Hospital Falls and Falls that Hospital Falls and Falls that Lead to HospitalizationLead to Hospitalization

The Inpatient PerspectiveThe Inpatient Perspective

Ethan Cumbler MD, FACPEthan Cumbler MD, FACPAssociate Professor of MedicineAssociate Professor of Medicine

Director UCH Acute Care For Elderly ServiceDirector UCH Acute Care For Elderly ServiceUniversity of Colorado DenverUniversity of Colorado Denver

20102010

DisclosuresDisclosures

NoneNone

ObjectivesObjectives

1: Teach actionable risk factors for falls leading to 1: Teach actionable risk factors for falls leading to admission with emphasis on interventions admission with emphasis on interventions which can be initiated in the inpatient settingwhich can be initiated in the inpatient setting

2: Identify strengths and weaknesses of risk 2: Identify strengths and weaknesses of risk stratification tools for the in-hospital fallstratification tools for the in-hospital fall

3: Critically appraise the quality of evidence for 3: Critically appraise the quality of evidence for interventions to reduce falls in the acute care interventions to reduce falls in the acute care hospitalhospital

Clinical Case #1Clinical Case #1Outpatient Fall Leading To AdmissionOutpatient Fall Leading To AdmissionGertrude is an 88 y/o Gertrude is an 88 y/o woman admitted for back woman admitted for back pain after a fall stepping pain after a fall stepping off a curb outside her off a curb outside her assisted livingassisted living

Xray demonstrates Xray demonstrates thoracic compression thoracic compression fracture. fracture.

Admit for pain control, Admit for pain control, inability to ambulate.inability to ambulate.

PMHPMH– Mild Alzheimer's DementiaMild Alzheimer's Dementia– HTNHTN– Urge incontinenceUrge incontinence– DepressionDepression– InsomniaInsomnia

MedicationsMedications– Clonidine 0.1 mg bidClonidine 0.1 mg bid– Aspirin 81 mg dailyAspirin 81 mg daily– Sertraline 50 mg dailySertraline 50 mg daily– Amitryptiline 50mg at nightAmitryptiline 50mg at night

IMPACTIMPACT

30-40% of people over age 65 will have a fall each 30-40% of people over age 65 will have a fall each yearyear

In an elderly patient who has fallen, the risk of In an elderly patient who has fallen, the risk of having a second fall within a year rises to 60% having a second fall within a year rises to 60%

Rao SS. Prevention of Falls in Older Patients. AAFP 2005;72:81-88

ConsequencesConsequences

5-10% of community dwelling elderly who fall 5-10% of community dwelling elderly who fall will suffer a serious injurywill suffer a serious injury– Up to 20-30% of elderly patients overallUp to 20-30% of elderly patients overall

Falls increase risk of going to nursing facilityFalls increase risk of going to nursing facility– 3 fold increase for falls without injury3 fold increase for falls without injury– 10 fold increase for falls with serious injury10 fold increase for falls with serious injury

8% of people 8% of people >> 70 come to ER for falls each year 70 come to ER for falls each year – 1/3 will be admitted1/3 will be admitted

Rubenstein LZ, Josephson KR. Falls and Their Prevention in the Elderly. Med Clin N Amer 2006;90:807-824Tinetti ME,et al. Falls, Injuries Due to Falls, and the Risk of Admission to a Nursing Home. NEJM 1997;337:1279-84

InjuriesInjuries

FracturesFractures

1% of falls in the 1% of falls in the elderly lead to hip fxelderly lead to hip fx

20-30% mortality in 20-30% mortality in the year after hip fxthe year after hip fx

¼ to ¾ of patients do ¼ to ¾ of patients do not recover prior level not recover prior level of ADLsof ADLs

Rubenstein LZ, Josephson KR. Falls and Their Prevention in the Elderly. Med Clin N Amer 2006;90:807-824

InjuriesInjuriesOther FracturesOther Fractures– HumerusHumerus– RibRib

Subdural HematomaSubdural Hematoma

Prolonged lie-Prolonged lie- half of all elderly patients half of all elderly patients who fall are unable to get back upwho fall are unable to get back up– 22oo rhabdo, dehydration/ARF, pressure injury rhabdo, dehydration/ARF, pressure injury

