Characteristics and effectiveness of fall prevention programs in nursing homes: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: To determine characteristics and effectiveness of prevention programs on fall-related outcomes in a defined setting. DESIGN: Systematic review and meta-analysis. SETTING: A clearly described subgroup of nursing homes defined as residential facilities that provide 24-hour-a-day surveillance, personal care, and limited clinical care for persons who are typically elderly and infirm. PARTICIPANTS: Nursing home residents (N = 22,915). MEASUREMENTS: The primary outcomes were number of falls, fallers, and recurrent fallers. RESULTS: Thirteen studies met the inclusion criteria. Six fall prevention programs were single (one intervention component provided to the residents), one was multiple (two or more intervention components not customized to individual fall risk), and six were multifactorial (two or more intervention components customized to each resident's fall risk). Meta-analysis found significantly fewer recurrent fallers in the intervention groups (4 studies, relative risk (RR) = 0.79, 95% confidence interval (CI) = 0.65-0.97) but no significant effect of the intervention on fallers (6 studies, RR = 0.97, 95% CI = 0.84-1.11) or falls (10 studies, RR = 0.93, 95% CI = 0.76-1.13). Multifactorial interventions significantly reduced falls (4 studies, RR = 0.67, 95% CI = 0.55-0.82) and the number of recurrent fallers (4 studies, RR = 0.79, CI = 0.65-0.97), whereas single or multiple interventions did not. Training and education showed a significant harmful effect in the intervention groups on the number of falls (2 studies, RR = 1.29, 95% CI = 1.23-1.36). CONCLUSION: This meta-analysis failed to reveal a significant effect of fall prevention interventions on falls or fallers but, for the first time, showed that fall prevention interventions significantly reduced the number of recurrent fallers by 21%.

Feasibility of implementing a practice guideline for fall prevention on geriatric wards: a multicentre study.

BACKGROUND: About 40% of all adverse events in hospital are falls, but only about one in three Belgian hospitals have a fall prevention policy in place. The implementation of a national practice guideline is urgently needed. OBJECTIVE AND DESIGN: This multicentre study aimed to determine the feasibility of a previously developed guideline. SETTING, PARTICIPANTS AND METHOD: Seventeen geriatric wards, selected at random out of 40 Belgian hospitals who agreed to take part in the study, evaluated the fall prevention guideline. After the one-month test period, 49 healthcare workers completed a questionnaire on the feasibility of the guideline. RESULTS: At the end of the study, 512 geriatric patients had been assessed using the practice guideline. The average time spent per patient on case finding, multifactorial assessment and initiating a treatment plan was 5.1, 76.1 and 30.6 min, respectively. For most risk assessments and risk modifications, several disciplines considered themselves as being responsible and capable. The majority (more than 69%) of the respondents judged the practice guideline as useful, but only a small majority (62.3%) believed that the guideline could be successfully integrated into their daily practice over a longer period of time. Barriers for implementation included a large time investment (81.1%), lack of communication between the different disciplines (35.8%), lack of motivation of the patient (34.0%), lack of multidisciplinary teamwork (28.3%), and lack of interest from the hospital management (15.4%). CONCLUSION: Overall, the guideline was found useful, and for each risk factor (except for visual impairment), at least one discipline felt responsible and capable. Towards future implementation of the guideline, following steps should be considered: division of the risk-factor assessment duties and interventions among different healthcare workers; patient education; appointment of a fall prevention coordinator; development of a fall prevention policy with support from the management of the hospital.

Fall prediction according to nurses' clinical judgment: differences between medical, surgical, and geriatric wards.

