Evidence-informed best practices are based on quality evidence and should be implemented into practice to optimize outcomes.8 Listed below you will find best practices graded according to the type of evidence. To view a description of the types of evidence, click here.
Change ideas are specific and practical changes informed by experience and research that focus on improving specific aspects of a system, process or behaviour. To learn more about change ideas see the QI: Getting Started tab.
A 2008 HQO analysis of falls and fall-related injuries in community-dwelling seniors examined the existing literature to identify interventions that may be effective in reducing the probability of a senior falling and/or sustaining a fall-related injury. Eleven interventions were identified in the literature, of which seven had some level of evidence to support their use in preventing falls and fall-related injuries.1 These interventions have been shown to be cost effective.2 For more details on the evidence found for each of these interventions, read the Aging in the Community: Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors report.
Listed below are best practices to reduce and prevent falls and related injuries. These are based on literature reviews of evidence for each practice. To help you move from best evidence to best practice, click on the + button next to each best practice to find implementation details, as well as change ideas that you can test using a PDSA approach.
Best practices need to be tailored to client characteristics. The Registered Nurses’ Association of Ontario has created an Implementation Toolkit to guide this process.
Evidence-Informed |
How To Implement |
Toolbox |
Assess risk for falls |
A range of risk factors influence whether people are likely to have falls, and should be considered in the assessment including:
Following each assessment develop an individualized Care Plan based on results of assessment |
|
Type of Evidence: IV (Expert Opinion)
REFERENCES:
Systematic Reviews
Scott V, Votova K, Scanlan A, Close J. Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings. Age and Ageing, 36. 2007:130-9. Available from at: http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?ID=12007001303#.U201mP3jh9A
Vlaeyen E, Coussement J, Leysens G, Van der Elst E, Delbaere K, Cambier D, Denhaerynck K, Goemaere S, Wertelaers A, Dobbels F, Dejaeger E, Milisen K; Center of Expertise for Fall and Fracture Prevention Flanders. Characteristics and effectiveness of fall prevention programs in nursing homes: a systematic review and meta-analysis of randomized controlled trials. J Am Geriatr Soc. 2015 Feb;63(2):211-21. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/25641225
Khatib R, Santesso N, Pickard L, Osman O, Giangregorio L, Skidmore C, Papaioannou A. Fracture risk in long term care: a systematic review and meta-analysis of prospective observational studies. BMC Geriatr. 2014 Dec 3;14:130. Full-text available at: http://www.biomedcentral.com/1471-2318/14/130
López-Soto PJ, Manfredini R, Smolensky MH, Rodríguez-Borrego MA. 24-hour pattern of falls in hospitalized and long-term care institutionalized elderly persons: A systematic review of the published literature. Chronobiol Int. 2015 May;32(4):548-56. Abstract available at: http://www.tandfonline.com/doi/full/10.3109/07420528.2014.987295
Supporting Research
Accreditation Canada. Required Organizational Practices Handbook 2014. Accreditation Canada; 2013. Available from: http://www.accreditation.ca/sites/default/files/rop-handbook-2014-en.pdf
Registered Nurses’ Association of Ontario (RNAO). Nursing Best Practice Guideline: Prevention of Falls and Fall Injuries in the Older Adult. Toronto: Registered Nurses’ Association of Ontario.Revised 2011. Available from: http://rnao.ca/sites/rnao-ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf
Safer Healthcare Now! Reducing Falls and Injuries from Falls Getting Stared Kit. Safer Healthcare Now!; 2010 Sept. Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Falls-resources-Getting-Started-Kit.aspx
Evidence-Informed |
How To Implement |
Toolbox |
Review medications |
|
Type of Evidence: I (High)
REFERENCES:
Systematic Reviews
Cameron ID, Murray GR, Gillespie LD, Robertson MC, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in nursing care facilities and hospitals (Review). The Cochrane Collaboration. 2010. Available from: http://www.cochranejournalclub.com/preventing-falls-in-nursing-care-facilities-and-hospitals/pdf/CD005465_standard.pdf
