Falls prevention

Fall Risk
Falls and fall-related injuries are a serious problem in acute care hospitals. Patient safety, efficient patient care and quality patient care are top priorities of healthcare organizations (Mha et al., 2012). Falls are a safety hazard that threatens the effectiveness, efficiency and timeliness of care rendered to a patient. The National Database for Nursing Quality Indicators (NDNQI) defined falls as “an unplanned descent to the floor, with or without an injury to the patient” (NDNQI, 2013). Falls are prevalent in the hospitalized adult population and even more common in those patients over 65 years of age (Joint Commission, 2013). Falls are the leading cause of injury among those
65 years and older, followed by trafficaccidents, burns,andfires (Gallardo, Asencio, Sanchez, Banderas, & Suarez, 2012). Over 84% of all adverse events that occur in the hospital setting have been associated with falls (Gallardo et al., 2012). Approximately 33% of hospital falls result in injury, with 4–6% resulting in serious injuries (i.e. fractures and subdural hematomas) that may lead to co-morbidity and death (Choi, Lawler, Boenecke, Ponatoski, & Zimring, 2011). The Joint Commission in 2002 established its National Patient Safety Goals (NPSGs) program that includes the goal to reduce falls and the risk of injury from falls (Joint Commission, 2013). Injury from falls is the fifth most common cause of death in acute care adult inpatient facilities (Mha et al., 2012).

Cost to hospitals
Inpatient falls are associated with increased length of stay; increased healthcare costs and higher rates of discharge from hospitals to long term care facilities (Miake-Lye, Hempel, Ganz, & Shekelle, 2013). Falls result in excessive healthcare costs for hospitals. Hospital related costs for falls that sustained a serious injury incurred $13,806 additional costs and had an increased length of stay of 6.9 per 100,000 patient care days in comparison to those patients who did not fall (Wong et al., 2011). The Centers for Medicare and Medicaid Services estimated that by 2020, the annual direct and indirect cost of fall related injuries in the United States is expected to reach $54.9 billion (CMS, 2012). Additionally, CMS will not pay for additional costs associated with many preventable errors, including those considered “never events” such as falls and falls with injury (CMS, 2012). Therefore, the high costs of falls are unreimbursed expenses to medical facilities.

Falls benchmarking
NDNQI is a proprietary database of the American Nurses Association (ANA) that was established in 1998. As of 2009, 25% of all hospitals nationwide participate in the database (Lake, Shang, Klaus, & Dunton, 2011). This database was established as a central resource for providing comparative information to healthcare organizations for quality improvement activities and to develop data to correlate nursing staffing to patient care outcomes. NDNQI is the only national quality measurement program that provides hospitals with unit-level performance comparison. This unit-level comparison gives organizations the opportunity to compare quality measures, such as falls, at the national, regional and state level. Institutions rely on the NDNQI database to identify and prioritize quality improvement initiatives. Prior to the establishment of this database, no consistent unit-level reporting benchmarking data source existed that allowed organizations to manage and prevent adverse quality outcomes (NDNQI, 2013).

Relevance for nursing
The quality of patient care outcomes is directly related to nursing care (Kolin, Minnier, Hale, Martin, & Thompson, 2010). The National Quality Forum (NQF) links rates of patient falls to nursing care (NQF, 2013). To this end, the NQF published a set of performance measures in 2004 that are used to assess the nurses' contribution to healthcare quality (NQF, 2013). Nurses at the forefront of care, should be able to identify which patients are considered “high risk” for falls. Nurses must ensure that all patients are assessed and re-assessed for fall related risk factors. Nurses have the role of initiating a comprehensive plan of care to aid in the safety of hospitalized patients.

Risk factors
There are multiple synergistic pathologies and risk factors that contribute to an inpatient fall. Hospitalized patients in the acute phase of their disease have specific characteristics requiring specialized assessment to prevent falls within the context of their environment (Gallardo et al., 2012). There are many variables that increase a patient's risk for falls and the risk of falling is directly related to the number of risk factors present at the time of the fall (Ang, Mordiffi, & Wong, 2012). Patient risks for falls are described as both intrinsic and extrinsic. Intrinsic factors are patient related factors such as age, co-morbidity, previous falls, gait, visual/auditory impairment, musculoskeletal deficits and cognitive impairment; extrinsic factors are related to the physical environment of the hospital, medications, supportive and assistive equipment in bathrooms, lighting, and footwear (Spoelstra, Given, & Given, 2012). Medications, such as opioids, neuroleptic agents, benzodiazepines and tricyclic antidepressants, were identified as extrinsic factors leading to increased fall risk (Graham, 2012).
Falls are positively related to medications such as cardiac medications, analgesics, psychotropic, anti-hypertensives, anti-arrhythmic, diuretics and anti-platelet medications as well as the number of medications a person is on, poly-pharmacy (Mamum & Lim, 2010). These medications may contribute to orthostatic hypotension and postural weakness (Mamum & Lim, 2010). Cardiac and analgesic medications have been implicated as one of the main risk factors leading to falls in the adult population (Mamum & Lim, 2010). In addition, patients over 65 years of age are at an increased risk of falls due to antihypertensive medications and co-morbidities that raise their fall risk (Gallardo et al., 2012).

