summary

Evidence-on-Fall-and-Injurious-Fall-Prevention1.pdf

AuthorAffiliations:Assistant Professor (DrZhao), School ofNurs- ing, Boise State University, Idaho; Associate Dean, and Research and Associate Professor (DrBott), School ofNursing; andAssociate Profes- sor (Dr He), Department of Biostatistics, University of Kansas, Kansas City; Assistant Professor (Dr Kim), College of Nursing, Yonsei Uni- versity, Seoul, South Korea; and Assistant Professor (Dr Park) and Research Professor (Dr Dunton), School of Nursing, University of Kansas, Kansas City.

The authors declare no conflicts of interest. Correspondence: Dr Zhao, School of Nursing, Boise State

University, 1910 University Dr, Mail Stop 1840, Boise, ID 83725 ([email protected]).

DOI: 10.1097/NNA.0000000000000715

D ow

nloaded from http://journals.lw

w .com

/jonajournal by B hD

M f5eP

H K

av1zE oum

1tQ fN

4a+ kJLhE

Z gbsIH

o4X M

i0hC yw

C X

1A W

nY Q

p/IlQ rH

D 3i3D

0O dR

yi7T vS

F l4C

f3V C

1y0abggQ Z

X dtw

nfK Z

B Y

tw s=

on 05/09/2023

T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

Evidence on Fall and Injurious Fall Prevention Interventions in Acute Care Hospitals

Yunchuan (Lucy) Zhao, PhD, RN Marjorie Bott, PhD, RN Jianghua He, PhD

Heejung Kim, PhD, RN Shin Hye Park, PhD, RN Nancy Dunton, PhD, RN

Falls and injurious falls are a major safety concern for patient care in acute care hospitals. Inpatient falls and injurious falls can cause extra financial burden to pa- tients, families, and healthcare facilities. This article provides clinical implications and recommendations for adult inpatient fall and injurious fall prevention through a brief review of factors associated with falls and injurious falls and current fall prevention prac- tices in acute care hospitals.

The problem of adult inpatient falls and injurious falls in acute care hospitals has been a serious safety con- cern for patient care. In acute care hospitals, inpatient falls are the most common incidents reported by nurses and other healthcare team members.1-4 In the United States, the average fall rate is about 3 to 5 falls per 1000 patient days with approximately 1 million annual falls in hospitals. Falls during hospitalization can have numerous negative consequences to patients and families, including fear of falling, depression, in- juries, reduced mobility and functional ability, and decreased independent living and quality of life.4,5

Injuries resulting from inpatient falls can cause extra financial burden and decreased revenue to healthcare facilities. On average, injurious falls lead

to an increased length of hospital stay by 6 to 12 days and an additional cost of $13,316.6 Because the Cen- ters forMedicare andMedicaid Services no longer re- imburses hospitals for treatment of preventable injuries, including fall-related injuries,7 not only will hospitals pay the extra cost for these fall-related injuries, hospi- tals will sustain revenue losses.

Falls and falls-related injuries are listed as one of the nursing-sensitive care outcome measures by the National Quality Forum.8 It is essential to prevent in- patient falls and related injuries so as to deliver high- quality care. To deliver high-quality care, nurse leaders in acute care hospitals need to have: a) the knowledge of specific risk factors associated with inpatient falls and injurious falls; b) common fall prevention inter- ventions; and c) potential strategies for effective fall and injurious fall prevention in acute care hospitals. The information presented hereinafter will assist nurse leaders to develop organizational policies and pro- grams that aim at effective fall and injurious fall pre- vention targeting adult inpatients.

Factors Associated With Falls and Injurious Falls Evidence shows that inpatient falls and injurious falls are a complicated phenomenon that involves multiple factors, including intrinsic and extrinsic factors.4,9,10

Intrinsic factors are patient-specific factors, and ex- trinsic factors include hospital organizational factors, nurse staffing, and nursing process factors.

