Description
For this article provide a summary and discusses how the article is pertinent and relevant to patient falls. Must be in APA 7th ed. which includes Times New Roman font, double spacing.This is the article. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC64469…
Unformatted Attachment Preview
HHS Public Access
Author manuscript
Author Manuscript
Clin Geriatr Med. Author manuscript; available in PMC 2020 May 01.
Published in final edited form as:
Clin Geriatr Med. 2019 May ; 35(2): 273–283. doi:10.1016/j.cger.2019.01.007.
Preventing Falls in Hospitalized Patients: State of the Science
Jennifer H LeLaurin, MPH1 and Ronald I Shorr, MD, MS, FACP2
1.Health Science Specialist, Center of Innovation on Disability and Rehabilitation Research
(CINDRR), Malcom Randall VA Medical Center, 1601 SW Archer Rd., CINDRR (151B),
Gainesville, FL 32608, [email protected]
2.Director, Geriatric Research Education and Clinical Center (GRECC) and Research Professor of
Author Manuscript
Epidemiology, University of Florida, Malcom Randall VA Medical Center, 1601 SW Archer Rd.,
GRECC (182), Gainesville, FL 32608, [email protected]
Keywords
accidental falls; hospitals; prevention; aged; alarms; restraints; nursing
1.
Introduction
Author Manuscript
Although hospital falls have been decreasing over the past several years, they remain a
significant problem.1 Patient falls are the most common adverse events reported in hospitals.
2–5 Each year, roughly 700,000 to 1 million patient falls occur in U.S. hospitals resulting in
around 250,000 injuries and up to 11,000 deaths.6 About 2% of hospitalized patients fall at
least once during their stay.7,8 Approximately one in four falls result in injury, with about
10% resulting in serious injury.9
Inpatient falls result in significant physical and economic burdens to patients (increased
injury and mortality rates and decreased quality of life) as well as to medical organizations
(increased lengths of stay, medical care costs, and litigation).10,11 In 2008, Centers for
Medicare & Medicaid Services (CMS) stopped reimbursing hospitals for fall-related
injuries.12 Given significant financial pressure, hospitals are seeking a “silver bullet” to fall
prevention.13
Author Manuscript
Hospitals employ various “guidelines” for fall prevention.14–16 In general these include: 1)
identify patients who are at high risk of falling and 2) use clinical judgment to decide which
of a multitude of fall prevention strategies to utilize to reduce fall risk. Not surprisingly,
there is considerable heterogeneity among the guidelines which adds to confusion on the
“right approach” to fall prevention; this is promoting the uptake of time- and labor- intensive
*
Corresponding author (RIS).
Publisher’s Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our
customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of
the resulting proof before it is published in its final citable form. Please note that during the production process errors may be
discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Disclosures:
Dr. Shorr serves as an expert witness in hospital falls cases.
LeLaurin and Shorr
Page 2
Author Manuscript
approaches to fall prevention into “standard of care.”17 The lack of clarity of prevention
guidelines may add to the cognitive burden of patient care and potentially increases patient
risk.18–20
Although there is a growing body of research on fall prevention in community dwelling
elderly, findings from these studies are not necessarily generalizable to the hospital
environment.17 Hospital patients have a myriad of acute and chronic illnesses which limit
judgement and mobility and they must navigate a new and unfamiliar environment.
Furthermore, staffing and even unit design considerations may play into fall risk. Short
lengths of stay offer a brief window of time to conduct interventions, rendering some
strategies (e.g. exercise programs) impractical. The unique organizational culture and
leadership structures of hospitals require specific implementation strategies. Thus, it is
imperative to examine fall prevention intervention strategies specific to the hospital setting.
Author Manuscript
2.
Study designs
While this manuscript is by no means a complete review of study designs, the goal is to
familiarize the reader with the strengths and limitations of the types of research often used to
test fall prevention interventions.
2.1.
Quality Improvement Studies
Author Manuscript
Many studies on fall prevention in hospitals take the form of a quality improvement (QI)
study. The goal of QI studies is not to generate generalizable knowledge but to share the
results of a programmatic change on health outcome such as falls.21 Many QI studies
employ an uncontrolled before-after design conducted on single nursing unit (or group of
units).