Risk assessment
Fall risk assessments provide an objective format for a structured evaluation to identify threats that may increase a patient's risk of falling. Comprehensive fall predictor tools can be used to facilitate nurse identification of patients at risk for falls so that processes and interventions can be implemented to decrease patient risk. Fall risk assessment tools were developed as a measurement to guide the healthcare provider in determining a patient's risk of suffering a fall or fall with an injury (Gallardo et al., 2012). Establishing a process for predicting the risk of falling in the adult inpatient population is a key factor in falls prevention. Many fall risk assessment tools have been developed in recent years. However, even the most promising tools when tested by other researchers have shown reduced specificity (Sheth, Faust-Smith, Sanders, & Palmer, 2013). These bedside tools have low specificity and are poorly predictive of injurious falls in hospitals (Sheth et al., 2013). As noted by Gallardo et al. (2012) no new systematic literature reviews have been published on fall risk instruments in the acute hospitalized patient population since 2007.
The most commonly used fall risk assessment tools are the Hendrich II Fall Risk Model (HFRM II) (Hendrich, Bender, & Nyhuis, 2003), the Morse Fall Scale (MFS) (Morse, Morse, & Tylko, 1989), and the St. Thomas Risk Assessment Tool (STRATIFY) (Oliver, Brittion, Martin, & Hopper, 1997). Fall risk assessment tools must have sound psychometric properties; the ability to correctly identify high risk populations (sensitivity) and similarly identify those populations not at risk (specificity).These instruments' are described in the following section.

Hendrich II Fall Risk Model
form Hendrich II Fall Risk Model
HFRMII published in 1995, and updated in 2003, is a standard widely used fall risk assessment tool (Hendrich et al., 2003). HFRM II established an acceptable sensitivity value of 74.9% and an acceptable level of specificity of 73.9% when tested in an acute care tertiary hospital (Hendrich et al., 2003). Ang, Mordiffi, Wong, Devi, and Evans (2007)), evaluated the HFRM II for use in an acute care population found substantially lower sensitivity (70%) and specificity (61.5%). The tool is intended for use by the nurse at the point of care to predict a patients' risk of falling.
Risk factor domains on the HFRM II include the following categories:
(1) confusion/disorientation,
(2) depression,
(3) altered elimination,
(4) dizziness/vertigo,
(5) gender,
(6) administration of antiepileptics/ benzodiazepines, and
(7) get up and go test/ability to rise in single movement.
Nurses use a point system to score each of the domains on the HFRM II from a 0 for not present to a 4 for present. If a patient accumulates 5 or more points, the patient is deemed high risk for falls.

Morse Fall Scale
form Morse Fall Risk
The MFS was published in 1989 and the tool has widespread use across the United States. This instrument was established to have an acceptable sensitivity value of 78% and an acceptable level of specificity of 83% (Morse et al., 1989). Ang et al. (2007), tested the MFS for use in acute care settings and found a sensitivity value of 88.3% and a specificity value of 48.3%. This tool is intended for use by the nurse at the point of care to predict a patients' risk of falling.
Risk factor domains on the MFS include the following categories:
(1) history of falling,
(2) secondary diagnosis,
(3) ambulatory aids,
(4) IV saline lock,
(5) gait, and
(6) mental status.
Using a point system the nurses' score each of the domains. A score of less than 25 is low fall risk. A score of 26–50 is medium fall risk. A score 51 or greater is of high fall risk. The fall risk numeric range on the MFS can range from 0 to 125 (Morse et al., 1989).

St. Thomas Risk Assessment Tool
Form St. Thomas Risk Assessment Tool
The STRATIFY was published in 1997 with an established acceptable sensitivity value of 93% and an acceptable specificity value of 87.7% (Oliver et al., 1997). Ang et al. (2007)), tested the STRATIFY for use in acute care settings and found a sensitivity value of 55% and specificity value of 75.3%. This tool is intended for use by the nurse at the point of care to predict a patients' risk of falling.
Risk factor domains on the STRATIFY tool include the following categories:
(1) history of falling,
(2) mental status,
(3) visual impairment,
(4) frequent toileting, and
(5) transfer and mobility.
Items on the scale are numerically scored as 1 if present and a score of 0 if not present. The total possible score is a 5. A score of 2 or greater is deemed high risk for falls (Oliver et al., 1997).
Although these tools have an acceptable level of sensitivity and specificity, the concern remains that a large percentage of patients who fell were scored as low risk using the identifi ed fall risk assessment instruments (Swartzell & Fulton, 2013). The fall risk scales have been developed to identify at risk patients, however the population and setting have been shown to affect the performance of these tests. These results indicate difficulty in identifying at risk patients, and salient risk factors that can be generalized across varying acute care populations (Swartzell & Fulton, 2013).
Limitations of fall risk assessment tools or inaccurate use, can lead to inappropriate identification of a patient at risk for falls and delay or result in non- implementation of fall prevention interventions and programs. This can provoke a dangerous diversion of attention and resources towards patients who would least benefit from preventative measures, or ignore those who really need them (Gallardo et al., 2012). Risk assessment tools cannot predict all inpatient falls and there is no gold standard for risk assessment, however, hospitals must examine the predictive accuracy when selecting a tool. Selecting the right assessment tool can influence the failure or success of a fall prevention program. Nurses should be able to use the tool as a guide to identify and predict those patients who may fall, however, when fall risk assessment tools are used correctly, and falls occur, new or modified assessment strategies should be considered (Spoelstra et al., 2012).
The risk factors listed on the assessment tools should be reevaluated periodically to ensure that risk factors are consistent with current treatments, including medical interventions. Unfortunately, HRM II, MFS, and the STRATIFY do not encompass all of the intrinsic and extrinsic fall risk factors identified as causative factors for inpatient falls. The initial and most effective approach to fall prevention is to use an accurate fall risk assessment tool that examines the etiology of falls, intrinsic, extrinsic and situational risk factors and match the risks identified on the tool with the implementation of appropriate interventions (Choi et al., 2011).

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