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STOP-FALLING: A Simple Checklist Tool for Fall Prevention in a Nursing Facility
Pragmatic Innovations in Post-Acute and Long-Term Care Medicine Feasible new, practical products or approaches intended to improve outcomes or processes in post-acute or long-term care
STOP-FALLING: A Simple Checklist Tool for Fall Prevention in a Nursing Facility Supakanya Wongrakpanich MD a, b, *, Katalin Danji MD b, Lewis Lipsitz MD a, b, Sarah Berry MD, MPH a, b a b
Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA Hebrew Senior Life, Institute for Aging Research, Boston, MA
a b s t r a c t Falls are highly prevalent and lead to major health morbidity and mortality in older adults. We developed a “STOP-FALLING” checklist as a multifactorial intervention tool kit for a single long-term care facility. The objective of this study was to determine feasibility and adherence of the checklist, and to determine whether STOP-FALLING reduces total number of falls, frequent fallers, and fall-related injuries. This is a quality improvement demonstration project comparing the effect on falls 3 months before and 3 months after introducing a STOP-FALLING checklist. All older adult patients who lived in the long-term care unit of a single facility were included. PTs, geriatricians, and registered nurses participated in the STOP-FALLING initiative. Staff were surveyed on satisfaction by 8-item questionnaires, which were obtained 3 months after checklist implementation. Data on the rate of falls, the number of recurrent fallers, the number of minor injuries, and the number of major injuries 3 months prior and 3 months after the intervention were collected by facility fall log. A total of 32 patients were screened using the STOP-FALLING checklist. Staff survey revealed a high satisfaction rate with 15 minutes to complete the checklist. Data at 3 months after initiation of the checklist revealed a reduction in the fall rates (2.80-1.65 falls per person-year), number of frequent fallers (5.00-2.30/mo after), number of falls without injuries (3.00-1.67/mo), number of minor injuries (4.00-2.67/mo), and number of major injuries (0.33-0/ mo). We observed excellent staff satisfaction using the STOP-FALLING checklist. Our pilot project suggests that the intervention may decrease fall rates and other fall-related injuries. Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Keywords: Falls, multidisciplinary, checklist, prevention, barriers, long-term care
Problem/Significance Falls are a major contributor to morbidity and mortality among nursing home (NH) residents. Implementation of fall prevention in the NH has been challenging. Reasons include lack of knowledge, difficulty in accessing information, time pressure, lack of involvement of patients and families, and inadequate staff communication.1e6 A realworld initiative that provides education, requires input from multidisciplinary team members, and takes minimal time helps to overcome some of the above barriers. Innovation We developed a “STOP-FALLING” checklist (Figure 1) and adapted interventions to make our checklist specific to the NH setting. For instance, we included family caregiver education because of significant numbers of participants with dementia. We made this checklist easy to implement by using a color-coding system. For example, the physical therapist (PT) was responsible for the “blue” section, which included PT evaluation and orthostatic hypotension measurement.
The authors declare no conflicts of interest. * Address correspondence to Supakanya Wongrakpanich, MD, Department of Gerontology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA. E-mail address: [email protected] (S. Wongrakpanich). https://doi.org/10.1016/j.jamda.2018.10.002 1525-8610/Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
The registered nurse (RN) and geriatrician were responsible for the “purple” and “red” sections, respectively. All staff participated in at least 1 of 3 training sessions for checklist implementation. Interventions were customized according to each patient’s clinical circumstance. Our checklist includes the following: Vitamin D Supplementation with oral vitamin D3 1000 IU per day Patient and family caregiver education (Teaching) by a physician or RN using Stopping Elderly Accidents, Deaths, and Injuries (STEADI) patient and family caregiver brochures.7,8 Also, all family caregivers received a STEADI brochure at their mailing address. Orthostatic vital signs measurement9,10 Physical therapist evaluation and ongoing treatment10,11 Foot and gait evaluation10,11 Hearing Aids and hearing evaluation12 Medication List and polypharmacy review13 (A medication review was conducted by physicians according to the 2015 AGS Beers Criteria. Medication reduction or withdrawal was attempted, whenever possible.) Low bed14 IN-room safety evaluation11 (All potential environmental hazards, including rugs, slippery floors, electrical cords, and chairs without handrails, were suggested to be removed or changed. Lighting was evaluated and improved, as needed.)