Author Manuscript
There are several reasons why most QI studies should not be viewed as “evidence” of
effectiveness of a fall prevention strategy. First, these studies are in general less rigorous
than research studies. Pronovost and Wachter state QI studies “commonly lack clarity
regarding the study population, interventions and co-interventions, outcome measurement
and definitions…and what data are available may be poor in quality.”22 QI interventions
frequently contain multiple components, often not well described, which can change
thorough the study. In addition, many of these interventions are led by a “champion” and it
is difficult to know how much the intervention was dependent on the “champion.” Also,
without a control group it is difficult to distinguish the effect of intervention from underlying
secular trends in falls. Finally, the incentive to publish a negative QI study is low, so the
possibility of publication bias is high. This may explain why Hempel found the intervention
effect for fall prevention across historical control studies (often QI) was 0.77 (95%
Confidence Interval = 0.5–1.18) whereas the intervention effect for fall prevention in studies
with concurrent controls (often research) was 0.92 (95% Confidence Interval = 0.65–1.30).23
In sum, we view QI studies as analogous to “case reports.” These studies are important for
hypothesis generation they do not serve as “evidence” that a fall prevention strategy is
effective outside of the context of the quality improvement initiative.
Clin Geriatr Med. Author manuscript; available in PMC 2020 May 01.
LeLaurin and Shorr
2.2.
Page 3
Research: Randomized Studies
Author Manuscript
Controlled trials represent a much stronger study design. Randomization and outcome
assessment can occur at the patient level or at a larger level—often the nursing unit. Such
designs are referred to as cluster randomized controlled trials (cRCTs). Traditionally cRCTs
were conducted using a parallel design, meaning once randomized, study units remain
intervention and control conditions through the duration of the study. A stepped wedge is a
newer design where all units in the study transition from control to experimental conditions
at regular intervals, called “steps,” which controls for underlying secular trends.24 This type
of design is particularly advantageous when evaluating a clinical or policy strategy has been
“made” but can be rolled out at flexible dates.
Author Manuscript
There are several advantages to employing a cluster- rather than a patient-randomized study
for hospital fall prevention. First, the possibility of contamination of the intervention onto
control patients is lessened when conducted by geographically separated staff. Second,
although an intervention may be effective at the patient-level (e.g., none of the patients fell
who had the intervention), the total number of falls a unit experiences may remain the
unchanged because the intervention was not applied to the “right” patients or so much
attention was paid to the intervention patients on the unit that “different” patients fell. Thus
an intervention could be efficacious for individual patients but not effective in practice.
Author Manuscript
In a cRCT units should be followed for several months prior to randomization to establish
baseline rates and then randomized to intervention and control conditions using methods that
would assure baseline fall rates are similar between intervention and control units. Followup should be long enough to minimize the study novelty, and to allow units to establish
stable fall rates. To minimize ascertainment bias is important that the visibility of the study
remain approximately equal between intervention and control units. To address secular
trends in fall rates the effect of the intervention should be tested using the interaction of the
slope of the rate of falls in the unit type (intervention or control) and the time (before and
after the initiate the intervention).
2.3.
Research: Non-randomized studies
Although randomized controlled studies yield the highest level of evidence, some
universally applied interventions (e.g., national policy changes) cannot be studied in a
controlled manor.25 In such cases, useful evidence can be derived from large, credible
parallel or before-and-after studies where the effect size cannot easily be attributable to
confounders, and where efforts have been made to control for secular trends.26
Author Manuscript
3.
Single Fall Prevention Interventions
3.1.
Fall risk identification
The use of fall risk prediction tools is widespread, but their value in hospital fall prevention
interventions is questionable.27–29 First, it is important distinguish between fall risk
assessments and fall prediction or screening tools. Risk assessments usually consist of a
checklist of risk factors for falls, but do not provide a score or value for the patient’s fall
Clin Geriatr Med. Author manuscript; available in PMC 2020 May 01.
LeLaurin and Shorr
Page 4
Author Manuscript
risk. Predictive tools use these known risk factors to calculate a score for the patient’s risk of
falling, with established cutoffs to identify risk level.
