Eileen Costantinou

Characteristics and Circumstances of Falls in a Hospital Setting: A Prospective Analysis

OBJECTIVE: To describe the epidemiology of hospital inpatient falls, including characteristics of patients who fall, circumstances of falls, and fall-related injuries.DESIGN: Prospective descriptive study of inpatient falls. Data on patient characteristics, fall circumstances, and injury were collected through interviews with patients and/or nurses and review of adverse event reports and medical records. Fall rates and nurse staffing levels were compared by service.SETTING: A 1,300-bed urban academic hospital over 13 weeks.PATIENTS: All inpatient falls reported for medicine, cardiology, neurology, orthopedics, surgery, oncology, and women and infants services during the study period were included. Falls in the psychiatry service and falls during physical therapy sessions were excluded.MEASUREMENTS AND MAIN RESULTS: A total of 183 patients fell during the study period. The average age of patients who fell was 63.4 years (range 17 to 96). Many falls were unassisted (79%) and occurred in the patient’s room (85%), during the evening/overnight (59%), and during ambulation (19%). Half of the falls (50%) were elimination related, which was more common in patients over 65 years old (83% vs 48%; P<.001). Elimination-related falls increased the risk of fall-related injury (adjusted odds ratio, 2.4; 95% confidence interval 1.1 to 5.3). The medicine and neurology services had the highest fall rates (both were 6.12 falls per 1,000 patient-days), and the highest patient to nurse ratios (6.5 and 5.3, respectively).CONCLUSIONS: Falls in the hospital affect young as well as older patients, are often unassisted, and involve elimination-related activities. Further studies are necessary to prevent hospital falls and reduce fall injury rates.

A Case‐control Study of Patient, Medication, and Care‐related Risk Factors for Inpatient Falls

AbstractOBJECTIVE: To comprehensively analyze potential risk factors for falling in the hospital and describe the circumstances surrounding falls. DESIGN: Case-control study. Data on potential risk factors and circumstances of the falls were collected via interviews with patients and/or nurses and review of adverse event reports, medical records, and nurse staffing records. SETTING: Large urban academic hospital. PATIENTS: Ninety-eight inpatients who fell and 318 controls matched on approximate length of stay until the index fall. MEASUREMENTS AND MAIN RESULTS: In a multivariate model of patient-related, medication, and care-related variables, factors that were significantly associated with an increased risk of falling included: gait/balance deficit or lower extremity problem (adjusted odds ratio [aOR], 9.0; 95% confidence interval [CI], 2.0 to 41.0), confusion (aOR, 3.6; 95% CI, 1.6 to 8.4), use of sedatives/hypnotics (aOR, 4.3; 95% CI, 1.6 to 11.5), use of diabetes medications (aOR, 3.2; 95% CI, 1.3 to 7.9), increasing patient-to-nurse ratio (aOR, 1.6; 95% CI, 1.2 to 2.0), and activity level of “up with assistance” compared with “bathroom privileges” (aOR, 8.7; 95% CI, 2.3 to 32.7). Urinary or stool frequency or incontinence was of borderline significance (aOR, 2.3; 95% CI, 0.99 to 5.6). Having one or more side rails raised was associated with a decreased risk of falling (aOR, 0.006; 95% CI, 0.001 to 0.024). CONCLUSIONS: Patient health status, especially abnormal gait or lower extremity problems, medications, as well as care-related factors, increase the risk of falling. Fall prevention programs should target patients with these risk factors and consider using frequently scheduled mobilization and toileting, and minimizing use of medications related to falling.

