Preventing Falls and Fall-Related Injuries in Hospitals

https://doi.org/10.1016/j.cger.2010.06.005Get rights and content

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

First page preview

First page preview
Click to open first page preview

References (130)

  • Patient Safety First

    The “How to” guide to reducing harm from falls

  • K.M. Tan et al.

    Falls in an acute hospital and their relationship to restraint use

    Ir J Med Sci

    (2005)
  • R. Schwendimann et al.

    Falls and consequent injuries in hospitalised patients; effects of an interdisciplinary falls prevention programme

    BMC Health Serv Res

    (2006)
  • F. Healey et al.

    Falls in English and Welsh Hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports

    Qual Saf Health Care

    (2008)
  • F. Healey et al.

    Using targeted risk factor reduction to prevent falls in older hospital inpatients

    Age Ageing

    (2004)
  • L. Nyberg et al.

    Incidence of falls in three different types of geriatric care. A Swedish prospective study

    Scand J Soc Med

    (1997)
  • D. Weintraub et al.

    Change in the rate of restraint use and falls on a psychogeriatric inpatient unit: impact of the health care financing administration’s new restraint and seclusion standards for hospitals

    J Geriatr Psychiatry Neurol

    (2002)
  • National Patient Safety Agency. Slips trips and falls data update. NPSA: London; 2010. Available at:...
  • A.B. Sari et al.

    Sensitivity of routine system for reporting patient safety incidents in an NHS hospital

    BMJ

    (2007)
  • T. Haines et al.

    Inconsistency in classification and reporting of in-hospital falls

    J Am Geriatr Soc

    (2009)
  • S. Brandis

    A collaborative occupational therapy and nursing approach to falls prevention in hospital inpatients

    J Qual Clin Pract

    (1999)
  • E. Hitcho et al.

    Characteristics and circumstances of falls in a hospital setting

    J Gen Intern Med

    (2004)
  • J.B. Nadkarni et al.

    Orthopaedic injuries following falls by hospital in-patients

    Gerontology

    (2005)
  • K.D. Hill et al.

    Falls in the acute hospital setting—impact on resource utilisation

    Aust Health Rev

    (2007)
  • G.R. Murray et al.

    The consequences of falls in acute and subacute hospitals in Australia that result in proximal femoral fracture

    J Am Geriatr Soc

    (2007)
  • J. Murphy et al.

    The post fall syndrome. A study of 36 elderly inpatients

    Gerontology

    (1982)
  • D. Oliver et al.

    Do falls and falls-injuries in hospital indicate negligent care – and how big is the risk? A retrospective analysis of the NHS Litigation Authority Database of clinical negligence claims, resulting from falls in hospitals in England 1995 to 2006

    Qual Saf Health Care

    (2008)
  • D. Oliver

    Preventing falls and falls injuries in hospital. A major risk management challenge

    Clin Risk

    (2007)
  • J.M. Morse

    Preventing patient falls

    (2000)
  • O’Byrne-Maguire. Epidemiological study of falls in Ireland based on incident and claims data created on STARSWeb from...
  • D. Fonda et al.

    Sustained reduction in serious fall-related injuries in older people in hospital

    Med J Aust

    (2006)
  • A.-M. Hill et al.

    Measuring falls events in acute hospitals—a comparison of three reporting methods to identify missing data in the hospital reporting systems

    J Am Geriatr Soc

    (2010)
  • L. Gillespie et al.

    Interventions for preventing falls for older people living in the community

    Cochrane Databse Syst Rev

    (2009)
  • D. Oliver et al.

    Risk factors and risk assessment tools for falls in hospital inpatients. A systematic review

    Age Ageing

    (2004)
  • V. Scott et al.

    Multifactorial and functional mobility assessment tools for falls risk among older adults in the community, home-support, long-term care and acute settings

    Age Ageing

    (2007)
  • National Ageing and Research Institute

    An analysis of research on preventing falls and falls injury in older people: community, residential care and hospital settings (2004 update). Report to the Australian Government, Department of Health and Ageing, Injury Prevention Section

    (2004)
  • British Geriatrics Society

    Guidelines for the prevention, investigation and management of older people in hospital with delirium

    (2006)
  • K. Sammet

    Autonomy of protection from harm. Judgement of German Courts on care for the elderly in nursing homes

    J Med Ethics

    (2007)
  • H. Myers

    Hospital falls risk assessment tools: a critique of the literature

    Int J Nurs Pract

    (2003)
  • K. Perell et al.

    Fall risk assessment measures; an analytic review

    J Gerontol

    (2001)
  • T.P. Haines et al.

    Design-related bias in hospital falls risk screening tool predictive accuracy evaluations: systematic review and meta-analysis

    J Gerontol A Biol Sci Med Sci

    (2007)
  • D. Oliver et al.

    Falls risk assessment tools for hospital inpatients. Do they work? Nursing Times Feb 2009

  • D. Oliver et al.

    A systematic review and meta-analysis of studies using the STRATIFY tool for prediction of falls in hospital patients: how well does it work?

    Age Ageing

    (2008)
  • D. Oliver et al.

    Development and evaluation of an evidence-based risk assessment tool (STRATIFY) to predict which elderly patients will fall: case control and cohort studies

    Br Med J

    (1997)
  • M. Vassallo et al.

    A comparative study of the use of four falls risk assessment tools on acute medical wards

    J Am Geriatr Soc

    (2005)
  • R. Schwendimann et al.

    Evaluation of the Morse Falls Scale in hospitalised patients

    Age Ageing

    (2006)
  • Haines T, McPhail S. Patient preference for falls prevention in hospitals revealed through willingness-to-pay,...
  • Medical Research Council (UK). Medical Research Council Developing and evaluating complex interventions: new guidance MRC 2008

  • G.H. Guyatt et al.

    GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

    BMJ

    (2008)
  • S.E. Lamb et al.

    Prevention of falls network Europe (PROFANE) outcomes consensus group. Development of a common outcome dataset for fall injury prevention trials

    J Am Geriatr Soc

    (2005)
  • Cited by (331)

    View all citing articles on Scopus
    View full text