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