How prevalent are falls and fall-related injuries?
The literature reports a range of three to five falls per 1,000 patient days. The National Quality Forum coined the word "never event"—those events we never want to happen in our care. Even though we never want a patient to fall in our care, we can’t prevent all falls because there are different types of falls.
It's a myth to think you can get to zero falls, but you can reach for zero injuries. If you accept the assumption that all patients are "at risk" for falls, just as all patients are "at risk" for hospital-acquired infections, then your approach to fall prevention will be transformed.
Research has shown between 30 to 51% of falls that occur in hospitals result in some injury (Oliver et al, “Preventing Falls and Fall-Related Injuries in Hospitals,” Clinics in Geriatric Medicine, Nov. 2010). This outcome can and should be reduced because it's injuries that lead to patients’ loss of function or loss of life. In the VA, our primary outcome is protection from injury should a fall occur.
Why isn't total fall rate a good indicator of fall reduction?
Total fall rate doesn’t provide enough information. There are different types of falls, and each one requires different interventions to reduce their occurrence:
- Accidental fall: Due to environmental risk factors, such as slipping on a spill or tripping over tubing. Interventions are related to creating a safer environment.
- Anticipated physiological fall: Due to known intrinsic and extrinsic risk. Interventions require a comprehensive, multifactorial fall risk assessment (not just screening) and an interdisciplinary team to assess and treat modifiable risk factors. If there are known, unmodifiable risk factors, you should teach the patient and family compensatory strategies.
- Unanticipated physiological fall: Due to an unanticipated sudden medical episode, such as a sudden heart attack, stroke, or seizure.
- Intentional fall: A fall associated with behavioral issues. Clinicians should rule out the other three types of falls before assigning one to this category.
The first three types of falls were defined by Dr. Janet Morse in 1997. The preventable falls we want to target are accidental falls and anticipated physiological falls.
Who should be on a fall prevention or fall-related injury (FRI) reduction team?
The evidence confirms the team has to be interdisciplinary to treat multifactorial fall risk factors and to design interventions to reduce both fall and injury risk factors. A nurse-managed, nurse-led fall prevention program is insufficient (Oliver, et al., 2010).
For the core team, I recommend:
- Prescribing provider: Reviews prescribing practices
Ideally a geriatrician specializing in fall prevention, a physiatrist, a geriatric nurse practitioner, or a geriatric clinical nurse specialist.
- Physical or occupational therapist: Addresses gait and balance problems contributing to falls (physical therapist) or helps with issues related to activities of daily living (occupational therapist)
- Quality improvement or systems redesign specialist: Helps monitor and evaluate the program within and across units
- Registered nurse: Directs and coordinates nursing and aspects of interdisciplinary fall prevention programs, evaluating patient responses to treatment plans
- Patient or family member: Sits on an advisory council to give feedback on and help evaluate the program
- Patient safety/risk manager: Monitors trends and effectiveness of interventions to increase safety and reduce fall and injury risk
- Mental health provider (as needed)
Some organizations may want to consider additional team members, such as staff from engineering or housekeeping, for input on specific agenda items. For example, when we introduced hip protectors in the VA, we included laundering staff to determine how to clean the hip protectors and return them to the unit.
Get best practices for preventing patient falls
What's the difference between a screening tool and an assessment for fall and injury risk?
If a patient is answering yes-no questions on admission, you're using a screening tool. But you can’t go straight from a yes-no answer to a care plan. Doing so requires an assessment that relies on clinical expertise and judgment—not merely an electronic template.
For example, we use the Morse Fall Scale in the VA. If a patient says yes, he has a history of falls, he has answered a screening question. The next step is to ask several follow-up questions, such as:
- "Do you fall inside or outside?"
- "When you stand up, do you get dizzy and fall?"
That’s an assessment. Every positive screen requires a comprehensive assessment by the interdisciplinary team.
At the VA, our electronic medical record helps caregivers move from screening questions to a multifactorial assessment. If the RN checks yes to history of falls, for example, a dialogue box prompts them to ask about the circumstances, frequency, and consequences.
Appropriately assessing an older adult who reports no falls in the last month or two requires true expertise to see whether there is more to a patient’s response. Most older people won’t tell you if they have fallen recently because they fear they won’t be able to live alone anymore or need to go to a nursing home. The RN must use expert skills to ask questions that invite the older adult to disclose fall experiences and their causes. This RN has progressed to assessment—beyond screening questions.
How should fall risk and FRI risk assessments drive interventions?
Interventions should not be based on a universal fall risk score. A fall risk factor, not a score, is what drives care.
The key is to link specific risk factors, determined from multifactorial assessment, to interventions. And that requires an interdisciplinary team.
For example, if an assessment reveals a patient has vertigo, the prescribing provider needs to treat him. If a functional assessment shows the patient has new gait and balance disorders, a physical therapist needs to treat him. With this approach, each patient has a fall prevention plan specific to his or her fall risk factors, not to a risk score from a screening tool.
Injury risk is a different assessment. This approach to care is based on patient populations.
Which patients should always have FRI interventions in place, regardless of screening results?
We know there are four patient populations who could suffer loss of function or loss of life if they have one more fall—regardless of whether they screen positively for FRI.
