Falls risk assessment and prevention in the acute hospital setting

Abstract

Falls are a major public health problem. They can have physical and psychological sequelae and may impose an economic burden for the patient, family, carers, staff and the healthcare system. Although much of the focus of falls prevention and its impact is in the community setting, falls can have equally devastating impact when they occur in hospitals. Despite an expansion in research investigating falls in hospitals, there remains uncertainty about the best way to help prevent falls, thereby minimising potential detrimental outcomes, in the acute setting.

Prior to commencement of this research, falls prevention within the acute hospital setting was thought to be best addressed using multifactorial falls prevention initiatives, guided by falls prevention screening or assessment. This research sought to develop a unique two-stage falls risk screening and assessment tool, the Western Health Falls Risk Assessment (WHeFRA), purposely designed for the acute hospital setting, and to determine its rater reliability and predictive validity. This tool was then utilised as the foundation for a multifactorial falls prevention program in the acute hospital setting, and evaluation of the immediate and sustained outcomes was undertaken.

Investigation of the clinimetric properties of the WHeFRA on acute hospital wards revealed very good intra-rater reliability and good inter-rater reliability. A further prospective investigation of WHeFRA screening tool accuracy in predicting patients at risk of falls found good predictive validity, and also favourable accuracy compared with the “gold standard” screening tool (STRATIFY).

A falls prevention program, based on the WHeFRA and utilising Falls Resource Nurses (FRN’s) as key drivers and ward champions, was implemented on 14 acute wards utilising a staggered rollout over three years. Falls rates monitored over ten years increased initially compared with the two-year baseline rate. Rates then gradually decreased for nearly three years post program completion, after which the rate began to increase again, however still remaining lower than baseline.

The program was further investigated through audits of WHeFRA compliance and nurses’ surveys at two time points, at completion of program implementation and 2.5 years following this. Sustainability of program achievements also appeared to be maintained initially, however at 2.5 years post completion it was apparent that booster activity and support avenues were required to preserve benefits longer-term.

Although growth in investigations based in the acute hospital setting occurred following commencement of this research, debate regarding the most ideal prevention approach and the use of falls screening tools continues today. Knowledge about staff acceptance of falls risk screening tools and falls prevention programs, and sustainability outcomes of falls prevention initiatives, remains limited.

In summary, this research spanning ten years in an acute hospital setting: i) developed a unique two-stage, reliable and accurate, falls risk screen and assessment tool, ii) successfully implemented a multifactorial falls prevention program, and iii) identified important elements required to initially achieve practice change and to maintain this culture change over a sustained period, highlighting what is needed to accomplish optimal long-term falls prevention benefits.