Multiple Interventions and Implementation Strategies

Spector W, Shaffer T, Potter DE, et al. Risk factors associated with the occurrence of fractures in U.S. nursing homes: resident and facility characteristics and prescription medications. Journal of the American Geriatric Society 2007;55:327-333.
Variable Studied: Multiple resident risk factors; resident and facility characteristics and prescription medications.
Setting-Situation: A nationally representative sample of nursing homes from the Medical Expenditure Panel Survey (MEPS).
Sample Size: Residents age 65+ who were in sample nursing homes on January 1, 1996.
Study Design: Panel study with 1-year followup. Risk factors: resident and facility characteristics and prescription medications. Outcome: fractures.
Results: In 1996, 6% of residents in a nursing home at the beginning of the year experienced a fracture during their stay. Resident risk factors included age 85 and older, admitted from community, exhibited agitated behaviors, and used both wheelchair and cane or walker. Use of anticonvulsants, antidepressants, opioid analgesics, iron supplements, bisphosphonates, thiazides, and laxatives were associated with fractures. A high certified nurse aide ratio was negatively associated with fractures.
Conclusions: Fractures are associated with resident and facility characteristics and prescribing practices.

Rubenstein LZ, Robbins AS, Josephson KR, et al. The value of assessing falls in an elderly population. A randomized clinical trial. Annals of Internal Medicine 1990 Aug15;113(4):308-316.
Variable Studied: Multiple resident risk factors.
Setting-Situation: Long-term care facility.
Sample Size: N=160 (79 intervention; 81 controls). Mean age=87.
Study Design: Randomized controlled trial. Risk factors: resident characteristics. Intervention: postfall assessment done within 7 days of a fall. Assessment included detailed physical examination and environmental assessment, lab tests, electrocardiogram, and 24-hour Holter monitoring. Control: residents receiving usual care after a fall. Outcome: hospitalization.
Results: Many remedial problems, such as weakness, environmental hazards, orthostatic hypotension, drug side effects, and gait dysfunction were detected with use of the postfall assessment. The intervention group had 26% fewer hospitalizations (p<0.05) and a 52% reduction in hospital days (p<0.01) compared with the control group.
Conclusions: Falls are a marker of underlying disorders easily identifiable by a careful postfall assessment, which in turn can reduce disability and costs.

Close JCT, Hooper R, Glucksman E, et al. Predictors of falls in a high-risk population: results from the prevention of falls in the elderly trial (PROFET). Emergency Medicine Journal 2003;20:421-425.
Variable Studied: Multiple resident risk factors.
Setting-Situation: Accident and emergency (A&E) units in the United Kingdom.
Sample Size: N=1,031 patients living in the local community who attended A&E during the recruitment period. N=397 patients who were randomized. Age=65+.
Study Design: Randomized controlled trial. Risk factors: history of falls, falls indoors, inability to get up after fall. Intervention: 184 residents who received a single medical assessment in a day hospital and single occupational therapy home assessment with onward referral where need identified. Control: 213 residents who received usual care. Outcomes: future falls and loss to followup.
Results: Positive fall predictors included: history of falls (odds ratio [OR] 1.5 (95% confidence interval [CI] 1.1-1.9)), falling indoors (OR 2.4 [95% CI 1.1-5.2]), and inability to get up after a fall (OR 5.5 [95% CI 2.3-13.0]). Negative predictors included: moderate alcohol consumption (OR 0.55 [95% CI 0.28-1.1]), a reduced abbreviated mental test score (OR 0.7 [95% CI 0.53-0.93]), and admission to a hospital as a result of a fall (OR 0.26 [95% CI 0.11-0.61]). Predictors of loss to followup included: history of fall (OR 1.2 [95% CI 1.0-1.3]), falling indoors (OR 3.2 [95% CI 1.5-6.6]), and reduced abbreviated mental test score (OR 1.3 [95% CI 1.0-1.6]). Intervention appears to be useful only when the presenting fall occurred indoors.
Conclusions: Risk factors found to predict falls are easily detectable in the A&E setting and may be useful to decide the priority for further assessment and assist in realistic planning of a service. Falls in the previous year and falling indoors predict both loss to followup and subsequent falling. Of the group lost to followup, the cause in 90% of cases was either death or a move to institutional care. Loss to followup in any program therefore signals high risk and a requirement to intervene.

