Hospital Falls and Falls that
Lead to Hospitalization
The Inpatient Perspective
Ethan Cumbler MD, FACP
Associate Professor of Medicine
Director UCH Acute Care For Elderly Service
University of Colorado Denver
2010
Disclosures
None
Objectives
1: Teach actionable risk factors for falls leading to
admission with emphasis on interventions
which can be initiated in the inpatient setting
2: Identify strengths and weaknesses of risk
stratification tools for the in-hospital fall
3: Critically appraise the quality of evidence for
interventions to reduce falls in the acute care
hospital
Clinical Case #1
Outpatient Fall Leading To Admission
Gertrude is an 88 y/o
woman admitted for back
pain after a fall stepping
off a curb outside her
assisted living
Xray demonstrates
thoracic compression
fracture.
Admit for pain control,
inability to ambulate.
PMH
–
–
–
–
–
Mild Alzheimer's Dementia
HTN
Urge incontinence
Depression
Insomnia
Medications
–
–
–
–
Clonidine 0.1 mg bid
Aspirin 81 mg daily
Sertraline 50 mg daily
Amitryptiline 50mg at night
IMPACT
30-40% of people over age 65 will have a fall each
year
In an elderly patient who has fallen, the risk of
having a second fall within a year rises to 60%
Rao SS. Prevention of Falls in Older Patients. AAFP 2005;72:81-88
Consequences
5-10% of community dwelling elderly who fall
will suffer a serious injury
– Up to 20-30% of elderly patients overall
Falls increase risk of going to nursing facility
– 3 fold increase for falls without injury
– 10 fold increase for falls with serious injury
8% of people > 70 come to ER for falls each year
– 1/3 will be admitted
Rubenstein LZ, Josephson KR. Falls and Their Prevention in the Elderly. Med Clin N Amer 2006;90:807-824
Tinetti ME,et al. Falls, Injuries Due to Falls, and the Risk of Admission to a Nursing Home. NEJM 1997;337:1279-84
Injuries
Fractures
1% of falls in the
elderly lead to hip fx
20-30% mortality in
the year after hip fx
¼ to ¾ of patients do
not recover prior level
of ADLs
Rubenstein LZ, Josephson KR. Falls and Their Prevention in the Elderly. Med Clin N Amer 2006;90:807-824
Injuries
Other Fractures
– Humerus
– Rib
Subdural Hematoma
Prolonged lie- half of all elderly patients
who fall are unable to get back up
– 2o rhabdo, dehydration/ARF, pressure injury
Tinetti ME et al. Predictors and Prognosis of Inability to Get Up after
Falls among Elderly Persons. JAMA 1993;169:65-70
Post Fall Anxiety Syndrome
“Fallophobia”
Self-limiting activity, worsening deconditioning, social isolation
Picture the geriatric fall as a
node on a decline spiral
Falls are a Prototypical Geriatric Syndrome
Multifactoral
Risk Factor
Odds
Ratio
Lower extremity weakness
4.4
History of falls
3.0
Gait deficit
2.9
Balance deficit
2.9
Need for assistive device
2.6
Visual defect
2.5
Arthritis
2.4
Impaired activities of daily living
2.3
Depression
2.2
Cognitive impairment
1.8
Age > 80 years
1.7
Rubenstein LZ. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin N Am. 2006;90:807-824
Tinetti ME, Speechley M, Ginter SF. Risk Factors for Falls Among Elderly Persons Living in the Community. NEJM 1988;319:1701-8
A Brief Diversion
In Malcolm Gladwell’s book on cognition “Blink”, he
describes a fascinating psychology experiment.
A sample table is set up at two grocery stores for
customers to try a sample of jam.
On table has 6 varieties of jams, the other has 24
selections.
Which table do you think sold more jam?
Multiple Alternatives Bias
Table with only 6 varieties sold 10X more jam
The reason lies in the human psyche.
Faced by too many choices, customers freeze
up and make no decision at all.
