Much as modern travelers rely on tools to plan, research, and implement journeys, nurse informaticists, and others have at their disposal tools to be

2/24/22, 12:50 PM Rubric Detail – Blackboard Learn

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  Excellent Good Fair Poor

In a 2- to 3-page paper:

Describe the evaluation tool that you selected for your Evaluation Plan Project. Provide a rationale for your selection. Develop a plan for utilizing the tool for your Evaluation Methodology Plan.

67 (74.44%) – 75 (83.33%)

The response clearly, accurately, and with detail describes the evaluation tool selected for the Evaluation Plan Project, including a rationale for the selection, and clearly and accurately presents a plan for utilizing the tool for the Evaluation Methodology Plan.

60 (66.67%) – 66 (73.33%) The response describes the evaluation tool selected for the Evaluation Plan Project, including a rationale for the selection, and presents a plan for utilizing the tool for the Evaluation Methodology Plan.

53 (58.89%) – 59 (65.56%) The response vaguely or inaccurately describes the evaluation tool selected for the Evaluation Plan Project, provides a vague rationale for the selection, and/or presents a vague or incomplete plan for utilizing the tool for the Evaluation Methodology Plan.

0 (0%) – 52 (57.78%)

The response vaguely or inaccurately describes the evaluation tool selected for the Evaluation Plan Project, provides a vague or missing rationale for the selection, and/or presents a vague, incomplete, or nonexistent plan for utilizing the tool for the Evaluation Methodology Plan.

Name: NURS_6541_Week8_Assignment1_Rubric EXIT

Grid View List View

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  Excellent Good Fair Poor

Written Expression and Formatting — Paragraph Development and Organization:

Paragraphs make clear points that support well- developed ideas, �ow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 (5.56%) – 5 (5.56%)

Paragraphs and sentences follow writing standards for �ow, continuity, and clarity.

A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 (4.44%) – 4 (4.44%)

Paragraphs and sentences follow writing standards for �ow, continuity, and clarity 80% of the time.

Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 (3.33%) – 3 (3.33%)

Paragraphs and sentences follow writing standards for �ow, continuity, and clarity 60%–79% of the time.

Purpose, introduction, and conclusion of the assignment are vague or o� topic.

0 (0%) – 2 (2.22%)

Paragraphs and sentences follow writing standards for �ow, continuity, and clarity < 60% of the time.

No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting — English Writing Standards:

Correct grammar, mechanics, and proper punctuation

5 (5.56%) – 5 (5.56%)

Uses correct grammar, spelling, and punctuation with no errors.

4 (4.44%) – 4 (4.44%)

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 (3.33%) – 3 (3.33%)

Contains several (3 or 4) grammar, spelling, and punctuation errors.

0 (0%) – 2 (2.22%)

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

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  Excellent Good Fair Poor

Written Expression and Formatting — The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in- text citations, and reference list.

5 (5.56%) – 5 (5.56%)

Uses correct APA format with no errors.

4 (4.44%) – 4 (4.44%)

Contains a few (1 or 2) APA format errors.

3 (3.33%) – 3 (3.33%)

Contains several (3 or 4) APA format errors.

0 (0%) – 2 (2.22%)

Contains many (≥ 5) APA format errors.

Total Points: 90

Name: NURS_6541_Week8_Assignment1_Rubric

EXIT

ORIGINAL RESEARCH

©2018 Un

Evaluation and refinement of a handheld health information technology tool to support the timely update of bedside visual cues to prevent falls in hospitals

Ruth C.-A. Teh FRACP, MBBS, B Pharm (Hons),1,2 Renuka Visvanathan PhD, FRACP, FANZSGM, G.Cert.Ed (H.Ed.),

MBBS, ATCL,1,2 Damith Ranasinghe PhD, BOE3 and Anne Wilson PhD, MN, BN, RN, FACN2,4,5

1Aged and Extended Care Services, The Queen Elizabeth Hospital, 2Adelaide Geriatrics Training and with Aged Care (GTRAC) Centre, Adelaide

Medical School, The University of Adelaide, Adelaide, South Australia, 3School of Computer Science, The University of Adelaide, Adelaide, South

Australia, Australia, 4College of Medicine and Public Health, Flinders University of South Australia, and 5Prince of Wales Medical School, University of

New South Wales, Sydney, New South Wales, Australia

A B S T R A C T

Aim: To evaluate clinicians’ perspectives, before and after clinical implementation (i.e. trial) of a handheld health information technology (HIT) tool, incorporating an iPad device and automatically generated visual cues for bedside display, for falls risk assessment and prevention in hospital.

