Nursing Standard of Practice Protocol: Fall Prevention
Deanna Gray-Micelli, PhD, GNP-BC, FAANP, Patricia A. Quigley, PhD, MPH, APRN, CRRN, FAAN, FAANP
Evidence-based Content - Updated August 2012
Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. The text is available here.
The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:
Background and Statement of the Problem
Parameters of Assessment Tools
Nursing Care Strategies
Follow-up Monitoring of Condition
Relevant Practice Guidelines
A. Prevent falls and serious injury outcomes in hospitalized older adults. B. Recognize multifactorial risks and causes of falls in older adults. C. Institute recommendations for falls prevention and management consistent with clinical practice guidelines and standards of care.
Falls among older adults are not a normal consequence of aging; rather, they are considered a geriatric syndrome most often due to discrete multifactorial and interacting, predisposing (intrinsic and extrinsic risks), and precipitating (dizziness, syncope) causes. 1,2
Fall epidemiology varies according to clinical setting. In acute care, fall incidence ranges from 2.3 to 7 falls per 1,000 patient days depending on the unit. Nearly one-third of older adults living in the community fall each year in their home. The highest fall incidence occurs in the institutional long-term-care setting (i.e., nursing home), where 50% to 75% of the 1.63 million nursing-home residents experience a fall yearly. Falls rank as the eighth leading cause of unintentional injury for older Americans and were responsible for more than 16,000 deaths in 2006. (Ref 3)
Background and Statement of the Problem
1. Fall: A fall is an unexpected event in which the participant comes to rest on the ground, floor, or lower level. (Ref 4)
B. Fall Etiology
1. Fall risk factors include intrinsic risks of cognitive, vision, gait or balance impairment, high-risk/contraindicated medications, and/or the extrinsic risks of assistive devices, inappropriate footwear, restraint, use of nonsturdy furniture or equipment, poor lighting, uneven or slippery surfaces. (Ref 5)
2. Fall causes include, among others, orthostatic hypotension, arrhythmia, infection, generalized or focal muscular weakness, syncope, seizure, hypoglycemia, neuropathy, and medication.
Parameters of Assessment Tools
A. Assess and document all older adult patients for intrinsic risk factors to fall:
1. Advancing age, especially if older than 75
2. History of a recent fall
3. Specific co-morbidities: dementia, hip fracture, Type II diabetes, Parkinson's disease, arthritis, and depression
4. Functional disability: use of assistive device
5. Alteration in level of consciousness or cognitive impairment
6. Gait, balance, or visual impairment
7. Use of high-risk medications (Ref 5)
8. Urge urinary incontinence (Ref 6)
9. Physical restraint use (Ref 7)
10. Bare feet or inappropriate footwear
11. Identify risks for significant injury due to current use of anticoagulants such as Coumadin, Plavix, or aspirin and/or those with osteoporosis or risks for osteoporosis (Ref 8)
B. Assess and document patient-care environment routinely for extrinsic risk factors to fall and institute corrective action:
1. Floor surfaces for spills, wet areas, unevenness
2. Proper level of illumination and functioning of lights (night light works)
3. Table tops, furniture, beds are sturdy and are in good repair
4. Grabrails and grab bars are in place in the bathroom
5. Use of adaptive aides work properly and are in good repair
6. Bedrails do not collapse when used for transitioning or support
7. Patient gowns/clothing do not cause tripping
8. IV poles are sturdy if used during ambulation and tubing does not cause tripping.
C. Perform a PFA following a patient fall to identify possible fall causes (if possible, begin the identification of possible causes within 24 hours of a fall) as determined during the immediate, interim, and longitudinal post-fall intervals. Because of known incidences of delayed complication of falls, including fractures, observe all patients for about 48 hours after an observed or suspected fall. (Ref 9; 10; 11)10,11
1. Perform a physical assessment of the patient at the time of the fall, including vital signs (which may include orthostatic blood pressure readings), neurological assessment, and evaluation for head, neck, spine, and/or extremity injuries.
2. Once the assessment rules out any significant injury:
a. obtain a history of the fall by the patient or witness description and document
b. note the circumstances of the fall: location, activity, time of day, and any significant symptoms
c. review of underlying illness and problems
d. review medications
e. assess functional, sensory, and psychological status
f. evaluate environmental conditions
g. review risk factors for falling (Ref 8; 9; 10; 12)9,10
D. In the acute-care setting, an integrated multidisciplinary team (consisting of the physician, nurse, health care provider, risk manager, physical therapist, and other designated staff) plans care for the older adult, at risk for falls or who has fallen, hinged on findings from an individualized assessment. (Ref 9; 13)
E. The process approach to an individualized PFA includes use of standardized measurement tools of patient risk in combination with a fall-focused history and physical examination, functional assessment, and review of medications. (Ref 8; 9; 10)9,10 When plans of care are targeted to likely causes, individualized interventions are likely to be identified. If falling continues despite attempts at individualized interventions, the standard of care warrants a reexamination of the older adult and their falls.
