Old Age Fall Prevention and Post-Fall Nursing Care
Aims of Care
Two specific aims of any effort in acute care institutions to
reduce falls among older adults are
(a) to reduce risk of injury from falls
including fatal falls
(b) to champion an inter professional fall prevention
program to prevent patient falls. Both aims seek to promote improvements in
patient safety by reducing preventable falls through system-wide solutions
whenever possible (Joint Commission National Patient Safety Goals, 2006).
Assessment, Diagnoses, and Intervention Strategies
Overall, across all patient settings, evidence exists that fall
prevention programs are effective. The RAND report cites, from a meta-analysis
of 20 randomized clinical trials (among all patient settings, but mostly
long-term care), that fall prevention programs reduced either the number of
older adults who fell or the monthly rate of falling (US Department of Health
and Human Services, 2004).
Hospital-based studies are emerging to provide solid
scientific evidence of the effect of fall prevention programs on fall rates
and, more importantly, fall-related injuries.Oliver and colleagues (2007) have produced a compilation of the
best evidence of practice innovations used by hospitals across the United
States and the United Kingdom, and their outcome effect on falls and injury
reduction.
After careful scrutiny (Oliver et al., 2007), they have identified
the key components guiding multifactorial interventions used to prevent falls
in hospitals (ie, education, use of toileting schedules, and alarm devices).
Oliver et al.’s (2007) approach has analyzed and weighed the individual intervention
within the multifactorial intervention into its constitute parts, thereby
minimizing any methodological design issues (Oliver, Healy, & Haines,
2010).
Many of these multifactorial interventions are targeted to education
initiatives, environmental issues, or seek to improve equipment implicated in
cases.Before beginning any discussion on specific individual fall
prevention intervention, the acute care nurse must realize one’s role in
championing a team effort in fall and injury prevention.
Professional nurses
are uniquely poised because they know the biopsychosocial and functional needs
of their patients and situational contexts of how patients respond to the acute
care environment. Such individual knowledge of each patient they care for
positions the professional nurse, along with leadership skill, in a unique
position to champion teamwork on their acute care unit.
The Importance of Fall and Injury Prevention in Acute Care
Many of the health care outcomes from falls, such as injury and/or
functional decline, typically strike those patients older than age 85 years and
can be prevented. The most serious outcome is a fatality.
The National Center
for Injury Prevention and Control (NCIPC) tabulates fatal falls across the ages
averaging more than 14,000 fatalities among seniors. Fatal falls rank as the
seventh leading cause of unintentional injury fatality among older adults
(Centers for Disease Control and Prevention (CDC), NCIPC, 2007). The fatal fall
incidence increases with age those older than age 85 years being the most
vulnerable.
Hospital in-patient falls are estimated to vary according to the
unit, with one study reporting 3.1 falls per 1,000 patient days (Fischer et
al., 2005). In this study, bleeding or laceration occurred in 53.6%, fracture
or dislocation in 15.9%, and hematoma or contusion in 13%. Other serious
injuries documented from falls included hip fracture and traumatic brain injury
(TBI), among others.
Assessment Of The Problem
Deciding Risk for a Serious Fall-Related Injury “One look is worth
a thousand words, but don’t forget to look more than once” Diagnosis: Impaired
consciousness Important characteristics of level of alertness are the patient’s
ability to sustain attention, and in determining if they are awake or not.
If
impairment exists in level of consciousness, the patient is at risk for injury;
Thus, any postoperative surgical patient is at greatest risk for injury from a
fall. An important factor in determining a patient’s safety within his or her
environment will be if he or she can process information and execute simple
one-, two-, and/or three-stage commands.
The ability to execute a command is
contingent on the level of consciousness, behavior, and cognition.
Traditionally, level of consciousness is assessed and written as alert and
oriented x 3,referring to person, place, and time. The ability of the person to
sustain attention can be gauged by observation of his or her ability (or not)
to execute a command, for instance, following instructions.
This type of
assessment is typically routine when the nurse first greets the patient and is
beyond a simple assessment of whether or not the patient is awake. alert,” and
oriented and can say, “Hello.” All of these determinations are critical factors
in the nurse’s judgment of patient safety. After the first assessment, the
nurse should reassess the older patient frequently because level of
consciousness can change quickly.
Critical Thinking Points
How many times do nurses reassess their own judgment and make
changes accordingly to their original impressions? Typically, in case of risk
assessments, the reassessment is made each shift and at the time of transition
to another unit. Although a patient may “look to be safe” resting in bed, they
may be totally unsafe when they sit up on the side of the bed or take a step to
walk. Therefore, the situational context is very important to note.
