Geriatric Nursing Fall Prevention Falls among older adults, particularly in acute care settings, are a significant concern due to the potential for severe injury or even fatality. Therefore, preventing falls and providing effective post-fall care are critical responsibilities for healthcare providers, especially nurses. This article discusses the aims and importance of fall prevention, strategies for post-fall assessment, management of head injuries and trauma, and the use of restraints in nursing care.
Aims of Fall Prevention in Acute Care
Efforts to prevent falls in acute care settings focus on two primary aims:
- Reducing the risk of injury from falls, including fatal falls: This involves implementing preventive measures to protect older adults from injuries that could result from falls, such as fractures, head injuries, or even death. Effective fall prevention strategies are aimed at minimizing these incidents and their potentially devastating consequences.
- Developing an interprofessional fall prevention program: This program is designed to prevent falls by fostering collaboration among various healthcare providers, such as nurses, physicians, physical therapists, and other allied health professionals. The goal is to create a system-wide approach to improve patient safety by identifying risk factors, applying preventive measures, and responding effectively when falls occur (Joint Commission National Patient Safety Goals, 2006).
Both of these aims are crucial for enhancing patient safety by reducing preventable falls through comprehensive, evidence-based strategies across healthcare systems.
Assessment, Diagnosis, and Intervention Strategies
Evidence consistently shows that fall prevention programs are effective across all patient settings. A meta-analysis of 20 randomized clinical trials highlighted that such programs reduced both the number of older adults who fell and the monthly rate of falling, particularly in long-term care settings (US Department of Health and Human Services, 2004). Emerging hospital-based studies provide robust scientific evidence of the impact of fall prevention programs on reducing fall rates and related injuries.
Research by Oliver and colleagues (2007) identified key components that guide multifactorial interventions to prevent falls in hospitals. These components include education, toileting schedules, and the use of alarm devices. Oliver et al. (2007) further broke down these multifactorial interventions into individual elements to minimize methodological issues in program design (Oliver, Healy, & Haines, 2010). Many of these interventions focus on educational initiatives, addressing environmental issues, and improving equipment used in patient care.
Role of Nurses in Fall and Injury Prevention
Nurses play a central role in leading fall and injury prevention efforts. As healthcare professionals who understand the biopsychosocial and functional needs of their patients, nurses are ideally positioned to spearhead teamwork and collaboration within their units. Their unique knowledge of each patient’s condition, combined with their leadership skills, enables them to effectively implement fall prevention strategies tailored to individual patient needs.
Importance of Fall and Injury Prevention in Acute Care
The consequences of falls, such as injuries or functional decline, disproportionately affect patients over the age of 85. Falls are a leading cause of unintentional injury and mortality in older adults, with over 14,000 fatalities reported annually (Centers for Disease Control and Prevention [CDC], NCIPC, 2007). As age increases, so does the incidence of fatal falls, making prevention efforts even more critical for the oldest and most vulnerable patients.
Falls in hospital settings can have severe consequences, including bleeding, fractures, dislocations, and traumatic brain injuries (TBIs). One study found that falls occurred at a rate of 3.1 per 1,000 patient days, with 53.6% resulting in bleeding or lacerations, 15.9% in fractures or dislocations, and 13% in hematomas or contusions (Fischer et al., 2005). Given these statistics, it is imperative to implement effective fall prevention and management strategies in healthcare settings.
Assessing the Risk of Fall-Related Injuries
Proper assessment of the risk for fall-related injuries is essential in managing and preventing falls among older adults. One critical factor in determining a patient’s safety is assessing their level of consciousness, behavior, and ability to execute commands. This is particularly important for patients who are recovering from surgery, as they may have impaired consciousness that puts them at a higher risk of injury from a fall.
Nurses should perform regular assessments of a patient’s ability to sustain attention and follow instructions. These assessments go beyond simply checking whether a patient is awake or oriented; they involve evaluating whether the patient can understand and carry out basic commands, which is crucial in determining their safety within their environment. Continuous reassessment is essential, especially in older patients, as their condition can change rapidly.