Intrinsic Factors Evidence demonstrates the association between ad- vanced age, and inpatient falls and injurious falls.11-15

Among inpatient falls, about 50% occur in patients

JONA � Vol. 49, No. 2 � February 2019

mailto:[email protected]

D ow

nloaded from http://journals.lw

w .com

/jonajournal by B hD

M f5eP

H K

av1zE oum

1tQ fN

4a+ kJLhE

Z gbsIH

o4X M

i0hC yw

C X

1A W

nY Q

p/IlQ rH

D 3i3D

0O dR

yi7T vS

F l4C

f3V C

1y0abggQ Z

X dtw

nfK Z

B Y

tw s=

on 05/09/2023

60years andolder,whereas patients older than80years are significantly at the highest risk for falls and injurious falls.11,14,15 Interestingly, the evidence on the relation- ship between gender and falls is inclusive because both genders are identified as a risk factor for falls or inju- rious falls in previous studies11-13,15,16 or no associa- tion is identified at all.10 Certain medical conditions such as cognitive impairment, impaired mobility, hy- pertension, osteoporosis, and stroke also are risk fac- tors for falls or injurious falls.4,9,11,16 However, being on anticoagulation therapy does not place patients at an increased risk for bleeding injury after a fall.17,18

Extrinsic Factors Hospital and unit organizational characteristics also are found to be associated with patient falls and inju- rious falls. Teaching and Magnet® hospitals in gen- eral have less falls and injurious falls.10,19,20 In these hospitals, nurses often report higher perceptions of the quality of work, work environment, nursing lead- ership, and job satisfaction, which all contribute to better quality of care and patient outcomes.20,21 Ac- cording to recent studies, mixed results are reported when analyzed by unit type—surgical units have an increasing rate of falls or injurious falls10,22—although previous studies suggested that medical units had the highest rates of falls and injurious falls.19,23

Several nursing process factors significantly con- tributing to falls and injurious falls require attention from nurse administrators and managers. Fall risk assessment and fall prevention protocols are 2 impor- tant nursing process factors in preventing falls and injurious falls.12,19 Patients who are identified at risk for falls through fall risk assessment are 21% less likely to have injurious falls.10 In clinical practice, nurses often initiate a fall prevention protocol to patients identified at fall risk. With a fall prevention protocol implemented, falls are more likely to be assisted by em- ployees, which can reduce fall-related injuries.10,19

Studies indicate that falls without employee assistance are 50%more likely to result in injuries than falls with employee assistance.10-13,19 Because about 12% to 69% of falls are related to urinary and bowel elimina- tion needs, providing assistance when patients need to go to the bathroom is essential in preventing falls.9

Fall Prevention Interventions

Existing Fall Prevention Interventions In the last decades, many fall prevention interventions have been developed and implemented in acute care hospitals. Based on the characteristics of intervention components, fall prevention interventions can be cate- gorized into (a) environmental, (b) educational, (c) com- municational, or (d) nursing process interventions.2,4,24

JONA � Vol. 49, No. 2 � February 2019

Environmental Interventions Environmental interventions may focus on the efforts to create a clutter-free, safe environment.2,4 Specifi- cally, environmental interventions include modifying the hospital environment with vinyl flooring2,25 and ensuring the patient bed is in low position.24 Modify- ing the hospital environment with vinyl flooring helps prevent falls because hospital units with carpeted floors have increased fall rates compared with units with vinyl floors.2,25 However, lowering hospital beds shows no significant effect in preventing inpatient falls.4,26

Educational Interventions Staff and patient education on fall prevention are 2 major components of educational interventions.2,24

Staff education is used to raise staff awareness of fall prevention or provide training for fall risk assessment tools.2,4 Patient education programs aim to improve patient knowledge of: a) fall prevalence and conse- quences; b) causes of falls; c) hospital fall prevention strategies; and d) self-reflection of individual risk and a goal-setting review.27,28 Evidence shows that staff or patient education as a single intervention strategy has been effective in preventing inpatient falls and injurious falls.2,4 With education, staff and patients often have improved knowledge on fall risks and pos- itive attitudes on fall prevention. Education can also help staff implement appropriate fall preventions and promote active patient engagement in fall prevention.4,26,28

Communicational Interventions Communicational interventions use visual alert signs, verbal communications, or electronic alarm systems to assist fall prevention. Visual signs including yellow wristband and fall risk signs alert staff to the patients at a high risk for falling.2,4,24 Electronic bed or chair alarms alert staff to the movement of high–fall risk patients so that the staff can provide assistance or sup- port.4,24 Awareness posters (ie, call don't fall, keep calm) remind the patient to call staff for help to pre- vent falls.2,24 These communicational interventions often are used in combination with other fall preven- tion strategies.4,24,29

Nursing Process Interventions Nursing process interventions aiming to prevent falls include fall risk assessment, fall protocol implementa- tion, and postfall review/evaluations.4,24,29 Fall risk assessment is the most common nursing process inter- vention.24,29 Based on fall risk assessment, a fall pre- vention protocol often is implemented on patients identified at a high risk for falls. A fall prevention pro- tocol usually consists of patient education; visual alert signs; electronic alert systems; care, safety, and toileting rounds; and ambulation assistance.4,24 Care, safety, and toileting rounds, often referred to as hourly rounding,

