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Patient Safety and Quality Healthcare
May / June 2006


Inpatient Falls:
Lessons from the Field

Preventing patient falls and related injuries in acute care settings has been an elusive goal for many hospitals. Falls are a high-risk and high-cost problem (human and fiscal) for all healthcare facilities. An estimated 30% of hospital-based falls result in serious injury (Stevens, 2004). Several factors have contributed to the complexity of sustaining true fall reduction and the avoidance of harm and injuries. An aging population, rising patient acuity, nurse shortages, and an inefficient work environment for caregivers can make any process improvement a challenge. Leadership plays an instrumental role in understanding the problem, establishing a safety climate culture, and improving the work environment of caregivers so that much needed direct nursing time for patient care can be increased.

Successful fall prevention programs have measurable attributes, which include:

  • research-based risk factors that are applied at the unit of care,

  • consistent attention to environmental hazards for all patients,

  • nursing and medical interventions aligned with reduction of fall risk factors for individual patients,

  • continuous learning about unit-specific fall occurrences derived from "good fall data," and

  • effective communication of patient risk and teamwork among caregivers and across units — no matter where the patient is in the hospital.

The literature describes a multitude of patient-fall risk factors, but only a few have been statistically validated from randomized, case-control, prospective studies. Prospective descriptive studies of inpatient falls contribute to the general knowledge of fallers but may over-target fall risk when controls (non-fallers) are not considered (Morse, 1997; Watson, 1994; Gluck, 1996; Oliver, 1997; Mendelson, 1996; Hitcho, et. al., 2004).

Many hospitals continue to use "home grown" lists of risk factors that have little scientific basis. Over time, the list of hospital-based risk factors often grows long, based on personal observations and opinions, and caregivers may feel overwhelmed. An exhaustive list that is not research-based may designate every patient as "high risk" for falling. Many of these lists have not been compared and statistically adjusted for suspected risk factors. It is necessary to measure risk factors in both fall patients and control patients who had same or similar risk factors but did not fall. This is the first step in identifying true risk factors versus suspected risk factors. For example, many risk-factor tools continue to use age as a discrete risk factor when age alone does not predict fall potential for an individual. There are just as many 70-year-olds who play golf and swim each day as those who fall. Age appears to be a risk factor because it is often correlated with the true risk factor of altered or ineffective gait and mobility (Hendrich, 1992; Hendrich, Nyhuis, Kippenbrock, & Soja, 2003).

Polypharmacy (more than six drugs) is a prevalent problem in American healthcare that contributes to fall risk. When individual drugs are added to risk factor assessments, over-targeting of fall risk can occur because side effects of drugs are very patient specific and highly variable. Extensive lists of drugs as part of a fall risk-factor assessment is one of the most common reasons for poor program compliance and staff dissatisfaction. The most common side effects of medications (especially in the elderly) include confusion/disorientation, altered elimination needs, dizziness/vertigo, and changes in gait and mobility. Two categories of drugs—benzodiazepines and antiepileptics—in and of themselves do cause an increased risk of falling and should be included in fall risk assessment when weighted risk factors are used (Hendrich, Bender & Nyhuis, 2003). Individuals react differently to medications; while it is crucial the caregiver knows the drug regimen, it may well be more effective to assess and predict fall risk based on the presence of drug side effects exhibited by the patient than by scoring the patient based on the drug alone.

No matter what tool is selected, it should be specific and sensitive to the population being screened and become part of professional nursing practice. The basic nursing assessment contains most if not all of the information needed to assess known risk factors before falls occur. Treating a fall risk assessment as an integrated component of an individual care plan is the first best step for proactive prevention of falls (Figure 1). Too often, fall prevention strategies begin after a fall occurrence, not before. This is a key reason why some fall programs fail to consistently reduce the overall fall index/injury rate over time. A reactionary fall program is one that depends upon a fall to signal reduction strategies instead of proactively seeking to reduce individual patient fall risk factors.



Figure 1. Hendrich II Fall Risk Model
© 2006 © Ann Hendrich, Inc. All rights reserved. Patent #11/059,435 Reproduction and use prohibited except by written permission from Ann Hendrich, Inc.

Environmental Safety
There are two types of fall risk factors, extrinsic or environmental and intrinsic or physiological. The majority of hospital adult falls are related to intrinsic causes, with fewer than 10% to 15% caused by the environment alone. In the pediatric populations (younger than age 10), the majority of falls can be clearly correlated with environmental causes such as cribs, rails, playrooms, and well intentioned but forgetful parents who leave children unattended or the side rail down while a child is alone.

Children's hospitals with high case-mix index and severely ill children will see a small percent of true intrinsic falls with similar risk factors as those in adults (confusion, weakness, dizziness). I am currently collecting data on this patient population.