2
S. Wongrakpanich et al. / JAMDA xxx (2018) 1e3
Review Board. All older adult patients aged >65 years who resided in the Orchard Cove long-term care nursing facility from October 1 to December 31, 2017, were included. There were no exclusion criteria. Fall rates between October and December 2017 were compared with fall rates 3 months prior to intervention (July 1 to September 30). At 3 months, staff were asked to complete a satisfactory survey using an 8-item questionnaire. A fall with a minor injury was classified as having bruising, hematoma, superficial laceration not requiring suture, or acute pain after a fall. A fall with a major injury was categorized as sustaining a fracture or as skin laceration requiring suture. Overall fall rates per person-years were calculated. Independent t tests were used to compare the mean difference for number of falls using SPSS version 21.0.
Evaluation
Fig. 1. STOP-FALLING checklist downloadable PDF of this form is available at www. sciencedirect.com.
Glasses and vision evaluation10,11 The objectives of our quality improvement project were to 1) determine the feasibility and adherence with a checklist intervention and 2) determine whether the checklist reduces total number of falls, fallers, recurrent falls, minor and major injuries from falls, and fall rates. Implementation We conducted a study with a protocol consistent with a quality improvement project, as determined by Hebrew Senior Life Institutional
The mean age of participants was 92.9 years (range 86-100). Dementia was the most common comorbidity. There were 3 deaths during the follow-up period. None of the deaths were fall-related. Among all STOP-FALLING interventions, teaching (patient and family education), medication review, and in-house safety evaluation were the 3 most common interventions implemented by staff (32/32 patient checklists, or 100%). Low bed application was the least common intervention implemented (2 of 32; 6.3%). Among 12 staff who completed the satisfaction survey (Table 1), 11/12 (91.7%) strongly agreed that training sessions for checklist implementation and fall prevention knowledge were useful. All participants either agreed or strongly agreed that the checklist does not interfere with routine patient care time. Staff participants also agreed that they feel more confident in their fall prevention skills and are able to confidently merge the checklist with NH initial assessments. During the 3 months before the study period, 32 patients experienced 22 falls. Thirteen falls were injurious (1 major and 12 minor). In the 3 months following checklist implementation, 32 patients experienced 13 falls (8 injurious, 0 major). At 3 months after initiation of the checklist compared with 3 months prior, there was a reduction in fall rates (2.80-1.65 falls per person-year), number of frequent fallers [5.00-2.30/mo; P < .001, 95% confidence interval (CI) 1.78-3.56], number of falls without injuries (3.00-1.67/mo; P < .001, 95% CI 0.691.97), number of minor injuries (4.00-2.67/mo; P ¼ .015, 95% CI 0.142.52), and number of major injuries (0.33-0.00/mo; P < .001, 95% CI 0.13-0.53) (Figure 2).
Table 1 Staff Satisfaction Survey After Completion of the STOP-FALLING Project
I found an introduction to fall prevention and STOPFALLING presentation in October was useful. Completing STOP-FALLING checklist does not interfere with the time I take care of my nursing home residents. STOP-FALLING checklist is clear, easy to understand, and easy to complete. I feel more confident that fall number could be reduced by multifactorial interventions. I feel more confident in my fall prevention and management skills. I feel more confident to MERGE this checklist to the initial assessment for nursing home resident. On average, how long does it take for you to complete 1 STOP-FALLING checklist in a part that you are responsible for? How satisfied were you with STOP-FALLING project overall?