Consider
these points: While patients are safe in bed, are they also safe to be
unsupervised alone? Are they safe to sit, transfer, or walk unassisted? All of
these nursing observations and ultimate clinical determination of patient
safety hinge on the older patient’s level of consciousness, level of alertness,
as well as behavior and current cognitive capabilities.
Level of consciousness is formally measured by use of standardized
assessment tools such as the Confusion Assessment Method and other such tools
(see http://consultgerirn.org/resources).
Diagnosis Impaired Behavior, Affect, or Cognition
Observation of a patient’s behavior includes the patient’s affect,
demeanor, and ability to process stimuli in the environment. Agitated older
adults are at risk for falls and injury because attention to the normal
environmental cues is blunted or lost altogether.
Depressed older adults may be
at risk for impaired safety awareness and management because of blunted
responses or apathy as well as centrally acting medications used to treat the
depressants. Cognitive impairment should be evaluated because dementia is an
independent risk factor of falls (van Doorn et al., 2003).
For each of these four factors-consciousness, affect, behavior, and
cognition-nurses work with physicians to evaluate underlying causes and find
treatable solutions wherever possible. Note that the root of many of the
disturbances of consciousness, behavior, and affect are due to some classic
acute medical events such as hypotension, profound blood loss, or toxicity from
medications
. If no identifiable solution exists, prudent and
standard care ( ie, best practice) requires nurses to ensure the safety of
patients by instituting interventions related to improved monitoring and
assistance with activities. In the order of least to most restrictive, nurses
employ various solutions until the patient is no longer judged by the nurse to
be at risk for a safety issue or in danger for a serious fall-related injury.
Note that research on these best practices for fall
prevention is slowly emerging, and the absence of research in this area does
not justify not using the intervention, because it may be a best practice
intervention accepted as standard care.
Assess and Diagnose the Older Adult Patient’s Risk for Serious
Injury Fractures
There are a few commonsense questions the acute care nurse must ask
when determining whether an elderly patient is at risk for serious injury (see
Table 15.3). Serious injury is defined as broken bones such as vertebral
fractures, pelvic fractures, internal bleeding, or fatality. All of the items are acute or chronic medical illnesses or conditions
giving rise to the possibility that an acute injury could result.
One of the
most prevalent conditions increasing risk for serious injury in older patients,
such as a fracture, is the presence of osteoporosis. For many reasons, the true
incidence of osteoporosis is unknown in the older population, especially in men
(Kaufman et al., 2000) who comprise a large percentage of the acute care hospital
and long-term care beds.
Therefore, it is entirely conceivable that the older
adult will fracture an extremity or vertebrae with a fall, even though there is
no documented diagnosis of osteoporosis.This is because osteoporosis can be
present, even though it has not been formally diagnosed.
Most older individuals
with hip fractures have osteoporosis, yet findings from a retrospective
analysis of records of patients receiving hip fracture surgery appears that the
frequency of treating these high-risk older patients for osteoporosis is less
than optimal; women are offered treatment more than men (Kamel, 2004).
If osteoporosis has been diagnosed, then certain protective
interventions should be considered such as the use of hip protectors
(Applegarth et al., 2009; Bulat, Applegarth, Quigley, Ahmed, & Quigley,
2008). As indicated for those older persons without safety judgment and are
unable to transfer and ambulate independently, the use of low-height beds
and/or floor mats placed around the bedside will lessen the height of the fall,
or padding a hard surface to reduce the chance for injury.
Treatment for
osteoporosis needs to be discussed, ranging from the use of medication agents
to supplemental calcium and vitamin D, although research findings show a controversial
association between vitamin D and physical performance improvements in gait and
balance (Annweiler, Schott, Berrut, Fantino, & Beautet, 2009).
However, a
recent meta-analysis found vitamin D to be the only intervention shown to be
effective in reducing falls among female stroke survivors in an institutional
setting (Batchelor, Hill, Mackintosh, & Said, 2010).Other medical comorbidities that increase the risk of serious
injury include bleeding disorders and use of blood-thinning medications to prevent
stroke.
A risk versus benefit analysis should always be part of fall management
decision making for patient safety and prevention of injury (Quigley &
Goff, 2011). Those with thrombocytopenia require monitoring of neurological
status post fall in an effort to early identify a patient with a looming
internal bleed or developing hematoma. These clinical conditions are very
serious and can be fatal if not assessed early.
Best Practice Interventions for Suspected Serious Injury Head trauma
Frequent neurological checks are done for several days following
head injury in older patients who are on blood thinners or who have coexisting
medical conditions to detect the development of serious conditions such as a
subdural hematoma. In addition, vital signs, assessing behavior, affect,
cognition, and level of consciousness are all part of any assessment of the
patient with head injury.
