In our January 2016 What's New in the Patient Safety World column “” we noted the reduction in overall hospital-acquired conditions that has occurred since 2010 as noted in a recent government report (AHRQ 2015). Notably, there was one salient HAC we did not comment on – falls. In fact, the reduction in falls between 2010 and 2014 was 0%. So there were no additional lives or dollars saved with respect to falls.
That is disheartening, given all the literature on fall risk assessments and various fall prevention interventions. On the other hand, it should not be surprising in view of the relative lack of strong evidence to show better patient outcomes resulting from these interventions.
A 2012 Cochrane review (Cameron 2012) concluded that limited evidence supports any one intervention and that more trials are needed to confirm the effectiveness of multifactorial interventions in the hospital setting. Another systematic review (Hempel 2013) also demonstrated the relative paucity of high quality evidence on fall prevention in acute care hospitals and pointed out many of the shortcomings in studies done. Frances Healey (Healey 2016), well-respected UK researcher on falls, has noted that high quality research on preventing falls in acute hospitals has been lacking and most studies showing a benefit of interventions have been at hospitals showing longer lengths of stay than we typically see in the US today (Oliver 2010).
In this regard, results of the recent 6-PACK fall prevention program (Barker 2016) in Australia are particularly disheartening. The 6-PACK program in Australia was a nurse-led targeted multifactorial intervention aimed at preventing falls and fall-related injuries in acute care hospitals. While previous studies had demonstrated multimodal fall prevention programs (some of which included elements of the 6-PACK but often including other elements) had reduced falls, the researchers felt that large scale randomized trials were needed to assess the robustness of the findings and generalizability. The 6-PACK program used a 9-item fall risk assessment tool and 6 specific interventions:
Randomization was done at the ward level rather than the patient level. The fall risk tool was updated at each shift by nurses and, if the patient was perceived to be at risk of falls, a “falls alert” sign was applied plus one or more of the remaining 6 intervention items. Patients on the “control” wards received usual care, which may have included some elements of the 6-PACK plus other interventions like no-slip socks and falls alert wristbands.
Use of all six 6-PACK interventions was three times more frequent on the intervention units. But despite the increased use of these fall prevention interventions, there was no improvement in either falls or fall-related injuries in the intervention group compared to the controls. It may well be that some of the chosen interventions (particularly the bed/chair alarms, low-low beds, and alert signs) have not had strong evidence in other studies.
Perhaps the real value of 6-PACK is that, in conjunction with a variety of other studies, it shows that we still have a long way to go in developing successful interventions to prevent falls and fall-related injuries. The study asks whether the considerable resources we now expend in acute care hospitals attempting to prevent falls might be better utilized on other patient safety issues.
The very insightful systematic review of fall prevention in acute care hospitals done a few years ago by Hempel and colleagues (Hempel 2013) noted that results of fall prevention interventions from long-term care settings may not apply to acute care settings because of increased acuity and short lengths of stay resulting in a greater burden on staffs. It then went on to review the quality and results of published studies on fall prevention interventions in acute care hospitals. Quite surprising was the overall poor quality of the studies (at least of what was reported in the studies) and the overall pooled analysis failed to show convincing results of interventions on patient outcomes. Almost all interventions targeted healthcare provider behavior rather than targeting patients directly. They noted several glaring shortcomings of many of the published studies. Most used multi-component interventions but many did not detail the individual components of those bundles. More than half used fall risk assessment tools that had not been validated. Very few included assessments of the adherence to the intervention components. And, perhaps most importantly, over half failed to note what fall prevention interventions were used in their control groups (either concurrent or historical comparators). While the majority of those published studies reported positive changes, there was considerable heterogeneity. They also noted that data on adherence to various strategies is also very relevant when it comes to the durability of the interventions over time.
In our October 27, 2015 Patient Safety Tip of the Week “” we discussed The Joint Commission’s latest Sentinel Event Alert “Preventing falls and fall-related injuries in health care facilities” (The Joint Commission 2015) which quantified the magnitude of the problem in acute US hospitals, including the morbidity and mortality and cost associated with falls. The most common contributing factors identified by TJC from sentinel event reports are:
Lack of adherence to protocols and safety practices has been problematic elsewhere. We’ve previously noted a recent audit of hospital falls in the UK (Royal College of Physicians 2015) which often found a disparity between policies and practices. For example, only a fifth of patients were able to access their call bell and a third could not safely access their walking aid (if they used one). In addition, only 16% had their orthostatic vital signs assessed.