Strongly Agree, n (%)
Agree, n (%)
Disagree, n (%)
Strongly Disagree, n (%)
No Opinion, n (%)
11 (91.7)
1 (8.3)
0 (0)
0 (0)
0 (0)
3 (25)
9 (75)
0 (0)
0 (0)
0 (0)
8 (66.7)
4 (0.3)
0 (0)
0 (0)
0 (0)
7 (58.3)
5 (41.7)
0 (0)
0 (0)
0 (0)
7 (58.3)
5 (41.7)
0 (0)
0 (0)
0 (0)
6 (50)
5 (41.7)
0 (0)
0 (0)
1 (8.3)
<5 min 2 (16.7)
5-10 min 4 (0.3)
10-15 min 6 (50)
15-20 min 0 (0)
>20 min 0 (0)
Very Satisfied, n (%) 7 (58.3)
Satisfied, n (%) 5 (41.7)
Neither, n (%) 0 (0)
Dissatisfied, n (%) 0 (0)
Very Dissatisfied, n (%) 0 (0)
S. Wongrakpanich et al. / JAMDA xxx (2018) 1e3
3
Fig. 2. Fall statistics pree and posteSTOP-FALLING checklist.
Comment We developed an innovative, real-world checklist aimed to prevent falls in a long-term care setting with the hope to overcome some implementation barriers in actual practice. It is well established in literature that multifactorial interventions for fall prevention are infrequently implemented in a nursing home setting.1 Campbell et al1 classified the most common reasons for low implementation rates for multifactorial fall and fracture programs into 5 categories: misconception that advanced age would not benefit from a fall prevention program, a long duration of time to benefit, limited resources, the requirement for ongoing participation, and lack of an effective delivery system. Other barriers included a lack of knowledge, difficulty in accessing information, frustration regarding staff’s ability for fall management, and lack of communication.1e6,15 After targeting challenges for multifactorial fall prevention programs, our initiative helps overcome those barriers by (1) providing interdisciplinary staff education on fall prevention, (2) monthly multidisciplinary meetings to facilitate ongoing communication, (3) involving patient and family caregivers for fall prevention knowledge, (4) giving clear solutions for each intervention, (5) obtaining multidisciplinary members’ input by using the color-coding system, (6) making sure that the intervention was not overly time-consuming, and (7) using the mnemonic “STOP-FALLING.” The satisfactory survey after project completion highlights that this STOP-FALLING checklist is associated with substantial staff satisfaction rate. After the completion of the STOP-FALLING initiative, all fall statistics were evidently reduced. Our checklist helps to ensure that multifactorial interventions that target an individual patient’s greatest risk factors will be addressed. Every study has limitations. Given the observational nature and a short follow-up period of our study, it is possible that the reduction in falls we observed was due to chance or unintended cointerventions. Providers should choose and adapt these interventions according to clinical circumstance and specific NH facility. The STOP-FALLING initiative appears promising as a practical intervention to implement evidence-based fall prevention measures in the long-term care setting. Our checklist overcomes many of the implementation barriers commonly experienced in the NH. Future randomized controlled trials for this intervention and future trials for
cost-effectiveness studies of multifactorial fall prevention programs in long-term care facility should be considered. Supplementary Data Supplementary data related to this article can be found online at https://doi.org/10.1016/j.jamda.2018.10.002. References 1. Campbell AJ, Robertson MC. Implementation of multifactorial interventions for fall and fracture prevention. Age Ageing 2006;35:ii60eii64. 2. Ohde S, Terai M, Oizumi A, et al. The effectiveness of a multidisciplinary QI activity for accidental fall prevention: Staff compliance is critical. BMC Health Serv Res 2012;12:197. 3. Schwendimann R, Buhler H, De Geest S, Milisen K. Falls and consequent injuries in hospitalized patients: Effects of an interdisciplinary falls prevention program. BMC Health Serv Res 2006;6:69. 4. Smith ML, Stevens JA, Ehrenreich H, et al. Healthcare providers’ perceptions and self-reported fall prevention practices: findings from a large New York health system. Front Public Health 2015;3:17. 5. McInnes E, Askie L. Evidence review on older people’s views and experiences of falls prevention strategies. Worldviews Evid Based Nurs 2004;1:20e37. 6. Aberg AC, Lundin-Olsson L, Rosendahl E. Implementation of evidence-based prevention of falls in rehabilitation units: a staff’s interactive approach. J Rehabil Med 2009;41:1034e1040. 7. STEADI Stopping Elderly Accidents DI. Family Caregivers: Protect Your Loved Ones From Falling. Available at: https://www.cdc.gov/steadi/pdf/STEADICaregiverBrochure.pdf. Accessed November 25, 2018. 