Purchase and data synthesis with citations

Falls

THE ISSUE OF ACCIDENTAL FALLS

At some point, anyone who had learned how to walk has had the experience of falling down -- it is a universal experience for infants as they gain ambulatory ability. In hospitals, however, the accidental fall is the most reported type of patient safety incident, with elderly patient populations displaying a particular vulnerability (Oliver 2007, p.173). Approximately one-third of adults over the age of sixty-five will experience an accidental fall this year (CDC 2012, n.p.) Fischer (2005) offers some clarification as to how these incidents should be defined -- the simplest basic definition is "a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object" (p822). This definition takes into account the unpredictable nature of the incident, and the fact that it frequently involves a certain loss of control on the part of the patient; it also reminds us that the fact that a patient can fall onto some "other object" may indicate a whole range of unforeseen damaging consequences involved in a fall.

Fischer (2005) rather crucially distinguishes different types of falling incidents -- obviously with a phenomenon as common as the accidental fall during a hospital stay, it is possible to make some broad categorical generalizations -- and offers two related phenomena, the "near fall" which is understood as a sudden loss of balance in which the patient never actually makes impact, and which would cover such actions as slipping, stumbling or tripping without subsequent impact injury (but still entirely capable of causing injury in the form of strains, sprains, bruises, or in various other ways) and the familiar hospital event of the "un-witnessed fall," in which a patient is discovered on the ground and no-one, including the patient, can describe how the patient got there (Fischer 2005, p.548). Oliver (2007) notes that, in terms of overall statistics, "most falls are unwitnessed by staff" in hospitals (p.177). If there are a variety of different ways for a patient to fall down and be injured, however, there are also numerous significant consequences for the accidental fall. Oliver (2007) gives a useful summary of the various possible consequences: accidental falls can, of course result in physical and psychological harm, up to and including more long-term functional impairment; accidental falls can prolong a patient's time in hospital, and substantially increase the cost of care; they are also a liability concern, provoking concern or outrage from the family of a patient, including frequent complaints, demands for inquests, and even lawsuits (pp173-5). In Oliver's (2007) assessment, accidental falls must therefore be included in any reasonable institutional strategy for risk management within a hospital, despite the fact that the amount paid out in damages for accidental falls amounts to "a relatively modest sum" (p.177). It is not the potential financial consequences of accidental falls that should concern hospitals, in the assessment of Oliver (2007), but instead the sheer volume of such accidents and the attendant claims upon them: after surveing the data, Oliver concludes that accidental falls account for "nearly 50% of all critical incidents" (p.177). The CDC states that, statistically speaking, accidental falls are "the most common cause of nonfatal injuries and hospital admissions for trauma" (2012, n.p.)

II. ACCIDENTAL FALLS: IDENTIFYING THE PROBLEM

The difficulty here is that accidental falls are not really a medical condition in and of themselves -- in reality they are frequently a result of the patient's illness or overall frail physical condition which necessitated a hospital stay in the first place. The absolute frequency of accidentall falls therefore should not be taken as a sign of negligence in medical care, or a symptom of a dysfunctional hospital system -- it has been established that the rate of accidental falls depends upon the medical condition of the patients who suffer them, and therefore an overall "rate" of accidental falls for a hospital facility overall is likely to seem misleading if it is not considered with adjustment for the rates specific to individual hospital units, with an eye on the specific patient populations within those units (Oliver 2007, p. 175). This presents a substantial institutional difficulty, though, in the operation of the average hospital: there are reported large variations in the rate of accidental falls, and it raises a question about standard of care. Should some falls (for example, with frail elderly patients) be regarded as essentially unpreventable? The difficulty here seems to be the risk of what Oliver terms "excessively custodial" care strategies -- those in which the rights and freedoms of patients are unnecessarily curtailed, in a fashion that could be viewed as "ageist," overly sensitive toward possible lawsuits, and generally paternalistic (Oliver 2007, p. 177-8). According to CDC statistics, however, the question of ageism may be precisely relevant: less than half of adults over the age of 65 will actually talk to their doctor about having fallen, presumably because of the general assumption that to admit to having suffered an accidental fall is, in some way, an admission of declining capability (CDC 2012, n.p.) Besides, with such a wide-ranging variety of potential incidents, it is not really clear what sort of strategy an institution should pursue -- acting out of fear of potential lawsuits over an accidental fall may, in fact, lead hospitals to pursue strategies of intervention which do not actually work, and are not even based on any particular assessment of the medical evidence (in terms of, say, an examination of whether installing larger bedrails on hospital beds actually increases or decreases the rate of falls related to a patient getting into or out of bed). Oliver (2007) notes that evidence from studies on the subject shows that, while it is possible to achieve a slight-to-moderate reduction in the overall rate of accidental falls, it does not seem to affect the number of actual patients undergoing the accidental falls.

III. ACCIDENTAL FALLS: SIGNIFICANCE OF THE PROBLEM

CDC statistics indicate that, in the year 2008 alone, nearly 20,000 adults died from injuries related to an accidental fall -- accidental falls are recorded as the leading cause of injury death among adults 65 and over (2012, n.p.). This is enough to indicate that accidental falls are a significant problem -- but the question here is what, if anything, can be done to address the problem. On the one hand, accidental falls should ostensibly be a preventable condition, despite the fact that the CDC, as noted earlier, has testified to the reluctance of many older adults to admit the problem to a medical care provider.

