Preventing patient falls

Medications and Patient Characteristics Associated With Falling in the Hospital

OBJECTIVES

The aim of this study was to evaluate specific medications and patient characteristics as risk factors of falling in the hospital.

METHODS

This is a case-control study comparing demographic, health, mobility, and medication data for 228 patients who fell between June 29, 2007, and November 14, 2007, at a large tertiary care hospital and 690 randomly selected control patients. Logistic regression was used to identify fall risk factors.

RESULTS

Independent risk factors of falling included history of falls (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.8-4.2); needing an assistive device (OR, 3.2; 95% CI, 1.5-6.8) or person assistance (OR, 2.1; 95% CI, 1.3-3.3) to ambulate; being underweight (OR, 2.4; 95% CI, 1.2-4.7) or obese (OR, 1.6; 95% CI, 1.0-2.5); confusion (OR, 2.4; 95% CI, 1.5-4.0); dizziness (OR, 2.1; 95% CI, 1.1-4.3); incontinence (OR, 1.5; 95% CI, 1.0-2.3); and an order for a hydantoin (OR, 3.3; 95% CI, 1.3-8.0) or benzodiazepine anticonvulsant (OR, 2.2; 95% CI, 1.5-3.3), haloperidol (OR, 2.8; 95% CI, 1.2-6.8), tricyclic antidepressant (OR, 2.4; 95% CI, 1.2-4.9), or insulin (OR, 1.5; 95% CI, 1.0-2.1). Female sex (OR, 0.8; 95% CI, 0.6-1.0), proton pump inhibitors (OR, 0.6; 95% CI, 0.4-0.9), and muscle relaxants (OR, 0.4; 95% CI, 0.3-0.7) were associated with lower risk for falling.

CONCLUSIONS

This study identified medications and patient characteristics associated with increased risk for falling in the hospital. High-risk medications identified in this study may serve as targets for medication review or adjustment, which have been recommended as a component of multifaceted fall prevention programs.

Evaluation of the "medication fall risk score"

PURPOSE

Results of a study evaluating the predictive validity of a fall screening tool in hospitalized patients are reported.

METHODS

Administrative claims data from two hospitals were analyzed to determine the discriminatory ability of the "medication fall risk score" (RxFS), a medication review fall-risk screening tool that is designed for use in conjunction with nurse-administered tools such as the Morse Fall Scale (MFS). Through analysis of data on administered medications and documented falls in a population of adults who underwent fall-risk screening at hospital admission over a 15-month period (n = 33,058), the predictive value of admission MFS scores, alone or in combination with retrospectively calculated RxFS-based risk scores, was assessed. Receiver operating characteristic (ROC) curve analysis and net reclassification improvement (NRI) analysis were used to evaluate improvements in risk prediction with the addition of RxFS data to the prediction model.

RESULTS

The area under the ROC curve for the predictive model for falls compromising both MFS and RxFS scores was computed as 0.8014, which was greater than the area under the ROC curve associated with use of the MFS alone (0.7823, p = 0.0030). Screening based on MFS scores alone had 81.25% sensitivity and 61.37% specificity. Combined use of RxFS and MFS scores resulted in 82.42% sensitivity and 66.65% specificity (NRI = 0.0587, p = 0.0003).

CONCLUSION

Reclassification of fall risk based on coadministration of the MFS and the RxFS tools resulted in a modest improvement in specificity without compromising sensitivity.

Impact of Drug Use and Comorbidities on In-Hospital Falls in Patients with Chronic Kidney Disease

Background:

In-hospital falls are a major problem in healthcare institutions and contribute to morbidity and mortality in this setting. Patients with chronic kidney disease (CKD) were previously found to be at higher risk for experiencing an in-hospital fall.

Objective:

To evaluate the association between comorbidities and drug use with the risk of in-hospital falls in adults with CKD.

Methods:

A retrospective case-control study was conducted in patients with CKD hospitalized between January 1, 1998, and June 30, 2003. Cases included patients who experienced an in-hospital fait, were 18 years of age or older, and had been hospitalized for more than 24 hours. For every case, 2 controls were identified and matched for CKD, age, and sex. Information about comorbidities and drug use was collected from an electronic medical data repository. Statistical tests performed were t-tests, χ2 analysis, and multivariate logistic regression, using occurrence of a fall as the dependent variable and race, comorbidities, and drug groups as covariates.

Results:

There were 635 fall cases that met study criteria. The mean age of patients was 68 ± 15 years, 54% were female, and 82% were white. There were 1270 matched controls with CKD who were included in the regression analysis. Comorbidities that increased the likelihood of experiencing an in-hospital fall were dementia (OR 2.63), pneumonia (OR 1.72), gastrointestinal disease (OR 1.41), and diabetes (OR 1.31). Drugs associated with an in-hospital fall were antidepressants (OR 1.65) and anticonvulsants (OR 1.52).