Oliver D, Daly F, Martin FC, et al. Risk factors and risk assessment tools for falls in hospital inpatients: a systematic review. Age and Aging 2004;33(2):122-130.
Variable Studied: Multiple resident risk factors.
Setting-Situation: Hospital inpatients.
Sample Size: N=28 papers on fall risk assessment tools.
Study Design: Systematic literature review. Risk factors: gait instability, agitated confusion, urinary incontinence/frequency, falls history, and prescription of "culprit" drugs (especially sedative/hypnotics). Outcome: falls.
Results: Twenty-eight papers on risk factors were identified, with 15 excluded from further analysis. Despite identification of 47 papers purporting to describe fall risk assessment tools, only 6 papers were identified where risk assessment tools had been subjected to prospective validation, and only 2 where validation had been performed in two or more patient cohorts. A small number of significant fall risk factors emerged consistently, despite the heterogeneity of settings. These included gait instability, agitated confusion, urinary incontinence/frequency, falls history, and prescription of "culprit" drugs (especially sedative/hypnotics).
Conclusions: Simple risk assessment tools constructed of similar variables have been shown to predict falls with sensitivity and specificity in excess of 70%, although validation in a variety of settings and in routine clinical use is lacking. Effective fall interventions in this population may require use of better validated risk assessment tools or, alternatively, attention to common reversible fall risk factors in all patients.

Montero-Odasso M, Levinson P, Gore B, et al. A flowchart system to improve fall data documentation in a long-term care institution: a pilot study. Journal of the American Medical Directors Association 2007;8(5):300-306.
Variable Studied: Multiple treatments to reduce risk; flowchart documentation system.
Setting-Situation: Long-term care facility.
Sample Size: N=107 incident reports; 7 reports excluded. Mean age=82.7 (standard deviation=3); 53% of participants had dementia.
Study Design: Pilot study of new flowchart system at one facility. Risk factors: resident characteristics. Intervention: flowchart instituted to advise on fall characteristics, postfall risk factor identification, and appropriate referral. Control: usual incident report data in order to register the fall preflowchart system. Outcome: extent of fall data documentation.
Results: Comparisons between pre- and postimplementation of the flowchart system revealed significant differences in documentation of history of previous falls (95% versus 35%; p<.001), and place of fall (89% versus 32%; p<.002). After implementation of the new flowchart, information not previously gathered was obtained (such as polypharmacy prevalence, use of benzodiazepines and psychotropic medication, and potential etiologies and contributors to fall episodes).
Conclusions: After the introduction of the flowchart system, documentation of risk factors and characteristics of fall episodes improved significantly and referrals to geriatrician for falls evaluation significantly increased. The process of education and implementation of a flowchart system with an ad hoc form improved data documentation performed following a fall.

Wagner LM, Capezuti E, Taylor JA, et al. Impact of a falls menu-driven incident-reporting system on documentation and quality improvement in nursing homes. The Gerontologist 2005;45(6):835-842.
Variable Studied: Multiple treatments to reduce risk; menu driven incident-reporting system (MDIRS).
Setting-Situation: Nursing homes.
Sample Size: N=910 residents at 6 nursing homes. Three nursing homes used MDIRS and three used an existing narrative incident report.
Study Design: Retrospective data collection. Risk factors: resident characteristics. Interventions: MDIRS. Control: existing narrative incident report. Outcome: nurses' assessment of fall risk.
Results: More than one-fourth (28.4%) of nursing home residents among the six facilities fell during the 4-month study period. Intervention nursing homes had significantly better documentation of fall characteristics on incident reports than did control nursing homes.
Conclusions: The current method of reporting adverse incidents in nursing homes does not provide sufficient data on circumstances regarding falls. MDIRS provides a method that is straightforward and can easily analyze adverse incident data for quality improvement purposes.

