Hospital Falls and Falls that Lead to Hospitalization The Inpatient Perspective

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Hospital Falls and Falls that Lead to
HospitalizationThe Inpatient Perspective
Ethan Cumbler MD, FACP Associate Professor of
Medicine Director UCH Acute Care For Elderly
Service University of Colorado Denver 2010
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Disclosures

• None

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Objectives

• 1 Teach actionable risk factors for falls
  leading to admission with emphasis on
  interventions which can be initiated in the
  inpatient setting
• 2 Identify strengths and weaknesses of risk
  stratification tools for the in-hospital fall
• 3 Critically appraise the quality of evidence
  for interventions to reduce falls in the acute
  care hospital

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Clinical Case 1Outpatient Fall Leading To
Admission

• PMH
• Mild Alzheimer's Dementia
• HTN
• Urge incontinence
• Depression
• Insomnia
• Medications
• Clonidine 0.1 mg bid
• Aspirin 81 mg daily
• Sertraline 50 mg daily
• Amitryptiline 50mg at night

• Gertrude is an 88 y/o woman admitted for back
  pain after a fall stepping off a curb outside her
  assisted living
• Xray demonstrates thoracic compression fracture.
• Admit for pain control, inability to ambulate.

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IMPACT

• 30-40 of people over age 65 will have a fall
  each year
• In an elderly patient who has fallen, the risk of
  having a second fall within a year rises to 60

Rao SS. Prevention of Falls in Older Patients.
AAFP 20057281-88
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Consequences

• 5-10 of community dwelling elderly who fall will
  suffer a serious injury
• Up to 20-30 of elderly patients overall
• Falls increase risk of going to nursing facility
• 3 fold increase for falls without injury
• 10 fold increase for falls with serious injury
• 8 of people gt 70 come to ER for falls each year
  
• 1/3 will be admitted

Rubenstein LZ, Josephson KR. Falls and Their
Prevention in the Elderly. Med Clin N Amer
200690807-824 Tinetti ME,et al. Falls, Injuries
Due to Falls, and the Risk of Admission to a
Nursing Home. NEJM 19973371279-84
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Injuries

• Fractures
• 1 of falls in the elderly lead to hip fx
• 20-30 mortality in the year after hip fx
• ¼ to ¾ of patients do not recover prior level of
  ADLs

Rubenstein LZ, Josephson KR. Falls and Their
Prevention in the Elderly. Med Clin N Amer
200690807-824
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Injuries

• Other Fractures
• Humerus
• Rib
• Subdural Hematoma
• Prolonged lie- half of all elderly patients who
  fall are unable to get back up
• 2o rhabdo, dehydration/ARF, pressure injury

Tinetti ME et al. Predictors and Prognosis of
Inability to Get Up after Falls among Elderly
Persons. JAMA 199316965-70
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Post Fall Anxiety SyndromeFallophobia
Self-limiting activity, worsening deconditioning,
social isolation

• Picture the geriatric fall as a node on a decline
  spiral

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• Falls are a Prototypical Geriatric Syndrome
• Multifactoral

Risk Factor Odds Ratio
Lower extremity weakness 4.4
History of falls 3.0
Gait deficit 2.9
Balance deficit 2.9
Need for assistive device 2.6
Visual defect 2.5
Arthritis 2.4
Impaired activities of daily living 2.3
Depression 2.2
Cognitive impairment 1.8
Age gt 80 years 1.7
Rubenstein LZ. Falls and Their Prevention in
Elderly People What Does the Evidence Show? Med
Clin N Am. 200690807-824 Tinetti ME, Speechley
M, Ginter SF. Risk Factors for Falls Among
Elderly Persons Living in the Community. NEJM
19883191701-8
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A Brief Diversion

• In Malcolm Gladwells book on cognition Blink,
  he describes a fascinating psychology experiment.
• A sample table is set up at two grocery stores
  for customers to try a sample of jam.
• On table has 6 varieties of jams, the other has
  24 selections.
• Which table do you think sold more jam?

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Multiple Alternatives Bias

• Table with only 6 varieties sold 10X more jam
• The reason lies in the human psyche.
• Faced by too many choices, customers freeze up
  and make no decision at all.