If we focus on a specific population -- adults 65 and over with a cardiac medical problem -- we can observe that accidental falls can be the cause of injury ranging from the moderate to the life-threatening, and are associated with increased risk of early death (CDC 2012, n.p.) Focusing on the 65 and older cardiac medical problems, the existing literature on the subject of accidental falls can give a relatively good sense of the population in question, including their medical background and the causes and results of the accidental falls themselves. According to the 2011 fall-related injury report from Barnes Jewish hospital, a total of 1165 accidental falls were recorded during that year in the hospital. Of the falls in that year, 962 of the patients involved sustained no injuries; 159 sustained minor injuries; 24 sustained moderate injuries; and 20 cases resulted in major injuries or death. 22% of the accidental falls were sustained by patients between 66 and 75 years old. In terms of causes related to the accidents, related to environmental issues within the hospital itself, rolling equipment (e.g., IV poles, bedside tables) accounted for 35% of the incidents, inappropriate footwear accounted for 22%, a necessary item being placed out of the patient's reach was the casue in 21% of incidents, slippery floors were involved in 12% of incidents, and finally trip-hazards or clutter were implicated in 9% of the accidental falls. Temporally, the breakdown for falls during shifts was 31% occurring during the day, 36% during the evening, and 33% at night. A 2005 study of the same hospital, conducted by Krauss et al., incidated that overall 30% of hospital patient accidental falls resulted in injury -- 4 to 6% of those accidental falls resulted in injury that was deemend serious (p.117). Hitcho et al. conducted a similar study at Barnest Jewish Hospital in Saint Louis, and concluded that accidental falls occurred at a rate roughly between 2.3 to 7 accidental falls per 1000 patient-days spent in the hospital (Hitcho p.734). These rates are high enough to be a concern to hospital administrators, both for reasons of the possibility of significant injury, but also for reasons related to hospital quality (with increased cost being the most significant). Hitcho et al. (2004) noted that those patients who are actually injured due to an accidental fall end up having additional health care costs, with an average increased amount recorded of $4,200 (p.732). The significance of this increased need for health care related to accidental falls that occur within the hospital environment is considerable; Oliver et al. (2007) note that the financial implications for the hospitals themselves in terms of additional costs and addition bed-days per involved patient adds up to a significant amount, with the National Health Service of Great Britain having to settle claims on the order of GBP 7.7 million, the equivalent of $12.2 million (p177). Over half of these costs were attributed to hip and pelvic fractures alone, suggesting that, in the population surveyed in Great Britain, a pattern can begin to emerge, related to the overhwhelming incidence of such accidental falls involving elderly patients. These statistics are borne out by reporting on the subject by the CDC in America. The CDC reports that, in 2009, there were 2.2 million emergency room visits required by older adults in relation to injury from accidental fall, and that a resulting 581,000 of those older adults were additionally hospitalized as a result of the fall (2012, n.p.) The CDC notes in addition that the death rates from accidental falls have been rising over the past decade, presumably because of the rising numbers of older people and the increased reporting of accidental falls. But the costs are significant -- the CDC report (2012) paints a grim picture in which, according to 2000 statistics, the total direct cost (i.e., monies paid out for treating injuries and conditions by both patients and their insurance companies) related to accidental falls registered at a little over $19 billion for non-fatal accidental falls, and an additional $179 million recorded with accidental falls that resulted in death -- adjusted for inflation, these would lead to statistics equivalent to approximately $28.2 billion dollars or more currently, for what is essentially a preventable medical issue. What is the money going for? Consider the results of an accidental fall -- not just hospital care or nursing home care, or the requirement for additional such care in the case of an accidental fall that occurs in one of these environments, but also additional costs for doctors and professional services including rehabilitation, community-based services, related medical equipment, drugs prescribed, outfitting patients' homes in order to safeguard against a further incident, and additional insurance-related processing costs. If these numbers and these services sound astonishingly high, it is worth noting that if anything this is understated. Direct costs of what is paid out immediately by both patients and insurers in the wake of an accidental fall do not include the long-term consequences which may be attendant upon an accident fall, as its direct long-term consequences -- these include, of course, disability payments, increased dependence upon caregivers, time lost from work or maintenance of household, and obviously a serious reduction in quality of life. Once accidental falls are identified as a problem, the scope of that problem can be seen as relatively astonishing. In this case, it is worth noting the chief recommendation of the CDC (2012) is for hospitals to encourage the position of an accidental falls "champion," a medical care team leader who can take charge of the issue of fall prevention, and be responsible for implementation of positive steps to achieve some reduction in the number of unnecessary falls (n.p.). This strategy, of course, would benefit both patients and medical personnel overall, and it seems like a sound and sensible recommendation.

IV. ACCIDENTAL FALLS: SIGNIFICANCE TO PATIENT CARE

Restricting the survey of those suffering accidental falls to patients 65 and older within the larger population of those with cardiac medical problems serves a twofold purpose in analyzing more closely the problems related to accidental falls: it focuses first on that age cohort which is most likely to be seriously impacted by an accidental fall, while at the same time focusing on a population where the existing medical condition is not necessarily intrinsically related to the issue of accidental falls in itself. To a certain degree, then, this approach allows us to isolate the question of what larger significance the issue of accidental falls may hold within patient care for this specific population more generally. In terms of how patient care may indeed play a role in accidental falls, it is necessary, however, to examine what different factors may play a role in the presence of accidental falls within this specific patient population. Here, three specific issues -- drugs, age, medical causes, and environmental factors -- are significant in terms of reaching a better understanding of why accidental falls take place.