Some tools have demonstrated acceptable sensitivity and specificity in single studies, but the
reported predictive values of these tools vary by study design, setting, and population.27,28,30
Further, a patient’s risk for falling is transitory, requiring periodic reassessment. Few tools
have been validated specifically with older hospital patients, and a recent systematic review
concluded that existing tools do not have sufficient specificity and sensitivity to be
effectively used in this population.31
Author Manuscript
The lack of evidence supporting the use of predictive tools led to 2013 National Institute for
Health and Care Excellence (NICE) guidelines which explicitly recommended against the
routine use of fall prediction tools, instead advising that all inpatients over the age of 65 be
considered at high-risk.32 The Agency for Healthcare Research and Quality (AHRQ)
cautions that it is more important to identify and address a patient’s specific fall risk factors
than to determine their risk for falling.3 Despite this, fall risk screening tools are frequently
used to identify patients for intervention,23 often, relying on “home-made” tools without
established psychometric properties.4 While these tools have the potential to tailor fall
prevention strategies to specific patient risk factors,33 they predict falls no better than
nursing judgement.34
3.2.
Alarms
Author Manuscript
Alarm systems are designed to reduce falls by alerting staff when patients attempt to leave a
bed or chair without assistance. They can also function as a reminder to patients to call for
assistance before getting up. There are several types of alarm systems in use, including
pressure mats, infrared movement detectors, cord-activated alarms, and wearable devices.35
Alarms are disruptive and may be especially disturbing to cognitively impaired patients,
contributing to confusion and agitation. They also restrict mobility and independence; in US
nursing homes, alarms are considered a type of restraint and facilities can be penalized for
indiscriminate use of the devices.36
Author Manuscript
There is now strong evidence that alarms are ineffective as a fall prevention maneuver in
hospitals.37,38 A large cRCT tested the effectiveness of bed/chair alarm systems to prevent
falls in 16 general medical, surgical and specialty units in a US community hospital.37
Although the intervention successfully increased alarm use, there was no significant effect
on falls or physical restraint use. In an RCT performed in three acute wards in a UK
hospital, Sahota et al. found that alarms did not reduce fall rates and were not cost-effective.
38 AHRQ has cautioned there is an overreliance on alarms on alarms as a fall prevention
measure,3 yet alarms remain in use by over 90% of nurse managers.39
There are a few possible explanations for the ineffectiveness of alarms as a fall prevention
strategy. Reliance on alarms assumes staff have enough time to intervene prior to a fall,
which could be only a matter of seconds. Alarms may decrease vigilance by giving staff a
false sense of security. Finally, the Joint Commission has expressed concerns about
excessive hospital noise leading to general “alarm fatigue”.40
Clin Geriatr Med. Author manuscript; available in PMC 2020 May 01.
LeLaurin and Shorr
Page 5
Author Manuscript
Although the current body of evidence does not support the effectiveness of alarms as a fall
prevention measure in hospitals, there is promising new technology that may better predict
and prevent falls.41,42 These new systems and devices have the potential to serve as effective
and sustainable fall prevention strategies.
3.3.
Sitters
Sitters, also known as companions or ‘specials’, are a potentially effective yet costly fall
prevention strategy. Sitters provide one-to-one surveillance for patients deemed at high risk
for falls and may additionally provide therapeutic care. Guidelines for the use of sitters and
their duties, qualifications, and training vary among hospitals.43,44
Author Manuscript
There is indirect evidence of sitter effectiveness, but no RCTs of sitters as a single
intervention have been performed to date. The evidence supporting effectiveness of sitters
has been limited to small observational studies conducted in a single hospital—each with its
own definition of what constitutes a sitter.45–48 In addition to the limited evidence of
effectiveness, there is the possibility that sitters may have an adverse effect on patient care;
for example, to save on costs, existing staff may be utilized as sitters, potentially placing
other patients at risk. Despite the lack of evidence, sitters are recommended in numerous fall
prevention guidelines.49
Sitters represent a considerable expense, with annual costs of over $1 million reported.45,50
These costs are rising and are typically not reimbursable by third-party payers.45,51 Due to
their expense, hospitals are increasingly interested in reducing sitter use without negatively
impacting patient safety. Several initiatives have successfully reduced sitter use without
increasing fall rates.43,52
Author Manuscript
In sum, patient sitters are costly and hospitals discourage their use. Although not studied
rigorously, whether sitters prevent falls is not well established.43 Feil found that more than 4
of 5 falls which occurred with a sitter present were unassisted,49 reinforcing the hypothesis
that sitters are not a panacea for hospital falls.
