We addressed some aspects of falls in our April 16, 2007 and July 17, 2007 Patient Safety Tip of the Week columns and also in our December 18, 2007 discussion about bed rails. Several additional publications shed additional light on the topic of falls with injury.
The UK National Patient Safety Agency in February 2007 published “Slips, trips and falls in hospital: the third report from the Patient Safety Observatory “. It provides some significant data on incidence, impact and cost of falls, circumstances of falls, risk factors and interventions. Though they report separately for acute hospitals, community hospitals, and mental health facilities, the overall rate of falls for hospitalized patients is 4.8 falls per 1000 bed days. The cost per fall obviously varies by the severity of any associated injury but they estimate the average annual cost related to falls for an average 800-bed acute care facility to be about £92,000.
Over 400 risk factors predisposing to falls have been identified and most falls result from a combination of factors. Older patients, particularly those over 80, are most vulnerable to both falls and to injury from falls. Only a minority of reported falls (about 5%) were actually witnessed by staff. What patients were doing when they fell: 24% were mobilizing, 23% were falls from bed, 14% were falls from a commode or toilet, 11% falls from trolleys, 5% falls from chairs, and 3% falls in bathrooms. Given the time spent in each activity, falls while using the commode or toilet seem to be disproportionately high.
They point out some very interesting findings. First and foremost is the use of fall risk scores. Very few have been validated in populations other than those in which they originated and most either over- or under-predict the risk of falls. Importantly, they were all designed to predict falls, which is not the same as preventing falls. So if a fall risk scoring tool is used, one must still look to see which risk factors are modifiable. Strikingly, the study quotes Dr. David Oliver, author of one of the most widely used tools (STRATIFY), as having become skeptical of the use of such tools.
They do note that multifactorial interventions have reduced falls by 18%. There are, of course, some potential benefits of reducing fall rates (such as improving patient confidence and independence) but the most important outcome indicator to monitor is falls with injury. Also, since many of the fall-related injuries are relatively minor scrapes, cuts and bruises, a good argument can be made the the the most important outcome indicator should be moderate or serious fall-related injury. But, in fact, there is almost no evidence in the literature supporting any intervention having a significant effect on the occurrence of fall-related injury.
There have been several articles in the past two months on fall prevention in the peer-reviewed literature. Von Rentein-Kruse and Krause(1) published a prospective cohort study on geriatrics wards that used a historical control and compared fall and injury rates before and after a multifactorial intervention. They found that the relative risk of falling was significantly reduced (RRR = 0.77) after implementation of the intervention but that the risk of injury was not reduced. Note that this degree of risk reduction is similar to that noted in the NHS study.
Coussement et al.(2) just published a meta-analysis on fall-prevention interventions in acute and chronic hospital settings and found no conclusive evidence that hospital fall prevention programs can reduce the number of falls or fallers. They noted more studies are needed to confirm the tendency observed in the analysis of individual studies that targeting a patient's most important risk factors for falls actively helps in reducing the number of falls. They also noted that these interventions seem to be useful only on long-stay care units.
Another recent meta-analysis, by Gates et al.(3), focused on older people in community and emergency settings rather than hospitalized patients. However, it focused on studies with multifactorial interventions similar to many of those used on inpatients. It also concluded that the evidence of improvement fall-related outcomes after such interventions is lacking. Again, most importantly, there is no convincing evidence that injuries are reduced by such interventions.
Thus, it is very clear that our evidence base is severely lacking when it comes to proven interventions that reduce the risk of injury from falls. Fortunately, there are ongoing programs actively seeking answers to the relevant questions.
IHI’s Reducing Harm from Falls initiative is already revealing some interesting findings. Some have found that the association between aging and falls is less strong than the literature would have us believe. Beverly Nelson, MS, RN, CNAA, Director of Nursing Practice Programs at MD Anderson Cancer Center instituted a fall prevention noted “Sometimes younger patients think they have more energy or strength than they do. That’s why we need to be vigilant about preventing falls for all patients.” She also noted “We discovered that many people who had had a particular kind of GI surgery were falling.” “Because these patients can develop diarrhea after surgery, we found that putting a bedside commode nearby reduced falls.” They also instituted hourly safety checks on that unit, in which a nurse checks on the patients and offers assistance with toileting or any other activity that requires patients to be mobile.
The WHO Collaborating Centre for Patient Safety and the WHO World Alliance for Patient Safety have proposed 5 new topics for Patient Safety Solutions that have been selected as priorities by the Collaborating Centre's International Steering Committee. Prevention of patient falls is one of those priority topics.
The Prevention of Falls Network Europe (ProFaNE) website has links to many useful fall prevention resources and has ongoing research into prevention of injuries from falls.
Update: See also our October 7, 2008 Patient Safety Tip of the Week “Lessons from Falls....from Rehab Medicine”