The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) and grades of recommendation (A-E, I) are defined at the end of the "Major Recommendations" field.
General Principles
- The client's perspective, individual desires, and needs are central to the application of the guideline.
- The over-arching principle that guides the intervention choices is the principle of maintaining the highest quality of life possible while striving for a safe environment and practices. Risk taking, autonomy, and self-determination are supported, respected, and considered in the plan of interventions.
- Individuals, their significant other(s), and the care team engage in assessment and interventions through a collaborative process.
Practice Recommendations
Assessment
Recommendation 1.0
Assess fall risk on admission.
(Level of Evidence = Ib; Grade of Recommendation = B)
Recommendation 1.1
Assess fall risk after a fall.
(Level of Evidence = Ib; Grade of Recommendation = B)
Intervention
Tai Chi
Recommendation 2.0
Tai Chi to prevent falls in the elderly is recommended for those clients whose length of stay (LOS) is greater than four months and for those clients with no history of a fall fracture. There is insufficient evidence to recommend Tai Chi to prevent falls for clients with length of stay less than four months.
(Level of Evidence = Ib; Grade of Recommendation = B)
Exercise
Recommendation 2.1
Nurses can use strength training as a component of multi-factorial fall interventions; however, there is insufficient evidence to recommend it as a stand-alone intervention.
(Level of Evidence = Ib; Grade of Recommendation = I)
Multi-factorial
Recommendation 2.2
Nurses, as part of the multidisciplinary team, implement multi-factorial fall prevention interventions to prevent future falls.
(Level of Evidence = Ia; Grade of Recommendation = B)
Medications
Recommendation 2.3
Nurses, in consultation with the health care team, conduct periodic medication reviews to prevent falls among the elderly in health care settings. Clients taking benzodiazepines, tricyclic antidepressants, selective serotonin-reuptake inhibitors, trazodone, or more than five medications should be identified as high risk. There is fair evidence that medication review be conducted periodically throughout the institutional stay.
(Level of Evidence = IIb; Grade of Recommendation = B)
Hip Protectors
Recommendation 2.4
Nurses could consider the use of hip protectors to reduce hip fractures among those clients considered at high risk of fractures associated with falls; however, there is no evidence to support universal use of hip protectors among the elderly in health care settings.
(Level of Evidence = Ib; Grade of Recommendation = B)
Vitamin D
Recommendation 2.5
Nurses provide clients with information on the benefits of vitamin D supplementation in relation to reducing fall risk. In addition, information on dietary, life style, and treatment choice for the prevention of osteoporosis is relevant in relation to reducing the risk of fracture.
(Level of Evidence = IV)
Client Education
Recommendation 2.6
All clients who have been assessed as high risk for falling receive education regarding their risk of falling.
(Level of Evidence = IV)
Environment
Recommendation 3.0
Nurses include environmental modifications as a component of fall prevention strategies.
(Level of Evidence = Ib)
Education Recommendations
Nursing Education
Recommendation 4.0
Education on the prevention of falls and fall injuries should be included in nursing curricula and on-going education with specific attention to:
- Promoting safe mobility
- Risk assessment
- Multidisciplinary strategies
- Risk management including post-fall follow-up
- Alternatives to restraints and/or other restricted devices
(Level of Evidence = IV)
Organization & Policy Recommendations
Least Restraint
Recommendation 5.0
Nurses should not use side rails for the prevention of falls or recurrent falls for clients receiving care in health care facilities; however, other client factors may influence decision-making around the use of side rails.
(Level of Evidence = III; Grade of Recommendation = I)
Recommendation 6.0
Organizations establish a corporate policy for least restraint that includes components of physical and chemical restraints.
(Level of Evidence = IV)
Organizational Support
Recommendation 7.0
Organizations create an environment that supports interventions for fall prevention that includes:
- Fall prevention programs
- Staff education
- Clinical consultation for risk assessment and intervention
- Involvement of multidisciplinary teams in case management
- Availability of supplies and equipment such as transfer devices, high low beds, and bed exit alarms
(Level of Evidence = IV)
Medication Review
Recommendation 8.0
Implement processes to effectively manage polypharmacy and psychotropic medications including regular medication reviews and exploration of alternatives to psychotropic medication for sedation.
(Level of Evidence = IV)
Registered Nurses Association of Ontario (RNAO) Toolkit
Recommendation 9.0
Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:
- An assessment of organizational readiness and barriers to education
- Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process
- Dedication of a qualified individual to provide the support needed for the education and implementation process
- Ongoing opportunities for discussion and education to reinforce the importance of best practices
- Opportunities for reflection on personal and organizational experience in implementing guidelines
In this regard, RNAO (through a panel of nurses, researchers, and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of the RNAO guideline Prevention of Falls and Fall Injuries in the Older Adult.
(Level of Evidence = IV)
Definitions:
Levels of Evidence
Level Ia: Evidence obtained from meta-analysis or systematic review of randomized controlled trials
Level Ib: Evidence obtained from at least one randomized controlled trial
Level IIa: Evidence obtained from at least one well-designed controlled study without randomization
Level IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
Level III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
Level IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities
Grades of Recommendations
A: There is good evidence to recommend the clinical preventive action.
B: There is fair evidence to recommend the clinical preventive action.
C: The existing evidence is conflicting and does not allow making a recommendation for or against use of the clinical preventive action; however other factors may influence decision-making.
D: There is fair evidence to recommend against the clinical preventive action.
E: There is good evidence to recommend against the clinical preventive action.
I: There is insufficient evidence (in quantity and/or quality) to make a recommendation, however other factors may influence decision-making.
