Fall Prevention Evidence and Workplace Policy Writing: Study Guide

This guide draws on two sources: the US Preventive Services Task Force (USPSTF) recommendation statement on interventions to prevent falls in community-dwelling older adults (JAMA, 2018;319(16):1696-1704), and the Writing Company Policy slides. The first provides the evidence base. The second explains how to turn that evidence into a clear, enforceable workplace policy.

Part 1: The USPSTF Falls Prevention Recommendation (2018)

Why falls matter

Falls are the leading cause of injury-related morbidity and mortality among older adults in the United States. In 2014, 28.7% of community-dwelling adults 65 years or older reported falling. That led to 29 million falls, 37.5% of which needed medical treatment or restricted activity for a day or longer. An estimated 33 000 deaths occurred in 2015.

In 2014, about 2.8 million older adults sought emergency department treatment for falls, about 800 000 were hospitalized, and more than 27 000 died from a fall. More than 90% of hip fractures are caused by falls, and 25% of older adults who sustain a hip fracture die within 6 months. Risk rises with age: in 2014, 27% of adults aged 65 to 74 and 37% of adults 85 or older reported a fall.

Population covered

The recommendation applies to community-dwelling adults 65 years or older who are not known to have osteoporosis or vitamin D deficiency. The exercise and multifactorial recommendations target those at increased risk for falls. The statement updates the 2012 USPSTF recommendation.

Identifying increased risk

No instrument has been clearly identified as accurate and feasible for identifying older adults at increased fall risk. Age is strongly related to fall risk, and a history of falls was the factor most commonly and consistently used to identify high-risk people. A pragmatic approach is to assess for a history of falls or for problems in physical functioning and limited mobility. Clinicians can also use gait and mobility assessments such as the Timed Up and Go test.

USPSTF grades and levels of certainty

• A: Recommended. High certainty that the net benefit is substantial. Offer or provide the service.
• B: Recommended. High certainty of a moderate net benefit, or moderate certainty of a moderate-to-substantial net benefit. Offer or provide the service.
• C: Selectively offer to individual patients based on professional judgment and patient preferences. At least moderate certainty that the net benefit is small.
• D: Recommended against. Moderate or high certainty that the service has no net benefit or that harms outweigh benefits. Discourage use.
• I statement: Evidence is insufficient (lacking, of poor quality, or conflicting) to assess the balance of benefits and harms.

The USPSTF defines certainty as the likelihood that its assessment of net benefit is correct, and net benefit as benefit minus harm. Certainty can be high, moderate, or low. The USPSTF does not consider costs in its assessment.

The three recommendations

• Exercise interventions: Grade B. Recommended for community-dwelling adults 65 or older at increased risk for falls. The USPSTF has moderate certainty of a moderate net benefit.
• Multifactorial interventions: Grade C. Clinicians should selectively offer them. The net benefit of offering them routinely is small, so decisions should weigh the circumstances of prior falls, comorbid medical conditions, and the patient's values and preferences.
• Vitamin D supplementation: Grade D. Recommended against for preventing falls. The USPSTF has moderate certainty that it offers no net benefit.

Exercise interventions: the evidence

Effective exercise interventions include supervised individual and group classes and physical therapy, although most studies used group exercise. Physical therapy is now counted as an exercise intervention; the 2012 statement described it separately. The most common component was gait, balance, and functional training (17 trials), followed by resistance training (13), flexibility (8), and endurance training (5). Three studies included tai chi. The most common schedule was 3 sessions per week for 12 months, with durations ranging from 2 to 42 months.

The USPSTF reviewed 21 studies (5 good-quality and 16 fair-quality; n = 7297). Exercise reduced the number of persons experiencing a fall (RR 0.89, 95% CI 0.81-0.97; 15 studies) and the number of injurious falls (IRR 0.81, 95% CI 0.73-0.90; 10 studies). The reduction in the total number of falls (IRR 0.87, 95% CI 0.75-1.00) was not statistically significant. Exploratory analyses suggested larger benefits from group-based exercise, multiple components, and strength or resistance training, but these findings should be interpreted with caution.

Harms were minor, mainly pain or bruising. One study reported 1 wrist fracture, and another reported 2.6 serious fall injuries per 100 000 physical activity sessions. Harms were bounded as no greater than small.