D ow

nloaded from http://journals.lw

w .com

/jonajournal by B hD

M f5eP

H K

av1zE oum

1tQ fN

4a+ kJLhE

Z gbsIH

o4X M

i0hC yw

C X

1A W

nY Q

p/IlQ rH

D 3i3D

0O dR

yi7T vS

F l4C

f3V C

1y0abggQ Z

X dtw

nfK Z

B Y

tw s=

on 05/09/2023

is a common practice in acute care hospitals. During these rounds, nursing staff purposely check on the pa- tients at regular intervals to ensure patients are receiv- ing the care and assistance as needed.30 As a single intervention, hourly rounding has proved to be an ef- fective strategy in preventing falls and improving pa- tient satisfaction of nursing care.25,30 Postfall review or evaluations that have shown some effectiveness in preventing future or recurrent inpatient falls31 are used in many hospitals.4,24,29

Issues With Existing Fall Prevention Interventions Falls and injurious falls are still prevalent in many US hospitals.23 Yet, the effectiveness of existing fall pre- vention interventions varies.2,4,24 In the literature, sev- eral major issues that affect the success of hospital fall prevention interventions are identified including fall risk assessment, fall prevention components, and inter- vention implementation and adherence.4,24,29

Fall Risk Assessment Most fall prevention intervention approaches include fall risk assessment.24,29 Fall risk assessment often is conducted with an assessment tool or nursing judg- ment. However, a recent systematic review of hospital fall prevention programs revealed that more than half of the studies used an assessment tool that did not have reported validity and reliability testing.24 Be- cause fall risk assessment is an important approach for fall prevention, using an assessment tool that does not have reported validity and reliability testing may threaten the accuracy of the assessment. As a result, fall assessment may not correctly identify patients at risk for falls.32

Fall Prevention Components Most fall prevention interventions consist of multiple common components including fall risk assessment, patient and staff education, visual alert signs, and hourly rounding.4,24,29 However, an optimal bundle of intervention components cannot be identified be- cause there has not been strong evidence on what components are most important for successful fall interventions.29

Intervention Implementation and Adherence The implementation and adherence of fall prevention interventions has been a determining factor in suc- cessful fall prevention programs. Without appropri- ate implementation and adherence, fall interventions may not be effective in preventing falls and injurious falls.24,29 Major challenges in the implementation and adherence of fall prevention interventions include poor organizational prioritization of fall prevention, complacent staff attitude toward fall prevention, and poor compliance with existing fall prevention protocols.33-36

Clinical Implications and Recommendations Existing evidence suggests that inpatient falls and injurious falls can be complicated. Therefore, preventing falls and injurious falls can be challenging. Nurse ad- ministrators and nurse managers need to consider multilevel factors associated with inpatient falls and injurious falls. Based on the evidence on the effective- ness of and issues in the existing fall prevention inter- ventions, the following strategies should be used in fall and injurious fall prevention interventions to improve the success of fall prevention interventions. Table 1 lists examples of effective multicomponent fall programs and implementation strategies.

Provide Strong Leadership Support Leadership support has been identified as an essential factor for successful fall and injurious falls prevention in acute care hospitals in several systematic reviews of inpatient fall prevention programs.24,29 With strong leadership support, patient safety and fall prevention are established as organizational priorities and a cul- ture of patient safety is emphasized and promoted throughout the hospitals, which facilitates fall preven- tion interventions.24,29,35,36

Develop Appropriate Prevention Programs Evidence suggests individualized fall prevention inter- ventions are important in preventing falls and injuri- ous falls. Given the known risk factors for inpatient falls and injurious falls and the positive impact of fall assessment on fall prevention,12,19 all fall prevention programs should begin with an appropriate fall risk assessment. Commonly used adult fall assessment tools includeMorse Fall Scale (MFS), St. Thomas Risk Assess- ment Tool in Falling Elderly Inpatients (STRATIFY), Hendrich II Fall Risk Model (HIIFRM), and Johns Hopkins Fall Risk Assessment Tool (JHFRAT). Among these tools, MFS and HIFRM have positive predica- tive validity in identifying patients at a high risk for falls, whereas STRATIFY and JHFRAT are better in differ- entiating patients at low fall risks from those at high risks24,43,44 (Table 2).