Diagnosis of Impaired Behavior, Affect, or Cognition
Behavioral assessment involves observing a patient’s demeanor, affect, and ability to process environmental stimuli. Older adults who are agitated or depressed, or who have cognitive impairments, are at higher risk for falls due to reduced attention to environmental cues or compromised safety awareness. In such cases, nurses must work closely with physicians to identify and address any underlying causes and develop appropriate interventions to ensure patient safety.
In situations where no clear solution exists, nurses must implement standard care practices, such as enhanced monitoring and assistance with daily activities, to reduce the risk of falls. These interventions should be tailored to the patient’s level of risk and may range from least to most restrictive measures.
Assessing the Risk of Serious Injury: Fractures and Other Injuries
To assess the risk of serious injury, nurses must consider various factors, including the presence of conditions like osteoporosis, which can increase the likelihood of fractures during falls. Osteoporosis is often undiagnosed in older adults, especially men, but significantly elevates the risk of fractures (Kaufman et al., 2000).
Preventative measures, such as using hip protectors, low-height beds, and floor mats, are recommended for older adults diagnosed with or at risk for osteoporosis. Discussions regarding osteoporosis treatment, including medication and vitamin D supplementation, should be included in the care plan despite mixed evidence about their effectiveness in reducing fall-related injuries (Annweiler et al., 2009; Batchelor et al., 2010).
Other conditions, such as bleeding disorders and the use of anticoagulants, also increase the risk of serious injury after a fall. A risk-benefit analysis is critical when developing fall prevention plans for these patients.
Best Practices for Managing Suspected Serious Injuries: Head Trauma
For patients suspected of having head injuries, frequent neurological checks are essential to detect the development of complications like subdural hematomas. Monitoring should include assessing vital signs, behavior, affect, cognition, and level of consciousness. Any subtle changes in speech or cognitive abilities following a fall should prompt immediate medical attention.
Patients who have had unwitnessed falls or who have cognitive impairments should be monitored closely for potential head injuries following established guidelines from the CDC (CDC, NCIPC, 2007). Special consideration should be given to older adults on anticoagulants, who are at increased risk for traumatic brain injuries.
Factors Contributing to Falls in Older Adults
Falls in older adults can result from intrinsic factors, such as impairments in consciousness, cognition, or behavior, and extrinsic factors, such as environmental hazards. A comprehensive assessment should consider both types of risk factors to develop a targeted intervention plan.
Environmental factors contributing to falls include hazards such as spills, improper footwear, and inadequate support. Preventive measures, including regular environmental assessments and specific nursing interventions like toileting rounds and the use of assistive devices, can help reduce fall risks related to these factors.
Use of Restraints in Fall Prevention
The use of physical restraints for fall prevention is highly controversial and has been associated with increased rather than reduced fall risks. Research indicates that restraints, including bedrails, do not prevent falls or related injuries and can cause harm when patients attempt to remove them or ambulate while restrained (Capezuti et al., 2002).
Given the risks associated with restraint use, alternative strategies should be prioritized. These include increased surveillance, the use of assistive devices, and environmental modifications that enhance patient safety without resorting to restraints.
Medications Contributing to Fall Risk
Certain medications, particularly those causing drowsiness, confusion, balance issues, or postural hypotension, increase the risk of falls in older adults. Medications known to elevate fall risk include psychotropic agents, antiarrhythmics, digoxin, and diuretics (Leipzig et al., 1999). While the risk of falls should not automatically disqualify a patient from receiving necessary medication, careful monitoring and appropriate adjustments are essential.
Post-Fall Assessment and Care
A thorough post-fall assessment (PFA) is vital to identify the underlying causes of a fall and develop a targeted care plan. PFAs should be comprehensive, involving a detailed history, physical examination, functional assessment, and review of medical history and medications. Using validated tools can help guide nurses in performing effective PFAs (Gray-Miceli et al., 2004).
The PFA typically occurs in three phases:
- Immediate Post-Fall Assessment: Conducted immediately after a fall to determine the extent of injuries and stabilize the patient.
- Interim Post-Fall Assessment: Involves continuous monitoring and reassessment of the patient’s condition over several hours to days.
- Longitudinal Post-Fall Assessment: Focuses on long-term monitoring to detect any delayed onset of injuries or complications.
