Several studies conducted in hospitalized elderly patients have repeatedly demonstrated a core group of inherent patient risk factors for falls: delirium, agitation or impaired judgment, burden of comorbidity, gait instability or lower-extremity weakness, urinary incontinence or frequency, and a history of falls.2,3,8 These risk factors are targeted as part of most inpatient fall prevention programs, as discussed below.
Several environmental hazards have been known to increase the risk of falls and injury. These include high patient-to-nurse ratio, inappropriate use of bedrails, wet floors, and lack of assistance with ambulation and toileting. The most studied of these is assistance with ambulation and toileting. Hitcho et al demonstrated that as many as 50% of falls are toileting-related.3 The study also showed that only 42% of patients who fell and used an assistive device at home had a fall in the hospital. As many as 85% of patients were not assisted with a device or person at the time of a fall.2 Unassisted falls are associated with increased injury risk (adjusted OR 1.70; 95% CI, 1.23-2.36).
Consistent with this, increased patient-to-nurse ratios are keenly associated with an increased risk of falls. Essentially, a patient whose nurse had more than five patients was 2.6 times more likely to fall than a patient whose nurse had five or fewer patients (95% CI, 1.6 to 4.1). Based on this data, hospitals have invested in low-to-the-floor beds and alarms for beds and chairs. Placing patients on a regular toileting schedule, avoiding medications that cause urinary incontinence, and attention to bowel regimens have become standard components of hospital fall prevention programs. Even though these issues have long been thought to be the purview of nurses and support staff, hospitalist involvement and awareness are crucial to ensuring that these issues are consistently addressed and enforced for every at-risk patient.
Inpatient Fall Prevention
Inpatient falls are similar to other geriatric syndromes and are multifactorial in etiology. Studies that report a decrease in the number of falls identify patients at the highest risk for falls and target multiple risk factors simultaneously.
Several inpatient fall risk assessment tools have been developed. The most widely used and validated in the acute hospital setting are the Morse Falls Scale and St. Thomas’ Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) (see Table 1, p. 24).9 Both tools incorporate the risk factors identified above—namely, the presence of cognitive or sensory deficits, environmental hazards, history of falls, lower-extremity or gait instability/weakness, and level of comorbidity to create a score. Higher scores are associated with increased fall risk. The scales have demonstrated sensitivities and specificities of 70% to 96% and 50% to 85%, respectively, depending on the population tested and the cutoff scores used.
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STOCK CONNECTION DISTRIBUTION / ALAMY
STOCK CONNECTION DISTRIBUTION / ALAMY
In 2004, Healey et al published the results of one of the few successful randomized, controlled fall-prevention trials in an acute-care setting.10 Pairs of identical hospital units were randomized to intervention and control groups. The sample size was 3,386 patients, with a mean length of stay of 19 days.1 As part of the intervention group, a fall-risk assessment was performed on admission. Patients were screened for deficits in visual acuity (identify a pen, key, or watch from a distance of 2 meters), polypharmacy, orthostatic hypotension, mobility deficits, appropriate bedrail use, footwear safety, bed height, distance of patient from nursing station, loose cables, wet floors, and availability of the nurse call bell.
Interventions for patients who were identified as high fall risks included ophthalmology/optician referral for those for whom reading aides could not be procured, medication review, adjustment of bed rails, and physical therapy. Patients with a history of falls were placed close to nursing stations. Environmental hazards were removed. Patients with orthostatic hypotension were educated on slowly changing body position. Call lights were moved to within easy reach. No additional money was allocated for this study, but by performing these simple interventions, the authors were able to decrease the relative risk of falls by 29% (RR 0.71, 95% CI 0.55–0.90, P=0.006). The incidence of injuries sustained as a result of falling, however, was unchanged.