We have stressed over and over is that fall risk is not a static characteristic. Patients acutely hospitalized have changes in their status daily or even hour to hour. So a patient might lack fall risk factors on admission yet acquire them during his/her hospital stay. It is for that reason that the fall risk assessment must be done at least daily, if not on every shift. For example, a patient lucid on admission may have developed delirium. Or a medication that produces drowsiness and predisposes to falls may have been added. Or a drug that has orthostatic hypotension as a side effect may have been added. Or a drug with extrapyramidal side effects may have been started. Or changes in a patient’s fluid status (mobilization of fluid from third spaces, addition of a diuretic, etc.) may have begun and might be expected to increase the frequency of the need to void, keeping in mind that over half of all falls occur on toileting activities. Or a patient may have simply progressed from being confined to bed to beginning to ambulate.
One thing that has become clearer over the recent past is that fall risk prediction scores have little value. Rather, fall risk assessments should be used to identify risk factors specific to each individual patient and the focus should be on modifiable risk factors.
Fall prevention strategies aimed at the entire hospital population (eg. proper lighting, proper footwear, non-slip and non-trip surfaces, etc.) still have a role but there is little evidence that things like labeling patients as high risk for falls with alert signs, tags, wristbands, etc. really has done much to prevent falls. The following are the universal fall precautions from the AHRQ falls toolkit:
Our October 2015 What's New in the Patient Safety World column “Patient Perception of Fall Risk” noted a study showing that over half of patients deemed by nurses to be at high risk for falls did not themselves perceive their risk to be high and many did not fear injury from falling. So, of course, patient/family education is always considered part of fall prevention programs but don’t expect too much from that alone.
So, keeping in mind that the evidence for single interventions in preventing falls is scant at best, what are the interventions for fall risk factors specific to the individual patient?
For those with cognitive impairment or delirium:
If your screening identifies a patient with delirium, use of multi-component interventions like the Hospital Elder Life Program (HELP) for Prevention of Delirium program, as discussed in our multiple columns on delirium, should be considered. Use of sitters may be necessary. The AHRQ falls toolkit notes that some hospitals have cohorted patients with cognitive impairments into designated areas that have enhanced staffing to observe patients more closely. One hospital implemented this strategy using “safety zones” consisting of four patient rooms with one dedicated staff member responsible for those patients, who checks on the patients every 15 minutes. The hospital originally adopted this model as a less costly alternative to a patient sitter program and found it reduced fall rates and improved patient and family satisfaction.
For those with impaired gait or balance:
Any needed assistive devices, such as canes or walkers, should be at the bedside and within safe reach. Staff should inspect any such assistive devices the patient brought from home to make sure they are safe for use in the hospital environment. Even with assistive devices, patients may need help from staff for mobility. Also note our March 2015 What's New in the Patient Safety World column “Another Paradox: Falls Due to Walking Aids” noted sometimes such ambulatory assist devices may paradoxically increase the risk of falling. That may especially apply when they are used in an unfamiliar environment. The AHRQ falls toolkit has a nice algorithm for mobilization of patients.
For those with urinary frequency, urgency, or incontinence:
In our Patient Safety Tips of the Week for December 22, 2009 “Falls on Toileting Activities” and June 9, 2015 “Add This to Your Fall Risk Assessment” we noted that almost half of falls in hospitals occur during activities related to toileting, most occurring when attempting to go from bed or chair to the bathroom or returning from the bathroom rather than when getting on or off the toilet. And, not surprisingly, most of those falls occur at night. While poor lighting at night is a major contributor to falls, staffing levels during evenings and nights may also contribute. In our December 22, 2009 Patient Safety Tip of the Week “Falls on Toileting Activities” we noted a study showing that most falls related to toileting activities occurred in patients already labeled as being at high risk for falls (Tzeng 2010) and another study (Krauss et al 2008) showing poor staff compliance with toileting schedules, even during a period of a targeted intervention. (Interesting: that is at least the third time in this column we’ve mentioned poor adherence to or compliance with recommended practices as being problematic in preventing falls!) Though toileting need should always be assessed during nursing hourly rounds, we’ve also suggested that perhaps the toileting needs of our patients might be better met by aides or staff other than nursing. Perhaps a specially-trained aide or team could work from 10 PM to midnight or 9 PM to 11 PM and just focus on ensuring all patients at high risk for falls get appropriate assistance toileting before they go to sleep. Keep in mind that such attention to toileting is also important in the patient at risk for delirium. Note that we have also mentioned the gender issue on several occasions. Many studies have identified male sex as a risk factor for falls. We don’t know if that is due to macho vs. modesty. If it is the latter, then male patients may be hesitant to ask a female nurse to help them to the bathroom. So consider having some male aides on your “team” to assist male patients with toileting as well.