For high–fall risk patients, appropriate fall pre- vention intervention should be developed based on the results of fall assessment. Multicomponent inter- ventions with different combinations of fall preven- tion strategies have been effective in hospitals with different sizes, locations, and teaching status.24,27,29,36-42

Although the components of these fall intervention pro- gram vary, the success of these multicomponent pro- grams suggests that an effective fall prevention program should include the following components: fall risk assessment, fall alert signs, staff education, patient education, movement alarms, and hourly rounding especially assessing patients' need for toileting.29,36-42

JONA � Vol. 49, No. 2 � February 2019

Table 1. Fall Intervention Components and Implementation Strategies

Intervention Components Implementation Strategies Outcomes Setting

Ang et al,27

2011 • Fall risk assessment • Staff education Significantly decreased falls

compared with the control group

Medical units/adult patients, geriatric patients

• Staff education • Patient education • Environment modification • Fall alert signs • Toileting schedules • Medication review • Low-low beds

Barker et al,37

2009 • Fall risk assessment • Staff education Significantly decreased

injurious falls after the intervention

Medical units, surgical units/adult patients• Staff education

• Fall alert signs • Assistance with toileting • Toileting schedules • Assistance with ambulating • Movement alarms • Low-low beds

Dykes et al,38

2010 • Fall risk assessment • Continuous quality

improvement Significantly decreased falls

compared with the control group

Medical units/adult patients, geriatric patients

• Patient education • Fall alert signs • Assistance with toileting • Assistance with ambulating • Purposeful rounding

France et al,39

2017 • Fall risk assessment • Leadership support Significantly decreased falls

after the intervention Medical, surgical,

medical-surgical units/adult patients

• Staff education • Multidisciplinary team • Patient education • Fall alert signs

• Ongoing audit

• Environment modification • Hourly rounding • Movement alarms

Hunderfund et al,40

2011

• Fall risk assessment • Staff education Significantly decreased falls compared with the control group

Medical units, neurology units/adult patients• Fall alert signs

• Patient education • Staff education • Assistance with ambulating • Care rounding • Movement alarms • Low-low beds

Krauss et al,41

2008 • Fall risk assessment • Staff education Significantly decreased falls

after the intervention Medical units/adult

patients• Environment modification • Fall alert signs • Staff education • Patient education • Hourly rounding • Movement alarms • Medication review • Low-low beds

Trepanier and Hilsenbeck,42

2014

• Fall risk assessment • Staff education Significantly decreased injurious falls after the intervention

Medical units, surgical units, medical- surgical units/adult patients

• Hourly rounding • Implementation audit • Staff education • Leadership support • Patient education • Continuous observation for

high–fall risk patients • Mediation review • Individualized care plan • Postfall assessment

Weinberg et al,36

2011

• Fall risk assessment • Staff education Significantly decreased falls and injurious falls after the intervention

Medical, surgical, rehabilitation units/ adult patients

• Fall alert signs • Leadership support • Patient education • Multidisciplinary fall

committee• Staff education • Hourly rounding • Movement alarms • Postfall review

JONA � Vol. 49, No. 2 � February 2019 89

D ow

nloaded from http://journals.lw

w .com

/jonajournal by B hD

M f5eP

H K

av1zE oum

1tQ fN

4a+ kJLhE

Z gbsIH

o4X M

i0hC yw

C X

1A W

nY Q

p/IlQ rH

D 3i3D

0O dR

yi7T vS

F l4C

f3V C

1y0abggQ Z

X dtw

nfK Z

B Y

tw s=

on 05/09/2023

Table 2. Fall Risk Assessment Tools

Tool Assessment Items Risk Score Validity/Reliability Setting/Population

MFS24 • History of falling <25, low risk Sensitivity, 0.72-0.96 Medical, surgical, medical-surgical units/ adult patients

• Secondary diagnosis 25-45, moderate risk Specificity, 0.51-0.83 • Ambulatory aid >45, high risk • Intravenous therapy • Gait • Mental status

STRATIFY Scale43 • History of falling 0, low risk Sensitivity, 0.54-0.69 Medical, surgical, geriatric, oncology units/geriatric patients

• Patient agitation 1, moderate risk Specificity, 0.67-0.73 • Visual impairment >=2, high risk • Frequent toileting • Transfer and mobility abilities

