Falls

Falls occur everywhere, including in hospital, and can cause injury and functional decline. They are the result of the interaction between personal and environmental factors and are often associated with fear, depression, anxiety and loss of confidence in older people.

Many falls can be prevented; so we all need to be aware of our patients’ falls risks and respond appropriately.

This topic gives an overview of falls in hospital, assessing and responding to falls risk, and preventing and managing falls in hospital. In addition to following health service policy and procedures, consider the following actions and discuss them with colleagues and managers.

Falls in hospital

In Australia, there are more hospital admissions for fall-related injuries than for transport related injuries¹.

Falls are one of the most common adverse events in hospital and can result in serious injury or death; falls are particularly common in older patients¹³. Every person admitted to hospital has risk factors for having a fall while in hospital.

According to the World Health Organization, a fall is defined as "an event which results in a person coming to rest inadvertently on the ground or floor or other lower level"². This includes slips, trips, loss of balance and applies to events that are witnessed as well as unwitnessed.

Falls contribute to increased length of stay, risk of functional decline and may trigger residential aged care admission.

Investigating a patient's risk of falls while in hospital will also help to reduce their risk of falls after they are discharged.

Falls can be described as:

• Accidental: resulting from environmental factors, such as clutter, tubing or spills that cause a patient to slip or trip.
• Anticipated physiological: stemming from known intrinsic factors (such as postural hypotension, dementia and gait or balance deficits) or extrinsic factors (for instance, certain medications or improper ambulatory aids).
• Unanticipated physiological: caused by unexpected or unknown medical episodes (such as sudden myocardial infarction, stroke, syncope, or seizure). These falls can’t always be prevented, which is one reason why organisations can’t expect to achieve a zero fall rate.
• Intentional: when patients intentionally fall to the floor; these are rare in general hospital settings³.

Regardless of falls classification or category, falls result from the interaction between the individual and their physiological risk factors, behaviour and the environment.

Identifying falls risks

Screening can determine whether a person has a low or high risk of falls and assessment of risk can inform the development of prevention strategies.

Currently, the National Standards require that all patients have a documented falls risk screen on admission to hospital and on transfer between settings.

Examples of screening tools currently in use in Victorian hospitals include:

• Falls Risk Assessment Tool: FRAT⁴
• STRATIFY^,5,6

Experts emphasise that drawing on our clinical judgement can be equivalent if not superior to using these types of tools. Given this we should consider the following patients as having a higher risk of falling:

• aged 65 and over
• aged between 50 and 64 who are at higher risk of falling (according to clinical judgement) due to an underlying condition⁷, for example Parkinson’s disease, stroke, early onset dementia
• all inpatients admitted following a fall.

For all these patients, we should undertake falls assessment and provide one to one patient education.

Assessment of falls risk and falls risk factors

Early identification of falls risk factors enables us to tailor care and respond to each patient's individual needs. Whilst the evidence for multifactorial intervention based on risk assessments is weak in the hospital setting, identifying, exploring and addressing these issues will be of benefit to the older person.

Assessment of risk factors should include assessment for individual risk factors such as:

• past history of falls
• cognitive impairment
• delirium
• incontinence, indwelling catheters
• extended period of medical illness
• foot problems and footwear
• visual impairment
• poor balance
• problems with walking and self-care
• health conditions that may increase the risk of falling, such as stroke, Parkinson’s disease, peripheral neuropathy and postural hypotension
• medication, including number and types of medication associated with falls, particularly sedatives, analgesics (opioids and antineuropathic pain medications) and antipsychotics
• musculoskeletal conditions, such as osteoarthritis of the knee and hip
• frailty
• significant weight loss and under nutrition leading to loss of muscle mass and strength
• prolonged bed rest.

Assessment for injury risk

Assessment for the risk of injury (for example, fracture, head injury) also needs to be undertaken and we should consider:

• conditions such as osteoporosis
• long term steroid use
• previous fractures
• conditions such as metastatic bone disease
• use of anticoagulants such as warfarin.