8. STEADI Stopping Elderly Accidents DI. What YOU Can Do to Prevent Falls. Available at: https://www.cdc.gov/steadi/pdf/STEADI-Brochure-WhatYouCanDo508.pdf. Accessed November 25, 2018. 9. Gupta V, Lipsitz LA. Orthostatic hypotension in the elderly: Diagnosis and treatment. Am J Med 2007;120:841e847. 10. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011;59:148e157. 11. Karlsson MK, Magnusson H, von Schewelov T, Rosengren BE. Prevention of falls in the elderlydA review. Osteoporos Int 2013;24:747e762. 12. Jiam NT, Li C, Agrawal Y. Hearing loss and falls: A systematic review and metaanalysis. Laryngoscope 2016;126:2587e2596. 13. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2015;63:2227e2246. 14. Barker A, Kamar J, Tyndall T, Hill K. Reducing serious fall-related injuries in acute hospitals: are low-low beds a critical success factor? J Adv Nurs 2013;69:112e121. 15. Vlaeyen E, Stas J, Leysens G, et al. Implementation of fall prevention in residential care facilities: A systematic review of barriers and facilitators. Int J Nurs Stud 2017;70:110e121.
The pragmatic innovation described in this article may need to be modified for use by others; in addition, strong evidence does not yet exist regarding efficacy or effectiveness. Therefore, successful implementation and outcomes cannot be assured. When necessary, administrative and legal review conducted with due diligence may be appropriate before implementing a pragmatic innovation.
STOP-FALLING: A Simple Checklist Tool for Fall Prevention in a Nursing Facility Supakanya Wongrakpanich MD a, b, *, Katalin Danji MD b, Lewis Lipsitz MD a, b, Sarah Berry MD, MPH a, b a b
Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA Hebrew Senior Life, Institute for Aging Research, Boston, MA
a b s t r a c t Falls are highly prevalent and lead to major health morbidity and mortality in older adults. We developed a “STOP-FALLING” checklist as a multifactorial intervention tool kit for a single long-term care facility. The objective of this study was to determine feasibility and adherence of the checklist, and to determine whether STOP-FALLING reduces total number of falls, frequent fallers, and fall-related injuries. This is a quality improvement demonstration project comparing the effect on falls 3 months before and 3 months after introducing a STOP-FALLING checklist. All older adult patients who lived in the long-term care unit of a single facility were included. PTs, geriatricians, and registered nurses participated in the STOP-FALLING initiative. Staff were surveyed on satisfaction by 8-item questionnaires, which were obtained 3 months after checklist implementation. Data on the rate of falls, the number of recurrent fallers, the number of minor injuries, and the number of major injuries 3 months prior and 3 months after the intervention were collected by facility fall log. A total of 32 patients were screened using the STOP-FALLING checklist. Staff survey revealed a high satisfaction rate with 15 minutes to complete the checklist. Data at 3 months after initiation of the checklist revealed a reduction in the fall rates (2.80-1.65 falls per person-year), number of frequent fallers (5.00-2.30/mo after), number of falls without injuries (3.00-1.67/mo), number of minor injuries (4.00-2.67/mo), and number of major injuries (0.33-0/ mo). We observed excellent staff satisfaction using the STOP-FALLING checklist. Our pilot project suggests that the intervention may decrease fall rates and other fall-related injuries. Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Keywords: Falls, multidisciplinary, checklist, prevention, barriers, long-term care
Problem/Significance Falls are a major contributor to morbidity and mortality among nursing home (NH) residents. Implementation of fall prevention in the NH has been challenging. Reasons include lack of knowledge, difficulty in accessing information, time pressure, lack of involvement of patients and families, and inadequate staff communication.1e6 A realworld initiative that provides education, requires input from multidisciplinary team members, and takes minimal time helps to overcome some of the above barriers. Innovation We developed a “STOP-FALLING” checklist (Figure 1) and adapted interventions to make our checklist specific to the NH setting. For instance, we included family caregiver education because of significant numbers of participants with dementia. We made this checklist easy to implement by using a color-coding system. For example, the physical therapist (PT) was responsible for the “blue” section, which included PT evaluation and orthostatic hypotension measurement.