Tinetti ME, Baker DI, King M, et al. Effect of dissemination of evidence in reducing injuries from falls. New England Journal of Medicine 2008 Jul 17;359(3):22-61.
Variable Studied: Multiple treatments to reduce risk; education.
Setting-Situation: Providers in Connecticut. Intervention region: N= 212 primary care offices; N=133 outpatient rehabilitation facilities; N=26 home care agencies; N=7 acute care hospitals; N=41 senior centers. Control region: N=146 outpatient rehabilitation facilities; N=30 home care agencies; N=7 acute care hospitals/emergency departments; N=43 senior centers.
Sample Size: N=204,846 total residents. Age ≥70. Intervention region: N=95,433 residents; 61.3% female; 91.8% white; 5.2% black; 2.5% other; 2.2% Hispanic or Latino. Control region: N=109,413 residents; 61.4% female; 92.3% white; 5.8% black; 2.4% other; 2.2% Hispanic or Latino.
Study Design: Nonrandomized controlled intervention study. Risk factors: postural hypotension, use of multiple medications, and impairments in cognition, vision, balance, gait, and strength. Intervention: adopt effective risk assessments and strategies to prevent falls (e.g., medication reduction and balance and gait training). Control: usual care. Outcomes: serious fall-related injuries (hip and other fractures, head injuries, and joint dislocations) and fall-related use of medical services per 1,000 person-years.
Results: Before interventions, adjusted rates of serious fall-related injuries (per 1,000 person-years) were 31.2 in the control region and 31.9 in the intervention region. During the evaluation period, adjusted rates were 31.4 and 28.6, respectively. Between the preintervention period and the evaluation period, the rate of fall-related use of medical services increased from 68.1 to 83.3 per 1,000 person-years in the control region and from 70.7 to 74.2 in the intervention region. Percentages of clinicians who received intervention visits ranged from 62% (131 of 212 primary care offices) to 100% (26 of 26 home care agencies).
Conclusions: Dissemination of evidence about fall prevention, coupled with interventions to change clinical practice, may reduce fall-related injuries in elderly persons.

Rapp K, Lamb SE, Büchele G, et al. Prevention of falls in nursing homes: subgroup analysis of a randomized fall prevention trial. Journal of the American Geriatric Society 2008;56(6):1092-1097. Epub 2008 May 14.
Variable Studied: Multiple treatments to reduce risk; education.
Setting-Situation: Six nursing homes in Germany.
Sample Size: N=725 long-stay residents. Median age=86; 80% female.
Study Design: Secondary analysis of cluster-randomized, controlled trial. Risk factors: cognitive impairment, history of falls, urinary incontinence, mood problems. Intervention: staff and resident education on fall prevention, advice on environmental adaptations, recommendation to wear hip protectors, and progressive balance and resistance training. Control: usual care. Outcome: time to first fall and number of falls.
Results: The intervention was more effective in people with cognitive impairment (hazard ratio [HR]=0.49, 95% confidence interval [CI] 0.35-0.69) than those who were cognitively intact (HR=0.91, 95% CI= 0.68-1.22). It also was more effective in people with a prior history of falls (HR=0.47, 95% CI 0.33-0.67) than in those with no prior fall history (HR=0.77, 95% CI 0.58-1.01), in people with urinary incontinence (HR=0.59, 95% CI 0.45-0.77) than in those with no urinary incontinence (HR=0.98, 95% CI 0.68-1.42), and in people with no mood problems (incidence rate ratio (IRR) =0.41, 95% CI 0.27-0.61) than in those with mood problems (IRR=0.74, 95% CI 0.51-1.09).
Conclusions: Effectiveness of a multifactorial fall prevention program differed between subgroups of nursing home residents. Cognitive impairment, history of falls, urinary incontinence, and depressed mood were important in determining residents' response to education on fall prevention.