Changes in speech, such as slurred speech, or subtle
diminution in cognitive abilities (ie, they no longer recognize you after recalling
your name) are significant findings post fall head injury that requires
immediate attention.Older patients who have unwitnessed falls or do not recall falling
despite evidence to the contrary should be monitored for head injury following
the CDC guidelines for head injury (see Resources).
Traumatic brain injury
caused by head injuries is a condition that is preventable and, more
importantly, readily recognizable. Subtle changes in cognition, level of
consciousness, or behavior post fall indicate underlying head trauma. Table
15.4 details best practice interventions in cases in which a head injury is
suspected post fall.
Of all causes, falls are the leading cause of TBI (CDC, NCIPC,
2007), with older adults age 75 and older having the highest rate of TBI-related
hospitalization and death (Langlois, Rutland-Brown, & Thomas, 2006). Groups
at risk for the development of TBI include men who are twice as likely to
sustain a TBI-adults age 75 or older; African Americans have the highest death
rate from TBI (CDC, NCIPČ, 2007).
There is strong clinical reason to suspect
that older adults in anticoagulants are at higher risk for TBI, should then
sustain a fall with head injury, but empirical research in this age group is
lacking. Still, best practice approaches to care of older adults must include a
risk-benefit evaluation of medications, such as Coumadin, Plavix, and/or
aspirin, among others, that place the older adult at increased risk for
bleeding following a fall.
Additionally, use of helmets may be considered
because they absorb trauma and reduce impact to the head (Quigley & Goff,
2011).Why Do Older Adult Patients in an Acute Care Setting Fall and Who
Is at Greatest Risk The Value of Identifying Fall Type Reasons for patient
falls are tied directly to impairments in consciousness, cognition, behavior,
and acute and chronic types of medical conditions. Some of these risks are due
to intrinsic factors, whereas others are due to extrinsic factors.
The standard
of care calls for assessment of fall risk factors and then to develop
intervention plan targeted toward these factors.Environmental falls are potentially preventable because they
encompass foreseeable events, such as spills or improper shoe wear, which is
correctable (Connell, 1996).
Positive predictive
validity of falls has also been used as evidence by the patient’s under lying history
of falls, visual impairment, requiring toileting assistance, dependency in
transfer/mobility, balance disturbance, and cognitive impairment (Blahak et
al., 2009; Papaioannou, 2004 ; Tinetti, Williams, & Mayewski, 1986). Last,
common extrinsic or environmental factors, which represent preventable falls,
are highlighted in Table 15.7.
Fall risk is formally assessed through administration of fall risk
tools (see Table 15.8). The National Center for Patient Safety recommends the
Morse Falls Scale, but not for long-term use (available at:
http://www.va.gov/ncps/CogAids/Fall Prevention/Index
.html#topofpage&page=page-4) .
The Stratify tool has also been widely used
but two very different and distinct approaches for falls prevention. Fall risk
assessment tools offer limited types of inquiry typically streamlined focusing
on five or six areas of inquiry, which are not a substitution or replacement
for a comprehensive post fall inquiry or assessment. Critical information is
missing in these streamlined fall risk assessment tools.
Patient-Specific Factors Linked to Fall Risk
Evidence from systematic reviews of fall risk factors in hospital
inpatients supports the following risk factors to be linked to falls: a recent
fall, muscle weakness, behavioral disturbance, agitation or confusion, urinary
incontinence or frequency, use of “culprit medications (especially sedative/
hypnotics), postural hypotension, syncope, and those older than age 85 years
(Oliver et al., 2010).
In the acute care setting, fall risk tools have been
summarized in an analytic review by Perell and colleagues (2001; Scott, Votova.
Scanlan, & Close, 2007).The nursing assessment of the older adult patient who falls does
not stop with administration of these assessment tools or other types of assessment.
Rather, the assessment is a dynamic and continuous process of quality
improvement, which extends to formulate an analysis of the information and
situational context of the patient so that corrective plans of action can
unfold.
Physical Restraint Use Contributing to Fall Risk
Capezuti and colleagues (2002) cite physical restraint use as a
contributor to risk for falling, not a solution for fall prevention. Also noted
by Capezuti et al. (2002), neither physical restraints nor side rails have ever
been shown to reduce falls or associated injury. In fact, in the last 20 years,
there have been numerous reports of restraint-related injuries reported in the
professional literature, by the US Food and Drug Administration, and The Joint
Commission.
Many of these injuries are due to patient attempts to remove
restraints or to ambulate while restrained (Agostini, Baker, & Bogardus,
2001). The injuries include neurological injuries (DiMaio, Dana, & Bux,
1985), stress-induced complications (related to agitation secondary to
restraint), and strangulation (Dube, & Mitchell, 1986; Miles, 2002).