The authors declare no conflicts of interest. * Address correspondence to Supakanya Wongrakpanich, MD, Department of Gerontology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA 02215, USA. E-mail address: [email protected] (S. Wongrakpanich). https://doi.org/10.1016/j.jamda.2018.10.002 1525-8610/Ó 2018 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
The registered nurse (RN) and geriatrician were responsible for the “purple” and “red” sections, respectively. All staff participated in at least 1 of 3 training sessions for checklist implementation. Interventions were customized according to each patient’s clinical circumstance. Our checklist includes the following: Vitamin D Supplementation with oral vitamin D3 1000 IU per day Patient and family caregiver education (Teaching) by a physician or RN using Stopping Elderly Accidents, Deaths, and Injuries (STEADI) patient and family caregiver brochures.7,8 Also, all family caregivers received a STEADI brochure at their mailing address. Orthostatic vital signs measurement9,10 Physical therapist evaluation and ongoing treatment10,11 Foot and gait evaluation10,11 Hearing Aids and hearing evaluation12 Medication List and polypharmacy review13 (A medication review was conducted by physicians according to the 2015 AGS Beers Criteria. Medication reduction or withdrawal was attempted, whenever possible.) Low bed14 IN-room safety evaluation11 (All potential environmental hazards, including rugs, slippery floors, electrical cords, and chairs without handrails, were suggested to be removed or changed. Lighting was evaluated and improved, as needed.)
2
S. Wongrakpanich et al. / JAMDA xxx (2018) 1e3
Review Board. All older adult patients aged >65 years who resided in the Orchard Cove long-term care nursing facility from October 1 to December 31, 2017, were included. There were no exclusion criteria. Fall rates between October and December 2017 were compared with fall rates 3 months prior to intervention (July 1 to September 30). At 3 months, staff were asked to complete a satisfactory survey using an 8-item questionnaire. A fall with a minor injury was classified as having bruising, hematoma, superficial laceration not requiring suture, or acute pain after a fall. A fall with a major injury was categorized as sustaining a fracture or as skin laceration requiring suture. Overall fall rates per person-years were calculated. Independent t tests were used to compare the mean difference for number of falls using SPSS version 21.0.
Evaluation
Fig. 1. STOP-FALLING checklist downloadable PDF of this form is available at www. sciencedirect.com.