Ruxton K, Woodman RJ, Mangoni AA. Drugs with anticholinergic effects and cognitive impairment, falls and all-cause mortality in older adults: A systematic review and meta-analysis. Br J Clin Pharmacol. 2015 Aug;80(2):209-20. Abstract availale at: http://www.ncbi.nlm.nih.gov/pubmed/25735839
Bloch F, Thibaud M, Dugué B, Brèque C, Rigaud A S Kemoun G. Psychotropic drugs and falls in the elderly people: updated literature review and meta-analysis. J Aging Health. 2011 Mar;23(2):329-46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20947876
Supporting Research
Blalock SJ, Casteel C, Roth MT, Ferreri S, Demby KB, Shankar V. Impact of enhanced pharmacologic care on the prevention of falls: a randomized controlled trial. Am J Geriatr Pharmacother. 2010 Oct;8(5):428-440. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21335296
Australian Commission on Safety and Quality in Health Care. Preventing Falls and Harm from Falls in Older People: Best Practice Guidelines for Australian Residential Aged Care Facilities. Australian Commission on Safety and Quality in Health Care. 2009 Aug. Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Guidelines-RACF.pdf
Registered Nurses’ Association of Ontario. Nursing Best Practice Guideline: Prevention of Falls and Fall Injuries in the Older Adult. Toronto: Registered Nurses’ Association of Ontario. Revised 2011. Available from: http://rnao.ca/sites/rnao-ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf
Evidence-Informed |
How To Implement |
Toolbox |
Review corrective vision and hearing aids |
|
Review Corrective Vision and Hearing Aids
Type of Evidence: II (Medium)
REFERENCES:
Systematic Reviews
Desapriya E, Subzwari S, Scime-Beltrano G, Samayawardhena LA, Pike I. Vision improvement and reduction in falls after expedited cataract surgery: systematic review and metaanalysis. J Cataract Refract Surg. 2010 Jan;36(1):13-19. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20117700
Supporting Research
Haran MJ, Cameron ID, Ivers RQ, Simpson JM, Lee BB, Tanzer M, Porwal M, Kwan MMS, Severino C, Lord, SR. Effect on falls of providing single lens distance vision glasses to multifocal glasses wearers: VISIBLE randomized controlled trial. BMJ. 2010;340:c2265. Available from: http://www.bmj.com/content/340/bmj.c2265.pdf%2Bhtml
Reed-Jones RJ, Dorgo S, Hitchings MK, Bader JO. Vision and agility training in community dwelling older adults: incorporating visual training into programs for fall prevention. Gait Posture. 2012 Apr;35(4):585-89. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22206782
Evidence-Informed |
How To Implement |
Toolbox |
Modify and optimize environmental factors to prevent falls |
Establish falls prevention strategies by optimizing environmental factors: modify and remove environmental hazards:
Clear identification of environmental risk factors:
Conduct checking and monitoring to ensure prevention measures are implemented effectively:
Regularly review causes and risks:
|
|
Modify and Optimize Environmental Factors to prevent falls
Type of Evidence: I (High)
REFERENCES:
Cochrane Systematic Reviews
Anderson O, Boshier PR, Hanna GB. Interventions designed to prevent healthcare bed-related injuries in patients. Cochrane Database Syst Rev. 2011 Nov 9;(11). Available from: http://www.ncbi.nlm.nih.gov/pubmed/22071860
Choi YS, Lawler E, Boenecke CA, Ponatoski ER, Zimring CM. Developing a multi-systemic fall prevention model, incorporating the physical environment, the care process and technology: asystematic review. J Adv Nurs. 2011 Dec;67(12):2501-24. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21545639
Gulpers MJ, Bleijlevens MH, Ambergen T, Capezuti E, van Rossum E, Hamers JP. Belt restraint reduction in nursing homes: effects of a multicomponent intervention program. J Am Geriatr Soc. 2011 Nov;59(11):2029-36. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22092189
Supporting Research
Pighills AC, Torgerson DJ, Sheldon TA, Drummond AE, Bland JM. Environmental assessment and modification to prevent falls in older people. J Am Geriatr Soc. 2011 Jan;59(1):26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21226674
Accreditation Canada. Required Organizational Practices Handbook 2014. Accreditation Canada; 2013. Available from: http://www.accreditation.ca/sites/default/files/rop-handbook-2014-en.pdf
American Medical Directors Association. Falls and Fall Risk: Clinical Practice Guideline. American Medical Directors Association; 2011. Available from: http://www.amda.com/tools/cpg/falls.cfm