Conclusions:

Several comorbidities, especially dementia, significantly increase the risk of experiencing an in-hospital fall in patients with CKD. Drugs that place CKD patients at risk include antidepressants and anticonvulsants.

Prevalence of falls with minor and major injuries and their associated factors among older adults in long-term care facilities

Aims and objectives.  The objectives of this study were to determine the prevalence of falls with minor and major injuries and identify their risk factors. Background.  Falls among residents of long-term care facilities (LTCF) constitute a significant health issue. Design.  This is a secondary analysis of a cross-sectional study carried out among older people (n = 2332). Methods.  This is a descriptive study focusing on the secondary analysis of a cross-sectional study carried out with a group of older people (n = 2332) in 28 LTCF in Quebec City, Canada. Research assistants collected original data for each resident from two sources: structured simultaneous interviews with two nurses per unit from each of the homes and a review of the residents' medical files. Results.  7.2% of subjects had a fall leading to minor injuries and 10.1% a fall leading to major injuries. Risk factors associated with fall-related minor injury are young age, male gender and cognitive impairment. Factors associated with fall-related major injury were functional autonomy and length of stay. In further statistical analysis, controlling for functional autonomy, disruptive behaviours and neuroleptic use were found associated with fall-related major injury. Conclusions.  This study demonstrates that the factors associated with fall-related minor injury are different from those associated with fall-related major injury. Relevance to clinical practice.  This study suggests that nurses working with LTCF residents who are concerned about the prevention of fall-related major injury, may contribute to a reduction in such falls through optimal management of behavioural problems and neuroleptic use.

Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review and meta-analysis

Background

Falls are a serious problem for hospitalized patients, reducing the duration and quality of life. It is estimated that over 84% of all adverse events in hospitalized patients are related to falls. Some fall risk assessment tools have been developed and tested in environments other than those for which they were developed with serious validity discrepancies. The aim of this review is to determine the accuracy of instruments for detecting fall risk and predicting falls in acute hospitalized patients.

Methods

Systematic review and meta-analysis. Main databases, related websites and grey literature were searched. Two blinded reviewers evaluated title and abstracts of the selected articles and, if they met inclusion criteria, methodological quality was assessed in a new blinded process. Meta-analyses of diagnostic ORs (DOR) and likelihood (LH) coefficients were performed with the random effects method. Forest plots were calculated for sensitivity and specificity, DOR and LH. Additionally, summary ROC (SROC) curves were calculated for every analysis.

Results

Fourteen studies were selected for the review. The meta-analysis was performed with the Morse (MFS), STRATIFY and Hendrich II Fall Risk Model scales. The STRATIFY tool provided greater diagnostic validity, with a DOR value of 7.64 (4.86 - 12.00). A meta-regression was performed to assess the effect of average patient age over 65 years and the performance or otherwise of risk reassessments during the patient’s stay. The reassessment showed a significant reduction in the DOR on the MFS (rDOR 0.75, 95% CI: 0.64 - 0.89, p = 0.017).

Conclusions

The STRATIFY scale was found to be the best tool for assessing the risk of falls by hospitalized acutely-ill adults. However, the behaviour of these instruments varies considerably depending on the population and the environment, and so their operation should be tested prior to implementation. Further studies are needed to investigate the effect of the reassessment of these instruments with respect to hospitalized adult patients, and to consider the real compliance by healthcare personnel with procedures related to patient safety, and in particular concerning the prevention of falls.

Protocole d’évaluation de la sécurité à domicile (PESAD) : version francophone du SAFER-HOME v.3

Les intervenants de la santé sont appelés à se prononcer sur la sécurité des aînés vivant à domicile et ils ont, à cet effet, très peu d’outils francophones à leur disposition. Le Protocole d’évaluation de la sécurité à domicile (PESAD) est issu de la traduction et de la validation transculturelle du SAFER-HOME. Le processus de validation et l’étude de la fidélité des résultats ont mis en lumière un outil intéressant et possédant de bonnes qualités métrologiques. Il permet aux intervenants francophones d’obtenir des résultats d’évaluation complets et rigoureux relativement à la sécurité à domicile des aînés francophones.

Evaluation of three fall-risk assessment tools in an acute care setting

AIM

This paper is a report of a study to evaluate the validity of three fall-risk assessment tools to identify patients at high risk for falls.

BACKGROUND

Patient falls make up 38% of all adverse events occurring in hospital settings, and may result in physical injury and undesirable emotional and financial outcomes. No single fall-risk assessment tool has been conclusively validated.

METHOD

The Morse Fall Scale, St Thomas Risk Assessment Tool in Falling Elderly Inpatients, and Hendrich II Fall Risk Model were validated in inter-rater reliability and validity studies in 2003. This included assessment of the probability of disagreement, kappa-values, sensitivity, specificity, positive predictive values and negative predictive values of the assessment tools with the associated 95% CI.