OBJECTIVES: To assess the value of nurses' clinical judgment (NCJ) in predicting hospital inpatient falls. DESIGN: Prospective multicenter study. SETTING: Six Belgian hospitals. PARTICIPANTS: Two thousand four hundred seventy participants (mean age 67.6 ± 18.3; female, 55.7%) on four surgical (n = 812, 32.9%), eight geriatric (n = 666, 27.0%), and four general medical wards (n = 992, 40.1%) were included upon admission. All participants were hospitalized for at least 48 hours. MEASUREMENTS: Within 24 hours after admission, nurses gave their judgment on the question "Do you think your patient is at high risk for falling?" Nurses were not trained in assessing fall risk. Falls were documented on a standardized incident report form. RESULTS: During hospitalization, 143 (5.8%) participants experienced one or more falls, accounting for 202 falls and corresponding to an overall rate of 7.9 falls per 1,000 patient days. NCJ of participant's risk of falling had high sensitivity (78-92%) with high negative predictive value (94-100%) but low positive predictive value (4-17%). Although false-negative rates were low (8-22%) for all departments and age groups, false-positive rates were high (55-74%), except on surgical and general medical wards and in participants younger than 75. CONCLUSION: This analysis, based on multicenter data and a large sample size, suggests that NCJ can be recommended on surgical and general medical wards and in individuals younger than 75, but on geriatric wards and in participants aged 75 and older, NCJ overestimates risk of falling and is thus not recommended because expensive comprehensive fall-prevention measures would be implemented in a large number of individuals who do not need it.

Content validity and internal consistency of the Dutch translation of the Safety Attitudes Questionnaire: an observational study.

BACKGROUND: Patient safety is fundamental to healthcare quality. Attention has recently focused on the patient safety culture of an organisation and its impact on patient outcomes. A strong safety climate appears to be an essential condition for safe patient care in the hospital. A number of instruments are used to measure this patient safety climate or culture. The Safety Attitudes Questionnaire is a validated, widely used instrument to investigate multiple dimensions of safety climate at the clinical level in a variety of inpatient and outpatient settings. OBJECTIVES: The purpose of this study is to explore the face- and content validity and the internal consistency of the Safety Attitudes Questionnaire in a large Belgian academic medical center. METHOD: The translation into Dutch was done by three researchers. A panel of fifteen Dutch speaking experts evaluated the translation and its content validity. Content validity was quantified by the content validity index (CVI) and a modified kappa index. Face validity was evaluated by two nurses and two physicians who assessed the Dutch version of the SAQ. A cross-sectional design was used to test internal consistency of the SAQ items by calculating Cronbach's alpha and corrected item-total correlations. RESULTS: Twenty-three of the 33 SAQ items showed excellent and seven items showed good content validity. One item had a fair kappa value (item 20) and two items had a low content validity index (items 15 and 16). The average CVI of the total scale was 0.83 and ranged from 0.55 to 0.97 for the six subscales. The face-validity was good with no fundamental remarks given. The SAQ's overall Cronbach's alpha was 0.9 and changed minimally when removing items. The item-total correlations ranged from 0.10 to 0.63, no single items were strongly correlated with the sum of the other items. CONCLUSION: We conclude that in this study the Dutch version of the Safety Attitudes Questionnaire showed acceptable to good psychometric properties. In line with previous evidence, this instrument seems to be an acceptable to adequate tool to evaluate the safety climate.

Nursing staff attitudes of hip protector use in long-term care, and differences in characteristics between adherent and non-adherent residents: a survey and observational study.

BACKGROUND: Hip fractures represent an increasing public health burden with a simple fall to the floor as the most common cause. Because nursing home residents are particularly at risk, nursing homes should implement a broad range of fall prevention strategies. However, not all fall incidents can be avoided and external hip protectors may contribute to prevent hip fractures. A major problem in studying the effectiveness of hip protectors is residents' poor adherence. In nursing homes, adherence is dependent not only on the resident, but also on staff knowledge of and attitudes about hip protectors. OBJECTIVES: To describe (1) attitudes of day versus night shift caregivers towards the use of a soft hip protector, (2) residents' adherence about the use of such protectors, and (3) differences in characteristics between adherent and non-adherent residents. DESIGN: Survey and observational study. SETTING: Nursing home. PARTICIPANTS/METHODS: : Survey of care staff (n=37) in a nursing home after 8 months of continued application of a soft hip protector policy in residents (n=68). Adherence to wearing the hip protector, measured by weekly unannounced, randomly determined checks during day and night in the 8 months after the start of the study. RESULTS: Overall, 85% agreed to wear a hip protector. At 8 months, only 29% was still wearing their hip protector; with significant differences between day and night shifts. Although virtually all caregivers (97%) considered a hip protector policy in residential care as feasible, the attitude towards hip protectors was found to be significantly different between day and night caregivers. Pain and discomfort, patient insight in the usefulness of these devices, interference with incontinence materials, and the overall resident mix and care acuity were reported as major barriers. CONCLUSION: Implementing a hip protector policy for injury prevention in long-term care is not an issue of whether or not to use the devices. Rather, it is a continued clinical nursing decision process about when and when not, by whom and by whom not, why and why not, for how long, and to what clinical benefit--considering both the needs of the individual resident and the feasibility of such a policy in the context of resident mix and nursing staff.

