Executive Summary

Noting that there are far too many falls in healthcare settings, The Joint Commission (TJC) has issued a Sentinel Event Alert, telling hospitals and other providers to take steps to identify patients at risk for a fall, and implement preventive interventions. However, while most falls occur in hospitals, preventing falls in the emergency setting presents some unique challenges.

  • Since 2009, TJC says it has received 465 reports of patient falls with serious injury, and more than half of these have resulted in death.
  • Most fall risk assessment tools are too cumbersome and take too long to complete at triage in the ED.
  • The ED at Hartford Hospital in Hartford, CT, has implemented a streamlined risk assessment tool with just five “yes or no” factors for the triage nurse to consider.
  • In concert with the risk assessment tool, the hospital has implemented a series of prevention interventions, including hourly rounding, bed alarms, post-fall huddles, and a non-punitive culture for reporting falls.

Underlying infections cited as possible cause of many falls

New research suggests that underlying infections, rather than slippery floors, dementia, or other more commonly cited factors, may in fact be the root cause of many falls that lead to ED visits or hospitalizations. The provocative findings were reported in October at IDWeek, a meeting that is held jointly by the Infectious Diseases Society of America, the HIV Medicine Association, the Society for Healthcare Epidemiology of America, and the Pediatric Infectious Diseases Society.

The findings stem from a retrospective review of 14 years of electronic medical records at Massachusetts General Hospital (MGH) in Boston. The researchers, led by Farrin Manian, MD, a hospitalist at MGH, identified 161 patients who presented to the ED for a fall and were hospitalized for their injuries, but were later found to have a coexisting systemic infection. The most common bugs cited were urinary, bloodstream, and respiratory infections.

Manian reported that the signs of infection in these patients were often subtle. Only 20% had a fever upon their initial examination and just 44% showed signs of a systemic inflammatory response. However, the investigators noted that in many cases, both the falls and the infections were quite serious. Close to 19% of the patients experienced a fracture from their fall, and nearly 40% had bacteremia. Further, 18% of the patients died while in the hospital.

Investigators reported that signs of altered mental status were apparent in as many as 25% of the patients upon admission. However, they said only a small number of family members observed such changes before the fall. Manion suggested that providers need to be more attuned to the subtle signs of infection in patients who have fallen. Further, if family members are made aware of such signs, it may be possible to prevent falls though earlier detection.

The average age of the identified patients was 76, but the investigators noted that 18% were younger than 65, including some in their 30s. Most of the patients still lived in the community (78%). The researchers said only 9.3% of the patients came from extended-care facilities, and just 8.1% had dementia.

While this is just a single-center study, Manian is hoping to investigate the issue further through a multi-center analysis.