Preventing falls takes planning

By Marva West Tan, RN, ARM, FASHRM
Risk Management Consultant
MW Tan Communications
Marietta, GA

Patient falls continue to be one of the most common causes of hospital-related claims for damages. Although the severity of fall-related claims is typically not high, the frequency highlights a major patient safety concern and should make this problem a high priority.

The Centers for Disease Control and Prevention (CDC) considers falls among older adults (ages 65 and older) a serious public health problem because falls result in severe injuries, particularly hip fractures, increased mortality, decreased mobility, premature nursing home admission and significant health care costs. One of every three older adults falls each year. Fall rates within nursing homes and hospitals are even higher. With the aging population, falls among older, hospitalized adults will likely pose an increasing patient safety and liability risk in the near future unless more aggressive steps in fall prevention are implemented.

Recognizing this problem, the third Institute of Medicine study on the quality of health care lists fall prevention for the frail, older adult as one of its priority areas for national action. Luckily, there are substantial data on patients at risk for falls and a number of environmental, behavioral, and clinical approaches to fall reduction and prevention are available. Health care risk managers should use this information to develop a fall prevention program or update your past work.

One of the first tasks is to identify patients at risk of falling. Major risk factors for falls include muscle weakness, history of falls, gait or balance deficit, use of an assistive device including a cane or walker, visual deficit, arthritis, impaired activities of daily living, depression, cognitive impairment, age older than 80 years, environmental factors such as lack of bathroom safety equipment or poor lighting, and polypharmacy (particularly involving psychotropic medications, Class Ia antiarrhythmic medications, digoxin and diuretics.) The risk of falling increases dramatically when multiple risk factors are involved.

Define falls and establish a reporting system

Fall prevention requires a well-coordinated facilitywide approach to be effective. Consider some of the following steps for implementing or updating a program:

  • Form a multidisciplinary work group to develop and champion the institutional fall prevention program. Include representatives from nursing, medical staff, rehabilitative, social, pharmacy, and environmental services, risk manager and patient safety or performance improvement manager. The diversity of expertise will be invaluable due to the multifactoral causes of patient falls and needed interventions.
  • Collect data on patient falls including facts about the fall incident, the patient’s risk assessment, and any interventions in place. To assure that data are comparable, develop a definition of a patient fall that will be applied uniformly throughout the facility or health system.
  • Decide if you want to include in your fall definition the "almost falls" — situations in which a staff member assists or controls the patient’s unplanned descent to the floor.
  • Determine whether unwitnessed falls, i.e., patient found on floor, will be counted separately from witnessed falls.
  • Incorporate fall data collection in your institutional incident reporting policy and procedure. Collect adequate information so that you can analyze data by unit, shift, and other factors you deem important.
  • If existing incident report forms are inadequate to collect needed data, you may want to develop a supplemental "fall data" form.
  • Encourage complete reporting through creation of a blame-free atmosphere that emphasizes identifying opportunities to improve patient safety.
  • Be aware that improvements in your institutional incident-reporting system may create the perception of an increased rate of falls when the rate of reported falls increases.
  • Follow institutional confidentiality and privacy requirements in any data collection process.
  • Analyze data on an ongoing basis — initially to identify a baseline for planning and action and periodically to evaluate the effect of interventions.
  • Pay particular attention to falls that result in serious injuries, such as hip or pelvic fracture, and patients who fall more than once during the admission.
  • Identify performance improvements suggested by these adverse events.
  • Make sure all staff know to refer cases, as indicated, to the risk manager or patient safety officer.

While people are often interested in benchmarking the fall rate at their facility with other similar facilities, valid comparable data are difficult to locate in professional literature due to differences in definition of a fall, variations in thoroughness of incident reporting and different denominators used to calculate fall rates. One source for comparable data may be the facility’s ORYX-approved quality indicator program if fall-related measures and data are available. For patient safety and risk management purposes, it is probably more useful to track your own facility’s or health system’s fall rate, rate of serious injury and frequency and severity of fall-related litigation over time to attempt to determine if your fall prevention program is having the desired impact.

Clinicians can and must be involved with preventing falls, so your program should include a fall risk assessment, using a risk-screening tool, on all older patients as part of the nursing admission process. Physicians should also ask their patients about the occurrence of falls. For patients with a history of falls or an admission due to a fall, consider a more comprehensive medical evaluation of physical and other deficits, possibly including a physical therapy consultation. Use the fall assessment results to develop a fall prevention plan tailored to the patient’s needs and medical condition. The combination of the assessment and planned interventions are the essential elements of a fall prevention approach.

Consider use of color-coded patient identification bracelets to identify patients at risk for falls. Because of confidentiality and privacy issues, it may be advisable to obtain the patient’s specific written consent for this use of the bracelet.

