Inpatient Fall Prevention: Programs, Risk Factors & EBP

Introduction to Inpatient Fall Prevention

Inpatient falls constitute a major clinical, supervisory, and legal issue, though relatively little information exists on the subject of successful fall reduction strategies (Rosenthal, 2007). The Centers for Medicare and Medicaid Services (CMS) has ceased to reimburse healthcare facilities for traumatic inpatient falls. With the continued aging of the American population, preventing falls has become more important than ever before. Elderly and physically weakened patients represent a greater risk of falling, with potentially more serious consequences.

Fall prevention within the nation's acute care facilities gives rise to distinctive challenges, given that it involves severely ill patients with an average hospital stay of only 4.9 days. This compressed acuity increases healthcare practitioners' burden to ensure patient safety. Consequently, fall prevention intervention results from long-term patient care organizations may not be applicable to facilities providing acute care. Likewise, international results may not be generalizable to the American context, as international hospitalization durations tend to be longer.

Fall prevention initiatives are generally multifaceted and involve a number of elements dependent on leader participation and multidisciplinary frontline employee cooperation. Initiatives may require sound monitoring plans to ensure hospital employees abide by established patient care protocols (Hampel et al., 2013).

Classifying Falls and Risk Factors

To facilitate identification of patients' fall risk factors and to guide fall prevention initiatives within the acute care context, falls are generally classified into three categories: expected physiologic falls, accidental falls, or unexpected physiologic falls. Risk factors are also grouped as either extrinsic or intrinsic. Intrinsic risk factors include the following:

Extrinsic factors — those with external origins — include physical environmental conditions such as inadequate lighting, slippery floors caused by spills, irregular thresholds, or cluttered walkways (American Nurse Today, 2015).

Implementation of a Falls Prevention Program

A complex, multidisciplinary strategy was adopted for formulating and applying a falls prevention initiative in 2004. First, baseline information was gathered and studied to determine the magnitude of the problem. The findings were communicated to every team member; team members then relied on their individual clinical networks to create initiative awareness among remaining staff. The initiative was policy-driven in nature, aligned with the 2003 WADOH (Western Australian Department of Health) Fall Prevention Policy. The policy's publication prompted the creation of a healthcare organizational Falls Risk Management Policy.

The subsequent step involved creating and implementing an official post-fall evaluation procedure, determined through group consensus. Normally, risk evaluation involves admission screening for established risks, focusing on patient mobility and psychological status in relation to age, post-surgical condition, or medications administered (McCarter-Bayer et al., 2005; Zdobysz et al., 2005). However, despite this risk awareness, a large number of risk evaluation instruments have proven imprecise or shown limited effectiveness due to the variability across different factors and units — such as new recruits, occupancy rates, and patient acuity.

In this context, it was essential to develop a risk evaluation instrument based on local knowledge of patient flow, the physical layout of the healthcare facility, available resources (including working relationships among fall prevention team members), and environmental elements. This facilitated contextualization of the initiative to the specific setting while enhancing inter- and intra-disciplinary communication — an outcome not always easily achievable within larger hospital settings (Woloshynowych, Rogers, Taylor-Adams, & Vincent, 2005).

The CFR (Clinical Fall Review) evaluation form was developed using contributions from every team member. It helps hospital staff reevaluate the range of possible causes and, where relevant, prompts referrals to allied health services or pharmacy. Causative factor evaluation includes: patient mobility and manual handling needs; clinical elements such as diagnostic tests and urinalysis; fall risk factors (including hazardous footwear); environmental elements (including height-adjustable beds and bedrails where appropriate, and the concentration of obstacles in patient bathrooms and bedrooms); and pharmacological elements (initiation of hypnotic or opioid medications, multiple drug alterations since hospitalization, or polypharmacy). Revisions to nurse care plans to reflect falls evaluation data provided clinical staff with updated prompts to remain aware of changing care requirements.

Since the initiative's introduction in 2004, the CFR evaluation form is completed following any in-hospital fall event and subsequently forwarded to Risk and Quality Management Coordinators for processing, along with the fall incident/accident form. This form is added to the patient's clinical record for future reference (McKinley et al., 2007).

A second key step involves the development of a flagging system, in which every fall-risk patient has a fall risk reminder added to his or her EPMS (electronic patient management system) record. Colorful laminated reminder cards are also added to the front covers of patient medical records to flag risk status. Additionally, a notification system was developed to alert pharmacists of patient falls and prompt a review of prescribed and administered medications. Pharmacist recommendations are added to patient health records for physician and nurse review. The alerts remain active during patient discharge and are visible upon re-hospitalization, ensuring that staff immediately become aware of a patient's prior fall risk history (McKinley et al., 2007).

References

Aiken, L. (2005). Improving quality through nursing. In D. Mechanic, D. L. Rogut, D. Colby, & J. Knickman (Eds.), Policy challenges in modern health care (pp. 177). New Brunswick: Rutgers University Press.

American Nurse Today. (2015). Focus on falls prevention. Retrieved from

Hampel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., … Ganz, D. (2013). Hospital fall prevention: A systematic review of implementation, components, adherence, and effectiveness. Journal of the American Geriatrics Society, 61(4), 483–494. doi:10.1111/jgs.12169

McCarter-Bayer, A., Bayer, F., & Hall, K. (2005). Preventing falls in acute care. Journal of Gerontological Nursing, 31(3), 25–33.

McKinley, C., Fletcher, A., Biggins, A., McMurray, A., Birtwhistle, S., Gardiner, L., … Lockhart, J. (2007). Evidence-based management practice: Reducing falls in hospital. Collegian, 14(2). Retrieved from https://www.collegianjournal.com/article/S1322-7696(08)60551-X/pdf

Rosenthal, M. B. (2007). Nonpayment for performance? Medicare's new reimbursement rule. New England Journal of Medicine, 357, 1573–1575.

Western Australia Department of Health. (2003). Falls Prevention Policy. Perth: WADOH.

Woloshynowych, M., Rogers, S., Taylor-Adams, S., & Vincent, C. (2005). The investigation and analysis of critical incidents and adverse events in healthcare. Health Technology Assessment, 9(19).

Zdobysz, J., Boradia, P., Ennis, J., & Miller, J. (2005). The relationship between functional independence scores on admission and patient falls after stroke. Stroke Rehabilitation, 12(2), 65–71.