Factors influencing fall prevention for patients with spinal cord injury from the perspectives of administrators in Canadian rehabilitation hospitals

All administrators questioned the applicability of their unit’s “generic” fall prevention policy and procedures as some parts were irrelevant to patients with SCI.

I find a lot of what is in the policy and procedures seems to be based on people with cognitive deficits rather than someone with a spinal cord injury, who has an incomplete injury, who is actually starting to mobilize and starting to transfer (A9).

One administrator explained how their unit made efforts to “[find] how we fit within the policy and how to manage within it” (A2). To enhance the utility of the fall prevention tools, it was explained that the tools should be clinician-led, “practical … visual, in your face, tells you about the patient situation in that moment, rather than onerous paperwork” (A1). Administrators recommended that the chosen tools should address the specific fall risk factors experienced after a SCI. It was also explained – in spite of the fall prevention policy recommendations – that the risk assessment tools used were not appropriate for patients with SCI. Similarly, an outpatient administrator on a SCI-specific unit explained, “we found through our data that almost all our patients were classified as a fall risk” (A2). This administrator further explained that the fall risk assessment process was modified for outpatients as it lacked useful information for clinicians. The outpatient team had also adopted a blanket approach to fall prevention.

It was explained that the way in which the organizations tracked falls suggested zero falls were expected by the organization. For instance, all falls were regularly tracked in each unit, regardless of whether an injury occurred. In some units, falls were tracked daily on boards posted in the unit. These boards were used as communication tools to inform staff of the numbers of falls that occurred on the unit. Further, each hospital received a “score card” where a hospital’s score reflected the number of patient falls that occurred in the hospital. However, administrators explained that the activity-based nature of rehabilitation made a goal of zero falls unrealistic to work towards. All administrators agreed that, “zero [incidents of falls] is what everyone wants but it’s not realistic” when working with patients with SCI in a rehabilitation hospital. Rather, the number of injurious falls “should be as low as possible” (A9). In the current study, administrators expected a five to 25% fall rate in SCI rehabilitation. Rather than striving for zero falls, administrators instead proposed two realistic goals that sought to: i) “reduce [the possibility of] falls and prevent injuries” (A6) and ii) “have zero serious outcomes from a fall” (A3).

Administrators explained that it was their responsibility to complete follow-up investigations of each fall to determine whether a fall could have been prevented and classify the fall. Since many patient falls were not witnessed, categorizing and determining the root cause of a fall was difficult. Administrators suggested that clinicians could consult patients on their perspectives about the cause of the fall to gain a clearer understanding of how to address this issue. For some, challenges with categorization were also attributed to a lack of clarity as to what could be defined as a preventable or non-preventable fall.

Each unit’s fall prevention policy required reporting of all falls including, “no harm therapy falls”. These were falls that occurred during therapy, but did not result in injury. Although there were reported advantages of tracking no injury therapy falls, such as documenting for liability and: “to see what we could do differently … perhaps the patient wasn’t ready to participate in therapy that day” (A3). Not all administrators agreed with their organization’s requirement to report every fall. One administrator contemplated excluding mandatory reporting of therapy falls that did not result in an injury on his/her unit due to the process being overly time consuming for clinical staff.

Administrators described barriers to learning from patient falls on a unit as including concerns that it left some staff feeling “defensive” about falls. Other concerns included the perception that some administrators had a “punitive” rather than a “learning” approach to reporting falls within the unit (A4). Additionally, the lack of “resources to complete well run debriefs” was another barrier to learning from falls (A4). Moreover, falls that occurred while a patient was off-site on a community pass were generally not tracked, but were viewed as opportunities to educate the patient. “Tracking falls that occur on the weekend gives the clinicians a chance to see whether the patient needs more education on specific risk factors or needs to be re-trained on how to do something like a transfer” (A1).

Administrators asserted that they reviewed incident reports pertaining to their units, but some questioned whether a larger review of current trends occurred. As depicted by A5, analyzing the trends of falls was viewed to be important for guiding improvements to fall prevention:

The other critical aspect is…the review of falls not only with staff on the unit at the time, but a larger review in general to look at what are the trends that we see and building prevention programs from that data (A5).

Two views were prevalent about the effectiveness of fall prevention in SCI rehabilitation. One view was since fall rates were “low” in SCI rehabilitation, fall prevention was seen to be effective. These administrators believed the aim and outcomes of fall prevention in SCI rehabilitation were to prevent falls only while the patient was in rehabilitation. The second view was that since fall rates were considerably higher in the community, some administrators questioned whether rehabilitation was adequately preparing people for falls in the community.