Critical Thinking in Fall Risk Assessment and Management
Effective nursing care relies on critical thinking, particularly in assessing and managing fall risks in older adults. Nurses must continuously reassess their initial judgments and adjust their interventions accordingly. Typically, these reassessments occur at the beginning of each shift and whenever a patient is transferred to another unit. However, the frequency and context of reassessment should depend on the patient’s condition.
While a patient may appear safe while resting in bed, they may be at significant risk of falling when attempting to sit up or walk. Nurses must ask critical questions: Is the patient safe to be left unsupervised? Are they capable of transferring or walking without assistance? Such decisions hinge on careful observation and evaluation of the patient’s level of consciousness, alertness, behavior, and cognitive abilities.
The level of consciousness, for instance, can be measured using standardized tools like the Confusion Assessment Method. This evaluation helps nurses gauge a patient’s ability to remain attentive and understand their surroundings, which are essential factors in determining safety within their environment.
Diagnosing Impaired Behavior, Affect, or Cognition
Observing a patient’s behavior involves assessing their affect, demeanor, and ability to respond to environmental stimuli. Older adults who are agitated or confused are at heightened risk of falls because they may not adequately interpret or respond to normal environmental cues. Similarly, depression may impair a patient’s safety awareness due to apathy or slowed responses, which can be compounded by medications used to treat their depression.
Cognitive impairment is a significant independent risk factor for falls, as established in studies by van Doorn et al. (2003). Nurses, in collaboration with physicians, should work to identify and address any underlying causes of cognitive, behavioral, or affective disturbances, such as hypotension, blood loss, or medication toxicity.
If a clear solution to these impairments is not immediately evident, standard care practices should prioritize patient safety. Interventions might include enhanced monitoring, assistance with daily activities, or the use of safety equipment. These measures are implemented progressively, from the least to the most restrictive, until the patient is no longer considered at risk of a serious fall-related injury. Although research on these best practices is still evolving, their absence should not prevent their use, particularly when they are widely accepted as standard care.
Assessing and Diagnosing the Risk of Serious Injury: Fractures
To determine whether an older adult patient is at risk for serious injury, such as fractures, nurses must ask several fundamental questions. Serious injuries, including vertebral fractures, pelvic fractures, internal bleeding, or fatalities, often arise from acute or chronic medical conditions.
One of the most common conditions that increases the risk of serious injury in older patients is osteoporosis. Despite its prevalence, the true incidence of osteoporosis is often underreported, especially in men, who occupy a significant portion of acute care hospital and long-term care beds (Kaufman et al., 2000). Therefore, even if there is no documented diagnosis of osteoporosis, the risk of fractures should not be discounted. Many older adults with hip fractures have osteoporosis, yet studies show that the treatment rate for this condition remains suboptimal, especially among men (Kamel, 2004).
If osteoporosis is diagnosed, protective interventions should be considered, such as using hip protectors (Applegarth et al., 2009; Bulat et al., 2008). For older adults who lack the judgment or ability to transfer and ambulate independently, the use of low-height beds and floor mats around the bedside can help reduce the risk of injury from falls. Treatment for osteoporosis might also include medication, calcium, and vitamin D supplements, although their effectiveness in improving gait and balance remains controversial (Annweiler et al., 2009). However, a meta-analysis has shown that vitamin D effectively reduces falls among female stroke survivors in institutional settings (Batchelor et al., 2010).
Other medical conditions that increase the risk of serious injury include bleeding disorders and the use of blood-thinning medications. A risk-benefit analysis is crucial for decision-making in fall prevention, especially for patients with thrombocytopenia, who require close monitoring of neurological status following a fall to detect internal bleeding or developing hematomas early on (Quigley & Goff, 2011).
Best Practices for Managing Suspected Serious Injuries: Head Trauma
In cases of suspected head trauma, frequent neurological checks are necessary, particularly for older patients on blood thinners or those with coexisting medical conditions. These checks should continue for several days to detect serious conditions such as subdural hematomas. Assessments should include vital signs, behavior, affect, cognition, and level of consciousness. Changes in speech, such as slurred speech or a subtle decline in cognitive abilities, can indicate a serious head injury requiring immediate medical attention.