The
most common mechanism of restraint-related death is by asphyxiation the person
is suspended by a restraint from a bed/chair and the ability to inhale is
inhibited by gravitational chest compression (DiNunno, Vacca, Costantinedes,
& Di Nunno, 2003).
Clearly, the risk of serious injury or fatality due to
physical restraint is substantial and must be considered when deciding about
using restraints. Serious direct injury from bedrails is usually related to use
of outmoded designs and incorrect assembly rather (Healey, Oliver, Milne, &
Connelly, 2008).
Medications Contributing to Fall Risk in Older Adults
“Culprit” drugs or medications implicated in increasing fall risk
are those causing potentially dangerous side effects including drowsiness,
mental confusion, problems with balance or loss of urinary control, and sudden
drops in blood pressure with standing (postural hypotension; Ensrud et al.,
2002: Neutel, Perry, & Maxwell, 2002; Smith.2003).
Classifications of
medications implicated in falls for older adults include psychotropic agents
(benzodiazepines, sedatives/hypnotics, antidepressants, and neuroleptics),
antiarrhythmics, digoxin, and diuretics (Leipzig, Cumming, & Tinetti,
1999), The risk of falls alone should not automatically disqualify a person
from being treated with warfarin (Garwood, & Corbett, 2008).
Post fall assessment
Determination of why the fall occurred is of vital. The value of
post fall assessment, if performed properly and comprehensively using
appropriately empirically tested tools, is that underlying fall etiologies can
be discerned so that appropriate plans of care can be instituted.
To simply
perform a fall risk assessment or perform a PFA and document the findings
without linking the risk or actual fall cause to a strategy is useless. Once
the type of fall is determined using a comprehensive post fall evaluation tool,
the nurse can put into motion an appropriate plan of care.
The purpose of the PFA is to identify the clinical status of the
older adult, verify and treat injuries, and to identify underlying causes of
the fall whenever possible. Components of the PFA are typically routinely
performed by professional nurses in all patient settings, although this
evaluation may be skeletal or limited according to the completeness of
questions and examination included on the tool used.
Eempirically published
tools for PFA exist, and previous research has shown that fall risk
determination, using short forms, asking 5-8 questions about risk, often
replace (inappropriately) PFA in institutionalized settings (Gray-Miceli,
Strumpf, Reinhard, Zanna, & Fritz, 2004; Ray et al., 1997; Rubenstein,
Robbins, Josephson, Schulman, & Osterweil, 1990).
Evidence shows comprehensive PFA tools are useful and available to
assist professional registered nurses in performing a PFA, especially in
institutionalized settings (Gray-Miceli, Strumpf. Johnson, Draganescu, &
Ratcliffe, 2006). In institutional setting where teams are unavailable,
comprehensive PFA may be carried out through consultation with
specialty-trained providers.
The PFA is a comprehensive, case-focused history and physical
examination of the present problem (falling), coupled with a functional assessment,
review of past medical problems, and medications.
Clinical fall prevention
guidelines are very clear about all of the necessary components for inclusion
for patients who have fallen, which include fall history; case circumstance;
medical problems, medication review; mobility assessment; vision assessment;
neurological examination, including mental status; and cardiovascular
assessment. In addition to this information, data are collected about the
patient’s physical status.
Performing a comprehensive PFA allows the clinician
to identify intrinsic risks and recent causes of a fall such as orthostatic
hypotension and/ or bradyarrhythmia or tachyarrhythmia associated with
dizziness (Gray-Miceli et al., 2006). In the hospital setting, certain components
of a PFA can be elicited immediately following a patient case, with the
decision to ask certain questions immediately depends on the medical stability
of the patient and nursing judgment.
The Immediate Post-Fall Assessment
As soon as possible, an assessment is made to determine the extent
of any sustained injuries. Before any intervention is taken, any staff member
should remain with the patient and call for help. During this time, the older
adult patient is verbally reassured and kept warm (but not moved) until help
arrives. There are many key observations to be noted about the fallen
individual’s medical and psychological condition, as well as the condition of
the environment.
The medical stability of the patient determines the sequence
of information gathered either immediately or in the interim period, according
to current standards of practice followed by licensed professionals. For
instance, if unconscious from a sustained head injury during the fall,
neurological checks, vital signs with apical pulse rate, and pulse oxygenation
are assessed first. Other assessments of gait or functional status are
conducted after the patient has stabilized.
While this is being performed, or
if shoes/slippers are worn, other staff members can assess environmental spills.