Patterns and predictors of inpatient falls and fall-related injuries in a large academic hospital

OBJECTIVES Most research on hospital falls has focused on predictors of falling, whereas less is known about predictors of serious fall-related injury. Our objectives were to characterize inpatients who fall and to determine predictors of serious fall-related injury. METHODS We performed a retrospective observational study of 1,082 patients who fell (1,235 falls) during January 2001 to June 2002 at an urban academic hospital. Multivariate analysis of potential risk factors for serious fall-related injury (vs no or minor injury) included in the hospitals adverse event reporting database was conducted with logistic regression to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CI95) RESULTS The median age of patients who fell was 62 years (interquartile range, 49-77 years), 50% were women, and 20% were confused. The hospital fall rate was 3.1 falls per 1,000 patient-days, which varied by service from 0.86 (women and infants) to 6.36 (oncology). Some (6.1%) of the falls resulted in serious injury, ranging by service from 3.1% (women and infants) to 10.9% (psychiatry). The most common serious fall-related injuries were bleeding or laceration (53.6%), fracture or dislocation (15.9%), and hematoma or contusion (13%). Patients 75 years or older (aOR, 3.2; CI95, 1.3-8.1) and those on the geriatric psychiatry floor (aOR, 2.8; CI95, 1.3-6.0) were more likely to sustain serious fall-related injuries. CONCLUSIONS There is considerable variation in fall rates and fall-related injury percentages by service. More detailed studies should be conducted by floor or service to identify predictors of serious fall-related injury so that targeted interventions can be developed to reduce them.

Circumstances of patient falls and injuries in 9 hospitals in a midwestern healthcare system.

OBJECTIVE Preventing hospital falls and injuries requires knowledge of fall and injury circumstances. Our objectives were to determine whether reported fall circumstances differ among hospitals and to identify predictors of fall-related injury. DESIGN Retrospective cohort study. Adverse event data on falls were compared according to hospital characteristics. Logistic regression was used to determine adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for risk factors for fall-related injury. SETTING Nine hospitals in a Midwestern healthcare system. PATIENTS Inpatients who fell during 2001-2003. RESULTS The 9 hospitals reported 8,974 falls that occurred in patient care areas, involving 7,082 patients; 7,082 falls were included in our analysis. Assisted falls (which accounted for 13.3% of falls in the academic hospital and 9.8% of falls in the nonacademic hospitals; P<.001) and serious fall-related injuries (which accounted for 3.7% of fall-related injuries in the academic hospital and 2.2% of fall-related injuries in the nonacademic hospitals; P<.001) differed by hospital type. In multivariate analysis for the academic hospital, increased age (aOR, 1.006 [95% CI, 1.000-1.012]), falls in locations other than patient rooms (aOR, 1.53 [95% CI, 1.03-2.27]), and unassisted falls (aOR, 1.70 [95% CI, 1.23-2.36]) were associated with increased injury risk. Altered mental status was associated with a decreased injury risk (aOR, 0.72 [95% CI, 0.58-0.89]). In multivariate analysis for the nonacademic hospitals, increased age (aOR, 1.007 [95% CI, 1.002-1.013]), falls in the bathroom (aOR, 1.46 [95% CI, 1.06-2.01]), and unassisted falls (aOR, 1.83 [95% CI, 1.37-2.43]) were associated with injury. Female sex (aOR, 0.83 [95% CI, 0.71-0.97]) was associated with a decreased risk of injury. CONCLUSION Some fall characteristics differed by hospital type. Further research is necessary to determine whether differences reflect true differences or merely differences in reporting practices. Fall prevention programs should target falls involving older patients, unassisted falls, and falls that occur in the patients bathroom and in patient care areas outside of the patients room to reduce injuries.

Intervention to prevent falls on the medical service in a teaching hospital.

OBJECTIVE To evaluate an intervention to prevent falls at a hospital. DESIGN A quasi-experimental intervention with historical and contemporaneous control groups. SETTING AND PARTICIPANTS Nursing staff and patients in the medicine service (comprising 2 intervention floors and 2 control floors) at an academic hospital. INTERVENTION Nursing staff were educated regarding fall prevention during the period from April through December 2005. Data on implemented prevention strategies were collected on control and intervention floors. Mean monthly fall rates were compared over time and between intervention and control floors, using repeated-measures analysis of variance. RESULTS Postintervention fall knowledge test scores for the nursing staff were greater than preintervention test scores (mean postintervention test score, 91%; mean preintervention test score, 72%; P < .001). Use of prevention strategies was greater on intervention floors than it was on control floors, including patient education via pamphlets (46% vs 15%; P < .001), use of toileting schedules (36% vs 25%; P = .016), and discussion of high-risk medications (51% vs 30%; P < .001). The mean fall rate for the first 5 months of the intervention was 43% less than that for the 9-month preintervention period for intervention floors (3.81 falls per 1,000 patient-days vs 6.64 falls per 1,000 patient-days; P = .043). Comparisons of mean rates for the overall 9-month intervention period versus the 9-month preintervention period showed a 23% difference in the fall rate for intervention floors, but this did not reach statistical significance (5.09 falls per 1,000 patient-days vs 6.64 falls per 1,000 patient-days; P = .182). CONCLUSION The nursing staffs knowledge and use of prevention strategies increased. Fall rates decreased for 5 months after the educational intervention, but the reduction was not sustained.

