Authors: Maryam Zadeh, Laura Pozzobon
An 85-year-old woman who lives independently at home was hospitalized three days ago for pneumonia. She has multiple comorbidities, including dementia, hypertension and diabetic neuropathy. While in hospital, the patient’s care team noticed her losing balance, and it was determined that the patient was at high risk of falling. One evening, the patient attempted to go to the bathroom independently. She put on her glasses and took the cane provided to her, as she forgot her walker at home. After only a few steps away from her bed, the patient began to lose balance and fell. When the hospital staff arrived in her room after hearing a “bang”, they found her on the ground, unable to get up. She seemed alert, disoriented in obvious distress and moaning in pain.
What do we know?
Injury is a common cause of hospitalization in older adults, with falls being a leading cause of injury-related hospitalization in seniors.(1) Falls are also a common complication of hospital care, especially in the elderly, bed-bound, and in long-term care centres.(1) More than a third of in-hospital falls can lead to injury, some as serious as fractures and major head trauma. Those that do not lead to injury can still be distressing to patients, family members, and care team members.(2)
Why is it important?
Patient falls can lead to substantial injuries such as fractures, with an estimate of over one-third of fall-related hospitalizations being due to post-fall hip fractures.(1) These injuries lead to fall-related physical limitations, and other complications, such as, negative mental health outcomes.(1)
There are multiple factors that put seniors at more risk for falling, some of which can be divided into categories of biological, behavioral, social and environmental.(1) For example, the patient in our vignette had multiple risk factors for falls, including chronic and acute health conditions, polypharmacy, poor gait, sensory deficits, social isolation, as well as some environmental factors such as dim lighting, lack of using non-slip shoes and inadequate help while mobilizing. These factors increased their risk of falling and prolonged hospitalization due to fall-related injuries.
Older adult patients hospitalized for fall-related injuries remain in hospital approximately nine days longer than those who are hospitalized for other reasons. Additionally, from 2003 to 2008, there was an increase of 65% in deaths due to falls by Canadian seniors.(1) While worrisome on its own, falls by seniors in Canada require a tremendous amount of resources from our healthcare system. In 2018, falls amongst seniors cost $5.6 billion.(3) Falls are immensely resource intensive on our healthcare system and as such, fall prevention initiatives in Canadian hospitals, targeted at the senior population, should be of highest priority.
Best Practices/Preventing Falls
An important step in fall prevention programs is individual assessment of risk of falling (e.g. using the Morse Fall Scale or Hendrich II Fall Risk Model).(1,4-5) Understanding patient specific risk factors can help providers work with patients / families to develop fall prevention plans that target their specific needs. In doing so, it is important to be considerate of the tension between fall prevention and meeting the patient’s needs. For example, limiting a patient’s mobility due to fall risk can ignore other patient goals, which may have long-term consequences.
There are toolkits that offer fall prevention best practices for hospitalized and long-term care patients.(6) Some key elements of a good fall prevention program include: addressing environmental factors (e.g. implementing non-slip floors), implementing clinical and care process interventions with a multidisciplinary team (e.g. fall risk assessment tools) and considering technological interventions (e.g. using hospital beds that go low to the ground).(7) Additionally, hospitals should implement “universal fall precautions” which are interventions applicable to all patients regardless of risk level (e.g. familiarize patients to their environment, call bell placed within patient reach, lock hospital bed wheels, have sturdy handrails, etc).
An Organizational Approach to Reducing Patient Falls
In 2017, University Health Network (UHN) – a multi-centre academic health sciences center in Toronto, Ontario – began an organization-wide approach to reducing patient falls. In three years, TeamUHN was able to reduce the overall Acute Care fall rate by 61% and the Rehabilitation and Complex Continuing Care fall rate by 44%.(7) There have been many learnings along the way, some of which are outlined below:
Establishing Accountability: The identification of committed organization leaders and partnership with existing fall prevention committees was key to the success of reducing falls at UHN, specifically the identification of policy and practice gaps.
Clearly defining a patient fall: TeamUHN defined patient fall types (preventable falls, unwitnessed falls, near-falls, and falls with injury) which allowed for consistent measuring of fall rates. TeamUHN recognized that not all patient falls are preventable.
Reducing variability, and building reliability: In collaboration with key stakeholders and subject matter experts, an evidence-based fall prevention “bundle” (see figure 1) was developed for the UHN context.
Collaboration: Engagement with patients and front-line clinicians was integral to the development of UHN’s fall prevention strategy and the scale and spread. Empowering clinicians to focus on fall prevention also resulted in novel fall prevention work. For example, a Physician Quality Practicum was created to engage physicians on reducing hospital acquired conditions, including falls.
A continuous focus on fall prevention at all levels: UHN’s huddle structure supports units in the review of past patient falls and anticipates risks associated with falls. Additionally, UHN has implemented a process for systematic review of patient falls to ensure continued learning from fall events. Moreover, the organization added patient fall outcome and process measures to the Safety and Quality scorecard to monitor organizational progress.
Conclusion
Returning to our patient’s case, we know that Jane Doe’s fall may have been prevented if the hospital had implemented an organization-wide fall prevention program. Specifically, a fall risk assessment should have been done on admission and an individualized fall prevention plan should have been co-developed and implemented with the patient and care team. We hope that this post provides you with a basic framework and tools to implement a fall and fall-related injury prevention program with your patients and your hospital. Good luck!
Senior editor for this post was Dr. Lucas Chartier
This post was copyedited by Maryam Zadeh
References
Public Health Agency of Canada. (2014). Seniors' falls in Canada: Second report. https://www.canada.ca/en/public-health/services/health-promotion/aging-seniors/publications/publications-general-public/seniors-falls-canada-second-report.html
Patient Safety Network. (2019).Falls. https://psnet.ahrq.gov/primer/falls
Parachute. (Content last reviewed August 17, 2021). Falls in seniors. https://www.parachutecanada.org/en/injury-topic/fall-prevention-for-seniors/
Morse, JM. Morse Fall Scale. University Park, PA: The Pennsylvania State University School of Nursing, 1985
Hendrich AL, Bender PS, Nyhuis A. Validation of the Hendrich II Fall Risk Model: a large concurrent case/control study of hospitalized patients. Appl Nurs Res. 2003;16: 9–21. pmid:12624858
Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals. A toolkit for improving quality of care. https://www.ahrq.gov/sites/default/files/publications2/files/fallpxtoolkit-update.pdf
University Health Network. (2020). Quality and safety journey. https://www.uhn.ca/corporate/News/Documents/Quality_Safety_Journey_2020.pdf