Preventing Falls and Fall-Related Injuries in Hospitals
Section snippets
How important and common is the problem?
The majority of hospital beds in the developed nations are occupied by older people, many of whom have been admitted because of mobility problems, falls, or injury from falls.1 With population aging and projected increases in the number of people surviving with functional impairment, cognitive impairment, or multiple long-term conditions, these trends are likely to continue,2 making fall prevention a very pressing risk management challenge for hospitals and a real threat to patient safety.3, 4,
What are the consequences of falls in hospital?
In acute and rehabilitation hospitals, falls resulting in some injury range from 30% to 51%.4, 7, 16 Proportions of falls resulting in any fracture range from 1% to 3%,7, 17, 18 with reports of hip fracture ranging from 1.1% to 2.0%.4, 7, 19 Falls in hospital are also associated with increased length of stay, higher rates of discharge to institutional care, and greater amounts of health resource use.20, 21, 22 Proximal femoral fractures caused by falls that occur in the hospital setting have
Where and when do people fall in hospital?
There have been several observational studies describing the location, timing, and circumstances of falls in hospitals and the characteristics of those who fall. (eg, Refs.7, 9, 17, 18). These studies are generally based on retrospective analysis of routinely collected incident reports that can be confounded by underreporting, by partial recording of information, and by reporting bias,15 but despite this may provide some useful points of learning. If we look at falls in acute and rehabilitation
Patient-Specific Factors
Just as in the community setting, falls usually result from synergistic interactions between several person-specific intrinsic risk factors, the physical environment, and the riskiness of a person’s own behavior.31 In the hospital setting there is an additional key ingredient: the actions of hospital staff and their interactions with the patient. Hospital staff may offer assistance to patients, allowing them to complete a range of personal tasks. Without this assistance the task would not have
Can falls in hospital reliably be predicted?
As already mentioned, falls in hospital are more likely in older patients and in those with underlying risk factors. And because most patients do not fall during their hospital stay there has been understandable interest, especially from nurses and risk managers, in tools purporting to predict patients who are at “high” or “low” risk of falls. Superficially, this is an attractive idea, in theory allowing staff to focus their preventive efforts and limited fall prevention resources on those at
What are the problems performing and interpreting research on falls in hospital?
Although the randomized controlled trial (RCT) coupled with meta-analysis of RCTs is widely seen as the gold standard, it is often hard to recruit acutely ill or cognitively impaired patients to conventional RCTs, or to recruit promptly enough to include the whole patient episode. Fall prevention is usually a complex intervention47 that aims to change practice at the level of teams or units, making cluster randomization more practical, but allowances for clustering effects can require very
So what is the empiric evidence for fall and injury prevention in hospitals?
Despite these challenges in designing and conducting research on fall prevention in the hospital setting, we should “not let the desire for best possible evidence stand in the way of using the best available evidence.”51 The authors now critically examine the empiric evidence for fall prevention in hospitals, beginning with trials of multifactorial interventions, then of single interventions, before examining the conclusions of recent systematic reviews.
Multifactorial interventions
Several studies of multifactorial interventions have been published. When multifactorial “bundles” of interventions are employed, they are never the same in any 2 trials, and it is difficult to determine the attributable benefit from each component in the “bundle” or the type of population where they may be most effective. Therefore, set out here are the key features for each in terms of settings, patient populations, design, and results (Table 1), the components included within the
Single interventions without empiric evidence
Despite the inclusion of the following single interventions as points of good practice (eg, Ref.3) and as components of some of the multifactorial interventions outlined here, and despite the evidence of some of these conditions as significant risk factors/causes of falls, and despite the likelihood that providing these interventions will improve other aspects of patient care, and despite their obvious intuitive value or in some cases their value in community settings, there is no direct
Systematic reviews and meta-analyses
There have been several recent systematic reviews focusing explicitly on the prevention of falls and fall injuries in hospitals (and long-term care facilities), which summarize and incorporate many of the trials set out above. Inevitably their conclusions depend on how restricted the inclusion criteria were, what the census dates for inclusion were, how the investigators decided to group and aggregate interventions and settings, and what statistical adjustments were made in meta-analysis.
Oliver
Potential harm resulting from focusing on fall prevention in hospital
Some reimbursement systems have recently changed their approach and do not fund the treatment of complications regarded as “preventable” (or even withhold payment for the whole treatment episode if a preventable complication occurs), and this “never event” approach has been applied to falls in hospitals.106, 115 This situation could motivate health care providers to innovate and invest in fall prevention strategies. Conversely, it could lead to a risk-averse, overly custodial approach to
Implications for clinical and organizational practice
It should be pointed out that good practice in fall prevention is not simply about clinical practice, organizational policies, or the empiric evidence base. There are also ethical considerations (eg, the balance between respect for autonomy, personhood, and liberty versus a duty of care to maintain safety, and the balance between a duty of care to all patients vs “high-risk” ones); cultural considerations (eg, the attitudes toward risk of patients, public, caregivers, and different cultural
Summary
Individuals who fall tend to have multiple interacting risk factors, and so we should not be surprised that fall prevention is a complex rather than a straightforward challenge. Previous fall prevention programs in the hospital setting have usually only been successful in reducing falls when multiple interventions were included; implementation of one part does not seem enough to improve outcomes. To be most effective, action needs to be taken both by leaders and by front-line staff, to be
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