Managing inpatient falls

The impact of inpatient falls is widespread. In an average 800-bed acute hospital trust there will be approximately 24 falls per week² and with underreporting this is a likely underestimate. On an individual level effects include physical disability, need for surgery and increased length of stay. Longer-term consequences include worsening of overall health, loss of confidence and independence and heightened pressure on families. Effects on staff and service include feelings of guilt and blame and subsequent reduced confidence in managing such patients, litigation and complaints, bed pressures and the enormous financial impact.³ The following discussion based around our multi-site inpatient audit aims to serve as a practical guide to targeting at risk individuals and avoid some of these high costs.Methods We conducted a retrospective audit in 2012 across two Glasgow hospitals. These findings led to the idea for this review and prompted further evidence search. A literature search was carried out for current clinical and best practice guidelines, reviews, trials and relevant publications. Online resources such as MEDLINE, Cochrane and Google Scholar were used in addition to Scottish Intercollegiate Guidelines (SIGN), National Institute for Health and Clinical Excellence (NICE) and British Geriatrics Society. We searched Medline and Google Scholar using terms €œfalls€, €œrisk factors for falls€, and €œfalls interventions or management€. Further specific researches were carried out to explore certain areas of this review.

   Who falls? Falls in the elderly population are a serious issue. The majority of inpatient falls occur in the elderly, mainly between ages of 75€“80 years.² In older adults, falls can be the result of a complex interaction between frailty, pre-morbid conditions, acute illness and environmental risks,⁴ compounded by behavioural issues. An unfamiliar hospital environment and encouragement to improve mobility will inevitably result in inpatient falls as an unavoidable consequence of rehabilitation.^5,6 The repercussions of falls cause psychological and physical complications for the patients and fear of recurrence. This makes this group of patients vulnerable and can impact on their progression and length of stay.

Why do patients fall? Risk factors for falls can vary depending on the population and environment of the patient group.⁷ In community dwelling older adults, standing balance can be a key factor in falls,⁸ whereas in hospitalised patients, different risk profiles appear to be in play. Morrison et al7 conducted a multicentre prospective longitudinal cohort study looking at falls risk factors across inpatient, outpatient and rehabilitation settings. Despite variability in the number of falls across these areas, they found that cognitive status and past history of falls were consistent risk factors throughout all groups.Our retrospective audit echoed these findings.9 We found that 50% of our patients had falls as pre- admission comorbidity and 60% had cognitive impairment with MMSE scores of less than 25.   The following outlines the major risk factors for inpatient falls:

