Fall risk assessment: a prospective investigation of nurses' clinical judgement and risk assessment tools in predicting patient falls. Fall Risk Assessment in Geriatric-Psychiatric Inpatients to Lower Events (FRAGILE). Prediction of falls using a risk assessment tool in the acute care setting Evaluation of the fall prevention program in an acute care setting. Hospital falls: development of a predictive model for clinical practice. The efficacy of a multidisciplinary falls prevention clinic with an extended step-down community program. Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial. Evaluation of the STRATIFY falls prediction tool on a geriatric unit. Falls prevention revisited: a call for a new approach. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. Using targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial. A new instrument for targeting falls prevention interventions was accurate and clinically applicable in a hospital setting. Lack of effectiveness of a multidisciplinary fall-prevention program in elderly people at risk: a randomized, controlled trial. A multifactorial approach to understanding fall risk in older people. Criteria for evaluation of measurement properties of clinical balance measures for use in fall prevention studies. Identifying nursing home residents at risk for falling. Use of initial risk assessment and recording as the main nursing intervention in identifying risk of falls.
A prospect i ve cohort study was used to determine the reliability and validity of two fall risk assessment tools and  nurses ' clinical judgement in predicting patient falls .  The study wards comprised two aged care and rehabilitation wards within a 570 bed acute care tertiary teaching hospital in Western Australia . Instrument testing included test-retest reliability and calculations of sensitivity , specificity , positive predictive value , negative predictive value and accuracy . The test retest reliability of all methods was good . In this setting , the three methods of assessing fall risk showed good sensitivity but poor specificity . Also , all methods had limited accuracy , and overall , exhibited an inability to adequately discriminate between patient population s at risk of falling and those not at risk of falling . Consequently , neither nurses ' clinical judgement nor the fall risk assessment tools could be recommended for assessing fall risk in this clinical setting The objectives of this retrospective case-control study were to identify risk factors of falls in geriatric-psychiatric in patients and develop a screening tool to accurately predict falls . The study sample consisted of 225 geriatric-psychiatric in patients at a Midwestern referral facility . The sample included 136 in patients who fell and a r and om stratified sample of 89 in patients who did not fall . Data collected included age , gender , activities of daily living , and nursing parameters such as bathing assistance , bed height , use of bed rails , one-on-one observation , fall warning system , Conley Scale fall risk assessment , medical diagnosis , and medications . History of falls , impaired judgment , impaired gait , dizziness , delusions , delirium , chronic use of sedative or antipsychotic agents , and anticholinergic urinary bladder medications significantly increased fall risk . Alzheimer 's disease , acute use of sedative or anti-psychotic agents , and depression reduced fall risk . A falls risk tool , Fall Risk Assessment in Geriatric-psychiatric In patients to Lower Events ( FRAGILE ) , was developed for assessment and risk stratification with new diagnoses or medications Background The British STRATIFY tool was previously developed to predict falls in hospital . Although the tool has several strengths , certain limitations exist which may not allow generalizability to a Canadian setting . Thus , we tested the STRATIFY tool with some modification and re-weighting of items in Canadian hospitals . Methods This was a prospect i ve validation cohort study in four acute care medical units of two teaching hospitals in Hamilton , Ontario . In total , 620 patients over the age of 65 years admitted during a 6-month period . Five patient characteristics found to be risk factors for falls in the British STRATIFY study were tested for predictive validity . The characteristics included history of falls , mental impairment , visual impairment , toileting , and dependency in transfers and mobility . Multivariate logistic regression was used to obtain optimal weights for the construction of a risk score . A receiver-operating characteristic curve was generated to show sensitivities and specificities for predicting falls based on different threshold scores for considering patients at high risk . Results Inter-rater reliability for the weighted risk score indicated very good agreement ( inter-class correlation coefficient = 0.78 ) . History of falls , mental impairment , toileting difficulties , and dependency in transfer / mobility significantly predicted fallers . In the multivariate model , mental status was a significant predictor ( P < 0.001 ) while history of falls and transfer / mobility difficulties approached significance ( P = 0.089 and P = 0.077 respectively ) . The logistic regression model led to weights for a risk score on a 30-point scale . A risk score of 9 or more gave a sensitivity of 91 % and specificity of 60 % for predicting