CLINICAL PRACTICE IN LONG-TERM CARE

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1 CLINICAL PRACTICE IN LONG-TERM CARE Fall Prevention and Injury Protection for Nursing Home Residents Patricia Quigley, PhD, ARNP, FAAN, Tatjana Bulat, MD, Ellen Kurtzman, MPH, RN, Ronald Olney, PhD, Gail Powell-Cope, PhD, ARNP, FAAN, and Laurence Rubenstein, MD, MPH Recognizing that risk factors for falls are multifactorial and interacting, providers require guidance on the components, intensity, dose, and duration for an effective fall and fall injury prevention program. Administrators of health care facilities require guidance on resources needed for these programs. Clear guidance does not exist for specifying the right combination of interventions to adequately protect specific at-risk populations, such as nursing home residents with dementia or osteoporosis. Staff education about fall prevention and resident fall risk assessment and reassessments has become part of standards of practice; however, the selection, specificity, and combination of fall prevention and injury protection interventions are not standardized. To address these gaps, this team of researchers conducted a critical examination of selected intervention studies relevant to nursing home populations. The objectives of this literature review were to (1) examine the selection and specificity of fall prevention and injury protection interventions described in the literature since 1990; (2) evaluate the strength of evidence for interventions that both prevent falls and protect residents from fall-related injury; and, (3) provide clinical and policy guidance to integrate specific interventions into practice. (J Am Med Dir Assoc 2010; 11: ) Keywords: Falls; fall-related injuries; nursing home; injury prevention Falls and fall-related injuries among nursing home residents are serious concerns for health care providers, administrators, nursing home residents, and families. Falls among nursing home residents occur frequently and repeatedly. Among published studies of falls in nursing homes, the mean number of falls per bed per year was about 1.5 with a range of 0.2 to Prevention is most effective when based on a thorough understanding of fall and injury risk factors at individual, staff, and organizational levels. A vast literature exists about fall risk factors, and there are a number of intervention studies for fall prevention in the institutional Patient Safety Center of Inquiry, James A. Haley Hospital, Tampa, FL (P.Q., T.B., R.O.); HSR&D Research Enhancement Award Program, James A Haley Hospital, Tampa, FL (G.P.-C.); Department of Nursing Education, School of Medicine and Health Sciences, The George Washington University, Washington, DC (E.K.); Greater Los Angeles VA Geriatric Research, Education and Clinical Center and UCLA School of Medicine, Sepulveda, CA (L.R.). Disclaimer: This material is based on work supported by the Office of Research and Development, Department of Veterans Affairs, Health Services Research and Development award #IIR and the Patient Safety Center of Inquiry, James A. Haley VAMC. The views expressed in this article are those of the authors and do not necessarily represent the views of the Veterans Healthcare Administration or Department of Veterans Affairs. Address correspondence to Patricia Quigley, PhD, ARNP, FAAN, Patient Safety Center of Inquiry, 8900 Grand Oaks Circle, Tampa, FL patricia. quigley@va.gov Copyright Ó2010 American Medical Directors Association DOI: /j.jamda setting, 2 although little is known about the risk for and prevention of fall-related injuries, such as hip fractures and head traumas. Research findings have shown that factors contributing to falls are multifactorial, complex, and interrelated, and can be fixed or transient. Fixed intrinsic factors (eg, visual changes, comorbidities, muscle weakness, and impaired balance) by definition do not change rapidly over time and are therefore poor indicators for change in risk status. Transient factors that change over time (eg, elevated temperature, dehydration, room change, or a medication change) may be more sensitive to changes in fall risk for nursing home residents and indicators for the need for additional interventions. 3 Recognizing the multifactorial and complex interaction of fall risk factors, the dose, intensity, duration, and components of an effective fall and fall injury prevention program are not clear. Although a considerable body of knowledge exists on fall prevention, little firm evidence demonstrates the cost benefit or return on investment of fall prevention and injury protection programs in nursing homes. Clear guidance does not exist for specifying the right combination of interventions to adequately protect specific at-risk populations, such as nursing home residents with dementia or osteoporosis. Staff education about fall prevention and resident fall risk assessment and reassessments is a standard of practice; however, the selection, specificity, and combination of fall prevention and injury protection interventions are not standardized. 284 Quigley et al JAMDA May 2010