Older patients who have experienced unwitnessed falls or cannot recall falling should be monitored for head injuries following CDC guidelines. Traumatic brain injury (TBI) is a preventable yet common consequence of falls, particularly among adults aged 75 and older, who have the highest rates of TBI-related hospitalizations and deaths (Langlois et al., 2006). Certain groups, such as men and African Americans, have an even higher risk of TBI-related mortality (CDC, 2007).
Older adults on anticoagulants are at a higher risk for TBI if they sustain a fall involving a head injury. Therefore, it is essential to evaluate the risks and benefits of medications like Coumadin, Plavix, and aspirin, which can increase the risk of bleeding following a fall (Quigley & Goff, 2011). Additionally, using helmets may be considered for high-risk patients to absorb trauma and reduce the impact on the head.
Understanding Why Older Adults in Acute Care Settings Fall
Understanding why older adults fall in acute care settings is crucial for effective prevention. Falls are often linked to impairments in consciousness, cognition, behavior, and both acute and chronic medical conditions. Some risks are intrinsic, such as muscle weakness or cognitive impairment, while others are extrinsic, such as environmental hazards like spills or improper footwear. Identifying and mitigating these risks is a standard part of care.
Preventable falls often result from environmental factors, which can be addressed by interventions targeting these specific hazards (Connell, 1996). Positive predictive validity for falls has been established through several factors, including a history of falls, visual impairment, the need for toileting assistance, mobility issues, balance disturbances, and cognitive impairment (Blahak et al., 2009; Papaioannou, 2004; Tinetti et al., 1986).
Using Fall Risk Assessment Tools
Fall risk is formally assessed using tools like the Morse Falls Scale or the Stratify tool. These tools offer streamlined assessments focusing on five or six key areas of inquiry, but they are not substitutes for comprehensive post-fall assessments. Critical information may be missing from these streamlined tools, highlighting the importance of a more thorough evaluation when necessary.
Patient-Specific Factors Linked to Fall Risk
Systematic reviews have identified several patient-specific factors linked to falls among hospital inpatients, including recent falls, muscle weakness, behavioral disturbances, agitation, urinary incontinence or frequency, use of certain medications (particularly sedatives or hypnotics), postural hypotension, syncope, and advanced age (Oliver et al., 2010). The use of fall risk tools in acute care settings should be part of a dynamic, continuous quality improvement process that extends beyond initial assessments to inform corrective plans of action.
Physical Restraint Use and Fall Risk
Using physical restraints to prevent falls is not only ineffective but also contributes to fall risk. Capezuti et al. (2002) argue that physical restraints, including side rails, have never been shown to reduce falls or related injuries. In fact, numerous reports over the past two decades have documented restraint-related injuries, including neurological damage, stress-induced complications, and strangulation (Agostini et al., 2001; DiMaio et al., 1985; Dube & Mitchell, 1986; Miles, 2002). The most common mechanism of restraint-related death is asphyxiation due to gravitational chest compression when a patient is suspended by a restraint (DiNunno et al., 2003).
Given these risks, healthcare providers must consider the potential for serious injury or fatality when deciding whether to use restraints. Instead, alternatives such as increased surveillance, use of assistive devices, and environmental modifications should be prioritized.
Medications Contributing to Fall Risk
Several medications increase the risk of falls in older adults due to side effects like drowsiness, confusion, balance issues, or postural hypotension (Ensrud et al., 2002; Neutel et al., 2002; Smith, 2003). Medications that fall into this category include psychotropic agents (such as benzodiazepines, sedatives/hypnotics, antidepressants, and neuroleptics), antiarrhythmics, digoxin, and diuretics (Leipzig et al., 1999). While the risk of falls should not automatically exclude a patient from necessary treatment, careful monitoring and adjustment of medication regimens are essential.
Conducting a Comprehensive Post-Fall Assessment
A comprehensive post-fall assessment (PFA) is critical for understanding why a fall occurred and implementing appropriate care plans. The PFA should be thorough, using empirically tested tools to identify the clinical status of the patient, verify and treat injuries, and uncover the underlying causes of the fall.
Merely conducting a fall risk assessment without linking findings to a care strategy is ineffective. By determining the type of fall through a comprehensive evaluation tool, nurses can develop a tailored care plan to address the identified risks.