Tinetti ME et al. Predictors and Prognosis of Inability to Get Up after Falls among Elderly Persons. JAMA 1993;169:65-70

Post Fall Anxiety SyndromePost Fall Anxiety Syndrome“Fallophobia”“Fallophobia”

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

Self-limiting activity, worsening deconditioning, social isolationSelf-limiting activity, worsening deconditioning, social isolation

Falls are a Prototypical Geriatric SyndromeFalls are a Prototypical Geriatric SyndromeMultifactoralMultifactoral

Risk FactorRisk Factor Odds Odds RatioRatio

Lower extremity weaknessLower extremity weakness 4.44.4

History of fallsHistory of falls 3.03.0

Gait deficitGait deficit 2.92.9

Balance deficitBalance deficit 2.92.9

Need for assistive deviceNeed for assistive device 2.62.6

Visual defectVisual defect 2.52.5

ArthritisArthritis 2.42.4

Impaired activities of daily livingImpaired activities of daily living 2.32.3

DepressionDepression 2.22.2

Cognitive impairmentCognitive impairment 1.81.8

Age > 80 yearsAge > 80 years 1.71.7

Rubenstein LZ. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin N Am. 2006;90:807-824

Tinetti ME, Speechley M, Ginter SF. Risk Factors for Falls Among Elderly Persons Living in the Community. NEJM 1988;319:1701-8

A Brief DiversionA Brief Diversion

In Malcolm Gladwell’s book on cognition “Blink”, he In Malcolm Gladwell’s book on cognition “Blink”, he describes a fascinating psychology experiment.describes a fascinating psychology experiment.

A sample table is set up at two grocery stores for A sample table is set up at two grocery stores for customers to try a sample of jam.customers to try a sample of jam.

On table has 6 varieties of jams, the other has 24 On table has 6 varieties of jams, the other has 24 selections.selections.

Which table do you think sold more jam?Which table do you think sold more jam?

Multiple Alternatives BiasMultiple Alternatives Bias

Table with only 6 varieties sold 10X more jamTable with only 6 varieties sold 10X more jam

The reason lies in the human psyche.The reason lies in the human psyche.

Faced by too many choices, customers freeze Faced by too many choices, customers freeze up and make no decision at all.up and make no decision at all.

A New Conceptual FrameworkA New Conceptual FrameworkFall risk has specific components:Fall risk has specific components:

Latent risk for fallLatent risk for fall– Physiologic changes of agingPhysiologic changes of aging– Disease and medicationsDisease and medications– Behavioral traitsBehavioral traits

Environmental triggerEnvironmental trigger– the “accident”the “accident”

Underlying frailtyUnderlying frailty– Vulnerability to injuryVulnerability to injury

EACH COMPONENT HAS CONCRETE ACTIONS TO EACH COMPONENT HAS CONCRETE ACTIONS TO REDUCE RISK OF FUTURE INJURYREDUCE RISK OF FUTURE INJURY

PosturalChallengesOf Aging

MedicationsAnd

Comorbidities

BehavioralContributors

↓Baroreceptor Sensitivity↓Balance from vestibular and proprioception

↓vision (esp night)↓reflex speed for correction

↑impulsivity(esp in dementia)

BenzodiazepinesPsychotrophicsAnticholinergicsAntihypertensives

ParkinsonsNeuropathyArthritisPodiatry problems

Fall Risk

Environmental Trigger“Accident”

Fall

INJURY

FrailtyOsteoporosisDecreased musclespeed to deflect injury

OPPORTUNITY FOR INTERVENTION1) Physical Therapy2) Ambulation/Gait assists3) Sensory Aids 4) Remove Problematic Medications5) Bed Alarms for dementia with impulsivity

6) OT Home Safety Eval-rugs -cords-lighting -rails

7) Calcium+Vitamin D/Bisphosphonate8) ? Hip protectors

What about Tests?What about Tests?Orthostatic Vital SignsOrthostatic Vital Signs

Vitamin D levelsVitamin D levels– Vitamin D deficiency associated with falls and osteoporosisVitamin D deficiency associated with falls and osteoporosis

CBC, Chem7, Urinalysis are reasonableCBC, Chem7, Urinalysis are reasonable– B12 levels and TSH if driven by other clinical cuesB12 levels and TSH if driven by other clinical cues