Krauss MJ, Tutlam N, Costantinou E, et al. Intervention to prevent falls on the medical service in a teaching hospital. Infection Control and Hospital Epidemiology 2008;29:539-545.
Variable Studied: Multiple treatments to reduce risk; education.
Setting-Situation: Teaching hospital; two intervention floors and two control floors.
Sample Size: N=135 (57 intervention; 78 controls). Mean age-intervention: 65.5±18. Mean age-control: 65.5±17.5. Gender: intervention, 58% female; control, 51% female.
Study Design: Quasi-experimental intervention with historical/contemporaneous control groups. Risk factors: resident characteristics. Intervention: education of nursing staff regarding fall prevention, implementing prevention strategies. Control: two floors without intervention. Outcomes: fall rates and fall knowledge.
Results: Postintervention fall knowledge test scores (mean 91%) for nursing staff were greater than preintervention scores (mean 72%). Use of prevention strategies was greater on intervention floors than on control floors, including patient education via pamphlets, use of toileting schedules, and discussion of high-risk medications. The mean fall rate for the first 5 months of intervention was 43% lower than the rate for the 9-month preintervention period for intervention floors (3.81 falls per 1,000 patient-days versus 6.64 falls per 1,000 patient-days; p=.043). Comparisons of mean rates for the overall 9-month intervention period versus the 9-month preintervention period showed a 23% difference in fall rates, but this did not reach statistical significance (5.09 falls per 1,000 patient-days versus 6.64 falls per 1,000 patient days; p=.182).
Conclusions: Nursing staff knowledge and use of prevention strategies increased after the educational intervention. Fall rates decreased for 5 months after the educational intervention, but reduction was not sustained. Intervention increased nursing staff knowledge, increased use of fall prevention strategies, and reduced fall rates. This suggests that multifaceted fall prevention programs that incorporate staff education could be effective. The program was not sustained. A method is needed to implement the program in daily practice.

Chang JT, Morton SC, Rubenstein LZ, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. British Medical Journal 2004 Mar 20;328(7441):680.
Variable Studied: Multiple treatments to reduce risk; multifactorial falls risk assessment and management program.
Setting-Situation: Varied according to trials.
Sample Size: N=40 trials with 4 trials scoring 1 on the Jadad scale (scores from 0 to 5), 22 scoring 2, and 14 scoring 3.
Study Design: Systematic review and meta-analysis. Risk factors: history of falls, lack of exercise, poor lighting, and sliding carpets. Intervention: multifactorial falls risk assessment and management program (focused postfall assessment or systematic risk factor screening among individuals at risk tied to intervention recommendations and followup for risks uncovered); exercise (walking, cycling, aerobic movements, and other endurance exercises; targeted toward balance, gait, and strength); environmental modifications (professional visit to check for hazards such as poor lighting or sliding carpets and recommend modifications); education (pamphlets and posters at senior centers/nursing homes, intensive interventions such as counseling about risk factors). Control: varies by study and trial. Outcomes: risk of falling and monthly fall rates.
Results: Random effects analysis combining trials with risk ratio data showed a reduction in risk of falling (risk ratio 0.88, 95% confidence interval 0.82 to 0.95), whereas combining trials with incidence rate data showed a reduction in monthly rate of falling (incidence rate ratio 0.80, 0.72 to 0.88). The multifactorial falls risk assessment and management program was the most effective component on risk of falling (0.82, 0.72 to 0.94, number needed to treat=11) and monthly fall rate (0.63, 0.49 to 0.83; 11.8 fewer falls in treatment group per 100 patients per month). Exercise interventions also had a beneficial effect on risk of falling (0.86, 0.75 to 0.99, number needed to treat=16) and monthly fall rate (0.86, 0.73 to 1.01).
Conclusions: Interventions to prevent falls in older adults are effective in reducing both risk of falling and monthly rate of falling. The most effective intervention was the multifactorial falls risk assessment and management program. Exercise programs were effective in reducing risk of falling. Limitations include lack of availability of original studies, common to all systematic reviews.

Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Annals of Internal Medicine 1994;12(6):442-451.
Variable Studied: Multiple treatments to reduce risk; multifactorial; functional; environmental; educational.
Setting-Situation: Nursing homes.
Sample Size: Not specified.
Study Design: Review of epidemiology and causes of falls and fall-related injuries. Risk factors: gait and balance disorders, weakness, dizziness, environmental hazards, confusion, visual impairment, postural hypotension, psychoactive medications. Intervention: improve strength and functional status, reduce environmental hazards, and allow staff to identify and monitor high-risk residents. Control: usual care. Outcomes: falls and fall-related injuries.
Results: Most successful fall prevention implementations consider multifactorial causes of falls and include interventions to improve strength and functional status, reduce environmental hazards, and allow staff to identify and monitor high-risk residents. Strategies that reduce mobility through use of restraints have been shown to be more harmful than beneficial and should be avoided.
Conclusions: A focused history and physical examination after a fall can usually determine both immediate underlying causes and contributing risk factors. In addition, regular evaluations in nursing homes can help identify patients at high risk who can then be targeted for specific treatment prevention strategies.

