One of the “under the radar” journals we like to read is “Nursing Times” out of the UK. We like it because they are not afraid to challenge conventional wisdom. We recently noted their position on bedrails (see our August 2009 “What’s New in the Patient Safety World” column).
They also recently had a great discussion on fall risk prediction tools (Oliver & Healy 2009). In particular, they discourage use of those prediction tools that have a “score” that places a patient in “high”, “moderate”, or “low” risk categories. Many of these “scores” use predictive risk factors that you cannot modify (eg. age, gender, prior falls). Instead, they favor those risk prediction tools that focus on modifiable risk factors that can be put in a checklist-style format (yes, our old favorite: the checklist!) so you can then focus your program on actually modifying those risk factors.
They do admit that some general risk reduction interventions may benefit all patients (eg. safer footwear, minimizing use of sedating drugs, etc.) but other interventions should be tailored to the individual patient’s modifiable risk factors. What can you modify? You can improve sensory deficits like visual and hearing impairment. You can improve orthostatic hypotension and, to a degree, postural instability. Bowel/bladder care and timed toileting may help since such a high proportion of falls occur on toileting activities. Knowing that a patient fell in the past is not modifiable but knowing the circumstances of the fall may help identify a modifiable risk factor. A history of falls shortly after assumption of the upright posture should lead to a formal assessment for orthostatic hypotension (another soapbox issue for us: see our April 16, 2007 Patient Safety Tip of the Week “Falls With Injury”).
They point out that most fall risk reduction programs reduce the risk of falls only about 20% and even the best only reduce falls by 30-40%. If a tool has a negative predictive value of 90%, that still means that of every 1000 patients you screened as “low” risk, 100 will still fall! Thus, some fall risk prediction tools may lead to a false sense of security. So focusing instead on things you can actually fix makes a lot of sense.
And, of course, Oliver & Healey note that like any other tools you need to also be sure that the tool has been validated for the type of setting and patient population in which you intend to use it. We certainly concur with that. A good example was in our October 7, 2008 Patient Safety Tip of the Week “Lessons from Falls....from Rehab Medicine” where we discussed the risk factors for falls in rehab medicine settings. Using risk assessment tools that had been validated in acute med/surg hospitals or SNF’s would have resulted in misleading predictions in the rehab setting.
We do like several of the concepts in the Oliver & Healey paper:
· Focus especially on those risk factors that a modifiable
· Beware that “scored” risk prediction tools may give you a false sense of confidence
But are there other risk prediction tools that “scoring” a patient as being high risk might be useful even if you cannot modify the individual risk factor? We think there are. For example, a preoperative screening tool for obstructive sleep apnea (OSA) would likely include obesity as a predictive factor for OSA. You obviously cannot modify obesity in the very short run. Yet if the patient scored “high risk” on such a tool, you would take precautions for appropriate postoperative monitoring of such patients and try to minimize use of those drugs that may further aggravate OSA. (But, even then, we’re sure Oiver & Healey may argue such tools will miss some patients who do have OSA and might produce a false sense of security.) Other tools, like the Pneumonia Severity Index (PSI) or the CURB-65 tool, have many risk factors that are not individually modifiable but still help us identify which patients should be admitted and which should probably be admitted to intensive care.
And even some non-modifiable fall risk factors may still lead to specific interventions. For example, male gender has been indentified in some tools as a risk factor for falls. While you obviously cannot modify that risk factor, you might look extra carefully at toileting needs of the male patient. As before, we don’t know how much of the male risk for falls is “macho” vs. “modesty”. But if that latter is a factor in raising the fall risk during toileting in males, you may need to consider having non-female staff assist the males in toileting activities.
So we don’t think you should ignore non-modifiable risk factors but we think there are some good lessons learned here. While general patient safety efforts are important, focus especially on those things you can modify for the individual patient. And make sure that a “score” on a predictive tool does not sway you from focusing on those modifiable risk factors in individual patients who score “low” risk.
Oliver D, Healey F. Falls risk prediction tools for hospital inpatients: do they work? Nursing Times 2009;105: 18–21