Brain imaging if neurologic findings on exam or if fall caused head injuryBrain imaging if neurologic findings on exam or if fall caused head injury

Echo is only indicated if exam suggests valvular diseaseEcho is only indicated if exam suggests valvular disease

EKG/holter monitoring- low yield without syncope, chest pain, or palpitationsEKG/holter monitoring- low yield without syncope, chest pain, or palpitations– Syncope is estimated to cause only 0.3% of fallsSyncope 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 2007;55:234-239Rubenstein LZ et al. Falls and Their Prevention in the Elderly. Med Clin N Amer 2006;90:807-824

The Hard PartThe Hard PartMedicationsMedications

Antidepressants Antidepressants 68% increased risk68% increased risk

Neuroleptics/Antipsychotics Neuroleptics/Antipsychotics 59% increased risk59% increased risk

Sedative/Hypnotics Sedative/Hypnotics 47% increased risk47% increased risk

Antihypertensives Antihypertensives 24% increased risk24% increased risk

NSAIDS NSAIDS 21% increased risk21% increased risk

There is usually a reason There is usually a reason patients were placed on a patients were placed on a medicationmedication

Patients and physicians Patients and physicians may be resistant to may be resistant to changechange

It is incumbent on us to It is incumbent on us to try to reduce problematic try to reduce problematic medications when medications when adverse events are adverse events are occurring. occurring.

Woolcott JC, et al. Metaanalysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Int Med 2009;169:1952-60

InpatientInpatientOutpatientOutpatient

Transient Ischemic AttackTransient Ischemic Attack

versus versus

Geriatric FallGeriatric Fall

Case #2Case #2The In-hospital FallThe In-hospital Fall

74 y/o previously independent man admitted for GIB74 y/o previously independent man admitted for GIB

– Felt most consistent with hemorrhoidsFelt most consistent with hemorrhoids

– Admit for observation overnightAdmit for observation overnight

– Double occupancy room with another patientDouble occupancy room with another patient

There are Some Who Think the Hospital is a Fancy Hotel

Fall Risk StratificationFall Risk Stratification

Physician assessment as “Low” Physician assessment as “Low” (binary)(binary) fall risk fall risk

““Moderate” risk per nursing assessmentModerate” risk per nursing assessment

The patients roommate is rated “High” riskThe patients roommate is rated “High” risk

The FallThe Fall

Patient incontinent and attempting to reach Patient incontinent and attempting to reach toilet using walker.toilet using walker.– Nursing aid assists patient to toiletNursing aid assists patient to toilet

While on toilet roommate’s bed alarm soundsWhile on toilet roommate’s bed alarm sounds– Imminent risk of falling out of bedImminent risk of falling out of bed

Nursing aid leaves bathroom to assist Nursing aid leaves bathroom to assist roommateroommate– Bed alarm also summons nurse to roomBed alarm also summons nurse to room

The FallThe Fall

Returns to find patient has fallen in Returns to find patient has fallen in bathroombathroom– Scalp lacerationScalp laceration– Humerus + Radius fractureHumerus + Radius fracture– Subdural hematomaSubdural hematoma

OutcomeOutcome

Patient transferred to ICUPatient transferred to ICU

Fails swallow evaluationFails swallow evaluation

Declines PEG tubeDeclines PEG tube

Aspirates in hospitalAspirates in hospital

DeathDeath

Hospital FallsHospital Falls2-12% of patients will have a fall in the hospital2-12% of patients will have a fall in the hospital

CircumstancesCircumstances

20% with toileting20% with toileting

34% from bed34% from bed

38% while ambulating38% while ambulating

Chelly JE. Risk Factors and Injury Associated with Falls in Elderly Hospitalized Patients in a Community Hospital. Journal of Patient Safety 2008;4:178-183Schwendimann R, et al. Falls and Consequent Injuries in Hospitalized Patients. BMC Health Ser Research 2006;6:69