The purpose of the PFA is to assess the clinical status of the older adult, confirm and treat any injuries, and identify the underlying causes of the fall. Components of the PFA are typically performed by nurses in all patient settings, but the extent of these evaluations can vary depending on the completeness of the tools used. Research has shown that comprehensive PFA tools are beneficial and available to assist nurses, particularly in institutionalized settings (Gray-Miceli et al., 2006).
A comprehensive PFA includes a case-focused history, a physical examination of the present problem (falling), a functional assessment, and a review of past medical issues and medications. Clinical fall prevention guidelines outline necessary components for assessing patients who have fallen, including their fall history, medical problems, medication review, mobility, vision assessment, neurological examination, and cardiovascular assessment.
Performing a comprehensive PFA allows healthcare providers to identify intrinsic risk factors and recent causes of a fall, such as orthostatic hypotension or arrhythmias associated with dizziness (Gray-Miceli et al., 2006). Certain components of a PFA can be elicited immediately following a fall, depending on the patient’s medical stability and the nurse’s clinical judgment.
The Immediate Post-Fall Assessment
Following a fall, the immediate priority is to assess the extent of any injuries the patient may have sustained. Before any intervention, a staff member should remain with the patient, offering reassurance while awaiting help. During this time, the patient should be kept warm but not moved unless necessary, ensuring their comfort and minimizing potential injury. A thorough assessment should focus on both the patient’s medical and psychological condition and the environmental factors that contributed to the fall.
The sequence of information gathered during the initial post-fall assessment depends on the patient’s medical stability and follows established standards of practice. For example, if the patient is unconscious due to a head injury, initial checks should include neurological assessments, vital signs, apical pulse rate, and pulse oxygenation. Additional assessments, such as evaluating gait or functional status, are performed once the patient is stable.
While assessing the patient, it is also crucial to examine the environment for factors that may have contributed to the fall. This includes checking for spills, poor lighting, or improper use of assistive devices. Noting any comments made by the patient regarding their condition is also important, as these can provide valuable insights into the cause and impact of the fall.
Critical observations to be reported to the primary care provider include signs of pain, swelling, unstable vital signs, discoloration of the skin, temperature changes, lacerations, contusions, loss of consciousness, restricted range of motion, evidence of head or neck injury, abnormal neurological responses, uncontrolled bleeding, and incontinence at the time of the fall. Communicating these details ensures that appropriate medical care is promptly administered.
Interim Post-Fall Assessment
During the interim period, which may span several hours to days, continuous monitoring and assessment are necessary to track the patient’s recovery and detect any complications. Nurses must reassess the patient’s condition frequently, recording pertinent findings and noting any progression or resolution of symptoms. This phase involves the interdisciplinary team reassessing the fall risk, identifying both intrinsic (patient-related) and extrinsic (environmental) factors, and developing a comprehensive care plan tailored to the patient’s specific needs.
Developing a care plan may also involve changing physician orders regarding the level of supervision required for the patient or imposing specific activity restrictions based on the fall assessment findings. For example, patients who are at higher risk may require more frequent monitoring or physical assistance with daily activities to prevent further incidents.
Longitudinal Post-Fall Assessment
In some cases, injuries sustained from a fall may not become evident immediately. Injuries such as fractures, joint instability, or internal bleeding can manifest days or even weeks later. If the patient has cognitive impairment, the accuracy of their pain reports immediately after the fall may be compromised, requiring healthcare providers to rely more on observed changes in functional status.
A patient who initially seems cognitively intact may develop acute delirium days after a fall, signaling a potential injury. In such instances, ongoing monitoring of vital signs and neurological status is crucial for several days, depending on clinical indications. Fall policies should reflect these provisions to ensure any changes in patient condition are promptly documented, communicated to senior providers and nursing staff, and shared with the patient’s family.
Overview of Effective Fall and Injury Prevention in Hospitals
Nurses play a pivotal role in championing fall prevention programs in acute care hospitals. Effective programs extend beyond simply measuring fall rates; they focus on assessing and mitigating injury risks associated with falls. This approach provides valuable data for tailoring specific interventions, such as using hip protectors, floor mats, and helmets, which help reduce injury severity.