HIIFRM43 • Confusion/disorientation/

impulsivity <3, low risk Sensitivity, 0.84-0.97 Medical units, geriatric

hospital/geriatric patients• Symptomatic depression

3-5, moderate risk Specificity, 0.33-0.41

• Altered elimination >5, high risk

• Vertigo/dizziness • Male gender • Use of antiepileptics • Use of benzodiazepines • Get-Up-and-Go test

JHFRAT44 • Age <6, low risk Sensitivity, 0.26 Medical units/adult

patients• Fall history 6-13, moderate risk Specificity, 0.89 • Elimination >13, high risk • Medications • Patient care equipment • Mobility • Cognition

Sensitivity indicates the proportion of fallers correctly classified as at high fall risk; specificity indicates the proportion of nonfallers correctly classified as at low fall risk.

D ow

nloaded from http://journals.lw

w .com

/jonajournal by B hD

M f5eP

H K

av1zE oum

1tQ fN

4a+ kJLhE

Z gbsIH

o4X M

i0hC yw

C X

1A W

nY Q

p/IlQ rH

D 3i3D

0O dR

yi7T vS

F l4C

f3V C

1y0abggQ Z

X dtw

nfK Z

B Y

tw s=

on 05/09/2023

In addition to these interventions, an individual- ized fall prevention plan needs to be developed by considering different patient populations in various hospital units. For example, research suggests that surgical units have more injurious falls among inpa- tient falls compared with medical, medical-surgical, and step-down units.10 In acute care hospitals, many surgical units have implemented the Enhanced Recovery After Surgery programs, in which early postoperative mobilization is promoted.45,46With early postoperative mobilization, patients can develop orthostatic intoler- ance that further causes falls and injurious falls.47,48

The administration of analgesic medications to post- operative patients also increases these patients' risk for falls because of the side effects of analgesics.47-50

Fall prevention interventions on surgical units need to be focused on providing ambulatory assistance by employees given the association between early post- operative mobilization and falls. Research shows that falls with employee assistance result in significantly less injurious falls compared with falls without employee assistance.10-13,19 Therefore, providing employee as- sistance to patients as needed is a critical method for injurious fall prevention.

For older adult patients, medication review is an essential component of fall interventions. Hospitalized older adult patients often have chronic diseases with

multiple medications. Polypharmacy is independently associated with adverse outcomes including falls. Cer- tain medications commonly prescribed in older adult patients, including antihypertensive, antiepileptics, psy- chotropics, and opioid analgesic drugs, contribute to falls because of the side effects of sedation, orthostatic hypotension, and confusion.47-50 Nurses need to care- fully reviewmedications in older adult patients and take appropriate actions to prevent falls.

Enhance Intervention Implementation andAdherence To ensure successful fall prevention, nurse leaders must ensure successful fall prevention intervention implementation and adherence. Given the issues of complacent attitude and poor compliance with existing fall prevention protocols in intervention implementa- tion and adherence,33-36 staff education should be en- hanced and staff should be engaged in fall prevention to change staff attitudes and improve intervention im- plementation and adherence. Staff education on the importance of patient safety and fall prevention has been an effective strategy in changing staff's complacent attitude toward fall prevention.33,34 Staff involvement is a key factor in successful fall prevention interven- tions. In many successful fall prevention programs, frontline nursing staff are engaged in the intervention design and implementation as either members of the

JONA � Vol. 49, No. 2 � February 2019

D ow

nloaded from http://journals.lw

w .com

/jonajournal by B hD

M f5eP

H K

av1zE oum

1tQ fN

4a+ kJLhE

Z gbsIH

o4X M

i0hC yw

C X

1A W

nY Q

p/IlQ rH

D 3i3D

0O dR

yi7T vS

F l4C

f3V C

1y0abggQ Z

X dtw

nfK Z

B Y

tw s=

on 05/09/2023

multidisciplinary fall prevention team or the unit champions for fall prevention enhancement.33,34,36

The involvement of frontline nursing staff has im- proved the compliance with fall prevention protocols, enhanced intervention implementation, and increased intervention adherence.33,34,36Nursing leadership should engage frontline nursing staff in fall prevention inter- vention development and implementation to ensure buy-in from staff and successful adoption of the pre- vention strategies.

