Assessing hospital patients who
have fallen
J Rush Pierce Jr, MD, MPH
Section of Hospital Medicine
Univ New Mexico School of Medicine
10/04/2010
Case
• You are providing cross-cover. The 4W nurse
calls you at 2 AM because an 84 year old
woman fell in her room. She was admitted
two ago with pneumonia and is receiving IV
antibiotics and oxygen. The nurse says the
patient fell when trying to get to the toilet.
The nurse says the patient “seems okay” but
thinks that maybe you should come see the
patient.
Questions you might have
• How promptly do I need to see this patient?
(“Can’t the primary team take care of this in
the morning?”)
• How should I evaluate this patient?
• How am I going to remember all this stuff?
General facts about falls
• Most of literature about falls is in elderly
patients who fall at home or in nursing homes
• Little literature about patients who fall in the
hospital
• Nonetheless, hospital falls are considered a
“never event” by Medicare
• UNMH will roll-out a multidisciplinary falls
prevention program in October, 2010
Why do patients fall?
• In the elderly, syncope is an uncommon cause
of falling (0.3%) – if present suggests
orthostatic hypotension, cardiac arrhythmia,
or seizure
• Most common mechanism of falling in the
elderly is impaired neuromuscular reflex
systems due to combination of age-related
changes plus illness/medications, precipitated
by environmental perturbation (“I tripped”)
Epidemiologic factors associated
with outpatients falls in the elderly
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Age (>80)
Cognitive impairment
Female gender
Past history of fall (second largest effect)
Lower extremity weakness (largest effect)
Balance difficulty
Arthritis
Meds: neuroleptics, sedatives, antidepressants,
antihypertensives
Epidemiology of inpatient falls
(Barnes Hospital 2001-2)
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1235 falls by 1082 pts (3.10 falls/1000 pt days)
89% single fall, 11% more than once
40% related to toileting
Serious injury (laceration requiring sutures,
loss of consciousness, fracture, SDH) – 6%
• Death – 0.2% (both in patient with more than
1 fall)
Source: Inf Control Hosp Epidem 2005;26:822
Can we predict which pts will fall?
• Outpatient - Best clinical predictors are
previous fall in past 6 months and Timed Upand-Go (TUG) test
• Inpatient – Falls risk tools (Morse, STRATIFY,
Hendrich II, Conley)
– Not very good, best sensitivity = 60%, specificity =
51%
What interventions prevent falls?
(outpatient data)
• Four interventions have been shown to be
effective
– Medication review and adjustment
– Environmental changes
– Physical therapy
– Vit D if deficient
• Combination of all four (multi-modality) result
in relative risk reduction of 10 – 25%
What interventions prevent falls?
(inpt data)
• Very limited data – two observational studies
show 20-25% reduction with
bundle of services
• 2 RCT in acute care hospitals – no sign
reduction in first fall; one showed reduction
for those with recurrent falls
Case
• You are providing cross-cover. The 4W nurse
calls you at 2 AM because an 84 year old
woman fell in her room. She was admitted
two ago with pneumonia and is receiving IV
antibiotics and oxygen. The nurse says the
patient fell when trying to get to the toilet.
The nurse says the patient “seems okay” but
thinks that maybe you should come see the
patient.
• How promptly do I need to see this patient?
How soon do you need to evaluate
the patient?
• Ask the following 7 questions:
1. Was the fall unwitnessed?
2. Did the patient hit his/her head?
3. Did the patient experienced loss of
consciousness?
4. Is the patient confused?
5. Is there any obvious laceration?
6. Is there any obvious new extremity deformity?
7. Does the patient complain of pain?
How soon do you need to evaluate
the patient (contd)?
• If answer to ANY of the seven is “yes” –
evaluate the patient within one hour
• If answer to ALL is no, may defer to primary
team in the morning.
• Evaluate all patients within 24 hours and
DOCUMENT your evaluation.
Case
• You are providing cross-cover. The 4W nurse
calls you at 2 AM because an 84 year old
woman fell in her room. She was admitted
two ago with pneumonia and is receiving IV
antibiotics and oxygen. The nurse says the
patient fell when trying to get to the toilet.
The nurse says the patient “seems okay” but
thinks that maybe you should come see the
patient.
• How should I evaluate this patient?
What evaluation should we do
after a fall occurs? 3 step approach
1. Assess for syncope
2. Assess for injury
3. Assess opportunity to prevent the second fall
Step 1. Assess for syncope
• Ask the patient and any possible observers
– Ask the patient “did you pass out”
– Ask the family “did he/she pass out”
– Ask the roommate “did he/she pass out?”
– Ask the nurse “did you observe syncope”
• If yes, remember common causes for syncope
(orthostatic hypotension, cardiac arrhythmia,
or seizure) – think about meds that can cause
orthostasis, consider telemetry
Step 2. Assessing for injury
Injury
Clues
Possible Interventions
Laceration
Pain, exam
Steri-strip, suture
Head injury
Hit head, LOC, scalp
laceration, new confusion
Additional imaging, closer
observation
C-spine fracture/injury
Risk (RA), other fx, mid-line C-collar, additional imaging
post neck tenderness, focal
neuro signs
Extremity fracture
Refusal to ambulate, limb
deformity, tenderness or
crepitance on limb
movement
Additional imaging,
splint/cast/surgery
Rib fracture
Chest wall tenderness,
sternal compression test
CXR for pneumothorax
Step 3. Review opportunity to
prevent subsequent falls
• This part should usually be done by primary
team
– Can tethering devices be stopped? (Foley, IV,
telemetry, Sequential compression devices)
– Is the patient getting physical therapy?
– Can some medications be stopped (esp narcotics,
sedatives, drugs with anticholinergic effects)
• Could the patient have delirium?
Case
• You are providing cross-cover. The 4W nurse
calls you at 2 AM because an 84 year old
woman fell in her room. She was admitted
two ago with pneumonia and is receiving IV
antibiotics and oxygen. The nurse says the
patient fell when trying to get to the toilet.
The nurse says the patient “seems okay” but
thinks that maybe you should come see the
patient.
• How am I going to remember all this stuff?
How am I going to remember all
this stuff?
• The nurses will help you – they are your
friends!
• Use a check list!
– Reminds you of what to do
– Helps you organize your brain
– Can use it to provide documentation
– Provides record for primary team
UNM’s Checklist
Questions?