Assessment of the environment

Assessment of the environment is also vital. Scan the ward environment for hazards such as:

• clutter
• poor lighting
• slippery surfaces
• equipment in need of repair
• equipment or gait aids without brakes locked appropriately.

Falls prevention in hospital

Falls are a complex problem with multiple causes and risk factors. Preventing falls in hospital is not easy, but there are many things we can do to help reduce the risk.

Some hospitals may routinely use some or all of the following strategies to prevent falls. Please note that not all strategies have been proven to work for all patients in all settings.

We should choose strategies in consultation with our care teams, considering all clinical and organisational factors.

Identify falls risk

• Use falls risk identifiers, for example coloured signs or traffic light symbols, to communicate level of falls risk.
• Ensure staff understand what the identifiers mean and what strategies they should be implementing.
• Explain what the identifiers mean to the patient and their visitors.

Intentional rounding

Consider undertaking regular rounds (for example hourly or two hourly) to check on patients to ensure fundamental needs are being met. Note that while there is evidence to suggest that rounding is associated with improved patient experience, the impact on falls is less clear.

Low-low beds

Consider using low-low beds for patients at risk of falling or rolling out of bed. Consult with all team members, considering the following aspects:

• Is the patient at risk of rolling out of bed? Would they benefit from a low-low bed with an adjacent floor mat?
• Is the use of the low-low bed a form of restraint? It may be inappropriate to use a low-low bed for patients who are mobile.
• Does the patient have enough strength to stand up but has poor balance or walking and has risk taking behaviour (such as decreased awareness of ability, perceptual difficulties, delirium, dementia)? A low-low bed may be contraindicated in this case.
• Is the use of a mat next to the bed a trip hazard for staff and other patients/carers?
• The availability of one low-low bed for three standard beds may contribute to a decrease in the rate of serious fall-related injuries⁸ whereas providing one low-low bed per 12 beds does not seem to effect rate of falls.⁹
• Where is the low-low bed placed? If it is close to the wall but there is space between the wall and the bed, this can be a hazard.
• What height is appropriate? For example, low when resting, raise bed for transfers and care activities.

Bed or chair alarms

Consider using bed or chair alarms for patients who do not ask or wait for assistance or who require supervision to mobilise.Note that there is high level evidence indicating that the use of bed or chair alarms as a single strategy has no effect on the rate of falls.

Clinical judgement should be used in deciding whether to use a bed or chair alarm, considering factors such as:

• patient characteristics: can and will the patient use their call bell?
• staffing: are there enough staff to respond? Is there a risk of ‘alarm fatigue’: have staff become desensitised to alarms?

Non-slip socks

Many hospitals have introduced non-slip (red) socks to identify individuals at risk of falls and focus attention on prevention strategies. Note there is no published high-level evidence to suggest that non-slip socks prevent falls in the hospital setting.

For patients with bone conditions

Patients with conditions such as osteoporosis, previous fracture and metastatic bone disease are at greatest risk of fracture following a fall. For these patients consider the following:

• hip protectors (worn at all times)
• low-low bed (low when resting, raised for transfers and care activities)
• evaluation of osteoporosis.

For patients with bleeding disorders

Patients with bleeding disorders due to use of anticoagulants or an underlying clinical condition are at increased risk of haemorrhage following a fall. For these patients consider the following:

• evaluate use of anticoagulation medication, including considering risk vs benefit
• use of a low-low bed (low when resting, raised for transfers and care activities)
• use of protective helmets for some patients.

For surgical patients

Surgical patients are at increased risk of falls. For these patients, consider the following:

• pre-op education
• post-op reinforcement about using call bell
• toileting prior to providing centrally acting pain medication.¹⁰

Referral to other health professionals

Consider whether the patient should be referred to other health professionals such as physiotherapists, occupational therapists or pharmacists. On completion of a comprehensive assessment, all health professionals should work with the patient and their family to develop an intervention plan.