A New Conceptual Framework
Fall risk has specific components:
Latent risk for fall
– Physiologic changes of aging
– Disease and medications
– Behavioral traits
Environmental trigger
– the “accident”
Underlying frailty
– Vulnerability to injury
EACH COMPONENT HAS CONCRETE ACTIONS TO
REDUCE RISK OF FUTURE INJURY
Postural
Challenges
Of Aging
OPPORTUNITY FOR INTERVENTION
↓Baroreceptor Sensitivity
↓Balance from vestibular and proprioception
↓vision (esp night)
↓reflex speed for correction
1) Physical Therapy
2) Ambulation/Gait assists
3) Sensory Aids
4) Remove Problematic Medications
5) Bed Alarms for dementia with impulsivity
Fall Risk
Benzodiazepines
Psychotrophics
Anticholinergics
↑impulsivity
(esp in dementia)
Antihypertensives
Parkinsons
Neuropathy
Arthritis
Podiatry problems
Behavioral
Contributors
Environmental Trigger
“Accident”
6) OT Home Safety Eval
Fall
Frailty
Osteoporosis
Decreased muscle
speed to deflect injury
Medications
And
Comorbidities
INJURY
-rugs
-lighting
-cords
-rails
7) Calcium+Vitamin D/Bisphosphonate
8) ? Hip protectors
What about Tests?
Orthostatic Vital Signs
Vitamin D levels
– Vitamin D deficiency associated with falls and osteoporosis
CBC, Chem7, Urinalysis are reasonable
– B12 levels and TSH if driven by other clinical cues
Brain imaging if neurologic findings on exam or if fall caused head injury
Echo is only indicated if exam suggests valvular disease
EKG/holter monitoring- low yield without syncope, chest pain, or palpitations
– Syncope is estimated to cause only 0.3% of falls
Broe KE, et al. A Higher Dose of Vitamin D Reduces the Risk of Falls in Nursing Home Residents: A Randomized, Multiple-Dose Study. JAGS 2007;55:234-239
Rubenstein LZ et al. Falls and Their Prevention in the Elderly. Med Clin N Amer 2006;90:807-824
The Hard Part
Medications
Antidepressants
68% increased risk
There is usually a reason
patients were placed on a
medication
Neuroleptics/Antipsychotics
59% increased risk
Sedative/Hypnotics
47% increased risk
Antihypertensives
24% increased risk
NSAIDS
21% increased risk
Patients and physicians
may be resistant to
change
It is incumbent on us to
try to reduce problematic
medications when
adverse events are
occurring.
Woolcott JC, et al. Metaanalysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Int Med 2009;169:1952-60
InpatientOutpatient
Transient Ischemic Attack
versus
Geriatric Fall
Case #2
The In-hospital Fall
74 y/o previously independent man admitted for GIB
– Felt most consistent with hemorrhoids
– Admit for observation overnight
– Double occupancy room with another patient
There are Some Who Think the
Hospital is a Fancy Hotel
Fall Risk Stratification
Physician assessment as “Low” (binary) fall risk
“Moderate” risk per nursing assessment
The patients roommate is rated “High” risk
The Fall
Patient incontinent and attempting to reach
toilet using walker.
– Nursing aid assists patient to toilet
While on toilet roommate’s bed alarm sounds
– Imminent risk of falling out of bed
Nursing aid leaves bathroom to assist
roommate
– Bed alarm also summons nurse to room
The Fall
Returns to find patient has fallen in
bathroom
– Scalp laceration
– Humerus + Radius fracture
– Subdural hematoma
Outcome
Patient transferred to ICU
Fails swallow evaluation
Declines PEG tube
Aspirates in hospital
Death
Hospital Falls
2-12% of patients will have a fall in the hospital
Circumstances
20% with toileting
34% from bed
38% while ambulating
10-20% of in-hospital falls are recurrent events
Chelly JE. Risk Factors and Injury Associated with Falls in Elderly Hospitalized Patients in a Community Hospital. Journal of Patient Safety 2008;4:178-183
Schwendimann R, et al. Falls and Consequent Injuries in Hospitalized Patients. BMC Health Ser Research 2006;6:69
Consequences
30% with minor injury
4% with major injury
–
–
–
–
Lacerations/bleeding
Hematomas
Fractures/dislocation
Traumatic brain injury
 hospital charges
 LOS
Litigation
– Serious injuries
– Failure to follow
procedures to prevent
recurrent falls
– Delays in injury
recognition
Half of all patients with hip fracture from in-hospital fall will be dead within the year
-Twice the rate seen in the community
Risk of injury from in-hospital fall rises by 19% for each decade of age
Schwendimann R, et al. Falls and Consequent Injuries in Hospitalized Patients. BMC Health Ser Research 2006;6:69
Bates DW. Serious Falls in Hospitalized Patients: Correlates and Resource Utilization. Am J Med 1995;99:137-143
Johal KS. Hip Fractures after Falls in Hospital: A Retrospective Observational Cohort Study. Injury 2009;40:201-204
Oliver D. Do Falls and Falls-Injuries in Hospital Indicate Negligent Care- and how big is the risk? Qual Saf Health Care 2008;17:431-436
The Challenge of the In-hospital Fall
Falls in the hospital are rarely witnessed
– Only 8% of hospital falls have staff present
Witnessed falls are still difficult to catch
Falls are widely underreported
– 44% of falls not reported as incident reports
Bradley SM. Predictors of serious injury among hospitalized patients evaluated for falls. JHM 2010;5:63-68
Sari AB. Sensitivity of Routine System for Reporting Patient Safety Incidents in an NHS Hospital. BMJ 2007;334:79
Regulatory Environment
Injuries from hospital falls are “Never Events”
– --Medicare will no longer pay for them
Hospital falls with significant injury are
JCAHO reportable
– --sentinel events
Falls with injury in the hospital pose
malpractice risk
Risk Assessment- Physicians
How do physicians assess fall risk?
