Many falls risk assessment tools have been developed to screen for risk factors most predictive of falls.
Studies have found that these tools accurately identify patients who will fall or those who are at high risk of falling with a sensitivity and specificity of greater than 70%.
Pairing risk assessment with functional assessment tests and injury risk assessments shows promise of further delineating patients at highest risk of falls and falls-with-injury events. Initial screening for falls risk using these tools forms the basis for further risk assessment and formulation of a multifactorial falls prevention plan with interventions targeted to the risk factors identified.
In 2011, the Pennsylvania Patient Safety Authority received reports of more than 32,000 falls. Of these patients who fell, 64% were reported to have had a falls risk assessment completed, 60% had been identified as at risk for falling, and 65% were reported to have had prevention strategies in place.
While these statistics may reflect a lack of documentation, rather than a deficiency in practice, evaluation of compliance with best practices with respect to falls prevention is warranted, beginning with performance of a falls risk assessment for all patients.IntroductionFalls are the leading cause of injury-related death in adults over age 65, with death rates rising sharply over the past decade.
The differentiation of fall types is important because methods for prediction and prevention differ according to the fall type. Anticipated physiological falls can be prevented through screening for falls risk factors, in-depth assessment, and implementation of targeted prevention strategies. Accidental falls can be prevented through environmental controls that seek to provide a safe environment. Unanticipated physiological falls are, by their nature, not preventable at first occurrence.3There is increasing regulatory and reimbursement pressure on hospitals to prevent patient falls.
The 30.4% finding suggests that, at minimum, there was no reported documentation that this activity was performed.
The subsequent analyses took the lack of documentation into consideration.The second analysis focused on the percentage of falls events reported for patients who were identified as at risk for a fall.
In order to identify patients at risk for falls, risk assessments must have been completed.
Therefore, falls event reports indicating completion of falls risk assessments (N = 21,117) were used for this analysis.
Once a patient is identified as at risk for a fall, the next step in a falls program is to perform an in-depth assessment of the risk factors identified through screening and to implement targeted falls prevention strategies. This final analysis evaluated whether the implementation of prevention strategies or protocols differed when risk assessments were completed and falls risks were identified. Table 1 shows the different levels of falls prevention strategy implementation, stratified by completed falls risk assessment and falls risk identification.   Table 1. Prevention Strategy or Protocol Implementation According to  Risk Assessment and Risk for Fall as Reported to the  Pennsylvania Patient Safety Authority in 2011Risk AssessmentFalls risk assessment is a foundational element of falls prevention programs.
These risk factors have then been translated into falls risk assessment tools.25,27,28 Other risk assessment tools have been created by individual facilities as part of quality improvement efforts based on review of the literature and facility-specific information from incident reports and medical record reviews for falls. The validity of falls risk assessment tools is measured in terms of sensitivity and specificity. Within the acute care setting, five nursing falls risk assessment tools and three functional assessment tests were evaluated. The eight tools were found to have sensitivity ranging from 66% to 93% and specificity ranging from 25% to 88%. The Morse Fall Scale was developed in the 1990s and is in widespread use across the United States.

