Overview of Patient Falls as Adverse Events

Background

Falls in the Community:    Approximately one-third of elderly people in the general population will have at least one fall during a 12-month period. More than 8% seek care in accident and emergency departments, and of these, 30-40% are admitted to hospital. Approximately 6% of all falls result in serious injuries, and often result in death from secondary causes. About 50% of elderly patients discharged from accident and emergency departments show an increase in dependency.

Falls are the most common cause of injury in the USA and are the second leading cause of accidental death after motor vehicle crashes. They are the leading cause of death from injury among people aged over 75 in the UK. Unlike other types of trauma, injury due to falls occurs at all ages and encompasses the widest possible group of patients, especially the very young and the elderly. Injury secondary to falling is largely preventable and has been targeted for a national prevention and public education campaign in USA.

Falls in Hospital:   The potential to fall multiplies once individuals are institutionalized. In Sweden almost one-third of all hip fractures occur in the hospital population. A study from Brisbane, Australia, shows rates of 7.8 falls per 1,000 bed days, with monthly rates ranging from 4.3 to 15.6. The Maryland QIP shows rates of 3.8 falls per 1,000 patient-days. Of those, 28% had injuries and around 9% had repeated falls. Bates found that 31% of falls among patients in hospitals resulted in minor injuries, and 6% in serious injuries. Direct comparison between studies is hampered by differences in methods, lack of clarity in definition, and differences in study populations. In general, the population at risk should be defined and a fall or injury index estimated.

Falls may result in substantial increases in the length (71%) and cost (61%) of hospitalization [Bates], and often leads to lawsuits. Most studies of hospital patients have been in nursing homes and long-term care facilities; there are relatively few studies of falls in acute care settings.

Search Strategy: Using the MeSH term "Accidental falls/" on the Medline database since 1966 resulted in over 3,000 hits. Most of these were related to falls in the community at large (before admission to hospital). Addition of the keyword "Inpatients/" reduced the set to about 40 articles, and eyeballing for relevancy further reduced the list by a quarter.
Level of Evidence: There were 2 literature reviews and no randomized controlled studies. One case-control and cohort study [Oliver] was criticized for its statistical design [Altman].
..........Wilson EB. Preventing patient falls. AACN Clinical Issues. 1998; 9(1):100-8 [Review: 28 refs]
..........Maciorowski LF. Munro BH. Dietrick-Gallagher M. McNew CD. Sheppard-Hinkel E. Wanich C. Ragan PA. A review of the patient fall literature. Journal of Nursing Quality Assurance. 1998; 3(1):18-27 [Review: 160 refs]

Definition

The MeSH index introduced the term "accidental falls" in 1991. It was defined as "falls due to slipping or tripping which result in injury". Although this definition does not define the word "fall", it implies that only falls that have an injury will be reported in the Medline literature (and if this code is applied strictly, only falls where the cause was slipping or tripping).

Not all falls result in an injury. However, even if no serious injury results, a fall can diminish quality of life because the fear of falling again inhibits activities. Since near-miss reporting systems are recommended for preventing medical mishaps [Barach], we will use the following definitions:

• fall: an involuntary or uncontrolled descent which has the potential to cause injury and may or may not be preventable

The patient may have been seen falling, or be found on the floor, or the fall may have been reported to nursing staff (by the faller or a witness).

Traditionally, falls have been treated as an adverse event and required written incident reports.
adverse event: an injury caused by medical management (rather than the disease process) that resulted in either prolonged hospital stay or disability at discharge [Thomas]
preventable: [an adverse event that is] avoidable by any means currently available (unless that means was not considered standard care) [Thomas]
near miss: any event that could have had adverse consequences but did not and was indistinguishable from fully fledged adverse events in all but outcome [Barach]

• near fall: an involuntary or uncontrolled descent ("nearly fell") where the potential for injury exists but the outcome was not a fall or injury

An example of this is a frail, confused elderly patient on bed rest who had an IV, a urinary catheter and a drain in situ and was prevented from falling by staff after having climbed over bedrails.

Some attempts have been made at defining falls objectively, probably to facilitate retrospective studies based on reviewing medical records. This leads to terms such as:

"fall event"

when a physician has to be consulted in the treatment (e.g. stiching of a wound) or a further diagnostic measure (such as an X-ray examination) has to be taken

"documented fall"

a fall that is officially recorded in the patient's medical record, on an incident report, or in some other patient record.

Injury Scores

Injuries from falls are rarely reported in any systematic way. Scoring systems reported in the literature include:

• Injury Severity Score (ISS) [Mosenthal]. This is used by Emergency Departments for trauma cases, and was validated using mortality as the outcome indicator. It is labor intensive, and probably not appropriate for the majority of injuries that result from falls.
• Disability ratings using the severity of injury scale of the National Association of Insurance Commissioners [Thomas]. This sounds more appropriate, but at present the source reference is not available to us.
• Maryland injury index for documented falls [MQIP]. Injury is defined as a disruption of structure or function of some part of the body as "a result of an unplanned event (e.g., fractures with or without treatment, sprains, cuts, bruises, aggravation of pre-existing complaints such as back pain)". Severity of injury is coded according to the following scale:
  1. Contusion, abrasion, small skin tear, or laceration involving little or no care or observation.
  2. Sprain, large or deep laceration, skin tear, or minor contusion with medical and/or nursing intervention. Forms of intervention include: suturing, ace bandage, splint, or ice bag.
  3. fracture, loss of consciousness, change in mental or physical status requiring medical intervention or consultation

Calculation of Incidence Rate

This indicator is calculated using the total number of <falls> during a specified period time as the numerator. The denominator is the "time the defined population was at risk"; that is, the total number of <days> for which the defined population were inpatients. Incidence is expressed as "falls per 1,000 days of patient care".