Australian Commission on Safety and Quality in Health Care. Preventing Falls and Harm from Falls in Older People: Best Practice Guidelines for Australian Residential Aged Care Facilities. Australian Commission on Safety and Quality in Health Care. 2009 Aug. Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Guidelines-RACF.pdf
Registered Nurses’ Association of Ontario (RNAO). Nursing Best Practice Guideline: Prevention of Falls and Fall Injuries in the Older Adult. Toronto: Registered Nurses’ Association of Ontario. Revised 2011. Available from: http://rnao.ca/sites/rnao-ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf
Safer Healthcare Now! Reducing Falls and Injuries from Falls Getting Stared Kit. Safer Healthcare Now!; 2010 Sept. Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Falls-resources-Getting-Started-Kit.aspx
Evidence-Informed |
How To Implement |
Toolbox |
Use hip protectors for high risk residents |
|
|
Use Hip Protectors for High Risk Residents
Type of Evidence: I (High)
REFERENCES:
Systematic Reviews
Santesso N, Carrasco-Labra A, Brignardello-Petersen R. Hip protectors for preventing hip fractures in older people. Cochrane Database Syst Rev. 2014 Mar 31;3:CD001255.Full-text available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001255.pub5/full
Supporting Research
Cameron ID, Kurrle SE, Quine S, Sambrook PN, March L, Chan DK, Schaafsma FF. Improving adherence with the use of hip protectors among older people living in nursing care facilities: A cluster randomized trial. J Am Med Dir Assoc. 2011 Jan;12(1):50-57. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21194660
Safer Healthcare Now! Reducing Falls and Injuries from Falls Getting Stared Kit. Safer Healthcare Now!; 2010 Sept. Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Falls-resources-Getting-Started-Kit.aspx
Evidence-Informed |
How To Implement |
Toolbox |
Maximize use of mobility aids |
|
|
Maximize Use of Mobility Aids
Type of Evidence: III (Low)
REFERENCES:
Guidelines
Registered Nurses’ Association of Ontario (RNAO). Nursing Best Practice Guideline: Prevention of Falls and Fall Injuries in the Older Adult. Toronto: Registered Nurses’ Association of Ontario. Revised 2011. Available from: http://rnao.ca/sites/rnao-ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf
Safer Healthcare Now! Reducing Falls and Injuries from Falls Getting Stared Kit. Safer Healthcare Now!; 2010 Sept. Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Falls-resources-Getting-Started-Kit.aspx
Evidence-Informed |
How To Implement |
Toolbox |
Establish strength and balance exercise programs |
Implement long-term exercise programs in mobile seniors to reduce falls Assess all residents for physical and functional abilities at admission and regularly review their status
|
Some suggested tools to consider include:
|
Establish Strength and Balance Exercise Programs
Type of Evidence: I (High)
REFERENCES:
Systematic Reviews
Howe TE, Rochester L, Neil F, Skelton DA, Ballinger C. Exercise for improving balance in older people. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD004963. Available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0013140/
Liu CJ, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD002759. Full-text available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4324332/
Thomas S, Mackintosh S, Halbert J. Does the 'Otago exercise programme' reduce mortality and falls in older adults?: a systematic review and meta-analysis. Age Ageing. 2010 Nov;39(6):681-87. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20817938
Wooton AC. An integrative review of Tai Chi research: an alternative form of physical activity to improve balance and prevent falls in older adults. Orthop Nurs. 2010 Mar-Apr;29(2):108-16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20335770
Supporting Research
da Silva Borges EG, de Souza Vale RG, Cader SA, Leal S, Miguel F, Pernambuco CS, Dantas EH. Postural balance and falls in elderly nursing home residents enrolled in a ballroom dancing program. Arch Gerontol Geriatr. 2014 Sep-Oct;59(2):312-6. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/24845606
Smulders E, Weerdesteyn V, Groen BE, Duysens J, Eijsbouts A, Laan R, van Lankveld W. Efficacy of a short multidisciplinary falls prevention program for elderly persons with osteoporosis and a fall history: a randomized controlled trial. Arch Phys Med Rehabil. 2010 Nov;91(11):1705-11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21044715
American Medical Directors Association. Falls and Fall Risk: Clinical Practice Guideline. American Medical Directors Association; 2011. Available from: http://www.amda.com/tools/cpg/falls.cfm
