General

Guideline Title

Preventing falls and reducing injury from falls, fourth edition.

Bibliographic Source(s)

Registered Nurses Association of Ontario (RNAO). Preventing falls and reducing injury from falls, fourth edition. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2017 Sep. 128 p. [179 references]

Guideline Status

This is the current release of the guideline.

This guideline updates previous versions:

Registered Nurses’ Association of Ontario (RNAO). Prevention of falls and fall injuries in the older adult 2011 supplement. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2011 May. 32 p. [95 references]

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 guideline meets NGC’s 2013 (revised) inclusion criteria.

NEATS Assessment

Disclosure of Guideline Funding Source

Disclosure and Management of Financial Conflict of Interests

Guideline Development Group Composition: Multidisciplinary Group

Guideline Development Group Composition: Methodologist Involvement

Unknown

Guideline Development Group Composition: Patient and Public Perspectives

Use of a Systematic Review of Evidence: Search Strategy

Use of a Systematic Review of Evidence: Study Selection

Use of a Systematic Review of Evidence: Synthesis of Evidence

Evidence Foundations for and Rating Strength of Recommendations: Grading the Quality or Strength of Evidence

Evidence Foundations for and Rating Strength of Recommendations: Benefits and Harms of Recommendations

Evidence Foundations for and Rating Strength of Recommendations: Evidence Summary Supporting Recommendations

Evidence Foundations for and Rating Strength of Recommendations: Rating the Strength of Recommendations

Specific and Unambiguous Articulation of Recommendations

External Review

Updating

Recommendations

Major Recommendations

Definitions for the levels of evidence ( Ia, Ib, IIa, IIb, III, IV, V ) are provided at the end of the “Major Recommendations” field.

Practice Recommendations

Recommendation 1.1

Screen all adults to identify those at risk for falls. Conduct screening as part of admission processes, after any significant change in health status, or at least annually. Screening should include the following approaches:

Identifying a history of previous falls
Identifying gait, balance, and/or mobility difficulties
Using clinical judgment.

(Levels of Evidence = Ia & V)

Recommendation 1.2a

For adults at risk for falls, conduct a comprehensive assessment to identify factors contributing to risk and determine appropriate interventions. Use an approach and/or validated tool appropriate to the person and the health-care setting.

(Level of Evidence = III)

Recommendation 1.2b

Refer adults with recurrent falls, multiple risk factors, or complex needs to the appropriate clinician(s) or to the interprofessional team for further assessment and to identify appropriate interventions.

(Level of Evidence = V)

Recommendation 2.1

Engage adults at risk for falls and fall injuries using the following actions:

Explore their knowledge and perceptions of risk, and their level of motivation to address risk
Communicate sensitively about risk and use positive messaging
Discuss options for interventions and support self-management
Develop an individualized plan of care in collaboration with the person
Engage family (as appropriate) and promote social support for interventions
Evaluate the plan of care together with the person (and family) and revise as needed

(Levels of Evidence = Ia, III, & V)

Recommendation 2.2

Provide education to the person at risk for falls and fall injuries and their family (as appropriate) in conjunction with other falls prevention interventions. This includes providing information about risk for falls, falls prevention, and interventions. Ensure that the information is provided in a variety of formats and in the appropriate language.

(Levels of Evidence = Ia & V)

Recommendation 2.3

Communicate the person’s risk for falls and related plan of care/interventions to the next responsible health-care provider and/or the interprofessional team at all care transitions to ensure continuity of care and to prevent falls or fall injuries.

(Level of Evidence = V)

Recommendation 2.4

Implement a combination of interventions tailored to the person and the health-care setting to prevent falls or fall injuries.

(Level of Evidence = Ia)

Recommendation 2.5

Recommend exercise interventions and physical training for adults at risk for falls to improve their strength and balance. Encourage an individualized, multicomponent program/activity that corresponds to the person’s current abilities and functioning.

(Level of Evidence = Ia)

Recommendation 2.6

Collaborate with prescribers and the person at risk for falls to reduce, gradually withdraw, or discontinue medications that are associated with falling, when the person’s health condition or change in status allows. This includes the following actions:

Identify polypharmacy and medications that increase risk for falls
Conduct a medication review, or refer to an appropriate health-care provider and/or the prescriber
Monitor for side effects of medications known to contribute to risk for falls

(Levels of Evidence = Ia & V)

Recommendation 2.7

Refer adults at risk for falls or fall injuries to the appropriate health-care provider for advice about vitamin D supplementation.

(Level of Evidence = V)

Recommendation 2.8

Encourage dietary interventions and other strategies to optimize bone health in adults at risk for falls or fall injuries, particularly those at risk for fracture. Refer to the appropriate health-care provider for advice and individualized interventions.

(Level of Evidence = V)

Recommendation 2.9

Consider hip protectors as an intervention to reduce the risk of hip fracture among adults at risk for falls and hip fracture. Review the evidence, potential benefits, harms, and barriers to use with the person to support individualized decisions.

(Level of Evidence = Ia)

Recommendation 3.1

After a person falls, provide the following interventions:

Conduct a physical examination to assess for injury and to determine the severity of any fall injuries
Provide appropriate treatment and care
Monitor for injuries that may not be immediately apparent
Conduct a post-fall assessment to determine factors that contributed to the fall
Collaborate with the person and the interprofessional team to conduct further assessments and determine appropriate interventions
Refer the person to the appropriate health-care provider(s) for physical rehabilitation and/or to support psychological well-being (as needed).

