Geriatric Nursing Fall Prevention in Old Adults

 Old Age Fall Prevention and Post-Fall Nursing Care

Aims and importance of fall prevention.Post falls effects assessment.Head Injury and trauma.Use of restrains and nursing care.

Aims of Care

    Two specific aims of any effort in acute care institutions to reduce falls among older adults are 

    (a) to reduce risk of injury from falls including fatal falls 

    (b) to champion an inter professional fall prevention program to prevent patient falls.     Both aims seek to promote improvements in patient safety by reducing preventable falls through system-wide solutions whenever possible (Joint Commission National Patient Safety Goals, 2006).

Assessment, Diagnoses, and Intervention Strategies

    Overall, across all patient settings, evidence exists that fall prevention programs are effective. The RAND report cites, from a meta-analysis of 20 randomized clinical trials (among all patient settings, but mostly long-term care), that fall prevention programs reduced either the number of older adults who fell or the monthly rate of falling (US Department of Health and Human Services, 2004). 

    Hospital-based studies are emerging to provide solid scientific evidence of the effect of fall prevention programs on fall rates and, more importantly, fall-related injuries.Oliver and colleagues (2007) have produced a compilation of the best evidence of practice innovations used by hospitals across the United States and the United Kingdom, and their outcome effect on falls and injury reduction. 

    After careful scrutiny (Oliver et al., 2007), they have identified the key components guiding multifactorial interventions used to prevent falls in hospitals (ie, education, use of toileting schedules, and alarm devices). Oliver et al.'s (2007) approach has analyzed and weighed the individual intervention within the multifactorial intervention into its constitute parts, thereby minimizing any methodological design issues (Oliver, Healy, & Haines, 2010). 

    Many of these multifactorial interventions are targeted to education initiatives, environmental issues, or seek to improve equipment implicated in cases.Before beginning any discussion on specific individual fall prevention intervention, the acute care nurse must realize one's role in championing a team effort in fall and injury prevention. 

    Professional nurses are uniquely poised because they know the biopsychosocial and functional needs of their patients and situational contexts of how patients respond to the acute care environment. Such individual knowledge of each patient they care for positions the professional nurse, along with leadership skill, in a unique position to champion teamwork on their acute care unit.

The Importance of Fall and Injury Prevention in Acute Care

Many of the health care outcomes from falls, such as injury and/or functional decline, typically strike those patients older than age 85 years and can be prevented. The most serious outcome is a fatality. 

    The National Center for Injury Prevention and Control (NCIPC) tabulates fatal falls across the ages averaging more than 14,000 fatalities among seniors. Fatal falls rank as the seventh leading cause of unintentional injury fatality among older adults (Centers for Disease Control and Prevention (CDC), NCIPC, 2007). The fatal fall incidence increases with age those older than age 85 years being the most vulnerable. 

    Hospital in-patient falls are estimated to vary according to the unit, with one study reporting 3.1 falls per 1,000 patient days (Fischer et al., 2005). In this study, bleeding or laceration occurred in 53.6%, fracture or dislocation in 15.9%, and hematoma or contusion in 13%. Other serious injuries documented from falls included hip fracture and traumatic brain injury (TBI), among others.

Assessment Of The Problem

Deciding Risk for a Serious Fall-Related Injury “One look is worth a thousand words, but don't forget to look more than once” Diagnosis: Impaired consciousness Important characteristics of level of alertness are the patient's ability to sustain attention, and in determining if they are awake or not. 

    If impairment exists in level of consciousness, the patient is at risk for injury; Thus, any postoperative surgical patient is at greatest risk for injury from a fall. An important factor in determining a patient's safety within his or her environment will be if he or she can process information and execute simple one-, two-, and/or three-stage commands. 

    The ability to execute a command is contingent on the level of consciousness, behavior, and cognition. Traditionally, level of consciousness is assessed and written as alert and oriented x 3,referring to person, place, and time. The ability of the person to sustain attention can be gauged by observation of his or her ability (or not) to execute a command, for instance, following instructions. 

    This type of assessment is typically routine when the nurse first greets the patient and is beyond a simple assessment of whether or not the patient is awake. alert,” and oriented and can say, “Hello.” All of these determinations are critical factors in the nurse's judgment of patient safety. After the first assessment, the nurse should reassess the older patient frequently because level of consciousness can change quickly.

Critical Thinking Points

    How many times do nurses reassess their own judgment and make changes accordingly to their original impressions? Typically, in case of risk assessments, the reassessment is made each shift and at the time of transition to another unit. Although a patient may “look to be safe” resting in bed, they may be totally unsafe when they sit up on the side of the bed or take a step to walk. Therefore, the situational context is very important to note. 