Registered Nurses’ Association of Ontario (RNAO). Nursing Best Practice Guideline: Prevention of Falls and Fall Injuries in the Older Adult. Toronto: Registered Nurses’ Association of Ontario. Revised 2011. Available from: http://rnao.ca/sites/rnao-ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf
Safer Healthcare Now! Reducing Falls and Injuries from Falls Getting Stared Kit. Safer Healthcare Now!; 2010 Sept. Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Falls-resources-Getting-Started-Kit.aspx
Evidence-Informed |
How To Implement |
Toolbox |
Prevent and treat osteoporosis. Provide calcium and vitamin D supplementation. |
|
Prevent and Treat Osteoporosis: Provide Calcium and Vitamin D Supplementation
Type of Evidence: I (High)
REFERENCES:
Systematic Reviews
Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2012 Dec 12;12:CD005465. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23235623
Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, Orav JE, Stuck AE, Theiler R, Wong JB, Egli A, Henschkowski J. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ. 2009;339:3692. Available from: http://www.bmj.com/content/339/bmj.b3692.abstract
Supporting Research
Karkkainen MK, Tuppurainen M, Salovaara K, Sandini L, Rikkonen T, Sirola J, Honkanen R, Arokoski J, Alhava E, Kröger H. Does daily vitamin D 800 IU and calcium 1000 mg supplementation decrease the risk of falling in ambulatory women aged 65-71 years? A 3-year randomized population-based trial. Maturitas. 2010 Apr;65(4):359-65. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20060665
Neelemaat F, Lips P, Bosmans JE, Thijs, A., Seidell, J. C., & van Bokhorst-de van der Schueren,M.A. (2012). Short-term oral nutritional intervention with protein and vitamin D decreases falls in malnourished older adults. J Am Geriatr Soc. 2012 Apr;60(4):691-99. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22316322
American Medical Directors Association. Falls and Fall Risk: Clinical Practice Guideline. American Medical Directors Association; 2011. Available from: http://www.amda.com/tools/cpg/falls.cfm
Australian Commission on Safety and Quality in Health Care. Preventing Falls and Harm from Falls in Older People: Best Practice Guidelines for Australian Residential Aged Care Facilities. Australian Commission on Safety and Quality in Health Care. 2009 Aug. Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Guidelines-RACF.pdf
Ontario Health Technology Advisory Committee (OHTAC). OHTAC Recommendation: Clinical Utility of Vitamin D Testing. Toronto: Ontario Health Technology Advisory Committee; 2010 Jun. Available from: http://www.health.gov.on.ca/english/providers/program/ohtac/tech/recommend/rec_vitamin d_201002.pdf
Registered Nurses’ Association of Ontario (RNAO). Nursing Best Practice Guideline: Prevention of Falls and Fall Injuries in the Older Adult. Toronto: Registered Nurses’ Association of Ontario. Revised 2011. Available from: http://rnao.ca/sites/rnao-ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf
Safer Healthcare Now! Reducing Falls and Injuries from Falls Getting Stared Kit. Safer Healthcare Now!; 2010 Sept. Available from: http://www.saferhealthcarenow.ca/EN/Interventions/Falls/Documents/Falls Getting Started Kit.pdf
Evidence-Informed |
How To Implement |
Toolbox |
Screen for cognitive impairement |
Sceen for cognitive impairement (using tool such as the Mini-Mental State Exam [MMSE] or the Confusion Assessment Method instrument [CAM] |
|
Screen for Cognitive Impairment
Type of Evidence: IV (Expert Opinion)
REFERENCES:
Supporting Research
Safer Healthcare Now! Reducing Falls and Injuries from Falls Getting Stared Kit. Safer Healthcare Now!; 2010 Sept. Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Falls-resources-Getting-Started-Kit.aspx
Evidence-Informed |
How To Implement |
Toolbox |
Implement individualized toileting routines |
|
|
Implement Individualized Toilet Routines
Type of Evidence: IV (Expert Opinion)
REFERENCES:
Guidelines
Registered Nurses’ Association of Ontario (RNAO). Nursing Best Practice Guideline: Prevention of Falls and Fall Injuries in the Older Adult. Toronto: Registered Nurses’ Association of Ontario. Revised 2011. Available from: http://rnao.ca/sites/rnao-ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf
Safer Healthcare Now! Reducing Falls and Injuries from Falls Getting Stared Kit. Safer Healthcare Now!; 2010 Sept. Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Falls-resources-Getting-Started-Kit.aspx
Lancet. 2003 Oct 11;362(9391):1225-30.