who would fall . Conclusion Good predictive validity for identifying fallers was achieved in a Canadian setting using a simple-to-obtain risk score that can easily be incorporated into practice PURPOSE To evaluate the effectiveness of a Falls Prevention Program ( FPP ) in reducing  patient fall rate  and to examine predictors of falls . SAMPLE A nonr and om , stratified convenience sample of 292 subjects was selected from medical-surgical/critical care patients at a large community hospital system . The sample included 101 patients who fell prior to the FPP , 98 patients who fell after FPP , and 93 patients who did not fall after FPP . METHODS A retrospective , preimplementation/long-term , postimplementation , comparative , descriptive design was used to address differences in patients who fell before and after FPP . Prediction factors associated with incidence of falls were assessed using a sample that included patients who fell and patients who did not fall in 1995 . Data were collected about the patients and the fall incidents via a retrospective chart and incident report review . FINDINGS No decrease in patient fall rate was found between patients who fell before and after implementation of the FPP . Patients tended to fall attempting to get out of the bed , suffering no injury . Model testing of the linear results of patients who fell and patients who did not fall after the implementation of the FPP demonstrated that fall prediction factors included age 60 or over , impaired memory , muscle weakness , and need of ambulatory assistance ( Log linear chi-square : 6.048 , df 4 , p = 0.811 ( p > .05 ) . CONCLUSION Identification of patients who exhibit characteristics of the fall prediction model may be useful in reducing falls in medical-surgical/critical care patients . Further testing of the four-factor model with subsequent inclusion of focused interventions may impact the incidence of falls A retrospective case-control study related to falls was conducted at an 1,120-bed acute care tertiary hospital . The case ( fall ) sample consisted of 102 falls and 236 control ( nonfall ) charts during a 1-month period . An instrument developed by Hendrich ( 1988 ) was modified for use in the study . Demographic data and risk factors were recorded . Descriptive statistics included risk factor percentages for each sample and the corresponding univariate relative risks . Logistic regression was used to develop a multivariate risk factor model with seven risk factors . The significant risk factors were recent history of falls , depression , altered elimination patterns , dizziness or vertigo , primary cancer diagnosis , confusion , and altered mobility . The adjusted relative risks were converted to risk points to be used to assess a patient 's level of fall risk . Within the data set , a sensitivity of 77 % ( 79 of 102 ) and specificity of 72 % ( 169 of 236 ) were calculated . The model was cross-vali date d in a 1987 data set with a sensitivity of 83 % ( 59 of 71 ) and specificity of 66 % ( 106 of 161 ) OBJECTIVE To investigate the efficacy of a falls prevention clinic and a community step-down program in reducing the number of falls among community-dwelling elderly at high risk of fall . DESIGN Prospect i ve cohort . SETTING Community . PARTICIPANTS Community-dwelling elderly ( N=200 ) were screened for risk of fall ; 60 were identified as being at high risk and were referred to the intervention program . INTERVENTION Twelve sessions of a once-a-week falls prevention clinic , including fall evaluation , balance training , home hazard management program , and medical referrals , were provided in the first 3 months . The community step-down program , including falls prevention education , a weekly exercise class , and 2 home visitations , was provided in the following 9 months . MAIN OUTCOME MEASURES Fall rate , injurious fall , and its associated medical consultation were recorded during the intervention period and the year before intervention . Balance tests included the Berg Balance Scale ( BBS ) , Sensory Organization Test , and limits of stability test ; fear of falling , as evaluated using the Activities-specific Balance Confidence ( ABC ) scale , was measured at baseline and after the training in the falls prevention clinic . RESULTS Significant reductions in fall rate ( 74 % ) , injurious falls ( 43 % ) , and fall-associated medical consultation ( 47 % ) were noted . Significant improvement in balance scores ( BBS , P<.001 ; endpoint excursion in limits of stability test , P=.004 ) and fear of falling ( ABC scale , P=.001 ) was shown . CONCLUSIONS The programs in the falls prevention clinic were effective in reducing the number of falls and injurious falls . The community step-down programs were crucial in maintaining the intervention effects of the falls prevention clinic AIM This article is a report of a r and omized controlled trial to examine the effectiveness of a targeted multiple intervention strategy in reducing the number of patient falls in an acute care hospital . BACKGROUND Prevention of patient falls remains a challenge that has eluded healthcare institutions . The effectiveness of targeted multiple fall prevention interventions in reducing the incidences of falling has not been established . METHODS Patients who scored 5 and above on the Hendrich II Fall Risk Model , a fall assessment tool , were recruited in 2006 . Patients