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Download a PDF of the Current Issue 2015 Volume 12 Number 3 July- September

Falls in the Acute Care Setting

Keith M. McKernan, RN, LHRM, MA, CEN

Falls are one of the most common adverse events leading to injury in hospitals (Krauss et al., 2007). Fall rates in acute care hospitals range from 2.3 to 13 falls per 1000 patient days. Falls are more common on geriatric units, followed by medical units and surgical units. Predictably, specialized units such as stroke rehabilitation units or geriatric psychiatric units have the highest rates of falls. The majority of these falls occur in patients aged 65 years and older (Mertens, Halfens, & Dassen, 2007). According to Lyons (2005), hospital units staffed with less experienced nurses have higher rates of falls than units staffed by more experienced nurses. Reasons for falls include such factors as gait instability, altered mental state, urgency, incontinence, a history of falling, use of medications such as sedatives and hypnotics, use of restraints, slippery high-gloss floors with excessive glare, and an environment unfamiliar to an acutely ill person (Milisen et al., 2007). In the pediatric patient population, the reasons for falls differ (Razmus, Wilson, Smith, & Newman, 2006). Contributing factors include medication use, a new environment, and underlying medical conditions that can hinder orientation and understanding of children (Cooper & Nolt, 2007). Injuries from falls commonly occur because of developmental risks (Razmus et al., 2006), but as with adults, the pediatric patient also may attempt to get out of bed without help. Certain activities are associated with falls. Krauss et al. (2007) report that 82% of hospital falls occur in the patient’s room, 85% are unassisted, and 47% are associated with toileting-related activities. Data from the Pennsylvania Patient Safety Reporting System (PA-PSRS) shows that 6.6% of falls occurred while the patient was ambulating, 5.7% while lying in bed, and 5.6% while toileting. Approximately 30% to 40% of hospital falls result in injury. Estimates of the number of falls that result in minor injuries vary from 30% (Milisen et al., 2007) to 42% (Krauss et al., 2007). Milisen et al. (2007) estimate that 15% result in serious injury or death and Krauss et al. (2007) estimate this number to be 8%. The types of injuries that result include scrapes, bruises, skin tears, and lacerations. More serious injuries such as concussion, subdural hematoma, and fractures such as hip and femur, also occur. Fractures, especially in the elderly population, can have a devastating effect on the individual’s health. Holloway (2006) reports that more than 24% die within a year of the fall and 50% never return to their prior level of functioning. The toll of falls includes more than physical injuries. Some consequences include fear of falling, social isolation, anxiety and depression, and loss of confidence (Milisen et al., 2007). The cost to hospitals and patients is significant. The cost of treating serious fall-related injuries is between $15,000 and $30,000 per fall. This totals $1.08 billion to hospitals annually to treat injuries sustained in falls. One estimate is that in the United States, the total number of falls resulting in injury will be over 17 million by the year 2020 at a projected cost of $85.4 billion per year (Koh, Manias, Hutchinson, & Johnson, 2007). The costs do not include the recent revisions to the Diagnosis-Related Groups (DRGs) by the Centers for Medicare and Medicaid Services (CMS). Effective October, 2008, hospitals will not be reimbursed for some hospital acquired co-morbidities not present on admission, which includes fall-related injuries. Clinical Implications It is evident from the literature, that a clear definition of a fall is the first step in a fall prevention program. Lyons (2005) defines a fall as unintentionally coming to rest on the ground, floor, or other lower level from a standing, sitting, or horizontal position. Another definition distinguishes between assisted and unassisted falls. A patient fall is a “sudden unexpected descent from a standing, sitting or horizontal position, including slipping from a chair to the floor and an assisted fall (where an individual guides the falling individual to the floor), with or without injury to the patient (Cooper & Nolt, 2007). The National Guideline Clearinghouse™ (NGC) is a public resource for evidence-based clinical practice guidelines. It is