• Registered Nurses Association of Ontario (RNAO). Prevention of falls and fall injuries in the older adult. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Mar. 56 p. [77 references]

This is the current release of the guideline.

This guideline updates a previous version: Registered Nurses Association of Ontario (RNAO). Prevention of falls and fall injuries in the older adult. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2002 Jan. 57 p.

Falls and fall injuries

Prevention
Risk Assessment

Family Practice
Geriatrics
Internal Medicine
Physical Medicine and Rehabilitation
Preventive Medicine

Advanced Practice Nurses
Nurses

• To present nursing best practice guidelines for the prevention of falls and fall injuries in the older adult
• To increase all nurses' confidence, knowledge, skills, and abilities in the identification of adults within health care facilities at risk of falling and to define interventions for prevention of falling

Older adults in acute care and long-term care settings at risk of falls and fall injuries

These guidelines are not intended for use in older adults living in community settings.

Risk Assessment

1. Assessment of risk for falling
2. Identification of risk factors (intrinsic and extrinsic) associated with potential falls and fall injuries

Prevention

1. Tai Chi
2. Strength training
3. Multi-factorial fall prevention interventions
4. Periodic medication review
5. Hip protectors
6. Vitamin D supplementation (and other dietary and lifestyle interventions)
7. Patient education
8. Environmental modifications

• Risk for falls and fall injuries among older adults
• Reliability of risk assessment instruments
• Effectiveness of fall-prevention interventions at reducing falls and fall injuries
• Rates of falls and fall injuries among older adults
• Morbidity, mortality, and hospitalization rates related to falls

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

Original Guideline: January, 2002

Three published guidelines related to prevention of falls and fall injuries in the older adult were identified through a systematic literature search. These guidelines were reviewed according to a set of inclusion criteria, which resulted in the elimination of one guideline. The inclusion criteria were:

• Guideline was in English
• Guideline was dated no earlier than 1996.
• Guideline was strictly about the topic area.
• Guideline was evidence based.
• Guideline was available and accessible for retrieval.

Two guidelines met these criteria and were evaluated using the Appraisal Instrument for Canadian Clinical Practice Guidelines, an adapted tool from Cluzeau, Littlejohns, Grimshaw, Feder, & Moran (1997). From this appraisal process, two documents were identified as relevant guidelines.

A critique of systematic reviews and relevant literature was also conducted and through a process of consensus, the recommendations were developed.

Update: March, 2005

A database search for existing evidence related to prevention of falls and fall injuries in the older adult was conducted by a university health sciences library. An initial search of the Medline, Embase, and CINAHL databases for guidelines and studies published from 2001 to 2004 was conducted in August 2004. A subsequent search of PubMed was conducted in October 2004. The P. I. C. O. (Population, Intervention, Control, Outcome) method was used to generate the parameters of the clinical questions and to guide the search.

One individual searched an established list of Web sites for content related to the topic area in July 2004. This list of sites, reviewed and updated in May 2004, was compiled based on existing knowledge of evidence-based practice Web sites, known guideline developers, and recommendations from the literature. Presence or absence of guidelines was noted for each site searched as well as date searched. The Web sites at times did not house a guideline but directed to another Web site or source for guideline retrieval. Guidelines were either downloaded if full versions were available or were ordered by phone/email.

A Web site search for existing practice guidelines on prevention of falls and fall injuries in the older adult was conducted via the search engine "Google," using key search terms. One individual conducted this search, noting the results of the search, the Web sites reviewed, date, and a summary of the results. The search results were further reviewed by a second individual who identified guidelines and literature not previously retrieved.

Additionally, panel members were asked to review personal archives to identify guidelines not previously found through the above search strategy. Results of this strategy revealed no additional clinical practice guidelines.