In our June 9, 2015 Patient Safety Tip of the Week “Add This to Your Fall Risk Assessment” we noted the following things you should be doing to reduce the risk of falls in your patients who have frequency, urgency or incontinence:
For those on high-risk medications for falls:
Get them off those medications if possible! Fall risk should be reassessed whenever medications are changed or a new medication is begun. Alerts during CPOE generated by a clinical decision support engine might be useful in this regard. Our experience is that physicians often ignore and override alerts like these unless they are presented with alternatives at the time of order entry. So consider sending the alerts instead to your pharmacists, who may be in a better position to contact the physician with their concern and suggest alternatives.
For those with orthostatic hypotension:
To review our annual harangue on how to properly assess patients for orthostatic hypotension see our January 15, 2013 Patient Safety Tip of the Week “Falls on Inpatient Psychiatry”. Orthostatic hypotension in acutely hospitalized patients is often medication-induced (antidepressants, antipsychotic agents, antihypertensives, many cardiac medications, etc.) but may also be related to dehydration, volume depletion, and even “deconditioning”. Plus many diabetic patients with neuropathy may have some pre-existing orthostatic hypotension. So once you’ve identified orthostatic hypotension (and you have to look for it rather than waiting for a fall to trigger your doing orthostatic signs!) you need to review the medication list and see which medications you might eliminate or adjust. You also need to optimize fluid status. And you need to make sure all staff and family understand the patient is at risk when standing, so they don’t attempt to keep the patient upright when they shouldn’t.
For those with sensory deficits:
Notice we did not just say “those with vision problems”. As neurologists, we see the most common cause of dizziness and unsteadiness is actually the “multiple sensory deficit” syndrome. That’s where patients have impairment of vision, hearing, proprioception, and perhaps vestibular function, none of which should cause unsteadiness by itself but the cumulative effects lead to unsteadiness. So, yes, make sure your patients have their glasses but don’t neglect their hearing aids either.
For those with a history of frequent falls:
Obviously, in these patients you need to identify the reasons they fall and include the relevant interventions noted above. But some would also consider interventions such as low beds in these patients to minimize the risk of injury should they fall.
Wow! That’s a lot of recommendations for a topic for which we just said there is scant evidence of efficacy. Perhaps the key lessons from projects like the Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool for Preventing Falls are that you need to have a robust data collection program regarding falls in place, do root cause analyses to identify the most frequent causes or contributing factors to falls at your facility, then implement those fall prevention interventions that address your most frequent causes and address individual-specific risk factors, monitor compliance/adherence related to those interventions, and track the outcomes.
Hopefully, some day we will get better evidence regarding which interventions actually make a difference in prevention of falls in the acute care setting.
Some of our prior columns related to falls:
AHRQ (Agency for Healthcare Research and Quality). Saving Lives and Saving Money: Hospital-Acquired Conditions Update. Interim Data from National Efforts To Make Care Safer, 2010-2014. AHRQ 2015
Cameron ID, Gillespie LD, Robertson MC et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev 2012; 12: CD005465. 23235623
Hempel S, Newberry S, Wang Z et al. Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. J Am Geriatr Soc 2013; 61: 483-494
Healey F. Preventing falls in hospitals (editorial). BMJ 2016; 352: i251 Published 26 January 2016
Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med 2010; 26: 645-692
Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. BMJ 2016; 352: h6781 (Published 26 January 2016)
The Joint Commission. Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert. 55: 1-5 September 28, 2015
Royal College of Physicians (UK). The Falls and Fragility Fracture Audit Programme (FFFAP) 2015. National audit of inpatient falls. Audit report 2015
AHRQ (Agency for Healthcare Research and Quality). Preventing Falls in Hospitals. A Toolkit for Improving Quality of Care.
Hospital Elder Life Program (HELP) for Prevention of Delirium
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
Krauss MJ, Tutlam M, Costantinou E, et al. Intervention to Prevent Falls on the Medical Service in a Teaching Hospital. Infection Control and Hospital Epidemiology. Volume 29, Issue 6, Page 539–545, Jun 2008
Joint Commission Center for Transforming Healthcare. Targeted Solutions Tool for Preventing Falls.