In our May 29, 2012 Patient Safety Tip of the Week “Falls, Fractures, and Fatalities” we briefly mentioned that the inpatient psychiatric/behavioral health unit is one area in which attention to fall risk tends to be less than optimal. Yet the risks on such units may be as great or greater than on even med/surg units or rehab units.
The Pennsylvania Patient Safety Authority published a “snapshot” of falls in behavioral health hospitals compared to other hospitals for the year 2009 (PPSA 2010). Falls accounted for 21.7% of submitted reports in behavioral health hospitals compared to 15.4% in non-behavioral hospitals. A greater percentage of medications related to falls were reported by behavioral health hospitals than other hospitals (70.3% versus 57.6%). Moreover, patient harm was more likely in falls in behavioral health hospitals (9.6% compared to 3.7% in non-behavioral health hospitals).
So why do patients on psychiatric inpatient units fall? Clearly many of the same risk factors for falls in any inpatient setting contribute. But there are also some risk factors and contributing factors that are unique to the inpatient psychiatry unit.
One obvious factor is simply the level of activity on the psychiatric unit. Compared to med/surg units where patients are largely confined to bed or chairs (even though we encourage early ambulation) patients on behavioral health units are usually much more active. Hence the increased risk for falls may simply be related to this increased opportunity to fall. Scanlan et al. (Scanlan 2012) looked at activity during falls and found that the majority occurred on walking or transferring. Location of falls was most often bedrooms, outdoor areas, corridors and bathrooms.
The VA National Patient Safety Center, which does a great job of aggregating lessons learned from RCA’s across the VA system, put together such lessons learned as they pertain to falls on behavioral health units (Lee 2012). They noted that falls most often occurred as patients were getting up from bed or a chair or wheelchair, walking/running, bathroom-related, or behavior-related. The most common root causes they identified were environmental hazards, poor communication of fall risk, lack of suitable equipment, and a need to improve the system of falls assessment.
Lee et al. point out that patients on behavioral health units are at risk for falls for a number of reasons. Most importantly, they are on a variety of medications that may increase the fall risk (antipsychotics, antidepressants, sedative/hypnotics, and others). Some may be confused or agitated. Others may have impaired gait or balance, sometimes as a result of extrapyramidal side effects of their medications. Many of the medications cause orthostatic hypotension. The elderly patient on the behavioral health unit is especially at risk for falls with injury. They also note that sometimes behavioral health units restrict use of canes or other devices that could assist ambulation because such might also be used as weapons.
The authors have numerous recommendations for ways to improve fall prevention on such units. One is assessing the environmental risks, using a checklist. Quite frankly we’d like to see a checklist-like audit tool for assessing all the risks they have pointed out, not just the environmental ones.
Because more traditionally used fall risk assessment tools have not been particularly applicable to psychiatric inpatients, Edmonson and colleagues (Edmonson 2011) have developed their own fall risk assessment tool for psychiatric inpatients. They identified 9 categories of fall risk factors from the literature, then determined how frequent those occurred in records of psychiatric inpatients who fell, resulting in a weighted tool for predicting falls in this population. They then administered this tool, the Edmonson Psychiatric Fall Risk Assessment Tool (EPFRAT), and a more traditional fall risk assessment tool (the Morse Fall Scale) simultaneously to an inpatient psychiatric population and found the EPFRAT had a higher sensitivity in predicting falls and comparable specificity. This tool is very promising and is awaiting validation of its utility in other settings. We did find one site that has used it and successfully reduced falls in a psychiatric hospital after implementing the tool and model (Vermont State Hospital 2011). The nine domains in the EPFRAT are age, mental status, elimination (bowel/bladder), medications, diagnosis, ambulation/balance, nutrition, sleep disturbance, and history of falls.
Age, by itself, may not be a good fall risk predictor. In the series reported by the Pennsylvania Patient Safety Authority (PPSA 2010) the average age of patients with falls in behavioral health hospitals was 45 years old, compared to 65 years old for those with falls in other hospitals. We suspect this may to some degree reflect the demographics of behavioral health hospitals but it may also reflect the other risk factors unique to this population and setting. In general, we see fall risk increase with increasing age. Other studies (Scanlan 2012) have shown higher fall rates in psychogeriatric units. However, many studies have found that age, per se, is not an independent risk factor for falls but rather older people are more likely to have multiple comorbidities and conditions that predispose to falls and are more likely to be on multiple medications. Also, the elderly are more likely to have the multiple sensory deficit syndrome. That is where deficits of such senses as vision, hearing, proprioception, etc. are individually not sufficient to causes falls but collectively do pose a significant fall risk.