3.4.
Intentional Rounding
Author Manuscript
In an effort to increase patient satisfaction and reduce patient harm, many hospitals have
instituted intentional rounding. Rounding is a proactive approach to meeting patient needs
that involves bedside checks at regular intervals, usually every one to two hours. The quality
of evidence for rounding is weak, with most of the literature consisting of QI studies.53,54
Difficulties with adherence and sustainability of rounding initiatives are widely reported,
55–57 and introduction of the practice is often perceived as a top-down approach which
restricts staff autonomy.57 Other barriers include increased workload, competing priorities,
poor documentation, inadequate education, and lack of staff buy-in.55,56 Thus, even if
stronger evidence supporting the effectiveness of rounding is produced, the feasibility of the
strategy as a sustainable fall prevention practice is uncertain.
Clin Geriatr Med. Author manuscript; available in PMC 2020 May 01.
LeLaurin and Shorr
3.5.
Page 6
Patient Education
Author Manuscript
There is some evidence that education is an effective component of multifactorial
interventions,58 but the body of evidence on their effectiveness as a single intervention is
limited. Haines et al. performed an RCT of a multimedia education intervention combined
with one-on-one follow up from a health professional. While the intervention did not
significantly reduce fall-related outcomes overall, subgroup analysis of cognitively intact
patients who received the intervention showed a 50% reduction in fall rates.58 When the
same intervention was tested in a cluster RCT in 8 hospital rehabilitation wards, a significant
reduction in rates of falls and falls resulting in injury.59 These results may be explained by
the fact that patients in rehabilitation wards tend to be more cognitively intact than those in
acute settings. Thus, although patient education is potentially effective in reducing hospital
falls for certain patients, it is not suitable for patients with cognitive impairment—a common
risk factors for inpatient falls.60
Author Manuscript
3.6.
Environmental Modifications
Author Manuscript
The physical environment can be an important contributor to falls. Of a total of 538 hospital
falls resulting in death or permanent loss of function that were reviewed by The Joint
Commission, 209 (39%) identified the physical environment as part of the root cause.8 Small
studies have explored the impact of a variety of environmental modifications. One RCT
found fewer falls occurred on vinyl flooring compared to carpet, but the findings were
limited by a small sample size and low fall rate during the 9-month trial.61 A cRCT found no
evidence that low-low beds reduced rates of falls or injuries from falls.62 Other interventions
have included visual cues (e.g. signage, wristbands), lighting, and the use of special rooms
for high-risk patients.63–65 Some of these fall prevention efforts have resulted in patient
harm; for example, in 2005 the FDA issued a recall of enclosed beds after reports of patient
injury and death from entrapment.66
3.7.
Physical Restraints
There is considerable controversy surrounding the use of physical restraints in hospital
settings.5,67 Patients who require restraints suffer a loss of dignity and autonomy;
furthermore, restraints may also cause agitation, delirium, pressure ulcers, deconditioning,
strangulation and death.68,69 Data suggest that restraints may not protect, but actually
increase risk of falling, or sustaining an injurious fall.70–72
Author Manuscript
Unfortunately, on the part of both health professionals and patients, there is a perception that
restraints reduce the risk of falling, and they are often employed as a “last resort” to protect
patients from falling.67,73,74 This perception of physical restraint effectiveness as a strategy
to prevent falls has persisted despite the increasingly restrictive regulations and standards
from CMS and The Joint Commission limiting their use.75,76
3.8.
Non-Slip Socks
Non-slip socks are often provided to hospitalized patients under the assumption that they
will provide additional traction to prevent patient falls. In contrast to manufacturers’ claims,
research has cast doubt on the slip-resistant properties of these products.77 The small body
of research on non-slip socks has not provided evidence of their efficacy as a fall prevention
Clin Geriatr Med. Author manuscript; available in PMC 2020 May 01.
LeLaurin and Shorr
Page 7
Author Manuscript
strategy.78 Further, non-slip socks carry the risk of spreading drug-resistant infection in
hospitals.79 Given the lack of evidence of effectiveness and potential to spread infection, a
patient’s own footwear remains the safest option for fall prevention.
4.