The search strategy described above resulted in the retrieval of numerous abstracts on the topic which were then screened by a research assistant according to inclusion/exclusion criteria related to the target population, intervention, control, and outcome. This resulted in a set of abstracts that were identified for article retrieval and quality appraisal. In addition, two clinical practice guidelines were identified for review by the panel.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

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

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

Original Guideline: January, 2002

A panel of nurses with expertise in falls prevention, education, and research, representing institutional, long-term care, and academic settings was convened under the auspices of the Registered Nurses Association of Ontario (RNAO). The first task of the group was to review existing clinical practice guidelines in order to build on current understanding of falls prevention in the older adult, and to reach consensus on the scope of the guideline. Through a process of consensus, the recommendations in this guideline were developed.

Update: March, 2005

In September of 2004, a panel of nurses and other healthcare professionals, from a range of practice settings and academic sectors, with expertise and interest in falls and fall injuries in the older population, was convened by the RNAO. This group was invited to participate as a review panel to revise the Prevention of Falls and Fall Injuries in the Older Adult guideline that was originally published in January 2002. This panel had representation from members of the original development panel, as well as other recommended specialists.

The panel members were given the mandate to review the guideline, focusing on the currency of the recommendations and evidence, keeping to the original scope of the document.

In the final step of the revision process, the revision panel reconvened to discuss and review the literature. The previous recommendations were revised or deleted, and new additional recommendations were developed in accordance with the new evidence. Figure 1 in the original guideline document summarizes the entire process.

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.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Clinical Validation-Pilot Testing
External Peer Review

Original Guideline: January, 2002

An initial draft of the Registered Nurses Association of Ontario (RNAO) Prevention of Falls and Fall Injuries in the Older Adult nursing best practice guideline was reviewed by stakeholders and responses were incorporated. The guideline was published following a seven-month pilot implementation phase in a selected practice setting in Ontario. Practice settings for RNAO nursing best practice guidelines are identified through a "request for proposal" process.

Update: March, 2005

Not stated

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

1. The client's perspective, individual desires, and needs are central to the application of the guideline.
2. 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.
3. 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.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Overall Benefits

• Increased nurses' confidence, knowledge, skills, and abilities in the identification of adults at risk of falling and the ability to define interventions to prevent falls
• Decreased falls in older adults
• Decreased morbidity, mortality, and hospitalization rates related to falls

Nurses, other health care professionals, and administrators who are leading and facilitating practice changes will find this document valuable for the development of policies, procedures, protocols, educational programs, assessment and documentation tools, etc.

Not stated

• These best practice guidelines are related only to nursing practice and not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor Registered Nurses Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products.
• This nursing best practice guideline is a comprehensive document providing resources necessary for the support of evidence-based nursing practice. The document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. Guidelines should not be applied in a "cookbook" fashion but used as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care.
• This nursing best practice guideline contains recommendations for Registered Nurses (RNs) and Registered Practical Nurses (RPNs). It is acknowledged that effective client care depends on a coordinated multidisciplinary approach incorporating ongoing communication between health professionals and patients/clients, ever mindful of the personal preferences and unique needs of each individual client. The recommendations made are not binding for nurses and should accommodate client/family wishes and local circumstances. It is the intention of this guideline to identify best nursing practices in the area of falls and prevention of falls. It is acknowledged that the individual competency of nurses varies between nurses and across categories of nursing professionals (RPNs and RNs), and is based on the knowledge, skills, attitudes and judgment enhanced over time by experience and education.

Best practice guidelines can only be successfully implemented if there are: adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. In this light, Registered Nurses Association of Ontario (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 any clinical practice guideline in a health care organization.

The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps:

1. Identifying a well-developed, evidence-based clinical practice guideline
2. Identification, assessment and engagement of stakeholders
3. Assessment of environmental readiness for guideline implementation
4. Identifying and planning evidence-based implementation strategies
5. Planning and implementing evaluation
6. Identifying and securing required resources for implementation

Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process.

Evaluation and Monitoring

It is suggested that organizations implementing the recommendations in this nursing best practice guideline consider how the implementation and its impact will be monitored and evaluated. A table found in the original guideline document, based on the framework outlined in the RNAO Toolkit, illustrates some indicators for monitoring and evaluation.