Some well-known environmental safety measures for all types of patients include lighting, assistive devices, furniture, clinical alarm systems, housekeeping, properly fitted shoes and clothing, personal assistance when needed to enable safe transfers and patient movement, partial side rails, keeping patient rooms and hallways free of clutter, and keeping objects within reach of the patient. Most hospitals are able to demonstrate fairly consistent application of these basic safety measures. If more falls are occurring in this category, immediate action should be taken to create a safe room environment for the patient. These types of interventions are integral to most fall prevention programs, but comprehensive fall prevention programs don't stop at this level of practice.

Inefficient work processes (hunting and gathering supplies), the physical distance nurses travel on a hospital unit to care for patients, documentation time, and fragmented communication between caregivers can compound the inability of nurses to provide safe, effective care, resulting in ineffective fall prevention strategies. Programs such as the Robert Wood Johnson initiative, Transforming Care at the Bedside (TCAB), have demonstrated this can be changed when nurses are supported by their leadership team. Returning time to the professional nurse will improve patient safety and help to eliminate patient falls (Hendrich & Lee, 2004).

The continued migration of specialty procedures from acute care to the outpatient setting has raised the acuity and complexity of all acute care delivery units as care for those who are less sick moves outside the hospital environment. As a result, fall prevention has become increasingly challenging, and more patients are in fact at risk for falling. In the recent past, certain acute care areas considered themselves exempt from fall prevention programs given the patient population was at minimal risk of falling. Today, all areas of acute care hospitals must assess for fall risk if their goal is to eliminate harm and injuries from falls. The number of emergency department (ED) hospital admissions is very high—often 30% to 50% of all admissions come from the ED. Patient flow bottlenecks and full census may result in extended holding times for bed placement. As a result, the number of ED falls is increasing in many hospitals. These are the same patients who will be assessed as high risk for falling once they go to their hospital beds.

Individual Risk Factors
Comprehensive programs combine environmental risks with key strategies to truly reduce the risk of patient falls and fall rates. There is a direct safety benefit from targeting individual patient risk factors so they can be reduced or eliminated. More than 50% of all falls occur while patients are trying to get to the toilet, return from the toilet, and while trying to exit the bed to get to the toilet. It is a universal phenomenon, and it is the one most often overlooked. Alert patients who have fallen trying to meet elimination needs often report they felt concerned about asking for nursing help given how "busy" they perceive nursing staff to be. Regularly scheduled toileting of high-risk patients with impaired gait and mobility due to functional deficits or drug side effects will reduce falls in most acute care hospitals between 50% and 70%, yet this intervention is inconsistently applied.

Successful programs use the critical thinking of nurses to link research-based risk factors with specific nursing interventions to ameliorate the risk of falling. Because lack of assistance while toileting accounts for the majority of falls, some hospitals have utilized small paper clocks (with moveable hands) that can be used on doors of patients to signal the next toileting time based upon the patient's needs. The entire care team contributes to meeting this goal, and as a result the risk factor of altered elimination needs is removed.

Fall risk factors can be reduced, and a few, such as over-medication, can even be eliminated. Interdisciplinary teams (medicine, nursing, pharmacy, allied health) should carefully review and screen medications, dosages, and interactions while attending to medication reconciliation during hospitalization and in preparation for discharge. Most falls are predictable and preventable when risk factors are used to guide fall prevention strategies—only a very small percent of hospital falls cannot be predicted (seizures, drop attacks, cardiac arrhythmias, stroke).

Continuous Learning and Good Fall Data
Developing an effective fall prevention program requires that clinical practice groups, shared governance councils, interdisciplinary care teams, and leadership work together to develop best-practice guidelines and adult-learning techniques and program components. Research-based risk factors provide a core element, but specialized nursing units and patient case-mix requires application of the risk factors unit by unit. For example, falls in the obstetrical population are different than those in the behavioral care area. Nurses and care teams will know best how to apply fall risk factors and prevention strategies in a way that compliments practice and makes sense.

Reliable fall data that include fall index and injury rates by unit and hospital are necessary to support a successful fall prevention program. The advent of event-reporting systems has increased the amount of data that can be collected. While this can be very helpful, it can result in being "data rich but information poor," by consuming large amounts of nursing time and providing more data than necessary to answer four basic questions:

  • Who fell?

  • When did they fall?

  • Where did they fall?

  • Why did they fall?

If the data is to be meaningful for unit-based committees, attention must be paid to how it is categorized and entered into the system. For example, "found on floor in room" is a common data entry category that can mask the true cause of the fall if other discriminators and mapping aren't included. The patient may have been found on the floor, but one also needs to know what he or she was doing just prior to the fall. Was the patient trying to get to the toilet to meet elimination needs? Good data enables continuous plan-do-check-act cycles of small improvements in the program. The ideal response to a fall is an immediate "team huddle" on the unit, so caregivers can quickly evaluate and learn as a team how to remove the fall risks.