In the implementation of fall prevention interven- tions, nurse staffing is an important factor that nurs- ing leadership needs to consider. Evidence shows a relationship between nurse staffing (ie, total nursing hours per patient day [TNHPPD], RN hours per pa- tient day [RNHPPD], and proportion of RN hours) and inpatient falls and/or injurious falls.10,18,20,22 Pre- vious studies suggest negative associations between in- patient fall rates with lower TNHPPD and proportion of RN hours.20,22 The relationship between injurious fall rates and TNHPPD, RNHPPD, and proportion of RN hours is complicated. The results of a recent study on injurious fall rates among inpatients who fell showed a nonlinear relationship between injuri- ous fall rates and RNHPPD. The optimal RNHPPD approximately reaches 5 in relation to injurious falls: the higher the RNHPPD before it reaches 5, the lower injurious falls; after RNHPPD reaches 5, the relationship

JONA � Vol. 49, No. 2 � February 2019

becomes positive.10 Given the nonlinear association between injurious fall rates and nurse staffing, nurse leaders need to ensure proper and adequate staffing in patient care. Without adequate staffing, it is chal- lenging for nursing staff to implement appropriate fall prevention interventions to prevent falls and in- jurious falls.

Conclusion Inpatient falls and injurious falls in acute care hospi- tals are a complicated phenomenon that makes fall and injurious fall prevention a challenge for nurse ad- ministrators and managers. To ensure prevention inter- ventions for falls and, more importantly, injurious falls are successful, multicomponent prevention and valid assessment under strong leadership should be imple- mented to focus on safety and quality nursing care. In addition, involving frontline staff in the develop- ment and implementation of fall prevention interven- tions and fall risk assessment is important for buy-in and successful adherence. Other strategies for suc- cessful fall prevention intervention adherence are staff education and appropriate nurse staffing. In addition, nurse leaders need to develop fall prevention interven- tions based on effective intervention strategies with the consideration of known factors associated with inpatient falls and injurious falls.

References

1. Anderson O, Boshier PR, Hanna GB. Interventions designed to prevent healthcare bed-related injuries in patients. Cochrane Database Syst Rev. 2012;1:CD008931. doi:10.1002/14651858. CD008931.pub3.

2. Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people in care facilities and hospi- tals. Cochrane Database Syst Rev. 2012;12:CD005465. doi: 10.1002/14651858.CD005465.pub2.

3. National Patient Safety Agency. Slips, trips and falls in hospital. http://www.nrls.npsa.nhs.uk. Accessed October 5, 2017.

4. Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med. 2010;26(4):645-692. doi:10.1016/j.cger.2010.06.005.

5. ChungMC,McKee KJ, AustinC, et al. Posttraumatic stress dis- order in older people after a fall. Int J Geriatr Psychiatry. 2009; 24(9):955-964. doi:10.1002/gps.

6. WongCA,RecktenwaldAJ, JonesML,WatermanBM,BolliniML, Dunagan WC. The cost of serious fall-related injuries at three Midwestern hospitals. Jt Comm J Qual Patient Saf. 2011;37(2): 81-87.

7. Centers forMedicare&Medicaid Services.Medicare program: changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates; payments for graduate medical edu- cation in certain emergency situations; changes to disclosure of physician ownership in hospitals and physician self-referral rules; updates to the long-term care prospective payment sys- tem; updates to certain IPPS-excluded hospitals; and collection

of information regarding financial relationships between hospi- tals. Final rules. Fed Regist. 2008;73(161):48433-49084.

8. National Quality Forum. National voluntary consensus stan- dards for nursing-sensitive care: an initial performance measure set. https://www.qualityforum.org/Publications/2004/10/ National_Voluntary_Consensus_Standards_for_Nursing- Sensitive_Care__An_Initial_Performance_Measure_Set.aspx. Accessed July 7, 2018.

9. Zhao YL, Kim H. Older adult inpatient falls in acute care hospitals: intrinsic, extrinsic, and environmental factors. J Gerontol Nurs. 2015;41(7):29-43. doi:10.3928/00989143- 20150616-05.

10. ZhaoYL, BottM,He J, KimH, Park SH,DuntonN.Multilevel factors associated with injurious falls in acute care hospitals. J Nurs Care Qual. 2017;33(1):20-28. doi:10.1097/NCQ. 0000000000000253.

11. Brand CA, Sundararajan V. A 10-year cohort study of the bur- den and risk of in-hospital falls and fractures using routinely collected hospital data. Qual Saf Health Care. 2010;19(6): e51. doi:10.1136/qshc.2009.038273.

12. Chari S, McRae P, Varghese P, Ferrar K, Haines TP. Predictors of fracture from falls reported in hospital and residential care facilities: a cross-sectional study. BMJ. 2013;3(8):e002948. doi:10.1136/bmjopen-2013-002948.

