May 29, 2012 Falls, Fractures, and Fatalities
One of the purposes of the ongoing switch to ICD-10 coding is to provide much greater detail about medical illnesses and issues from administrative databases. The US ICD-10 CM has some 68,000 codes and the ICD-10 PCS, a procedure code system not used by other countries, contains 76,000 codes. One of the areas in which ICD-10 coding provides considerably more detail that ICD-9 coding is related to cause of death. Hu and Baker (Hu 2012) recently analyzed ICD-10 coding and demonstrated a significant relationship between falls and death. In the old system we might sign a death certificate with a cause of death something like “pneumonia” or “pulmonary embolism” and there would be no way to show that the patient really suffered these events after being hospitalized for a fall that resulted in a hip fracture. They found in seniors a 42% increase in falls as a cause of death between 1999 (when the ICD-10 was first implemented in their study) and 2007. They are quick to point out that this likely reflects an improvement in coding rather than an actual increase in falls leading to death. Nevertheless, it highlights how important falls are in relation to people dying.
We’ve discussed in previous columns fall risk and prevention on med/surg units and rehab units (see our October 7, 2008 Patient Safety Tip of the Week “Lessons from Falls....from Rehab Medicine”). We’ve also stressed the multiple substantial risks that occur in the radiology suite. One of those risks in radiology is that of patients falling from tables or gurneys or when they try to walk to a bathroom (January 2010 What’s New in the Patient Safety World column “Falls in the Radiology Suite”). That’s the reason we have strongly recommended that 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 “ ”). And, as a recent malpractice claim alleged (Christoffersen 2012) falls off any table where procedures being done are possible, particularly when patients get medicated for the procedure.
Another area where attention to fall risk tends to be less than optimal is the behavioral health unit. Yet the risks on such units may be as great or greater than on even med/surg units or rehab units. Fortunately the VA National Patient Safety Center, which does a great job of aggregating lessons learned from RCA’s across the VA system, recently 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. This topic is also a good one for a FMEA (failure mode and effects analysis) if you have a behavioral health unit.
Lastly, many of you are familiar with the QFracture algorithms. These were developed and validated to provide a prediction of the risk of osteoporotic fracture or hip fracture in primary care settings based upon data elements easily obtainable from the medical record or directly from the patient without the need to rely on special testing. Though the original algorithms worked well, a guidance from NICE (National Institute for Health and Clinical Excellence) had suggested additional risk variables might improve the tools. So multiple new potential variables were considered in a derivation population to develop new algorithms and validated in separate populations (Hippisley-Cox 2012). While many of the variables that proved to have predictive ability do impact osteroporosis per se, many probably exert their influence by increasing the risk of falls. We suspect that to be the case for variables such as diabetes and Parkinson’s disease. All classes of antidepressants increased the fracture risk. Epilepsy or treatment with anticonvulsants also increased the risk (not just those anticonvulsants known to promote osteoporosis). The updated QFracture®-2012 risk calculator is available online and allows you to predict the fracture risk over defined periods of time (1-10 years).
Hu G, Baker SP. An Explanation for the Recent Increase in the Fall Death Rate Among Older Americans: A Subgroup Analysis. Public Health Reports 2012; 275-281
Christoffersen J. Woman sues hospital over fall off operating table. Associated Press May 22, 2012
Lee A, Mills PD,
Watts BV. Using root cause analysis to reduce falls with injury in the
psychiatric unit. General Hospital Psychiatry 2012; 34(3): 304-311
Hippisley-Cox J, Coupland C. Derivation and validation of updated QFracture algorithm to predict risk of osteoporotic fracture in primary care in the United Kingdom: prospective open cohort study. BMJ 2012; 344:e3427 doi: 10.1136/bmj.e3427 (Published 22 May 2012)
QFracture®-2012 risk calculator: http://qfracture.org