    Consider these points: While patients are safe in bed, are they also safe to be unsupervised alone? Are they safe to sit, transfer, or walk unassisted? All of these nursing observations and ultimate clinical determination of patient safety hinge on the older patient's level of consciousness, level of alertness, as well as behavior and current cognitive capabilities.

    Level of consciousness is formally measured by use of standardized assessment tools such as the Confusion Assessment Method and other such tools (see http://consultgerirn.org/resources).

Diagnosis Impaired Behavior, Affect, or Cognition

    Observation of a patient's behavior includes the patient's affect, demeanor, and ability to process stimuli in the environment. Agitated older adults are at risk for falls and injury because attention to the normal environmental cues is blunted or lost altogether.    

    Depressed older adults may be at risk for impaired safety awareness and management because of blunted responses or apathy as well as centrally acting medications used to treat the depressants. Cognitive impairment should be evaluated because dementia is an independent risk factor of falls (van Doorn et al., 2003).

    For each of these four factors-consciousness, affect, behavior, and cognition-nurses work with physicians to evaluate underlying causes and find treatable solutions wherever possible. Note that the root of many of the disturbances of consciousness, behavior, and affect are due to some classic acute medical events such as hypotension, profound blood loss, or toxicity from medications

    . If no identifiable solution exists, prudent and standard care ( ie, best practice) requires nurses to ensure the safety of patients by instituting interventions related to improved monitoring and assistance with activities. In the order of least to most restrictive, nurses employ various solutions until the patient is no longer judged by the nurse to be at risk for a safety issue or in danger for a serious fall-related injury. 

    Note that research on these best practices for fall prevention is slowly emerging, and the absence of research in this area does not justify not using the intervention, because it may be a best practice intervention accepted as standard care.

Assess and Diagnose the Older Adult Patient's Risk for Serious Injury Fractures

    There are a few commonsense questions the acute care nurse must ask when determining whether an elderly patient is at risk for serious injury (see Table 15.3). Serious injury is defined as broken bones such as vertebral fractures, pelvic fractures, internal bleeding, or fatality. All of the items are acute or chronic medical illnesses or conditions giving rise to the possibility that an acute injury could result. 

    One of the most prevalent conditions increasing risk for serious injury in older patients, such as a fracture, is the presence of osteoporosis. For many reasons, the true incidence of osteoporosis is unknown in the older population, especially in men (Kaufman et al., 2000) who comprise a large percentage of the acute care hospital and long-term care beds. 

    Therefore, it is entirely conceivable that the older adult will fracture an extremity or vertebrae with a fall, even though there is no documented diagnosis of osteoporosis.This is because osteoporosis can be present, even though it has not been formally diagnosed. 

    Most older individuals with hip fractures have osteoporosis, yet findings from a retrospective analysis of records of patients receiving hip fracture surgery appears that the frequency of treating these high-risk older patients for osteoporosis is less than optimal; women are offered treatment more than men (Kamel, 2004).

    If osteoporosis has been diagnosed, then certain protective interventions should be considered such as the use of hip protectors (Applegarth et al., 2009; Bulat, Applegarth, Quigley, Ahmed, & Quigley, 2008). As indicated for those older persons without safety judgment and are unable to transfer and ambulate independently, the use of low-height beds and/or floor mats placed around the bedside will lessen the height of the fall, or padding a hard surface to reduce the chance for injury. 

    Treatment for osteoporosis needs to be discussed, ranging from the use of medication agents to supplemental calcium and vitamin D, although research findings show a controversial association between vitamin D and physical performance improvements in gait and balance (Annweiler, Schott, Berrut, Fantino, & Beautet, 2009). 

    However, a recent meta-analysis found vitamin D to be the only intervention shown to be effective in reducing falls among female stroke survivors in an institutional setting (Batchelor, Hill, Mackintosh, & Said, 2010).Other medical comorbidities that increase the risk of serious injury include bleeding disorders and use of blood-thinning medications to prevent stroke. 

    A risk versus benefit analysis should always be part of fall management decision making for patient safety and prevention of injury (Quigley & Goff, 2011). Those with thrombocytopenia require monitoring of neurological status post fall in an effort to early identify a patient with a looming internal bleed or developing hematoma. These clinical conditions are very serious and can be fatal if not assessed early.