10-20% of in-hospital falls are recurrent events

ConsequencesConsequences

Schwendimann R, et al. Falls and Consequent Injuries in Hospitalized Patients. BMC Health Ser Research 2006;6:69Bates DW. Serious Falls in Hospitalized Patients: Correlates and Resource Utilization. Am J Med 1995;99:137-143Johal KS. Hip Fractures after Falls in Hospital: A Retrospective Observational Cohort Study. Injury 2009;40:201-204Oliver D. Do Falls and Falls-Injuries in Hospital Indicate Negligent Care- and how big is the risk? Qual Saf Health Care 2008;17:431-436

30% with minor injury30% with minor injury

4% with major injury4% with major injury– Lacerations/bleedingLacerations/bleeding– HematomasHematomas– Fractures/dislocationFractures/dislocation– Traumatic brain injuryTraumatic brain injury

hospital charges hospital charges LOSLOS

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

LitigationLitigation

– Serious injuries Serious injuries

– Failure to follow Failure to follow procedures to prevent procedures to prevent recurrent fallsrecurrent falls

– Delays in injury Delays in injury recognition recognition

The Challenge of the In-hospital FallThe Challenge of the In-hospital Fall

Falls in the hospital are rarely witnessedFalls in the hospital are rarely witnessed– Only 8% of hospital falls have staff presentOnly 8% of hospital falls have staff present

Witnessed falls are still difficult to catchWitnessed falls are still difficult to catch

Falls are widely underreportedFalls are widely underreported– 44% of falls not reported as incident reports44% of falls not reported as incident reports

Bradley SM. Predictors of serious injury among hospitalized patients evaluated for falls. JHM 2010;5:63-68Sari AB. Sensitivity of Routine System for Reporting Patient Safety Incidents in an NHS Hospital. BMJ 2007;334:79

Regulatory EnvironmentRegulatory 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

Risk Assessment- PhysiciansRisk Assessment- PhysiciansHow do physicians assess fall risk?How do physicians assess fall risk?

For the most part, physicians pay little or no For the most part, physicians pay little or no attention to this issue.attention to this issue.

A simple physician falls screen:A simple physician falls screen:– ““Have you fallen in the last 6 months or are you afraid of Have you fallen in the last 6 months or are you afraid of

falling?”falling?”– Get-Up-And-Go testGet-Up-And-Go test

You learn a lot about strength, balance, and gait in 30 seconds.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 2008;168:390-396

Screening tools are available to target Screening tools are available to target interventions to high risk patientsinterventions to high risk patients

STRATIFY ScoreSTRATIFY ScoreDownton ScoreDownton ScoreMorse Falls ScaleMorse Falls ScaleHendrich IIHendrich II

Using the standards of EBM, even the best of Using the standards of EBM, even the best of these tools has poor test performancethese tools has poor test performance– Sens 67%Sens 67% Spec 51% Spec 51%– Predictive accuracy of 43.2% to 60% Predictive accuracy of 43.2% to 60%

ACTION on modifiable risk factors is far more ACTION on modifiable risk factors is far more important than risk stratificationimportant than risk stratification

Fall Risk Scoring ToolsFall Risk Scoring Tools

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 Aging;37:621-627Coussement J et al. Interventions for Preventing Falls in Acute and Chronic Care Hospitals: A Systematic Review and Meta-Analysis. JAGS 2008;56:29-36Oliver D. Falls Risk-Prediction Tools for Hospital Inpatients. Time to Put Them to Bed? Age and Ageing 2008;37:248-250

The literature provides little guidance The literature provides little guidance as to how the probability ofas to how the probability of injury injury

should be incorporated into hospital fall should be incorporated into hospital fall policies as a modifier of the risk of a fall policies as a modifier of the risk of a fall

itself.itself.

Acute Post-Fall EvaluationAcute Post-Fall Evaluation

First priority is evaluation for injuryFirst priority is evaluation for injury– Obvious and occultObvious and occult

Head to toe examinationHead to toe examination– Palpation of spine, pelvis and ROM of extremitiesPalpation of spine, pelvis and ROM of extremities– Fractures between occiput and C2 more likely in elderlyFractures between occiput and C2 more likely in elderly

Immobilize neck pending CT scan if neck injury suspectedImmobilize neck pending CT scan if neck injury suspected

Head injury prompts CT scanHead injury prompts CT scan– Up to 10% of elderly pts with ICH lack focal deficitsUp to 10% of elderly pts with ICH lack focal deficits– Scheduled neuro checks prudentScheduled neuro checks prudent