Implementation Strategies

The Registered Nurses Association of Ontario and the guideline development panel have compiled a list of implementation strategies to assist healthcare organizations or healthcare disciplines who are interested in implementing this guideline. See the original guideline document for a summary of strategies.

Staying Healthy

Effectiveness
Patient-centeredness

• Registered Nurses Association of Ontario (RNAO). Prevention of falls and fall injuries in the older adult. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2005 Mar. 56 p. [77 references]

The Registered Nurses Association of Ontario (RNAO) panel selected the following guidelines to adapt and modify for the current guideline:

Original Guideline: January, 2002

• American Medical Directors Association (AMDA). (1998). Falls and fall risk: Clinical practice guidelines. Author.
• Ledford, L. (1996). Prevention of falls research-based protocol. In M. G. Titler (Series Ed.), Series on Evidence-Based Practice for Older Adults, Iowa City, IA: The University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core.

Update: March, 2005

• Queensland Health. (2003). Falls Prevention: Best Practice Guideline.
• Salsbury Lyon, S. (2004). Fall prevention for older adults evidence-based protocol. Fall prevention for older adults evidence-based protocol. In M. G. Titler (Series Ed.), Series on Evidence-Based Practice for Older Adults, Iowa City, IA: The University of Iowa College of Nursing Gerontological Nursing Interventions Research Centre, Research Translation and Dissemination Core.

2002 Jan (revised 2005 Mar)

Registered Nurses' Association of Ontario - Professional Association

Funding was provided by the Ontario Ministry of Health and Long Term Care.

Not stated

Revision Panel Members

Kathleen Heslin, RN, BScN, MScN
Team Leader
Chief of Nursing & Professional Practice
West Park Healthcare Centre
Assistant Lecturer, University of Toronto
Toronto, Ontario

Nancy Berdusco, RPN
Stoney Creek, Ontario

Laurie Bernick, RN, MScN, ACNP, GNC(C)
Assistant Lecturer, York University
Toronto, Ontario

Lucy Cabico, RN, MS, ACNP, FNP, GNC(C)
Clinical Nurse Specialist
Baycrest Centre for Geriatric Care
Toronto, Ontario

Diane Carter, RN
Clinical Practice Facilitator
Cambridge Memorial Hospital
Cambridge, Ontario

Sharon Mooney, RN, BA, MA, BSN
Nursing Professional Development Educator
McGill University Health Centre
Montreal General Hospital
Montreal, Quebec

Mireille Norris, BScPT, MD, FRCP(C)
CSPQ, ABIM, MHSc
Internist/Geriatrician
Sunnybrook and Women's Health Sciences Centre
Toronto, Ontario

Tim Pauley, PhD(C)
Research Coordinator
West Park Healthcare Centre
Toronto, Ontario

Jane M. Schouten, RN, BScN, MBA
RNAO Program Staff – Facilitator
Best Practice Guidelines Program
Registered Nurses Association of Ontario
Toronto, Ontario

Sandra Tully, RN, BScN, MA(Ed), ACNP, GNC(C)
Acute Care Nurse Practitioner
Geriatrics and Wound Care
University Health Network
Toronto Western Hospital
Toronto, Ontario

Declarations of interest and confidentiality were requested from all members of the guideline revision panel. Further details are available from the Registered Nurses Association of Ontario.

This is the current release of the guideline.

This guideline updates a previous version: Registered Nurses Association of Ontario (RNAO). Prevention of falls and fall injuries in the older adult. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2002 Jan. 57 p.

None available

This NGC summary was completed by ECRI on December 17, 2003. The information was verified by the guideline developer on January 16, 2004. This NGC summary was updated by ECRI on June 9, 2005. The updated information was verified by the guideline developer on June 21, 2005.

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses Association of Ontario (2005). Prevention of fall injuries in the older adult (revised). Toronto, Canada: Registered Nurses Association of Ontario.