Multifactorial fall prevention programs have strong evidence supporting their effectiveness in reducing injurious falls in acute care settings. These programs typically include system-level interventions that incorporate innovative practices such as nurse champions, safety huddles, teach-back strategies, and post-fall assessments.
Role of Nurse Champions
Nurse champions are critical at the point of care. They help build program capacity, infrastructure, and expertise by mentoring and coaching other nurses in fall prevention strategies. For example, the Institute for Healthcare Improvement’s (IHI) Transforming Care at the Bedside program partnered with the VISN 8 Patient Safety Center to focus on fall and injury prevention. This approach has proven transformational by enabling nurses to address the needs of vulnerable older adults who are at significant risk for falls and associated injuries (Boushon et al., 2008).
Teach-Backs
Health literacy is essential for effective patient education. Teach-back methods involve asking patients to repeat back what they have learned to ensure comprehension and identify any gaps in understanding. This technique helps healthcare providers tailor their education efforts to meet the patient’s specific needs and improve their ability to make informed health decisions (Institute of Medicine, 2004).
Safety Huddle Post-Fall
Safety huddles, modeled after the military’s “After Action Review” (AAR) process, provide a structured way to learn from errors and near misses. In a safety huddle, staff members immediately assess what happened, what should have happened, the differences between the two, and corrective actions to prevent a similar incident in the future. These huddles promote immediate knowledge transfer and encourage a culture of continuous learning and safety improvement.
All staff members are trained to conduct safety huddles promptly after a fall, with nurse managers leading the initial discussions and coaching staff through role-playing exercises. Over time, safety huddles become a routine part of patient care, extending to other safety situations and ensuring precautions are consistently applied during shift handovers (Quigley et al., 2009).
Interventions to Reduce Trauma
For patients at risk of serious injury, such as those with osteoporosis or on anticoagulant therapy, high-risk fall precautions should be automatically implemented. Specific interventions to reduce trauma risk include placing a bedside mat on the floor, using height-adjustable beds, wearing helmets for head injury-prone patients, and using hip protectors.
These interventions can be combined to create protective bundles. For example, patients at risk of hip fractures should use height-adjustable beds, wear hip protectors, and have floor mats placed around the bed. Patients at risk of hemorrhagic bleeding should also receive similar interventions, and helmets may be considered for those with a history of head injuries or on anticoagulants. Education about fall risks and prevention should be provided to all patients.
Program Evaluation
Effective program evaluation involves using incident report forms specifically designed for falls, which collect detailed data on fall occurrences, such as the time of day, location, activity, and contributing factors like orthostasis and incontinence (Elkins et al., 2004). Analyzing these data helps classify falls by type (accidental, anticipated physiological, unanticipated physiological) and injury severity (minor, moderate, severe) (Donaldson et al., 2005).
This analysis enables clinicians, administrators, and risk managers to identify patterns and trends in fall occurrences, helping them develop targeted interventions to reduce falls and associated injuries.
Fall Prevention Program
An effective fall prevention program begins with a coordinated approach that includes fall risk determination and comprehensive post-fall assessments. Accurate documentation in care plans, nursing notes, and medical records ensures continuous monitoring and communication across the interdisciplinary team.
Reviewing fall-related information allows team members, including medical providers, nurses, therapists, risk managers, pharmacists, and other healthcare professionals, to offer their unique perspectives and insights into managing fall risks and care.
Early Mobility for Older Patients Who Fall
Early mobility is a fundamental aspect of care for older patients who are medically stable. It helps prevent deconditioning, reduced mobility, and complications like pneumonia or atelectasis that can result from prolonged immobility. Nursing staff should encourage patients to get out of bed and walk whenever possible rather than relying on bedpans or bedside commodes. Proper footwear, use of corrective lenses, and a clutter-free environment are essential.
Assistive devices, such as canes or walkers, may be necessary, and consulting with physical or occupational therapists can help determine the most appropriate equipment. Monitoring patients for symptoms like lightheadedness, vertigo, or muscular stiffness is vital to ensure they remain safe during mobility activities.
Interventions for Fall Prevention and Management
Hospitals and staff must ensure that the environment is free from hazards to promote patient safety. Routine environmental assessments should include patient rooms, corridors, entrances, exits, and other areas patients frequent. These assessments focus on potential hazards such as slippery floors, poor lighting, and inadequate safety equipment. Using checklists helps maintain compliance and facilitates audits.