For the most part, physicians pay little or no
attention to this issue.
A simple physician falls screen:
– “Have you fallen in the last 6 months or are you afraid of
falling?”
– Get-Up-And-Go test
You learn a lot about strength, balance, and gait in 30 seconds.
Fernandez HM. House Staff Member Awareness of Older Inpatients’ Risk for Hazards of Hospitalization. Arch Intern Med 2008;168:390-396
Fall Risk Scoring Tools
Screening tools are available to target
interventions to high risk patients
STRATIFY Score
Downton Score
Morse Falls Scale
Hendrich II
Using the standards of EBM, even the best of
these tools has poor test performance
– Sens 67%
Spec 51%
– Predictive accuracy of 43.2% to 60%
ACTION on modifiable risk factors is far more
important than risk stratification
Oliver D, et al. A Systematic Review and Meta-analysis of Studies Using the STRATIFY Tool for Prediction of Falls in Hospital Patients. Age and Aging;37:621-627
Coussement J et al. Interventions for Preventing Falls in Acute and Chronic Care Hospitals: A Systematic Review and Meta-Analysis. JAGS 2008;56:29-36
Oliver D. Falls Risk-Prediction Tools for Hospital Inpatients. Time to Put Them to Bed? Age and Ageing 2008;37:248-250
The literature provides little guidance
as to how the probability of injury
should be incorporated into hospital fall
policies as a modifier of the risk of a fall
itself.
Acute Post-Fall Evaluation
First priority is evaluation for injury
– Obvious and occult
Head to toe examination
– Palpation of spine, pelvis and ROM of extremities
– Fractures between occiput and C2 more likely in elderly
Immobilize neck pending CT scan if neck injury suspected
Head injury prompts CT scan
– Up to 10% of elderly pts with ICH lack focal deficits
– Scheduled neuro checks prudent
Touger M. Validity of a Decision Rule to Reduce Cervical Spine Radiography in Elderly Patients with Blunt Trauma. Ann Emerg Med 2002;40:287-293
Gangavati AS. Prevalence and Characteristics of Traumatic Intracranial Hemorrhage in Elderly Fallers Presenting to the Emergency Room without Focal Findings.
J Am Geriatr Soc 2009;57:1470-1474
NEXUS-II Closed Head Injury
Decision Aid
NEXUS Cervical Spine Injury
Decision Aid
Criteria
Criteria
1
Evidence of significant skull
fracture
1
Evidence of Intoxication
2
Scalp haematoma
2
Posterior midline neck
tenderness
3
Neurologic deficit
3
Distracting painful injury
4
Altered level of alertness
4
Altered level of alertness
5
Abnormal behavior
5
Altered neurologic function
6
Coagulopathy
7
Persistent vomiting
8
Age 65 or more
Pts with none of these factors are low risk for significant injury and do not require imaging.
Mower WR. Developing a Decision Instrument to Guide Computed Tomographic Imaging of Blunt Head Injury Patients.