The first issue that must be taken into consideration is drugs. In a patient population of those 65 and over, those who are admitted for a hospital stay are more likely than younger patients to be on multiple medications, and they are vastly more likely than younger patients to be on drugs which can reduce blood pressure or can slow down heartrate. This carries with it an additional implicit risk of fainting, sedative or soporific effect, or other pharmacological causes (whether as a side effect or as a result of the synergistic interaction of separate medications) that can increase the possibility of unsteadiness or muscle weakness. Other drugs -- for example, sleeping pills and anxiolytic sedatives, antidepressants and other types of psychotropic medication, and painkillers (especially opiates) -- can also have this sort of effect, making patients to a certain degree unstable on their feet or weak in their muscle control. (Oliver 2007, p. 178). Obviously this singles out pharmacology as a significant risk factor in promoting accidental falls. In terms of medical care, therefore, it is important especially with people who are at risk of an accidental fall that care providers review the list of medications prescribed to the patient, and to consider the risks associated with each, and to attempt to minimize the number of superfluous prescriptions.

Age itself is, in itself, a significant predictive risk factor in assessing accidental falls. Oliver (2007) reports that muscle function and proprioceptive balance function both decline as a result of the general process of aging, although to a certain extent regular exercise may help to forestall this general trend (p. 174). Additional features of age-related declining functions also increase the risk of accidental falls: these include the gradual slowing down of reflex functions, the increase of problems with eyesight, and -- especially in women -- the substantially higher occurrence of osteoporosis, which of course increases the likelihood of bone-fracture even from an otherwise insignificant-seeming accidental fall. Older adults also have difficulty dealing with certain conditions which would not pose such a significant burden on the system of a younger person -- in this case, relatively minor infections or overall dehydration can, in an older adult, increase the likelihood of low blood pressure, again affecting balance or causing the patient to become faint. In terms of cognitive function, the older adult is vastly more prone than a younger adult to the experience of acute confusion or delirium as a condition concomitant with other illness: in particular, such delirium is particularly common among hospital inpatients, but is under-diagnosed and seldom receives proper medical care which recognizes the seriousness of the condition (Oliver 2007, p. 174).

The third issue to consider are those medical causes which may increase likelihood of accidental falls. In this aspect, it is important to recognize that the hospitalized older adult is already in a weakened position and may therefore be entirely more susceptible to factors related to medical care that might increase the risk of an accidental fall. Here, the effect of any additional illness, or the effects of pharmacological treatment, or any additional environmental factor is likely to be magnified due to the age and condition of the patient -- indeed simple illness might very well immobilize an older patient where it would not have any such effect with a younger one. The difficulty here is that such impairment of ability in the older adult may ultimately be misdiagnosed, with Oliver (2007) noting that frequently a patient can be given "completely inappropriately a 'social admission' or 'acopia'," when the condition should indeed be recognized as a real -- if not obvious -- medical condition like any other, requiring actual diagnosis and actual treatment (p.174). In particular, there are a number of medical conditions -- Parkinson's disease, stroke -- that can manifest themselves in terms of ambulatory unsteadiness or weakness of the muscles, and that can exacerbate the likelihood of an accidental fall. Other medical conditions -- such as the postural hypotension extremely common in the older adult, or additional cardiac rhythm irregularities frequently attendant upon aging -- can cause a patient to become faint, again greatly increasing the frequency of accidental falls. The importance here is recognizing the necessity of diagnosis for these risk factors -- and indeed recognizing them as risk factors -- when considering the prospects of an older patient potentially suffering an accidental fall as a result.

The final issue that must be considered in assessing the risks for accidental falls among the older patient population is that of environmental causes of such falls. Here we confront something which is, of course, familiar to anyone working in a contemporary hospital -- these are the material facts of the hospital facility itself, and they can of course be all-important in terms of increasing the likelihood of a patient suffering an accidental fall. Oliver (2007) gives a summary of some of the basic environmental factors within a hospital itself that can contribute to the increased likelihood of an accidental fall. These include the type of flooring within the hospital, which can influence not only the likelihood of a fall (based on the slipperiness of the material involved) but also can increase the risk of fracture (based on the hardness). Environmental hazards, clutter, and spillages can also increase the likelihood of an accidental fall. Visibility -- particularly when considering the often impaired eyesight of the older population -- can also increase the likelihood of a fall, but here this includes not only the amount of lighting in an area but also the level of contrast, visually speaking, between different surface materials. When we consider the causes of accidental falls within a hospital environment -- bearing in mind here the statistic of 21% of accidental falls that were attributed, in the 2011 injury report from Barnes Jewish Hopsital, to an item being placed out of reach -- we should also be prepared to acknowledge that even furniture in a hospital room and availability of objects can have a significant impact on the likelihood of accidental falls, and the seriousness of injury sustained: this includes such matters as the height level of chairs and beds, and the ready availability of devices to assist walking (such as walkers or canes) and also call buttons. It is also worth noting that other environmental factors -- such as light level and also noise level -- can increase the level of confusion within an elderly population with risk of delirium or dementia. In such circumstances, the increased confusion may exacerbate the sense of physical agitation or restlessness, and within an unfamiliar environment and without appropriate levels of supervision and regular contact with staff, and this can easily precipitate the sort of situation which results in an accidental fall. Oliver (2007) additionally reports that in a full consideration of the overall population of inpatients within a given hospital, there will always be present certain individuals who are only prone to an accidental fall within the immediate period after admission, when they are in the immediate phase of recovery for whatever illness necessitated their hospitalization, and are consequently in a particularly unstable condition and frame of mine -- this contrasts with the separate subset of inpatients who are prone to the restlessness, wandering, mental confusion and physical ambulatory impairments (such as gait instability or balance problems) that contribute to a pattern of repeated falling. He suggests that it is worth serious consideration as to whether different intervention strategies might be required for these two identifiable subgroups within the overall inpatient population (p.175).