Gillespie LD, Gillespie WJ, Robertson MC, et al. Interventions for preventing falls in elderly people. Cochrane Database of Systematic Reviews 2001;(3):CD000340.
Variable Studied: Multiple treatments to reduce risk; multiple interventions.
Setting-Situation: Elderly people living in the community or in institutional or hospital care.
Sample Size: Not applicable/identified.
Study Design: Assessment of randomized controlled trials and literature and databases by two reviewers who independently assessed trial quality and extracted data. Data taken from the Cochrane Musculoskeletal Group specialized register, Cochrane Controlled Trials Register, MEDLINE® EMBASE, CINAHL, National Research Register, and Current Controlled Trials. Risk factors: muscle weakness, balance impairment, home hazards, psychotropic medication. Intervention: group-delivered exercise, nutritional supplementation, pharmacological therapy, fall prevention programs, muscle strengthening and balance retraining, Tai Chi group exercise, home hazard assessment and modification, withdrawal of psychotropic medication, and multidisciplinary, multifactorial health/environmental risk factor screening. Outcome: relative risk of intervention methods.
Results: Beneficial interventions to prevent falls: muscle strengthening and balance retraining (relative risk [RR] 0.80, 95% confidence interval [CI] 0.49-0.84), Tai Chi group exercise (risk ratio 0.51, 95% CI 0.36-0.73), home hazard assessment and modification (RR 0.64, 95% CI 0.49-0.84), withdrawal of psychotropic medication (relative hazard 0.34, 95% CI 0.16-0.74), multidisciplinary, multifactorial health/environmental risk factor screening/intervention programs (RR 0.73, 95% CI 0.63-0.86). Interventions of unknown effectiveness: group-delivered exercise interventions, nutritional supplementation, vitamin D supplementation (with or without calcium), pharmacological therapy (raubasine-dihydroergocristine), fall prevention programs in institutional settings, interventions using a cognitive/behavioral approach alone, home hazard modification without a history of falling, hormone replacement therapy.
Conclusions: Interventions to prevent falls are available; less is known about their effectiveness in preventing fall-related injuries.

Scott V, Donaldson M, Gallagher E. A review of the literature on best practices in falls prevention of long-term care facilities. Long Term Care Falls Review 2003 Sept:1-29.
Variable Studied: Multiple treatments to reduce risk; falls prevention strategies.
Setting-Situation: Long-term care facilities.
Sample Size: 40 articles included in review.
Study Design: Literature review. Evidence divided under categories: strong evidence for fall reduction, strong evidence for fall-related injury reduction, strong evidence for risk factor reduction, promising fall and risk factor reduction strategies, common sense strategies, cost-effectiveness of fall and fall injury reduction strategies. Risk factors: resident characteristics. Intervention: comprehensive fall prevention plan. Outcome: falls.
Results: Components of comprehensive falls prevention plans typically include: facility wide multidisciplinary team responsible for implementation and evaluation of fall prevention activities; education for all staff, residents, family members, and visitors; falls surveillance system; system to assess fall injury and risk; and a visual mechanism to identify individuals at high risk for falls such as a bracelet or color coding on charts or above beds. They also include a process to investigate individual falls and implement tailored prevention plans, a policy to investigate facility wide fall and injury patterns and use a collaborative process to prioritize and implement appropriate preventions, an evaluation plan to determine effectiveness of specific strategies and overall approaches to fall prevention, and a process to recognize and reward staff and residents for fall prevention efforts.
Conclusions: Selecting appropriate prevention strategies is best done through a collaborative process that reflects risk profiles of individual residents, as well as unique facility characteristics, and involves key stakeholders who can build on the strengths and capacities of each setting.

