ED falls not same as others, require different strategy

Falls occur in the emergency department (ED) with distressing frequency, but the typical fall prevention strategies that work in other areas of health care may not be so effective in this special setting. Emergency medicine professionals and risk managers are learning that one size does not fit all when it comes to reducing falls in the ED.

Methodist Hospital in Indianapolis is leading the way in addressing this particular challenge of fall reduction, and ED nurse Mary J. Ross, RN, BSN, CEN, says it has been difficult to even quantify and compare fall rates. Though there are plenty of data on falls in health care facilities, most of that information is not broken down by department, and there is little available that specifically applies to EDs, she says.

Ross and other nurses at Methodist decided to do their own literature search to break down some of the statistics in a way that would be useful in the ED, and they also drilled down in to Methodist's own fall numbers. They compared ED falls to falls in an inpatient setting, using the Hendrich II Fall Risk Scale, and the results were surprising. The patients who fell in the ED often did not fit the risk profile commonly used by inpatient units. (See box below, for more on the Methodist Hospital research.)

Study revealed unique aspects of ED falls

Research into fall reduction in the emergency department (ED) started in January 2006 at Methodist Hospital in Indianapolis. ED nurse Mary J. Ross, RN, BSN, CEN, provides this synopsis of the work:

The ED team implemented the quality improvement project using the Plan-Do-Study-Act model. Ross and her colleagues studied all patient falls in the Methodist ED for a two-year period from Oct. 1, 2003, to Sept. 30, 2005. One goal was to apply the Hendrich II Fall Risk Scale retroactively to determine if it would have accurately predicted the falls. In addition, the team collected data on type and severity of injuries sustained in the fall, the use of side rails, the location within the ED of the fall, intoxication, prior history of falls, ED diagnosis, and whether the patient was admitted or released.

There were 57 falls by 56 patients during the study period. The total ED volume was 190,000 visits, meaning there were 0.3 falls per 1,000 visits. The average age of the ED fall patient was 50.3 years, and 66% were male. Intoxication was a factor in 55% of the falls. Sixty-six percent of those who fell were admitted to the hospital (not because of the fall). Thirty-four percent had minor fall-related injuries, and there were no serious injuries.

The analysis revealed that only 37.5% of those who fell in the ED would have met the Hendrich II parameters for a fall risk (scoring 5 or greater on the Hendrich II risk factors). Confusion and male gender, two of the risk factors used on the Hendrich II, were confirmed as risk factors in the ED.

Ross and her colleagues concluded that relying on the Hendrich II for identifying patients at risk of falling in the ED can be misleading.

For starters, the patients were much younger, reflecting the more varied age groups that appear in the ED and not the elderly patients that are most often at risk of falling on inpatient units. The falls in the ED also were likely to have alcohol or drugs in their system — not a typical risk found elsewhere in the hospital.

Like many hospitals, Methodist relies on the risk factors in the Hendrich II Fall Risk Scale to identify patients at risk for fall so preventive measures can be taken. The eight risk factors are confusion and disorientation, depression, altered elimination, dizziness and vertigo, male gender, prescribed use of anti-epileptics, prescribed use of benzodiazepines, and altered mobility. Looking back on the patients who fell in the Methodist ED, Ross and her colleagues found that the Hendrich II Fall Risk Scale did not accurately predict they would fall.

It was interesting to see the numbers. We're all trained to watch for falls with the elderly patients and those who are confused," Ross says. But that's not who was falling in our ED. It was patients who were intoxicated or medicated. The conclusion was that the typical fall reduction plan that works elsewhere in the hospital might not work here."

Ross and her colleagues used those findings to develop a fall reduction plan that is specific to the ED. (See box below, for details of the fall reduction plan.) In addition to warning ED staff that the risk profile is different than elsewhere in the hospital, Ross explains to them that location and type of falls are not the same. In most inpatient units, for instance, falls often occur from the bed, and guardrails are a key prevention strategy. Not so much in the ED. Most patients were falling in the hallway, and guardrails didn't help us," she says. It was when they were moving about, most often slipping in their own urine."

