83 Implementation strategies of fall prevention interventions in hospitals: A systematic review 3 our study, the desired strong evidence base for successful implementation strategies of FPIs could not be established with the additional literature from the last 10 years. There is still insufficient evidence on which implementation strategies are most effective for FPIs in hospitals. Effective implementation strategies constitute the “how to” of changing practice [13]. Executing a process evaluation could help to understand why, and how implementation strategies in a particular context are either successful or unsuccessful in changing practice [73]. However, often it is unknown whether strategies are performed as intended, and to what extent they are adopted and adhered to. Implementation theories are helpful to explaining the working mechanisms pre-, per- and post-implementation [74]. In this systematic review, we identified two studies that reported using an implementation theory; however, both studies lacked an elaboration how the theory related to the outcomes [43, 61]. Process models were used frequently, but most studies lacked an elaboration on how the process model was operationalized. An example of a comprehensive description can be found in Semin-Goossens et al. [56], where they provided a step-by-step description of the implementation process based on Grol’s 5-step implementation model. Hence, future research on the implementation of FPIs should explicitly describe their implementation strategies, duration, and the impact on implementation and clinical outcomes, preferably related to implementation frameworks, models or theories. There is a need for higher-quality reporting of implementation studies where the effectiveness of implementation strategies is the primary research focus. Although we expected studies from the last 10 years to incorporate more tech-inspired implementation strategies. We found limited tech-inspired implementation strategies such as facilitating relay of clinical data [26, 32, 34, 49], using data experts [28, 69], or providing local technical assistance [28, 31, 75]. We did found several studies with more tech-enabled FPIs such as video surveillance or an AI-risk prediction model [29, 58, 59, 69, 71, 76]. Most included studies used education as an implementation strategy, which aligns with the findings of Albasha et al., who conducted a similar systematic review in long-term care facilities [77]. Throughout this paper we used the term implementation strategies for the methods that are used to promote the uptake of the FPIs, in quality and safety papers these methods are also called safety interventions [78]. In the hierarchy of safety interventions, education and providing information is the second-last intervention. A Cochrane review to assess the effect of educational strategies showed that educational meetings as the main component of an intervention can probably slightly improve professional practice [79], fortunately almost all studies used additional implementation strategies. In another systematic review about the implementation of FPIs by VanderVelde et al. in community dwelling elderly [80], tailoring was the most frequently reported implementation strategy, which is in contrast to only eleven of the included studies using tailored strategies in this systematic review. We can explain this difference through
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