Best Practice Interventions for Suspected Serious Injury Head trauma

    Frequent neurological checks are done for several days following head injury in older patients who are on blood thinners or who have coexisting medical conditions to detect the development of serious conditions such as a subdural hematoma. In addition, vital signs, assessing behavior, affect, cognition, and level of consciousness are all part of any assessment of the patient with head injury. 

    Changes in speech, such as slurred speech, or subtle diminution in cognitive abilities (ie, they no longer recognize you after recalling your name) are significant findings post fall head injury that requires immediate attention.Older patients who have unwitnessed falls or do not recall falling despite evidence to the contrary should be monitored for head injury following the CDC guidelines for head injury (see Resources). 

    Traumatic brain injury caused by head injuries is a condition that is preventable and, more importantly, readily recognizable. Subtle changes in cognition, level of consciousness, or behavior post fall indicate underlying head trauma. Table 15.4 details best practice interventions in cases in which a head injury is suspected post fall.

    Of all causes, falls are the leading cause of TBI (CDC, NCIPC, 2007), with older adults age 75 and older having the highest rate of TBI-related hospitalization and death (Langlois, Rutland-Brown, & Thomas, 2006). Groups at risk for the development of TBI include men who are twice as likely to sustain a TBI-adults age 75 or older; African Americans have the highest death rate from TBI (CDC, NCIPČ, 2007). 

    There is strong clinical reason to suspect that older adults in anticoagulants are at higher risk for TBI, should then sustain a fall with head injury, but empirical research in this age group is lacking. Still, best practice approaches to care of older adults must include a risk-benefit evaluation of medications, such as Coumadin, Plavix, and/or aspirin, among others, that place the older adult at increased risk for bleeding following a fall. 

    Additionally, use of helmets may be considered because they absorb trauma and reduce impact to the head (Quigley & Goff, 2011).Why Do Older Adult Patients in an Acute Care Setting Fall and Who Is at Greatest Risk The Value of Identifying Fall Type Reasons for patient falls are tied directly to impairments in consciousness, cognition, behavior, and acute and chronic types of medical conditions. Some of these risks are due to intrinsic factors, whereas others are due to extrinsic factors. 

    The standard of care calls for assessment of fall risk factors and then to develop intervention plan targeted toward these factors.Environmental falls are potentially preventable because they encompass foreseeable events, such as spills or improper shoe wear, which is correctable (Connell, 1996).

    Positive predictive validity of falls has also been used as evidence by the patient's under lying history of falls, visual impairment, requiring toileting assistance, dependency in transfer/mobility, balance disturbance, and cognitive impairment (Blahak et al., 2009; Papaioannou, 2004 ; Tinetti, Williams, & Mayewski, 1986). Last, common extrinsic or environmental factors, which represent preventable falls, are highlighted in Table 15.7.

    Fall risk is formally assessed through administration of fall risk tools (see Table 15.8). The National Center for Patient Safety recommends the Morse Falls Scale, but not for long-term use (available at: http://www.va.gov/ncps/CogAids/Fall Prevention/Index .html#topofpage&page=page-4) . 

    The Stratify tool has also been widely used but two very different and distinct approaches for falls prevention. Fall risk assessment tools offer limited types of inquiry typically streamlined focusing on five or six areas of inquiry, which are not a substitution or replacement for a comprehensive post fall inquiry or assessment. Critical information is missing in these streamlined fall risk assessment tools.

Patient-Specific Factors Linked to Fall Risk

    Evidence from systematic reviews of fall risk factors in hospital inpatients supports the following risk factors to be linked to falls: a recent fall, muscle weakness, behavioral disturbance, agitation or confusion, urinary incontinence or frequency, use of “culprit medications (especially sedative/ hypnotics), postural hypotension, syncope, and those older than age 85 years (Oliver et al., 2010). 

    In the acute care setting, fall risk tools have been summarized in an analytic review by Perell and colleagues (2001; Scott, Votova. Scanlan, & Close, 2007).The nursing assessment of the older adult patient who falls does not stop with administration of these assessment tools or other types of assessment. 

    Rather, the assessment is a dynamic and continuous process of quality improvement, which extends to formulate an analysis of the information and situational context of the patient so that corrective plans of action can unfold.

Physical Restraint Use Contributing to Fall Risk

    Capezuti and colleagues (2002) cite physical restraint use as a contributor to risk for falling, not a solution for fall prevention. Also noted by Capezuti et al. (2002), neither physical restraints nor side rails have ever been shown to reduce falls or associated injury. In fact, in the last 20 years, there have been numerous reports of restraint-related injuries reported in the professional literature, by the US Food and Drug Administration, and The Joint Commission. 