2 Table 1. Agency for Healthcare Research and Quality (AHRQ) Types of Research: Evidence Hierarchies to Rate the Level of the Study Design, from Lowest (a Case Study) to Highest (a Meta-analysis) Types of Research: Evidence Hierarchies Agency for Healthcare Research and Quality (AHRQ) Level I Meta-analysis (combination of data from many studies) Level II Experimental designs (randomized control trials) Level III Well-designed quasi-experimental designs (not randomized or no control group) Level IV Well-designed nonexperimental designs (descriptive can include qualitative) Level V Case reports/clinical expertise OBJECTIVES The objectives of this literature review were the following: (1) to examine the selection and specificity of fall prevention and injury protection interventions described in the literature since 1990; (2) to evaluate the strength of evidence for interventions that both prevent falls and protect residents from fallrelated injury; and, (3) to provide clinical and policy guidance to integrate specific interventions into practice. Vu et al 4 completed a differential effect analysis of multifaceted intervention programs addressing multiple intrinsic and extrinsic risk factors in nursing home residents who fell. Their results acknowledged that fall prevention programs were not uniform. We based our review on the work of Vu et al 4 by adding the grade of evidence for interventions, and extended our search for intervention studies addressing injury protection. METHOD Eligible studies were limited to multifactorial intervention studies conducted in long-term care settings since 1990, and in English. All articles were reviewed by 2 research geriatricians, 2 research nurse scientists, 1 policy analyst, and 1 health science specialist. To build on prior analyses, 5 this review differed from other systematic reviews in that we used 2 rating scales for our analysis: The Agency for Healthcare Research and Quality (AHRQ) 6 Types of Research: Evidence Hierarchy (Table 1), and the United States Preventive Services Task Force (USPSTF) 7 Grading Scale (Table 2) to apply the evidence in practice. DEFINITION OF TERMS Fall Prevention is the multifaceted approach that has been tested in nursing homes to modify intrinsic and extrinsic fall risk factors such as modifying medications to reduce fall risk. In contrast, Injury Protection includes interventions (such as hip protectors, floor mats, low beds, and elimination of sharp edges) to mitigate physical injury, such as fracture, hemorrhage, and head trauma, when a fall occurs. We focused on physical injury because of the potential for loss of function and loss of life. We searched for interventions that could be implemented at organizational, staff, or patient levels, listed in Table 3. RESULTS Article sources included databases (ie, Journals@Ovid, PsycINFO, Ovid MEDLINE(R), HAPI, Your Journals@ Ovid, HealthSTAR, and Google Scholar) and hand searching of references from clinical guidelines and literature reviews. Separate searches were also conducted to locate publications for economic consequences of nursing home falls and injuries and in dissertation abstracts to capture relevant new research. Using key words (fall prevention and injurious falls or loss of life, and nursing home and fall* and injury), 841 articles were identified. With the further restriction to include research studies, 52 were considered. However, we restricted articles to clinical trials or prospective studies conducted in nursing home settings, and those that included injury as an outcome, resulting in retaining 9 articles in this review We categorized the intervention components for each of the studies by specific levels: organizational, unit/staff level, and patient level. This approach easily displays the breadth of a fall prevention and injury protection program tested, versus the traditional intrinsic or extrinsic fall risk factors and risk for injury (Table 4). From this table, most interventions were at the patient level, then organizational level, and last the unit/staff level. The 4 most common interventions addressed organizational level/extrinsic factors (care delivery 5 9; environmental 5 8; medications 5 7; equipment 5 6) and the patient level/intrinsic factor of Table 2. Grades A B C D I United States Preventive Services Task Force Grading Scale to Determine Recommendation of Services Grade Definitions The Task Force recommends the service. There is high certainty that the net benefit is substantial. The Task Force recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. The Task Force recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is moderate or high certainty that the net benefit is small. The Task Force recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. The Task Force concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality or conflicting, and the balance of benefits and harms cannot be determined. CLINICAL PRACTICE IN LONG-TERM CARE Quigley et al 285