V. ACCIDENTAL FALL PREVENTION: LENGTH OF PROBLEM

For almost fifty years, the prevention of accidental falls among hospital inpatients has been identified as a significant area of concern and of research and inquiry for the nursing profession (Grubel 1959, p.37; Thurston 1957, p.396). The chief difficulty in approaching the problem is that all accidental falls tend to be treated alike in hospital procedures for reporting incidents: they are regarded as preventable or avoidable incidents and thus classified as "adverse events." They are, as has been noted, the most commonly recorded adverse events in the population of adult hospital inpatients. For the past twenty years, however, gerontology specialists -- in a research group spearheaded by Mary Tinnetti of Yale University -- have carried out significant amounts of research geared toward examining the overall problem of accidental falls within the community of older adults. The chief salient difficulty remaining is procedural: as yet, there is no standardized uniform consensus on the implementation of successful intervention strategies, and therefore such strategies are not as yet in place within this vulnerable community. But the changing dynamic of the health care profession itself may ultimately alter the status quo in this regard: as health care begins an overall transition toward a model of patient-centered care, and as the increasing amount of relevant research begins to offer guidance and recommendations for workable and broadly implementable intervention strategies and programs for the prevention of accidental falls, the care continuum as a whole might acquire the potential to make positive steps toward prevention of accidental falls and their attendant injuries. But it is incumbent upon us to recognize that there is, at present, a significant gap between what is currently happening in this field and what the overall desired state might be.

It is here that the question of desired results becomes most important. Within the context of addressing the specific issue of accidental falls among the older patient population, it is necessary to acknowledge the conflicting motivations which have led to the present impasse. As Oliver (2007) argues, it is an important aspect of the hospital experience that patients are, overall, being encouraged to regain their independence, while seeing their own sense of personal autonomy both fostered and respected -- an important aspect of this is personal mobility, and getting a patient up on his or her feet before being discharged from the hospital is a good worth pursuing and probably a necessity, psychologically and institutionally as well. All of this is undeniable, but it does raise the additional difficulty that contributes to certain undesirable aspects of the present state of affairs -- chiefly it enables the mindset which states that accidental falls are inevitable, and that they are bound to occur as part of this process of rehabilitation for the older patient population. The conventional wisdom seems to be that a hospital unit which records no accidental falls is a hospital unit where rehabilitation strategies are not being pursued and implemented aggressively enough, and where an excessively custodial ethic toward the older patient population is being allowed to prevail. Oliver (2007) argues persuasively that this custodial ethic is likely to substantially infringe upon patient autonomy -- whether considered as a personal right, or as a necessity for maximizing the effectiveness of a hospital stay and abnormally inflating the patient's psychological dependence upon the level of supervision provided -- and possibly also to inhibit a swift and effective recovery. Nonetheless, even within the context of acknowledging the desirability of avoiding too great a custodial approach to the relevant patient population, it is possible to state firmly that much more can be done to modify and lessen the level of risk, and to establish a hierarchy whereby some accidental falls can be deemed more or less preventable and unnecessary than others. A further difficulty in addressing the overall problem is recorded by Krauss et al. (2008), who note a significant gap in the existing literature on the topic -- studies dealing with the prevention of accidental falls frequently do not report the degree of staff compliance with the intervention strategies during the time period under examination, nor do they extend that time period significantly enough to be able to observe rates of change and therefore possible improvement in response to those intervention strategies (p.544). Krauss et al. (2008) go on to discuss the difficulty in determining why some multifaceted programs are ultimately seen to be more successful than others, but their basic conclusion is simple: according to both their experience and the hypotheses laid out in their survey of data from the Barnes Jewish Hospital study, they argue that a simplified and standardized approach to the problem, including buy-ins from staff, a strong leadership strategy and institutional support are the most important overall factors (p.544).