We can help train and educate them before they’re discharged to make it a better situation in the community … typically when somebody leaves unless we hear something from outpatients, we wouldn’t really know what’s happening to that patient until maybe they are readmitted to acute care (A3).

A larger research gap was recognized by some administrators with respect to the evidence available for both fall prevention for individuals with SCI, and effective fall prevention interventions in general. While universal precautions were considered useful strategies to prevent falls, there was discussion that more useful strategies were needed to effectively prevent and prepare patients with SCI for fall risks in the community. An administrator involved in quality improvement highlighted that limited research existed on effective strategies to reduce falls after someone sustains a SCI. This administrator suggested a future direction for SCI fall prevention research: “the field (is) to focus on other things like improving mobility, reducing injury as a result of falling and … co-creating care plans with patients and their families” (A4).

Inconsistent staff adherence with fall prevention procedures within some rehabilitation/SCI units were reported. It is important to note this challenge was not experienced by all administrators, as some administrators reported excellent adherence with all aspects of their fall prevention procedures but questioned relevance. According to the administrators, a unit’s fall prevention policy mandated that all falls must be reported; however, this did not always occur in practice. Although administrators recognized that clinicians “try their best”, one identified area of non-adherence was related to tracking of the no injury therapy falls.

I wouldn’t be surprised if we have more falls than are documented in therapy...the organization wants it for every fall. I think that’s where we struggle because I think the therapists feel often like it … was more a controlled fall than a fall (A2).

The challenges associated with reporting therapy falls were believed to be a result of the clinician’s lack of time, and a blurring of when falls were a part of therapy versus when they were not. A4 explained that another reason for clinician’s underreporting related to “attitudes that falls are completely not preventable and that it’s a natural course of a spinal cord injury”. Since falls were common during therapy, it was suggested that clarification of which falls were to be reported during the therapy would be beneficial to improve adherence with reporting. An administrator opined that ultimately it was the manager who was responsible for creating a positive staff safety culture and influencing staff adherence with fall prevention procedures.

Another identified area of non-adherence concerned completion of the unit’s fall risk assessment. As A10 described, “what was difficult for my team [was] to do it on day one because they might not find that was the right moment to do it”. A1 hypothesized the reason for the clinician’s non-adherence could be due to a “resource disconnect” because, “we have asked them to do a process that is very onerous” (A1). In contrast, A3 – an administrator who worked in the same facility but on a different SCI-specific inpatient unit – reported that clinicians were complying with fall prevention procedures. In their views, A9 and A10 explained that non-adherence was justified in some cases because the available fall prevention tools or procedures were not applicable to the SCI population or the unit. As A9 explained, “I can’t always justify following the procedure to the letter because I don’t think it could be applied to all of our patients”.

Inconsistent delivery of fall prevention education was noted by most administrators. All but one administrator explained that after a patient with SCI experienced a fall, there was a post-fall staff huddle that takes place. The post-fall huddle was a discussion of the details of a patient’s fall and identification of additional fall prevention strategies. It was reported that clinicians inconsistently conducted thorough follow-ups with patients after the huddle. Administrators explained that patients received some fall prevention education, but were unclear about the level of detail and whether it occurred consistently with all patients. The lack of consistent delivery of patient education was believed to result in patients being less prepared for their risk of falls in the community after being discharged.

There was no formal process for fall prevention education. A structured discussion centering fall etiology/cause and how to prevent future falls was viewed as a beneficial part of a patient’s rehabilitation. In order to improve patient education, one unit planned to add a patient educator to their team.

Fall prevention education was generally not a top priority in outpatient rehabilitation because, “they are maybe with us for 30 minutes” (A2). The outpatient manager explained that the patient’s fall history was only brought up by staff, “at the beginning of the first four sessions” or when, “patients sometimes bring it up when they come in” (A2). The outpatient administrator assumed that those who attend outpatient SCI rehabilitation had already been provided with the appropriate fall prevention education while an inpatient. In contrast, some inpatient administrators strongly believed that fall prevention education for community fall risk factors should be the responsibility of outpatient rehabilitation. “Structured” fall prevention education should be provided at discharge from inpatient units with a focus on ensuring, “the patients are well aware and competent to make the decisions on risks of mobility and the outcomes of potential falls” (A4). According to A4, efforts should also be made to ensure clinicians had “the best practice skills around teaching”, were aware of “their roles as teachers”, and equipped with skills to “deliver education to different kinds of learners”.

