Preventing Fall-Related Injuries in Older Patients

Every 15 seconds, an older adult requires treatment in an emergency department for a fall-related injury. Every 29 minutes, an older adult dies after falling. More than half of all injury-related deaths among senior citizens are related to falls. Even more sobering: The number of older patients who die from fall-related injuries doubled between 2000 and 2013. Many of these falls—and the injuries and deaths that result— are preventable.

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The Fallout

The reason that fall prevention is on the radar of every health care system and care provider is clear from the data. One in five people who fall sustains a serious injury such as a fracture or head trauma. In fact, falls are the number one cause of traumatic brain injury. Emergency departments treat 2.5 million older adults each year for injuries caused by falls. More than 700,000 patients are hospitalized, at least 250,000 of them for hip fractures. The risk of falling increases with age. The older the patient, the more likely he will need subsequent treatment, either in a hospital or rehabilitation setting. For those who have already suffered a fall, their chance of falling again doubles. Falls are not only serious but costly, totaling $34 billion annually in direct medical costs. Hospital costs make up about two thirds of these costs. The older the patient, the higher the medical costs.

Recognizing that up to 30% of adverse events in the acute care setting are due to falls, The Joint Commission issued a National Patient Safety Goal to reduce the incidence of falls. The Centers for Medicare and Medicaid Services (CMS) has reinforced these efforts by identifying falls and fall-related injuries as a never event, which CMS will no longer cover.

Assessing Risk

Most falls are caused by a combination of risk factors. Many occur as a result of a combination of geriatric syndromes that may include poor nutrition, difficulty with balance and coordination, or impaired cognitive abilities. Impaired vision can also play a role as can some medications such as tranquilizers and antidepressants or medications that affect balance. The greater the number of risk factors, the greater the patient’s risk of falling.

Nurses Improving Care for Healthsystem Elders (NICHE)—a program designed to help care providers improve the care of older adults—stresses that fall risk assessment is a key factor in preventing falls. At minimum, a fall risk assessment should include assessment of the patient’s age (especially if the patient is older than 75) and presence of other contributing factors that may include dementia, hip fracture, Type 2 diabetes mellitus, Parkinson’s disease, or arthritis. Other important risk factors to consider include a history of a recent fall, use of an assistive device, and psychiatric issues such as depression.

Risk assessment tools, such as the Hendrich II Fall Risk Model, the Morse Fall Scale, or the St. Thomas Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY), can help to identify and minimize fall risk. Also, 4-P rounding—where nurses round hourly to check patients for bathroom/personal care needs, positioning, possessions/proximity, and pain—can also help prevent falls. Signs that display special fall-risk symbols help staff identify high-risk patients.

Putting a Stop to Falls

However complex the patient’s condition, many falls can be prevented. A number of public health initiatives are attempting to reduce fall-related injuries and deaths among older patients. One of these is “Make Stopping Elderly Accidents, Deaths, and Injuries (STEADI) Part of Your Medical Practice,” an initiative developed by the Centers for Disease Control (CDC). STEADI provides tools and educational materials that help care providers assess and classify fall risk and identify risk factors that can be modified. An algorithm is available to assess fall risk.

Still, fall prevention continues to challenge care providers. Working to meet this challenge, some hospitals are looking for innovative approaches. In the 48-bed cardiac care unit (CICU) at the Hospital of the University of Pennsylvania (HUP), fall rates increased 41% with an increase in the rate of falls with injury of 65% between 2012 and 2013. The increase occurred despite enforcing all of the standard fall precaution protocols, which included assessing patients for fall risk every 12 hours using the Morse Fall Scale, instructing patients to wear nonskid socks and to use the call bell for help when getting out of bed, using bed and chair alarms, and posting fall-risk signs at the bedside. Despite all of this, the fall rate was on the rise.

With leadership’s support, four CICU clinical nurse champions formed a fall prevention evidence-based practice committee to evaluate the data. They saw that most falls occurred when patients were unassisted, usually during toileting. The committee researched best practices and looked for creative solutions. Their work ultimately resulted in new fall reduction guidelines, fall prevention education for fellow CICU nurses, and a new approach built upon a reflective accountability model.

The new initiative was named “Prevent One Fall at a Time.” Information about the initiative was shared in daily nurse huddles and emails. Nurse champions provided education to both shifts of clinical nurses and certified nurse assistants. Unit policy called for answering call bells in less than 60 seconds and required staff to stay with the patient until toileting is completed. Policy was reinforced and audited. Findings on staff toileting procedures and call bell response times were shared in staff meetings. Patient safety goals were incorporated into employee performance evaluations.

The unit’s renewed fall prevention efforts included a post-fall huddle when a fall did occur to provide an opportunity for staff members to discuss the cause of each fall and ways that it might have been prevented. But the most innovative aspect of the new policy was the integration of reflective post-fall emails. Reflective practice promotes critical analysis, problem-solving abilities, evaluation, and identification of patterns of thought and behavior. Initially, the CICU leadership team sent the post-fall email to unit staff. The email communicated both the nurse’s and patient’s perspective on the fall along with the nurse’s reflection on what could have been done to prevent it. To reinforce nurse-driven accountability, responsibility for sending the post-fall email was later shifted to the nurse who was caring for the patient who fell. The emails raised staff awareness and promoted a connection among the nurse, the patient involved in the fall, and the unit staff.

The initiative has proven successful, reducing the unit’s fall rate by 55%. The rate of falls with injury dropped 72%.

Not every fall can be prevented. But these CICU nurses have proven that coupling best practices with creative approaches can make a significant difference. Undoubtedly, reducing the rate of patient falls will continue to be a nursing priority. With increased accountability, education, awareness, communication, and teamwork, fall rates can improve and patient safety can

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