Methods: This pilot study utilized mixed-methods research with focus group discussions and Likert-scale surveys to elicit clinicians’ attitudes. The study was conducted across three phases within two medical wards of the Queen Elizabeth Hospital. Phase 1 (pretrial) involved focus group discussion (five staff) and surveys (48 staff) to elicit preliminary perspectives on tool use, benefits and barriers to use and recommendations for improvement. Phase 2 (tool trial) involved HIT tool implementation on two hospital wards over consecutive 12-week periods. Phase 3 (post- trial) involved focus group discussion (five staff) and surveys (29 staff) following tool implementation, with similar themes as in Phase 1. Qualitative data were evaluated using content analysis, and quantitative data using descriptive statistics and logistic regression analysis, with subgroup analyses on user status (P�0.05). Results: Four findings emerged on clinicians’ experience, positive perceptions, negative perceptions and recom- mendations for improvement of the tool. Pretrial, clinicians were familiar with using visual cues in hospital falls prevention. They identified potential benefits of the HIT tool in obtaining timely, useful falls risk assessment to improve patient care. During the trial, the wards differed in methods of tool implementation, resulting in lower uptake by clinicians on the subacute ward. Post-trial, clinicians remained supportive for incorporating the tool into clinical practice; however, there were issues with usability and lack of time for tool use. Staff who had not used the tool had less appreciation for it improving their understanding of patients’ falls risk factors (odds ratio 0.12), or effectively preventing hospital falls (odds ratio 0.12). Clinicians’ recommendations resulted in subsequent technological refinement of the tool, and provision of an additional iPad device for more efficient use.

Conclusion: This study adds to the limited pool of knowledge about clinicians’ attitudes toward health technology use in falls avoidance. Clinicians were willing to use the HIT tool, and their concerns about its usability were addressed in ongoing tool improvement. Including end-users in the development and refinement processes, as well as having high staff uptake of new technologies, is important in improving their acceptance and usage, and in maximizing beneficial feedback to further inform tool development.

Key words: falls prevention, health information technology, mixed-methods, perspectives

Int J Evid Based Healthc 2018; 16:90–100.

Correspondence: Ruth C.-A. Teh, FRACP, MBBS, B Pharm (Hons),

Sunbury Hospital, 7 Macedon Road, Sunbury, Victoria, 3429,

Australia. E-mail: ruth.teh@wh.org.au

DOI: 10.1097/XEB.0000000000000129

90 International Journal of Evidence-Based

iversity of Adelaide, Joanna Briggs Institute. U

Background

F alls are the seventh most common cause of hospi-tal-acquired injury1 and are more prevalent among older persons.2,3 Despite the introduction of mandatory

Healthcare � 2018 University of Adelaide, Joanna Briggs Institute

nauthorized reproduction of this article is prohibited.

ORIGINAL RESEARCH

©2018 Un

hospital falls risk assessment and prevention strategies

as a healthcare priority, the incidence of inpatient

falls continues to rise by 2% each year.3–5 Overall, the

reported incidence of falls in hospital varies widely from

2–3 (acute setting) to 46% (rehabilitation setting).6,7 Falls

are more prevalent in medical compared with surgical

wards,8 in public compared with private hospitals (4.2 vs.

1.6 per 1000 hospitalizations), and among patients living

in major cities compared with remote areas (3.4 vs.