Due to the clinicians often using a “blanket approach to intervention,” which meant applying universal fall prevention strategies rather than tailoring fall prevention strategies to a patient’s specific risk factors, administrators found it was challenging to anticipate falls. During a patient’s inpatient stay, it was common practice for the fall risk assessment to be completed at admission but it was often only reassessed if the patient had fallen. Administrators believed that a patient’s fall risk assessment score was not meaningfully used by clinicians to inform individualized fall prevention plans. As A6 explained: “the challenges are for staff not to complete just a form … I don’t know if people are thinking through those individual risk factors and coming up with strategies for those” (A6). In terms of the format of the risk assessment tools, administrators indicated that although a checklist format streamlined documentation for clinicians, it was a barrier to critically thinking about patients’ unique risk factors. It was suggested that the fall risk assessment form be reformatted to allow, “for more problem-solving and [to make it easier to] look at individualized risk factors, and then care planning around those” (A6). Administrators felt that creating customized and individualized fall prevention plans was an area for improvement. An inter-professional team approach to fall prevention was also seen as important to, “really understand what the root causes of a patient’s risks for falls are and then mitigating those [risk factors]” (A4). Two particular units adopted an inter-professional team approach to fall prevention: “a physiotherapist and occupational therapist and also the nurse, they all do the assessment together, and then after that, they put in recommendations” (A7).

Another challenge identified with respect to individualizing fall prevention policies/procedures included determining the most appropriate time to provide patient education, and how to tailor it to the patients’ post-discharge environments. A recommendation for individualizing fall prevention plans was to create a formal dialogue with patients on their specific fall risk factors in rehabilitation and the community.

Administrators agreed that rehabilitation presented an inherent risk of falls for patients as they attempted to regain their mobility and autonomy, and prepare for community reintegration. During rehabilitation sessions patients were: “pushing their limits and they want to see what they can do. They [also] want to see what they can’t [do] yet” (A5).

A tension between adhering to fall prevention policies/procedures, while simultaneously allowing patients to re-learn their physical abilities and improve their mobility was apparent. Administrators recognized the challenges patients faced as they were, “very independent prior to their injury … They want to try to get that sense of control back” (A5). Falls that occurred during therapy were viewed as safer, better controlled, and supported. Therapy falls gave patients the opportunity to learn fall prevention and self-management skills considered instrumental for community reintegration.

Balancing the autonomy of a patient was important during the rehabilitation process. Some administrators felt the current policies and procedures were not clear on how staff should respond to situations where a patient did not want to comply. Below, A3 recounted a complicated and delicate situation. Here, staff were doing their best to follow the fall prevention procedures after a patient fell, but the patient was eager to get up from the fall:

“The patient was insisting I’m fine, I need to get up. We are saying no, no, we need to do this assessment first … At what point do we say we listened to what the patient has to say before we do all of our safety checks?” (A3).

In the hospital settings, clinicians were responsible for any activities related to fall prevention. Within some inpatient units, there was an apparent transfer of responsibility whereby the responsibility for fall prevention activities were transferred to the patient upon discharge. Administrators stressed that preparing patients to recognize and prevent fall risks in the community through providing fall prevention education was paramount. However, given a clinician’s lack of time and other priorities, this could be overlooked. One administrator explained to effectively prepare patients on how to manage and mitigate fall risk factors in the community, “we need to look at the model of care differently” (A1). Instead of clinicians conducting all fall prevention activities, clinicians should share this responsibility with patients. Shared responsibility for fall prevention was surprisingly only described by administrators from two inpatient units. Clinicians at these particular inpatient units provided patients with the knowledge to self-manage their fall risk from day one of rehabilitation.

Community passes were recognized as a way to prepare patients for the risk of falls in the community. Administrators explained that home visits were conducted with most inpatients to provide patients with additional information on the fall hazards in their post-discharge environment. According to administrators, it was difficult to prepare patients for fall risk in the home environment because the recommended level of assistance and funding for appropriate equipment may not be widely available outside a hospital setting.

Administrators discussed many scenarios where they felt they were not able to prevent falls. For instance, some falls that were believed to be a result of the “patient’s own actions” were considered non-preventable. Impulsive behavior and non-adherence with safety recommendations were examples of patient-related challenges to fall prevention. One proposed solution for these challenges was to tailor fall prevention education to match the personality and behaviour of the patient.

Another challenging situation where administrators felt they could not prevent falls was when a patient leaves the facility. A3 explained, “it’s out of our control once they leave the building in terms of if a fall happens, but you know we still feel accountable because they are our patients” (A3). Finally, some administrators believed that non-preventable falls were seemingly inevitable due to the nature of SCI. As A9 stated, “I have an incomplete spinal cord injury patient, where a patient could be walking with two staff and we have everything in place but a leg could buckle”. As such, their efforts were shifted to minimizing injuries from the fall.