    Many of these injuries are due to patient attempts to remove restraints or to ambulate while restrained (Agostini, Baker, & Bogardus, 2001). The injuries include neurological injuries (DiMaio, Dana, & Bux, 1985), stress-induced complications (related to agitation secondary to restraint), and strangulation (Dube, & Mitchell, 1986; Miles, 2002).     

    The most common mechanism of restraint-related death is by asphyxiation the person is suspended by a restraint from a bed/chair and the ability to inhale is inhibited by gravitational chest compression (DiNunno, Vacca, Costantinedes, & Di Nunno, 2003). 

    Clearly, the risk of serious injury or fatality due to physical restraint is substantial and must be considered when deciding about using restraints. Serious direct injury from bedrails is usually related to use of outmoded designs and incorrect assembly rather (Healey, Oliver, Milne, & Connelly, 2008).

Medications Contributing to Fall Risk in Older Adults

    “Culprit” drugs or medications implicated in increasing fall risk are those causing potentially dangerous side effects including drowsiness, mental confusion, problems with balance or loss of urinary control, and sudden drops in blood pressure with standing (postural hypotension; Ensrud et al., 2002: Neutel, Perry, & Maxwell, 2002; Smith.2003). 

    Classifications of medications implicated in falls for older adults include psychotropic agents (benzodiazepines, sedatives/hypnotics, antidepressants, and neuroleptics), antiarrhythmics, digoxin, and diuretics (Leipzig, Cumming, & Tinetti, 1999), The risk of falls alone should not automatically disqualify a person from being treated with warfarin (Garwood, & Corbett, 2008).

Post fall assessment

    Determination of why the fall occurred is of vital. The value of post fall assessment, if performed properly and comprehensively using appropriately empirically tested tools, is that underlying fall etiologies can be discerned so that appropriate plans of care can be instituted. 

    To simply perform a fall risk assessment or perform a PFA and document the findings without linking the risk or actual fall cause to a strategy is useless. Once the type of fall is determined using a comprehensive post fall evaluation tool, the nurse can put into motion an appropriate plan of care.

    The purpose of the PFA is to identify the clinical status of the older adult, verify and treat injuries, and to identify underlying causes of the fall whenever possible. Components of the PFA are typically routinely performed by professional nurses in all patient settings, although this evaluation may be skeletal or limited according to the completeness of questions and examination included on the tool used. 

    Eempirically published tools for PFA exist, and previous research has shown that fall risk determination, using short forms, asking 5-8 questions about risk, often replace (inappropriately) PFA in institutionalized settings (Gray-Miceli, Strumpf, Reinhard, Zanna, & Fritz, 2004; Ray et al., 1997; Rubenstein, Robbins, Josephson, Schulman, & Osterweil, 1990).

    Evidence shows comprehensive PFA tools are useful and available to assist professional registered nurses in performing a PFA, especially in institutionalized settings (Gray-Miceli, Strumpf. Johnson, Draganescu, & Ratcliffe, 2006). In institutional setting where teams are unavailable, comprehensive PFA may be carried out through consultation with specialty-trained providers.

    The PFA is a comprehensive, case-focused history and physical examination of the present problem (falling), coupled with a functional assessment, review of past medical problems, and medications. 

    Clinical fall prevention guidelines are very clear about all of the necessary components for inclusion for patients who have fallen, which include fall history; case circumstance; medical problems, medication review; mobility assessment; vision assessment; neurological examination, including mental status; and cardiovascular assessment. In addition to this information, data are collected about the patient's physical status. 

    Performing a comprehensive PFA allows the clinician to identify intrinsic risks and recent causes of a fall such as orthostatic hypotension and/ or bradyarrhythmia or tachyarrhythmia associated with dizziness (Gray-Miceli et al., 2006). In the hospital setting, certain components of a PFA can be elicited immediately following a patient case, with the decision to ask certain questions immediately depends on the medical stability of the patient and nursing judgment.

The Immediate Post-Fall Assessment

    As soon as possible, an assessment is made to determine the extent of any sustained injuries. Before any intervention is taken, any staff member should remain with the patient and call for help. During this time, the older adult patient is verbally reassured and kept warm (but not moved) until help arrives. There are many key observations to be noted about the fallen individual's medical and psychological condition, as well as the condition of the environment. 

    The medical stability of the patient determines the sequence of information gathered either immediately or in the interim period, according to current standards of practice followed by licensed professionals. For instance, if unconscious from a sustained head injury during the fall, neurological checks, vital signs with apical pulse rate, and pulse oxygenation are assessed first. Other assessments of gait or functional status are conducted after the patient has stabilized. 