Multifactorial interventions

Multifactorial interventions have been shown to work in some, but not all, settings^11,12. This type of intervention refers to strategies to address risk factors identified in a comprehensive falls risk assessment. It can include a combination of interventions such as:

• treatment of delirium and agitation
• improving continence, for example through regular toileting, treating constipation, referral to a continence nurse specialist, urinalysis to check for infection
• footwear: ask family and carers to bring in supportive shoes or slippers
• foot problems: provide foot care and refer to podiatrist
• visual impairment: ensure patient has the right glasses and they can reach these easily
• poor balance: refer to physiotherapist, consider using a gait aid, assist or supervise the patient when walking to the toilet
• stay with patients who require assistance on the toilet or while showering
• medication review: consider medications known to increase falls risk such as sedatives, centrally acting analgesics, psychotropic medications
• treat postural hypotension
• ensure nutritional needs are met and consider referral to a dietitian
• exercise program: strength and balance training may be effective in reducing falls and improving awareness of risk.

Educate the patient, their family and carers

Provide personally tailored falls prevention education to the patient and their family and carers. Talk to them about their knowledge and perceptions of falls risk, their goals for their hospital stay, and things they can do to reduce the risk of falls. Encourage patients to ask for assistance. Remember, simply providing a brochure on falls prevention is not enough: talking to the patient and their family and carers is essential.

On each shift, we can:

• orientate new patients to the ward, including to the toilet, and provide regular reorientation for patients with cognitive impairment
• place the call bell within reach
• reduce clutter around the bedside
• position the gait aid within reach
• provide easy access to objects according to patient’s needs and preferences, for example the TV control, glasses, magazines
• lock wheels on the bed and other equipment
• help the patient put on appropriate footwear and clothing
• ensure adequate lighting
• encourage the patient to walk regularly, even for short distances
• provide assistance or supervision for walking as needed
• keep hallways clear, provide safe seating opportunities.

Responding to falls

If a patient falls in hospital, review their falls risk status as they are at high risk of falling again. Refer to your health service’s policies and procedures for post-fall management guidelines. These may vary between hospitals and settings but will generally include actions such as:

• reassuring the patient
• calling for assistance
• checking for injury
• providing treatment as indicated
• assessing vital signs and neurological observations
• notifying medical officer and nurse in charge
• notifying next of kin
• ensuring falls risk assessment and interventions are updated and implemented
• providing education to patient and family.

Some health services use post-fall huddles to decrease the likelihood of patients experiencing recurrent falls by determining the cause of the fall and guiding intervention.

Generally a huddle is an immediate bedside evaluation of a fall, which includes staff present, the patient and their family and carers and the interdisciplinary team. The purpose of the huddle is to analyse the factors leading to the fall and plan for prevention of falls. The huddle information should be documented.

Falls and discharge planning

You can help patients make a smooth transition from the hospital to their home or residential aged care facility through comprehensive and clear discharge planning and communication.

When a patient is being discharged:

• Reinforce the strategies you have outlined to the patient and their family to prevent falls.
• Emphasise the importance of maintaining a combination of interventions.
• If the person has experienced a fall, explain that maintaining levels of physical activity, perhaps in group settings, may not only minimise their risk of further falls but may also be helpful to increase opportunities for socialising and decrease loneliness.
• A fear of falling may limit a person’s confidence to maintain or initiate new activities or social connections. Explore with them ways they might address their fears.
• Provide documentation about falls risk and falls risk factors in discharge information for the person’s GP and other services.
• Ask the GP to reinforce the strategies and to monitor their effectiveness post hospitalisation.
• Consider referral to other services for ongoing management of fall risk. Victoria's Health Independence Program provides ambulatory care support for people following hospitalisation. Falls and mobility clinics are provided through HIP. Group strength and balance classes are available through most community centres, and are also useful to promote socialisation. The Victorian Falls and Balance Directory provides information on services and locations .