Nursing Care Strategies
A. General safety precaution and fall prevention measures that apply to all patients, especially older adults:
1. Assess the patient care environment routinely for extrinsic risk factors and institute appropriate corrective action.
a. Use standardized environmental checklists to screen; document findings.
b. Communicate findings to risk managers, housekeeping, maintenance department, all staff and hospital administration, if needed.
c. Re-evaluate environment for safety. (Ref 9)
2. On admission, assess/screen older adult patient for multifactorial risk factors to fall, following a change in condition, on transfer to a new unit, and following a fall. (Ref 9)
a. Use standardized or empirically tested fall-risk tools in conjunction with other assessment tools to evaluate risk for falling.(Ref 10; 14)
b. Document findings in nursing notes, interdisciplinary progress notes, and the problem list.
c. Communicate and discuss findings with interdisciplinary team members.
d. In the interdisciplinary discussion, include review and reduction or elimination of high-risk medications associated with falling.
e. As part of falls protocol in the facility, flag the chart or use graphic or color display of the patient's risk potential to fall.
f. Communicate to the patient and the family caregiver identified risk to fall and specific interventions chosen to minimize the patient’s risk.
g. Include patient and family members in the interdisciplinary plan of care and discussion about fall-prevention measures.
h. Promote early mobility and incorporate measures to increase mobility, such as daily walking, if medically stable and not otherwise contraindicated.
i. Upon transfer to another unit, communicate the risk assessment and interventions chosen and their effectiveness in fall prevention.
j. Upon discharge, review with the older patient and or family caregiver the fall risk factors and measures to prevent falls in the home. Provide patient literature/brochures if available. If not readily available, refer to the Internet for appropriate Web sites and resources.
k. Explore with the older patient and/or family caregiver avenues to maintain mobility and functional status; consider referral to home-based exercise or group exercises at community senior centers. If discharge is planned to a subacute or rehabilitation unit, label the older adult's mobility status, functional status, and other forms of activity in the home to increase gait or balance on the transfer form.
3. Institute general safety precautions according to facility protocol, which may include:
a. Referral to a falls prevention program
b. Use of a low-rise bed that measures 14 inches from floor
c. Use of floor mats if patient is at risk for serious injury, such as osteoporosis
d. Easy access to call light
e. Minimization and/or avoidance of physical restraints
f. Use of personal or pressure sensors alarms
g. Increased observation and surveillance
h. Use of rubber-soled healed shoes or nonskid slippers
i. Regular toileting at set intervals and/or continence program; provide easy access to urinals and bedpans
j. Observation during walking rounds or safety rounds
k. Use of corrective glasses for walking
l. Reduction of clutter in traffic areas
m. Early mobility program (Ref 9)
4. Provide staff with clear, written procedures describing what to do when a patient fall occurs.
B. Identify specific patients requiring additional safety precautions and/or evaluation by a specialist, or:
1. those with impaired judgment or thinking due to acute or chronic illness (delirium, mental illness)
2. those with osteoporosis, at risk for fracture
3. those with current hip fracture
4. those with current head or brain injury (standard of care)
C. Review and discuss with interdisciplinary team findings from the individualized assessment and develop a multidisciplinary plan of care to prevent falls (Ref 5)
1. Communicate to the physician or advance practice nurse important PFA findings (Ref 9)
2. Monitor the effectiveness of the falls prevention interventions instituted.
3. Following a patient's fall, observe for serious injury due to a fall and follow facility protocols for management (standard of care).
4. Following a patient's fall, monitor vital signs, level of consciousness, neurological checks, and functional status per facility protocol. If significant changes in patient's condition occurs, consider further diagnostic tests such as plain film x-rays, CT scan of the head/spine/extremity, neurological consultation, and /or transfer to a specialty unit for further evaluation (standard of care).
1. Safety will be maintained.
2. Falls will be avoided.
3. Will not develop serious injury outcomes from a fall if it occurs.
4. Will know their risks for falling.
5. Will be prepared on discharge to prevent falls in their homes.
6. Prehospitalization level of mobility will continue.
7. Who develops fall-related complications such as injury or change in cognitive function will be promptly assessed and treated to prevent adverse outcomes.
B. Nursing Staff:
1. Will be able to accurately detect, refer, and manage older adults at risk for falling or who have experienced a fall.
2. Will integrate into their practice comprehensive assessment and management approaches for falls prevention in the institution.