3 Table 3. Examples of Fall Prevention and Injury Protection Interventions Organizational level Unit/Staff level Patient level Fall Prevention Interdisciplinary fall team Fall Prevention Committee Program evaluation Leadership Architectural and design changes, eg, elimination uneven floor surfaces Environmental modifications, eg, noncluttered environment Safe patient equipment, eg, anti-tippers on wheelchairs Education Communication-handoff Near miss debriefing Universal fall-prevention approaches Specific fall prevention approaches for select populations (ie, patients with traumatic brain injury, hip fracture, or stroke) Strength, balance, and endurance training Medication modification Orthostasis management Assistive mobility aides Injury Protection Environmental management, eg, floor mats, height adjustable beds Architectural and design changes, eg, elimination of sharp edges on furniture, reengineered bathrooms Injury prevention (osteoporosis treatment) Use of protective equipment, eg, hip protectors, helmets, floor mat at bedside Medication adherence (calcium, vitamin D, anticoagulants, Fosamax) muscle weakness (n 5 7). Least represented interventions targeted patient level/intrinsic risk factors of gait and balance impairment (n 5 3), cardiovascular risk (n 5 2), and visual impairment (n 5 2). No study addressed neurological impairment. All studies used combinations of interventions that addressed multiple risk factors. Seven studies addressed from 5 to 7 risk factors, whereas 2 studies addressed 3 or fewer risk factors. For example, to address the medications risk factor, 2 studies focused on psychotropics, 9,16 2 on cardiovascular medications, 10 1 on diuretics, 13 and others seemed comprehensive. 8,12 14 Most studies addressed fall prevention; few interventions included strategies to protect from injury. Three studies included the use of hip protectors as part of their interventions for fall prevention No study provided data on the relative effectiveness of each intervention component on the outcomes, which is consistent with results of prior systematic reviews 5,17 and limits program policy decisions. We then assigned AHRQ and USPSTF ratings and compared sample size, intervention, effect size, and outcomes for each study (Table 5). We did not examine methodological issues, as this has been published. 5 Eight AHRQ ratings were II, or experimental designs, and one rating was IV, prospective time-series study. USPSTF ratings were either B (recommends) or C (recommends against routinely providing the service). Recommended interventions included comprehensive post fall assessment by a registered nurse, interdisciplinary falls consultative service, multifactoral interventions, and hip protectors. Only 3 studies discussed effect size and power. Five studies included recurrent falls as an outcome; all but 1 study included fall-related injuries, hip fractures. Two studies included health care use as an outcome variable. DISCUSSION Based on this detailed review of the multifaceted interventions, the interventions clearly vary in specificity, dose, intensity, and duration. Several studies show a beneficial effect of the program on fall and/or injury prevention, whereas several others do not. It seems apparent that no one study provides a definitive multifactorial model to guide clinical practice programs in nursing homes. Studies that included reducing serious injuries in nursing home residents focused on fractures, lacerations, and head injury. 18 No randomized controlled trial on the prevention of injuries has been published. 19 Of interest is the increased injurious falls among nursing home residents because of their higher repeat fall rates, having a higher overall risk of sustaining injurious falls over time. 20 Injuries classified were fractures, soft tissue injury, and any injury documented within 7 days of the fall. It was found that to determine the extent of injury required ongoing assessment after the fall, especially in residents with cognitive impairment. These investigators acknowledge that not all falls and injuries were included, because dementia patients who are ambulatory could recover from a fall and not report it to providers. Also, extra care and evaluation of these residents after a fall are necessary to avoid missing post fall injuries that might not be self-reported or observed on initial assessment. Thus, assessment of injury after the fall event is essential. van Doorn et al 20 examined dementia as an independent risk factor for injurious falls in 59 randomly selected nursing homes in Maryland over a 2-year period. Although not addressing injury risk assessment, these researchers recommended injury prevention measures: reduction of environmental hazards, hip protectors, and management of bone active medications, along with fall prevention (proper footwear, learning how to identify weakness or dizziness, vigilant management of psychotropic medications, moving residents with dementia closer to the nursing station). Assessment of injury risk for fracture or bleeding was not addressed in these studies. Yet, interventions to prevent hip 286 Quigley et al JAMDA May 2010

