Geoff Cooper, RGN, DMS, PGCert (Clinical Governance).
Senior Clinical Risk Manager, Winchester and Eastleigh Healthcare NHS Trust, Winchester, Hampshire
The National Service Framework for Older People (Department of Health, 2001a) has the stated aim: ‘To reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen.’
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We knew from the literature that falls among older inpatients are common and result in morbidity, loss of confidence, and higher health-care costs (Oliver et al, 1997). Falls result in serious injuries and are the leading cause of death from injury among people over 75 in the UK (Oakley et al, 1996).
Like Moore et al (1996) we felt that the identification of the patient at risk is the first step in falls prevention. Risk assessment assists staff in targeting patients at risk and in choosing appropriate individualised preventive strategies. Our initial objective therefore was to review the literature and identify an appropriate risk assessment tool that had good predictive value and which was validated for use in an acute trust.
There is much published literature on the difficulties of developing valid risk assessment scales for pressure sores, which seems highly relevant to the development of a falls scale.
Having identified a number of published works on falls-risk assessments we wanted to critically appraise them for validity and predictability. Fortunately for us almost all of the authors addressed the issue of validity in their reflective discussions and many were very frank about their perceptions of the limitations of their own works.
In addition to their general observations on validity some of the authors also commented on their tool’s validity in different clinical settings mostly, it has to be said, to urge caution with regard to the likely generalisability of their assessment tool.
While validity and predictability are key elements in the design of a risk assessment so too is the ability to use it in the clinical area. Conley et al (1999) rejected a very detailed tool on the grounds that it was too lengthy. Moore et al (1996) suggested that nurses frequently see the tools as being just ‘another piece of paper’, offer little advantage over their own clinical judgement and, understandably, are concerned about having less time available to deliver patient care.
Determining an evidence-based strategy for risk assessment and falls prevention is also not helped by the current level of scientific evidence with regard to the effectiveness of preventive interventions. Oliver et al (1997) and Stetler et al (1999) raise questions about the evidence base for the falls-prevention interventions. Oliver et al (1997) argues that further study is needed to determine whether the falls of inpatients identified as high risk can be prevented by a targeted intervention. Stetler et al (1999) comments that ‘initial interventions gleaned from the falls literature were not well substantiated by science’.
Clinical risk management unit staff had defined three strategic objectives:
Our new policy document ‘Guidelines to identify patients at risk of falling’ identifies a strategy for falls prevention based on a clear, evidence-based, context. This is that falls are unwelcome but are often the inevitable consequence of encouraging patients to regain their mobility and reduce their dependence after an acute illness (Oliver et al, 1997). The policy further informs staff that, while they may see an increase in the numbers of reported falls, the incidence of serious injury will reduce if the suggested preventive strategies are followed (Stetler et al, 1999). All of this is firmly within the context of the National Service Framework for Older People (Department of Health, 2001a), which aims to ‘reduce the number of falls which result in serious injury’.
We decided to use Conley’s risk assessment tool on the basis of its development with complex acutely ill patients, and its ease of use. However, we accepted the argument that risk assessment tools are not scientific instruments for predicting the inevitable development of the risk in question. Consequently we decided not to score the risk factors but instead stated that ‘the risk of a further fall increases with the number of positive responses in the assessment’.
Our policy statement takes account of the uncertainty in the published literature about the effectiveness of preventive interventions yet seeks to provide nurses with a useful falls intervention resource. It provides a list of strategies that have been shown to minimise the risk of serious injury through falling from Oliver et al (1997) and Uden et al (1999) and groups these interventions under four main headings:
Our review of the literature identified that many authors have attempted to produce a validated falls-risk assessment tool but the result is a proliferation of different scales based on varying criteria and different definitions of a fall.
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