Beyond the 'tick and flick': facilitating best practice falls prevention through an action research approach

Aims and objectives. To examine residential aged care facility staff views on using falls risk assessment tools and the implications for developing falls prevention practices in the context of an action research project. Background. Falls risk assessments play an important role in care planning by identifying and monitoring aged care facility residents most at risk of falls. Yet while such assessments are recommended in falls prevention best practice guidelines, there is little published research that examines staff procedures and views related to conducting falls risk assessments. Design. Falls risk assessments were undertaken in the context of an action research project. Method. Twelve staff members from two residential aged care facilities (RACFs) in Tasmania formed a single Falls Action Research Group, which met 22 times over a year, providing the study’s qualitative data. During this time, key group members assessed 178 residents using a new falls risk assessment tool (FROP‐Resi). Results. According to group members, facilities evolved from a ‘tick‐and‐flick’ approach to falls risk assessment to a more individualised, face‐to‐face assessment process. Group members perceived the process to be more meaningful and enjoyable for staff involved in the assessment process resulting in higher quality of assessments and leading to improved levels of falls awareness among staff, residents and family caregivers. Conclusions. An action research process is useful for facilitating a new approach to falls risk assessments, engaging aged care facility staff with falls prevention and prompting improvements in falls prevention practices. Relevance to clinical practice. RACFs need to provide opportunities for staff to meet regularly to discuss practice, identify issues and take action. By doing so, staff can engage meaningfully with best practice activities such as optimising falls risk assessment processes.     

Reducing staff isolation and developing evidence-informed practice in the aged care environment through an action research approach to falls prevention

This study aimed to examine whether an action research approach was effective in reducing the isolation of staff in 2 residential aged care facilities, within the context of an evidence-informed falls prevention program. A Falls Action Research Group comprising 12 nursing/nonnursing staff across 2 residential aged care facilities was established and engaged in critical dialogue and action over 12 months to improve their fall prevention activities. Through the group members' engagement, a research community was established that diminished staff isolation by engaging members in a sustained process of collaboration around falls prevention, which worked to disrupt occupational silos and challenge traditional staff hierarchies.     

Fall prevention by nursing assistants among community‐living elderly people. A randomised controlled trial

Falls among elderly are a major public health issue in Sweden. The aim was to determine whether nursing assistants can prevent falls by supervising community‐living elderly individuals with a history of falling in performing individually designed home exercise programmes. A randomised controlled trial was performed in Sweden, in eight municipalities in the county of Örebro, during 2007–2009. Community‐living persons 65 years or older having experienced at least one fall during the last 12 months were included. The intervention group consisted of 76 participants, and there were 72 in the control group. The interventions were free of charge and were shared between a physiotherapist and a nursing assistant. The former designed a programme aiming to improve balance, leg strength and walking ability. The nursing assistant supervised the performance of activities during eight home visits during a 5‐month intervention period. The measures and instruments used were health‐related quality of life (SF ‐36), activity of daily living (ADL ‐staircase), balance, (Falls Efficacy Scale, and Berg Balance Scale), walking ability (Timed Up and Go and the 3‐metre walking test), leg strength, (chair stand test). All participants were asked to keep a structured calendar of their physical exercise, walks and occurrence of falls during their 12‐month study period. Hospital healthcare consumption data were collected. Although the 5‐month intervention did not significantly decrease the risk for days with falls, RR 1.10 (95% CI 0.58, 2.07), p = 0.77, significant changes in favour of the intervention group were noted for balance (p = 0.03), ADL (p = 0.035), bodily pain (p = 0.003) and reported health transition over time (p = 0.008) as well as less hospital care due to fractures (p = 0.025). Additional studies with more participants are needed to establish whether or not falls can be significantly prevented with this model which is workable in home‐based fall prevention.     