4 CLINICAL PRACTICE IN LONG-TERM CARE Quigley et al 287 Table 4. Interventions: Organizational, Staff, and Patient Levels Level Article Organizational Level (Extrinsic Factors) Unit/Staff Level (Extrinsic Factors) Rubenstein et al 8 Environmental assessment Post fall comprehensive medical assessment Ray et al 9 McMurdo et al 10 Environ and personal safety by study team nurse Wheelchair maintenance and safety Falls Consultation Service (Intervention study team): Individual safety assessment and treatment planning. Fall risk factor assessment and recommendations for modifications at baseline in the intervention group, and reassessments at 6 months. Recommendations to general practitioner. Lighting adjustments Ambient Patient Level (Intrinsic/Extrinsic Factors) Muscle strengthening Gait training Evaluation for an assistive device Medication modification Transferring and ambulation safety Psychotropic drug use by study team geropsychiatric nurse reviewed by team psychiatrist (letters of recommended changes sent to attending physician) Visual acuity evaluation Seated exercise balance training (intervention group): 6 months, twice weekly for 30 minutes group exercise. Adjustment of antihypertensives (polypharmacy; modify postural hypotension) lighting Jensen et al 11 Environmental modification Staff education Individual exercise program Medication adjustment Assistive device repair Becker et al 12 Hofmann et al 13 Dyer et al 14 Environmental adaptation (environmental hazard check reviewed with staff and administrators) list contained 76 items Telephone hotline for caregivers to discuss problems Hip protectors Supply and repair aids Additional staffing during times with greatest number of falls Mid-afternoon restorative activity program (during time of high fall rates) Interdisciplinary fall risk assessment (PT, nurse, and OT) Staff education (1hour) Monthly feedback on fallers, fall rates, and server injuries Post fall problem solving conferences Staff education Exercise program (group program: balance exercises and progressive resistance training with ankle weights and dumbbells; 75minutes twice weekly for at least 2 months duration) Resident education (written, personal consultation on fall prevention or with exercise instructor, hip protectors) Post fall assessment by an OT with environmental assessment Medication changes Treatment for medical conditions Optometry Flexibility, strength and endurance training (group or individual) Gait and balance training Walking aids Medical assessments (recommendations to general practitioner by letter) Medication review Podiatry evaluation (Continued)

5 Table 4. (Continued) Patient Level (Intrinsic/Extrinsic Factors) Level Organizational Level (Extrinsic Factors) Unit/Staff Level (Extrinsic Factors) Article Staff education (1hour) (RNs, CNAs, Primary care physicians, management staff Kerse et al 15 Environmental assessment Falls coordinator (fall risk assessment, individualized plan of care, care coordination, and follow-up) Staff training (2 days) (transfer and ambulation training, living space and personal safety, use of wheelchairs, canes and walkers, and use of psychotropic medications) Ray et al 16 Fall team: RN coordinator, 1 2 CNAs, PT and OT, and an engineer CNA, certified nursing assistant; PT, physical therapist; OT, occupational therapist; RN, registered nurse. fracture are a priority in nursing home settings. Hip fracture has been a primary area of interest, and is often considered the most serious common fall-related injury for older adults. Abrahamsen et al 21 completed a systematic literature epidemiological review of excess mortality following hip fracture. They revealed that hip fracture is associated with excess mortality compared to non-hip fracture/community control populations, during the first year after fracture ranging from 8.4% to 36%; had an increased relative risk for mortality after hip fracture that was highest in the days and weeks following the index fracture, and remained elevated for months and even years (p 1). Hip fractures are relatively rare events and thus most studies on hip fracture prevention have been underpowered for statistical significance, 22 compromised because of limited adherence with hip protectors, or failed to control for specific hip protector impact characteristics. Jensen et al 23 also reported that hip fractures were fewer in residents who wore hip protectors at the time of the fall, adjusted odds ratio (OR) 0.23 (95% confidence interval [CI], ). Two most recent meta-analyses 24,25 on hip protectors effectiveness addressed methodological issues, uncontrolled bias, and uncontrolled biomechanical properties of the hip protectors with prior research targeting community-dwelling older adults. These authors concluded that hip protectors are effective in reducing hip fractures in older people in institutional settings. No intervention trials have been published related to (1) reducing risk of bleeding for residents on anticoagulants, (2) the effectiveness of helmets to reduce head trauma and injury in long-term care