Previous history of falls A systematic review in 201110 looked at falls risk factors in geriatric rehabilitation settings.  They found that a history of falls was a significant risk factor for further falls and 58% patients who are multiple fallers will repeat the same type of fall.^10,11 The reason for this is unclear. It may be a consequence of functional impairment with behaviour and extrinsic contributors such as medications and environment also playing a role. Pre-existing mobility problems have previously been shown to adversely affect falls risk^11,12 and this should be considered when trying to risk stratify patients for falls.Gait instabilityGait instability is a well recognised contributor to falls.1 It can be worsened by inappropriate footwear, environmental hazards, medications and muscle weakness. Recognition of gait disorders and early intervention with physiotherapy is crucial to address this risk.^{1,2  Cognitive impairment}Impaired cognition is a potent predictor of falls and has an adverse effect on falls outcomes.^12,13 Dementia patients can have difficulty sequencing and with retention of new information, making them vulnerable. If they have gait instability, compensatory motor mechanisms are often reduced, causing fall related sequelae such as fractures.^14,15 Impaired attention can impede ability to co-operate with physiotherapy or falls interventions. Early identification of cognitive impairment may help to highlight this group of patients and allow for early intervention.MedicationsOur audit showed that polypharmacy (defined in our group as regular use of five or more medications) was present in 80% of patients on admission.⁹ Adverse effects associated with multiple medications can have a cumulative effect and overwhelm older adults. Common medications such as antihypertensives may lower blood pressure to an unacceptable level or be a culprit for pre-existing orthostatic hypotension. This leads to a negative impact on postural control and gait adding to falls risk. Psychotropic or sedative drugs, which are often prescribed in the elderly have been highlighted as culpable in adding to the risk of falls.^10,11    Micturition difficulties Urinary incontinence is a distressing condition that can be common in the elderly. The need for medications and regular toileting can add to a patient’s falls risk.¹¹ In those individuals with cognitive impairment, they may try to get up unassisted due to urinary problems, increasing their vulnerability to falls. Previous studies have shown that falls often occur in the toilet or on the floor between the patient’s room and their toilet.¹⁵ Therefore, patients with urinary incontinence should be identified as potential fallers and consideration given to continence assessment to minimise this risk.Coexistent medical conditionsElderly patients are likely to have multiple medical conditions which may contribute to their risk of falls. Previous studies have shown that stroke patients have a greater risk,¹⁶ especially in the early stage of rehabilitation.¹⁷ Impaired gait and balance can be a frequent feature in fallers, often secondary to cerebrovascular disease or postural instability seen with Parkinson’s disease. A study in 2001¹⁸ showed that patients with Parkinson’s disease have an increased risk of falls due to disease severity which is compounded by polypharmacy.   NICE guidelines1 have also shown that syncope, arthritis and diabetes can contribute to falls risk and should be sought as risk factors.Individual factorsAge over 65 has been extensively shown to be a risk for falls.^1,2  Gender has been looked at previously in some studies. No studies, however, have conclusively shown a gender difference in risk of falls. Loss of confidence post fall is commonly reported. This can lead to reduced physical activity, social isolation and increased risk of further falls.¹⁹ Fear of falling may subsequently impact the effect of any falls prevention strategies and can be challenging to manage.  Sensory impairment is prevalent among older adults. Visual deficits secondary to glaucoma or age-related macular degeneration can contribute to falls risk.²⁰ This risk was exacerbated by coexistent hearing or balance impairments. A study in 2005 showed that correction of cataracts reduces falls and fracture risk in addition to improving visual function.²¹ This was based on community dwelling patients who were cognitively intact. Recent NICE guidelines suggest that correction of vision may not be as effective as a single intervention; however, perhaps cataract surgery should be expedited in hospital fallers if appropriate. Visual assessment should continue to be a key part of a multifactorial falls assessment.¹Environmental factorsPrevious studies have illustrated the effectiveness of home assessment for hazards in community dwelling fallers. There is little evidence looking at hazard modification in the hospital setting but removing potential risks will be of benefit in protecting vulnerable fallers. These include avoidance of ill-fitting footwear, poor lighting, cluttered floors or inappropriate seating. Patients should be encouraged to use the buzzer to call for assistance with mobilising and ideally cared for in an appropriately staffed and visualised area. 

    How can we target these fallers?Sadly no sole intervention has shown to be of benefit in preventing inpatient falls.²² However, based on recent evidence and our own audit findings, we propose a multidisciplinary pragmatic approach is adopted by staff looking after these at risk patients, focusing on the following areas:Flag up at risk patients on admissionAdmission to hospital is a pivotal time for those at risk of falling. Disorientation due to a new, noisy environment, often compounded by multiple ward moves and a host of tests and treatments, is linked to many falls within the first 24 hours.9,10 Simply having a prompt in nursing and medical admission proformas asking the question €œhas this patient fallen before?€ is a starting point in the risk-stratifying process and can tailor care appropriately.Furthermore, as with certain subgroups such as heart failure and oncology patients, an IT-led trigger to highlight known high-risk falls patients as soon as they enter hospital could also enable steps to be put in place to assist with their hospital journey at this early stage.Identify cognitive impairmentAs discussed, early identification of cognitive impairment is key to managing high-risk patients. Be it secondary to acute delirium or established dementia, all such patients are more vulnerable to falls.² They require closer supervision, a suitably adapted environment and regular orientation to help them adjust to their new surroundings. An early cognitive screen alongside a collateral history will rapidly identify the confused patient and suggest a timescale to this. Various assessment tools such as the abbreviated mental test score (AMTS) and the confusion assessment method (CAM) can help differentiate delirium from dementia, although in reality there is often overlap between these conditions.Reversible factors for delirium such as sepsis, constipation and offending drugs should be sought as treating these can often improve confusion-inducing falls. Limit polypharmacy and key offendersEarly medication reconciliation to ensure correct drugs at correct doses are prescribed is essential to all patients’ care. Ensuring no additional inappropriate or potentially harmful drugs are prescribed is paramount in preventing side-effects which can exacerbate falls risk. Cardiac and psychotropic medications are notoriously the worst culprits although many other classes of drugs can potentiate falls and a high number of drugs in itself is a risk factor for falls.²³ Indeed with polypharmacy, one of the strongest risk factors for falls, reducing the burden of medications in all those we treat should be a priority and we should facilitate our pharmacy colleagues to lead on this. Our local Community Falls Prevention Programme has designated pharmacists who specialise in offering mainly primary care advice on appropriate prescribing in falls patients.²⁴ Ideally such pharmacists should extend to secondary and tertiary care.Carry out falls risk assessmentsAlthough nurse-led falls risk assessment scoring charts correlate closely with falls risk, the practical value of these documents when used in isolation is debatable³€”documentation does not equate to intervention. All elderly admissions to hospital should have a multidisciplinary falls risk assessment completed such as the York tool,25 adapted from recommendations by the National Patient Safety Agency, which should instigate targeted multidisciplinary falls intervention in those at risk. Based on our audit findings we have compiled our own multidisciplinary falls assessment checklist.Ideally each inpatient fall should trigger a further reassessment of that particular individual’s main risk factors. Intervention may include further physiotherapy or medical or environmental changes.Falls specialist nurses, when available, should lead on this comprehensive falls assessment and educate ward nurses on key interventions and link in with families. Where specialist nurses are in short supply, each ward should designate a €œfalls champions€ to lead on this. Target individual risk factorsAs outlined, undoubtedly key to limiting falls is managing each patient as an individual with individual risk factors. Whilst one patient may have orthostatic hypotension, fear of falling and an ill-sized walking stick compounding their falls risk, another may have cataracts, poor footwear and be taking several falls-inducing drugs. Clearly the necessary intervention in each of these cases is different. However we should remain structured and methodical in our assessments to ensure no important risk factors are overlooked. Re-review of these patients should address response to intervention and need for any further action.