FINDINGS

One hundred and forty-four patients were recruited for the inter-rater reliability study. The probabilities of disagreement were between 2.8% and 9.7%, and 95% CI for all tools ranged from 1.1% to 15.7%. The kappa-values were all higher than 0.80. In the validity study, 5489 patients were recruited to observe 60 falls. The Morse Fall Scale at a cutoff score of 25 and Heindrich II Fall Risk Model at a cutoff score of 5 had strong sensitivity values of 88% and 70%, respectively. However, in comparison with the Morse Fall Scale (specificity = 48.3%), only the Heindrich II Fall Risk Model had a more acceptable level of specificity (61.5%).

CONCLUSION

The Heindrich II Fall Risk Model is potentially useful in identifying patients at high risk for falls in acute care facilities.

Predicting In-Hospital Falls

Falling is the most common hospital accident, and up to 15% of fallers sustain a serious injury. This study focused on developing a simple, practical fall risk screener using routine admission and daily in-hospital stay data. A case-control design was used. Logistic regression identified individual characteristics associated with an increased risk of a fall. Four variables were identified: history of falls, ambulation assistance, disoriented, and bowel control problems, creating a fall risk model with 70% sensitivity and 57% specificity.

PREVENTING FALLS in Acute Care: An Innovative Approach

Falls among elderly individuals have been significant sources of disability and death. Falls have affected as many as 10% of older adults during an acute care inpatient stay. The acute care environment has contributed to elderly patient falls. Additionally, manifestations of acute illness, polypharmacy, and medication side effects have been risk factors for falls in the acute care setting. Individualized fall prevention strategies, initial patient assessments, and ongoing patient reassessments have been linked to a decrease in falls in the acute care setting. Approaches to fall prevention have included identification of high-risk patients, communication among staff and family members about an individual's risk of falls, and both case-specific and universal interventions for fall prevention. The purpose of this article is to describe a fall prevention program instituted in an acute care setting in southern Arizona that has produced encouraging results. Moreover, this article addresses individualizing interventions through a continuous clinical feedback loop, which provides patient care areas with relevant information about their patients who fell and recommendations for improving fall prevention.

Developing a Unit-Specific Falls Reduction Program

Though an extensive amount of literature addresses the significance of patient falls and mechanisms to identify those at high risk, much less has been written regarding units in which nearly every patient fits the high-risk category. In addition, little information describes specific interventions designed to protect at-risk patients. In response to a record number of falls in the Transitional Care Unit at an acute care facility, an interdisciplinary team was developed to review patient falls, design a unit-specific falls reduction program, and begin its implementation. In the subsequent 6 quarters, the number of patient falls was reduced by 57%.

A pilot study of CME on risk management in long-term care

This pilot study's purpose was to evaluate behavioral changes among medical directors and physicians following CME on risk management in long-term care (LTC) facilities. The setting was a satellite conference at the AGS Meeting Symposium 2000. CME participants included 51 medical directors, attending physicians, and nurses. Evaluations were based on 20 LTC medical directors and physicians. Descriptive statistics were used for outcome measurements. Respondents (n = 15, 75%) "committed" to an average of 3 changes. Of the 45 commitments, no progress was reported on 8 (17.7%); another 8 commitments were reported as fully completed. The mean implementation rate was 60%. LTC physicians departed the course with intentions to alter their behaviors, but important obstacles such as "lack of time" and "staff not available or interested" interfered with implementation.

Prospective study of fall risk assessment among institutionalized elderly in Japan

The purpose of the present study was to identify risk factors for falls among institutionalized elderly, using the standardized risk assessment tool developed by Izumi. We examined 746 patients from three types of facilities: rehabilitation wards in four general hospitals, three long-term care facilities, and three nursing homes, for up to three months. The incidence of falls within all facilities was 12.5%. Patterns of relative risks of falling differed among types of facilities. The highest relative risk of fall in long-term care facilities and nursing homes was nurses' prediction, followed by history of fall and altered mentation. In contrast, that in general hospitals was mobility. In long-term care facilities, history of falls (odds 3.68, 95CI: 1.47-9.23) and interaction (history of falls and assistance with toileting) (odds 3.13, 95CI: 1.48-6.64) showed significance on adjusted-odds ratios for fall. History of falls, altered mentation, and assistance with toileting may be used to screen patients at a high risk for fall at admission.

The efficacy of an educational program to improve direct caregiver knowledge regarding fall prevention

One hundred seventy-one (N = 171) direct caregivers were tested to determine their baseline knowledge about patient falls and fall prevention and to determine the impact of a fall prevention education program on their knowledge. Following the pretesting of participants for baseline knowledge a 20-minute educational videotape was viewed. Identical posttesting of knowledge followed. Mean posttest scores (M = 14.01) were significantly higher (t = 17.883; p < 0.001) than the pretest scores, supporting the effectiveness of the educational program in increasing direct caregivers' knowledge related to fall prevention.

Psychiatric unit fall events

Patient falls in psychiatric units may have an impact on patient outcomes. Fall risk assessment among psychiatric patients is an important issue. Gait/balance problems and history of falling are important considerations in assessing psychiatric patients for fall risk.