Identify multifactoral interventions. There is a wide range of interventions that are being used to prevent falls. The fall prevention plan for an individual patient often includes several approaches. The major intervention categories include:

  • Environmental adaptations that include grab bars and safety call signals in patients’ bathrooms, use of nightlights, positioning beds in low position at night, using mats on floor near bed, decreasing clutter and electric cords on floor, and dry floors. Side rails can help prevent falls but also can be a factor in a fall if the patient tries to crawl over them. The evidence regarding the role of chair and bed alarms in preventing falls is not yet clear.
  • Medication review to reduce the number of medications the patient is taking particularly those that may impact balance or alertness.
  • Exercise training to improve strength, endurance, gait, and balance.
  • Training in correct use of assistive devices such as canes and walkers.
  • Visual interventions to correct deficits when possible. Encourage patients to use their prescription glasses and keep the lenses clean and smudge-free.
  • Footwear interventions such as use of fitted slippers with a firm sole rather than paper slippers or flimsy slip-ons.

Restraints must be used carefully

Restraint use and the role of restraints in preventing or causing falls are a controversial area and one that is heavily regulated. Follow your institutional policy regarding restraint use and required documentation carefully. Many institutions are working to move to a restraint-free environment.

Anticipating the patient’s behavior is an important part of designing a fall prevention plan. Patients often fall when they are attempting to fulfill a need, such as walking to the toilet, getting a drink of water or answering the phone. Patients who require assistance to ambulate should be placed on a defined toileting schedule whereby nursing staff, without waiting for a patient request, help patients to the bathroom or bedside commode upon their awakening, after meals and physical therapy and before bedtime. Patients on diuretics may require more frequent toileting. Phones, call bells, and water pitchers should be placed well within the patient’s safe reach.

Some other potential interventions that are being considered to reduce falls are bone-strengthening medications to prevent or treat osteoporosis and appropriate use of cardiac medications or cardiac pacing to prevent syncope.

Ongoing patient and environmental monitoring by nursing staff is crucial to effective implementation of any intervention plan and is probably as important to fall prevention as the use of any other technique. But providing adequate nurse monitoring presents challenges in creative staff assignments and delegation of care in these times of nursing shortages.

Unfortunately, while there is much published information about fall prevention techniques, there is scanty scientific evidence on those approaches or combinations of approaches that are most successful in preventing falls in hospitalized patients. Also, interventions vary in costs, which complicates the decision of what approach to use.

Education, good documentation are key

Though a fall prevention program may be structured in different ways, be certain to include these elements:

  • Educate staff about the institutional fall prevention program. Emphasize that success is dependent on participation by everyone. Refresh training on your incident reporting policy and procedures as part of this training. Repeat training twice a year, if possible, to keep people motivated. Use posters, newsletters, and other media to remind staff of fall prevention efforts and successes.
  • Educate patients and families on the risk factors for falls, the individualized plan to reduce the specific patient’s falls in the hospital and suggestions for fall prevention in the home. Involve the family, if possible, with creating a safe patient environment. A home assessment by occupational therapy could be very beneficial to increase home safety and prevent future falls for the high-risk patient.
  • Manage falls that do occur as you would other adverse events. Conduct an assessment of the patient’s condition, obtain any needed clinical care, document the occurrence objectively and report as required by hospital policy. Disclose information to the patient and family in accordance with the hospital’s disclosure of unanticipated outcomes policy. For falls that result in patient injury, risk management, after investigation and in cooperation with the facility’s liability insurer, may decide to make an early offer of settlement.
  • Document the fall risk assessment, any planned interventions, patient and family education, and ongoing patient monitoring carefully. While you may not be able to prevent all falls, be prepared to demonstrate that appropriate patient safety measures were taken. Flow sheets may simplify documentation of ongoing monitoring.
  • Provide feedback to administration, the fall prevention work group, medical staff, nursing units, and other involved services on the results of the fall prevention program. Aggregate fall data analysis, injuries and fall-related litigation can be used to inform them of the successes in reducing falls and to keep everyone interested in participating in the program.
  • Consider piloting the fall prevention program on higher-risk units before rolling the program out to the whole facility and other age groups. Revise the risk assessment and fall data collection tools and refine the program as indicated.
  • Keep assessing and updating the fall prevention program as more scientific evidence becomes available about the interventions that are most effective in preventing falls as well as those approaches which have been most successful in your facility.
  • Ongoing feedback and periodic publicity about the program are essential to obtain buy-in and continued support for the program. Sharing success stories can help build pride and staff participation as you strive to reduce falls in your facility.

Resources

  • Best Practices: Analysis of Hospital Claims Trends and Information on Factors Driving Claims, Health Care Update, June 2002, The St. Paul.
  • Centers for Disease Control and Prevention. Falls and Hip Fractures Among Older Adults and The Costs of Fall Injuries Among Older Adults at www.cdc.gov/ncipc/cmprfact.htm.
  • American Geriatric Society, British Geriatric Society, and American Academy of Orthopedic Surgeons Panel on Fall Prevention, Guideline for the Prevention of Falls in Older Persons. Journal of the American Geriatrics Society 2001; 49:664-671.
  • Institute of Medicine. Priority Areas for National Action: Transforming Healthcare; Guideline for the Prevention of Falls in Older Persons. Accessed at www.nap.edu.
  • Fish J. Using Nonclinical Evidence Practices to Face Complex Challenges; Guideline for the Prevention of Falls in Older Persons, National Patient Safety Foundation. Accessed at www.npsf.org.