Patient Falls Focusing on Human Factors rather than Clinical Conditions

Falls have consistently been the largest single category of reported incidents for acute hospital in-patients. The number of falls and risk factors have been identified and reported since the 1950s and are mostly unchanged in the 2010s. The main response to patient falls has been to treat the physiological and psychological presenting symptoms and condition by providing nursing care (mostly through assessment and monitoring) to minimise risk with the patient as a passive care recipient. As over 70% of falls are un-witnessed (unassisted) the active role of the patient in falls has not been fully explored. The new model (DIAL-F) is proposed which reverses the traditional Human Factors / Ergonomics model by describing the system elements in terms of the level of flexibility or transience (duration of action/involvement). The patient is the most transient element of the system, represented as a series of personas (archetypal descriptions) to include physical, cognitive and behavioural changes. This allows a more stimulating, riskier environment described as the ‘horticultural model of care’.

Ending the Vicious Cycle of Patient Falls

Over the past two years Barnes-Jewish Hospital has used Lean and Six Sigma methodologies in process improvement projects to prevent inpatient falls and falls with injury. These intensive programs have validated that falls are a multifaceted, complex problem that need constant vigilance and continuous improvement to sustain patient safety. Falls that result in serious injury can be life-changing for patients and families as well as impact the caregivers with potentially severe financial and health consequences. Trends in fall rates after completion of two Case Studies show that while decreasing the number of falls continue to be a challenge; the severity of injury from a fall can be reduced with patient and staff collaboration.

Medications and Patient Characteristics Associated With Falling in the Hospital.

Objectives The aim of this study was to evaluate specific medications and patient characteristics as risk factors of falling in the hospital. Methods This is a case-control study comparing demographic, health, mobility, and medication data for 228 patients who fell between June 29, 2007, and November 14, 2007, at a large tertiary care hospital and 690 randomly selected control patients. Logistic regression was used to identify fall risk factors. Results Independent risk factors of falling included history of falls (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.8–4.2); needing an assistive device (OR, 3.2; 95% CI, 1.5–6.8) or person assistance (OR, 2.1; 95% CI, 1.3–3.3) to ambulate; being underweight (OR, 2.4; 95% CI, 1.2–4.7) or obese (OR, 1.6; 95% CI, 1.0–2.5); confusion (OR, 2.4; 95% CI, 1.5–4.0); dizziness (OR, 2.1; 95% CI, 1.1–4.3); incontinence (OR, 1.5; 95% CI, 1.0–2.3); and an order for a hydantoin (OR, 3.3; 95% CI, 1.3–8.0) or benzodiazepine anticonvulsant (OR, 2.2; 95% CI, 1.5–3.3), haloperidol (OR, 2.8; 95% CI, 1.2–6.8), tricyclic antidepressant (OR, 2.4; 95% CI, 1.2–4.9), or insulin (OR, 1.5; 95% CI, 1.0–2.1). Female sex (OR, 0.8; 95% CI, 0.6–1.0), proton pump inhibitors (OR, 0.6; 95% CI, 0.4–0.9), and muscle relaxants (OR, 0.4; 95% CI, 0.3–0.7) were associated with lower risk for falling. Conclusions This study identified medications and patient characteristics associated with increased risk for falling in the hospital. High-risk medications identified in this study may serve as targets for medication review or adjustment, which have been recommended as a component of multifaceted fall prevention programs.