Pragmatic development of an evidence-based intensive care unit–specific falls risk assessment tool: The Tyndall Bailey Falls Risk Assessment Tool

BackgroundFalls may result in significant patient harm. A recommended strategy to prevent falls is the use of a falls risk assessment tool, but these tools are often specific for older people. Evidence suggests context-specific tools are more effective. Although a rare event in the intensive care unit (ICU), patients in the ICU are at high risk of falling. The primary trigger for the current study was an increase in falls in the study ICU.AimThe objective of this study was to develop and implement a valid and reliable ICU-specific falls risk assessment tool, with the aim of reducing falls.MethodsRetrospective incident-monitoring database audits were performed. Prospective validity and reliability testing of an ICU-specific tool (Tyndall Bailey Falls Risk Assessment Tool [TB FRAT]) and the existing method for assessing falls risk (ONTARIO Modified Stratify [Sydney Scoring] Falls Risk Screen) was conducted. Seven raters (nurse clinicians) independently performed falls risk assessment using both tools on two occasions for six patients.ResultsCorrelation for risk stratification categories between the two tools was moderate (r = 0.60, P < .001). Intrarater reliability (correlation) for individual rater's scores was strong (r = 0.86, P < .001). Interrater reliability for the TB FRAT was moderate to excellent (interclass correlations = 0.76 [95% confidence interval: 0.54–0.94]), and internal consistency was excellent (Cronbach's alpha, 0.97). Falls resulting in serious injury reduced from 3.35 per 1000 separations 12 months before implementing the specific ICU tool to 0.85 per 1000 in the 12 months after implementation.ConclusionsThe TB FRAT provided a more reliable falls risk assessment than the existing method of assessing falls risk in this single-room occupancy ICU. This TB FRAT could be a valuable addition to quality improvement initiatives aimed at improving patient safety related to falls; however, adaptation to the local context should be considered.     

Identification of Fall Risk Factors in Older Adult Emergency Department Patients

Objectives: Falls represent an increasingly frequent source of injury among older adults. Identification of fall risk factors in geriatric patients may permit the effective utilization of scarce preventative resources. The objective of this study was to identify independent risk factors associated with an increased 6‐month fall risk in community‐dwelling older adults discharged from the emergency department (ED). Methods: This was a prospective observational study with a convenience sampling of noninstitutionalized elders presenting to an urban teaching hospital ED who did not require hospital admission. Interviews were conducted to determine the presence of fall risk factors previously described in non‐ED populations. Subjects were followed monthly for 6 months through postcard or telephone contact to identify subsequent falls. Univariate and Cox regression analysis were used to determine the association of risk factors with 6‐month fall incidence. Results: A total of 263 patients completed the survey, and 161 (61%) completed the entire 6 months of follow‐up. Among the 263 enrolled, 39% reported a fall in the preceding year, including 15% with more than one fall and 22% with injurious falls. Among those completing the 6 months of follow‐up, 14% reported at least one fall. Cox regression analysis identified four factors associated with falls during the 6‐month follow‐up: nonhealing foot sores (hazard ratio [HR] = 3.71, 95% confidence interval [CI] = 1.73 to 7.95), a prior fall history (HR = 2.62, 95% CI = 1.32 to 5.18), inability to cut one’s own toenails (HR = 2.04, 95% CI = 1.04 to 4.01), and self‐reported depression (HR = 1.72, 95% CI = 0.83 to 3.55). Conclusions: Falls, recurrent falls, and injurious falls in community‐dwelling elder ED patients being evaluated for non–fall‐related complaints occur at least as frequently as in previously described outpatient cohorts. Nonhealing foot sores, self‐reported depression, not clipping one’s own toenails, and previous falls are all associated with falls after ED discharge.     

Relationship between pre‐discharge occupational therapy home assessment and prevalence of post‐discharge falls

Rationale, aims and objective Pre‐discharge occupational therapy home assessments are common practice, and considered important for falls prevention in older people. This prospective, observational cohort study describes the association between pre‐discharge home assessment and falls in the first month post‐discharge from a rehabilitation hospital. Methods 342 inpatients were recruited and followed up 1 month post‐discharge. Patients were classified into diagnostic groups (cardiac, orthopaedic trauma, spinal, peripheral joint surgery, neurological and deconditioned). Age, gender, falls risk [Falls Risk Assessment Scoring System (FRASS)], functional independence scores (FIM?) and receipt (or not) of a home assessment were recorded. Patients completed a diary to document post‐discharge falls. Logistic regression analysis tested the effect on falling of receiving a home assessment, age, gender, diagnostic group, FRASS and FIM?. Results Considering all subjects, not receiving a home assessment increased the risk of falling 1 month post‐discharge [odds ratio (OR) 2.6, 95% confidence interval (CI) 1.4–4.7, P = 0.003]. Neurological and orthopaedic trauma patients had significantly elevated risks of falling [OR (95% CI), respectively, 12.5 (4.7–33.2), 3.4 (1.4–8.4)] relative to the orthopaedic joint group. For all diagnostic groups except neurological, falls risk was mitigated by a home assessment. In non‐neurological patients, adjusting for the effect of diagnostic group, FRASS and FIM? scores indicated a significant association between not receiving a home assessment and falling (OR 4.2, 95% CI 2.1–8.2, P < 0.001). Conclusions Pre‐discharge occupational therapy home assessments are sound post‐discharge falls‐prevention strategies in non‐neurological patients. The decision to conduct a home assessment should consider diagnosis, falls risk and functional independence.     

住院病人跌倒危险因素评估量表的设计与应用

目的减少和避免住院病人跌倒发生。方法设计住院病人跌倒危险因素评估量表及住院病人跌倒危险护理措施表,应用于内科4个护理单元评估病人。结果427例病人实施护理措施表后,无一例跌倒事件发生。结论应用病人跌倒评估量表,使护理措施更具体及个性化,可以预防病人跌倒的发生。     

Falls are a fact of life for some patients after discharge from a rehabilitation programme

Purpose.?This paper reports on a 3-month post-discharge falls profile of a cohort of patients discharged home from an acute rehabilitation setting.

Methods.?A consecutively-sampled cohort of consenting patients was prospectively followed for 3 months after discharge from a large Australian metropolitan acute rehabilitation facility. Patients were diagnostically classified by the reason for admission. All patients completed a monthly falls diary. Each month, falls were described by severity, location, frequency and outcome. Patients also completed the World Health Organisation's quality of life (QoL-BREF) at Months 1 and 3.

Results.?Almost a third of the study participants fell during the study [105 fallers of 342 total (31%)]. Of these, 21 fell more than once (20%). There were significant differences in falls reported per diagnostic group, including frequency, impact, severity and ability to get up. Irrespective of diagnostic group, fallers had lower QoL scores compared to non-fallers. Both the neurological and orthopaedic trauma groups were most at risk of falling in Months 1 and 3, whereas in Month 2, only the neurological group was most at risk of falling.

Conclusion.?Falls are a fact of life for some patients during their community rehabilitation phase. Patients from different diagnostic groups have different over-time risk profiles for falling. Thus, there is no ‘one-size fits all’ solution for falls prevention. This study provides useful data to assist in formulating appropriate falls prevention strategies for recently ill people.     

Thinking falls-taking action: a falls prevention tool for care homes

Falls in older people resident within care home settings are common and serious, often resulting in injury and mortality. Yet there is no standardised approach within UK care homes to assessing the risk of falls for individuals or identifying risk factors relevant for that person. The Guide to Action for Falls Prevention Tool - Care Homes (GtACH) was developed with local care homes in Nottinghamshire. Ten care homes were selected to participate in the study, four withdrawing before data collection commenced. Fourteen care home staff across six care homes tested the tool for usability and found it quick (20 minutes) and easy to use, yet only 53% of the recommended interventions highlighted were completed. The GtACH needs further evaluation to test whether its use prompts actions which reduce the number of falls, and the barriers to these actions being taken.     

The impact of COVID-19 in an assisted living community

The purpose of this study was to use routinely collected resident assessment data from a single site to evaluate the impact of COVID-19 restrictions on cognition, physical function and behavioral symptoms of residents with dementia. Specifically, it was hypothesized that controlling for age and sex, there would be a decline in cognition and function and an increase in behavioral symptoms at 12 months post implementation of COVID-19 restrictions. Twelve residents from a single memory care site with required Resident Assessments completed prior to and 12 month post initiation of the pandemic and associated quarantines were included. No significant change was noted in function or behavioral symptoms but there was a statistically significant decline in cognition over the 12 month period. Although this study did not support our hypothesis, the findings supported some prior research also noting little significant change among the majority of individuals over the course of the pandemic regardless of regulations.     