Which long-term approaches should we employ?

Staff education Educational sessions with medical and nursing staff at induction and departmental training sessions should highlight the importance of falls avoidance. Teaching should offer a structured proforma to assist with assessment of patients and the importance of reassessment should be stressed. As outlined in our falls assessment checklist, core assessments should include a cognitive screen, visual assessment, standing and lying blood pressures, medication review, footwear review and consideration of the need for a walking aid or further physiotherapy.Option to refer to third parties such as orthotics, psychology and optometry as well as falls specialists including community falls teams should be highlighted.Recent literature confirms that a multidisciplinary approach where all staff take responsibility for falls and it is not seen as one particular group’s problem is the most effective approach to falls prevention.²⁶Family educationWith increasing expectations from patients’ relatives for staff to account for inpatient falls, the focus of discussions should be pre-emptive. These should highlight why the patient is at risk of falls and what measures are in place to address this risk. Ideally relatives should accept that not all falls, both at home and in hospital, are avoidable but with a pragmatic, €œdamage limitation€ approach, many falls can be avoided. Prolonged physiotherapyFalls prevention strategies aimed at intensive, sustained physiotherapy in both primary and secondary care settings have consistently been shown to be effective in falls prevention. Recent evidence suggests the role of the physiotherapist should be that of an €œenabler€ where they use their professional knowledge to promote self-management of those at risk of falling rather than acting as the €œexpert€.²⁷With many positive outcomes such as improved strength and balance, reduced fear of falling and improved socialisation, all suitable elderly should be offered the opportunity for sustained rehabilitation. Bone healthIt is well established that osteoporotic older people should all be prescribed regular calcium and Vitamin D supplementation, as well as bisphosphonate therapy, side-effects allowing. In addition there is evidence that calcium and Vitamin D supplementation in non-known osteoporotic patients impacts favourably on falls risk, potentially by their musculoskeletal actions.²⁸ This is clearly a low cost therapy with potential high cost gains and should therefore be utilised where appropriate in clinical practice. Prescribing vitamin D alone has not been shown to impact on inpatient falls²⁹ although this may well relate to limited timescales for musculoskeletal actions to take effect and in reality the majority of these patients would benefit in the longer term from this therapy.Service improvementsGrowing evidence suggests increased access to falls avoidance tools such as bed and chair alarms and low-rise beds can impact on falls prevalence. Unfortunately these tools are often in short supply. As discussed earlier, inpatient hazard modification is a relatively under-researched and under-resourced area. Furthermore, falls research supports our findings suggesting that increased staffing levels, patient cohorting, open-visiting and events co-ordinators all help with falls avoidance but again, scarcity of resources impedes many of these in actual practice.Each Trust should designate funds to key areas worth developing based on their DATIX reports and local trends highlighting specific deficiencies in inpatient falls prevention. 