The 2008 HHS guidelines cited in the statement recommend that older adults get at least 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity aerobic activity, muscle strengthening twice a week, and balance training on 3 or more days a week for those at risk of falling.

Multifactorial interventions: the evidence

These start with an initial assessment of modifiable risk factors, followed by customized interventions for each patient. The assessment may cover balance, gait, vision, postural blood pressure, medication, environment, cognition, and psychological health. In studies, nursing staff usually performed the assessment. Interventions could include exercise, cognitive behavioral therapy, nutrition therapy, education, medication management, urinary incontinence management, environmental modification, physical or occupational therapy, social or community services, and referral to specialists.

The USPSTF reviewed 26 studies (7 good-quality and 19 fair-quality; n = 15 506). The interventions reduced the number of falls (IRR 0.79, 95% CI 0.68-0.91). They did not significantly reduce the number of persons experiencing a fall (RR 0.95, 95% CI 0.89-1.01) or experiencing an injurious fall (RR 0.94, 95% CI 0.85-1.03). Harms were rare and minor, and mostly linked to the exercise component. The American Geriatrics Society (AGS) recommends multifactorial assessment for older adults who have had 2 falls in the past year (or 1 fall with gait or balance problems), who have gait or balance problems, or who present with an acute fall. Follow-up and comprehensive management of identified risks are essential.

Vitamin D: the evidence

Seven studies (4 good-quality and 3 fair-quality; n = 7531) were reviewed. Pooled analyses showed no significant reduction in falls (IRR 0.97, 95% CI 0.79-1.20) and no significant effect on persons experiencing a fall (RR 0.97, 95% CI 0.88-1.08). A trial of 500 000 IU per year showed more falls and more injurious falls (IRR 1.15, 95% CI 1.02-1.29). Overall harms were rated small to moderate. A separate review found that combined vitamin D and calcium supplementation increased kidney stones. In 2012, vitamin D had a B grade. It dropped to D because studies of vitamin D-deficient people were excluded (that would be treatment, not prevention) and newer trials showed no benefit.

Other interventions and research gaps

On their own, environmental modification, medication management, psychological interventions, and non-customized combination interventions lack sufficient evidence for or against their use. The USPSTF calls for validated primary care risk tools, more research in adults older than 85, and identification of the effective components of exercise. The CDC's STEADI approach has 3 core elements: screen for fall risk, assess modifiable risk factors, and intervene with effective clinical and community strategies.

Part 2: Writing a Workplace Policy

Why workplace policies are important

• They set the tone and pace of employment.
• They ensure all employees are on the same page.
• They reduce stress, because people are less likely to make needless mistakes or misunderstand each other.
• They create a fair and just work environment.
• By setting out accountability and transparency, they give legal security.

Steps to policy writing

1. Set a goal or goals using SMART: Specific, Measurable, Attainable, Realistic, and Timed.
2. List tasks and the procedures that regulate them, especially tasks that need consistency, that affect patient care, or that affect the hospital as a whole.
3. List potential problems and their solutions, so predetermined options lessen the impact of problems. The slides use a social media policy as an example.
4. Create categories to organize policies. This helps explain what a policy does and helps people find it.
5. Determine consequences for violating the policy. Sanctions should be proportional to the violation. The slides use security policies as an example.
6. Use clear, precise language. Keep it unambiguous, avoid alternate interpretations or confusion, and use simple language and clear directives.
7. Make sure the policy is legal. It must adhere to current law.
8. Once the policy is approved, make sure employees sign new drafts and that all employees can access it.

Note: the slides present policy writing as these steps. They do not list formal section headings such as purpose, scope, definitions, responsibilities, or review schedule, so this guide does not treat those as slide content.

Applying the evidence to a fall-prevention policy

Combining both sources, a fall-prevention policy could:

• set a SMART goal for fall prevention;
• write procedures for identifying increased fall risk (history of falls, mobility problems, and gait tests such as Timed Up and Go);
• prioritize exercise interventions (Grade B);
• offer multifactorial assessment selectively based on individual circumstances (Grade C);
• avoid routine vitamin D supplementation for fall prevention in people not known to be deficient (Grade D);
• anticipate problems and solutions;
• set proportional consequences;
• use clear, lawful language;
• require staff signatures and make the policy accessible to everyone.