Falls and injury prevention should be part of every stroke rehabilitation plan

OBJECTIVE: To evaluate falls incidence, circumstances and consequences in people who return home after stroke rehabilitation, so that appropriate falls and injury prevention strategies can be developed. DESIGN: Prospective cohort study. SETTING: Community. SUBJECTS: Fifty-six subjects with stroke who were participating in a rehabilitation programme and returning to live in a community setting completed the study. MAIN MEASURES: Subjects completed a prospective falls diary for six months after discharge from rehabilitation, and were interviewed after falls. Physical function was measured by the Berg Balance Scale (BBS) and the Functional Independence Measure (FIM). RESULTS: Forty-six per cent of people (26/56) fell, with most falls (63/103 falls) occurring in the two months after discharge from rehabilitation. One subject had 37 similar falls and these falls were excluded from further analysis. Falls occurred more often indoors (50/66), during the day (46/66) and towards the paretic side (25/66). People required assistance to get up after 25 falls (38%) and 36 falls (55%) resulted in an injury. People sought professional health care after only 16 falls, and activity was restricted after 29 falls (44%). The Berg Balance Scale and Functional Independence Measure scores were lower in people who had longer lies after a fall, and who restricted their activity after a fall (p < 0.05). Lower physical function scores were also associated with falling in the morning, wearing multifocal glasses at the time of a fall, and injurious falls (p < 0.05). CONCLUSION: Falls are common when people return home after stroke. Of concern are the small number seeking health professionals' assistance after a fall, the high proportion restricting their activity as a result of a fall and the number of falls occurring towards the paretic side.     

Patient falls: profile for prevention

Patient falls are common in the hospital or long-term care setting. In a large Southwestern teaching hospital, patient falls have been monitored on an ongoing basis. A multidisciplinary task force developed a method of identifying patient fall risk factors. A survey was used concurrently as falls were reported during the month of July. Forty-seven falls were reported. Of this sample, neurological patients accounted for 12 (25.5%) of the incidents. The neurological patient fall profile was identified as a high-risk profile, and interventions were taken to prevent falls in this group. A second data collection was conducted six months later with this population. While the number of patients on the neurological services remained constant, the incidence of falls decreased (25%). By using a comprehensive approach of data collection and assessment, education, and follow-up, the institution has decreased neurological patient falls.     

Correlates of post-hospital physical function at 1 year in skilled nursing facility residents

Title. Correlates of post‐hospital physical function at 1 year in skilled nursing facility residents Aim. This paper is a report of a study to examine the relationship between health‐related admission factors and post‐hospital physical function at 3, 6, 9 and 12 months in older adult nursing facility residents. Background. Physical functional decline is a significant health problem for older adults and has far‐reaching effects. In particular, the immediate post‐hospital period is a high‐risk time, because shortened hospital stays make it likely that older patients are discharged in a state of incomplete recovery. Method. Data spanning from July 2002 to June 2005 were extracted from a comprehensive assessment tool, the Minimum Data Set, for 38,591 beneficiaries of a federal health insurance programme covering older adults in the Midwestern region of the United States of America. We investigated relationships between admission factors and post‐hospital physical function at 3, 6, 9 and 12 months. The admission factors were health‐related variables assessed at the time of skilled nursing facility admission from an acute care hospital. Findings. The most important admission factors related to post‐hospital physical function at 3, 6, 9 and 12 months were baseline physical function, urinary incontinence and pressure ulcer. Cognitive impairment at admission demonstrated a stronger relationship with poor physical function as resident length of stay increased. Conclusion. Nurses in skilled nursing facilities should screen post‐hospital older adults for risk of physical functional decline at admission using identified admission factors. For continuous nursing care, older adults need to be assessed at least once a month during the first 3 months after hospital discharge.     

Are your residents safe in their beds?

Of all the issues facing the long term care industry today, perhaps none are more prominent than the two issues of resident falls and bed siderails (restraints). Across the country, care providers are facing the reality of reducing and eliminating patient restraints, including siderails. At the same time, resident falls have also come to the forefront as an extremely important issue; it's now nearly impossible to find a facility without a special Falls Committee focussed on reducing the injuries sustained to residents, often caused when they are transferred or climb out of bed.     

Development of a clinical practice guideline for palliative sedation

Palliative sedation is an effective symptom control strategy for patients who suffer from intractable symptoms at the end of life. Evidence suggests that the use of this practice varies considerably. In order to minimize variation in the practice of palliative sedation within our health region, we developed a clinical practice guideline (CPG) for the use of palliative sedation. Using available evidence from the literature, a five step process was employed to develop the CPG: (1) a working group was charged with the mandate to develop a draft guideline; (2) a working definition for palliative sedation was developed; (3) criteria for use of sedation were determined; (4) critical steps to be taken prior to initiation of sedation were defined; and (5) the CPG was reviewed by local stakeholders. Feedback from the wider group of stakeholders was used to arrive at the final CPG, which subsequently received approval from the local Medical Advisory Board. The process used to develop the CPG served to develop consensus within the local community of palliative care clinicians regarding the practice of palliative sedation. Subsequently, the CPG was used as a tool for educating other health care providers.     