settings, or (3) effectiveness of multiple interventions combined to mitigate injury. SUMMARY AND RECOMMENDATIONS Our approach to this review builds on and is supported by the recommendations of Cusimano et al 5 who evaluated 5 rigorous trials of multifaceted programs. They recommended more well-designed research to assess the effectiveness of intervention on reducing injuries, quality of life, cost-effectiveness, and sustainability. Thus, we propose testing a model that is a populationbased approach and includes both fall prevention and injury protection, which could potentially mobilize changes on a large scale, produce a normative effect, and achieve a more permanent diffusion process, as suggested by McClure et al. 19 This proposed research model would be specific for nursing home residents and include fall prevention and injury protection interventions at the organizational, unit, and patient level. Reduced Falls and Injury among Nursing Home Residents 5 Organizational Level (Expert Fall Team, Equipment) 1 Unit/Staff Level (Unit-based Fall Program Champion, Rounds, Injury Risk Assessment Education) 1 Patient Level (Medication Modification, Exercise, Hip Protector Adherence) 288 Quigley et al JAMDA May 2010

6 CLINICAL PRACTICE IN LONG-TERM CARE Quigley et al 289 Table 5. Levels of Research, Grade of Evidence, and Study Description/Outcomes Article Sample Size Intervention Effect Size Recurrent Fall Rate Reduction Rubenstein et al 8 USPSTF: B Ray et al 9 USPSTF: B McMurdo et al 10 USPSTF: C 160 (2-y follow-up) Comprehensive post fall assessment by an RN 482 (14 nursing homes in TN) 1-y follow-up Falls Consultation Service (study team conducted multidisciplinary, structured individual assessments that encompassed each of the 4 safety domains: environment and personal safety, wheelchairs, psychotropic drugs, and transferring and ambulation). 133 (9 NH in UK) Residents invited to take part of all or part: environmental modification, medication review, twice weekly 30- minute exercise program, or 6 months duration (not reported how many residents participated in each component) No prior data to aid in calculating initial sample size. Assumed a 25% reduction in falls would be reasonable estimate of a possible intervention outcome. Pooled estimators of intervention effect Not stated Objective to reduce number of recurrent falls Mean proportion of recurrent fallers Recurrent falls as measured by reduced orthostatic hypotension and improved visual acuity Fall Injury Reduction Incidence rate of injurious falls (serious injuries) 1 y after the intervention 13.7 falls per 100 person years (31.2% 95% CI, 24.6% 86.4%, less than control group) Residents sustaining a fracture after a fall. (No difference.) Cost Lower hospitalization rates in the intervention group, although hospitalizations, emergency department visits, physician visit, or onsite radiological examination were the elements of medical treatment for an serious injurious fall. (Continued)

7 290 Quigley et al JAMDA May 2010 Table 5. (Continued) Article Sample Size Intervention Effect Size Recurrent Fall Rate Reduction Jensen et al 11 USPSTF: B Becker et al 12 USPSTF: B Hofmann et al 13 AHRQ: IV USPSTF: B Dyer et al 14 USPSTF: C 402 (9 NHs in Sweden) (34-week follow-up program) 981 (6 NHs in Germany (1 y follow-up); 509 intervention group; 472 control group) 120-bed NH in PA, prospective timeservices study 196 residents (aged 60 years and older) in 20 residential care homes were enrolled. Homes were randomly allocated to groups. Total of 102 residents were consigned to the intervention arm and 94 to the control arm. 11-wk intervention program (general and residentspecific); environmental modification; resident-specific exercise program; medication review; provision and repair of aids and free hip protectors for those prone to fall-related hip fractures; staff invitation to participate in education program 6-month multifaceted intervention program; residents could participate in any combination of interventions: information, education, exercise, hip protectors; staff training and feedback; environmental modification Combined interventions: environmental actions; shift change and restorative activity program. Multifactorial fall prevention program including 3 months of gait and balance training, medication review, podiatry, and optometry. Not stated Reduction in fallers Reduction in frequent fallers Fall Injury Reduction Number of injuries resulting from falls Not stated Reduction in fallers No difference in hip fracture study under-powered to detect differences in fractures Cost Not stated Not stated Reduction of fractures Based on a conservative figure of 1.5 falls per person per year with a standard deviation of 1.5 we would require a total of 300 subjects to demonstrate a 33% reduction in falls with 80% power at the 5% significance level. Recurrent falls (3 or more) were measured Secondary outcomes were number of oral medications, including number of sedative medications, change in Tinetti gait and balance score, and number of injurious falls (fractures).