Information about the lighting and use of assistive devices can be gathered.
Any verbalizations made by the patient should be noted about his or her
condition.
Critical observations made during the immediate PFA that should be communicated to the primary care provider include observation or
verbalizations of pain, extremity swelling, unstable vital signs, discolored
skin, temperature, laceration or contusions of the skin, loss of conscious –
ness, decreased range of motion, evidence of head or neck injury and abnormal
or erratic neurological responses, uncontrollable bleeding, and incontinence of
bowel or bladder at the time of the fall.
Interim Post-Fall Assessment
During the interim period of PFA and monitoring (anywhere from
several hours to days), the nurses continue to review, determine, and
communicate pertinent findings from this assessment and its progression or
resolution. Once the patient is medically stable, fall risk assessment can be
reassessed by the interdisciplinary team, revaluating intrinsic and extrinsic
risks so that a plan of care can be determined.
Developing a plan of care and
requesting a change in physician orders for level of supervision required by
nursing staff of the older patient or specific activity restrictions depending
on the fall assessment findings.
Longitudinal Post-Fall Assessment
Following a patient fall, the presence of injury may not be
apparent until days or even weeks later. When cognitive impairment exists, the
accuracy of the historical accounts of pain obtained immediately after the fall
may be questioned. Observations of functional status with attention to any
subtle or blatant changes in mobility can signal an underlying fracture or a
looming unstable joint that was not previously reported.
Likewise, during a
patient fall in which the older adult is cognitively intact, and then later
develops, an acute delirium should signal to the professional nurse the
possibility of injury. In these two instances, the standard of care warrants as
part of the ongoing post fall assessment, to monitor vital signs and
neurological status for a period of several days or more, as clinically
indicated.
Fall policy and procedures should reflect this provision because any
change in patient condition warrants follow-through, documentation, and
communication to senior level providers, other nursing staff, and family.
Overview Of Effective Fall And Injury Prevention In Hospitals
Effective fall prevention programs in acute care hospitals are
championed by nurses using one or more approaches. Moving beyond traditional
measures of fall rates to assessing and measuring patient injury from falls
provides more information and segmentation of vulnerable patients so that a new
level of intervention is applied.
This process advances the evidence related to
falls into the quality management program for falls prevention. Assessing risk
for injury provides the evidence for nurses to provide specific interventions
to reduce injury (eg, hip protectors, floor mats, and helmets) based on using
existing tools.
The evidence is strong to support the benefit of multifactorial
fall prevention programs for injurious falls in acute care. System-level
interventions with emerging evidence of effectiveness emerge from the work of innovation:
nurse champions, safety huddles, teach-back strategies, post fall huddles, and
interventions to reduce fall-related trauma. Nurse champions
Embracing nurse champions at the point of care, the Institute for
Healthcare Improvement’s (IHI) Transforming Care at the Bedside has partnered
with the VISN 8 Patient Safety Center to focus on acute care fall and injury
prevention for the last 5 years.
Dedicated to building program capacity,
infrastructure, and expertise, fall experts have mentored and coached nurses
from across acute care settings to address vulnerable older adults are at
greatest risk for loss of function or loss of life if any type of fall occurs.
This approach to nursing practice has been transformational (Boushon et al.,
2008).
Teach-backs
Health literacy requires that providers evaluate the degree to
which individuals learn by assessing their capacity to obtain information,
process, and understand basic health information and services so that they can
make informed health decisions (Institute of Medicine, 2004).
Teach backs
identifies what the patient learned by a return demonstration or feedback, and
more importantly, what the patient had difficulty learning, so that the
provider can fill that gap through ongoing education.Comfort Care and Safety Rounds. Nursing staff are completing
comfort care and safety rounds as one of their tests of change.
This
intervention has emerging evidence of effectiveness based on the results of
researchers Meade, Bursell, and Ketelsen (2006), hourly rounds in acute care
reduced cases (p = 0.01), and by 60% 1 year later in the follow-up hospitals.
Safety Huddle Post-Fall
Safety huddles were patterned after the military’s “After Action
Review” (AAR) process. Safety huddles provide a mechanism for immediate knowledge
transfer for learning from errors and close calls. In a safety huddle, staff
are instructed to immediately assess a situation or event to understand what
happened, what should have happened, what accounted for the difference, and
what corrective action could be implemented to prevent a similar event. This
AAR mimics a modified root cause analysis.
All staff received a brochure
explaining the AAR process and are instructed to perform a safety huddle as
soon as possible after becoming aware of a fall. Nurse managers or advanced
practice nurses coach staff in the safety huddle process through role playing
and use of a brochure and presentation that describes the process. The nurse
managers lead the initial huddles, and staff followed thereafter.