3. Will gain appreciation for older adults’ unique experience of falling and how it influences their daily living, functional, physical, and emotional status.
4. Educate older adult patients anticipating discharge about falls prevention strategies.
Follow-up Monitoring of Condition
A. Monitor fall incidence and incidences of patient injury due to a fall, comparing rates on the same unit over time.
B. Compare falls per patient month against national benchmarks available in the National Database of Nursing Quality Indicators.
C. Incorporate continuous quality improvement criteria into falls prevention program.
D. Identify falls team members and roles of clinical and nonclinical staff. (Ref 9)
E. Educate patient and family caregivers about falls prevention strategies so they are prepared for discharge.
Relevant Practice Guidelines
A. Panel on Prevention of Falls in Older Persons. (2011). Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for prevention of falls in older persons. Journal of the American Geriatrics Society, 59, 148-157. doi:10.1111/j.1532-5415.2010.03234.x. Evidence Level I.
B. American Medical Directors Association (2003). Falls and fall risk. Columbia, MD: American Medical Directors Association. Evidence Level VI.
C. University of Iowa Gerontological Nursing Interventions Research Center (UIGN). (2004). Falls prevention for older adults. Iowa City, IA: University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core. Evidence Level VI.
D. ECRI Institute. (2006). Falls Prevention Strategies in Healthcare Settings. Plymouth Meeting, PA. Evidence Level VI. 8
For Definition of Levels of Quantitative Evidence Click Here
From Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition. © Springer Publishing Company, LLC.
1. Rubenstein, L. Z., & Josephson, K. R. (2006). Falls and their prevention in the elderly: What does the evidence show? Medical Clinics of North American, 90 (5), 807–824. Evidence Level I.
2. Gray-Miceli, D., Johnson, J. C., & Strumpf, N. E. (2005). A step-wise approach to a comprehensive post-fall assessment. Annals of Long-Term Care: Clinical Care and Aging, 13(12), 16–24. Evidence Level VI.
3. Oliver, D., Healy, F., & Haines, T.P. (2010). Preventing falls and fall-related injuries in hospitals. Clinic Geriatric Medicine, 26(4), 645-692.
4. Prevention of Falls Network Europe (ProFaNE) (2006). Retrieved April 19, 2007, from http://www.profane.eu.org. Evidence Level VI.
5. Chang, J. T., Morton, S. C., Rubenstein, L. Z., Mojica, W. A., Maglione, M., Suttorp, M. J., et al. (2004). Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomized controlled trials.British Medical Journal, 328(7441), 680. Evidence Level I.
6. Brown, J. S., Vittinghoff, E., & Wyman, J. F. (2000). The study of osteoporotic fractures research group. Urinary incontinence: Does it increase risk for falls and fractures? Journal of the American Geriatric Society, 48, 721–725. Evidence Level III.
7. Capezuti, E., Maislin, G., Strumpf, N., & Evans, L. K. (2002). Side-rail use and bed-related fall outcomes among nursing-home residents. Journal of the American Geriatrics Society, 50(1), 90–96. Evidence Level III.
8. Resnick, B. (2003). Preventing falls in acute care. In M. Mezey, T. Fulmer, I. Abraham (Eds.) & D. Zwicker (Managing Ed.), Geriatric Nursing Protocols for Best Practice (2nd Ed., pp. 141–164). New York: Springer Publishing Company, Inc. Evidence Level VI.
9. ECRI Institute (2006). Falls Prevention Strategies in Healthcare Settings Guide. Plymouth Meeting, PA: ECRI Publishers. Evidence Level VI.
10. Panel on Prevention of Falls in Older Persons. (2011). Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for prevention of falls in older persons. Journal of the American Geriatrics Society, 59, 148-157. doi:10.1111/j.1532-5415.2010.03234.x. Evidence Level I.
11. Gray-Miceli, D., Strumpf, N. E., Johnson, J. C., Dragascu, M., & Ratcliffe, S. (2006). Psychometric properties of the post-fall index. Clinical Nursing Research, 15(3), 157–176. Evidence Level III.
12. American Medical Directors Association (AMDA). (1998). Falls and fall risk. Columbia, MD: AMDA. Evidence Level VI.
13. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2006). Root causes of patient falls. Joint Commission on Accreditation of Healthcare Organizations. Retrieved on March 31, 2007, fromhttp://www.jointcommission.org/NR/rdonlyres/FA5A080F-C259-47CC-AAC8-BAC3F5C. Evidence Level V.
14. Tinetti, M.E., Williams, T.S., & Mayewski, R. (1986). Fall risk index for elderly patients based on number of chronic disabilities. American Journal of Medicine, 80(3), 429-434. Evidence Level II.
Last updated - August 2012