Vassallo M, Stockdale R, Sharma JC, et al. A comparative study of the use of four fall risk assessment tools on acute medical wards. Journal of the American Geriatric Society 2005;53(6):1034-1038.
Variable Studied: Multiple treatments to reduce risk; four falls risk assessment tools: STRATIFY, Downton, Tullamore, and Tinetti.
Setting-Situation: Acute medical wards.
Sample Size: N=135 patients on 2 acute medical wards. Mean age= 83.8; 86% female.
Study Design: Prospective, open observational study. Risk factors: resident characteristics. Intervention: four different fall assessment tools. Outcome: identifying patients at high risk of falls.
Results: Number of patients that STRATIFY correctly identified (n=90) was significantly higher than the Downton (n=46; p<.001), Tullamore (n=66, p=.005), or Tinetti (n=52, p<.001) tools, but STRATIFY had the poorest sensitivity (68.2%). STRATIFY was the only tool that could be fully completed in all patients (n=135), compared with Downton (n=130; p=.06), Tullamore (n=130; p=.06), and Tinetti (n=17; p<.001). The time required to complete the STRATIFY tool (average 3.85 minutes) was significantly less than for Downton (6.34 minutes; p<.001), Tinetti (7.4 minutes; p<.001), and Tullamore (6.25 minutes; p<.001). The Kaplan-Meier test showed that STRATIFY (log rank p=.001) and Tullamore (log rank p<.001) were effective at predicting falls over the first week of admission. Downton (log rank p=.46) and Tinetti tools (log rank p=.341) did not demonstrate this characteristic.
Conclusions: The STRATIFY tool was the shortest and easiest to complete and had the highest predictive value but the lowest sensitivity.

Vassallo M, Poynter L, et al. Fall risk-assessment tools compared with clinical judgment: an evaluation in a rehabilitation ward. Age and Ageing 2008;37:277-281.
Variable Studied: Multiple treatments to reduce risk; fall risk identification tools (Downton and STRATIFY).
Setting-Situation: Geriatric rehabilitation hospital.
Sample Size: 200 patients. Mean age = 80.9; 123 female; 51 fallers; 17 recurrent fallers.
Study Design: Prospective observational study. Risk factors: resident characteristics. Intervention: fall risk identification tools (Downton and STRATIFY). Outcome: effectiveness of proposed risk identification tools.
Results: Predictive accuracy: wandering=78%; Downton=50%; STRATIFY=46.5%. Downton and STRATIFY were not statistically different (p=0.55; 95% confidence interval 0.77-1.71). Predictive sensitivity: wandering=43.1%; Downton=92.2%; STRATIFY=82.3%.
Conclusions: Clinical observation had higher accuracy than the two fall risk assessment tools. However, observation was significantly less sensitive, suggesting that fewer patients who fell were correctly identified as being at risk. It is therefore not recommended that using clinical observation of wandering should replace current risk assessment tools despite their limitations.

Capezuti E, Taylor J, Brown H, et al. Challenges to implementing an APN-facilitated falls management program in long-term care. Applied Nursing Research 2007; 20(1):2-9.
Variable Studied: Multiple treatments to reduce risk; falls management program (FMP).
Setting-Situation: Nursing homes.
Sample Size: Two geriatric advanced practice nurses (APNs), four nursing homes (average 160 beds). Age=38% >84; 78% female; 51% African American.
Study Design: Observational study. Risk factors: resident characteristics. Intervention: diffusion of an innovative FMP in four nursing homes. Outcome: success of implementation strategy.
Results: Factors facilitating FMP implementation were strong interest in fall prevention and staff who were highly receptive to new clinical resources. Barriers to implementation were inadequate time to coordinate multiple components of the project, inadequate computer proficiency and accessibility/availability, inability to implement individualized care planning, lack of reimbursement for rehabilitative services, high administrative turnover, and lack of quality improvement skills.
Conclusions: It is important to have enough staff with adequate time and clinical decisionmaking skills to effectively apply best practices. Administrative staff play a critical role in supporting change. Although nursing homes are under a great deal of regulatory pressure to improve care, they often lack the organizational capacity to initiate and sustain improvement. Lack of consistent and strong clinical leadership hampers adoption of innovative practices. Innovations involve more than simply using new interventions. They include an organizational culture that endorses continuing quality improvement.