Sleep disturbances are common on inpatient psychiatric units and may increase the fall risk. Keep in mind that sedative/hypnotic medications are at the top of the list of medications commonly increasing the risk for falls.
Primary psychiatric diagnosis may play a role related both to both the diagnosis and the treatment for that diagnosis. Depression is a risk factor for falls, at least in the elderly. One metanalysis showed an odds ratio of 1.63 for the association between depression and falls (Deandrea 2010). But the relationship is very complex and bidirectional (Iaboni 2012). The psychomotor slowing and fear of falling in depression may lead to falls but treatment with antidepressants may also lead to falls. In a metanalysis of relation of medication classes to falls in the elderly antidepressants had an odds ratio of 1.68 (Woolcott 2009). Antidepressants may lead to falls via either causing orthostatic hypotension or by their effects on cognitive function.
Similarly, patients with acute psychosis or the manic phase of bipolar disorder may be predisposed to falls either because of the increased physicial activity and clouded mental status or because of the medications used to treat these conditions. In the study by Lee et al (Lee 2012) the authors noted that as root causes both undertreatment and overtreatment. The “undertreated” patients had falls related to agitation, etc. But patients with acute psychosis are often treated with multiple drugs that increase the risk of falls. Some are sedating drugs used to treat agitation or anxiety. Others are antipsychotic drugs that may have extrapyramidal side effects which affect gait, balance, and reaction times.
Estrin and colleagues (Estrin 2009) did a retrospective analysis of fallers vs. matched nonfallers at a psychiatric inpatient facility and looked at a variety of potential variables that might predict falls. Fallers were more likely to have an acute medical condition at the time of the fall, to have more physical symptoms on the day of the fall, and to be on more medications. They were also more likely to have urinary frequency or incontinence, generalized weakness, dizziness, mental status impairment, history of falls within 90 days, history of syncope and history of impaired mobility. However, after multivariate logistic regression analysis only summed physical complaints on the day of the fall and current clonazepam use held up as independent predictors of falls.
An important point made by Estrin and colleagues (Estrin 2009) is that tools with low specificity for predicting falls (i.e. a high percentage of false positives) may have a “desensitizing” effect on staff. Given that just about every patient on an inpatient psychiatric unit is on one or more drugs that increase their fall risk, almost all inpatients could be classified as being at high risk for falls. That, of course, could justify some of the general fall prevention interventions you might consider on a psychiatric inpatient unit (eg. non-slip footware, beds low to the ground, bedside mats, etc.) but it doesn’t really pick out those who need more specific individualized interventions to prevent falls. We discussed the issue of general vs. individualized fall risk assessment in our August 4, 2009 Patient Safety Tip of the Week “ ”.
We could find no good reviews on the role of time of day of falls on psychiatric inpatient units. Logically, one might expect more to occur at night because of factors such as poor lighting, need to get out of bed for toileting, sleep disturbances, etc. An increased frequency of falls has been reported at night in a psychogeriatric hospital ward (Tangman 2010). Another inpatient psychiatric unit discovered that falls were occurring during shift report and this improved when they divided up report into two separate groups so that one group of nurses was always with the patients (Lusky 2008).
In our December 22, 2009 Patient Safety Tip of the Week “Falls on Toileting Activities” we noted that almost half of falls in the nonpsychiatric hospital occur during activities related in some way to toileting. Falls on inpatient psychiatric units also often occur during toileting activities. Many of the fall risk assessment tools include urinary frequency and bladder/bowel incontinence as risk factors for falls. Of falls that took place on medical, surgical or mixed medical/surgical units in a community hospital only 6% of the falls actually occurred while getting on or off the toilet but most of the falls occurred when attempting to go from bed or chair to the bathroom or returning from the bathroom (Tzeng 2010). Such falls are especially likely to occur at night. While lighting issues may play a role, another root cause is not having enough staff to help such patients do their toileting activities before they go to bed. On a busy psychiatry inpatient service, where 20-30 patients may be on every 15 minute safety checks, staff often do not have adequate time to help those patients with their toileting activities. Note also that polydipsia, a common occurrence on psychiatric floors whether psychogenic or because of medication-induced dryness of the mouth, might lead to the need to urinate multiple times at night, further increasing the opportunity for falls.
