October 7, 2008
Lessons from Falls….from Rehab Medicine
Now that CMS is no longer paying for certain “never events”, it’s appropriate that our first Patient Safety Tip of the Week for October is on falls. We can learn some valuable lessons on falls from our colleagues in rehab medicine.
The nature of the medical conditions giving rise to the need for rehabilitation medicine services results in differences in the likelihood of falling compared to other typical acute care hospital services. Both the risk of falls and the risk of injury are higher on inpatient rehab units than on other acute care units. But the lessons learned are very applicable to all areas of the hospital. Lee and Stokic (Lee 2008) recently published a paper on the risk factors for falls during inpatient rehabilitation. They found that 9.5% of such patients fell at least once. Most falls occurred during the daytime (85%) and most occurred in the patient’s room (90%). But falls varied substantially by the type of diagnosis a patient was admitted with. A multivariate model showed high risk of falls with the following factors: diagnosis of stroke or amputation, age between 41 and 50, lower cognitive FIM scores, and large number of medical comorbidities. Most falls are also unwitnessed. In the Lee study, 74% of the falls were not observed.
The Lee paper also notes how the rate of falls is very dependent on the nature of the patient population and varies considerably among the different diagnostic groups. Patients with stroke and amputation were more likely to fall than those with spinal cord injury. Similarly, in an acute hospital population there is likely a considerable difference in fall rates between a hospital that does lots of obstetrics, pediatrics and behavioral health and one that does lots of trauma and orthopedic care. So it is very difficult to benchmark fall rates across hospitals without knowing details about the patient population. It is much more important to measure (and display for feedback) the fall rates on individual units of a hospital so that they can compare their own experience and trends from month to month.
One of the most interesting findings was that the risk of falls was greatest for the age range 41-50 years. Most studies on fall risk have found that the risk increases with age. However, if one uses appropriate multivariate logistical models, age often disappears as an independent predictor of falls. Rather, other risk factors that often appear with increasing age (eg. impaired mobility, impaired cognition) are the true underlying risk factors for falls. In fact, data actually suggests that increasing age may have a preventive effect on falls (Hendrich 2003) when considered as an independent risk factor.
The FIM (functional independence measure) score on admission to rehab may turn out to be valuable in predicting which patients are at risk for falls. The FIM scores in the Lee study showed that patients requiring moderate assistance with motor activities (those who could do 50-75% of activities on their own) may be at greatest risk for falls. Further research is needed to clarify the exact role of the FIM score as a predictor of falls.
In the Lee paper, the risk for falls among the more dependent patients actually increased as they gained more motor activities. On rehab, we are usually encouraging patients to do more for themselves and this may lead to an increased fall risk.
The Lee paper also notes that many of the unobserved falls that occurred in the patients’ rooms were related to the patient attempting to use the bathroom. It is well known that over half the falls which occur in hospitals are related to toileting activities. The Hendrich II Fall Risk Score includes male sex as a risk factor. We’ve never been quite sure whether that risk factor is due to macho vs. modesty. Particularly relating to the risk of falls during toileting, many males may have a “can do” attitude that increases their risk. Alternatively, since the nursing profession is still predominantly female, it may be that modesty keeps male patients from asking for assistance with toileting. At any rate, it is imperative to recognize which patients are at increased risk for falls and ensure that staff are available to assist those patients in toileting activities. Use of timed or scheduled toileting is a very useful tool. Hi-tech systems, such as alarms that trigger when a patient attempts to get out of bed, may be useful. However, see our June 19, 2007 Patient Safety Tip of the Week “Unintended Consequences of Technological Solutions” for an example where a hospital had to swap the nurse call button for the new alarm button and a patient fell when he tried to get out of bed after no one responded when he pushed the nurse call button!
All areas of hospital must understand fall risk and be able to identify which patients are at risk for falls. We’ve had several columns about the risk of adverse events in the radiology suite. That is an area where falls often happen. Patients are often on a gurney or a table or in a wheelchair and may fall when they attempt to get up to use the bathroom. They may be tethered to IV poles or other equipment that become obstacles to trip over. And they may have received benzodiazepines or other sedating medications for the radiology procedure, further increasing their fall risk. So it is critical that the fall risk of a patient is accurately conveyed to all staff when a patient is sent to radiology. This is another example of the hazards of handoffs (see last week’s tip of the week on handoffs). One way to facilitate this handoff would be to include information on fall risk in a structured communication tool for transports like the “ticket to ride” we described in our April 8, 2008 column. A new paper on use of the “ticket to ride” type checklist as a handoff tool (Pesanka 2008) also just appeared in the Journal of Nursing Quality. Also, as per this month’s “What’s New in the Patient Safety World” column, the movement toward color-coded wristbands is gaining momentum. The yellow wristband is the one that signifies the patient is at risk for falls in that system. However, do not use that color-coding convention unless all the hospitals in your area or state have agreed to that convention. And be wary that the yellow wristband does not get confused with the Lance Armstrong wristband commonly worn outside the hospital.
Don’t forget the importance of updating the fall risk. Most hospitals are very good at performing a fall risk assessment on admission. However, lots of things change during a hospitalization that may increase the fall risk (medications are the most obvious change that impacts the fall risk) and hospitals are not as good at recognizing those things. A good fall prevention program has fall risk assessments done on each nursing shift. And a good CPOE system has clinical decision support that may remind the physician about fall risk at the time of order entry (or has a rule that alerts nursing when a medication is added that may increase the fall risk).
We’ve previously discussed fall risk (see April 16, 2007 Patient Safety Tip of the Week “Falls with Injury”) and pointed out that the risk of injury is probably more important than the simple risk of falling, though a fall for a rehab patient may result in a fear of falling that could interfere with the rehab process.
See our January 1, 2008 Patient Safety Tip of the Week “Fall Prevention” for other tips on fall prevention. We’ve also 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.
Lee JE, Stokic, DS. Risk Factors for Falls During Inpatient Rehabilitation. American Journal of Physical Medicine & Rehabilitation. 1988; 87(5):341-353
Hendrich AL, Bender PS, Nyhuis A.Validation of the Hendrich II Fall Risk Model: A Large Concurrent Case/Control Study of Hospitalized Patients. Applied Nursing Research 2003; 16: 9-21 http://www.ahincorp.com/hfrm/ARTICLE.PDF
Hendrich II Fall Risk Model
Pesanka DA, Greenhouse PK, Rack LL, Delucia GA, Perret RW, Scholle CC, Johnson MS, Janov CL. Ticket to Ride: Reducing Handoff Risk During Hospital Patient Transport. J Nurs Care Qual. 2008 Aug 26. [Epub ahead of print]