Nevertheless, the existing body of research on this subject is ultimately not large enough yet to enable us to state with certainty what specific strategies are most effective and should be endorsed. To a certain degree, this is related to the most basic question of the wide variety of circumstances which enable accidental falls to happen, despite our own tendency to assume that the aetiology of accidental falls is relatively simplistic or usually more or less the same. Hitcho et al. (2004) note that previous literature on the subject has tended to emphasize those falls that occurred when patients were getting out of bed -- as though this were the only or even the primary circumstance under which an accidental fall could occur -- the results of their data concluded that "the most common activity performed at the time of the fall was ambulation" which contradicts the earlier accounts (p.735). They record that the majority of these cases involved patients who were walking unassisted, but they note that 25% of the patients they surveyed would employ an ambulatory aid when they were at home, while only three individuals (among a population of 183 studied, who had suffered an accidental fall during the survey period) were actually using one in the hospital at the time of the fall (p. 737). This is merely one example whereby it becomes evident that, in many cases, the assumptions being made are not only unwarranted but may in fact be contributing to the problem overall. However we need to be cautious about drawing too many conclusions from any one simple example along these lines. Oliver (2007) argues that it is, ultimately, a rarity for any accidental fall to have one single simple explanation, and encourages us to see the phenomenon as the result of "synergistic interactions between frailty, long-term medical illness, medications, the person's own behaviour, and environmental hazards" (p.174). This explanation necessitates a more holistic approach to understanding the problem, and indeed to collecting data and drawing conclusions from it. In the case of the suggestive findings by Hitcho et al. (2004) regarding ambulatory ability and the use (or absence) of devices for assistance, their own study concludes that the relative inability to supply patients with an adequate number of such devices was only part of the larger question of institutional obstacles toward implementing larger prevention tactics -- these include the behavior of the patients themselves (such as not calling a nurse after suffering an accidental fall, due to an unwillingness to admit or a refusal to believe that help was required).

VI. ACCIDENTAL FALL PREVENTION: OBJECTIVES OF STUDY

The goals and objectives of our own study here are intertwined with the recognition throughout the existing literature of the need for more data and greater understanding, in addition to the desire for pursuing an implementable scheme of accidental fall prevention measures. Here, the notion of structural obstacles within the institution becomes important, and necessitates in our opinion the presence of an institutional fall team leader/"fall champion" to coordinate response to the issue among the personnel. From this perspective, then, the first priority must be to survey and assess the existing proposals and strategies for prevention, looking at the fall measures/interventions described in the extant literature. Krauss et al. (2005) place a serious emphasis on the idea that fall prevention strategies should be intrinsically related to the characteristics of that subgroup within the patient population who are inclined to fall, thereby leading to an increased emphasis on the specific patient-related reasons that preciptate the fall, within a larger examination of the circumstances surrounding these falls. From their standpoint, our intervention or prevention strategies should concentrate on providing the patient population with mobilization on schedule, occurring frequently and with supervision or assistance where necessary; as a part of that assistance, this includes ambulatory aids for those with deficits in gait or balance, or weakness or other physical difficulty with the lower extremities. This emphasis on scheduling can also be expanded, leading to further strategies that could be employed and studied, such as the use of toileting schedules for patients who have problems with incontinence, and an increased monitoring and potential adjustment of medication levels with those patients who are using medications that have been statistically correlated with an increased incidence of accidental falls.

Overall, this greater emphasis on actually implementing strategies for prevention of accidentall falls is a primary goal of any institutional intervention. But this entails a closer and detailed examination of environmental factors within the hospital itself, including a full assessment of existing safety concerns on wards including visibility and lighting, guardrails, handrails, grab-rails and the like, and the number of available bathrooms and toilet facilities with a close attention to their accessibility and "user-friendlienss" for the older population under survey, especially as this population becomes increasingly the core demographic that will be using hospital facilities overall. The general demographic trend here should, of course, be the most basic indicator that if the care provided to the older population in general can be improved, then the rates of accidental falls (which occur predominantly among this population) will perforce go down. Public policy statements such as the 2001 National Service Framework for Older People, and the recapitulation of its chief goals and conclusions within the more recent statement New Ambition for Old Age, make it a clear priority that older people throughout the hospital system within any part of it should be cared for by staff who have the right relevant training, skills and experience. Sadly, observational experience has made it evident that these goals and priorities are far from being realized in many institutions, and even some extremely common age-related complaints which can relate to accidental falls, issues such as delirium or incontinence, are not handled by staff with the relevant level of recognition, or the appropriate skills for coping with a problem that better relevant education might have taught them to expect and understand.

Oliver (2007) offers the relatively sensible suggestion that an initial screening should be required upon admission, which would assess all the relevant factors that predispose a patient to accidental falls, with a specific recommendation for care provided in the case of each separate factor (p.177). With such a strategy in place, he argues, any accidental fall that does occur can be the occasion for a serious examination and reassessment of levels of risk, and the implementation of renewed or revised strategies to minimize the possibility of future occurrences. Here it is worth noting that the use of the tools of risk assessment are not in and of themselves a strategy for intervention, and may lead to approaches of doubtful value -- instead these need to be employed under the supervision of a dedicated team leader or "falls champion" who can utilize the techniques of risk assessment within the proper context of pursuing and implementing overall intervention strategies. But this individual needs to bear in mind a number of different strategies here, including basic strategies of education and training, raising awareness of the issues involved with accidental falls, and sound policy based on specific evidence of what takes place within hospital units. There is no simple and easy solution that can be imposed from without, rather the real necessity lies in making a large-scale effort to learn from hospital incident reporting and applying what has been learned to actual practice. Even here, though, the level of information may be compromised by neglecting relevant factors. Krauss et al. (2008) note that many hospitals do not think it necessary to monitor or report upon whether staff are following recommendations or policies implemented as part of an accidental-fall-related intervention (p.544). Yet this lack of compliance can have a profound effect on the causes and therefore incidence of accidental falls. Insufficient compliance can, it must be conceded, stem from any number of factors: a high turnover among staff, insufficient numbers of nurses, overwork or increasingly complicated demands placed upon nursing staff in addition to the new demands imposed by the accidental fall intervention plan, or the absence of buy-in from those caregivers dealing directly with the patient population. In this sense, the compliance of staff might be viewed as the chief priority of the team leader or "falls champion" who organizes policy in this area -- the goals and objectives of education and consciousness-raising related to this issue are paramount. In short, the objectives are to have sound measures and interventions with fall risk assessment tools and strategies; the goal is that those objectives have staying power and are implemented to the best of the best that is possible in the long-term through the continued awareness and motivation of our falls team leader/"falls champion" approach.