13. Krauss M, Nguyen S, Dunagan C, et al. Circumstances of pa- tient falls and injuries in 9 hospitals in aMidwestern healthcare system. Infect Control Hosp Epidemiol. 2007;28(3):544-550.

http://www.nrls.npsa.nhs.uk

https://www.qualityforum.org/Publications/2004/10/National_Voluntary_Consensus_Standards_for_Nursing-Sensitive_Care__An_Initial_Performance_Measure_Set.aspx

D ow

nloaded from http://journals.lw

w .com

/jonajournal by B hD

M f5eP

H K

av1zE oum

1tQ fN

4a+ kJLhE

Z gbsIH

o4X M

i0hC yw

C X

1A W

nY Q

p/IlQ rH

D 3i3D

0O dR

yi7T vS

F l4C

f3V C

1y0abggQ Z

X dtw

nfK Z

B Y

tw s=

on 05/09/2023

14. Mion LC, Chandler AM, Waters TM, et al. Is it possible to identify risks for injurious falls in hospitalized patients? Jt Comm J Qual Patient Saf. 2012;38(9):408-413.

15. Williams T, Szekendi M, Thomas S. An analysis of patient falls and fall prevention programs across academic medical centers. J Nurs Care Qual. 2014;29(1):19-29. doi:10.1097/ NCQ. 0b013e3182a0cd19.

16. Neumann L, Hoffmann VS, Golgert S, Hasford J, von Renteln- Kruse W. In-hospital fall-risk screening in 4,735 geriatric pa- tients from the LUCAS project. J Nutr Health Aging. 2013; 17(3):264-269. doi:10.1007/s12603-012-0390-8.

17. Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med. 2012; 125(8):773-778. doi:10.1016/j.jvs.2012.11.053.

18. Inui TS, Parina R, Chang DC, Inui T, Coimbra R.Mortality af- ter ground-level fall in the elderly patient taking oral anticoag- ulation for atrial fibrillation/flutter: a long-term analysis of risk versus benefit. J Trauma Acute Care Surg. 2014;76(3):642-650. doi:10.1097/TA.0000000000000138.

19. StaggsVS,MionLC, ShorrRI. Assisted and unassisted falls: differ- ent events, different outcomes, different implications for quality of hospital care. Jt Comm J Qual Patient Saf. 2014;40(8):358-364.

20. Lake ET, Shang J, Klaus S, Dunton NE. Patient falls: associa- tion with hospital Magnet status and nursing unit staffing. Res Nurs Health. 2010;33:413-425. doi:10.1002/nur.20399.

21. Aiken LH, Sermeus W, Van den Heede M, et al. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012;344:e1717. doi:10.1136/bmj.e1717.

22. He J, Dunton N, Staggs V. Unit-level time trends in inpatient fall rates of US hospitals.Med Care. 2012;50(9):800-807.

23. Bouldin EL, Andersen EM, Dunton NE, et al. Falls among adult patients hospitalized in the United States: prevalence and trends. J Patient Saf. 2013;9(1):13-17. doi:10.1097/ PTS.0b013e3182699b64.

24. Hempel S, Newberry S,Wang Z, et al. Hospital fall prevention: a systematic review of implementation, components, adher- ence, and effectiveness. J Am Geriatr Soc. 2013;61(4):483-494. doi:10.1111/jgs.12169.

25. Donald IP, Pitt K, Armstrong E, Shuttleworth H. Preventing falls on an elderly care rehabilitation ward.Clin Rehabil. 2000; 14(2):178-185.

26. Haines T, Bell R, Varghese P. Pragmatic, cluster randomised trial of a policy to introduce low-low beds to hospital wards for the prevention of falls and fall injuries. J Am Geriatr Soc. 2010;58(3):435-441.

27. Ang E,Mordiffi SZ,WongHB. Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial. J Adv Nurs. 2011;67(9):1984-1992. doi:10.1111/j.1365-2648.2011.05646.x.

28. Haines TP, Hill AM, Hill KD, et al. Patient education to pre- vent falls among older hospital inpatients: a randomized con- trolled trial. Arch Intern Med. 2011;171(6):516-524. doi: 10.1001/archinternmed.2010.444.

29. Miake-Lye IM, Hempel S, GanzDA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:390-396. doi:10.7326/0003- 4819-158-5-201303051-00005.

30. MitchellMD, Lavenberg JG, Trotta RL, Umscheid CA. Hourly rounding to improve nursing responsiveness: a systematic review. J Nurs Adm. 2014;44(9):462-472. doi:10.1097/ NNA. 0000000000000101.