Journal of Trauma-Injury Infection & Critical Care 2005;59:954-959
Touger M. Validity of a Decision Rule to Reduce Cervical Spine Radiography in Elderly Patients with Blunt Trauma. Ann Emerg Med 2002;40:287-293
There is No Better Sign of the
Next Fall….
Than the First Fall
Institute Secondary
Prevention Measures
What Interventions Reduce Falls?
Interventions to Reduce Falls
Outpatient and Long Term Nursing Homes
Expedited cataract surgery
– One trial showed benefit, two did not
Cardiac pacing for cardio-inhibitory carotid sinus
sensitivity
Home safety evaluation in patients with prior falls
Vitamin D supplementation
Exercise/balance programs
Medication withdrawal
Tinetti ME, et al. The Patient Who Falls. JAMA 2010;303:258-266
Interventions
Ambulation Aids
Modification of bedside
environment
Staff education
Eyewear (glasses)
Modification of drug
regimen
Patient and family
education
Modified footwear
Posted alerts to staff on
patient fall risk
Increased supervision
(more frequent status
assessments by nursing)
Exercise/balance training Scheduled toileting
Referral to P.T.
Bedside “sitter”
Hip protector use
Bed and chair alarms
Bedside commode
Evaluation and treatment Screening for urine
of postural hypotension infection
Beds placed in lowest
position
Cumming RG. BMJ 2008; 336: 758–760
von Renteln-Kruse. J Am Geriatr Soc 2007;55:2068-2074
Healey F. Age and Ageing 2004;33:390-395
Haines TP. BMJ 2001;328:676-681
High risk patients moved
to close proximity to
nursing station
Staff assistance with
transfers
Observational Trials of
Hospital Fall Reduction Protocols
2004 Observational trial
– 25% reduction in fall rates
2004 RCT in Community Hospital
– 21% reduction in falls
– No difference in fall related injuries
Falls Prevention Programs
Effective…. According to Less
Rigorous Scientific Standards
Loch Ness Monster
Sasquatch
Of course by these standards….lots of
things are plausible
2006 Observational Trial of
Interdisciplinary Fall Prevention Program
No reduction in falls
No reduction in fall related injuries
Schwendimann R et al. Falls and Consequent Injuries in Hospitalized Patients: Effects of an Interdisciplinary Falls Prevention Program.
BMC Health Serv Research 2006
Identified Problems
Incomplete predictive power of screening tools
Limited exposure time for intervention impact
– LOS in days vs. months to years
Incomplete adherence to fall reduction protocol
– Prior research demonstrates 43% non-adherence rates
– Our investigation found 64% non-adherence to bed alarms
Bakarich A. The Effect of a Nursing Intervention on the Incidence of older Patient Falls. Aust J of Adv Nurs 1997, 15:26-31
Lampignano DW. Using rare inpatient accidents to evaluate and improve the system-based practice:
an example in process mapping and the Vanderbilt Healthcare Matrix-2010
RCTs to Reduce In-hospital Falls
8 Trials Since 1966
– Only two were exclusively acute care hospitals
1993 RCT of bed alarms
– Very small trial (35 patients in each arm)
– Non-significant reduction of falls
2006 Quasi-experimental multi-component trial
– Reduction in pts with recurrent falls
20% versus 56%
– No reduction in first falls
12.6% versus 11.8%
Tideiksaar R. Falls Prevention: The Efficacy of a Bed Alarm System in an Acute-Care Setting. Mt Sinai J Med 1993;60:522-527
Schwendimann R. Fall prevention in a Swiss acute care hospital setting. J Gerontol Nurs 2006;32:13–22.
Findings of Systematic Review and
Meta-Analysis
No conclusive evidence that hospital fall
prevention programs can reduce the number of
falls or fallers
More studies are needed to evaluate trend
towards efficacy of actively targeting patient’s
most important risk factors
No evidence demonstrates acute care fall
prevention programs reduce injuries
Coussement J. Interventions for Preventing Falls in Acute and Chronic-Care Hospitals: A Systematic Review and Meta-Analysis.
JAGS 2008;56:29-36
Cochrane Review
In hospitals, multi-factoral interventions
reduced the rate of falls and risk of fallers.
– Results most robust for patients with longer
lengths of stay
Cameron ID. Interventions for Preventing Falls in Older People in Nursing Care Facilities and Hospitals.
Cochrane Databse Syst Rev 2010;20(1):CD005465
Final Thoughts