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A New Conceptual Framework

• Fall risk has specific components
• Latent risk for fall
• Physiologic changes of aging
• Disease and medications
• Behavioral traits
• Environmental trigger
• the accident
• Underlying frailty
• Vulnerability to injury
• EACH COMPONENT HAS CONCRETE ACTIONS TO REDUCE
  RISK OF FUTURE INJURY

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OPPORTUNITY FOR INTERVENTION 1) Physical
Therapy 2) Ambulation/Gait assists 3) Sensory
Aids 4) Remove Problematic Medications 5) Bed
Alarms for dementia with impulsivity
?Baroreceptor Sensitivity ?Balance from
vestibular and proprioception ?vision (esp
night) ?reflex speed for correction
Fall Risk
Benzodiazepines Psychotrophics Anticholinergics An
tihypertensives Parkinsons Neuropathy Arthritis P
odiatry problems
?impulsivity (esp in dementia)
Environmental Trigger Accident
6) OT Home Safety Eval -rugs -cords -lighting -rai
ls
Fall
Frailty Osteoporosis Decreased muscle speed to
deflect injury
7) CalciumVitamin D/Bisphosphonate 8) ? Hip
protectors
INJURY
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What about Tests?

• Orthostatic Vital Signs
• Vitamin D levels
• Vitamin D deficiency associated with falls and
  osteoporosis
• CBC, Chem7, Urinalysis are reasonable
• B12 levels and TSH if driven by other clinical
  cues
• Brain imaging if neurologic findings on exam or
  if fall caused head injury
• Echo is only indicated if exam suggests valvular
  disease
• EKG/holter monitoring- low yield without syncope,
  chest pain, or palpitations
• Syncope is estimated to cause only 0.3 of falls

Broe KE, et al. A Higher Dose of Vitamin D
Reduces the Risk of Falls in Nursing Home
Residents A Randomized, Multiple-Dose Study.
JAGS 200755234-239 Rubenstein LZ et al. Falls
and Their Prevention in the Elderly. Med Clin N
Amer 200690807-824
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The Hard PartMedications

• Antidepressants
• 68 increased risk
• Neuroleptics/Antipsychotics
• 59 increased risk
• Sedative/Hypnotics
• 47 increased risk
• Antihypertensives
• 24 increased risk
• NSAIDS
• 21 increased risk

• There is usually a reason patients were placed on
  a medication
• Patients and physicians may be resistant to
  change
• It is incumbent on us to try to reduce
  problematic medications when adverse events are
  occurring.

Woolcott JC, et al. Metaanalysis of the Impact
of 9 Medication Classes on Falls in Elderly
Persons. Arch Int Med 20091691952-60
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Inpatient?Outpatient
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• Transient Ischemic Attack
• versus
• Geriatric Fall

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Case 2The In-hospital Fall

• 74 y/o previously independent man admitted for
  GIB
• Felt most consistent with hemorrhoids
• Admit for observation overnight
• Double occupancy room with another patient

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There are Some Who Think the Hospital is a Fancy
Hotel

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Fall Risk Stratification

• Physician assessment as Low (binary) fall risk
• Moderate risk per nursing assessment
• The patients roommate is rated High risk

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The Fall

• Patient incontinent and attempting to reach
  toilet using walker.
• Nursing aid assists patient to toilet
• While on toilet roommates bed alarm sounds
• Imminent risk of falling out of bed
• Nursing aid leaves bathroom to assist roommate
• Bed alarm also summons nurse to room

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The Fall

• Returns to find patient has fallen in bathroom
• Scalp laceration
• Humerus Radius fracture
• Subdural hematoma

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Outcome

• Patient transferred to ICU
• Fails swallow evaluation
• Declines PEG tube
• Aspirates in hospital
• Death

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Hospital Falls2-12 of patients will have a fall
in the hospital

• Circumstances
• 20 with toileting
• 34 from bed
• 38 while ambulating

10-20 of in-hospital falls are recurrent events
Chelly JE. Risk Factors and Injury Associated
with Falls in Elderly Hospitalized Patients in a
Community Hospital. Journal of Patient Safety
20084178-183 Schwendimann R, et al. Falls and
Consequent Injuries in Hospitalized Patients. BMC
Health Ser Research 2006669
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Consequences

• 30 with minor injury
• 4 with major injury
• Lacerations/bleeding
• Hematomas
• Fractures/dislocation
• Traumatic brain injury
• ?? hospital charges
• ? LOS

• Litigation
• Serious injuries
• Failure to follow procedures to prevent recurrent
  falls
• Delays in injury recognition

