Practice Tips

Inpatient falls are the leading cause of hospital-acquired injury, prolonging and complicating hospital stays. In 2008, Centers for Medicare and Medicaid Services (CMS) communicated to hospitals that preventable falls, which occurred during the patient's hospitalization, would no longer be reimbursed. Visitors, outpatients, and patients in physician office practices are also at risk for falls, especially older adults. According to the CDC, each year an estimated one-third of older adults fall, and the likelihood of falling increases substantially with advancing age. The CDC found that approximately 15.9% of all U.S. adults over 65, fell at least once during the preceding 3 months, and 1.8 million (31.3%) of those who fell sustained an injury.

So what can be done to prevent/reduce the risk of fall and injury?

Fall Prevention Program

A comprehensive, multidisciplinary, organization-wide Fall Prevention Program provides structure and defines processes to assess, identify, plan and implement appropriate interventions. The program should address:

1. Department and patient population-specific identification and prevention methods.
2. Identification of a multidisciplinary team responsible for oversight, ongoing review, and assessment of fall program functions.
3. Policies, protocols, and definitions that support the Program.
4. Identification of education needs and development of educational programs for staff, patients and families including outpatient department and hospital-owned physician office staff.
5. Periodic analysis of falls data, including near misses, to assess the appropriateness of program policies and need for staff education.
6. Feedback to all staff involved in the falls prevention process.
7. Evidence-based fall risk assessment tools specific to the types of patients treated.
8. Incorporation of fall risk assessment in handoff communication protocols.
9. Development of pre- and post- fall interventions.
10. Defined criteria for post-fall assessment and reassessment. Include post-fall disclosure to family.
11. Review of post-fall assessment data to identify contributing factors, including intrinsic and extrinsic factors. Include visitor falls in the data.
12. Annual evaluation of the overall effectiveness of the Falls Prevention Program.
13. Ongoing efforts to provide an environment that decreases fall risks.

Inpatients

1. Select a falls risk assessment tool: A number of fall risk assessment tools are available and validated for use in the hospital setting. Each organization should decide which tool best meets the needs of their patient population, with consideration given to analysis of fall data. Appropriate staff education and training on tool terminology definitions and applications provides for a more consistent, uniform approach to the assessment process. This process, and how effectively it is carried out within the organization, is an important risk management approach to falls.
2. Implement the falls risk assessment tool: Complete a fall risk assessment on admission, when there are changes in patient condition, medications, and during handoffs. Handoff communication is especially important between caregivers, department to department, shift to shift, and at level of care changes. Communicate complete and accurate patient information in handoffs to assure safe transitions in care.
3. Evaluate the tool: Provide periodic evaluation of the tool to determine if the tool is meeting the need of the patient population and if it is being administered as designed. Measurement of outcomes, before tool implementation and after tool implementation will help determine tool efficacy. In addition to efficacy evaluate the tool for staff resource time to administer the tool and for patient sensitivity (i.e., identification of true "positives", decrease in false "negatives").
4. Intervention: Develop an appropriate plan of care for the patient at risk for falls that includes risk-specific interventions such as:
   • Universal protocol for falls risk reduction that includes clutter free walkways, patient personal items and call bell within reach, appropriate non-skid footwear, placement of patient near nurses' station and environmental surveillance.
   • Hourly intentional bedside rounding.
   • Protocol for staff remaining "within arms reach" of high risk patients when toileting.
   • Include changes in fall risk during shift change reports.
   • Use appropriate assistive devices such as gait belts, elevated toilet seats with grab bars, low beds with floor mats.
5. Post-fall: Conduct a comprehensive post-fall assessment that includes:
   • Where and how patient was found (witnessed, un-witnessed, found on floor).
   • Patient appearance at time of discovery.
   • Vital signs including level of consciousness to be repeated at defined intervals.
   • Evidence of injury, location of injury.
   • Manager notification.
   • Medical provider notification.
   • Family notification.
   • Medical, nursing actions.
   • Reassessment of the patient's fall risk and revision to the care plan.