Translating fall incidence data into fall-preventive measures in geriatric wards--a survey in Belgian hospitals.

BACKGROUND: Fall incidents and their negative outcomes represent a considerable problem in hospitals, especially in geriatric wards, and require implementation of strategies to prevent these undesirable events. For this reason, the College of Geriatrics, a body funded by the Belgian Government to set up quality improvement initiatives in geriatric wards, selected 'Fall prevention in Belgian hospitals' as a quality project for the year 2006. OBJECTIVES: Before developing and implementing a practice guideline specifically adapted to the clinical context in Belgian geriatric wards, this study was set up to gain insight into fall prevention measures currently implemented in geriatric wards of Belgian hospitals. METHODS: In this study, we used a cross-sectional survey design. The study involved 113 hospitals with a geriatric department. Participants were geriatricians, head nurses, medical directors, care coordinators and occupational therapists. Measurements were carried out using a survey questionnaire (response rate: 56.6%). RESULTS: Less than one third (32.8%) of Belgian geriatric wards had a formal fall prevention policy. However, more than 90.0% systematically registered falls, but less than a quarter used these data to improve preventive measures. Although the majority used screening (78.1%), comprehensive assessment (92.2%), and preventive strategies (98.4%) when patients are admitted, only about 10% used a standard plan to direct these efforts. Furthermore, 93.8% acknowledged using physical restraints as a fall prevention strategy. CONCLUSION: Given the high rates and complexity of falls in geriatric wards, hospitals need to further implement evidence-based assessment and standard intervention care plans to maintain uniformity and quality of care.

Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis.

OBJECTIVES: To determine the characteristics and the effectiveness of hospital fall prevention programs. DESIGN: Systematic literature search of multiple databases (Medline, Cinahl, Precinahl, Invert, the Cochrane Library) and of the reference list of each identified publication. SETTING: Inclusion of prospective controlled-design studies reporting the effectiveness of fall prevention programs in hospitals. PARTICIPANTS: Two reviewers. MEASUREMENTS: The methodological qualities of the studies were assessed based on 10 criteria. For the meta-analysis, the relative risk of a fall per occupied bed day (RR(fall)) and the relative risk of being a faller (RR(faller)) were calculated. RESULTS: Eight studies met the inclusion criteria, of which four studies tested multifactorial interventions. Although these studies took place in hospitals, most were conducted on long-stay (mean length of stay (LOS) >1.5 years) and rehabilitation units (mean LOS 36.9 days). For analysis of the number of falls, one unifactorial and two multifactorial studies showed a significant reduction of 30% to 49% in the intervention group, with the greatest effect obtained in the unifactorial study that assessed a pharmacological intervention. The pooled RR(fall) for the four multifactorial studies became nonsignificant after adjustment for clustering (RR(fall)=0.82, 95% confidence interval (CI)=0.65-1.03). No studies reported a significant reduction, either single or pooled, in the number of fallers in the intervention group (pooled RR(faller)-0.87, 95% CI=0.70-1.08). CONCLUSION: This meta-analysis found no conclusive evidence that hospital fall prevention programs can reduce the number of falls or fallers, although more studies are needed to confirm the tendency observed in the analysis of individual studies that targeting a patient's most important risk factors for falls actively helps in reducing the number of falls. These interventions seem to be useful only on long-stay care units.