Over time,
staff begin to use safety huddles to examine other patient safety situations
and to ensure that if precautions are consistently applied in the
shift-to-shift hand-off process. Incorporation into the hand-off process also
provided the opportunity for staff to reassess a patient’s status (Quigley et
al., 2009).
Interventions to Reduce Trauma
Patients with risk factors for serious injury (osteoporosis or
osteoporosis risk factors; anti-coagulants for postoperative patients) should
be automatically placed on high-risk falls precautions and interventions to
reduce risk for serious injury should be implemented.
Interventions to reduce
the risk of trauma and prevent injury include the following: place a bedside
mat on floor at side of bed unless contraindicated; use height-adjustable bed
(low-bed position to reduce distance from bed to floor); helmet use for
patients at risk for head injury (those on anticoagulants, patients with severe
seizure disorder, and history of falling and hitting head); and dress with hip
protectors for patients at risk for hip fracture.
These interventions when
combined create protective bundles. For example, those patients at risk for hip
fracture should be placed at high risk for falls and in height-adjustable beds,
wear hip protectors, have floor mats at bedside when in bed, and receive
comfort and safety rounds.
Those patients at risk for hemorrhagic bleed should
be placed at high risk for falls and in height-adjustable beds, have floor mats
at bedside when in bed, and receive comfort and safety rounds. Helmets should
be considered for patients with history of head injury and falls, and on
anticoagulants. All patients should receive education about their fall and
injury risks.
Program Evaluation
Many health systems use a specifically designed incident report
form for falls that collects detailed literature-based data about fall
occurrences (Elkins et al., 2004). For example. these data might include time
of day, location, activity, orthostasis, and incontinence.
From the analysis of
the data, one can determine the type of fall, such as accidental, anticipated
physiological, and unanticipated physiological fall and severity of injury-
minor, moderate, or major/severe (Donaldson, Brown, Aydin, Bolton,
&Rutledge , 2005).
Analysis of data of this depth and scope enables
clinicians, administrators, and risk managers to profile the level of fall risk
of their patients along with actual factors contributing to the fall, as well
as identifying overall patterns and trends surrounding fall occurrence.
Fall Prevention Program
Fall prevention begins with an integrated/coordinated approach
including determination of fall risk and PFA to identify risk factors. Accurate
documentation should be provided in the plan of care, nursing and
interdisciplinary notes, and other aspects of the medical record such as the
problem-list help to ensure communication and ongoing monitoring.
Review of
fall-related information collected about a fall event or a person deemed at
risk for fall by the interdisciplinary team adds an important dimension to fall
care. The team offers input from their unique perspective of the fall
circumstance and how to best manage a fall or a patient at high risk for falls.
The interdisciplinary team consists of the medical provider, nurse, physical or
occupational therapist, risk manager, pharmacist, and other direct health care
providers.Hospital-based fall prevention programs have been described in the
literature, but few trials have been conducted, demonstrating their
effectiveness due to methodological limitations associated with this complex
clinical fast-paced setting.
One study examined the effect of a program of fall
prevention that includes multifactorial components of fall risk assessment, a
choice of interventions, patient education, and staff education, as well as
labels or “graphics alerting others to at risk patients.” Use of this model and
its outcomes were examined prospectively for 5 years by Dempsey (2004) who
reported a significant reduction in fall rates.
However, over time compliance
deteriorated warranting further nursing inquiry considering use of a process
approach to increase nurse autonomy in fall prevention.Exemplary models of care also exist through the National Center for
Patient Safety at the United States Department of Veterans Affairs (available
at: http://www.va.gov/ncps/SafetyTopics/fallstoolkit/index.html).
The Veterans
Affairs, VISN 8 Patient Safety Center of Inquiry, under the direction of an
advanced nurse practitioner nurse scientist. spearheads an impressive program
of fall prevention through its health care network of inpatient hospitals.
Fall
prevention through best practice approaches are evaluated and translated into
standard practices among general falls prevention, interventions for high-risk
patients, and education of staff, patients, and families.Models of care, serving as exemplars of the geriatric
nurse-centered approach, realize improvements in hospital lengths of stay and
health outcomes as well as fewer iatrogenic geriatric syndromes such as
inpatient falls.
Use of the Acute Care of the Elderly (ACE) units: Nurses
Improving Care for Health system Elders (NICHE) program; and the Geriatric
Resource Nurse (GRN) model, which use a system-level quality improvement
approach, including educational programs for staff, realized a decrease fall
rate by 5.8% (Smyth, Dubin, Restrepo, Nueva-Espana, & Capezuti, 2001) .
