.8%) and high reliability (ICC = 0.79). The PH-FRAT is now used in 50 local subacute and residential facilities.

CONCLUSION

The 4-item PH-FRAT is a popular, moderately predictive, reliable and brief method of screening fall risk in subacute and residential aged care.

The STRATIFY tool and clinical judgment were poor predictors of falling in an acute hospital setting

OBJECTIVE

To compare the effectiveness of the STRATIFY falls tool with nurses' clinical judgments in predicting patient falls.

STUDY DESIGN AND SETTING

A prospective cohort study was conducted among the inpatients of an acute tertiary hospital. Participants were patients over 65 years of age admitted to any hospital unit. Sensitivity, specificity, and positive predictive value (PPV) and negative predictive values (NPV) of the instrument and nurses' clinical judgments in predicting falls were calculated.

RESULTS

Seven hundred and eighty-eight patients were screened and followed up during the study period. The fall prevalence was 9.2%. Of the 335 patients classified as being "at risk" for falling using the STRATIFY tool, 59 (17.6%) did sustain a fall (sensitivity=0.82, specificity=0.61, PPV=0.18, NPV=0.97). Nurses judged that 501 patients were at risk of falling and, of these, 60 (12.0%) fell (sensitivity=0.84, specificity=0.38, PPV=0.12, NPV=0.96). The STRATIFY tool correctly identified significantly more patients as either fallers or nonfallers than the nurses (P=0.027).

CONCLUSION

Considering the poor specificity and high rates of false-positive results for both the STRATIFY tool and nurses' clinical judgments, we conclude that neither of these approaches are useful for screening of falls in acute hospital settings.

Simple balance and mobility tests can assess falls risk when cognition is impaired

To examine the ability of the Romberg test and the original untimed version of the Get-Up-and-Go test (GUG) to elders at risk for falls. At baseline and two annual follow-up visits, nurses administered the Romberg and GUG tests to 358 primary care patients aged 65+ years. Logistic regression models examined cross-sectional and longitudinal associations between abnormal balance tests and self-reported falls over the preceding year. Models were adjusted for age, sex, education and self-rated health (and, in the longitudinal models, for baseline falls), and the Mini-Mental State Examination (MMSE) as a measure of cognitive status. In cross-sectional analyses, falls reported at baseline were significantly associated with concurrently abnormal Romberg and GUG tests, after adjustment for covariates. In longitudinal analyses, abnormal GUG remained significantly associated with future falls, adjusting for covariates. Among those with low MMSE, GUG remained a significant predictor of future falls. Both balance tests were associated with low MMSE among those reporting no falls. Simple balance tests can help assess falls risk, particularly in cognitively impaired elderly who have elevated falls risk and might not accurately recall previous falls.

Patient falls: acute care nurses' experiences

AIM

To describe the findings from a qualitative study exploring acute care nurses' experiences with patient falls.

BACKGROUND

Patient falls continue to be a problem in acute care settings for nurses at the point of care. Despite the growing body of knowledge related to risk factors and interventions for fall prevention, minimal attention has been given to nurses' perspectives of patient falls.

DESIGN

A qualitative descriptive design was used.

METHOD

Focus group discussions were conducted with nurses working on a cross-section of inpatient acute care settings. Audio-taped sessions were transcribed and analysed thematically.

RESULTS

Nurses described their experience of falls as 'knowing the patient as safe', an ongoing affirmation that the patient was free from harm. In this focused, narrowly defined and highly specific knowing, nurses employed the key strategies of assessment, monitoring and communicating. Variable conditions influenced whether these strategies were effective in giving nurses the knowledge they needed to keep the patient safe. When strategies failed to provide nurses with knowledge of their patients as safe and patients fell, this created considerable stress for nurses and prompted them to use a range of coping strategies.

