Falls with injury occur in virtually all health care settings. Some excellent resources are available to help institutions reduce the risk of harm to their patients from falls: IHI (The Institute for Healthcare Improvement), the VA National Center for Patient Safety, the Health Care Association of New Jersey, to mention just a few.
The Institute for Healthcare Improvement also has an upcoming web-based initiative to help organizations reduce harm from falls .
Having reviewed numerous reports and RCA’s involving falls with injury, we have a couple observations that merit discussion. First is that, though most hospitals/facilities use some sort of fall risk assessment tool, these are often only used on admission to the facility. It is not uncommon for a patients to have a low risk for falls on admission, only to have multiple factors change during the hospitalization that now make them fall-prone. It is therefore imperative that any fall prevention program have built-in flags that trigger reassessment for fall risk.
Our second observation is that the initial medical responder to a patient who has fallen often has a focus much different from that of a quality improvement professional. That responder typically is most concerned with whether any injury has resulted from the fall. Ascertaining the reason for the fall is often only an afterthought and often neglected all together. And, sometimes, the only clue to the cause of the fall can be found only around the time of the fall (for example, orthostatic hypotension may no longer be present a day or so later when someone finally gets around to looking for it). The initial responder is often a housestaff member who has little knowledge about the patient prior to the fall. And we have not done a particularly good job of educating housestaff on how to perform a good post-fall assessment. Therefore, facilities should build protocols and checklists for housestaff (or other first medical responders) to utilize in their post-fall assessment. Several good tools for post-fall assessment are available (see references above).
Now that we’ve mentioned orthostatic hypotension, it is most notable that orthostatic signs are very seldom actually checked by the medical responder to a fall. Even when they are checked, they are often inadequately assessed. The proper technique for checking orthostatic signs is as follows:
First, have the patient lie supine for at least 5 minutes prior to beginning measurements (this is because many of the neurological causes of orthostatic hypotension are associated with supine hypertension, so one is most interested in the magnitude of the orthostatic change rather than just in the absolute standing blood pressure). One should then measure both the blood pressure and pulse of the patient in the supine position. Then, after telling the patient what you will be doing and asking him to tell you about symptoms such as dizziness or graying out of vision that might occur when upright, one stands the patient upright (being sure you can safely lie him down if they do become symptomatic!). The pulse should be measured first on standing, since what the heart rate does in response to orthostatic hypotension may provide clues to the etiology of orthostatic hypotension. The blood pressure is then recorded. If there is a drop in blood pressure, one should keep the patient upright (unless symptomatic) and record the blood pressure and pulse again at 1-2 minutes intervals until it has stabilized.
Sorry for the digression! But we find this one of the simplest, yet most neglected, parts of the physical examination in the post-fall patient.
Lastly, food for thought: How many of you have had osteoporosis screening? If you did, how many had a fall-risk assessment? Not many, we’ll bet! Isn’t the goal of osteoporosis screening to prevent fractures? Wouldn’t it be wise to incorporate a fall-risk assessment (and education) any time someone is sent for osteoporosis screening? Sounds like an opportunity for providers, quality improvement professionals, and third-party payors to all climb on board.
Update: See also our January 1, 2008 Patient Safety Tip of the Week “Fall Prevention” and our October 7, 2008 Patient Safety Tip of the Week “Lessons from Falls....from Rehab Medicine” for other tips on fall prevention.