Unfortunately, one of the dilemmas on inpatient psychiatric units is that there is sometimes a tradeoff between the fall risk and the suicide risk. Some of the bathroom assist devices we might use to help prevent falls (eg. grab bars) may be “loopable” items that represent a suicide risk. We don’t have good advice on resolving that dilemma.
Medications, of course, are a major risk factor for falls regardless of whether a patient is on an inpatient psychiatric unit or a med/surg floor. The total number of medications, regardless of type, is a risk factor for falls. But certain categories, most of which are commonly used on inpatient psychiatric units, are especially likely to be associated with falls. These include benzodiazepines, sedative/hypnotic drugs, antidepressants, antipsychotic drugs, and anticonvulsants.
Many of the drugs used on psychiatric inpatient units may have orthostatic hypotension as a side effect. And some patients may have underlying conditions or other medications that are associated with orthostatic hypotension. Yet virtually every inpatient psychiatric unit we’ve ever reviewed does inadequate monitoring for orthostatic hypotension. Moreover, most also fail to perform assessment for orthostatic hypotension appropriately. Our seemingly annual tirade on the appropriate way to look for orthostatic hypotension goes back to our April 16, 2007 Patient Safety Tip of the Week “Falls With Injury”. The proper technique for checking orthostatic signs is as follows:
On most inpatient psychiatric units that look for orthostatic hypotension they simply measure blood pressure going from the sitting position to the standing position. That will underestimate the magnitude of any orthostatic hypotension. Remember, the patient with orthostatic hypotension is most likely to fall when they get out of bed from the supine to standing position to use the bathroom.
The other major category typically used on inpatient psychiatric units are antipsychotic drugs that may have extrapyramidal side effects. These may affect gait, balance, and reaction times to increase the risk of falls. When these drugs are started the patient should be examined daily to identify the occurrence of extrapyramidal side effects and the fall prevention strategies modified appropriately as they occur.
One of the frequent root causes identified by Lee et al. (Lee 2012) was failure to adequately communicate the fall risk from caregiver to caregiver. It should be a part of the daily discussion during the multidisciplinary case conference on each patient. Fall risk must be addressed during all handoffs and should be a formal item on your standardized handoff tool.
The Lee study also notes that the culture on many inpatient psychiatry units is such that staff may not see psychiatric patients as medically ill and thus may overlook their need for assistance in avoiding falls. Yet we know that the underlying medical conditions may be contributory factors to falls in many cases.
We’ve also stressed the risks of falls that occur when patients are sent to the radiology suite (see our January 2010 What’s New in the Patient Safety World column “Falls in the Radiology Suite”). One of the items on your “Ticket to Ride” (or other structured tool you use to communicate various risks and concerns when you send a patient off to another part of the hospital) needs to be a flag for fall risk. Note also that some of the other items you’ll put on your “Ticket to Ride” (such as altered mental status, certain medications, etc.) may also infer an increased risk of falling (see our November 18, 2008 Patient Safety Tip of the Week “ ”).
Not only does fall risk status need to be communicated between nursing staff and ancillary staff but it must also be adequately communicated between physicians. In most psychiatric inpatient units the psychiatrist often attends to just the psychiatric needs of the patient and another physician or midlevel practitioner attends to the “medical” issues. The latter is often attuned to the fall risk but the psychiatrist, if not aware of fall risk at all times, may make alterations in the treatment plan that increase the fall risk. Hopefully, all such parties are represented at the daily multidisciplinary rounds to make sure they are all on the same page.
To summarize key action points:
Update: See also our Patient Safety Tips of the Week for December 3, 2013 “Reducing Harm from Falls on Inpatient Psychiatry” and March 14, 2017 “”.
Some of our prior columns related to falls:
April 16, 2007 “Falls With Injury”
January 1, 2008 “Fall Prevention”
October 7, 2008 “Lessons from Falls....from Rehab Medicine”
November 18, 2008 “ ”
August 4, 2009 “ ”
September 22, 2009 “Psychotropic Drugs and Falls in the SNF”
December 22, 2009 “Falls on Toileting Activities”
January 2010 “Falls in the Radiology Suite”
May 29, 2012 “Falls, Fractures, and Fatalities”
PPSA. Data Snapshot: Falls Reported by Behavioral Health
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Lee A, Mills PD, Watts BV. Using root cause analysis to
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Tzeng H-M. Understanding the Prevalence of Inpatient Falls Associated With Toileting in Adult Acute Care Settings. Journal of Nursing Care Quality 2010; 25(1):22-30
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