The Elements of Patient Fall Prevention:A Literature Synthesis

Damon Gates, BSN, RN, CCRN-CMCEvidence-Based Practice Fellow

Staff Nurse, H4200 Medical Cardiac Intensive Care

Heart HospitalAbbott Northwestern Hospital

Minneapolis, MN

The Scope of the Problem

• Patient fall risk identification and fall prevention have been identified as an urgent need in countries across the globe by regulatory agencies, payers, and patient care advocates.

• A multitude of falls risk assessment tools and fall prevention programs have been developed to address this need.

• There is very little consensus on a single, effective, broadly applicable fall prevention strategy.

The Scope of the LiteratureSearches of PubMed, CINAHL, guidelines.gov,

and the Cochrane Library yielded 168 citations, of which 68 were applicable to the question, “What does current research tell us we should be doing to prevent patient falls?”

Current literature describes over 30 different falls risk assessment scales, in varying levels of testing and validation.

A distinct divide is evident between the research literature and clinical case studies concerning identifying and managing falls risk.

The Great DivideResearch studies conclude:

[a] Falls risk assessment tools have inadequate predictive power and are therefore clinically useless, and [b] Falls prevention interventions cannot be individually tested for validity, and therefore cannot be trusted as useful or effective.

Clinical case studies demonstrate that these “useless” assessment tools and interventions still somehow yield a decrease in falls frequency and injury severity.

So who's right?

And the Winner Is...Research concerning the effectiveness of falls

risk assessment tools is confounded by contamination and by a poor understanding of “risk factors.” The “gold standard” of double-blind studies of risk assessment tools and interventions is often impractical, as well as unethical.

Case studies demonstrate a wide variety of programs that meet with varying degrees of success. Comparisons of these successes allow for common elements to be identified.

Using all these element will most likely produce the greatest improvements in falls prevention.

The Elements of Patient Falls Prevention

• Use a Falls Risk Assessment Tool• Assure the Tool is used correctly• Use interventions that work• Tailor interventions to the

patient• Fall prevention is everyone's job• Monitor your program, change as

needed

Use a Falls Risk Assessment Tool•Tools allow for more inexperienced

clinicians to identify patients at risk as well as more expert colleagues.

•Tools allow for systematic attention to be paid to falls risk assessment.

•Tools must be appropriate to the patient population.

•Regular, thorough training in use of the tool is required.

•Tool selection is not a “marriage.”

Assure the Tool is Used Correctly

•Have system elements in place to assure the tool is used correctly.

•Monitor how tool is used:1. Consistency of results (inter-rater reliability)2. Results consistent with observable reality

•Monitor results and association with actual falls events.

Use Interventions that Work

•Easy to say, difficult to do. • Interventions are often

“bundled,” making it difficult to identify the “effective” interventions.

•Consideration must be given to the mechanism of patient falls.

•Start with the obvious!

Tailor Interventions to the Patient

•Consider physical, environmental, and behavioral elements that place this patient at higher risks for falls.

•Your falls risk assessment tool may guide you, but it is often insufficient.

•Set up intervention selection methods to simplify selection process.

•Again, start with the obvious!

Falls Prevention is Everyone's Job!

•Clearly communicate patients' fall risk status to everyone who has even transient contact with the patient.

•Have clear, role-specific expectations and training for all clinical and non-clinical personnel regarding fall prevention.

•Welcome the patient, family members, and other visitors to your facility's “Patient Falls Prevention Team.”

Monitor Your Program, Change as Needed

•Monitor your Falls Risk Assessment Tool to make sure it is properly capturing patients at risk.

•Monitor interventions to make sure the are properly selected and rigorously enforced.

•Critically analyze patient falls events to assure tool accuracy and that appropriate preventions measures were taken, and to identify additional opportunities.

•Monitor trends in patient falls.

Bad News, Good News• Not all patient falls

are predictable or preventable.

• There is no perfect risk assessment tool.

• There is no single, globally effective intervention.

• An effective falls prevention program entails difficult and tedious work.

• A substantial percentage of patient falls can be prevented.

• A population-specific risk assessment tool can be selected or developed that has a high level of accuracy.

• Carefully selected clusters of interventions can be effective.

• Falls prevention can substantially improve patient care value.

Selected ReferencesDiduszyn, J., Hofmann, M., Naglac, M., & Smith, D.(2008) Use of a wireless nurse alert fall monitoring system to prevent

inpatient falls. JCOM 15(6), 293-296

Dykes, P., Carroll, D., Hurley, A., Benoit, A., & Middleton, B. (2009) Why do patients in acute care hospitals fall? Can falls be prevented? Journal of Nursing Administration 39(6), 299-304

Gowdy, M., Godfrey, S. (2003) Using tools to assess and prevent inpatient falls. Joint Commission Jouranl on Quality and Safety (2003) 29(7). 363-368.

Healey, F., Monro, A., Cockram, A., Adams, V., Heseltime, D. (2004) Using Targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial. Age and Aging 33(4) 390-395.

Hendrich, A. (2007) Predicting patient falls: using the Hendrich II Fall Risk Model in clinical practice. Am Jnl of Nsg 107(11) 50-58

Hendrich, A., Bender, P., & Nyhuis, A. (2003) Validation of the Hendrich II fall risk model, a large concurrent case/control study of hospitalized patients. Applied Nursing Research 16(1), 9-21.

Institute for Clinical Systems Improvement (ICSI) (2008) Prevention of falls (acute care) [health care protocol]. Bloomington (MN): Institute for Clinical Systems Improvement.

Myers, H. (2003) Hospital fall risk assessment tools: a critique of the literature. Internat’l Jnl of Nsg Practice 9, 223-235.

Myers, H., Nikoletti, S., (2003) Fall risk assessment: a prospective investigation of nurses’ clinical judgment and risk assessment tools in predicting patient falls. International Journal of Nursing Practice 9, 158-165

Oliver, D. (2006) Assessing the risk of falls in hospitals: time for a rethink? Canadian Journal of Nursing Research 38(2), 89-94

Oliver, D., Daly, F., Martin, F., McMurdo, M (2004) Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age and Aging 33, 122-130

Vassallo, M., Stockdale, R., Sharma, S., Briggs, R., & Allen, S. (2005) A comparative study of the use of for fall risk assessment tools on acute medical wards. J of the American Geriatrics Soc. 53:1034-1038