For older adults, especially those with cognitive impairments, verbal instructions to “be careful” may be insufficient. Other safety measures, such as increased surveillance or sitter services, may be necessary to ensure patient safety. Early engagement of the interdisciplinary team, including discussions with family caregivers, is crucial for developing a comprehensive care plan.
Best Practice Examples Used by Acute Care Hospitals
To effectively prevent falls in acute care hospitals, different strategies are employed, including environmental safety assessments and safety rounds. Environmental safety assessments are one-time checks of the hospital environment to identify potential hazards. In contrast, safety rounds involve regular, systematic observations by one or two key personnel who are responsible for continuously assessing and addressing risks. Safety rounds occur at regular intervals, such as every 2 or 4 hours, ensuring that hazards are promptly identified and addressed, and that patients in need of assistance are quickly detected.
This frequent monitoring enables early detection of problems, which allows for timely interventions that can prevent environmental falls. For instance, safety rounds might identify obstacles or spills that could cause a fall, allowing them to be addressed before an accident occurs. The use of checklists during these rounds helps ensure that all potential hazards are considered, and they can be used to monitor patterns or recurring types of hazards that may require corrective action.
Toileting Rounds
Toileting rounds are another important component of many hospital-based fall prevention programs. These rounds involve regular checks by nurse aides to assess older adult patients for the need to urinate and to provide assistance as necessary. The primary purpose of toileting rounds is to prevent urinary accidents, which can often lead to falls. For example, an older adult may sense a need to urinate, attempt to get out of bed unassisted, and experience a fall due to unrecognized physiological factors, such as orthostatic hypotension.
Another scenario might involve an older adult having a urinary accident en route to the bathroom, slipping on the wet floor, and falling. By conducting toileting rounds regularly, the potential for these occurrences is minimized, thereby reducing fall rates and the likelihood of associated complications, such as hip fractures. Although toileting is a fundamental element of basic care, its role in fall prevention is often underrecognized. According to a study by Brown et al. (2000), urge incontinence (not stress incontinence), especially if occurring weekly or more often, significantly increases the risk of falls and non-spinal, non-traumatic fractures in older women living in the community.
Specific Nursing Interventions
Personal alarms are another common tool used to alert nursing staff to potential falls or changes in a patient’s mobility status. These devices are designed to sound an alarm when a patient changes position, thereby heightening staff awareness and prompting timely intervention. However, it is important to recognize that alarms do not prevent falls from occurring (Oliver et al., 2010). Instead, they act as a secondary measure to alert staff to a potential fall after it has already started.
Various types of personal alarms are available, including those clipped to the patient’s gown or chair and bed-chair pressure sensors. Despite their widespread use, there is limited evidence supporting their effectiveness in reducing falls in acute care hospital settings. A study conducted in a geriatric rehabilitation unit found that bed sensor alarms neither reduced physical restraint use nor improved clinical outcomes for older adults perceived to be at an increased risk for falling (Kwok, Mok, Chien, & Tam, 2006).
However, in a nursing home-based study, the use of the “NOC WATCH,” a non-intrusive monitor for older adults at high risk for falling, was associated with a 91% reduction in fall rates (Kelly, Phillips, Cain, Polissar, & Kelly, 2002). These findings suggest that the timeliness of rescue, rather than the alarm itself, may be the most critical factor in preventing falls (Quigley & Goff, 2011). Additionally, greater nurse surveillance capacity has been linked to better quality care and fewer adverse events (Kutney-Lee, Lake, & Aiken, 2009).
Floor Mats and Low-Rise Beds
Both floor mats and low-rise beds play an important role in fall prevention strategies aimed at minimizing the severity of injuries when falls do occur. Floor mats are typically placed around the patient’s bed to cushion the impact of a fall. These mats vary in thickness, and if any areas remain uncovered, significant injuries can still occur if a patient attempts to get out of bed and falls. Despite their intuitive appeal, there is limited empirical evidence supporting the effectiveness of floor mats in preventing falls that cause hip fractures or traumatic brain injuries in acute care settings.
