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March/April 2023
Fall Prevention: Fall Prevention in Hospitals Reducing Environmental Risks The Joint Commission considers a fall in a health care setting that results in certain injuries to be a sentinel event, defined as a patient safety event unrelated to the patient’s medical condition that results in death or permanent or severe harm. For a fall to be classified as a sentinel event, it must have caused the patient to experience any of the following:1 • any type of fracture; • surgery; • casting or traction; • neurological consultation, management, or comfort care (eg, for a brain hemorrhage or skull fracture); • consultation, management, or comfort care for an internal injury (eg, fractured rib, liver laceration); • receipt of blood products specifically due to the fall (eg, for a patient with coagulopathy); and • death or permanent harm due to fall-related injuries (ie, not from medical events/conditions causing the fall). According to The Joint Commission, falls were the most frequently reviewed sentinel events from 2018 to June 2022.1 However, sentinel event reporting by health care facilities is voluntary and, therefore, represents only a small percentage of actual falls occurring in health care facilities each year. Patient falls are consistently the most commonly reported adverse event in US hospitals, with approximately 700,000 to 1 million patient falls occurring annually. These falls result in approximately 250,000 injuries and 11,000 deaths.2 It’s estimated that injuries occur in about one-third of inpatient falls.3 According to The Joint Commission, head injuries and hip and leg fractures are the most common inpatient fall-related injuries.1 Despite the known risk of patient injury and concerted fall prevention efforts, fall rates among hospitalized inpatients have not decreased substantially over the last 10 years. Hospitalized older adults have a 50% greater fall rate than do hospitalized younger patients, and the consequences are worse, including increased length of stay, increased mortality rate, loss of independence/mobility, and greater likelihood of institutionalization.3,4 There is a large body of published evidence on fall prevention strategies for community-dwelling older adults; however, this research cannot necessarily be transferred to hospitalized older adults. The hospital setting, including the physical environment and organizational/leadership structure, increases the risk of falls and the need for fall prevention. In addition, the health status of hospitalized older patients, coupled with their presence in an unfamiliar environment, also translates to a potentially higher risk of falls than for community-dwelling older adults.2 Research and falls tracking by The Joint Commission indicates that the physical environment is a contributing factor in approximately 40% of falls experienced by hospitalized inpatients.2,5 Of multifactorial fall risk assessment tools commonly used in hospitals, none incorporates environmental factors related to hospital design, such as lighting and physical design of patient areas. Research has tended to overlook how physical design can influence staff workflow and patient care delivery, which affect patient fall rates. These environmental factors may include corridor layout, door placement, nursing station locations, and placement of windows for patient viewing, all of which can affect the ability of nursing staff to see patient movements and respond to patient calls in a timely manner. Some research has shown that inadequate patient bed visibility from nursing stations and corridors was associated with a greater incidence of patient falls.5 According to The Joint Commission, the most common activities associated with patient falls are ambulating and toileting—which occur in patient rooms or nearby corridors and are related to environmental risk factors, as are falls from bed.1 In addition to toileting, other primary environmental fall risks for older hospitalized patients include isolation, too much medical equipment to navigate, an unfamiliar environment, and delayed staff response to call bells, says Debra F. Stern, PT, DPT, MSM, DBA, certified fall prevention specialist and certified exercise expert in aging, and a professor in the physical therapy department at Nova Southeastern University in Fort Lauderdale, Florida. Older adults also may contend with confusion, weakness from bedrest, medication side effects, postanesthesia cognitive impairment, and communication difficulties that further increase fall risk in the hospital, Stern adds. Research suggests that, despite implementation of fall prevention programs in hospitals and staff compliance with prevention measures, a major cause of inpatient falls is that patients themselves are not participating in fall prevention measures.6 In a study of older patients in a Chinese hospital, a fall prevention strategy that included patient engagement was conducted. The patient-focused strategy included the following:6 • Nurse-delivered patient education within a few hours of admission, consisting of fall-related videos watched by the patient. Videos communicated the risks and adverse consequences of falls as well as the importance of fall prevention measures. • Completion of an engagement form to assess risk. With nurse assistance, the patients also selected the fall prevention measures they could complete. • Analysis