who were r and omized to the intervention group received targeted multiple interventions . Both the research groups received the st and ard fall prevention interventions from the ward nurses . The rates of fall incidences for both groups were reported with 95 % CI , calculated using Wilson method and compared using the Chi-square test . The relative risk was estimated and 95 % CI was calculated using the methods described by Armitage and Berry . The times to first fall events were constructed using the Kaplan-Meier method . The hazard ratio was reported at 95 % CI and the comparison was made using the log-rank test . RESULTS There were 912 and 910 participants in the control and intervention groups , respectively . The fall incidence rates were 1·5 % ( 95 % CI : 0·9 - 2·6 ) and 0·4 % ( 95 % CI : 0·2 - 1·1 ) in the control and intervention groups , respectively . The relative risk estimate of 0·29 ( 95 % CI : 0·1 - 0·87 ) favours the intervention group . CONCLUSION This study showed that targeted multiple interventions were effective in reducing the incidences of falls in patients in the acute care setting Accurate prediction of fall-prone hospitalized older adults may be integral to reducing falls . The STRATIFY , a simple 5-point falls prediction tool , was prospect ively vali date d on a Geriatric Assessment and Rehabilitation Unit as a one-time initial predictor of patients likely to fall . Sensitivity and specificity were lower than in the original British study . Introducing risk assessment s vali date d elsewhere on a patient care unit or on a hospital-wide scale requires caution BACKGROUND Patient falls  constitute a major threat to health services ' ability to provide care . Previous studies confirm that nurses can identify patients at risk and that a preventative programme can reduce the rate of falls but few studies have been evaluated over time . AIMS AND OBJECTIVES A study was undertaken to test a Falls Prevention Programme in an acute medical area that was re-evaluated 5 years later to determine if the effects were sustainable . DESIGN The design included two groups of patients admitted before and after the programme . Variables such as staffing , equipment , environment and routines were controlled . However , because of ethical approval constraints , some variables such as age , mental status , mobility and gender were not . METHODS The programme included a risk assessment tool , a choice of interventions , a graphic that alerted others to ' at risk patients ' and simple patient and staff education . Data were collected using incident forms and a formula was used to calculate a rate of falls . A non-paired t-test compared rates and anova examined the relationship of age , gender , mobility and mental status on the incidence of falls . Control graphs determined the stability of the process . RESULTS The falls rate was significantly reduced . Control graphs demonstrate that the process achieved greater control with less variation . In the next 5 years the falls rate increased to preprogramme levels and control graphs demonstrated that the process was no longer controlled . Compliance with the programme had deteriorated . CONCLUSIONS The practice review considered skill mix , patient activity and acuity but provided no definitive answers to explain non-compliance . The implication s to nursing are discussed . RELEVANCE TO CLINICAL PRACTICE Clinicians are called to conduct more rigorous research into falls prevention but it may be more useful to direct research towards examining nursing work and increasing nurse autonomy in falls prevention This large prospect i ve cohort study was undertaken to construct a fall-risk model for elderly . The emphasis of the study rests on easily measurable predictors for any falls and recurrent falls . The occurrence of falls among 1285 community-dwelling elderly aged 65 years and over was followed during 1 year by means of a " fall calendar . " Physical , cognitive , emotional and social functioning preceding the registration of falls were studied as potential predictors of fall-risk . Previous falls , visual impairment , urinary incontinence and use of benzodiazepines were the strongest predictors identified in the risk profile model for any falls ( area under the curve [ AUC ] = 0.65 ) , whereas previous falls , visual impairment , urinary incontinence and functional limitations proved to be the strongest predictors in the model for recurrent falls ( AUC = 0.71 ) . The probability of recurrent falls for subsequent scores of the screening test ranged from 4.7 % ( 95 % Confidence Interval [ CI ] : 4.0 - 5.4 % ) to 46.8 % ( 95 % CI : 43.0 - 50.6 % ) . Our study provides a fall-risk screening test based on four easily measurable predictors that can be used for fall-risk stratification in community-dwelling elderly BACKGROUND falls and related injuries are known to be a significant problem for older people . There is evidence that identifying and addressing individual risk factors can reduce the incidence of falls in the community but no evidence of the effectiveness of targeted risk factor reduction methods applied to hospital in- patients . OBJECTIVE to test the efficacy of a targeted risk factor reduction core care plan in reducing risk of falling while in hospital . DESIGN a group ( ward ) r and omised trial . SETTING elderly care wards and associated community units of a district general hospital