October 7, 2008
Lessons from Falls….from Rehab Medicine
Now that CMS is no
longer paying for certain “never
events”, it’s appropriate that our first Patient Safety Tip of the Week for
October is on falls. We can learn some valuable lessons on falls from our
colleagues in rehab medicine.
The nature of the
medical conditions giving rise to the need for rehabilitation medicine services
results in differences in the likelihood of falling compared to other typical
acute care hospital services. Both the risk of falls and the risk of injury are
higher on inpatient rehab units than on other acute care units. But the lessons
learned are very applicable to all areas of the hospital. Lee and Stokic (Lee
2008) recently published a paper
on the risk factors for falls during inpatient rehabilitation. They found
that 9.5% of such patients fell at least once. Most falls occurred during the
daytime (85%) and most occurred in the patient’s room (90%). But falls varied
substantially by the type of diagnosis a patient was admitted with. A
multivariate model showed high risk of falls with the following factors:
diagnosis of stroke or amputation, age between 41 and 50, lower cognitive FIM
scores, and large number of medical comorbidities. Most falls are also
unwitnessed. In the Lee study, 74% of the falls were not observed.
The Lee paper also notes
how the rate of falls is very dependent on the nature of the patient population
and varies considerably among the different diagnostic groups. Patients with
stroke and amputation were more likely to fall than those with spinal cord
injury. Similarly, in an acute hospital population there is likely a
considerable difference in fall rates between a hospital that does lots of
obstetrics, pediatrics and behavioral health and one that does lots of trauma
and orthopedic care. So it is very difficult to benchmark fall rates across
hospitals without knowing details about the patient population. It is much more
important to measure (and display for feedback) the fall rates on individual
units of a hospital so that they can compare their own experience and trends from
month to month.
One of the most
interesting findings was that the risk of falls was greatest for the age range
41-50 years. Most studies on fall risk have found that the risk increases with
age. However, if one uses appropriate multivariate logistical models, age often
disappears as an independent predictor of falls. Rather, other risk factors
that often appear with increasing age (eg. impaired mobility, impaired
cognition) are the true underlying risk factors for falls. In fact, data
actually suggests that increasing age may have a preventive effect on falls (Hendrich 2003) when
considered as an independent risk factor.
The FIM (functional
independence measure) score on admission to rehab may turn out to be valuable
in predicting which patients are at risk for falls. The FIM scores in the Lee
study showed that patients requiring moderate assistance with motor activities
(those who could do 50-75% of activities on their own) may be at greatest risk
for falls. Further research is needed to clarify the exact role of the FIM
score as a predictor of falls.
In the Lee paper, the
risk for falls among the more dependent patients actually increased as they
gained more motor activities. On rehab, we are usually encouraging patients to
do more for themselves and this may lead to an increased fall risk.
The Lee paper also notes that many of the unobserved falls that occurred in the patients’ rooms were related to the patient attempting to use the bathroom. It is well known that over half the falls which occur in hospitals are related to toileting activities. The Hendrich II Fall Risk Score includes male sex as a risk factor. We’ve never been quite sure whether that risk factor is due to macho vs. modesty. Particularly relating to the risk of falls during toileting, many males may have a “can do” attitude that increases their risk. Alternatively, since the nursing profession is still predominantly female, it may be that modesty keeps male patients from asking for assistance with toileting. At any rate, it is imperative to recognize which patients are at increased risk for falls and ensure that staff are available to assist those patients in toileting activities. Use of timed or scheduled toileting is a very useful tool. Hi-tech systems, such as alarms that trigger when a patient attempts to get out of bed, may be useful. However, see our June 19, 2007 Patient Safety Tip of the Week “Unintended Consequences of Technological Solutions” for an example where a hospital had to swap the nurse call button for the new alarm button and a patient fell when he tried to get out of bed after no one responded when he pushed the nurse call button!
All areas of hospital
must understand fall risk and be able to identify which patients are at risk
for falls. We’ve had several columns about the risk of adverse events in the
radiology suite. That is an area where falls often happen. Patients are often
on a gurney or a table or in a wheelchair and may fall when they attempt to get
up to use the bathroom. They may be tethered to IV poles or other equipment
that become obstacles to trip over. And they may have received benzodiazepines
or other sedating medications for the radiology procedure, further increasing
their fall risk. So it is critical that the fall risk of a patient is
accurately conveyed to all staff when a patient is sent to radiology. This is
another example of the hazards of handoffs (see
last week’s tip of the week on handoffs). One way to facilitate this
handoff would be to include information on fall risk in a structured
communication tool for transports like the “ticket
to ride” we described in our April 8, 2008 column. A new
paper on use of the “ticket to ride” type checklist as a handoff tool (Pesanka 2008) also just appeared in the Journal of Nursing
Quality. Also, as per this month’s “What’s New in the Patient Safety World”
column, the movement toward color-coded
wristbands is gaining momentum. The yellow wristband is the one that
signifies the patient is at risk for falls in that system. However, do not use
that color-coding convention unless all the hospitals in your area or state have
agreed to that convention. And be wary that the yellow wristband does not get
confused with the Lance Armstrong wristband commonly worn outside the hospital.
Don’t forget the
importance of updating the fall risk. Most hospitals are very good at performing
a fall risk assessment on admission. However, lots of things change during a
hospitalization that may increase the fall risk (medications are the most
obvious change that impacts the fall risk) and hospitals are not as good at
recognizing those things. A good fall prevention program has fall risk
assessments done on each nursing shift. And a good CPOE system has clinical
decision support that may remind the physician about fall risk at the time of
order entry (or has a rule that alerts nursing when a medication is added that
may increase the fall risk).
We’ve previously
discussed fall risk (see April 16, 2007 Patient Safety Tip of the Week “Falls
with Injury”) and pointed out that the risk of injury is probably more
important than the simple risk of falling, though a fall for a rehab patient
may result in a fear of falling that could interfere with the rehab process.
See our January 1, 2008
Patient Safety Tip of the Week “Fall
Prevention” for other tips on fall prevention. We’ve also
addressed some aspects of falls in our April
16, 2007 and July
17, 2007 Patient Safety Tip of the Week columns and also in our December
18, 2007 discussion about bed rails.
References:
Lee JE, Stokic, DS. Risk Factors for Falls During Inpatient Rehabilitation. American Journal of Physical Medicine & Rehabilitation. 1988; 87(5):341-353
Hendrich AL, Bender PS,
Nyhuis A.Validation of the Hendrich II Fall Risk Model: A Large Concurrent
Case/Control Study of Hospitalized Patients. Applied Nursing Research 2003; 16:
9-21 http://www.ahincorp.com/hfrm/ARTICLE.PDF
Hendrich II Fall Risk Model
Pesanka DA, Greenhouse PK, Rack LL, Delucia GA, Perret RW,
Scholle CC, Johnson MS, Janov CL. Ticket to Ride: Reducing Handoff Risk During Hospital
Patient Transport. J Nurs Care Qual. 2008 Aug 26. [Epub ahead of print]
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