Half of all patients with hip fracture from
in-hospital fall will be dead within the
year -Twice the rate seen in the community Risk
of injury from in-hospital fall rises by 19 for
each decade of age
Schwendimann R, et al. Falls and Consequent
Injuries in Hospitalized Patients. BMC Health Ser
Research 2006669 Bates DW. Serious Falls in
Hospitalized Patients Correlates and Resource
Utilization. Am J Med 199599137-143 Johal KS.
Hip Fractures after Falls in Hospital A
Retrospective Observational Cohort Study. Injury
200940201-204 Oliver D. Do Falls and
Falls-Injuries in Hospital Indicate Negligent
Care- and how big is the risk? Qual Saf Health
Care 200817431-436
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The Challenge of the In-hospital Fall

• Falls in the hospital are rarely witnessed
• Only 8 of hospital falls have staff present
• Witnessed falls are still difficult to catch
• Falls are widely underreported
• 44 of falls not reported as incident reports

Bradley SM. Predictors of serious injury among
hospitalized patients evaluated for falls. JHM
2010563-68 Sari AB. Sensitivity of Routine
System for Reporting Patient Safety Incidents in
an NHS Hospital. BMJ 200733479
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Regulatory Environment

• Injuries from hospital falls are Never Events
• --Medicare will no longer pay for them
• Hospital falls with significant injury are JCAHO
  reportable
• --sentinel events
• Falls with injury in the hospital pose
  malpractice risk

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Risk Assessment- Physicians

• How do physicians assess fall risk?
• For the most part, physicians pay little or no
  attention to this issue.
• A simple physician falls screen
• Have you fallen in the last 6 months or are you
  afraid of falling?
• Get-Up-And-Go test
• You learn a lot about strength, balance, and gait
  in 30 seconds.

Fernandez HM. House Staff Member Awareness of
Older Inpatients Risk for Hazards of
Hospitalization. Arch Intern Med 2008168390-396
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Fall Risk Scoring Tools

• Screening tools are available to target
  interventions to high risk patients
• STRATIFY Score
• Downton Score
• Morse Falls Scale
• Hendrich II
• Using the standards of EBM, even the best of
  these tools has poor test performance
• Sens 67 Spec 51
• Predictive accuracy of 43.2 to 60
• ACTION on modifiable risk factors is far more
  important than risk stratification

Oliver D, et al. A Systematic Review and
Meta-analysis of Studies Using the STRATIFY Tool
for Prediction of Falls in Hospital Patients. Age
and Aging37621-627 Coussement J et al.
Interventions for Preventing Falls in Acute and
Chronic Care Hospitals A Systematic Review and
Meta-Analysis. JAGS 20085629-36 Oliver D. Falls
Risk-Prediction Tools for Hospital Inpatients.
Time to Put Them to Bed? Age and Ageing
200837248-250
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The literature provides little guidance as to how
the probability of injury should be incorporated
into hospital fall policies as a modifier of the
risk of a fall itself.
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Acute Post-Fall Evaluation

• First priority is evaluation for injury
• Obvious and occult
• Head to toe examination
• Palpation of spine, pelvis and ROM of extremities
• Fractures between occiput and C2 more likely in
  elderly
• Immobilize neck pending CT scan if neck injury
  suspected
• Head injury prompts CT scan
• Up to 10 of elderly pts with ICH lack focal
  deficits
• Scheduled neuro checks prudent

Touger M. Validity of a Decision Rule to Reduce
Cervical Spine Radiography in Elderly Patients
with Blunt Trauma. Ann Emerg Med
200240287-293 Gangavati AS. Prevalence and
Characteristics of Traumatic Intracranial
Hemorrhage in Elderly Fallers Presenting to the
Emergency Room without Focal Findings. J Am
Geriatr Soc 2009571470-1474
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NEXUS-II Closed Head Injury Decision Aid NEXUS-II Closed Head Injury Decision Aid NEXUS Cervical Spine Injury Decision Aid NEXUS Cervical Spine Injury Decision Aid
Criteria Criteria Criteria Criteria
1 Evidence of significant skull fracture 1 Evidence of Intoxication
2 Scalp haematoma 2 Posterior midline neck tenderness
3 Neurologic deficit 3 Distracting painful injury
4 Altered level of alertness 4 Altered level of alertness
5 Abnormal behavior 5 Altered neurologic function
6 Coagulopathy
7 Persistent vomiting
8 Age 65 or more
Pts with none of these factors are low risk for
significant injury and do not require imaging.
Mower WR. Developing a Decision Instrument to
Guide Computed Tomographic Imaging of Blunt Head
Injury Patients. Journal of Trauma-Injury
Infection Critical Care 200559954-959 Touger
M. Validity of a Decision Rule to Reduce Cervical
Spine Radiography in Elderly Patients with Blunt
Trauma. Ann Emerg Med 200240287-293
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There is No Better Sign of the Next Fall.Than
the First Fall