1.9 per 1000 hospitalizations).9 Actual fall rates are likely

to even be higher as there is no universal definition for a

fall, and falls incidents tend to be under-reported.10

Hospital falls tend to cause serious complications,

with 44–60% resulting in harm,11,12 especially among

older persons.13 The 6-PACK trial (2011–2013) in six

Australian hospitals demonstrated that hospital falls

increased length of stay (LOS) by 8 days [95% confidence

interval (CI) 5.8–10.4, P<0.001], and hospital costs by

AU$6669 (95% CI $3888–9450, P<0.001), even after

adjusting for age, sex, cognitive impairment, comorbid-

ities and admission type.14 Older persons who sustain

hip fractures in hospital have poorer outcomes com-

pared with their peers who sustain hip fractures in the

community,15 including longer LOS,16 reduced return

to preadmission ambulation and functional status,

increased rates of discharge to permanent residential

care15 and higher mortality rates.16 Indeed, falls may lead

to chronic pain, reduced quality of life, functional

impairment, permanent disability and higher rates of

inpatient mortality.13,17,18

Health technology has the potential to influence this

outcome but has been limited by the lack of rigorous

evidence for effective single-technology interventions,

including sensors and electronic medical records.19

Moreover, clinicians’ perspectives toward the use of

health technology in falls prevention are not well-known,

despite systematic review evidence that staff attitudes

are crucial to successfully integrating any falls preventive

strategy.19,20

Nursing staff are familiar with using visual cues to

communicate falls risk and preventive strategies.21 Visual

cues, as part of a Falls Prevention Tool Kit, have been

shown in a single randomized controlled trial to be

effective in lowering hospital falls rate (3.15 vs. 4.18

per 1000 patient-days; P¼0.04), especially among those aged 65 years and over (rate difference 2.08 vs. 1.03 per

1000 patient-days; P¼0.03).22 However, further research was needed into whether such findings could be repli-

cated in different settings. Within the Geriatric and

Evaluation (GEM) unit at the Queen Elizabeth Hospital

(TQEH), a preliminary audit found 20% staff compliance

with existing patient bedside posters for falls prevention

International Journal of Evidence-Based Healthcare � 2018 University

iversity of Adelaide, Joanna Briggs Institute. Un

(Fig. 1; Visvanathan R, Ranasinghe D, Hoskins S, Wood J,

Mahajan N, unpublished data). Nursing staff reported

these paper-based posters were time-consuming and

hence not completed, as they involved placing adhesive

colored dots on eight different locations of the poster

to indicate falls risk (i.e. green for low risk, yellow for

medium risk, red for high risk), before displaying the

poster by the patient’s bedside (Visvanathan R, Rana-

singhe D, Hoskins S, Wood J, Mahajan N, unpublished

data). Due to poor uptake and negative feedback of the

existing posters, and mindful of the pending electronic

health record (EHR) system due to roll out across public

hospitals statewide in South Australia, the opportunity

was seized to develop a health information technology

(HIT) tool in collaboration with ward clinicians. This HIT

tool incorporated an iPad 2 device (model number

A1315; Apple, Cupertino, California, USA) for direct clini-

cians’ entry of up to 13 common falls risk activities23

(Fig. 2), with automatic generation of visual cues for

bedside display (Fig. 3).

Our pilot study aimed to evaluate clinicians’ attitudes

toward this HIT tool, in particular, their experiences,

positive and negative perspectives and recommenda-

tions for improvement, both preclinical and postclinical

implementation (i.e. trial), to inform ongoing tool refine-

ment, ultimately as part of a novel movement-detection

sensor technology system for hospital falls prevention.

Methods Ethics approval The study protocol was approved by the Human

Research Ethics Committee of the Basil Hetzel Institute,

South Australia (HREC/13/TQEHLMH/66), and conformed

to the World Medical Association Declaration of Hel-

sinki.24 Each participant provided written, informed con-

sent prior to research involvement, and participant

information was deidentified.

Research methodology Mixed methods design was applied to allow for greater

robustness and richness of information gathered,25,26

with focus group research used to obtain qualitative

data simultaneously from multiple individuals on differ-

ent ideas and perspectives.27

Study protocol The current pilot study was divided into three phases.

Phase 1 (pretrial) evaluated clinicians’ perspectives on

the HIT tool (i.e. study aims) prior to implementation,

using focus group discussion and surveys. Phase 2 (tool

trial) involved tool implementation on hospital wards.

Phase 3 (post-trial) examined clinicians’ perspectives on

of Adelaide, Joanna Briggs Institute 91

authorized reproduction of this article is prohibited.