    While this is being performed, or if shoes/slippers are worn, other staff members can assess environmental spills. Information about the lighting and use of assistive devices can be gathered. Any verbalizations made by the patient should be noted about his or her condition.

    Critical observations made during the immediate PFA that should be communicated to the primary care provider include observation or verbalizations of pain, extremity swelling, unstable vital signs, discolored skin, temperature, laceration or contusions of the skin, loss of conscious - ness, decreased range of motion, evidence of head or neck injury and abnormal or erratic neurological responses, uncontrollable bleeding, and incontinence of bowel or bladder at the time of the fall.

Interim Post-Fall Assessment

    During the interim period of PFA and monitoring (anywhere from several hours to days), the nurses continue to review, determine, and communicate pertinent findings from this assessment and its progression or resolution. Once the patient is medically stable, fall risk assessment can be reassessed by the interdisciplinary team, revaluating intrinsic and extrinsic risks so that a plan of care can be determined. 

    Developing a plan of care and requesting a change in physician orders for level of supervision required by nursing staff of the older patient or specific activity restrictions depending on the fall assessment findings.

Longitudinal Post-Fall Assessment

    Following a patient fall, the presence of injury may not be apparent until days or even weeks later. When cognitive impairment exists, the accuracy of the historical accounts of pain obtained immediately after the fall may be questioned. Observations of functional status with attention to any subtle or blatant changes in mobility can signal an underlying fracture or a looming unstable joint that was not previously reported. 

    Likewise, during a patient fall in which the older adult is cognitively intact, and then later develops, an acute delirium should signal to the professional nurse the possibility of injury. In these two instances, the standard of care warrants as part of the ongoing post fall assessment, to monitor vital signs and neurological status for a period of several days or more, as clinically indicated. 

    Fall policy and procedures should reflect this provision because any change in patient condition warrants follow-through, documentation, and communication to senior level providers, other nursing staff, and family.

Overview Of Effective Fall And Injury Prevention In Hospitals

    Effective fall prevention programs in acute care hospitals are championed by nurses using one or more approaches. Moving beyond traditional measures of fall rates to assessing and measuring patient injury from falls provides more information and segmentation of vulnerable patients so that a new level of intervention is applied. 

    This process advances the evidence related to falls into the quality management program for falls prevention. Assessing risk for injury provides the evidence for nurses to provide specific interventions to reduce injury (eg, hip protectors, floor mats, and helmets) based on using existing tools. 

    The evidence is strong to support the benefit of multifactorial fall prevention programs for injurious falls in acute care. System-level interventions with emerging evidence of effectiveness emerge from the work of innovation: nurse champions, safety huddles, teach-back strategies, post fall huddles, and interventions to reduce fall-related trauma. Nurse champions

    Embracing nurse champions at the point of care, the Institute for Healthcare Improvement's (IHI) Transforming Care at the Bedside has partnered with the VISN 8 Patient Safety Center to focus on acute care fall and injury prevention for the last 5 years. 

    Dedicated to building program capacity, infrastructure, and expertise, fall experts have mentored and coached nurses from across acute care settings to address vulnerable older adults are at greatest risk for loss of function or loss of life if any type of fall occurs. This approach to nursing practice has been transformational (Boushon et al., 2008).

Teach-backs

    Health literacy requires that providers evaluate the degree to which individuals learn by assessing their capacity to obtain information, process, and understand basic health information and services so that they can make informed health decisions (Institute of Medicine, 2004). 

    Teach backs identifies what the patient learned by a return demonstration or feedback, and more importantly, what the patient had difficulty learning, so that the provider can fill that gap through ongoing education.Comfort Care and Safety Rounds. Nursing staff are completing comfort care and safety rounds as one of their tests of change. 

    This intervention has emerging evidence of effectiveness based on the results of researchers Meade, Bursell, and Ketelsen (2006), hourly rounds in acute care reduced cases (p = 0.01), and by 60% 1 year later in the follow-up hospitals.

 Safety Huddle Post-Fall

    Safety huddles were patterned after the military's “After Action Review” (AAR) process. Safety huddles provide a mechanism for immediate knowledge transfer for learning from errors and close calls. In a safety huddle, staff are instructed to immediately assess a situation or event to understand what happened, what should have happened, what accounted for the difference, and what corrective action could be implemented to prevent a similar event. This AAR mimics a modified root cause analysis. 

    All staff received a brochure explaining the AAR process and are instructed to perform a safety huddle as soon as possible after becoming aware of a fall. Nurse managers or advanced practice nurses coach staff in the safety huddle process through role playing and use of a brochure and presentation that describes the process. The nurse managers lead the initial huddles, and staff followed thereafter. 