- Patients 85 and older—Falls are the leading cause of death for patients 85 and up
- Patients with a fracture or osteoporosis—Any fall could lead to fracture
- Patients on anticoagulants—Any fall could lead to severe bleeding
- Post-operative, surgical patients
What types of interventions can be put in place for these patients?
First, design injury-free environments to reduce lacerations. Evaluate your care settings for sharp edges and hard surfaces. Implement strategies to remove the items, round sharp edges, or pad them.
Second, integrate technology to reduce fall-related trauma. We've recommended the use of floor mats throughout the VA since 2004.
We place floor mats along the bedside of patients at risk for FRI who we worry will get up without help. We published an article in Rehabilitation Nursing (Bowers, et al., 2008) showing that falling on a floor mat from a low bed had a 1% risk of serious head injury—compared to 40% for falling on unprotected flooring from a normal-height bed over a bedrail. Two additional studies by other groups have confirmed our findings that floor mats are protective in reducing fall-related impact during a fall.
Check out our floor mat technology guide for more information.
We’ve also tested the efficacy of hip protectors—low-cost, padded clothing that protects the head of the trochanter during a fall by shunting trauma away from the bone. Hip protectors can reduce the risk of hip fractures. For prescribing guidelines, laundering and replacement protocols, and more, check out our hip protector toolkit.
What metrics should leaders use to monitor their programs?
You’re never going to achieve the outcome you’re looking for unless you have the structures and processes in place. If you don’t measure the process over time, if you measure the outcome and you don’t achieve it, you won't know what the stumbling blocks were. So you want to have both process and outcome measures.
Process measures answer the question: “Are we doing the things we think will lead to improvement in the outcome?” I can give several examples of process measures that could be obtained from patient questions or observation.
First, the percentage of patients who are able to tell you that they were asked the "4 Ps" (Personal needs, Positioning, Pain, Potty) by a nurse during intentional rounding. You can measure this percentage by asking patients questions such as:
- "Were you asked if you needed to use the toilet before the nurse left the room?"
- "Were you asked if you had your personal items within reach?"
Second, the percentage of patients over the age of 75 whose fall prevention plans of care include interventions by interdisciplinary care team members (beyond nursing). You can measure this by reviewing medical records.
Third, the percentage of patients with hip fracture history and fall history who have floor mats down at their bedside when they are resting in bed. You can measure this through observation.
With process measures, remember that there’s no need to over-burden yourself with measurement by doing 100% chart reviews. You can randomly select five or 10 charts to review to see if there are interdisciplinary interventions in place. Or better yet, you can ask five patients five questions about what was covered during intentional rounding. You could also observe staff during hand-offs to see what fall risk and FRI risk information is communicated.
Of course, we also need to measure the ultimate outcomes. Sample outcome measures include:
- Major injury rate: The percentage of patients who fall and have major injuries per month
- Fall rate, analyzed by type of fall (accidental, anticipated physiological, and unanticipated physiological): The number of falls (by type of fall) divided by number of bed days times 1,000
You should also have balancing measures in place to ensure a decreasing fall rate isn’t accompanied by unintended changes in other key metrics. Examples include:
- Use of restraints
- Use of one-to-one sitters
- Staff injuries with assisted falls
- Patient satisfaction
What tactics should leaders use to breathe life into existing fall prevention and injury reduction programs?
Breathing life into your program is critical for engaging staff in the effort and helping them understand the importance of assessing and addressing fall and FRI risk factors. Here are a few ideas to try:
- Fall rounds: Ask a hospitalist or physical therapist to accompany staff on rounds to discuss specific risk factors. The rounds can help teach staff that one patient’s care plan to reduce falls and FRI should be different from the next—because each is customized to the patient’s risk factors.
- Pre-shift huddles: Gather staff before the shift to talk about particularly vulnerable patients and how to meet their needs.
- Daily care planning: Focus on care plans for patients 75 and older to ensure fall prevention and FRI reduction are integrated into their care.
- Patient and family education: Build fall and FRI content into your teach-back strategies and evaluate patients’ knowledge and skills.
- Hand-off communication: Observe hand-offs to radiology, physical therapy, or the oncoming nurse to ensure the conversation includes fall and FRI risk factors and related interventions.
What role should bed alarms play in fall and FRI prevention?
Bed alarms were never designed to prevent falls; they were designed as an early warning system to get us to the patient’s room quickly. So the effectiveness of bed alarms should be timeliness of rescue—not whether or not someone fell. Dr. Ronald Shorr published a randomized control trial last year on bed alarms in the Annals of Internal Medicine. He found that bed alarms led to an increased number of falls, which has to give us pause.
One piece of technology doesn’t work for all patients. For example, if you put an alarm on the bed of a patient with Alzheimer’s, the patient may be afraid when the alarm starts going off and may try to get out of bed to figure out what’s going on.
The take-away message is that bed alarm use should not be based on a screening score for fall risk or level of fall risk.
What are some of your favorite "must-read" articles on this topic?
The following journal issues are wholly devoted to the topic of falls:
Additional resources for reducing patient falls
The following resources are available in the Falls Toolkit developed by the VA National Center for Patient Safety and the Patient Safety Center of Inquiry:
- A guide to developing a multi-disciplinary falls team
- Interventions to reduce fall risk and injuries from falls
- A guide to measuring the success of your interventions
- Annotated references on topics related to falls