Because many falls result from patients trying to get to the bathroom, Dr. Wald advises scheduled toileting, with the staff regularly assisting the patient to the bathroom. If a patient cannot ambulate to the restroom independently, ensure that a urinal or a bedpan is nearby and readily accessible to the patient.
Dr. Wald also advises utilizing the expertise and skills of those clinicians most familiar with the patient: the nursing staff. The nurses who have daily contact with the patient are in the best position to provide information regarding changes in the patient’s mental status, ability to ambulate, response to medications, compliance, and other factors that may increase the risk for a fall.
“The bottom line of any quality initiative will often fall to the nurses’ assessment,” says Dr. Shaw. “The front-line caregivers for fall assessments are our nurses.”
A Multidisciplinary Approach to Prevention
Drs. Wald and Shaw both stress the importance of a multidisciplinary approach to prevention of falls (both in hospital and following discharge). A patient who has already fallen—or one identified to be at risk for falling—can be offered a great deal of support and guidance pending discharge. And discharge planning can begin literally at admission.
It’s Dr. Shaw’s practice with at-risk patients to involve physical and occupational therapy (as well as social workers) in the patient’s care right from the beginning. Those individuals are then in a position not only to perform a thorough assessment of the patient but also to begin working on ways to reduce the patient’s risk following discharge. As Dr. Shaw points out, the hospitalist has access to resources the patient’s primary-care physician generally does not, and those resources should be utilized to full advantage.
Physical therapy can offer rehabilitative interventions, including transfer, gait, and balance training; strength and range-of-motion exercises; and habituation exercises for vestibular problems. Occupational therapy can offer the patient instruction on simplifying tasks and on performing everyday activities safely. Social workers can assist the patient with finding educational and assistive resources. All disciplines can be involved in home safety evaluations, patient and family education, and the procurement of assistive and adaptive equipment, such as ambulation devices, grab bars, handrails, raised toilet seats, and so on.
When all of these healthcare providers are involved in the patient’s care from the beginning and can coordinate discharge planning as a team, a more well-rounded and comprehensive plan for prevention of falls can be formulated. This team approach also offers a more accurate view of whether the patient is capable of returning home with or without help or if placement in a rehabilitation or long-term care facility may be more appropriate.
Involve the Patient
Once an at-risk patient has been identified, communicate that risk to everyone involved with the patient’s care, including the medical staff, the family, and the patient. “Patients have a certain degree of risk-taking behavior, and they won’t necessarily ask for help,” says Dr. Wald. “Part of that is that they’re not willing to admit that they need help.”
Patients need to be reminded that they are or have recently been sick—that’s why they’re in the hospital in the first place. She says patients and caregivers must be attuned to the fact that as patients begin to feel better and stronger and become more mobile, their risk for falling will go up before it starts to come down.
If a patient remains resistant to asking for or accepting assistance, Dr. Wald suggests finding out what the patient’s barriers are and trying to get around them. “Try to get people to admit that they have a problem,” she advises. “A lot of times, the barriers aren’t rational, so rationalizing isn’t always effective.”