Available from:
http://www.ncbi.nlm.nih.gov/pubmed/14568747
How will we know if a change is an improvement? Measurement is one of the critical steps in a quality improvement (QI) initiative that assesses the impact of your tests of change. Quality indicators are used to measure how well something is performing. There are three types of quality indicators used to measure your QI efforts: outcome (indicators that capture clinical outcomes and or system performance), process (indicators that track the processes that measure whether the system is working as planned), and balancing indicators (indicators that ensure that changing one part of the system does not cause new problems in other parts of the system).
Type of Indicator | Indicator of Quality Improvement | How to Calculate: numerator __________ denominator |
Targets/ Benchmarks | How is This Indicator Used? |
---|---|---|---|---|
Outcome | Percentage of residents who had a recent fall (in the last 30 days) |
Residents who had a fall in the last 30 days recorded on their target assessment Residents with valid assessments |
Targets: As low as possible (set by individual organizations) Provincial benchmarks: 9% |
Quality improvement QIP indicator Publicly reported by HQO |
For a more comprehensive list of tools and resources, visit the following links on our HQO website:
A fall is defined as an event or unintentional change in position that results in a person coming to rest inadvertently on the ground or floor or other lower level.1,2 Falls and fall-related injuries are among the most serious and common medical problems experienced by older adults. Even a fall that does not result in an injury can trigger a fear of falling, which can reduce a resident’s mobility, social interactions, and quality of life.3
Health Quality Ontario reported on its public report Long-Term Care web page that in 2014-2015, 14.8% of long-term care residents had a fall in any given 30-day period, changing a little from 14.2% in 2013-2014.3 As well, approximately 25,000 people in residential care across Canada were at risk of falling.4
The good news is that some falls can be prevented. A growing body of research indicates that assessing risk and implementing prevention strategies are effective in reducing falls, thereby maintaining health outcomes and quality of life among seniors. According to the Long-Term Care Homes Act, 2007, all homes in Ontario are required to have a falls prevention and management program, so to enhance your program, you can find evidence informed best practices outlined in the Best Practices tab to support efforts to reduce falls in Ontario.
The overarching goal is to maintain and or improve the quality of life for long-term care residents by preventing and reducing the number and impact of falls, which in turn, will also lessen the burden on the health care system. There has been little to no change in the falls rate over the past several years,3 and the considerable variation in the rate of falls amongst long-term care homes suggests there is room for improvement and better consistency in Ontario’s long-term care homes.3 The provincial target is to bring falls rates down as low as possible.
Ontario is the first jurisdiction that publicly reports on long-term care home specific quality indicators. As you may have already learned, being able to measure and monitor your efforts is one of the first steps in any quality improvement journey. While the tools and information provided in this quality improvement resource focus on the process of quality improvement for the home, the ultimate goal is to provide residents with the best possible care.
Toronto: Registered Nurses' Association of Ontario (RNAO); 2005 Mar.
Available from: http://rnao.ca/sites/rnao-ca/files/Prevention_of_Falls_and_Fall_Injuries_in_the_Older_Adult.pdf
Canadian Institute for Health Information; 2012 Feb.
Available from: https://secure.cihi.ca/estore/productSeries.htm?pc=PCC127
Toronto: Queen’s Printer for Ontario; 2015.
Available from: http://www.hqontario.ca/portals/0/Documents/pr/measuring-up-2015-en.pdf
Public Reporting. 2014
Available from: http://www.hqontario.ca/Public-Reporting/Long-Term-Care
Accreditation Canada, Canadian Institute for Health Information, and Canadian Patient Safety Institute. Ottawa, ON: CIHI; 2014.
Available from: https://secure.cihi.ca/free_products/FallsJointReportAugust6_2014_CPHI_EN_web.pdf