    Over time, staff begin to use safety huddles to examine other patient safety situations and to ensure that if precautions are consistently applied in the shift-to-shift hand-off process. Incorporation into the hand-off process also provided the opportunity for staff to reassess a patient's status (Quigley et al., 2009).

Interventions to Reduce Trauma

    Patients with risk factors for serious injury (osteoporosis or osteoporosis risk factors; anti-coagulants for postoperative patients) should be automatically placed on high-risk falls precautions and interventions to reduce risk for serious injury should be implemented. 

    Interventions to reduce the risk of trauma and prevent injury include the following: place a bedside mat on floor at side of bed unless contraindicated; use height-adjustable bed (low-bed position to reduce distance from bed to floor); helmet use for patients at risk for head injury (those on anticoagulants, patients with severe seizure disorder, and history of falling and hitting head); and dress with hip protectors for patients at risk for hip fracture.

    These interventions when combined create protective bundles. For example, those patients at risk for hip fracture should be placed at high risk for falls and in height-adjustable beds, wear hip protectors, have floor mats at bedside when in bed, and receive comfort and safety rounds. 

    Those patients at risk for hemorrhagic bleed should be placed at high risk for falls and in height-adjustable beds, have floor mats at bedside when in bed, and receive comfort and safety rounds. Helmets should be considered for patients with history of head injury and falls, and on anticoagulants. All patients should receive education about their fall and injury risks.

Program Evaluation

    Many health systems use a specifically designed incident report form for falls that collects detailed literature-based data about fall occurrences (Elkins et al., 2004). For example. these data might include time of day, location, activity, orthostasis, and incontinence. 

    From the analysis of the data, one can determine the type of fall, such as accidental, anticipated physiological, and unanticipated physiological fall and severity of injury- minor, moderate, or major/severe (Donaldson, Brown, Aydin, Bolton, &Rutledge , 2005). 

    Analysis of data of this depth and scope enables clinicians, administrators, and risk managers to profile the level of fall risk of their patients along with actual factors contributing to the fall, as well as identifying overall patterns and trends surrounding fall occurrence.

Fall Prevention Program

    Fall prevention begins with an integrated/coordinated approach including determination of fall risk and PFA to identify risk factors. Accurate documentation should be provided in the plan of care, nursing and interdisciplinary notes, and other aspects of the medical record such as the problem-list help to ensure communication and ongoing monitoring. 

    Review of fall-related information collected about a fall event or a person deemed at risk for fall by the interdisciplinary team adds an important dimension to fall care. The team offers input from their unique perspective of the fall circumstance and how to best manage a fall or a patient at high risk for falls. 

    The interdisciplinary team consists of the medical provider, nurse, physical or occupational therapist, risk manager, pharmacist, and other direct health care providers.Hospital-based fall prevention programs have been described in the literature, but few trials have been conducted, demonstrating their effectiveness due to methodological limitations associated with this complex clinical fast-paced setting. 

    One study examined the effect of a program of fall prevention that includes multifactorial components of fall risk assessment, a choice of interventions, patient education, and staff education, as well as labels or “graphics alerting others to at risk patients.” Use of this model and its outcomes were examined prospectively for 5 years by Dempsey (2004) who reported a significant reduction in fall rates. 

    However, over time compliance deteriorated warranting further nursing inquiry considering use of a process approach to increase nurse autonomy in fall prevention.Exemplary models of care also exist through the National Center for Patient Safety at the United States Department of Veterans Affairs (available at: http://www.va.gov/ncps/SafetyTopics/fallstoolkit/index.html). 

    The Veterans Affairs, VISN 8 Patient Safety Center of Inquiry, under the direction of an advanced nurse practitioner nurse scientist. spearheads an impressive program of fall prevention through its health care network of inpatient hospitals. 

    Fall prevention through best practice approaches are evaluated and translated into standard practices among general falls prevention, interventions for high-risk patients, and education of staff, patients, and families.Models of care, serving as exemplars of the geriatric nurse-centered approach, realize improvements in hospital lengths of stay and health outcomes as well as fewer iatrogenic geriatric syndromes such as inpatient falls. 

    Use of the Acute Care of the Elderly (ACE) units: Nurses Improving Care for Health system Elders (NICHE) program; and the Geriatric Resource Nurse (GRN) model, which use a system-level quality improvement approach, including educational programs for staff, realized a decrease fall rate by 5.8% (Smyth, Dubin, Restrepo, Nueva-Espana, & Capezuti, 2001) .