  ConclusionClearly falls avoidance is just that, falls avoidance. Despite actioning all of the listed measures, with a growing frail, elderly population and stretched health budgets, inpatient as well as outpatient falls will continue. However, undoubtedly we can make an impact and should continue to target this vulnerable group with the interventions discussed, whilst also disseminating knowledge of this known €œfalls risk€ to staff and families alike.

Conflict of interest: none declaredReferences1. NICE. CG161. June 2013. Falls in older people pathway2. National Patient Safety Agency. Slips, Trips and Falls in Hospital. London: NPSA. 20073. Oliver D et al. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age and Ageing 2004; 33: 122€“30 4. Kannus P et al. The prevention of falls and related injuries. Lancet. 2005; 366: 1885€“935. Oliver D. Bed falls and bedrails€”what should we do? Age and Ageing 2002; 31: 415€“186. Oliver D. Preventing falls and fall Injuries in hospital: a major risk management challenge. Clinical Risk 2007; 13: 173€“787. Morrison G, et al. Changes in falls risk factors for geriatric diagnostic groups across inpatient, outpatient and domiciliary rehabilitation settings. Disability and Rehabilitation 2011; 33(11): 900€“78. Shumway-Cook A, et al. Assessing environmentally determined mobility disability: self-report versus observed community mobility. J Am Geriatr Soc 2005; 53: 700€“49. McKee H, McNeil L. An audit of inpatient fallers across South Glasgow Hospitals 2012€“201310. Vieira ER, et al. Risk factors for geriatric patient falls in rehabilitation hospital settings: a systematic review. Clinical Rehabilitation 2011; 25(9): 788-9911. Gaebler S. Predicting which patient will fall again€¦and again.    J Adv Nurs 1993; 18: 1895€“190212. Hauer K, et al. Cognitive impairment decreases postural control during dual tasks in geriatric patients with a history of severe falls. J Am Geriatr Soc 2003; 51: 1638€“44  13. American Geriatrics Society, British Geriatrics Society and American Academy of Orthodpaedic Surgeons Panel on Falls Prevention.  Guidelines for the prevention of falls in older persons. J Am Geriatr Soc 2001; 49: 664€“7214. Taylor ME, et al. Gait impairment and falls in cognitively impaired older adults: an explanatory model of sensorimotor and neuropsychological mediators.   Age and Ageing 2012; 41(5): 665€“6915. Morrison V, et al. Lower urinary tract symptoms, incontinence and falls in elderly people: time for an intervention study. Int J Clin Pract 2007; 61(2): 320€“2316. Jorgensen L, et al. Higher incidence of falls in long-term stroke survivors than in population controls: depressive symptoms predict falls after stroke. Stroke 2002; 33: 542€“4717. Czernuszenko, A et al. Risk factors for falls in stroke patients during inpatient rehabilitation.   Clinical Rehabilitation 2009; 23: 176-18818. Ashburn A, et al. A community-dwelling sample of people with Parkinson’s disease: characteristics of fallers and non-fallers.  Age and Ageing 2001; 30 (1): 47€“5219. Boyd, R, et al. Falls and fear of falling: burden, beliefs and behaviours. Age and Ageing 2009; 38: 423€“2820. Kulmala J, et al. Poor vision accompanied with other sensory impairments as a predictor of falls in older women. Age and Ageing. 2009; 38: 62€“6721. Harwood RH, et al. Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. Br J Ophthalmol 2005; 89(1): 53€“59 22. Oliver D, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ 2007 2013; 334(7584): 8223. Freeland KN,  et al. Medication use and associated risk of falling in a geriatric outpatient population. Ann Pharmacother 2012; 46(9): 1188€“9224. http://www.nhsggc.org.uk/content/default.asp?page=s136125. York falls assessment fina~1.pdf€Ž taken from National Patient Safety Agency. Slips, Trips and Falls in Hospital. London: NPSA. 200726. Miake-Lye IM, et al. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med 2013; 158(5 Pt 2): 390€“9627. Robinson L, et al. Self-management and adherence with exercise-based falls prevention programmes: a qualitative study to explore the views and experiences of older people and physiotherapists. Disabil Rehabil 201328. Birschoff HA, et al. Effects of vitamin D and calcium supplementation on falls: a randomized controlled trial. J Bone Miner Res 2003; 18(2): 343€“5129. Burleigh E, et al. Does Vitamin D Stop Inpatients Falling? A Randomised Controlled Trial. Age and Ageing 2007; 36(5): 507€“13