Glasses and vision evaluation10,11 The objectives of our quality improvement project were to 1) determine the feasibility and adherence with a checklist intervention and 2) determine whether the checklist reduces total number of falls, fallers, recurrent falls, minor and major injuries from falls, and fall rates. Implementation We conducted a study with a protocol consistent with a quality improvement project, as determined by Hebrew Senior Life Institutional
The mean age of participants was 92.9 years (range 86-100). Dementia was the most common comorbidity. There were 3 deaths during the follow-up period. None of the deaths were fall-related. Among all STOP-FALLING interventions, teaching (patient and family education), medication review, and in-house safety evaluation were the 3 most common interventions implemented by staff (32/32 patient checklists, or 100%). Low bed application was the least common intervention implemented (2 of 32; 6.3%). Among 12 staff who completed the satisfaction survey (Table 1), 11/12 (91.7%) strongly agreed that training sessions for checklist implementation and fall prevention knowledge were useful. All participants either agreed or strongly agreed that the checklist does not interfere with routine patient care time. Staff participants also agreed that they feel more confident in their fall prevention skills and are able to confidently merge the checklist with NH initial assessments. During the 3 months before the study period, 32 patients experienced 22 falls. Thirteen falls were injurious (1 major and 12 minor). In the 3 months following checklist implementation, 32 patients experienced 13 falls (8 injurious, 0 major). At 3 months after initiation of the checklist compared with 3 months prior, there was a reduction in fall rates (2.80-1.65 falls per person-year), number of frequent fallers [5.00-2.30/mo; P < .001, 95% confidence interval (CI) 1.78-3.56], number of falls without injuries (3.00-1.67/mo; P < .001, 95% CI 0.691.97), number of minor injuries (4.00-2.67/mo; P ¼ .015, 95% CI 0.142.52), and number of major injuries (0.33-0.00/mo; P < .001, 95% CI 0.13-0.53) (Figure 2).
Table 1 Staff Satisfaction Survey After Completion of the STOP-FALLING Project
I found an introduction to fall prevention and STOPFALLING presentation in October was useful. Completing STOP-FALLING checklist does not interfere with the time I take care of my nursing home residents. STOP-FALLING checklist is clear, easy to understand, and easy to complete. I feel more confident that fall number could be reduced by multifactorial interventions. I feel more confident in my fall prevention and management skills. I feel more confident to MERGE this checklist to the initial assessment for nursing home resident. On average, how long does it take for you to complete 1 STOP-FALLING checklist in a part that you are responsible for? How satisfied were you with STOP-FALLING project overall?
Strongly Agree, n (%)
Agree, n (%)
Disagree, n (%)
Strongly Disagree, n (%)
No Opinion, n (%)
11 (91.7)
1 (8.3)
0 (0)
0 (0)
0 (0)
3 (25)
9 (75)
0 (0)
0 (0)
0 (0)
8 (66.7)
4 (0.3)
0 (0)
0 (0)
0 (0)
7 (58.3)
5 (41.7)
0 (0)
0 (0)
0 (0)
7 (58.3)
5 (41.7)
0 (0)
0 (0)
0 (0)
6 (50)
5 (41.7)
0 (0)
0 (0)
1 (8.3)
<5 min 2 (16.7)
5-10 min 4 (0.3)
10-15 min 6 (50)
15-20 min 0 (0)
>20 min 0 (0)
Very Satisfied, n (%) 7 (58.3)
Satisfied, n (%) 5 (41.7)
Neither, n (%) 0 (0)
Dissatisfied, n (%) 0 (0)
Very Dissatisfied, n (%) 0 (0)
S. Wongrakpanich et al. / JAMDA xxx (2018) 1e3
3
Fig. 2. Fall statistics pree and posteSTOP-FALLING checklist.