in the North of Engl and . SUBJECTS all elderly patients who received care in eight wards and community units during a 12-month study period . METHODS matched pairs of wards were r and omly allocated to intervention or control groups . In the intervention wards , staff used a pre-printed care plan for patients identified as at risk of falling and introduced appropriate remedial measures . Numbers of falls in each group were then compared . RESULTS after introduction of the care plan there was a significant reduction in the relative risk of recorded falls on intervention wards ( relative risk 0.79 , 95 % CI 0.65 - 0.95 ) but not on control wards ( RR 1.12 , 95 % CI 0.96 - 1.31 ) . The difference in change between the intervention wards and control wards was highly significant ( RR 0.71 , 95 % CI 0.55 - 0.90 , P = 0.006 ) . There was no significant reduction in the incidence of falls-related injuries . CONCLUSION the use of a core care plan targeting risk factor reduction in older hospital in- patients was associated with a reduction in the relative risk of recorded falls 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 prospect ively compared to a gold st and ard ( 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 OBJECTIVES To assess whether a pragmatic multidisciplinary fall-prevention program was more effective than usual care in preventing new falls and functional decline in elderly people . DESIGN A two-group , r and omized , controlled trial with 12 months of follow-up . SETTING University hospital and home-based intervention , the Netherl and s. PARTICIPANTS Three hundred thirty-three community-dwelling Dutch people aged 65 and over who were seen in an emergency department after a fall . INTERVENTION Participants in the intervention group underwent a detailed medical and occupational-therapy assessment to evaluate and address risk factors for recurrent falls  , followed by recommendations and referral if indicated . People in the control group received usual care . MEASUREMENTS Number of people sustaining a fall ( fall calendar ) and daily functioning ( Frenchay Activity Index ) . RESULTS Results showed no statistically significantly favorable effects on falls ( odds ratio=0.86 , 95 % confidence interval (CI)=0.50 - 1.49 ) or daily functioning ( regression coefficient=0.37 , CI=-0.90 to 1.63 ) after 12 months of follow-up . CONCLUSION The multidisciplinary fall-prevention program was not effective in preventing falls and functional decline in this Dutch healthcare setting . Implementing the program in its present form in the Netherl and s is not recommended . This trial shows that there can be considerable discrepancy between the " ideal " ( experimental ) version of a program and the implemented version of the same program . The importance of implementation research in assessing feasibility and effectiveness of such a program in a specific healthcare setting is therefore stressed OBJECTIVE To identify the interrelationships and discriminatory value of a broad range of objective ly measured explanatory risk factors for falls . DESIGN Prospect i ve cohort study with 12-month follow-up period . SETTING Community sample . PARTICIPANTS Five hundred community-dwelling people aged 70 to 90 . MEASUREMENTS All participants underwent assessment s on medical , disability , physical , cognitive , and psychological measures .  Fallers were defined as people who had at least one injurious fall or at least two noninjurious falls during a 12-month follow-up period . RESULTS Univariate regression analyses identified the following fall risk factors : disability , poor performance on physical tests , depressive symptoms , poor executive function , concern about falling , and previous falls . Classification and regression tree analysis revealed that balance-related impairments were critical predictors of falls . In those with good balance , disability and exercise levels influenced future fall risk-people in the lowest and the highest exercise tertiles were at greater risk . In those with impaired balance , different risk factors predicted greater fall risk-poor executive function , poor dynamic balance , and low exercise levels . Absolute risks for falls ranged from 11 % in those with no risk factors to 54 % in the highest-risk group . CONCLUSIONS A classification and regression tree approach highlighted interrelationships and discriminatory value of important explanatory fall risk factors . The information may prove useful in clinical setting s to assist in tailoring interventions to maximize the potential benefit of falls prevention strategies Work Package 3 of the Prevention of Falls Network Europe has evaluated measurement properties of clinical balance measures to be used to : ( 1 ) select participants for interventions with the goal to prevent falls in older people , and ( 2 ) assess the results of such intervention on balance function . Inclusion in a fall prevention study may be based on measures identifying subjects who have impaired balance or increased risk of future falls . We propose that an appropriate statistical method to analyse discriminative ability of a balance measure is discriminant analysis or logistic regression analysis . The optimal cut-off score is best determined by plotting a receiver-operating-characteristic curve for different cut-off values . The evaluation of predictors for risk of future falls should be