Multifactorial Interventions
Author Manuscript
Given the multitude of factors contributing to falls, it is intuitive that multi-component
interventions would be most effective in improving fall outcomes. Although fall prevention
guidelines typically recommend the use of multicomponent interventions,3,14,16,32 there
have been relatively few controlled trials of multi-component interventions. Of these, some
have found a reduction in fall rates80,81 while others reported no intervention effect.82,83
Barker et al. recently conducted the largest cRCT of a hospital fall prevention intervention to
date in 24 wards in 6 Australian hospitals (n=46,245 admissions). Despite successful
implementation of the 6-PACK program, the intervention did not produce lower rates of falls
or fall-related injuries.83
Author Manuscript
The limited number of high-quality studies and heterogeneity among intervention sites make
it challenging to combine studies for quantitative overviews. In a 2012 Cochrane review84,
pooled analysis of four small multicomponent RCTs revealed an overall reduction in fall rate
ratio (0.69, 95% CI 0.49–0.96) but not injurious falls. However, three of the cited studies
included subacute care units and the fourth was conducted in a single geriatric orthopedic
unit. A 2012 meta-analysis of six acute care interventions found a statistically significant,
but small reduction in fall rates (OR 0.9, CI 0.83–0.99) (DiBardino).85 A 2013 updated
review2 supported the evidence for multicomponent interventions, additionally identifying
factors associated with successful. It should be noted that none of these analyses did not
include the most recent negative results of the 6-PACK trial; this information will be
included in a forthcoming Cochrane Review.
The current body of evidence on multi-factorial interventions is limited in several respects.
The heterogeneity of components, delivery characteristics, and target populations make it
difficult to identify which specific components are effective. Implementation is a key
component of any successful patient safety initiative, but there is a lack of reporting on how
interventions were implemented in published studies.23 Finally, the body of evidence also
tends to be limited to older populations with a longer length of stay.5
5.
Conclusion
Author Manuscript
Although decreasing, hospital falls are a significant patient safety problem. While there is a
growing literature on strategies to prevent these events, most are uncontrolled quality
improvement studies. Even though a number of successful quality improvement programs
have been described, most controlled studies of fall prevention have been “negative.” This is
typical for any “emerging science.” Thus, there is an urgent need for well-designed research
studies in hospital fall prevention.
Clin Geriatr Med. Author manuscript; available in PMC 2020 May 01.
LeLaurin and Shorr
Page 8
Author Manuscript
References
Author Manuscript
Author Manuscript
Author Manuscript
1. He J, Dunton N, Staggs V. Unit-level time trends in inpatient fall rates of US hospitals. Med Care
2012;50:801–807. [PubMed: 22889804]
2. Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient
safety strategy: a systematic review. Ann Intern Med 2013;158:390–396. [PubMed: 23460095]
3. Ganz DA, Huang C, Saliba D, Shier V. Preventing falls in hospitals: a toolkit for improving quality
of care (Prepared by RAND Corporation, Boston University School of Public Health, and ECRI
Institute under Contract No. HHSA290201000017I TO #1.). Rockville, MD: Agency for Healthcare
Research and Quality; 2013.
4. Hempel S, Newberry S, Wang Z, et al. Review of the Evidence on Falls Prevention in Hospitals:
Task 4 Final Report. Santa Monica, Calif.: RAND Corporation, WR-907-AHRQ2012: http://
www.rand.org/pubs/working_papers/WR907. Accessed September 21, 2014.
5. Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr
Med 2010;26:645–692. [PubMed: 20934615]
6. Fall Currie L. and Prevention Injury. In: Hughes RG, ed. Patient safety and quality: an evidencebased handbook for nurses (Prepared with support from the Robert Wood Johnson Foundation)
AHRQ Publication NO.08-0043. Rockville, MD: Agency for Healthcare Research and Quality;
2008.
7. Agostini JV, Baker DI, Bogardus ST. Chapter 26. Prevention of Falls in Hospitalized and
Institutionalized Older People. Making Health Care Safer: A Critical Analysis of Patient Safety
Practices File Inventory, Evidence Report/Technology Assessment Number 43. AHRQ Publication
No. 01-E058. Rockville, MD: Agency for Healthcare Research and Quality; 2001:281–299.