ST Margaretõs Rehabilitation

Hospital

Stepping forward programš falls risk chart

Showeringš once seated Toiletingš once seated

Wet area

Wet area transfer Wet area mobility/AMB

StickerSticker

Sticker Sticker

StickerSticker

StickerSticker

Patient sticker

Dry area

Dry area mobility/AMB Night mobility

Red dot needs hands on assistance

Yellow dot needs supervision and/or standby

Green dot independent

Bed mobility Dry area transfer

Figure 1. Example of a paper-based bedside poster using colored stick-on dots to indicate patient’s falls risk.

RC-A Teh et al.

©2018 Un

the tool after trial completion, using focus group discus-

sion and surveys with similar themes as in Phase 1.

Focus group sessions were led by the chief researcher,

who was employed by TQEH as a medical doctor, but not

working on the wards at the time of the study. The chief

researcher defined focus group goals (i.e. study aims)

at each session and facilitated discussion for an hour or

until data saturation was reached (i.e. when information

occurred so repeatedly that additional data collection had

no additional worth).28 Textual data were transcribed

verbatim by the chief researcher from Dictaphone (Philips

PocketMemo voice recorder DPM8000; Atlanta, Georgia,

USA) recordings and written notes. Transcripts were not

returned to participants for comment.

Likert-scale surveys were derived following focus

group discussion and utilized similar themes. These were

distributed to ward staff over 2 week periods, before and

after the tool trial, by the chief researcher and two ward

clinical nurse consultants (CNCs), who were considered

nursing leaders and experts in clinical care.29 Completed

nonidentifiable questionnaires were returned to the

92 International Journal of Evidence-Based

iversity of Adelaide, Joanna Briggs Institute. U

researcher personally or via a designated tray on the

wards.

The HIT tool was implemented on the GEM unit (June

to August 2014), followed by the Acute Medical Unit

(AMU) (September to November 2014), over two conse-

cutive 12-week periods. Ward clinicians had up to

6 weeks of researcher training and reminders on tool

use (3-h-long sessions each week) and were indepen-

dent for the remaining 6 weeks. GEM staff utilized the full

period of researcher-led support, whereas AMU staff

declined researcher input after 1 day, citing staff confi-

dence with tool use.

The HIT tool took less than 5 min to use for each

patient. There was no automatic trigger for staff to use

the tool, other than reminders from the researcher in the

first 6 weeks. The iPad device was carried by the clinician

responsible for using the tool. This person directly

entered patient’s details (age, bed location, mobility

aid) and their own clinical judgment (yes/no responses)

about the patient’s day and nighttime falls risk for

13 different movement and location types (Fig. 2).

Healthcare � 2018 University of Adelaide, Joanna Briggs Institute

nauthorized reproduction of this article is prohibited.

Walking

Sitting/standing

Toilet

Corridor

Next

Shower

In/out of bed

Yes

No

Yes

No

At-risk

No risk

At-risk

No risk

At-risk

No risk

Yes

No

Movements requiring supervision?

State additional locations where supervision required?

Figure 2. Example of a screenshot of direct clinician entry of patient’s falls risk assessment using the health information technology tool.

ORIGINAL RESEARCH

©2018 Un

Black-and-white A4-sized visual cues were automatically

printed at assessment completion (Fig. 3), and the same

clinician was responsible for displaying these paper-

based visual cues by the patient’s bedside. Ward staff

subsequently targeted falls preventive interventions

according to clinical judgment.

Both wards were given freedom on how to imple-

ment the HIT tool. AMU staff used the tool daily on all

ward patients. All registered nurses on AMU were rotated

to use the tool, which was usually completed by the

International Journal of Evidence-Based Healthcare � 2018 University

iversity of Adelaide, Joanna Briggs Institute. Un

registered nurse allocated to nonpatient-related duties

(e.g. ward medication management), to allow for timely

use of the HIT tool, unencumbered by other duties. GEM

staff used the tool on new admissions and in which falls

risk altered (e.g. posthospital fall), reasoning this as

appropriate for a subacute setting, in which patients’

falls risk changed less often compared with an acute

ward. The CNC and two registered nurses from GEM used

the HIT tool, due to limited confidence by the rest of the

staff in using the device.

of Adelaide, Joanna Briggs Institute 93

authorized reproduction of this article is prohibited.