of fall risk assessment involving nurse feedback to patients. A patient-specific fall prevention plan was generated and a fall prevention guidance manual was provided to patients, who were empowered to alert nurses if they found any fall risk factors, such as failure of a bed rail to work, obstacles on the floor, or failure of call bells. • Daily evaluation of patients’ participation in fall prevention measures. Nurses offered feedback on patient fall risk behaviors and encouraged daily practice of fall prevention measures. • Electronic information support, which involved all fall risk and prevention materials being accessible on hospital information systems and easily modified daily. Patients were able to access fall prevention materials via a tablet computer anytime. The study found that implementation of this patient-focused fall prevention strategy significantly reduced the fall rate in older patients to zero.6 In addition to patient education, Stern notes that working with patients regarding their physical capabilities, balance, and gait is also needed. “Get patients moving! Avoid leaving patients in their beds. Nursing assistants can be very helpful for this,” she says. In her work as a physical therapist and certified fall prevention specialist, Stern has also found the following to be helpful for hospital staff to help prevent falls due to environmental risk factors: • issuing gait belts for patients; • ensuring call buttons work and are accessible at all times; • placing tray tables close enough so that patients do not have to reach for frequently used items; • ensuring that patients are properly nourished and hydrated; • assisting the patient to the bathroom on a regular schedule; and • letting patients adjust to sitting on edge of bed first before standing. Because many falls occur when patients are getting out of bed, Stern emphasizes the importance of the sitting-to-standing adjustment period. “Do it slowly, allowing the patient to adjust to position changes. Make sure they aren’t dizzy or light-headed. Have them place their feet on the floor and wiggle them,” she advises. Early mobilization of patients after a procedure or bedrest is important to help them navigate environmental obstacles. Stern also recommends range-of-motion exercises with the patient in bed or seated in a chair—for example, active and passive ankle range of motion exercises to facilitate balance. Guidance for Hospitals and Geriatric Medical Professionals For geriatric professionals who wish to contribute to fall prevention strategies in hospitals, Stern recommends first working with administrative staff and communicating to them that falls can be prevented, which ultimately will reduce costs. “Convince them that strategies have to be a full team effort, including all nursing assistants and support services. Spending in the short term ensures spending less in the long term with better outcomes,” she states. She also suggests that facilities consider becoming an Age-Friendly Health System (see www.aha.org/center/age-friendly-health-systems). “The CDC has evidence-based guidelines to prevent inpatient falls,” Stern notes. Therefore, CDC fall prevention resources should be utilized to develop fall prevention programs; another resource is the Agency for Healthcare Research and Quality. See, respectively, www.cdc.gov/steadi/materials.html and www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/overview.html#Problem. Some of the guidance from the Agency for Healthcare Research and Quality toolkit related to environmental risk factors in hospitals includes the following: • Install handrails and other supports in bathrooms, patient rooms, and corridors. • Lock hospital bed brakes at all times until the bed needs to be moved for patient transport or care. • Make protective/supportive equipment easily accessible to patients, including grab bars, alarms/call bells, nonslip footwear, walkers, and canes. • Assess patient rooms and corridors for fall risks regularly and make modifications as necessary. • Consider patient fall risk when assigning rooms, with patients at high risk for falls located closer to, or in view of, a nursing station. Additional research findings on environmental factors and inpatient falls are expected to be published soon and will report on fall risk related to hospital design factors at three large Veteran’s Health Administration medical centers.5 — Jennifer Van Pelt, MA, is a freelance writer and health care researcher located in the Lancaster, Pennsylvania, area.
References 2. LeLaurin JH, Shorr RI. Preventing falls in hospitalized patients: state of the science. Clin Geriatr Med. 2019;35(2):273-283. 3. Dolan H, Rishel C, Rainbow JG, Taylor-Piliae R. Relying on myself: the lived experience of being at risk for falling in the hospital among older adults. Geriatr Nurs. 2022;47:116-124. 4. Magnuszewski L, Wojszel A, Kasiukiewicz A, Wojszel ZB. Falls at the geriatric hospital ward in the context of risk factors of falling detected in a comprehensive geriatric assessment. Int J Environ Res Public Health. 2022;19(17):10789. 5. Shorr RI, Ahrentzen S, Luther SL, et al. Examining the relationship between environmental factors and inpatient hospital falls: protocol for a mixed methods study. JMIR Res Protoc. 2021;10(7):e24974. 6. Guo X, Wang Y, Wang L, et al. Effect of a fall prevention strategy for the older patients: a quasi-experimental study. Nurs Open. 2023;10(2):1116-1124. |