Rask K, Parmelee PA, Taylor JA, et al. Implementation and evaluation of a nursing home fall management program. Journal of the American Geriatric Society 2007;55(3):342-349.
Variable Studied: Multiple treatments to reduce risk; falls management program (FMP).
Setting-Situation: Nursing homes in Georgia owned by a single nonprofit organization.
Sample Size: All residents of the participating nursing homes; 19 nursing homes implemented the FMP. Other nursing homes did not.
Study Design: Quality improvement observational study. Risk factors: resident characteristics. Intervention: FMP and multifaceted quality improvement and culture change intervention; a facility-based falls coordinator and interdisciplinary team, intensive education and training, and ongoing consultation and oversight by advanced practice nurses with expertise in fall management. Control: nursing homes not implementing the FMP. Outcomes: restraint use; fall rates.
Results: Restraint use decreased from 7.9% to 4.4% (a relative reduction of 44%) in the intervention nursing homes. Restraint use decreased from 7.0% to 4.9% (a relative reduction of 30%) in the nonintervention nursing homes. Fall rates remained stable in the intervention nursing homes (17.3 falls/100 residents per month at start and 16.4 falls/100 residents per month at end). Fall rates increased 26% in the nursing homes not implementing the FMP (from 15.0 falls/100 residents per month to 18.9 falls/100 residents per month).
Conclusions: Implementation of the FMP was associated with significantly improved care process documentation and a stable fall rate during a period of substantial reduction in use of physical restraints. Fall rates increased in nursing homes that did not implement the FMP. The FMP may be a helpful tool for nursing homes to manage fall risk while attempting to reduce physical restraint use.

Ray WA, Taylor JA, Meador KG, et al. A randomized trial of a consultation service to reduce falls in nursing homes. JAMA 1997 Aug 20;278(7):557-562.
Variable Studied: Multiple treatments to reduce risk; comprehensive structured individual assessment.
Setting-Situation: Nursing homes in Tennessee.
Sample Size: Seven pairs of nursing homes. N=482 residents (221 intervention; 261 controls). Participants had high risk of falls and a potential safety problem that could be addressed by the intervention.
Study Design: Randomized controlled trial. Risk factors: suboptimal practices in environmental and personal safety, wheelchair use, psychotropic drug use, and transferring and ambulation. Intervention: 221 individuals who received comprehensive structured individual assessment with specific safety recommendations targeted at reforming suboptimal practices. Control: 261 individuals who did not receive structured individual assessment. Outcomes: proportion of recurrent fallers, incidence rate of injurious falls in facility 1 year after intervention.
Results: Mean proportion of recurrent fallers in intervention facilities (43.8%) was 19% (95% confidence interval 2.4%-35.8%) lower than that in control facilities (54.1%; p=.03). Intervention facilities had a nonsignificant trend toward a lower mean rate of injurious falls (13.7 versus 19.9 per 100 person-years, a reduction of 31.2%; p=.22).
Conclusions: Structured individual assessments were most effective with patients who had three or more falls in the preceding year. High rates of falls and related injuries in nursing homes should not be viewed as inevitable but as outcomes that can be substantially improved through structured safety programs.

Miceli DG, Strumpf NE, Reinhard SC, et al. Current approaches to postfall assessment in nursing homes. Journal of the American Medical Directors Association 2004;5(6):387-394.
Variable Studied: Multiple treatments to reduce risk; postfall assessment (PFA) tools.
Setting-Situation: Long-term care facilities in New Jersey.
Sample Size: N=379 long-term care facilities. Census >40,000 residents.
Study Design: Observational study. Risk factors: resident characteristics. Intervention: PFA tools, including risk assessment tools, fall prevention programs, policies and procedures for fall management, and incident reports. Control: national and professionally recommended PFA tools. Outcome: falls.
Results: Forty percent of facilities used a wide array of PFA tools, including risk assessment tools, fall prevention programs, policies and procedures for fall management, and incident reports. Almost two-thirds (63.7%) of facilities used fall risk assessment tools in place of PFA. Many nationally recommended guidelines for PFA were not included, except for environmental questions. Other fall circumstances related to time, mobility, footwear, diuretics, mental status, and ambulation ability were included less often.
Conclusions: Despite recommendations, comprehensive PFA tools were unavailable for use by nursing home staff. When a PFA was performed, there was no consistency among facilities sampled. Data collected were minimal and unlikely to reveal the full range of possible underlying etiologies.