Comment We developed an innovative, real-world checklist aimed to prevent falls in a long-term care setting with the hope to overcome some implementation barriers in actual practice. It is well established in literature that multifactorial interventions for fall prevention are infrequently implemented in a nursing home setting.1 Campbell et al1 classified the most common reasons for low implementation rates for multifactorial fall and fracture programs into 5 categories: misconception that advanced age would not benefit from a fall prevention program, a long duration of time to benefit, limited resources, the requirement for ongoing participation, and lack of an effective delivery system. Other barriers included a lack of knowledge, difficulty in accessing information, frustration regarding staff’s ability for fall management, and lack of communication.1e6,15 After targeting challenges for multifactorial fall prevention programs, our initiative helps overcome those barriers by (1) providing interdisciplinary staff education on fall prevention, (2) monthly multidisciplinary meetings to facilitate ongoing communication, (3) involving patient and family caregivers for fall prevention knowledge, (4) giving clear solutions for each intervention, (5) obtaining multidisciplinary members’ input by using the color-coding system, (6) making sure that the intervention was not overly time-consuming, and (7) using the mnemonic “STOP-FALLING.” The satisfactory survey after project completion highlights that this STOP-FALLING checklist is associated with substantial staff satisfaction rate. After the completion of the STOP-FALLING initiative, all fall statistics were evidently reduced. Our checklist helps to ensure that multifactorial interventions that target an individual patient’s greatest risk factors will be addressed. Every study has limitations. Given the observational nature and a short follow-up period of our study, it is possible that the reduction in falls we observed was due to chance or unintended cointerventions. Providers should choose and adapt these interventions according to clinical circumstance and specific NH facility. The STOP-FALLING initiative appears promising as a practical intervention to implement evidence-based fall prevention measures in the long-term care setting. Our checklist overcomes many of the implementation barriers commonly experienced in the NH. Future randomized controlled trials for this intervention and future trials for
cost-effectiveness studies of multifactorial fall prevention programs in long-term care facility should be considered. Supplementary Data Supplementary data related to this article can be found online at https://doi.org/10.1016/j.jamda.2018.10.002. References 1. Campbell AJ, Robertson MC. Implementation of multifactorial interventions for fall and fracture prevention. Age Ageing 2006;35:ii60eii64. 2. Ohde S, Terai M, Oizumi A, et al. The effectiveness of a multidisciplinary QI activity for accidental fall prevention: Staff compliance is critical. BMC Health Serv Res 2012;12:197. 3. Schwendimann R, Buhler H, De Geest S, Milisen K. Falls and consequent injuries in hospitalized patients: Effects of an interdisciplinary falls prevention program. BMC Health Serv Res 2006;6:69. 4. Smith ML, Stevens JA, Ehrenreich H, et al. Healthcare providers’ perceptions and self-reported fall prevention practices: findings from a large New York health system. Front Public Health 2015;3:17. 5. McInnes E, Askie L. Evidence review on older people’s views and experiences of falls prevention strategies. Worldviews Evid Based Nurs 2004;1:20e37. 6. Aberg AC, Lundin-Olsson L, Rosendahl E. Implementation of evidence-based prevention of falls in rehabilitation units: a staff’s interactive approach. J Rehabil Med 2009;41:1034e1040. 7. STEADI Stopping Elderly Accidents DI. Family Caregivers: Protect Your Loved Ones From Falling. Available at: https://www.cdc.gov/steadi/pdf/STEADICaregiverBrochure.pdf. Accessed November 25, 2018. 8. STEADI Stopping Elderly Accidents DI. What YOU Can Do to Prevent Falls. Available at: https://www.cdc.gov/steadi/pdf/STEADI-Brochure-WhatYouCanDo508.pdf. Accessed November 25, 2018. 9. Gupta V, Lipsitz LA. Orthostatic hypotension in the elderly: Diagnosis and treatment. Am J Med 2007;120:841e847. 10. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011;59:148e157. 11. Karlsson MK, Magnusson H, von Schewelov T, Rosengren BE. Prevention of falls in the elderlydA review. Osteoporos Int 2013;24:747e762. 12. Jiam NT, Li C, Agrawal Y. Hearing loss and falls: A systematic review and metaanalysis. Laryngoscope 2016;126:2587e2596. 13. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2015;63:2227e2246. 14. Barker A, Kamar J, Tyndall T, Hill K. Reducing serious fall-related injuries in acute hospitals: are low-low beds a critical success factor? J Adv Nurs 2013;69:112e121. 15. Vlaeyen E, Stas J, Leysens G, et al. Implementation of fall prevention in residential care facilities: A systematic review of barriers and facilitators. Int J Nurs Stud 2017;70:110e121.
The pragmatic innovation described in this article may need to be modified for use by others; in addition, strong evidence does not yet exist regarding efficacy or effectiveness. Therefore, successful implementation and outcomes cannot be assured. When necessary, administrative and legal review conducted with due diligence may be appropriate before implementing a pragmatic innovation.