CONCLUSION

Knowing the patient as safe has the potential to resolve the tension between patient safety and independence. The critical, often taken for granted, activities used by nurses in this knowing must be expanded to include the meaning falls have for patients and attend to factors beyond nurses control such as environmental redesign and staffing.

RELEVANCE TO CLINICAL PRACTICE

Nurses play an important role in fall prevention through knowing the patient as safe but must be supported through the use of a multi-faceted approach extending from the individual nurse to the institutional level.

Balance performance, aging and falling: A comparative study based on a Turkish sample

The effects of aging and gender on balance performance (BP) among ambulatory adults were investigated in the current work. If there was a relation between the BP and a history of falling, this was also detected. Two hundred and forty ambulatory subjects were divided into two groups depending on their age: (1) 125 middle-aged subjects (50-64 years); (2) 115 elderly subjects (65-75). The functional reach (FR) test, the timed up and go (TUG) test, the sit to stand (STS) test and the step test (ST) were used to evaluate the BP. The fall rate (1-2 in the last year) was 8% for the middle-aged group and was 13.9% for the elderly group. Middle-aged adults had better scores on all tests in comparison to the elderly people. There have been differences found between genders regarding the BP in both groups, except the FR scores in the middle-aged group. The FR distance of the faller subjects was rather low in comparison to non-faller elderly subjects. However, there were no significant differences between the faller and non-faller subjects in both groups regarding other tests' scores. The results of this study indicate that aging affects the BP year by year. The information in this paper can provide normative data to be used as a comparison to clinically obtained information.

Fall risk-assessment tools compared with clinical judgment: an evaluation in a rehabilitation ward

OBJECTIVES

to compare the use of two falls risk-identification tools (Downton and STRATIFY) with clinical judgment (based upon the observation of wandering behaviour) in predicting falls of medically stable patients in a rehabilitation ward for older people.

METHODS

in a prospective observational study, with blinded end-point evaluation, 200 patients admitted to a geriatric rehabilitation hospital had a STRATIFY and Downton Fall Risk assessment and were observed for wandering behaviour.

RESULTS

wandering had a predictive accuracy of 78%. A total of 157/200 were identified correctly compared to 100/200 using the Downton score (P < 0.0001 95%, CI 0.18-0.42), or 93/200 using STRATIFY (P < 0.0001; 95% CI 0.15-0.37). The Downton and STRATIFY tools demonstrated predictive accuracies of 50% and 46.5%, respectively, with no statistical significance between the two (P = 0.55; 95% CI 0.77-1.71). Sensitivity for predicting falls using wandering was 43.1% (22/51). This was significantly worse than Downton 92.2% (47/51: P < 0.001) and STRATIFY 82.3% (42/51: P < 0.001).

CONCLUSIONS

this study showed that clinical observation had a higher accuracy than two used falls risk-assessment tools. However it was significantly less sensitive implying that fewer patients who fell were correctly identified as being at risk.

Evaluation of three fall-risk assessment tools in an acute care setting

AIM

This paper is a report of a study to evaluate the validity of three fall-risk assessment tools to identify patients at high risk for falls.

BACKGROUND

Patient falls make up 38% of all adverse events occurring in hospital settings, and may result in physical injury and undesirable emotional and financial outcomes. No single fall-risk assessment tool has been conclusively validated.

METHOD

The Morse Fall Scale, St Thomas Risk Assessment Tool in Falling Elderly Inpatients, and Hendrich II Fall Risk Model were validated in inter-rater reliability and validity studies in 2003. This included assessment of the probability of disagreement, kappa-values, sensitivity, specificity, positive predictive values and negative predictive values of the assessment tools with the associated 95% CI.

FINDINGS

One hundred and forty-four patients were recruited for the inter-rater reliability study. The probabilities of disagreement were between 2.8% and 9.7%, and 95% CI for all tools ranged from 1.1% to 15.7%. The kappa-values were all higher than 0.80. In the validity study, 5489 patients were recruited to observe 60 falls. The Morse Fall Scale at a cutoff score of 25 and Heindrich II Fall Risk Model at a cutoff score of 5 had strong sensitivity values of 88% and 70%, respectively. However, in comparison with the Morse Fall Scale (specificity = 48.3%), only the Heindrich II Fall Risk Model had a more acceptable level of specificity (61.5%).

CONCLUSION

The Heindrich II Fall Risk Model is potentially useful in identifying patients at high risk for falls in acute care facilities.

Bed and Toilet Height as Potential Environmental Risk Factors

Seat height that is too high (> 120% of lower leg length [LLL]) or too low (< 80% of LLL) can impede safe transfer and result in falls. This study examines the difference between LLL of frail nursing home residents and the height of their toilets and beds in the lowest position, compares the patient or environmental characteristics of those able to transfer from the bed or toilet to those who cannot, and determines the relationship of patient or environmental characteristics to bed-related falls. A retrospective observational design using secondary data from 263 nursing home residents finds that bed height of three fourths of participants was greater than 140% of LLL, whereas toilet height of more than half was 100% to 120% of LLL. Increased fall risk is associated with increased age, shorter length of stay, normal lower extremity range of motion, less cognitive impairment, more behavioral symptoms, and no complaints of pain during exam.

Spartanburg Fall Risk Assessment Tool: a simple three-step process

The purpose of this study was to develop a valid, reliable, and user-friendly fall risk assessment tool that is a sensitive predictor for falls in the acute care population. Fall risk factors were determined from extensive review of evidence-based studies available from a PubMed search. Previous falls, medications, and gait were found to be the top three risk factors for predicting a true risk for falls in multiple health care settings. The Spartanburg Fall Risk Assessment Tool (SFRAT) is unique from other fall risk assessment tools in combining intrinsic, patient-related factors, with a direct measure of the patient's functional status. Interrater reliability of the SFRAT using Cohen's kappa was .9008, which reflects almost perfect agreement. The predictability analysis found the SFRAT to be 100% sensitive for falls (27/27) with no false negatives. Specificity was 28% (48/172) with 124 false positives. These false positives may actually reflect patients who were at true risk for fall but were prevented from falling due to effective interventions instituted by the staff providing their care. The SFRAT fall risk assessment is a simple, reliable tool easily incorporated by nurses into their direct care routine.

Evaluation of the Morse Fall Scale: Applicability in Chinese hospital populations

BACKGROUND

Patient falls have been identified as a significant health problem in the general hospital patient population. The Morse Fall Scale (MFS) is an individualized criterion-referenced assessment tool designed for measuring the likelihood of patient falls in hospitals. Despite the scale has demonstrated high validity and reliability in the previous researches, this study is to provide additional validity tests to determine the applicability in the Chinese hospital population.

OBJECTIVES

To examine the predictive power of the MFS to predict patient falls. To conduct reliability tests on internal consistency, item analysis, inter-rater and test-retest reliability.

DESIGN

The study was a cross-sectional study.

SETTINGS

The medical and geriatric units of three rehabilitation hospitals in Hong Kong participated in the study.

PARTICIPANTS

A convenience sample of 954 Chinese patients was recruited sequentially upon admission in the hospital ward units. They ranged in age from 17 to 100 years, with a mean of 70.2 years.

METHODS

The patients were assessed for fall risk using the MFS on admission. Data was collected on the number of patients who fell rather than the number of falls.

RESULTS

The scale had a sensitivity of 31% and a specificity of 83% when the cut-off point was determined at 45. The field test demonstrated excellent inter-rater reliability with an ICC value of 0.97 (95%CI 0.94-0.98). Repeatability was high with an ICC of 0.98 (95% CI 0.98-0.99). The evaluation revealed a low Cronbach's alpha coefficient and a low to moderate item-to-scale correlation.