Interventions For Fall Prevention And Management Institute General Safety Measures
Hospitals and their staff have a legal responsibility and due
diligence to ensure freedom from environmental hazards and safety for all
patients, staff, and visitors. Routine environmental assessment using a
checklist should include the unit, corridors, entrance, and exits, as well as
patient holding areas, patient rooms, and areas where patients are transported
to (radiology, nuclear imaging, operating room).
In each of these areas, an
environmental assessment is performed focusing on floor surfaces, furniture,
hallways, steps, device safety such as stretchers, wheelchairs, and other types
of chairs, free of clutter, bathrooms with appropriate grab rails, and routine
assessment of equipment. Use of a checklist signed by the designated employee
allows for audit review of compliance, serving as an internal benchmark of
compliance.
As part of general safety, some facilities designate any older
adult age 65 years and older admitted to be on “safety precautions,” which can
include various other safety measures (presented in the succeeding text).
Clinically, it is important to recognize, in advance whenever possible, that if
instructions are given to the patient for general safety precautions, that the
older adult is actually able to hear, understand, and demonstrate that he or
she can follow instructions.
Simply “telling the older adult”To be careful or
to not get up without assistance is insufficient in the face of an ongoing or
new onset of delirium or cognitive impairment. Rather, other safety measures
need to be instituted immediately, discussed with the team and the family
caregiver, and incorporated as part of the plan of care.
Immediate options
always include (a) increasing surveillance by either staying with the patient
continuously; (b) moving the patient to a closer location (provided there is
staff constantly observing the patient); (c) providing a one-on-one type of
sitter service for continual surveillance; or (d) engaging the older patient in
diversional activities or other forms of therapeutic recreation.
Sitter type
services may be provided by hospital staff, volunteers, or through private duty
services. Discussion with family caregivers and the interdisciplinary team are
essential in these cases.
Early Mobility for Older Patients Who Fall
Early mobility, whenever the older patient is medically stable, is
a fundamental and basic aspect of care for all older adult patients to receive
during their hospitalization. It is a step toward the prevention of
deconditioning, reduced mobility and immobility, and other cascading problems
that can result when less sedentary (for instance, orthostatic pneumonia or
atelectasis).
Early mobility as an intervention begins with the simple and
conscious decision by nursing to assist the patient out of bed to walk to the
bathroom whenever possible, rather than to use a bedpan or even a bedside
commode that offers little opportunity for mobility. Wearing proper footwear,
corrective lenses, and clearing a path that is clutter- and spill-free are
essential.
Use of a walking aid such as a standard cane or walker may also be
required; appropriate assistive devices can be ascertained through an
occupational or physical therapist consultation (Quigley & Goff, 2011).Another essential aspect for the older adult with comorbidities is
for nurses to preemptively ask the older patient, who is transitioning with
your assistance, from sitting to standing and then while walking, “How are you
feeling”?
Of concern is the detection of symptoms such as lightheadedness,
vertigo with rotational movement, or muscular stiffness. These symptoms can be
managed and monitored, if significant enough to prohibit mobility, once they
are detected. Another concern exists for the older adult patient with
orthostatic hypotension.
this instance, gradual upright incline with
assistance while monitoring for symptoms of lightheadedness are important.
Should an older adult experience symptoms or develop acute physiological
evidence of a problem (for instance, near syncope, syncope, or changes in heart
rate or blood pressure), slowly casing him or her back to a recumbent position
and notifying the physician for further evaluation is warranted.
Mobility programs build upon the positive feedback that the patient
is feeling and objectively gaining strength each day is instituted. Checklist
can monitor progress and serve to validate to the patient his or her clinical
progression. Care must be taken, how ever, to remind persons who are restricted
from independent mobility to always wait for assistance.
Recommendations are to
set a similar time each day and to use consistent staff. An integral component
of any mobility program is footwear of patients. A recent study found patients
who wore their own footwear significantly improved participants’ balance
compared to being barefoot; in fact, the greatest benefit was seen in those
individuals with the poorest balance (Horgan et al., 2009).
Some Best Practice Examples Used by Acute Care Hospitals
The difference between environmental safety assessment and safety
rounds is that safety rounds are a regular, systematic observation by one or
two key personnel of the hospital unit; when assumed by the same personnel,
hazards may be more quickly appreciated. Further, they occur at regular points
in time, such as every 2 or 4 hours around the clock and also detect patients
in need of assistance.
This level of frequency is likely to detect problems
early so that intervention can ensure the prevention of environmental type of
falls. Use of checklist can help to ensure compliance and monitor for patterns
of hazards and types of hazards that need correction.Many hospital-based fall prevention programs include toileting
rounds. Toileting rounds use nurse’s aides to regularly assess older adult
patients for the need to urinate and to provide the patient with assistance.