Balance score and a history of falls in hospital predict recurrent falls in the 6 months following stroke rehabilitation

OBJECTIVE: To investigate predictors of recurrent falls in adults who return to community dwelling after stroke rehabilitation. DESIGN: Prospective observational study. SETTING: Community. PARTICIPANTS: Fifty-five adults with stroke (mean age +/- standard deviation, 68.1+/-12.8y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Baseline measures included balance, gait speed, muscle strength and tone, activity level, hemianopia, visual contrast sensitivity, hemineglect, medication use, fear of falling, and depression. Participants kept a 6-month prospective falls diary after discharge from rehabilitation. RESULTS: Twenty-five (45%) participants reported falling, 12 had recurrent falls (> or =2 falls), and 13 fell once. Participants who fell recurrently had histories of falling during hospitalization or rehabilitation, poorer physical function measures, were taking more medications, and were more likely to have hemineglect than participants who fell once or did not fall (P<.05). A history of falling in the hospital or during rehabilitation, combined with poor balance (either Berg Balance Scale score <49 or step test score <7), predicted recurrent falls with sensitivity and specificity values greater than 80%. CONCLUSIONS: Falls are a common occurrence after stroke. The predictive model developed can be used to identify people who are likely to have recurrent falls in the 6 months after stroke rehabilitation.     

Incidence and related clinical factors of falls among older Chinese veterans in military communities: a prospective study

[Purpose] The aim of this study was to determine fall incidence and explore clinical factors of falls among older Chinese veterans in military communities. [Subjects and Methods] We carried out a 12-month prospective study among 13 military communities in Beijing, China. Fall events were obtained by self-report to military community liaisons and monthly telephone interviews by researchers. [Results] Among the final sample of 447 older veterans, 86 fell once, 25 fell twice or more, and 152 falls occurred altogether. The incidence of falls and fallers were 342/1,000 person-years and 249/1,000 person-years. In Cox regression models, independent clinical factors associated with falls were visual acuity (RR=0.47), stroke (RR=2.43), lumbar diseases (RR=1.73), sedatives (RR=1.80), fall history in the past 6 months (RR=2.77), multiple chronic diseases (RR=1.53), multiple medications (RR=1.34), and five-repetition sit-to-stand test score (RR=1.41). Hearing acuity was close to being statistically significant. [Conclusion] The incidences of falls and fallers among older Chinese veterans were lower than those of Hong Kong and western countries. The clinical risk factors of falls were poor senses, stroke, lumbar diseases, taking sedatives, fall history in the past 6 months, having multiple chronic diseases, taking multiple medications, and poor physical function. The preventive strategies targeting the above risk factors are very significant for reducing falls.Key words: Falls, Incidence, Clinical factors     

Long-term follow-up of exercise interventions aimed at preventing falls in older people living in the community: a systematic review and meta-analysis

BackgroundFall-related injuries are the leading cause of accident-related mortality for older adults, with 30% of those aged 65 years and over falling annually. Exercise is effective in reducing rate and risk of falls in community-dwelling adults; however, there is lack of evidence for the long-term effects of exercise.ObjectivesTo assess the long-term effect of exercise interventions on preventing falls in community-dwelling older adults.Data SourcesSearches were undertaken on MEDLINE, EMBASE, AMED, CINAHL, psycINFO, the Physiotherapy Evidence Database (PEDro) and The Cochrane Library from inception to April 2017.Study selectionRandomised controlled trials (RCTs), cohort studies or secondary analyses of RCTs with long-term follow-up (>12 months) of exercise interventions involving community-dwelling older adults (65 and over) compared to a control group.Data extraction/ Data synthesisPairs of review authors independently extracted data. Review Manager (RevMan 5.1) was used for meta-analysis and data were extracted using rate ratio (RaR) and risk ratio (RR).ResultsTwenty-four studies (7818 participants) were included. The overall pooled estimate of the effect of exercise on rate of falling beyond 12-month follow-up was rate ratio (RaR) 0.79 (95% confidence interval (CI) 0.71 to 0.88) and risk of falling was risk ratio (RR) 0.83 (95% CI 0.76 to 0.92) Subgroup analyses revealed that there was no sustained effect on rate or risk of falling beyond two years post intervention.ConclusionsFalls prevention exercise programmes have sustained long-term effects on the number of people falling and the number of falls for up to two years after an exercise intervention.Systematic review registration numberCRD42017062461.