VII. Short- and Long-TERM GOALS

The primary goal here is simple and easily defined: achieving a sustainable reduction in falls and fall injury by utilizing fall measures and interventions via a fall team leader/"falls champion." To achieve this goal, a collective group comprised of various members of the hospital staff will help draw up an outline of educational and practical application designed to be utilized in chief by the fall team leader. While education/teaching models are being implemented, the hospital staff will maintain their current protocol for fall prevention. Fall prevention measures and intervention may be adjusted slightly in the long-term, based on evidence acquired; in the short-term, the stage must be set for fall measures and interventions to be orchestrated under a fall team leader/"falls champion." In the 2008 Krauss study, it was concluded that a noticeable short-term reduction in fall rates could be achieved merely with a raised awareness of the issue and the use of specific simple strategies, however, as is customary with such research-studies, the Hawthorne effect (in which the presence of researchers within the hospital environment is, in itself, a chief cause of the observed results) may have been responsible for such pronounced improvement. The same study noted that the short-term results did not ultimately translate into a long-term decline in the number or frequency of accidental falls, demonstrating that even the most carefully designed and implemented approaches to the problem may fail in the absence of a permanent designated leader or "champion" for the problem, in charge of the overall direction and motivation required to achieve some kind of measurable results in accidental fall reduction. But the presence of a designated individual seems to be a crucial factor: it is from this vantage that other critical components of any successful approach, including standardized techniques, buy-in from hospital staff, and generalized leadership on the issue, can be orchestrated. This corresponds ultimately with the results recorded by Wexler et al. (2011) where a reduction in the rate of accidental falls -- from 2.79 incidents per thousand patient days to 2.72 incidents per thousand patient days -- seems to have been accomplished primarily by a team-based strategy, utilizing an accidental falls prevention committee helmed by an RN serving as "falls champion." In their survey of data, the presence of teams with a designated champion were essential for keeping staff informed overall of the prevention measures proposed and implemented, and also removed the burden of preventive measures from the judgment of individual members of the nursing staff, making indiividuals the chief responsible party for prevention.

VIII. ACCIDENTAL FALL PREVENTION: BUY-IN STRATEGIES

Buy-in from members of hospital staff is obviously an essential part of any larger viable strategy for reducing the number of accidental falls. It is the nurses and to a lesser degree the other technicians involved with patient care who are in the best position to implement and facilitate success for any prevention strategy. Similarly in terms of the collection of data relevant to improving results, the secretarial staff for any given hospital unit should be included in this core of those who are most closely involved with patient care. However, buy-in is not only advantageous in terms of these nurses and technicians, but should also be extended to therapists (both physical and occupational), hospital nurse-educators, nurse practitioners, physician assistants, and physicians as an ancillary staff to that primary core of personnel comprised of the nurses, patient care technicians, and unit secretaries.

In terms of buy-in strategy, the program should be most likely be presented to personnel in terms of the basic belief that preventing accidental falls is ultimately a concern for everyone who works in a hospital, and that everyone can and should play a positive role in implementing prevention strategies. Krauss et al. (2008) notes that self-evaluation can be a useful goal for personnel in and of itself, and therefore it is possible to distribute pre-intervention evaluation tests as well as self-study modules before implementing any sort of strategy -- to a certain extent this process can be used as part of the strategy for educating and selling the revised protocol for prevention. This would enable a natural progression into evaluating existing protocols for fall prevention, and staff could feel invested in the implementation of policy, including risk assessment conducted on a daily basis, regular review of prevention strategy including review with patients and their families, and physical improvements (such as lighting, clearance of obstructions, or the posting of signage related to fall prevention). Strategies to obtain buy-in would include all of the above, while also appealing to staff with the results of prior studies already performed at other hospitals, demonstrating how a team approach with a designated "falls champion" can ultimately have positive tangible effects.

X. ACCIDENTAL FALL PREVENTION: PROCESS MAP

The process begins with the admission to the floor and ends with the discharge to home. Within this time frame, orientation with regards to the floor and equipment is very important as well as using fall assessments to help decide what fall interventions are best for that particular patient.

The process starts with the admission to the floor, which in our case is the cardiac floor, and does not stop until the patient is safely discharged home. The output of the process consists of anything that includes fall prevention measures. These measures can consist of the following: fall bracelet, bed/chair alarm, frequent toileting, sitter consideration, side rails are up (max up times 3), room close to the nurses station, and frequent rounding on the patients. The customers for this process are the patients admitted to our floor that are 65 or older with cardiac medical problems.