It is one of only two falls risk assessment tools that have been validated prospectively with sensitivity and specificity testing in its development and in subsequent remote cohorts. The other is the STRATIFY tool, which was developed in and is in more common use across the United Kingdom.30   Table 2.
Risk Factors Assessed by Falls Risk Assessment Tools  in Use by Hospitals Participating in the Pennsylvania Hospital Engagement  Network Falls Reduction and Prevention Collaboration. It was developed in an acute care setting with a diverse patient population and has been tested for validity in other settings on a limited basis. Initial results suggest superior predictive validity, reproducibility, and feasibility for use in acute care settings as compared with the Morse Fall Scale and the STRATIFY tool.31 The Johns Hopkins Fall Risk Assessment Tool was developed and implemented in 2003 at the Johns Hopkins Hospital. The challenge in evaluating the sensitivity and specificity of falls risk assessment methods is the fact that the identification of someone at a high risk of falling may be associated with implementation of falls prevention measures, even in the absence of a formal falls prevention program. They are intended to be used as a consistent and reliable screening tool for identifying patients at risk of falling. Screening should be followed by an in-depth multifactorial risk assessment and formulation of a plan of care detailing targeted falls prevention interventions.15,17-22,40Individual Falls Risk FactorsFalling is a complex phenomenon that results from a combination of risk factors. Meta-analyses of individual retrospective case-control studies have been completed in order to calculate the relative risk associated with each risk factor.
Because of this, it has been suggested that all falls risk assessments begin with screening for a history of falls within the previous 12-month period.45Impaired MobilityGait speed and stride length decrease markedly beginning at age 85 for women and age 90 for men.
Use of antidepressants, especially selective serotonin reuptake inhibitors, has been found to have a strong association with falls and falls with injury. But apart from medication use, symptoms of depression, ranging from questionable to clinically significant, have been found to be independent predictors of falls43,44 and have been included in at least one formal falls risk assessment tool.28Functional Assessment TestsSeveral simple screening tools have been created to assess functional mobility.
The Timed Up and Go test is one such tool that requires patients to rise from a chair, ambulate three meters, turn, return to the chair, and sit. Patients who require more than 14 seconds to complete this test are more likely to fall (sensitivity and specificity of 87%),58 though debate exists as to the cutoff that is most sensitive and specific.59A similar test called the Get Up and Go test was originally included as part of the Hendrich II Fall Risk Model but later modified to only include the observation of the patient rising from a seated position while resting their hands on their thighs. Patients who require use of their hands to push up in a single attempt are more likely to fall than those able to rise without using their hands (OR = 2.16). Those who push up and require multiple attempts have further increased risk of falling (OR = 4.67). In this case, it is suggested that hospital falls prevention teams assess the validity of the tool internally, ensuring assessment for risk factors identified in the literature as being most predictive of falls. If validity cannot be confirmed, use of evidence-based falls risk assessment tools with established validity is suggested.ConclusionFalls prevention begins with screening for falls risk using a falls risk assessment tool.
The Johns Hopkins Fall Risk Assessment Tool requires further testing to establish validity.32 The process of falls risk assessment does not end with screening for risk through use of these tools. Screening is to be followed by an in-depth assessment of each risk factor identified.15,17-22,40Risk assessment alone does not prevent falls.
Effective falls prevention interventions are multifactorial, provided by a multidisciplinary team, targeted to common falls risk factors for all patients, and tailored to each patient’s specific falls risk factors.40 Falls risk assessment is the foundational element necessary to establishing a successful falls prevention program. Hospitals must first perform a thorough evaluation of their current falls risk assessment processes before shifting focus to prevention interventions.NotesCenters for Disease Control and Prevention. Falls, a hospital-acquired condition: the Pennsylvania Patient Safety Authority’s enhanced reporting program. Clinical practice guideline for the assessment and prevention of falls in older people [online].

Transforming care at the bedside how-to guide: reducing patient injuries from falls [online]. Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case­control and cohort studies. Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings.
Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review.
Testing the sensitivity, specificity and feasibility of four falls risk assessment tools in a clinical setting. Accidental falls in hospital inpatients: evaluation of sensitivity and specificity of two risk assessment tools.
Fall risk assessment: a prospective investigation of nurses’ clinical judgment and risk assessment tools in predicting patient falls. Comparison of three instruments in predicting accidental falls in selected inpatients in a general teaching hospital.
Design-related bias in hospital fall risk screening tool predictive accuracy evaluations: systematic review and meta-analysis. Interventions for preventing falls in older people in nursing care facilities and hospitals. Falls, depression and antidepressants in later life: a large primary care appraisal [online]. Depressive symptoms in addition to visual impairment, reduced strength and poor balance predict falls in older Taiwanese people. Relationship between age-associated changes of gait and falls and life-space in elderly people. Cognition and the risk of hospitalization for serious falls in the elderly: results from the Cardiovascular Health Study. The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis.
Understanding the prevalence of inpatient falls associated with toileting in adult acute care settings. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Association between prescription medications and falls at home among young and middle-aged adults. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go test. The history of falls and the association of the Timed Up and Go test to falls and near-falls in older adults with hip osteoarthritis.
Becoming a high reliability organization: operational advice for hospital leaders [website].

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