8 CLINICAL PRACTICE IN LONG-TERM CARE Quigley et al 291 Kerse et al 15 USPSTF: C Ray et al 16 USPSTF: C 628 (95% participation rate) older residents from 14 randomly selected residential care homes in Auckland, New Zealand 112 facilities in TN; 10,558 study residents 65 years and older and not bedridden Residential care staff, using existing resources (use of a falls coordinator), implemented systematic individualized fall risk management for all residents using a fall-risk assessment tool high-risk logo, and strategies to address identified risks Intervention was an intensive 2-day safety training program with 12- month follow-up. The training program targeted 4 domains: living space and personal safety; wheelchairs, canes, and walkers; psychotropic med use; and transferring and ambulation To adjust for the cluster design of the trial, the sample size was inflated. Inflating this number by a design effect of 2 (estimated), 206 residents were needed in each arm of the randomized trial (power50.8; alpha50.05) Insufficient power to detect an intervention effect. No statistically significant difference in the injurious fall incidence rate between the 2 groups, adjusting for dependency level of the home, baseline fall rate, and clustering. No affect on incidence rate of serious injury adjusting for dependency level of home, baseline fall, and clustering. Main outcome was serious fall-related injury leading to hospital admission or an emergency department or physician visit. No difference in injury occurrence between intervention and control facilities. AHRQ, Agency for Healthcare Research and Quality; CI, confidence interval; NH, nursing home; RN, registered nurse; USPSTF, United States Preventive Services Task Force.

9 Additionally, we suggest the need for a research program that builds on prior evidence and tests interventions that include both fall prevention and injury protection: 1. Cost effectiveness of sustainability for organization-, staff-, and patient-level interventions; 2. Effectiveness of population-specific intervention studies, eg, residents with dementia, residents who repeatedly fall, residents with known history of injurious falls; 3. Cost-effectiveness trials to determine the optimal dose, intensity, and depth of injury prevention interventions: hip protectors, floor mats, height adjustable beds, plus falls clinical nurse specialist; use of unit-based fall champions, use of clinical interdisciplinary falls team; 4. Cost-effectiveness of falls consult teams versus dedicated program staff on falls, recurrent falls, injurious falls, and staff/patient behaviors; and 5. Effectiveness of injury protection (injury risk assessment, post fall injury evaluation and treatment) versus standard of care fall prevention programs. We also suggest cost-effectiveness analysis based on the model suggested by Sorensen et al. 26 They provided a methodology that introduces a taxonomy of nursing home falls that accounts for both the severity of fall consequences and the duration of the treatment episode. Their taxonomy categorized injury by magnitude of associated treatment resources rather than anatomical site (ie, hip fracture). They used Resource Utilization Groups III to define case mix and associated resource intensity. The 9-level taxonomy included (1) noninjurious, (2) psychological/functional injury only, (3) abrasion/contusion, (4) laceration/hematoma, (5) nonsurgical fracture and orthopedic injury, (6) fracture requiring casting, (7) fracture requiring surgery, (8) intracranial injury, and (9) multiple injuries. Cost includes acute care, convalescent care, and permanent post-fall care. In nursing homes, best practices exist for multifactorial fall prevention that involve the nursing staff and prescribing providers. Our assertion is that fall prevention programs must adopt interventions to protect residents from any level of injury. Emerging evidence exists that even mild injury has devastating outcomes for older adults. 21,27 If injuries and falls can be prevented, the long-term survival and quality of life of institutionalized older adults can be extended. 28 Based on our review, no study has examined the effectiveness of both fall prevention and protection from injury nor estimated the relative weight of intervention components to outcomes. Although we recognize the difficulty conducting prospective studies or other robust research designs, we assert it is essential to target risks for physical injury in combination with fall prevention. The exact combination of interventions for specific populations must build on the assumption that all residents are at risk for falls, repeat falls, injury and unfortunately death from a fall, in order to provide a protective approach. To reduce injury and deaths among older adults, further research is needed to give direction to clinicians and administrators for sustainable and cost-effective programs. REFERENCES 1. Rubenstein L, Josephson K, Robbins A. Falls in the nursing home. Ann Intern Med 1994;121: Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older people in residential care facilities and hospitals. Cochrane Database Syst Rev 2005;3: Neutel C, Perry S, Maxwell C. Medication use and risk of falls. Pharmacoepidemiol Drug Saf 2002;11: Vu MQ, Weintraub N, Rubenstein LZ. Falls in the nursing home: Are they preventable? J Am Med Dir Assoc 2006;7:S53 S58, Cusimano MD, Kwok J, Spadafora K. 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