Interventions For Fall Prevention And Management Institute General Safety Measures

    Hospitals and their staff have a legal responsibility and due diligence to ensure freedom from environmental hazards and safety for all patients, staff, and visitors. Routine environmental assessment using a checklist should include the unit, corridors, entrance, and exits, as well as patient holding areas, patient rooms, and areas where patients are transported to (radiology, nuclear imaging, operating room). 

    In each of these areas, an environmental assessment is performed focusing on floor surfaces, furniture, hallways, steps, device safety such as stretchers, wheelchairs, and other types of chairs, free of clutter, bathrooms with appropriate grab rails, and routine assessment of equipment. Use of a checklist signed by the designated employee allows for audit review of compliance, serving as an internal benchmark of compliance.

    As part of general safety, some facilities designate any older adult age 65 years and older admitted to be on “safety precautions,” which can include various other safety measures (presented in the succeeding text). Clinically, it is important to recognize, in advance whenever possible, that if instructions are given to the patient for general safety precautions, that the older adult is actually able to hear, understand, and demonstrate that he or she can follow instructions. 

    Simply “telling the older adult”To be careful or to not get up without assistance is insufficient in the face of an ongoing or new onset of delirium or cognitive impairment. Rather, other safety measures need to be instituted immediately, discussed with the team and the family caregiver, and incorporated as part of the plan of care. 

    Immediate options always include (a) increasing surveillance by either staying with the patient continuously; (b) moving the patient to a closer location (provided there is staff constantly observing the patient); (c) providing a one-on-one type of sitter service for continual surveillance; or (d) engaging the older patient in diversional activities or other forms of therapeutic recreation. 

    Sitter type services may be provided by hospital staff, volunteers, or through private duty services. Discussion with family caregivers and the interdisciplinary team are essential in these cases.

Early Mobility for Older Patients Who Fall

    Early mobility, whenever the older patient is medically stable, is a fundamental and basic aspect of care for all older adult patients to receive during their hospitalization. It is a step toward the prevention of deconditioning, reduced mobility and immobility, and other cascading problems that can result when less sedentary (for instance, orthostatic pneumonia or atelectasis). 

    Early mobility as an intervention begins with the simple and conscious decision by nursing to assist the patient out of bed to walk to the bathroom whenever possible, rather than to use a bedpan or even a bedside commode that offers little opportunity for mobility. Wearing proper footwear, corrective lenses, and clearing a path that is clutter- and spill-free are essential. 

    Use of a walking aid such as a standard cane or walker may also be required; appropriate assistive devices can be ascertained through an occupational or physical therapist consultation (Quigley & Goff, 2011).Another essential aspect for the older adult with comorbidities is for nurses to preemptively ask the older patient, who is transitioning with your assistance, from sitting to standing and then while walking, “How are you feeling”? 

    Of concern is the detection of symptoms such as lightheadedness, vertigo with rotational movement, or muscular stiffness. These symptoms can be managed and monitored, if significant enough to prohibit mobility, once they are detected. Another concern exists for the older adult patient with orthostatic hypotension. 

    this instance, gradual upright incline with assistance while monitoring for symptoms of lightheadedness are important. Should an older adult experience symptoms or develop acute physiological evidence of a problem (for instance, near syncope, syncope, or changes in heart rate or blood pressure), slowly casing him or her back to a recumbent position and notifying the physician for further evaluation is warranted.

    Mobility programs build upon the positive feedback that the patient is feeling and objectively gaining strength each day is instituted. Checklist can monitor progress and serve to validate to the patient his or her clinical progression. Care must be taken, how ever, to remind persons who are restricted from independent mobility to always wait for assistance. 

    Recommendations are to set a similar time each day and to use consistent staff. An integral component of any mobility program is footwear of patients. A recent study found patients who wore their own footwear significantly improved participants' balance compared to being barefoot; in fact, the greatest benefit was seen in those individuals with the poorest balance (Horgan et al., 2009).

Some Best Practice Examples Used by Acute Care Hospitals

The difference between environmental safety assessment and safety rounds is that safety rounds are a regular, systematic observation by one or two key personnel of the hospital unit; when assumed by the same personnel, hazards may be more quickly appreciated. Further, they occur at regular points in time, such as every 2 or 4 hours around the clock and also detect patients in need of assistance. 

    This level of frequency is likely to detect problems early so that intervention can ensure the prevention of environmental type of falls. Use of checklist can help to ensure compliance and monitor for patterns of hazards and types of hazards that need correction.Many hospital-based fall prevention programs include toileting rounds. Toileting rounds use nurse's aides to regularly assess older adult patients for the need to urinate and to provide the patient with assistance. 