Action plan calls for red footies, special signage

The emergency department (ED) at Methodist Hospital in Indianapolis recently implemented several fall reduction strategies that are specific to the risks found in their patient population. ED nurse Mary J. Ross, RN, BSN, CEN, provides this overview of the effort:

• ED-specific staff training on fall reduction.

The ED staff undergo special training to recognize patients at risk of falling, with an emphasis on watching confused and intoxicated patients. All of the ED staff were inserviced on fall reduction at five staff meetings in June, and Ross also looks for ongoing opportunities to remind people, such as when orienting new staff. Triage staff receive extra education because they have the opportunity to identify a patient as a fall risk from the first moment they enter the ED, Ross says.

• Updated risk profiles.

In addition to the standard profile of a patient at risk for falling, staff are instructed to watch for patients who are intoxicated or medicated, confused or disoriented, and acutely ill or likely to be admitted. Those risk factors were identified from the analysis of falls at the Methodist ED.

• Fall risk signs.

Special signs are used to designate a patient as a fall risk. The sign says "Identify patients at risk for falls!" and lists the most common risk factors. It also instructs staff to activate a warning icon in the computer system. A copy of this sign is placed on the patient's stretcher or hung on the door to the exam room.

• A special fall risk icon in the computer tracking system.

Once a patient is identified as a fall risk, a special icon on the electronic tracking board notifies all staff. The icon uses the same graphics as the fall risk sign to encourage instant recognition.

• Red footies.

Any at-risk patient who undresses or is without footwear is given special red disposable footies that identify him or her as a fall risk.

• Warnings to patient and family.

When a patient is at risk of falling, staff warn the patient and family members. The patient is instructed not to get up without assistance, and a call button is always within reach. Staff members accompany these patients to and from the bathroom.

Ross says the ED staff are embracing the new approach to reducing falls, though as with all new approaches, there was delay as people got used to the new way of doing things. One positive aspect of the work was that the research confirmed what a lot of experienced ED staff already knew. A lot of staff knew that the intoxicated patient was most likely to fall, so in that sense this work vindicated their experience, which didn't always match with the risk profile they were told to use," she says. I think the results mostly surprised people outside the ED, the administrators who think in terms of the general patient population and not this different group of patients that we deal with in the ED."

Research highlights unique part of ED

Clarian uses the Safe Passage approach to patient safety, which includes having champions in each unit to promote safety initiatives and other risk management activities, and Ross is the representative in the ED. She collaborated on the fall reduction project with Kathryn Davies, RN, BC, MSN, patient safety clinical nurse specialist with Clarian Health Partners in Indianapolis. Davies is responsible for many risk management activities for Clarian, including fall reduction, and she says the ED initiative was an eye-opener.

There's a tendency to want to think that once we've addressed a problem, we've addressed it for everybody in the hospital," she says. That's not always the case, and the ED research showed just how different some of the patients can be in that area."

Davies notes that in addition to the difference in patients, an ED can be a hard place to implement some of the typical fall reduction strategies used elsewhere. The Methodist ED is a Level 1 trauma center, for instance, so it can be a challenge for staff to monitor patients as much as you might find on other units. We were really pleased to see that the ED staff delved deeper into the numbers to find meaningful data, rather than just looking on the surface," Davies says. Falls are such a big problem in health care, so this kind of innovation can have a major impact."


For more information on preventing falls in the ED, contact:

  • Kathryn Davies, RN, BC, MSN, Patient Safety Clinical Nurse Specialist, Clarian Health Partners, 1801 N. Senate Blvd., Indianapolis, IN 46202. Phone: (317) 962-2000. E-mail: KDavies@clarian.org.
  • Mary J. Ross, RN, BSN, CEN, Emergency Medicine Trauma Center, Methodist Hospital at Clarian Health Partners, 1801 N. Senate Blvd., Indianapolis, IN 46202. Phone: (317) 962-8355. E-mail: MJRoss@clarian.org.