TQEH Ward: GEMU

0700–2000 Day

Movements requiring

supervision:

Walking Corridor Walking Corridor

Sitting/standing Sitting/standingShower

In/out of bed In/out of bedToilet

Toilet

Issue date: 28/01/2013

Movements requiring

supervision:

Additional locations where

supervision required:

Additional locations where

supervision required:

2001–0659 NightYes

Requires walking aid? UR: 100001

Name: Alice Aliceman Bed No.: 7.1

Figure 3. Example of an automatically generated visual cue from the health information technology tool.

RC-A Teh et al.

©2018 Un

Setting and participants The study was conducted on two ground-floor medical

wards at TQEH, a tertiary teaching hospital in metropoli-

tan Adelaide, South Australia. The 16-bed AMU managed

patients in the acute phase of illness, whereas the 20-bed

GEM unit provided rehabilitative care aimed at restoring

patients’ function and independence after an acute

illness, usually with the goal of returning back home.30

Ward clinicians consisted of nursing [38.68 FTE (full-

time equivalent) GEM, 32 FTE AMU], junior medical (four

FTE GEM, five FTE AMU), and allied health staff, meaning

occupational and physical therapists (2.5 FTE GEM, two

FTE AMU). No pharmacists, speech therapists, dieticians,

social workers or senior medical staff were approached

to be part of this study.

Focus group participants were identified by ward

CNCs as clinicians having an expertise in falls prevention,

94 International Journal of Evidence-Based

iversity of Adelaide, Joanna Briggs Institute. U

with greater than 5 years of clinical experience, and

working within GEM, AMU or the Central Adelaide Local

Health Network (CALHN) Falls Prevention group at the

time of the study. Five clinicians were involved in each

pretrial and post-trial focus group discussion, with one

participant involved on both occasions. All five post-trial

focus group participants were HIT tool users from AMU,

with six clinicians from GEM and CALHN declining to

participate as they had not used the tool or were unable

to attend the focus group session.

Survey participants consisted of clinicians working

within GEM or AMU at the time of the study, and

consecutively approached by the chief researcher in

the 2-week periods, before and after the tool trial. There

were 49 pretrial (29 GEM, 20 AMU) and 28 post-trial (20

GEM, eight AMU) participants. It was not recorded which

participants were involved both pretrial and post-trial.

Healthcare � 2018 University of Adelaide, Joanna Briggs Institute

nauthorized reproduction of this article is prohibited.

ORIGINAL RESEARCH

©2018 Un

Post-trial, both those who had used the HIT tool (i.e. tool

users, n¼11) and those who had not (i.e. nonusers, n¼17), were included to reflect tool uptake. Post-trial, 54 clinicians (65.9%) declined to participate as they had

no experience with or recommendations for improving

the HIT tool. Participation was voluntary with the option

to withdraw at any point.

Analysis Qualitative data from focus group sessions were manu-

ally analyzed using content analysis to systematically

code data and identify themes, to gain new knowledge

and initiate action.31,32 Descriptive statistics and logistic

regression were performed on quantitative survey data,

to describe and evaluate differences between clinicians’

perspectives pretrial and post-trial (P<0.05), with sub-

group analysis on users and nonusers using SPSS Statis-

tics for Windows, Version 22.0 (IBM Corp., Armonk, New

York, USA). Responses indicating ‘strongly agree’ or

‘agree’ were classified as positive, whereas those indicat-

ing ‘strongly disagree’, ‘disagree’ or ‘uncertain’ were

classified as negative responses to the item statement.

Results The qualitative and quantitative data were integrated

into four main findings, and presented from Phase 1

(pretrial), followed by Phase 3 (post-trial), regarding

clinicians’ experience, positive perceptions, negative per-

ceptions and barriers to use, and recommendations for

refinement of the HIT tool.

Phase 1 (pretrial): Qualitative results from focus group session Clinicians’ experience Pretrial, no participant had used the HIT tool. All partic-

ipants were familiar with using visual cues in falls pre-

vention, with four participants expressing negative views

about the existing posters using colored stick-on dots to

indicate falls risk. These were seen as a bit complicated,

tedious to complete, ineffective and therefore, underu-

tilized, due to time constraints with high patient turnover

and competing clinical duties.