    The purpose of toileting rounds is to prevent patients from incurring urinary accidents (and potential falls) by encouraging regular voiding. In many circumstances, urinary accidents can lead to falls. Scenarios include the older adult sensing a need to urinate, getting up out of bed unassisted, and occurring a fall by an unrecognized physiologic mechanism (eg, orthostatic hypotension). 

    Another scenario is in route to the bathroom; the older adult has a urinary accident on the floor and slips and falls on the wet floor. By offering toileting rounds on a regular basis, the potential for these occurrences is minimized, reducing fall rates as well as the iatrogenic complications (eg, hip fracture). 

    Toileting is a fundamental element of basic care that has an important place in the prevention of patient falls, but its importance is underrecognized. In a study by Brown et al. (2000), urge incontinence (and not stress), especially if occurring weekly or more often, increased risk of falls and non-spinal, non-traumatic fractures in older White women living in the community.

Specific Nursing Interventions

    Personal alarms are routinely used to alert nursing staff about impending falls or changes in patient mobility status. Care should be taken when deciding to use these devices because they do not prevent a fall from occurring (Oliver et al., 2010); Rather, they heighten staff's awareness by sounding an alarm, indicating a change in position has occurred. 

    There are many commercial products available, but generally, they are of two types, personal alarms clipped to the patient's gown or chair and bed-chair pressure sensors. Despite their widespread use, there is little evidence regarding their effectiveness in reducing falls in an acute care hospital setting. Use of a bed sensor alarm was studied in a geriatric rehabilitation unit with older adult patients, deemed by nurses to be at increased fall for falling (Kwok, Mok, Chien, & Tam, 2006). 

    In this study, the availability of bed sensor devices neither reduced physical restraint use nor improved the clinical outcomes of older adults with perceived fall risk. In a nursing home-based study. however, use of the “NOC WATCH,” a nonintrusive monitor used with older adults at high risk for falling (Kelly, Phillips, Cain, Polissar, & Kelly, 2002), reduced fall rate by 91%, thereby supporting other clinical trials using a randomized design. 

    If may not be the best indicator of the effectiveness of alarms, rather timeliness of rescue (Quigley, & Goff, 2011). Further, greater nurse surveillance capacity was significantly associated with better quality care and fewer adverse events (Kutney-Lee, Lake, & Aiken, 2009).Both floor mats and use of low-rise beds have an important place in the armamentarium of clinical interventions to prevent the occurrence of serious injury when a bed fall occurs. 

    Floor mats are simply placed surrounding the bed and serve to cushion the impact of the fall. They vary in thickness, and if portions of an area are uncovered, substantial injury could still occur if a patient attempts to get out of bed and a bed fall ensues, Little, if any, empirical research evidence exists regarding their effectiveness in preventing falls from bed causing fractures to the hip or traumatic brain injury in acute care settings.

     However, one observational cluster randomized trial in 18 nursing homes found that both types of hip protectors (soft and hard), when worn correctly, had the potential to reduce the risk of a hip fracture in falls by nearly 60% (Bentzen, Bergland, & Forsen, 2008).

    A recent meta-analysis, however, reported that hip protectors are an ineffective intervention for those living at home and that their effectiveness in the institutional setting is uncertain (Parker, Gillespie, & Gillespie, 2006)..echnological advances have occurred, offering staff and patients a greater variety of solutions to the problem of falling. 

    Improvements realized have occurred with walking aides such as canes that “talk” and provide feedback to the user, balance retraining that help patients learn about where their body is in space and to help learn how to compensate for muscular impairments, and other types of equipment used at the bedside when transitioning patients. 

    Although these devices are available, research is evolving and limited in terms of their effectiveness in fall prevention (Nelson et al., 2004).An integral component of any fall prevention educational intervention for hospitalized older adults or preparing for discharge home concerns their working knowledge of what their fall was due to and what can be done about it. 

    Exploring the older adult's beliefs and attitudes are important and can lead to dispelling myths they may hold about falling; for instance, they may believe it is a normal part of aging or that nothing can be done about it. An older person's view and conceptualization about their falling is a starting point for a tailored educational intervention. 

    A systematic review of the literature of many studies examining older adults' preferences, views, and experiences in relation to fall prevention strategies reported several important findings (McInnes, & Askie, 2004): (a) In clinical practice, it is important to consult with individuals to find out what they are willing to modify; and (b) what changes they are prepared to make to reduce their risk of falling, otherwise they may not attend fall prevention programs.