8. Morse JM. Enhancing the safety of hospitalization by reducing patient falls. Am J Infect Control
2002;30:376–380. [PubMed: 12360147]
9. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med
2002;18:141–158. [PubMed: 12180240]
10. The Joint Commission. Sentinel Event Data Root Causes by Event Type 2004–2012. http://
www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_04_4Q2012.pdf. Published 2012
Accessed October 8, 2014.
11. Gulwadi GB, Calkins MP. The impact of healthcare environmental design on patient falls.
Concord, CA: Center for Healthcare Design; 2008.
12. Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended
consequences. N Engl J Med 2009;360:2390–2393. [PubMed: 19494213]
13. Goldsack J, Cunningham J, Mascioli S. Patient falls: searching for the elusive “silver bullet”.
Nursing 2014;44:61–62.
14. (1) Prevention of falls and fall injuries in the older adult. (2) Prevention of falls and fall injuries in
the older adult 2011 supplement. National Guideline Clearinghouse. 2011 https://rnao.ca/sites/
rnaoca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf. Accessed August 6,
2018.
15. Fall prevention. In: Evidence-based geriatric nursing protocols for best practice. National
Guideline Clearinghouse. 2013 https://www.guidelinecentral.com/summaries/fall-prevention-inevidence-based-geriatric-nursing-protocols-for-best-practice/. Accessed August 6, 2018.
16. Australian Commission on Safety and Quality in Health Care. Preventing Falls and Harm From
Falls in Older People: Best Practice Guidelines for Australian Hospitals. https://
www.safetyandquality.gov.au/wp-content/uploads/2009/01/Guidelines-HOSP.pdf.
17. Haines TP, Waldron NG. Translation of falls prevention knowledge into action in hospitals: what
should be translated and how should it be done? J Safety Res 2011;42:431–442. [PubMed:
22152261]
18. Lopez KD, Gerling GJ, Cary MP, Kanak MF. Cognitive work analysis to evaluate the problem of
patient falls in an inpatient setting. J Am Med Inform Assoc 2010;17:313–321. [PubMed:
20442150]
19. Graham KC, Cvach M. Monitor alarm fatigue: standardizing use of physiological monitors and
decreasing nuisance alarms. Am J Crit Care 2010;19:28–34; [PubMed: 20045845]
Clin Geriatr Med. Author manuscript; available in PMC 2020 May 01.
LeLaurin and Shorr
Page 9
Author Manuscript
Author Manuscript
Author Manuscript
Author Manuscript
20. Lea E, Andrews S, Hill K, et al. Beyond the ‘tick and flick’: facilitating best practice falls
prevention through an action research approach. J Clin Nurs 2012;21:1896–1905. [PubMed:
22672455]
21. Fiore LD, Lavori PW. Integrating Randomized Comparative Effectiveness Research with Patient
Care. N Engl J Med 2016;374:2152–2158. [PubMed: 27248620]
22. Pronovost P, Wachter R. Proposed standards for quality improvement research and publication: one
step forward and two steps back. Qual Saf Health Care 2006;15:152–153. [PubMed: 16751460]
23. Hempel S, Newberry S, Wang Z, et al. Hospital fall prevention: a systematic review of
implementation, components, adherence, and effectiveness. J Am Geriatr Soc 2013;61:483–494.
[PubMed: 23527904]
24. Hemming K, Haines TP, Chilton PJ, Girling AJ, Lilford RJ. The stepped wedge cluster randomised
trial: rationale, design, analysis, and reporting. BMJ 2015;350:h391. [PubMed: 25662947]
25. Waters TM, Daniels MJ, Bazzoli GJ, et al. Effect of Medicare’s nonpayment for Hospital-Acquired
Conditions: lessons for future policy. JAMA Intern Med 2015;175:347–354. [PubMed: 25559166]
26. Soumerai SB, Ceccarelli R, Koppel R. False Dichotomies and Health Policy Research Designs:
Randomized Trials Are Not Always the Answer. J Gen Intern Med 2017;32:204–209. [PubMed:
27757714]
27. Aranda-Gallardo M, Morales-Asencio JM, Canca-Sanchez JC, et al. Instruments for assessing the
risk of falls in acute hospitalized patients: a systematic review and meta-analysis. BMC Health
Serv Res 2013;13:122. [PubMed: 23547708]
28. da Costa BR, Rutjes AW, Mendy A, Freund-Heritage R, Vieira ER. Can falls risk prediction tools
correctly identify fall-prone elderly rehabilitation inpatients? A systematic review and metaanalysis. PLoS One 2012;7:e41061. [PubMed: 22815914]
29. Oliver D, Daly F, Martin FC, McMurdo ME. Risk factors and risk assessment tools for falls in
hospital in-patients: a systematic review. Age Ageing 2004;33:122–130. [PubMed: 14960426]
30. Haines TP, Hill K, Walsh W, Osborne R. Design-related bias in hospital fall risk screening tool
predictive accuracy evaluations: systematic review and meta-analysis. J Gerontol A Biol Sci Med
Sci 2007;62:664–672. [PubMed: 17595425]
31. Matarese M, Ivziku D, Bartolozzi F, Piredda M, De Marinis MG. Systematic review of fall risk
screening tools for older patients in acute hospitals. J Adv Nurs 2015;71:1198–1209. [PubMed:
25287867]
32. National Institute for Health and Care Excellence. Assessment and prevention of falls in older
people. NICE clinical guideline 161. https://www.nice.org.uk/guidance/cg161/evidence/fullguideline-pdf-190033741. Published 6 2013 Accessed August 6, 2018.
33. Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized trial.
JAMA 2010;304:1912–1918. [PubMed: 21045097]
34. Oliver D Falls risk-prediction tools for hospital inpatients. Time to put them to bed? Age Ageing
2008;37:248–250. [PubMed: 18456789]
35. Wong Shee A, Phillips B, Hill K, Dodd K. Feasibility, acceptability, and effectiveness of an
electronic sensor bed/chair alarm in reducing falls in patients with cognitive impairment in a
subacute ward. J Nurs Care Qual 2014;29:253–262. [PubMed: 24487696]
36. Centers for Medicare & Medicaid Services. State Operations Manual: Appendix PP – Guidance to
Surveyors for Long Term Care Facilities (Rev. 173, 11-22-17). https://www.cms.gov/Medicare/
Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html.
Published 6 12, 2018 Accessed July 5, 2017.
37. Shorr RI, Chandler AM, Mion LC, et al. Effects of an intervention to increase bed alarm use to
prevent falls in hospitalized patients: a cluster randomized trial. Ann Intern Med 2012;157:692–
699. [PubMed: 23165660]
38. Sahota O, Drummond A, Kendrick D, et al. REFINE (REducing Falls in In-patieNt Elderly) using
bed and bedside chair pressure sensors linked to radio-pagers in acute hospital care: a randomised
controlled trial. Age Ageing 2014;43:247–253. [PubMed: 24141253]
39. Shever LL, Titler MG, Mackin ML, Kueny A. Fall prevention practices in adult medical-surgical
nursing units described by nurse managers. West J Nurs Res 2011;33:385–397. [PubMed:
20921126]
Clin Geriatr Med. Author manuscript; available in PMC 2020 May 01.
LeLaurin and Shorr
Page 10
Author Manuscript
Author Manuscript
Author Manuscript
Author Manuscript
40. The Joint Commission 2014 Hospital National Patient Safety Goals. Goal 6: Reduce the harm
associated with clinical alarm systems. 2013 http://www.jointcommission.org/assets/1/6/
HAP_NPSG_Chapter_2014.pdf. Accessed December 13, 2014.
41. Wolf KH, Hetzer K, zu Schwabedissen HM, Wiese B, Marschollek M. Development and pilot
study of a bed-exit alarm based on a body-worn accelerometer. Z Gerontol Geriatr 2013;46:727–
733. [PubMed: 24271253]
42. Balaguera HU, Wise D, Ng CY, et al. Using a Medical Intranet of Things System to Prevent Bed
Falls in an Acute Care Hospital: A Pilot Study. J Med Internet Res 2017;19:e150. [PubMed:
28473306]
43. Lang CE. Do sitters prevent falls? A review of the literature. J Gerontol Nurs 2014;40:24–33;
44. Wood VJ, Vindrola-Padros C, Swart N, et al. One to one specialling and sitters in acute care
hospitals: A scoping review. Int J Nurs Stud 2018;84:61–77. [PubMed: 29772447]
45. Spiva L, Feiner T, Jones D, Hunter D, Petefish J, VanBrackle L. An evaluation of a sitter reduction
program intervention. J Nurs Care Qual 2012;27:341–345.
