Delirium is a risk factor for falls and falls in patients with delirium are particularly likely to result in injuries. A recent CDPH (California Department of Public Health) statement of deficiencies provides an example (CDPH 2017). A patient was admitted to an acute rehabilitation service following a stroke. Fall Risk Indicators assessed on admission indicated the patient was at high risk for falling. A sitter was ordered and an order was issued to assess assistance level required for safe/effective self care. Encourage functional activity performance with appropriate level of assistance based upon level of ability." (Keep in mind that on rehab services there is often a fine line between promoting fall safety and pushing patients to ambulate as part of their rehab program. We discussed many issues related to falls on rehab in our October 7, 2008 Patient Safety Tip of the Week Lessons from Falls....from Rehab Medicine.) The patient was receiving gait training and safe bed mobility and transfers with a four-wheel walker.
During the second week she was described as being uncooperative and combative. A sitter was in the doorway with a clear view of the patient. However, the sitter may have temporarily gone outside the room to get a nurse to assist in transferring the patient from a wheelchair to bed. The patient apparently arose from the wheelchair on her own and fell forward, striking her face on the floor. There was no loss of consciousness. Exam showed facial ecchymoses and blood coming from her mouth. No other head or neck injuries were noted. CT scan of the head showed a small amount of subarachnoid blood, felt to be most likely from trauma. The patient was transferred to the Trauma ICU for observation. Plavix and subcutaneous heparin, which she had been on prior to the fall, were held. A Consult-Liaison psychiatrist diagnosed delirium. She had a progressive decline in function and cognition and an impaired alertness level. Family decided she should be placed on comfort care. She died several months later. During the latter period she was described as moving from a hyperactive delirium to a profound hypoactive delirium.
Review by the CDPH found that, rather than having a 1:1 sitter as ordered, one sitter had been assigned to observe patients in two adjacent rooms. There were also issues regarding the training the sitter had for observing such patients (lack of proper training of sitters is a problem weve noted in several other columns). The sitter (a CNA) stated that she had gone outside the patients room to call for help in moving the patient but then saw the patient rise from the wheelchair and fall before she could get back to the patient. The Director of Risk Management stated the sitter should not have left the room and should have remained within arms distance of the patient so she could reach the patient if she stood up. Also, the patient had not already been diagnosed as having delirium and the patients combative and aggressive behavior should have led to a call to the physician for evaluation.
Unfortunately, the case example above is repeated at multiple hospitals every year. Timely recognition of delirium is important and patients with delirium can be very difficult to manage. Therefore, prevention and early recognition are important.
One healthcare organization recently published results of its years-long program on delirium and saw a substantial reduction in falls related to delirium (Ferguson 2017). A multidisciplinary team at Virginia Mason Medical Center developed a program for both prevention of and recognition and treatment of delirium. They used an EMR-based version of the CAM (Confusion Assessment Method) and the CAM-ICU tools to screen for delirium. This used nonpharmacological interventions that included efforts to minimize, treat, or prevent sensory deprivation or overload; impaired sleep-wake cycle; immobility; poor nutrition or dehydration; urinary retention; constipation; suboptimal pain management; deliriogenic medications; unnecessary lines or tethers; hypoxia; and alcohol withdrawal. Regular readers of our own columns (see full list below) will recognize those interventions as part of the HELP (Hospital Elder Life Program) or similar multicomponent programs used to prevent and manage delirium. An EMR-based form included questions about risk factors for delirium and CAM assessment was to be completed at least twice per day for every hospitalized patient. Rates of the latter increased from 9.5% at baseline to 86% over a 5-year period. Audits also revealed CAM accuracy ranged between 85% and 98% (average 91%).
The rate of delirium-related falls decreased from 0.91 per thousand patient days before the intervention to 0.75 per thousand patient days during the implementation, before stabilizing at a postintervention rate of 0.50 per thousand patient days. The rate of delirium falls with injury was too low for analysis. Overall hospital falls also decreased during the period from 2.58 to 2.03 per thousand patient days (P = .0007).
The authors also found that education related to delirium screening, prevention, and treatment and bedside tools such as The Language of Delirium (Puelle 2015) were vital foundational elements necessary to nurse and program success.
Falls related to delirium may be devastating. Programs like the one at Virginia Mason demonstrate that organization-wide nonpharmacologic multicomponent programs can substantially reduce rates of delirium-related falls. They also likely help mitigate the numerous other consequences of delirium that weve discussed in our prior columns. The Ferguson study did not report a cost effectiveness analysis of their program but wed be willing to bet that the savings accrued (not just from fall prevention but also from prevention of other consequences of delirium) likely exceeded the costs of implementing and maintaining the program.
Some of our prior columns on delirium assessment and management:
Some of our prior columns related to falls:
CDPH (California Department of Public Health). 2017. Intake Number CA00500940
Ferguson A, Uldall K, Dunn J, et al. Effectiveness of a Multifaceted Delirium Screening, Prevention, and Treatment Initiative on the Rate of Delirium Falls in the Acute Care Setting. Journal of Nursing Care Quality 2017; Published Ahead of Print: October 13, 2017
Puelle MR, Kosar CM, XU G, et al. The language of delirium: keywords for identifying delirium from medical records. J Gerontol Nur. 2015: 41(8): 34-42