based on a study design with a prospect i ve data collection of falls . Sensitivity to change is a measurement property needed to evaluate the outcome of an intervention . The st and ardized response mean is frequently encountered in the literature and is recommended as a statistical measure of sensitivity to change in the context of an intervention study . Adequate reliability is a prerequisite for consistent measurement . Relative reliability may be reported as an intraclass correlation coefficient and absolute reliability as the within-subject st and ard deviation ( s(w ) ) , also called st and ard error of measurement . When measurement error is proportional to the score , calculation of a coefficient of variation can be considered . In a second paper , the authors will evaluate  clinical balance measures  for use in fall prevention studies based upon criteria recommended in this report OBJECTIVES To develop a fall risk model that can be used to identify prospect ively nursing home residents at risk for falling . The secondary objective was to determine whether the nursing home environment independently influenced the development of falls . DESIGN A prospect i ve study involving 1 year of follow-up . SETTING Two hundred seventy-two nursing homes in the state of Washington . PARTICIPANTS A total of 18,855 residents who had a baseline assessment in 1991 and a follow-up assessment within the subsequent year . MEASUREMENTS Baseline Minimum Data Set items that could be potential risk factors for falling were considered as independent variables . The dependent variable was whether the resident fell as reported at the follow-up assessment . We estimated the extrinsic risk attributable to particular nursing home environments by calculating the annual fall rate in each nursing home and grouping them into tertiles of fall risk according to these rates . RESULTS Factors associated independently with falling were fall history , w and ering behavior , use of a cane or walker , deterioration of activities of daily living performance , age greater than 87 years , unsteady gait , transfer independence , wheelchair independence , and male gender . Nursing home residents with a fall history were more than three times as likely to fall during the follow-up period than residents without a fall history . Residents in homes with the highest tertile of fall rates were more than twice as likely to fall compared with residents of homes in the lowest tertile , independent of resident-specific risk factors . CONCLUSIONS Fall history was identified as the strongest risk factor associated with subsequent falls and accounted for the vast majority of the predictive strength of the model . We recommend that fall history be used as an initial screener for determining eligibility for fall intervention efforts . Studies are needed to determine the facility characteristics that contribute to fall risk , independent of resident-specific risk factors The consequences of falls among hospital patients are a great problem , for the patient , the family and society , and cost billions of dollars . In Sweden , almost one-third of all hip fractures occur in the hospital population . Despite this , very few prevention strategies have been developed and tested . In this study , a risk assessment and recording programme in relation to the risk of falling among patients in a geriatric department at a Swedish hospital was implemented . The records of all patients admitted to a geriatric unit during one year , and a stratified r and om sample of patient records , constituting the control group from the year before , were review ed . No recording of assessment s regarding the patients ' risk of falling , and no preventive nursing interventions , were found in the records of the control group . The study group , however , increased the recording of risk assessment to 96 % . Only implemented nursing interventions were found in the patients ' records , despite the fact that Swedish law makes it obligatory for the registered nurse to record both the planning and implementation of nursing care . In the study group there were explicit descriptions of problems of concern for nursing regarding the patients ' risk of falling in less than one-third of the records , the nursing care plans were rare , and the evaluations were not satisfactory . Nursing interventions consisted mostly of information or education , promotion of patient participation , and structuring of the environment . There was no agreement on any st and ard-care plan . Recording of falls was found more often in the study group than in the control group ( probably due to more careful recording ) , but the proportion of injuries in relation to falls was higher in the control group . The results of this study may be used as a baseline for developing a nursing strategy and documentation relating to falls
Heterogeneity between studies indicates that the Morse Falls Scale and STRATIFY may still be useful in particular setting s , but that widespread adoption of either is unlikely to generate benefits significantly greater than that of nursing staff clinical judgment
INTRODUCTION Fall risk screening tools are frequently used as a part of falls prevention programs in hospitals .
Design -related bias in evaluations of tool predictive accuracy could lead to overoptimistic results , which would then contribute to program failure in practice .