The purpose of toileting rounds is to prevent patients from incurring urinary
accidents (and potential falls) by encouraging regular voiding. In many
circumstances, urinary accidents can lead to falls. Scenarios include the older
adult sensing a need to urinate, getting up out of bed unassisted, and
occurring a fall by an unrecognized physiologic mechanism (eg, orthostatic
hypotension).
Another scenario is in route to the bathroom; the older adult has
a urinary accident on the floor and slips and falls on the wet floor. By
offering toileting rounds on a regular basis, the potential for these
occurrences is minimized, reducing fall rates as well as the iatrogenic
complications (eg, hip fracture).
Toileting is a fundamental element of basic
care that has an important place in the prevention of patient falls, but its
importance is underrecognized. In a study by Brown et al. (2000), urge
incontinence (and not stress), especially if occurring weekly or more often,
increased risk of falls and non-spinal, non-traumatic fractures in older White
women living in the community.
Specific Nursing Interventions
Personal alarms are routinely used to alert nursing staff about
impending falls or changes in patient mobility status. Care should be taken
when deciding to use these devices because they do not prevent a fall from
occurring (Oliver et al., 2010); Rather, they heighten staff’s awareness by
sounding an alarm, indicating a change in position has occurred.
There are many
commercial products available, but generally, they are of two types, personal
alarms clipped to the patient’s gown or chair and bed-chair pressure sensors.
Despite their widespread use, there is little evidence regarding their
effectiveness in reducing falls in an acute care hospital setting. Use of a bed
sensor alarm was studied in a geriatric rehabilitation unit with older adult
patients, deemed by nurses to be at increased fall for falling (Kwok, Mok,
Chien, & Tam, 2006).
In this study, the availability of bed sensor devices
neither reduced physical restraint use nor improved the clinical outcomes of
older adults with perceived fall risk. In a nursing home-based study. however,
use of the “NOC WATCH,” a nonintrusive monitor used with older adults at high
risk for falling (Kelly, Phillips, Cain, Polissar, & Kelly, 2002), reduced
fall rate by 91%, thereby supporting other clinical trials using a randomized
design.
If may not be the best indicator of the effectiveness of alarms, rather
timeliness of rescue (Quigley, & Goff, 2011). Further, greater nurse
surveillance capacity was significantly associated with better quality care and
fewer adverse events (Kutney-Lee, Lake, & Aiken, 2009).Both floor mats and use of low-rise beds have an important place in
the armamentarium of clinical interventions to prevent the occurrence of
serious injury when a bed fall occurs.
Floor mats are simply placed surrounding
the bed and serve to cushion the impact of the fall. They vary in thickness,
and if portions of an area are uncovered, substantial injury could still occur
if a patient attempts to get out of bed and a bed fall ensues, Little, if any,
empirical research evidence exists regarding their effectiveness in preventing
falls from bed causing fractures to the hip or traumatic brain injury in acute
care settings.
However, one observational cluster randomized trial in 18
nursing homes found that both types of hip protectors (soft and hard), when
worn correctly, had the potential to reduce the risk of a hip fracture in falls
by nearly 60% (Bentzen, Bergland, & Forsen, 2008).
A recent meta-analysis, however, reported that hip protectors are
an ineffective intervention for those living at home and that their
effectiveness in the institutional setting is uncertain (Parker, Gillespie,
& Gillespie, 2006)..echnological advances have occurred, offering staff and patients a
greater variety of solutions to the problem of falling.
Improvements realized
have occurred with walking aides such as canes that “talk” and provide feedback
to the user, balance retraining that help patients learn about where their body
is in space and to help learn how to compensate for muscular impairments, and
other types of equipment used at the bedside when transitioning patients.
Although these devices are available, research is evolving and limited in terms
of their effectiveness in fall prevention (Nelson et al., 2004).An integral component of any fall prevention educational
intervention for hospitalized older adults or preparing for discharge home
concerns their working knowledge of what their fall was due to and what can be
done about it.
Exploring the older adult’s beliefs and attitudes are important
and can lead to dispelling myths they may hold about falling; for instance,
they may believe it is a normal part of aging or that nothing can be done about
it. An older person’s view and conceptualization about their falling is a
starting point for a tailored educational intervention.
A systematic review of
the literature of many studies examining older adults’ preferences, views, and
experiences in relation to fall prevention strategies reported several
important findings (McInnes, & Askie, 2004): (a) In clinical practice, it
is important to consult with individuals to find out what they are willing to
modify; and (b) what changes they are prepared to make to reduce their risk of
falling, otherwise they may not attend fall prevention programs.