Positive perceptions Incorporating technology into falls risk assessment was

identified by three participants as beneficial in providing

staff with a fun, quick means of risk assessment. One

participant stated the HIT tool would serve as a stress

reduction tool for staff, in providing an immediate visual

of each patient’s falls risk factors. Four participants cited

benefits to patients and their families in increasing

knowledge on falls risk and preventive strategies, both

in hospital and on discharge.

International Journal of Evidence-Based Healthcare � 2018 University

iversity of Adelaide, Joanna Briggs Institute. Un

Negative perceptions and barriers to use Clinicians perceived the main barrier to tool implemen-

tation to be shifting a workplace culture that resisted

change and did not view hospital falls as a problem. The

HIT tool was seen as increasing work for clinicians, with

time pressures on staff thought to compromise accuracy

of falls risk assessment and placement of visual cues

at the correct patient’s bedside. Three participants

expressed apprehension about clinicians using new

health technology, with one participant especially con-

cerned about older workers and technology use.

Recommendations for refinement Three participants requested tool technology be simple

to use, and eventually incorporated into the upcoming

EHR system. They recommended providing staff with

tool education, with training attendance linked to points

for continuous professional development (CPD). CPD

referred to the number of hours stipulated by national

registration standards for clinicians to engage in ongoing

professional education per annum.33 Four participants

suggested involving patients and families in the tool

process, to improve adherence to falls preventive mea-

sures in hospital and at home. One participant advo-

cated senior leadership endorsement to drive tool

integration into hospital programs.

Phase 1 (pretrial): Quantitative results from survey participants The majority of survey participants were women (81.6%),

nursing staff (73.4%), aged between 18 and 39 years old

(63.3%) and had 10 years or less of experience in clinical

care (57.1%).

Clinicians’ experience No participants had used the HIT tool pretrial.

Positive perceptions The majority perceived the HIT tool as an easy,

accurate and timely means of assessing patients’ falls

risk (items 1, 2 and 3, Table 1). Over 70% thought it

facilitated safer, better quality patient care, improved

staff’s understanding of patients’ falls risk factors, effec-

tively prevented falls, and were willing to use the tool if

made available (items 4, 5, 6, 8 and 9). Half the partic-

ipants cited that it would effectively prevent inpatient

falls (item 7).

Negative perceptions and barriers to use Less than half the participants considered potential

barriers to tool use as being duplication of written work

(44.9%), lack of time to use the tool (38.8%) and lack of

of Adelaide, Joanna Briggs Institute 95

authorized reproduction of this article is prohibited.

T a b le

1 . C o m p a ri so n b e tw

e e n p re tr ia l a n d p o st -t ri a l re su lt s o f cl in ic ia n s’

p e rs p e c ti v e s o f th e h e a lt h in fo rm

a ti o n te ch

n o lo g y to o l, w it h

su b g ro u p a n a ly se s fo r u se r st a tu s P re tr ia l,

n ¼ 4 9 (%

)

P o st -t ri a l

T o ta l,

n ¼ 2 8 (%

) U se rs ,

n ¼ 1 1 (%

) N o n u se rs ,

n ¼ 1 7 (%

) P re u se rs

v s.

p o st u se rs

P re n o n u se rs

v s.

p o st n o n u se rs

P re

v s.

p o st

(u se rs þ n o n u se rs )

P o st u se rs

v s.

p o st n o n u se rs

B e n e fi ts

o f H IT

to o l u se

O R

O R

O R

O R

E a sy

to u se

d u ri n g b e d to

b e d

h a n d o v e r

3 9 (7 5 % )

1 3 (4 6 .4 % )

6 (5 4 .5 % )

7 (4 1 .2 % )

0 .2 2 �

0 .1 3 �

0 .1 6 �

0 .5 8

M o re

a cc u ra te

u p d a ti n g fa ll s ri sk

in fo rm

a ti o n cf . cu rr e n t m e th o d

3 7 (7 5 .5 % )

1 7 (6 0 .7 % )

7 (6 3 .6 % )

1 0 (5 8 .8 % )

0 .5 7

0 .5 4

0 .5 5

0 .9 5

U p d a te s fa ll s ri sk

in fo rm

a ti o n in

a ti m e ly

m a n n e r

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