Incidence of falls =	Number of falls in period	x 1,000
	Number of patient-days in period

In older systems, data for "patient-days" was collected by counting occupancy once a day at a specified time (often midnight). Even this varied between institutions (e.g. Taiwan counted the day of admission as one but did not count the day of discharge, consequently all patients have a minimum stay of at least one day. Compare this with the Maryland QIP where zero patient-days are a possibility). With computerized patient tracking, it is now possible to have "patient-days" calculated as the difference between two time points, and express the result as a fraction of a day.
..........e.g. a patient admitted at 5:00pm and discharged at 11:00pm the same night
..........patient-days: 1 day (Taiwan), 0 day (Maryland), 0.25 day (actual time).
In actual fact, the census system of counting heads at midnight would not have counted this patient since he was no longer an occupant by then. This significantly underestimated the nursing workload and the population at risk.

In some studies, the number of admissions during that period is used as the denominator, and the rate expressed as "falls per 100 (or 1,000) admissions". This may have been because the study was done retrospectively, and data on occupancy rates was not available. However, this does not adequately reflect the workload of caring for these patients, and the number of days of patient care should be used as the denominator.

Risk Factors

The potential to fall is influenced by a complex interaction of various factors. Intrinsic factors are patient conditions and/or diagnoses that may increase the risk of falls. Some well documented in the literature include:

• age (over 75 years)
• poor health status coupled with a longer hospital stay (particularly if they had not accepted the loss of their previous physical ability)
• mental status deficiencies (including disorientation or dementia), loss of consciousness (syncope or epileptic seizure)
• sensory deficiencies such as impaired vision, hearing, vertigo and dizziness (particularly in those who have had a stroke)
• mobility deficiencies, including general weakness, decreased mobility and an unsteady gait, or sudden onset of paralysis (as in a stroke)
• increased toileting needs
• Charlson comorbidity index: assess information on 18 specific comorbidities and assign weights between 1 and 6, then sum
• Confusion Assessment Method (CAM) score: five questions regarding course, fluctuation, inattention, disorganized thinking, and altered level of consciousness: three or more indicates delirium.
  Both the Charlson comorbidity index and the CAM are independent correlates of a fall, and can be combined to create a single risk score [Bates].

• drugs, after-effects of surgery and anesthesia
• use of restraints
• environmental factors (ward positioning and hazards, slippery floors, misplaced objects that cause tripping)
• time of day (night time being a time of highest risk)

Fall-Prevention Program

Assessment

Several scales have been published either to predict the probability of falling, or to assess factors that contribute to the patient's risk of falling. Few are based on research findings from controlled studies. Risk factors for falls should be documented when assessing a new patient.

Preventive Actions

The ideal situation would be research-based recommendations of interventions to prevent falls. This is not the case today. Most of the recommendations for use in institutions are based on consensus groups (ward nurses) and concern technical equipment such as bed-alarms and side-rails.

Examples of nursing-patient interventions are:

• give information to the patient to increase his insight into situations in which falls are highly likely to occur. Also give this Information to the patient's falmily when relevant
• encourage the patient to ask for help and to inform the staff when he has some problem associated with a risk of falling
• advise the patient to slow down and take it very carefully when transferring from bed to chair, and to take a rest and wait for a short while when rising from bed

• put the patient's bed near the nursing station
• minimize environmental hazards; e.g. provide good lighting

Selected References

1. Maryland Hospital Association Quality Indicator Project (MHA QIP). The indicator is called "Documented Falls" and appears in two versions:
   • Acute Care Indicators: Indicator 13
   • Long-Term Care Indicators: Indicator 3
2. Oliver D, Britton M, Seed P, Martin FC, Hopper AH. Development and evaluation of evidence based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies. BMJ 1997; 315: 1049-1053. (25 October) [Fulltext]
   • Altman DG. Study to predict which elderly patients will fall shows difficulties in deriving and validating a model. [Letter] BMJ 1997; 315: 1309 (15 November). [Fulltext]
3. National Guideline Clearinghouse (NGC)
   • Falls and fall risk. American Health Care Association/American Medical Directors Association. 1998. 16 pages . [Fulltext]
   • Prevention of falls. University of Iowa Gerontological Nursing Interventions Research Center. 1996. 37 pages. [Fulltext]
4. Bates D, Pruess K, Souney P, Platt R. Serious falls in hospitalized patients: correlates and resource utilization. Am J Med 1995; 99(2): 137-143. [Fulltext available online, but requires a HINT user account]
5. The CONQUEST database is a collection of indicators used throughout the USA (including the IMSystem of the JCAHO). It is published online as an Access database which can be downloaded to your computer. The following four indicators were found using the keyword "fall":

   Fall among psychiatric patients (HCFA Psychiatric: HPSY5A02)

   Numerator: "patients who fall".

   Fall with injury for skilled nursing facility patients (HCFA SNF: HSNF2B02)

   Numerator: "patients with fall and injury or untoward effect not appropriately addressed".

   Prevalence of falls in the nursing home (UWisc.-Nursing Home Quality Indicators: NHQI1B01)

   Numerator: "residents having a fall within the past 30 days".

   In-hospital hip fracture or fall (Complications Screening Program BIH: SCRE1A14)

   Numerator: "patients experiencing an in-hospitalhip fracture OR fall as defined by the CSP: secondary diagnosis only and excluding patients with trauma or metastatic cancer as any diagnosis; excluding patients with principal diagnosis of seizure, syncope, stroke, coma, cardiac arrest, or poising; excluding patients in MDC 8".
   Denominator: "inpatients undergoing major surgery OR minor or miscellaneous surgery OR invasive cardiac procedures OR invasive radiologic procedures OR endoscopy OR medical patients OR all patients as defined by the CSP".