• Institute Secondary Prevention Measures

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What Interventions Reduce Falls?
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Interventions to Reduce FallsOutpatient and Long
Term Nursing Homes

• Expedited cataract surgery
• One trial showed benefit, two did not
• Cardiac pacing for cardio-inhibitory carotid
  sinus sensitivity
• Home safety evaluation in patients with prior
  falls
• Vitamin D supplementation
• Exercise/balance programs
• Medication withdrawal

Tinetti ME, et al. The Patient Who Falls. JAMA
2010303258-266
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Interventions Interventions Interventions
Ambulation Aids Modification of bedside environment Staff education
Eyewear (glasses) Modification of drug regimen Patient and family education
Modified footwear Posted alerts to staff on patient fall risk Increased supervision (more frequent status assessments by nursing)
Exercise/balance training Referral to P.T. Scheduled toileting Bedside sitter
Hip protector use Bedside commode Bed and chair alarms
Evaluation and treatment of postural hypotension Screening for urine infection High risk patients moved to close proximity to nursing station
Beds placed in lowest position Staff assistance with transfers
Cumming RG. BMJ 2008 336 758760 von
Renteln-Kruse. J Am Geriatr Soc
2007552068-2074 Healey F. Age and Ageing
200433390-395 Haines TP. BMJ 2001328676-681
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Observational Trials of Hospital Fall Reduction
Protocols

• 2004 Observational trial
• 25 reduction in fall rates
• 2004 RCT in Community Hospital
• 21 reduction in falls
• No difference in fall related injuries

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Falls Prevention Programs Effective. According
to Less Rigorous Scientific Standards
Sasquatch
Loch Ness Monster

• Of course by these standards.lots of things are
  plausible

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2006 Observational Trial of Interdisciplinary
Fall Prevention Program

• No reduction in falls
• No reduction in fall related injuries

Schwendimann R et al. Falls and Consequent
Injuries in Hospitalized Patients Effects of an
Interdisciplinary Falls Prevention Program. BMC
Health Serv Research 2006
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Identified Problems

• Incomplete predictive power of screening tools
• Limited exposure time for intervention impact
• LOS in days vs. months to years
• Incomplete adherence to fall reduction protocol
• Prior research demonstrates 43 non-adherence
  rates
• Our investigation found 64 non-adherence to bed
  alarms

Bakarich A. The Effect of a Nursing Intervention
on the Incidence of older Patient Falls. Aust J
of Adv Nurs 1997, 1526-31 Lampignano DW. Using
rare inpatient accidents to evaluate and improve
the system-based practice an example in process
mapping and the Vanderbilt Healthcare Matrix-2010
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RCTs to Reduce In-hospital Falls

• 8 Trials Since 1966
• Only two were exclusively acute care hospitals
• 1993 RCT of bed alarms
• Very small trial (35 patients in each arm)
• Non-significant reduction of falls
• 2006 Quasi-experimental multi-component trial
• Reduction in pts with recurrent falls
• 20 versus 56
• No reduction in first falls
• 12.6 versus 11.8

Tideiksaar R. Falls Prevention The Efficacy of a
Bed Alarm System in an Acute-Care Setting. Mt
Sinai J Med 199360522-527 Schwendimann R. Fall
prevention in a Swiss acute care hospital
setting. J Gerontol Nurs 2006321322.
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Findings of Systematic Review and Meta-Analysis

• No conclusive evidence that hospital fall
  prevention programs can reduce the number of
  falls or fallers
• More studies are needed to evaluate trend towards
  efficacy of actively targeting patients most
  important risk factors
• No evidence demonstrates acute care fall
  prevention programs reduce injuries

Coussement J. Interventions for Preventing Falls
in Acute and Chronic-Care Hospitals A Systematic
Review and Meta-Analysis. JAGS 20085629-36
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Cochrane Review

• In hospitals, multi-factoral interventions
  reduced the rate of falls and risk of fallers.
• Results most robust for patients with longer
  lengths of stay

Cameron ID. Interventions for Preventing Falls in
Older People in Nursing Care Facilities and
Hospitals. Cochrane Databse Syst Rev
201020(1)CD005465
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Final Thoughts