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Aims and objectives: To investigate the impact of removing a falls risk screening tool from an overall falls risk assessment programme on the rate of falls, injurious falls and completion of falls prevention activities by staff. Background: Falls in older patients are common adverse events in hospital settings. Screening and assessing individual patients for risk of falls are a common, but controversial element of falls prevention strategies in hospitals. Design: A stepped-wedge, cluster-randomised controlled trial using a disinvestment approach. Methods: This trial was carried out according to the Consolidated Standards of Reporting Trials (CONSORT). All patients were admitted to 20 health service wards (9 units) over the 10-month study period. The control condition contained a falls risk screening tool element, a full falls risk factor assessment and intervention provision section. In the intervention condition, only the full falls risk factor assessment and intervention provision section was applied, and the falls risk screening tool element was removed. Fall rates were extracted from hospital level data, files were audited for tool completion, and nurses surveyed about tool use. Results: There did not appear to be an impact on the falls rate per month when the risk screening tool component was removed (incidence rate ratio (IRR) = 0.84-favours intervention, 95%CI = 0.67 to 1.05, p = .14) nor on the falls rate with serious injury (IRR = 0.90, 95%CI = 0.26 to 3.09, p = .87). There was a thirty-six second reduction of time per patient reported by staff to complete paperwork (p < .001). There was no difference in the proportion of patients for whom the tool was completed, nor the number of falls prevention interventions identified for implementation. Conclusion: Removing the falls risk screening tool section did not negatively impact falls and reduced time spent completing falls prevention paperwork. Relevance to clinical practice: Falls prevention is an important issue in health services. Removal of a screening risk tool is unlikely to impact falls. This has the potential to

Disinvestment is the removal or reduction of previously provided practices or services, and has typically been undertaken where a practice or service has been clearly shown to be ineffective, inefficient and/or harmful. However, practices and services that have uncertain evidence of effectiveness, efficiency and safety can also be considered as candidates for disinvestment. Disinvestment from these practices and services is risky as they may yet prove to be beneficial if further evidence becomes available. A novel research approach has previously been described for this situation, allowing disinvestment to take place while simultaneously generating evidence previously missing from consideration. In this paper, we describe how this approach can be expanded to situations where three or more conditions are of relevance, and describe the protocol for a trial examining the reduction and elimination of use of mobilisation alarms on hospital wards to prevent patient falls. Our approach utilises a 3-group, concurrent, non-inferiority, stepped wedge, randomised design with an embedded parallel, cluster randomised design. Eighteen hospital wards with high rates of alarm use (≥3%) will be paired within their health service and randomly allocated to a calendar month when they will transition to a “Reduced” (<3%) or “Eliminated” (0%) mobilisation alarm condition. Dynamic randomisation will be used to determine which ward in each pair will be allocated to either the reduced or eliminated condition to promote equivalence between wards for the embedded parallel, cluster randomised component of the design. A project governance committee will set non-inferiority margins. The primary outcome will be rates of falls. Secondary clinical, process, safety, and economic outcomes will be collected and a concurrent economic evaluation undertaken.