Chang JT, Ganz DA. Quality indicators for falls and mobility problems in vulnerable elders. Journal of the American Geriatric Society 2007;55:S327-S334.
Variable Studied: Multiple resident and treatment risk factors.
Setting-Situation: Various settings.
Sample Size: N=182 articles.
Study Design: Systematic literature review. Risk factors: recent history of falls, orthostatic hypotension, visual impairment, gait and balance disorders, cognitive impairment, environmental hazards, psychotropic medications, proprioception, excessive postural sway, strength, endurance. Outcomes: falls and mobility problems in vulnerable elders.
Results: Supporting evidence for previously stated risk factors and treatments: multifactorial approaches to assessing and intervening on falls; fall history; medication review; orthostatic hypotension; visual impairment; gait and balance disorders; cognitive impairment; environmental hazards; psychiatric medication use; proprioception or excessive postural sway; and exercise programs.
Conclusions: There are many risk factors for falls in older adults. Many approaches to treatment exist and are effective but only if underlying risks are recognized using a comprehensive approach.

Perell KL, Nelson A, Goldman RL, et al. Fall risk assessment measures: an analytic review. Journal of Gerontology Medical Sciences 2001; 56A(12): M761-M766.
Variable Studied: Review article.
Setting-Situation: Various.
Sample Size: N=21 articles published from 1984-2001. N=14 articles focused on nursing assessment scales. N=6 articles focused on functional assessment scales.
Study Design: Systematic literature review of 14 articles using standardized review form of 20 parameters; articles from Medline, CINAHL, and HealthSTAR databases. Risk factors: mental status, mobility, history of previous fall, secondary or specific diagnoses, incontinence or toileting issues, medications, and sensory deficits. Intervention: fall risk assessment scales. Outcome: falls.
Results: All form developers used empirically derived patient characteristics to illuminate key characteristics of fallers. Classifying patients into risk categories enables clinicians to link risk assessment with specific interventions.
Conclusions: A substantial number of fall risk assessment tools are readily available, most with evidence supporting their reliability and validity. There is little need for facilities to develop their own scales, which may be counterproductive to the overall goal of fall risk assessment because scores and scales would not be comparable across similar types of facilities. Different types of settings should use different assessment scales. For acute care settings, nursing assessment tools are most appropriate and efficient. For outpatient settings, functional assessment instruments are most appropriate. For extended care settings, a universal-precautions fall prevention program may be most efficient.

American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. Journal of the American Geriatric Society 2001; 49:664-672.
Variable Studied: Review article; guidelines to assess fall risk and management.
Study Design: Systematic reviews and meta-analyses, randomized trials, controlled before-and-after studies, cohort studies, review articles and bibliographies, contact with subject area experts. Risk factors: history of falls; abnormalities of gait and/or balance; recurrent falls; medications; acute or chronic medical problems; mobility challenges; vision, gait, balance, and lower extremity joint function limitations; mental status; muscle strength; lower extremity peripheral nerves, proprioception, reflexes; and tests of cortical, extrapyramidal, and cerebellar function. Intervention: multifactorial, including gait training and advice on use of assistive devices, medication modification, exercise with balance training, treatment of postural hypotension, environmental hazard modification, treatment of cardiovascular disorders, staff education programs. Outcome: falls.
Results: A fall evaluation for older persons presenting with one or more falls, abnormalities of gait and/or balance, or recurrent falls includes: history of fall circumstances, medications, acute or chronic medical problems, mobility challenges, and vision, gait, balance, and lower extremity joint function limitations; examination of basic neurologic function, including mental status, muscle strength, lower extremity peripheral nerves, proprioception, reflexes, and tests of cortical, extrapyramidal, and cerebellar function; and assessment of basic cardiovascular status, including heart rate and rhythm, postural pulse and blood pressure, and heart rate and blood pressure responses to carotid sinus stimulation. Intervention techniques separated by resident locations include:

• Community dwelling: Beneficial multifactorial interventions should include gait training and advice on use of assistive devices; review and modification of medication, especially psychotropic medications; exercise programs, with balance training; treatment of postural hypotension; modification of environmental hazards; and treatment of cardiovascular disorders.
• Long-term care and assisted living: Beneficial interventions include staff education programs; gait training and advice on use of assistive devices; and review and modification of medications, especially psychotropic medications.
• Acute hospital setting: Evidence is insufficient to make recommendations for or against multifactorial interventions.

Conclusions: Use of guidelines should prevent falls in older persons.

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