Within this process, the falls "champion" or leader will be able to contribute the most time and resources because they will be able to focus only on the prevention of falls. But, every team member of the patient care team -- such as the registered nurses, patient care techs, PT, OT, etc. -- will have to contribute to the implementation of fall prevention. If needed, the care team can use the charge nurse or team leader for any extra supplies or voice concerns regarding staffing issues. The inputs to the process start at the admission and also include bed management, nursing/aid staffing, availablility of PT/OT timely evaluation, availability of the MD or pharmacist, availability of equipment such as walkers or low beds, environmental safety, and ongoing training of nursing and allied staff.

XI. ACCIDENTAL FALL PREVENTION: PROPOSED DATA COLLECTION

To pursue this overall strategy, a detailed data collection tool would be necessary to identify all factors which might possibly contribute to accidental falls and their related injuries. In this case, necessary statistics would include not just individual patient information, but overall demographic data for the relevant patient population, as well as information on diagnosis, any variables related to health status, the mental condition of any given patient at the time a fall occurred, the medication levels taken within a 24-hour period prior to a fall, the level of assessed risk for falling established by a nurse at the time of admission, and all fall prevention measures that were in place when the fall occurred. Further incident details would be required including the date and time of any accidental fall, the location, how it was discovered and whether it was observed, what type of assistance was provided, what activity was being performed by the patient at the time of the incident, the patient's reason for that activity, what type of accidental fall occurred, the mechanisms, and a full list of all possible contributing factors, including the amount of staff on duty at the time, the location and use of call-lights, the position of side-rails and of the bed, whether any furniture or equipment (such as an ambulatory assistance device) was in use at the time ht efall occurred, the condition of the floor including any problems observed, the condition of the patient's footwear and its suitability, the visibility level, and further information where appropriate about the condition of the bathroom, exit alarm, patient restraints (whether such were ordered or in place), presence and use of commode, and presence of Foley catheter. Required reporting would also necessarily include the actions taken after the fall, an assessment of any injury and its severity, information as to the extent prevention measures were put in place after the incident, and anything else that might be deemed relevant to a full statistical documentation of the incident.

This data is, of course, necessary to return with a renewed approach for fall prevention in the wake of actual recorded incidents. Because one of the most crucial elements of any prevention strategy must always be education, this data would assist nurses and staff in raising awareness among the patient population regarding prevention measures, as well as helping staff to make positive safety modifications within an individual patient's environment. If the risk of a fall is assessed as being high, with the use of a modified Morse Fall Scale, then nurses would also be instructed to put in place additional prevention measures, including informing all staff as to the increased risk associated with that patient (including visible identification with a green armband on the patient's arm or a green prevention sign placed above the bed or on the door, and a written list of patient's mobility issues on the dry-erase board, as well as verbal communication of the patient's risk level at all changes of shift). These measures can be the responsibility of the designated falls "champion" although in the actual environment other staff could certainly be placed to double-check and ensure high safety levels are in place. The educational approach would also review and reinforce all teaching on fall prevention with both the patient and the family. A fixed toileting schedule (occurring every 2 hours during day, and every 4 hours at night) which could double as a "safety rounds" would be implemented. A review of medications as possible contributing factors to patient's fall risk would be conducted for the purpose of informing patients and family about the specific effects of the medications involved, with reference to the increased risk of accidental falls. Finally, doctors could be aksed to order consultation on physical or occupational therapy, or to assess the need of those patients with increased fall risk as to the suitability of a walking-aid in hospital, especially if the patient in question uses one at home. Once these measure were in place, the staff could choose from a myriad of other fall prevention strategies, including the use of bed alarms or a low bed and floor mat, the placement of the patient at risk in a room closer to the nurses' station, and the stated request that family members sit with the patient.

XII. ACCIDENTAL FALL PREVENTION: ANALYSIS

Analysis of the data on accidental falls is of paramount importance in the quest to find a workable solution that can decrease the number of accidental falls in any given hospital. In particular, the specific concerns regarding the accidental falls of hospitalized individuals over 65 with cardiac problems must be taken into account, since there is an overwhelming number of the total accidental falls occurring within this age group alone on the cardiac floor at Barnes Jewish Hospital in studies conducted there. In our given case, there were many identifiable causes of the accidental falls of hospitalized individuals that needed to be examined and analyzed to propose eventually the best overall solution for the problem identified. The data that was analyzed throughout this quality-improvement project is necessarily all quantitative and retrospective in nature. Prior to beginning the process of analysis, the hypothesis was proposed that the incidence of accidental falls would decrease when adequate fall-related precautions -- such as low beds, inclusion of bed alarms, fitting patients with wrist band, increased frequency of rounds by hospital staff, etc. -- were all implemented with an accidental fall "team leader" or "champion" included on the shift. The analytic section of the quality-improvement project is therefore conducted with this hypothesis in mind.