CONCLUSIONS

The evidence collected in this study has shown both the positive and negative aspects of using the MFS in assessing the fall risk of Chinese patients during rehabilitation. The discriminative validity and internal consistency reliability provide researchers and clinicians with a major step in further developing or modifying the scale.

A new instrument for targeting falls prevention interventions was accurate and clinically applicable in a hospital setting

BACKGROUND AND OBJECTIVE

To describe the diagnostic accuracy and practical application of the Peter James Centre Falls Risk Assessment Tool (PJC-FRAT), a multidisciplinary falls risk screening and intervention deployment instrument.

METHODS

In phase 1, the accuracy of the PJC-FRAT was prospectively compared to a gold standard (the STRATIFY) on a cohort of subacute hospital patients (n = 122). In phase 2, the PJC-FRAT was temporally reassessed using a subsequent cohort (n = 316), with results compared to those of phase 1. Primary outcomes were falls (events), fallers (patients who fell), and hospital completion rates of the PJC-FRAT.

RESULTS

In phase 1, PJC-FRAT accuracy of identifying fallers showed sensitivity of 73% (bootstrap 95% confidence interval CI = 55, 90) and specificity of 75% (95% CI = 66, 83), compared with the STRATIFY (cutoff > or = 2/5) sensitivity of 77% (95% CI = 59, 92) and specificity of 51% (95% CI = 41, 61). This difference was not significant. In phase 2, accuracy of nursing staff using the PJC-FRAT was lower. PJC-FRAT completion rates varied among disciplines over both phases: nurses and physiotherapists, > or =90%; occupational therapists, > or =82%; and medical officers, > or =57%.

CONCLUSION

The PJC-FRAT was practical and relatively accurate as a predictor of falls and a deployment instrument for falls prevention interventions, although continued staff education may be necessary to maintain its accuracy.

Modification of the functional reach test: Analysis of lateral and anterior functional reach in community-dwelling older people

The purpose of this study was to evaluate the validity and reproducibility of the modified lateral functional reach (FR), and to examine the associations between a variety of functional variables and the FR in community-dwelling older people (>65 years of age). A total of 383 aged Japanese participated in this study at the rural district Kahoku, Kochi, Japan, in 2002. The average age of the subjects was 78.6 years. The activity of daily living (ADL) and mental status were measured as outcomes. FR (anterior and lateral) and timed up and go (TUG) were measured as predictors. The test-retest reliability of lateral FR between the first and second measurement was very consistent. Subjects with greater lateral FR had higher basic and instrumental ADL (IADL) scores than did those with shorter lateral FR. However, there was no significant relationship between anterior FR and ADLs. The lateral FR of participants with depression was shorter than in those without depression, while the anterior FR did not correlate with the participants' scores on the geriatric depression scale (GDS). Lateral FR should be considered as a new, alternative means of assessing geriatric social activity and mental status in the elderly.

Predicting the risk of falling--efficacy of a risk assessment tool compared to nurses' judgement: a cluster-randomised controlled trial [ISRCTN37794278]

Background

Older people living in nursing homes are at high risk of falling because of their general frailty and multiple pathologies. Prediction of falls might lead to an efficient allocation of preventive measures. Although several tools to assess the risk of falling have been developed, their impact on clinically relevant endpoints has never been investigated. The present study will evaluate the clinical efficacy and consequences of different fall risk assessment strategies.

Study design

Cluster-randomised controlled trial with nursing home clusters randomised either to the use of a standard fall risk assessment tool alongside nurses' clinical judgement or to nurses' clinical judgement alone. Standard care of all clusters will be optimised by structured education on best evidence strategies to prevent falls and fall related injuries. 54 nursing home clusters including 1,080 residents will be recruited. Residents must be ≥ 70 years, not bedridden, and living in the nursing home for more than three months. The primary endpoint is the number of participants with at least one fall at 12 months. Secondary outcome measures are the number of falls, clinical consequences including side effects of the two risk assessment strategies. Other measures are fall related injuries, hospital admissions and consultations with a physician, and costs.