(Levels of Evidence = III & V)

Education Recommendations

Recommendation 4.1

Educational institutions incorporate content on falls prevention and injury reduction into health-care education and training programs.

(Level of Evidence = V)

Recommendation 4.2

Health-care organizations provide ongoing organization-wide education to all staff in conjunction with other activities to help prevent falls and reduce injuries among persons in their care.

(Level of Evidence = Ia)

Organization and Policy Recommendations

Recommendation 5.1

To ensure a safe environment:

Implement universal falls precautions
Identify and modify equipment and other factors in the physical/structural environment that contribute to risk for falls and fall injuries.

(Level of Evidence = Ia)

Recommendation 5.2

Organizational leaders, in collaboration with teams, apply implementation science strategies to enable successful implementation and sustainability of falls prevention/injury reduction initiatives. This includes identifying barriers and establishing formalized supports and structures within the organization.

(Level of Evidence = Ia)

Recommendation 5.3

Implement rounding as a strategy to proactively meet the person’s needs and prevent falls.

(Level of Evidence = Ia)

Definitions

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic reviews of randomized controlled trials, and/or synthesis of multiple studies primarily of quantitative research.

Ib Evidence obtained from at least one randomized controlled trial.

IIa Evidence obtained from at least one well-designed controlled study without randomization.

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization.

III Synthesis of multiple studies primarily of qualitative research.

IV Evidence obtained from well-designed non-experimental observational studies, such as analytical studies or descriptive studies, and/or qualitative studies.

V Evidence obtained from expert opinion or committee reports, and/or clinical experiences of respected authorities.

Adapted from the Scottish Intercollegiate Guidelines Network (Scottish Intercollegiate Guidelines Network [SIGN], 2011) and Pati (2011).

Clinical Algorithm(s)

An algorithm titled “Flow Chart for Falls Prevention and Injury Reduction” is available in the original guideline document.

Scope

Disease/Condition(s)

Falls and fall injuries

Note : The following topics are not covered in this guideline: population-level falls prevention strategies, workplace/industry-related falls, intentional falls, sport-related falls, falls among children (<18 years old), and building environment or environmental design outside of settings specified for this guideline (e.g., design of curbs and sidewalks in communities).

Guideline Category

Prevention
Risk Assessment

Clinical Specialty

Family Practice
Geriatrics
Nursing
Physical Medicine and Rehabilitation
Preventive Medicine

Intended Users

Advanced Practice Nurses
Health Care Providers
Nurses
Patients

Guideline Objective(s)

To outline evidence-based approaches for preventing falls and reducing fall injuries for adults

Target Population

All adults (>18 years) at risk for falls and receiving care from nurses and other health-care providers across the health-care continuum, including those living in the community

Interventions and Practices Considered

Assessment and screening of fall risk and identification of factors contributing to risk
Referral to appropriate clinician(s) or interprofessional team
Patient engagement and education
Continuity of care in care transitions
Tailored interventions
Exercise interventions and physical training
Medication review and modification of medications that increase fall risk
Referral for vitamin D supplementation
Dietary interventions and other strategies to optimize bone health
Hip protectors
Post-fall physical examination, treatment, and monitoring
Falls prevention and injury reduction education and training programs
Environmental modifications
Rounding

Major Outcomes Considered

Risk for falls and fall injuries
Rates of falls and fall injuries
Hospitalization rates related to falls
Length of stay related to falls and fall injuries
Cost per adult per day/visit
Rate of transfer to long-term care

Methodology

Methods Used to Collect/Select the Evidence

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

Description of Methods Used to Collect/Select the Evidence

Guideline Review

The Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline Program Team’s Project Coordinator searched an established list of websites for guidelines and other relevant content published between July 2010 and May 2016. The resulting list was compiled based on knowledge of evidence-based-practice Web sites and recommendations from the literature. Expert panel members were also asked to suggest additional guidelines. Detailed information about the search strategy for existing guidelines, including the list of Web sites searched and inclusion criteria, is available at http://rnao.ca/.

Systematic Review

A comprehensive search strategy was developed by RNAO’s research team and a health sciences librarian, based on inclusion and exclusion criteria created with the RNAO expert panel. A search for relevant reviews published in English only between January 2011 and May–August 2016 was applied to the following databases: Cumulative Index to Nursing and Allied Health (CINAHL), MEDLINE, MEDLINE In Process, Cochrane Library (Cochrane Database of Systematic Reviews), and EMBASE; Education Resources Information Center (ERIC) was used for question four only. Panel members were asked to review personal libraries for key reviews not found through the above search strategies.

Detailed information on the search strategy for the systematic review, including the inclusion and exclusion criteria and search terms, is available in the search strategy document (see the “Availability of Companion Documents” field).

Reviews were independently assessed for relevance and eligibility based on the inclusion/exclusion criteria by two RNAO nursing research associates. Any disagreements were resolved through tie-breaking by the guideline development lead.

Hand Search

Panel members were asked to review personal libraries to identify key articles not found through the above search strategies. Articles identified by panel members were included in the search results if two nursing research associates independently determined the articles had not been identified by the literature search and met the inclusion criteria. Two (n = 2) articles were submitted, however, no hand search articles for any of the five research questions were included in the final results.

Number of Source Documents

Five guidelines and 125 studies were included. See the flow diagrams in Appendix D in the original guideline document for more information on the review process.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence