What kind of progress have we made toward preventing elderly patient falls in healthcare?
For the last decade, I’ve been more than I might seem on the surface. I’m a statistic. Although I am hesitant to admit it unless circumstances require, I’m a fall risk. I have fallen more than once. In fact, I have fallen several times, and I have the injuries to prove it: remnants of fractured ribs, fractured toes, serrated rotator cuffs, and numerous bumps and bruises. Elderly patient falls are a serious issue: one that needs to be addressed with vigilance and sincerity.
Why would I mention this? It has helped me understand the intricacies of both sides when patients need to be assessed for possible harm once they are admitted. It has also helped when working on numerous Falls Task Forces to help initiate innovative approaches to keep patients safe. No independent adult sets out with a plan to fall. Falls are defined as “a sudden, unintended, uncontrolled downward displacement of a patient’s body to the ground or other object.” Falls hurt. Additionally, falls are defined as either assisted or unassisted, but all must be reported. Falls are never events according to the Centers for Medicare and Medicaid Services. Since 2008, financial penalties have been instituted whenever falls occur, as an additional incentive to keep patients safe when they are hospitalized.1
Falls are classified as either those occurring with injury or without, but patients will tell you that even those without visible injury leave a lasting memory. Patients are left with a fear of falling again, and nurses are fearful the patient might fall on their watch. Both factors tend to lead to a decrease in patient mobility, even if the event was an isolated occurrence.
Unfortunately, hospitals don’t track how much total time patients get up and move, whether they are a fall risk or not. One study conducted in 2006-2007 found that patients >65 who did not have dementia or delirium and could walk in the two weeks before admission found patients spent, on average, ~ 83% of their time in bed. Imagine how much weaker an elderly patient might become after a short hospital stay if they spend all their time recumbent!4
Up to one million hospitalized patients fall annually in the United States, but it is believed these figures may under-represent rural areas and smaller community hospitals. Approximately one fourth of those falls involve injuries, with “costs involving $7000 per injury”, not accounting for the additional costs involved with the extended stay that most falls accrue. Currently, injurious falls are one of the hospital-acquired conditions for which hospitals are financially penalized, making them a very expensive “incident”.1
Hospital Fall Teams have utilized various resources to reduce elderly patient falls, such as the “Falls” Primer by the Agency for Healthcare Research and Quality, which focuses on interdisciplinary effort. By utilizing clinical tools, whether through assessing patient strength and mobility, or by the patient’s understanding of instruction (call light use, when to get up, etc.) patient falls decreased 15% in the years between 2010-2015 at US hospitals. Many factors accounted for these changes. First, it was a recognition that falls were taking place around toileting: in the bathroom, getting on or off the toilet, or attempting to get out of bed with the goal of accessing the bathroom or bedside commode. Medications such as diuretics and laxatives also were involved in patient urgency in getting up, especially during the evening or at night.3
A second finding was the recognition that gait belts were extremely helpful in preventing falls with injuries. Even if the patient became weak or began a descent, they could be lowered to the floor gently and without injury. Gait belts proved extremely helpful in mobilizing seniors that needed a steady hand for ambulation.
Safe footwear and bed alarms have been widely utilized throughout US hospitals with mixed results, for alarms proved only as good as the mix of staffing that was available to respond to the beeping. For patients in the beds, the sound could be disturbing, amplifying their anxiety or distress. Socks with non-slip grippers proved helpful for patients that could ambulate but did little for patients who remained bedbound other than to keep the feet toasty.3 Larger hospital systems showed excellent creativity, placing signs on the ceiling warning patients to call for assistance before getting up, or choosing seasonal pictures (such as fall leaves) posted on the doors of patients identified as high risk for falls, so ancillary services could assist with keeping an eye on patients disposed to scooting out of bed.
All helped to remind interdisciplinary staff during daily huddles to be alert to the patient who may be a risk for getting up and falling.
However, despite these findings, no significant study has demonstrated that hospitals have made lasting gains in fall rates since CMS instituted penalties for falls during hospital stays. The most effective means of keeping a patient in bed remains one of the most expensive: hiring a sitter or keeping watch one on one.
Even then, patients who fall during a hospital stay are more frequently discharged to a nursing home. Unfortunately, the fall rate for nursing homes is worse than it is for acute care, so this outcome needs to be avoided at all costs. Approximately half of the 1.6 million nursing home residents in the US fall each year, with 10% experiencing a significant injury. What might be the answer to this perplexing problem?3
An article examining elderly patient falls from the perspective of a consult geriatrician in London believes all members of the hospital team, from physicians and board members, to those in the care huddle, must discuss and examine each patient from aspects of physicality and functionality to improve fall statistics. His approach considers whether the use of Vitamin D, for example, might be more appropriate for an elderly male than the buzzers and bed alarms that have been utilized to decrease falls. It is an insightful approach to the care of the elderly, one that may warrant more than a quick glance.2
Whatever the approach, what we should not do is become overly cautious in protecting elderly patients from falls. Dorothy Twigg, who was a patient in her 80’s and at risk for falling, was confined to her bed for three days, tethered by siderails and a bed alarm. She became so weak after an admission that she needed extensive therapy to be able to regain mobility. She was hospitalized several times in two years and each time, the same response. Kevin Covinsky, a geriatrician and researcher at the University of California at San Francisco, has found that one-third of patients >70 leave the hospital more disabled than when they first arrived. This factor alone makes them more likely to fall when discharged.4
While the desire to protect elderly patients from falls (and particularly from injury) is high when they are hospitalized, a balance is needed, especially when elderly patients are admitted over the weekend, when less support staff might be available to assist with ambulation. Passive or active ROM can be completed at the bedside, especially if a willing family member is nearby. Patients can be assisted to the chair with a gait belt, so they are not recumbent throughout their stay. Their muscles will thank you long after the admission.
I’ve been in their shoes. I’ve been a fall statistic, which cannot be changed. The one thing every patient will tell you once they have fallen is this: the fear of falling again does not leave. An elderly patient who falls is motivated to work with staff to ensure they stay safe.
They just need the tools.
- Bmcgeriatr.biomedcentral.com “Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study.” Venema, D., Skinner, A., & jones, K., BMC Geriatrics, 19, Article # 348, 2019.
- Ncbi.nlm.nih.gov “Prevention of falls in hospital.” Clin med (Lond). 2017 Aug; 17 (4):360-362. Doi: 10.7861/clinmedicine.17-4-360.
- Psnet.ahrq.gov Patient Safety Primer “Falls”. Last updated September 2019. Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.
- Washingtonpost.com “Overzealous in preventing falls, hospitals are producing an ‘epidemic of immobility’ in elderly patients.”, Bailey, M., October 13, 2019.