The first step to analyzing the data on accidental falls is to compile the data of the number of falls specific to the population indicated, i.e. hospitalized patients over 65 years with cardiac issues. Gathering and organizing the data is the most significant aspect of the analytic process, then, when considering accidental falls in order to reach the set goal. To collect the numerical information on accidental falls necessitated the implementation of a specific and easy-to-use database for all staff members to enter the relevant information in the wake of an accidental fall, in addition to using the existing methods of electronic medical records and nurse/patient interviews. Using this combination of data collection methods allows for examination of all the circumstances of the accidental falls, as recommended by Krauss et al. (2005). The data base will therefore require easy-to-access cues including all relevant demographic information on the patient, pre-fall prevention intervention strategies, possible causes and post-fall prevention interventions -- all of which will, thanks to the design of the database, ideally take less than five minutes for a health care provider to fill out.

Many risk factors and circumstances of falls such as environment of fall, activity at time of fall, assistance, orthostatic hypotension, call light activity, footwear, equipment, dizziness, increased age and medications to name a few have been found to be associated with an increased risk for falls (Krauss et all, 2005). To avoid duplicates in our database, the program will merge entries with the same fall time and patient demographics. This information can be easily organized in a table with the patient demographics and the fall rates. After reviewing the information entered into the data base we will use the patient's medical record and interviews to fill in the gaps if needed. From this data, we will be able to total up the number of falls and limit it to the patients over sixty-five with cardiac disorders. By having straight to the point, objective choices on the data base forum, the time constraint placed on nurses will not be a problem. This data base to collect our data on falls will be the key to determine the relationship with falls and patients over 65 years of age with a cardiac background.

From this vast amount of information included in the database, we can narrow our focus to examine information that pertains to our specific population. To find the percentage of falls that happen in hospitalized patients over six-five years of age with cardiac problems we will take this number and divide it by the total number of falls reported in the database. This creates a baseline to see the prevalence of falls in older adults with cardiac complications. To display the patient demographics, we will present the data in a table showing the percentage of falls in a specific category next to each demographic. The demographics will be things like age, sex, BMI, mental status, fall risk assessment score, impaired memory and history of falls (Hitcho et al., 2005). Next, we must sift through the information to look at the other possible variables effecting the fall such as call lights, activity at time of fall, time of fall, assistance at time of fall, high risk medications, low bed, sitter, hourly rounded or a combination of a few. Each of these common causes of falls will be an option on our database to make the grouping of information easier. To easily display this information of causing factors to the fall, we will organize the information in a pie chart. This will serve as a visual aid to see which factors cause the most falls in our patient population of interest. The total population of the pie chart will be patients with falls over 65 and cardiac disorders. Each slice of the pie will have fall that occurred with each variable in place such as call light used, high risk medications, assisted fall, etc. Visualizing our data on why the fall occurred allows the information to speak for itself.

After analyzing the data on the possible causes of the falls, we will analyze the information regarding pre- and post- fall interventions to avoid the fall. Looking at the steps the health care teams were taking prior to the fall is a good predictor of the likelihood of the fall. If the staff was taking many preventative interventions, such as hourly rounds, patient's items in reach, call light in reach, bed alarm being used, footwear, the likelihood of a fall would decrease and vice versa. To better display this information is an easy to understand manner, a bar graph comparing the number of falls in our target population (on the y-axis) to the fall intervention(s) would be used prior to fall (on the x-axis). Another bar graph would be used to compare the number of interventions used post fall (x-axis) to the number of falls (y-axis) in hospitalized patients over the age of 65 years with cardiac issues. This graph will show the more interventions used to prevent the fall resulted in less falls occurring (Hitcho et al., 2005). The greatest thing to realized regarding post-fall interventions is that after a fall the healthcare team always realizes more interventions need to be taken to avoid a fall. If these interventions were taken in the first place, the likelihood of the fall occurring would be greatly decreased.

Falls place a great financial burden on the hospital and continue to be a consistent problem in the institution (Hitcho et al., 2005). Many of the fall tactics to prevent falls require a very low monetary investment for the hospital compared to the fall its self. Simple things like putting the side rails up can effectively decrease the occurrence of falls if used correctly (Krauss et al., 2005). A fall in the hospital brings about fall injuries, increased length of stay, malpractice lawsuits in addition to 4,000 dollars more in charges per hospitalization. This can total a great amount of money the hospital must dispense after a fall, especially when an individual has a 3-20% chance of falling on each admission. These results in numbers in dollars make it easy for individuals running a hospital to see the importance of preventing inpatient falls.

Falls occur in the hospital for a combination of reasons. The hospital is a new, unfamiliar place for the patients. There are many obstacles such as cords, equipment, and attachments that can get in the way in trying to move around in the room. Medications that are given in the hospital are usually new for the patient and can have different reactions on the patient (Krauss et al., 2005). When an individual enters the hospital they give up much of their freedom and want to do as much as they still can individually. Many individuals feel that walking is something they can do without assistance and do not ask for help. Some patients are the opposite and call for help, but do not receive help in a timely manner so attempt to move about without assistance. The patient could also get the sense that the health care provider is too busy to assist them to the restroom and choose to do it alone. The majority of the time the patients in the hospital are weak due to a procedure, surgery or health intervention and do not realize it until they get up out of bed and it is too late. Due to a medical condition such as stroke or heart attack, the patient could have some physical changes that could increase the risk of a fall. Falls can also occur in the hospital due to an alternation in the patient's mental state. The patients can be confused or non-compliant with the health care team's instructions. Patients in the hospital have a combination of all these risk factors that contribute to falls.