Outpatients and Office Practice Patients

1. Utilize a patient fall risk assessment tool such as the Timed Up & Go (TUG) test. Provide a more intensive assessment of patients who have a positive history of falls to include:
   • Medication review
   • History of relevant factors: acute and chronic conditions (osteoporosis, urinary incontinence, cardiovascular disease)
   • Assessment of gait, balance, mobility, and lower extremity joint function and muscle strength
   • Examination of feet and footwear
   • Consider questions such as:
     1. Is the patient prone to falls or has the patient had a recent fall?
     2. Does the patient need assistance sitting or standing? Does the patient use an assistive device? Is the device with the patient?
     3. Does the patient require assistance in the dressing area or restroom?
     4. Is the patient in stocking feet (with or without grips)? Are shoes untied? Does the patient need assistance with laces?
     5. Does the patient have clothing which poses a trip hazard (long gown, pants or skirt)?
     6. Does the patient take or has the patient taken medications that pose an increased risk for falls such as anxiolytics, sedatives and/or psychotropics?
     7. Does the patient have difficulty following instructions?
     8. Is the patient fasting?
2. Train staff to implement fall prevention interventions, e.g., modifying the procedure or positions, assuring assistive devices are in reach, assisting the patient with access to exam table, securing the patient before leaving them unattended, etc.
3. If the patient was medicated, educate the patient on any side effects that may increase the risk for a fall.
4. Routinely perform safety rounds to assure a hazard free environment; post signs for patients and families that address fall prevention.
5. Assessment of visual acuity, neurological function and cardiovascular status.
6. Once a patient's level of fall risk is determined, educate the patient and family on fall prevention at home and in the community. Develop tools and educational material that will assist the patient in identifying risks, establishing healthy nutrition and engaging in ongoing exercise. Consider referral to agencies for physical therapy, occupational therapy, exercise and nutrition programs, etc.

Visitors

Visitor falls, like patient falls, pose a potential safety issue which may require further evaluation and assessment in order to determine cause. Consider the following as part of the visitor falls evaluation process:

1. Routinely conduct an environmental "walk-around" to identify safety hazards that may contribute to falls. Include the parking lot, walkways, steps, entrances, etc.
2. Develop a response protocol for staff to utilize in response to a visitor fall, including initiation of aid and medical treatment.
3. Provide staff education on reporting requirements of visitor falls (injury or no injury).
4. Educate staff on investigation and workup of witnessed and un-witnessed falls.
5. Visitor Fall Prevention Checklist
6. Visitor Fall Response Audit Checklist

Resources:

• MMWR March 7, 2008 / 57(09); 225-229 Self-Reported Falls and Fall-Related Injuries Among Persons Aged 65 Years --- United States, 2006, www.cdc.gov.
• ECRI, Falls, Risk Analysis, Volume 2, March 2009 https://www.ecri.org
• Institute for Clinical Systems Improvement Health Care Protocol: Prevention of Falls (Acute Care) http://www.icsi.org
• Veterans Administration National Center for Patient Safety http://www.patientsafety.gov
• Centers for Disease Control, Injury Prevention & Control: Home and Recreation Safety, Falls Among Older Adults: An Overview http://www.cdc.gov
• Minnesota Hospital Association, Patient Safety, SAFE from FALLS Call to Action http://www.mnhospitals.org/index/tools-app/tool.362
• Patient Safety Authority, Commonwealth of Pennsylvania, Falls in Radiology: Establishing a Unit-Specific Prevention Program http://patientsafetyauthority.org
• The Joint Commission; www.jointcommission.org; Sentinel Event Alert 55; Preventing falls and fall related injuries in health care facilities; 9/28/2015

With permission: Lisa Eisenmenger, PT, DPT and Katherine Jones, PhD, PT. TUG Test Document [Falls]. Retrieved from University of Nebraska Medical Center, College of Medicine Department of Internal Medicine, Division of Geriatrics & Gerontology website: http://www.unmc.edu