Reducing Falls and Fall-Related Injuries in Acutely and Critically Ill Patients

Falls are a major public health problem around the world, and are the number 1 adverse event in the hospital. From 3% to 20% of inpatients fall at least once, with injury prevalence ranging from 30% to 51%.1 Of these, 6% to 44% experience similar injuries such as fractures, subdural hematomas, or excessive bleeding that may cause death. Certain to affect morbidity and mortality, injury falls are “never events” that also cut reimbursement. Adjusted to 2010 dollars, a fall without serious injury costs an additional $3500, whereas 2 or more falls without serious injury cost $16500. Falls with serious injury are the costliest, with additional costs of $27000.2Interventions to prevent falls and fall-related injuries require multidisciplinary support for program adoption and reliable implementation for specific at-risk and vulnerable subpopulations, such as frail elderly persons and those at risk for injury. The purpose of this clinical evidence review is to address the effects of fall and injury risk assessment and targeted interventions on fall and injury rates in acutely hospitalized patients.The search strategy involved CINAHL and MEDLINE with the following key words: falls, fall prevention, injury prevention and reduction, acute and critical care. The search was limited to the past 10 years. All forms of evidence were considered.Eleven reports focused on in-hospital fall prevention in a variety of settings (medical/surgical, neurological, geriatric, all units). The reports included 1 meta-analysis, 2 randomized controlled trials, 2 observational studies, and 6 quality improvement studies. The interventions to prevent falls that were evaluated are noted in Table 1. Fall metrics were assessed in the studies for periods from 6 months to 5 years.The meta-analysis9 did not reveal significant reductions in fall-associated metrics (level A evidence in Table 2). However, examination of the results of individual studies shows that the fall rate per 1000 patient-days decreased in 4 studies,6,8,12,13 including 1 study with older patients.13 The relative risk of falling was reduced by 23% to 29% in 2 studies.4,8 Significant reductions were also realized in the injury rate in 2 studies.6,10 Other investigators found a reduction in both minor and serious injuries, including fractures.3,5,7 Collectively, these findings represent level B-C evidence (Table 2).Falls are rare events in progressive and critical care settings owing to higher patient acuity and staffing ratios. However, falls do still occur and are devastating to patients, their families, and nurses. Nurses manage competing priorities for these patients, dealing with medically acute conditions and unexpected acute/emergent situations and complications while ensuring the patient’s safety. These safety needs include protecting patients from falls and fall-related injuries, and nurses must be sensitive to the geriatric population.15 The American Association for Critical-Care Nurses’ scope and standards document16 provides the framework for specialty practice and these fall prevention practice recommendations: assessment, diagnosis, outcomes management, planning, implementation, and evaluation.We assert that all progressive and critical care patients are at high risk for falls, unless the patient is in a coma. Therefore, nurses should not spend time on basic screening for fall risk level on admission, but rather should complete an in-depth risk assessment to identify: (1) patients admitted because of a fall, “known” fallers (those who have already fallen during the episode of care), and those with a diagnosis of “falls” on their problem list and (2) modifiable risk factors for falling, such as medications, orthostasis, mobility impairment, delirium, and incontinence.1 The second major assessment priority is to identify patients at risk for moderate-to-serious injury should a fall occur. Injury risk assessment is a separate practice from fall risk assessment and focuses on identifying the presence of “ABCS” factors (Age, >85 years; Bones, osteoporosis diagnosis or treatment, history of fracture, especially hip fracture; Coagulation, anticoagulant therapy; Surgery, recent major abdominal, thoracic, or lower extremity).11 Handoff communication should include initial assessment and any changes to fall and injury risk on future handoff. Critical care nurses’ assessments are often the first safety assessments before those of interdisciplinary team members.Comprehensive fall risk assessment is the foundation for differential diagnosis. Critical care nurses are positioned to diagnose orthostasis, urgency, medication side effects, delirium, and unstable mobility, enhanced and confirmed through interdisciplinary collaboration.17 These diagnostic conditions are modifiable with nurses as active leaders in interdisciplinary teams.Outcomes at the patient and unit level are focused on reducing the 2 types of preventable falls: accidental and anticipated-physiological falls.18 When unpreventable falls occur in progressive and critical care areas, these falls are expected to be unanticipated-physiological falls—those due to unexpected conditions such as syncope, stroke, or heart attack.18 Reduction and elimination of modifiable risks are also measurable outcomes, such as eliminating orthostasis, reducing numbers of centrally acting medications, and treating incontinence. Because falls are rare, nurses can measure reduction and elimination of modifiable risk factors as a primary outcome. Secondary outcomes would be prevention by type of fall (anticipated-physiological, accidental, and unanticipated-physiological) and elimination of moderate-to-serious injury.To achieve outcomes, plans of care are individualized, implemented, and evaluated. Individualized fall and injury prevention programs should be established on the basis of multifactoral assessment/diagnoses. This plan is implemented with all members of the interdisciplinary team, modified during the patient’s stay, and evaluated for effectiveness. Individualized interventions must be complemented by unit-level practices as cited earlier: purposeful rounding, assessment of orthostasis before initiating mobility, and toileting before pain medication. We know that acute care patients fall when getting out of bed, transferring from bed to chair, or toileting. Nurses should work with physical therapists to have walkers available to assist with mobility and transfers for the first time out of bed. Beds and chairs must be at correct heights for safe transfers and standing.Elderly patients are most vulnerable for sustaining serious injuries, even with low-velocity and low-distance falls, so efforts must include reducing trauma and injury.1,11 Individualized care plans must include environmental safety actions specific to patients’ needs. Observational rounds are an effective tool to verify that interventions are in place and working. If changes are needed, action must occur to modify the plan and protect the patient from falls and injury. These practices are confirmed by the literature synthesis of best practices to reduce falls and fall-related injuries in hospitals: “(1) implementation of safer environments of care for the whole patient cohort (ie, flooring, lighting, observation, threats to mobilizing, signposting, personal aids/possessions, furniture, footwear); (2) identification of modifiable fall risk factors; (3) implementation of interventions targeting modifiable risk factors; and (4) interventions to reduce risk of injury to those who fall.”1Education of patients, their family members, and staff is an important intervention across all phases of practice. All staff involved in the patient’s care should be informed about the patient’s risk factors and plan of care. Patients and family members must be taught by using adult education principles to ensure that they learn and can generalize their knowledge to their next location or home. Without education, patients cannot be expected to be partners in their care. Patient- and family-centered care necessitates education grounded in health literacy principles that includes cognitive and psychomotor domains of learning. Evidence of effective teaching of patients would be the patient who can “teach back”—that is, tell and show you back correctly and consistently.11 These principles of patient education are not new to ICU nurses but may require redesign of care delivery so that patient education for fall and injury prevention emerges as a priority in care management. Although a patient may not fall in the critical care unit, nurses are influential in patients’ continued safety while the patients are in the hospital and after discharge. Any education that is provided should be included in handoff to staff members and reinforced by other members of the health care team across the continuum of care.