31. Gray-Miceli D, Ratcliffe SJ, Johnson J. Use of a postfall assess- ment tool to prevent falls.West JNursRes. 2010;32(7):932-948. doi:10.1177/0193945910370697.

32. Waltz CF, Strickland OL, Lenz ER. Measurement in Nursing andHealthResearch. 4th ed.NewYork,NY: Springer Publishing Company; 2010.

33. Capan K, Lynch B. A hospital fall assessment and intervention project. J Clin Outcomes Manag. 2007;14:155-160.

34. Gutierrez F, Smith K. Reducing falls in a definitive observation unit: an evidence-based practice institute consortium project. Crit Care Nurse. 2008;31:127-139.

35. Kolin MM, Minnier T, Hale KM, Martin SC, Thompson LE. Fall initiatives: redesigning best practice. J Nurs Adm. 2010; 40:384-391.

36. Weinberg J, Proske D, Szerszen A, et al. An inpatient fall pre- vention initiative in a tertiary care hospital. Jt Comm J Qual Patient Saf. 2011;37:317-325.

37. Barker A, Kamar J, Morton A, Berlowitz D. Bridging the gap between research and practice: review of a targeted hospital in- patient fall prevention programme. Qual Saf Health Care. 2009;18(6):467-472. doi:10.1136/qshc.2007.025676.

38. Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized trial. JAMA. 2010;304(17): 1912-1918. doi:10.1001/jama.2010.1567.

39. France D, Slayton J,Moore S, et al. A multicomponent fall pre- vention strategy reduces falls at an academic medical center. Jt Comm J Qual Patient Saf. 2017;43(9):460-470. doi:10.1016/j. jcjq.2017.04.006.

40. Hunderfund AN, Sweeney CM, Mandrekar JN, Johnson LM, Britton JW.Effect of amultidisciplinary fall risk assessment on falls among neurology inpatients.Mayo Clin Proc. 2011;86(1):19-24.

41. KraussMJ, TutlamN, Costantinou E, et al. Intervention to pre- vent falls on the medical service in a teaching hospital. Infect Control Hosp Epidemiol. 2008;29(6):539-545.

42. Trepanier S, Hilsenbeck J. A hospital system approach at decreas- ing falls with injuries and cost.Nurs Econ. 2014;32(3):135-141.

43. MatareseM, IvzikuD, Bartolozzi F, PireddaM,DeMarinisM. Systematic review of fall risk screening tools for older patients in acute hospitals. J Adv Nurs. 2015;71(6):1198-1209. doi: 10.1111/jan.12542.

44. Klinkenberg W, Potter P. Validity of the Johns Hopkins Fall Risk Assessment Tool for predicting falls on inpatient medicine services. J Nurs Care Qual. 2017;32(2):108-113. doi:10.1097/ NCQ.0000000000000210.

45. Feldman LS, Lee L, Fiore J Jr. What outcomes are important in the assessment of Enhanced Recovery after Surgery (ERAS) pathways? Can J Anaesth. 2015;62(2):120-130. doi:10.1007/ s12630-014-0263-1.

46. Watson DS. The benefits of enhanced recovery pathways in perioperative care. AORN J. 2015;102(5):464-467. doi:10.1016/ j.aorn.2015.09.010.

47. Bundgaard-Nielsen M, Jørgensen CC, Jørgensen TB, et al. Or- thostatic intolerance and the cardiovascular response to early postoperative mobilization. Br J Anaesth. 2009;102(6):756-762. doi:10.1093/bja/aep083.

48. Jans Ø, Bundgaard-Nielsen M, Solgaard S, Johansson PI, Kehlet H. Orthostatic intolerance during early mobilization after fast-track hip arthroplasty. Br J Anaesth. 2013;108(3):436-443. doi:10.1093/bja/aer403.

49. Marvin V, Ward E, Poots AJ, et al. Deprescribing medicines in the acute setting to reduce the risk of falls. Eur J Hosp Pharm Sci Pract. 2017;24(1):10-15. http://dx.doi.org/10.1136/ejhpharm- 2016-001003.

50. Costa-Dias MJ, Oliveira AS, Martins T, et al. Medication fall risk in old hospitalized patients: a retrospective study.Nurse Educ Today. 2014;34(2):171-176. doi:10.1016/j.nedt.2013.05.016.

JONA � Vol. 49, No. 2 � February 2019