an initiative of the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services (HHS). One guideline available is “Prevention of Falls and Fall Injuries in the Older Adult.” This guideline was originally developed by a panel of nurses with expertise in falls prevention, education, and research, representing institutional, long-term care, and academic settings under the auspices of the Registered Nurses Association of Ontario (RNAO) and published in January 2002. An update published in March 2005 was developed by a panel of nurses and other healthcare professionals, from a range of practice settings and academic sectors, with expertise and interest in falls and fall injuries in the older populations convened by the RNAO. The nurse practice recommendations supported by the strongest evidence include: ◆ Assessment of fall risk on admission. ◆ Assessment of fall risk after a fall. ◆ Strength training as a component of multi-factorial fall interventions; however, there is insufficient evidence to recommend it as a standalone intervention. ◆ Multidisciplinary team, implementation of multi-factorial fall prevention interventions to prevent future falls. ◆ Periodic medication reviews throughout the institutional stay to prevent falls among the elderly in health care settings. Patients taking benzodiazepines, tricyclic antidepressants, selective serotoninreuptake inhibitors, trazodone, or more than five medications should be identified as high risk. ◆ Consideration of the use of hip protectors to reduce hip fractures among those clients considered at high risk of fractures associated with falls; however, there is no evidence to support universal use of hip protectors among the elderly in health care settings. ◆ Inclusion environmental modifications as a component of fall prevention strategies. These practice recommendations do not include the methodology for assessing fall risk. The evidence in the literature shows that the Morse Fall Scale (MFS) and Hendrich II Fall Risk Model (Hendrich II) are not effective in predicting falls in children (Razmus et al., 2006). However,elements of the MFS were found to be predictive of falls and were used as part of a proposed new tool called the CHAMPS Pediatric Fall Risk Assessment Tool. The effectiveness of this tool has not been tested. The Hendrich II was shown to predict falls effectively in adults (Hendrich, Bender, & Nyhuis, 2003). Many studies describe fall prevention strategies for all age groups. It is important for hospital staff to select effective strategies for preventing falls that consider both extrinsic and intrinsic factors. Nursing staff are key to a successful fall prevention program and all should be knowledgeable about fall prevention strategies and actively participate in the development, implementation and evaluation of a facility’s fall assessment and prevention program. References: -Cooper, CL., & Nolt, JD. (2007). Development of an Evidence-based Pediatric Fall Prevention Program. Journal of Nursing Care Quality, 22(2), 107-112. -Hendrich, AL., Bender, PS., & Nyhuis, A. (2003). Validation of the Hendrich II Fall Risk Model: A Large Concurrent Case/Control Study of Hospitalized Patients. Applied Nursing Research, 16(1), 9-21. -Holloway, KAREN. (Ed.). (2006). Falls Prevention Strategies in Healthcare Settings. Plymouth Meeting, PA: ECRI. -Koh, SSLK., Manias, E., Hutchinson, AM., & Johnson, L. (2007). Fall Incidence and Fall Prevention Practices at Acute Care Hospitals in Singapore: A Retrospective Audit. Journal of Evaluation in Clinical Practice, 13(5), 722-727. -Krauss, MJ., Nguyen, SL., Dunagan, WC., Birge, S., Costantinou, E., Johnson, S., et al. (2007). Circumstances of Patient Falls and Injuries in 9 Hospitals In a Midwestern Healthcare System. Infection Control and Hospital Epidemiology, 28(5), 544-550. -Lyons, SS. (2005). Fall Prevention in Older Adults. Journal of Gerontological Nursing, 31(11), 9-147. -Mertens, EI., Halfens, RJG., & Dassen, T. (2007). Using the Care Dependency Scale for fall risk screening. Journal of Advanced Nursing, 58(6), 594-601. -Milisen, K., Staelens, N., Schwendimann, R., De Paepe, L., Verhaeghe, J., Braes, T., et al. (2007). Fall Prediction in Inpatients by Bedside Nurses Using the St. Thomas’s Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) Instrument: A Multicenter Study. Journal of the American Geriatric Society, 55(5), 725-733. -Razmus, I., Wilson, D., Smith, R., & Newman, E. (2006). Falls in Hospitalized Children. Pediatric Nursiing, 32(6), 568-572.