However, an observational cluster randomized trial conducted in 18 nursing homes found that both types of hip protectors (soft and hard), when worn correctly, could reduce the risk of hip fractures in falls by nearly 60% (Bentzen, Bergland, & Forsen, 2008). On the other hand, a recent meta-analysis reported that hip protectors were ineffective for individuals living at home, and their effectiveness in institutional settings remains uncertain (Parker, Gillespie, & Gillespie, 2006).
Technological Advances in Fall Prevention
Technological advances have provided staff and patients with a broader range of solutions to prevent falls. These innovations include walking aids such as “talking” canes that provide feedback to the user, balance retraining devices that help patients learn about their body’s position in space and how to compensate for muscular impairments, and other types of equipment used at the bedside to facilitate safer patient transitions. Although these devices show promise, research on their effectiveness in preventing falls is still evolving and somewhat limited (Nelson et al., 2004).
Fall Prevention Education and Patient Engagement
An integral component of any fall prevention program for hospitalized older adults or those preparing for discharge is patient education. Understanding the reasons behind a fall and what can be done to prevent future falls is crucial for both the patient and their caregivers. Exploring the patient’s beliefs and attitudes toward falls is essential, as it can help dispel myths they may hold—for example, the belief that falls are a normal part of aging or that nothing can be done to prevent them.
A systematic review of the literature examining older adults’ preferences, views, and experiences with fall prevention strategies highlighted several important findings (McInnes & Askie, 2004). First, in clinical practice, it is crucial to consult with individuals to understand what modifications they are willing to make. Second, understanding what changes they are prepared to implement is essential to ensuring their participation in fall prevention programs.
Multicomponent Interventions for Fall Prevention
Fall prevention strategies in acute care settings often rely on multicomponent interventions tailored to individual patient needs. These interventions can include modifying the environment, using assistive devices, providing regular staff education, and implementing specific fall prevention protocols. For example, implementing scheduled toileting rounds, as mentioned earlier, can help prevent falls related to urgent toileting needs. Additionally, providing education on the importance of proper footwear and safe mobility practices can reduce the risk of falls.
Multicomponent interventions also benefit from the use of interdisciplinary teams, which may include physical therapists, occupational therapists, and pharmacists, in addition to nursing staff. These teams work together to assess the patient’s fall risk factors and develop comprehensive, individualized care plans that address both intrinsic (patient-related) and extrinsic (environmental) risks.
Implementing Evidence-Based Fall Prevention Programs
Implementing evidence-based fall prevention programs in acute care hospitals requires a coordinated approach that includes leadership commitment, staff training, and continuous evaluation. Programs must be designed to be sustainable and adaptable to changing patient populations and care environments. An example of an effective program is the Veterans Affairs (VA) fall prevention initiative, which has integrated best practices across its network of inpatient hospitals. The VA’s approach focuses on general falls prevention, targeted interventions for high-risk patients, and comprehensive education for staff, patients, and families.
The success of such programs depends on consistent implementation and ongoing evaluation to identify areas for improvement. This may involve regular audits of fall prevention practices, reviewing incident reports, and analyzing data to identify trends and patterns. Programs should also include mechanisms for staff feedback, allowing for adjustments and enhancements based on frontline experiences.
Ongoing Research and Future Directions
Ongoing research into fall prevention continues to explore new interventions, technologies, and strategies to reduce fall risk and injury severity in older adults. Future directions may include the development of more sophisticated monitoring devices, such as wearable sensors that provide real-time data on patient movements and alert staff to potential risks before a fall occurs.
Additionally, there is a growing interest in understanding the role of nutrition, exercise, and medication management in fall prevention. Research is exploring how targeted interventions, such as vitamin D supplementation or strength training, can improve balance and reduce the likelihood of falls.
Conclusion
Effective fall prevention in acute care hospitals requires a multifaceted approach that includes environmental modifications, regular patient monitoring, education, and the use of assistive devices. By incorporating best practices and leveraging technological advances, healthcare providers can significantly reduce the incidence of falls and improve patient outcomes. Ongoing research and continuous program evaluation will be essential to advancing fall prevention strategies and ensuring they are effective, sustainable, and responsive to the needs of older adults in acute care settings.