Predicting In-Hospital Falls

Falling is the most common hospital accident, and up to 15% of fallers sustain a serious injury. This study focused on developing a simple, practical fall risk screener using routine admission and daily in-hospital stay data. A case-control design was used. Logistic regression identified individual characteristics associated with an increased risk of a fall. Four variables were identified: history of falls, ambulation assistance, disoriented, and bowel control problems, creating a fall risk model with 70% sensitivity and 57% specificity.

PREVENTING FALLS in Acute Care: An Innovative Approach

Falls among elderly individuals have been significant sources of disability and death. Falls have affected as many as 10% of older adults during an acute care inpatient stay. The acute care environment has contributed to elderly patient falls. Additionally, manifestations of acute illness, polypharmacy, and medication side effects have been risk factors for falls in the acute care setting. Individualized fall prevention strategies, initial patient assessments, and ongoing patient reassessments have been linked to a decrease in falls in the acute care setting. Approaches to fall prevention have included identification of high-risk patients, communication among staff and family members about an individual's risk of falls, and both case-specific and universal interventions for fall prevention. The purpose of this article is to describe a fall prevention program instituted in an acute care setting in southern Arizona that has produced encouraging results. Moreover, this article addresses individualizing interventions through a continuous clinical feedback loop, which provides patient care areas with relevant information about their patients who fell and recommendations for improving fall prevention.

A volunteer companion‐observer intervention reduces falls on an acute aged care ward

PURPOSE

Falls are the most frequently reported adverse event in hospitalised patients and carry a risk of great harm for the frail elderly. This intervention aimed to prevent high-risk in-patients on an acute aged care ward from falling.

DESIGN/METHODOLOGY/APPROACH

Patients assessed at high falls risk were accommodated in a room staffed by volunteer companion-observers. The volunteers engaged them in conversation, played cards, opened meals and used the call bell to summon nurses if patients attempted to move from the bed or chair without assistance. Because of occupational health and safety considerations, the volunteers did not assist patients to ambulate.

FINDINGS

The falls rate in the acute aged care ward decreased by 44 percent (p < 0.000). No patients fell in the observation room when volunteers were present. Relatives of participating in-patients expressed appreciation of the volunteer role, in terms of increased safety and also companionship. Volunteers exercised initiative in determining their pattern of work and developing resources to support their role.

RESEARCH LIMITATIONS/IMPLICATIONS

Because volunteers are not present around the clock, other strategies are needed to prevent wandering, frequently confused older in-patients from falling during the night.

PRACTICAL IMPLICATIONS

In a context where frail elderly patients need constant supervision, using volunteers is a reasonable strategy.

ORIGINALITY/VALUE

This intervention used an inexpensive, human resources-based approach to significantly reduce the incidence of falls in the population at highest risk of falling. The additional benefits to patients in terms of cognitive improvement bear further investigation.

Artificial Neural Networks and Center-of-Pressure Modeling: A Practical Method for Sensorimotor-Degradation Assessment

Numerous methods for studying the prevention of falls and age-related sensorimotor degradation have been proposed and tested. Some approaches are too impractical to use with seniors or too expensive for practitioners. Practitioners desire a simple, reliable technique. The goals of this research were to develop such an approach and to apply it in exploring the effect of Tai Chi on age-related sensorimotor degradation. The method employed artificial-neural-network (ANN) models trained by using individuals' center-of-pressure (COP) measurements and age. Ninety-six White and Chinese adults without Tai Chi training were tested. In contrast, a third group, Chinese seniors with Tai Chi training, was tested to ascertain any influence from Tai Chi on sensorimotor aging. This study supported ANN technology with COP data as a feasible tool in the exploration of sensorimotor degradation and demonstrated that Tai Chi slowed down the effects of sensorimotor aging.

Hospital fall risk assessment tools: a critique of the literature

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