Using a standardized definition of a fall is also necessary to have valid and reliable data to make program improvements. Assisted falls (those who were assisted to a seated or floor position) should be categorized as a "near miss" to avoid falsely concluding that a patient fell without assistance, even if the organization requires it to be logged as a fall occurrence.

Effective Communication
Successful programs also work to assure the fall risk is communicated to the entire care team regardless of where the patient is within the hospital. For example, visual clues (arm bands, stickers, colored socks) can help to communicate fall risk in a specific unit, but if the radiology department is not knowledgeable about this component of the fall program, patients transported to this area will be at risk. Patients still move two to three times between nursing units due to change in conditions and/or testing (Hendrich, 2005). High reliability organizations assure that patient needs and access to patient information is not hindered by patient location. Frequent fallers (those who fall more than once) have often been negatively impacted by the failure to communicate risk among members of the care team.

Interviews with patients who have fallen often show that they did not understand their own personal risk, and staff failed to involve the family. Speaking directly and clearly about fall risk to patients and their families can help to reduce personal risk taking that contributes to falls. Letting the patients know they may suffer a minor injury, a permanent injury, or even a fracture as a result of fall should be considered as a possible element of effective patient education. Patients with symptoms of confusion, depression, or dementia will benefit from continuous monitoring (chair and bed alarms and visual or remote monitoring) to assure they do not attempt to get up without assistance.

Summary
Completing a fall risk assessment takes less than 1 minute of nursing time and is a crucial component of overall patient safety (Figure 1). All ancillary departments must also include a fall risk assessment to assure the same or similar standard of care and compliance with the Joint Commission Accreditation of Healthcare Organizations' Patient Safety Goals (2005/2006) related to falls. Few events have such devastating consequences as that of an injurious patient fall. Even when a physical injury is not present, the psychological fear of falling (fallophobia) in older adults can dramatically impact gait and mobility, causing secondary complications that affect the quality of life and health. Creating a comprehensive fall prevention program is within every hospital's reach when practical strategies and teamwork are used to provide a safe environment for care delivery.


Ann Hendrich is vice president of clinical excellence operations at Ascension Health in St. Louis, Missouri. She is a faculty member for the Institute of Healthcare Improvement, a board member for the Center for Health Design, and a frequent advisor to the Nurse Executive Center at The Advisory Board Company in the areas of hospital/health environmental designs, care delivery models, strategic use of technology, and computer-based-simulation learning modules. Hendrich was selected for a 3-year Robert Wood Johnson Executive Nurse Fellowship in 1998 with a focus on lean manufacturing and the Toyota Production system. She may be contacted at [email protected].

References

Gluck, T., Wientjes, H. J. F. M., & Rai, G. S., (1996). An education of risk factors for inpatient falls in acute and rehabilitation elderly care wards. Gerontology, 42, 104-107.

Hitcho, E. B., Krauss, M. J., Birge, S., et.al. (2004). Characteristics and circumstances of falls in a hospital setting: A prospective analysis. Journal of Geriatric Internal Medicine, 19(7), 732-739.

Hendrich, A., (1992). Falls, immobility and restraints: A resource manual. St. Louis, MO: Mosby Publishers.

Hendrich, A., Nyhuis, A., Kippenbrock, T., & Soja, M. E. (1995). Hospital falls: Development of a predictive model for clinical practice. Applied Nursing Research, 8, 129-139.

Hendrich, A., Bender, P. S., & Nyhuis, A., (2003). Validation of the Hendrich fall risk model: A large concurrent case/control study of hospitalized patients. Applied Nursing Research, 9-21

Hendrich, A., & Lee, N., (2004). Effect of the physical design of workspace on efficiency and safety. In Committee on the Work Environment for Nurses and Patient Safety, Institute of Medicine, Keeping patients safe: Transforming the work environment of nurses. Quality Chasm Series (pp.248-275). Washington, DC: National Academy Press.

Hendrich, A., & Lee, A. (2005) Intra-unit patient transports: Time, motion and cost impact on hospital efficiency. Nursing Economics, 23(4), 157-164.

Mendelson, W. B., (1996). The use of sedative/hypnotic medication and its correlation with falling down in the hospital. Sleep, 19, 698-701.

Morse, J. M., (1997). Preventing patient falls. Thousand Oaks CA: Sage Publications.

Oliver, D., Britton, M., Seed, P., Martin, F. C., & Hopper, A. H. (1997). Development and evaluation of evidence-based risk assess-ment tool (stratify) to predict which elderly inpatients will fall: Case-control and cohort studies. British Medical Journal 315, 1049-1053.

Stevens, J. A. (2004). Falls among older adults-risk factors and prevention strategies. In falls free: Promoting a national falls prevention action plan (pp.318). Washington, DC: National Council on Aging.

Watson, M. E., & Mayhew, P. A. (1994). Identifying fall risk factors in preparation for reducing the use of restraints. Med/Surg Nurse, 3(1), 25-35.

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