March / April 2012
Evidence-Based Methods and Tools Help Reduce Risk of Falls in Hospitals
Wider acceptance of practices, methods, and tools to prevent the risk of patient falls holds promise in preventing a serious, and often catastrophic, event for older Americans. Evidence-based practices that can lower the incidence of falls are especially important in light of the aging of the U.S. population and the federal government’s inclusion of injuries from falls that occur during a hospital stay as a “never event” whose additional costs are not reimbursed (Centers for Medicare & Medicaid Services, 2008).
Falls occur in a wide range of settings—in the home, hospital, and nursing and rehabilitation facilities. Their consequences are significant and costly. Fall-related injuries were responsible for more than 2 million emergency department visits among patients over age 65 in 2006, at a cost of approximately $7 billion for emergency and subsequent inpatient care, according to data from the Agency for Healthcare Research and Quality (AHRQ, 2009).
Studies on the prevalence of falls within hospitals suggest average rates of between 3 and 5 falls per 1,000 bed-days, with significantly higher rates occurring in rehabilitation and neurology units (Dunton et al., 2004). Of the 1.6 million residents in U.S. nursing facilities, approximately half fall annually, and of those, about 65,000 suffer a hip fracture (AHRQ, 2010).
Defining Who’s at Risk
In light of federal payment policy and the relationship between age and fall prevalence, it’s not difficult to understand why health providers may classify all patients based on age alone as being at high risk for falls. And indeed, the incidence of falls increases with age, especially for people over age 85.
Yet age alone tends to target too many patients and can blur the identification of intrinsic risks that are a more accurate predictor of falls, according to Ann L. Hendrich, RN, PhD, vice president at Ascension Health, St. Louis, MO, and the developer of a widely used fall risk assessment tool (Hendrich, Bender, Nyhuis, 2003). She discussed her research findings on fall prevention in a recent edition of AHRQ’s Morbidity and Mortality Rounds on the Web (AHRQ, 2011).
Dr. Hendrich has identified these intrinsic risk factors as significant in predicting falls:
• Confusion or dementia
• Altered elimination needs
• Impaired gait and mobility (high predictive factors)
• Dizziness and vertigo
Out of hundreds of medications tested, only two categories, benzodiazepines and anti-epileptics, were independently associated with a statistically meaningful increase in increased risk of fall, her research has found. The common side effects of many other medications often used by elderly patients increase one’s intrinsic risk factors for falls, however.
With intrinsic risk factors in mind, what practices should health providers follow to identify high-risk patients on a typical medical-surgical unit?
Although all patients on admission should be evaluated for fall risks as part of a baseline nursing assessment, according to Dr. Hendrich, they should also be reassessed when their condition changes, such as when pain subsides and mobility improves following surgery. Care providers should score patients on the fall risk protocol and help determine the appropriate level of intervention, such as therapist-assisted walking or strength training during bed rest. Scores have also been used to identify and address the presence of intrinsic risk factors caused by dehydration or infections that might have gone undetected for longer periods of time.
Immediate and Long-Term Management
Screening upon admission and change of condition are also important elements of an evidence-based falls management program developed for nursing facilities by researchers at Emory University’s Division of Geriatric Medicine and Gerontology, Atlanta, Georgia, and Vanderbilt University’s School of Medicine, Nashville, Tennessee (AHRQ, 2010).
The program, funded by AHRQ, is intended to help nursing facilities provide individualized care and improve their fall care process and outcomes through education and quality improvement tools. It takes a two-pronged approach to managing falls and fall-related injuries by:
• Responding immediately to a fall through careful evaluation and investigation and intervention in the first 24 hours.
• Providing long-term assessment through screening at admission, change of condition, quarterly, and annually as well as developing individual care plans and revising as needed.
Clearly, this approach is not a quick fix and represents a challenge to many financially strapped nursing facilities. Yet the emphasis on creating a culture of safety and fostering interdisciplinary teamwork helps build an environment for nurses, nurse assistants, and therapists to work together to continuously assess and reduce residents’ risk.
Suggested roles and responsibilities for the administrator and director of nursing translate this concept into reality. They include:
• Appointing a nurse coordinator, back-up coordinator, and a falls team to meet weekly.
• Setting specific goals for the facility, using key indicators.
• Giving the falls team members time away from other duties to meet weekly and implement the program.
• Identifying and removing barriers that prevent team members from completing their tasks.
• Providing a small budget to repair safety problems in the facility and equipment.
• Monitoring progress and guiding data collection and analysis.
Reports from the literature offer examples of multiple, coordinated interventions that can significantly reduce the incidence of falls and fall-related injuries.
For example, as part of a year-long intervention, staff at James A. Haley Veterans Hospital, Tampa, Florida, a 327-bed tertiary care teaching hospital, implemented a bundle of interventions on two medical-surgical units. (Quigley, Hahm, Collazo, et al., 2009). Interventions sought to prevent falls and related injuries through patient education, identifying and intervening with high-risk patients, promoting patient comfort and safety, and convening safety “huddles” when a fall or near fall occurred. Specific interventions for high-risk patients included putting patients in a room close to the nurses’ station, using a chair and bed alarm, placing a mat on the floor at the side of the bed, and having those at risk of hip fracture wear hip protectors.
Both units saw a reduction in total falls after the program was implemented in 2007, as compared with baseline data from 2003 through 2005. Fall rates on one unit declined from 4.5 falls to 4.1 per 1,000 patient days, while the second unit saw reductions of 3.7 to 1.1 falls per 1,000 patient days. One unit completely eliminated fall-related injuries, while the second saw a more modest decline from 2.1 to 1.7 injuries per 1,000 patient days.
Reducing falls and fall-related injuries is hard work that demands leadership, clinical skill, teamwork, and vigilance. Evidence-based research has honed our ability to identify the clinical interventions that can make a difference. It is our job to put these findings into practice on behalf of our patients and to search for ways to build on the improvements we know can be achieved.
Carolyn Clancy is director of the Agency for Healthcare Research and Quality, Rockville, Maryland. She is a general internist and holds an academic appointment at the George Washington School of Medicine in Washington, DC. She may be contacted at
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