Touger M. Validity of a Decision Rule to Reduce Cervical Spine Radiography in Elderly Patients with Blunt Trauma. Ann Emerg Med 2002;40:287-293Gangavati AS. Prevalence and Characteristics of Traumatic Intracranial Hemorrhage in Elderly Fallers Presenting to the Emergency Room without Focal Findings. J Am Geriatr Soc 2009;57:1470-1474

NEXUS-II Closed Head Injury Decision Aid

NEXUS Cervical Spine Injury Decision Aid

Criteria Criteria1 Evidence of significant skull

fracture1 Evidence of Intoxication

2 Scalp haematoma 2 Posterior midline neck tenderness

3 Neurologic deficit 3 Distracting painful injury4 Altered level of alertness 4 Altered level of alertness5 Abnormal behavior 5 Altered neurologic function6 Coagulopathy7 Persistent vomiting8

Age 65 or more

Mower WR. Developing a Decision Instrument to Guide Computed Tomographic Imaging of Blunt Head Injury Patients. Journal of Trauma-Injury Infection & Critical Care 2005;59:954-959Touger M. Validity of a Decision Rule to Reduce Cervical Spine Radiography in Elderly Patients with Blunt Trauma. Ann Emerg Med 2002;40:287-293

Pts with none of these factors are low risk for significant injury and do not require imaging.

There is No Better Sign of the There is No Better Sign of the Next Fall….Next Fall….

Than the First FallThan the First Fall

Institute Secondary Institute Secondary Prevention MeasuresPrevention Measures

What Interventions Reduce Falls?What Interventions Reduce Falls?

Interventions to Reduce FallsInterventions to Reduce FallsOutpatient and Long Term Nursing HomesOutpatient and Long Term Nursing Homes

Expedited cataract surgeryExpedited cataract surgery– One trial showed benefit, two did notOne trial showed benefit, two did not

Cardiac pacing for cardio-inhibitory carotid sinus Cardiac pacing for cardio-inhibitory carotid sinus sensitivitysensitivity

Home safety evaluation in patients with prior fallsHome safety evaluation in patients with prior falls

Vitamin D supplementationVitamin D supplementation

Exercise/balance programsExercise/balance programs

Medication withdrawalMedication withdrawalTinetti ME, et al. The Patient Who Falls. JAMA 2010;303:258-266

InterventionsAmbulation Aids Modification of bedside

environmentStaff 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 trainingReferral 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: 758–760von Renteln-Kruse. J Am Geriatr Soc 2007;55:2068-2074Healey F. Age and Ageing 2004;33:390-395Haines TP. BMJ 2001;328:676-681

Observational Trials of Observational Trials of Hospital Fall Reduction ProtocolsHospital Fall Reduction Protocols

2004 Observational trial2004 Observational trial– 25% reduction in fall rates25% reduction in fall rates

2004 RCT in Community Hospital2004 RCT in Community Hospital– 21% reduction in falls21% reduction in falls– No difference in fall related injuriesNo difference in fall related injuries

Falls Prevention Programs Falls Prevention Programs Effective…. According to Less Effective…. According to Less Rigorous Scientific StandardsRigorous Scientific Standards

Of course by these standards….lots of Of course by these standards….lots of things are plausiblethings are plausible

SasquatchLoch Ness Monster

2006 Observational Trial of 2006 Observational Trial of Interdisciplinary Fall Prevention ProgramInterdisciplinary Fall Prevention Program

No reduction in fallsNo reduction in falls

No reduction in fall related injuriesNo 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

Identified ProblemsIdentified ProblemsIncomplete predictive power of screening toolsIncomplete predictive power of screening tools

Limited exposure time for intervention impactLimited exposure time for intervention impact– LOS in days vs. months to yearsLOS in days vs. months to years

Incomplete adherence to fall reduction protocolIncomplete adherence to fall reduction protocol– Prior research demonstrates 43% non-adherence ratesPrior research demonstrates 43% non-adherence rates– Our investigation found 64% non-adherence to bed alarmsOur 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, 15:26-31Lampignano DW. Using rare inpatient accidents to evaluate and improve the system-based practice: an example in process mapping and the Vanderbilt Healthcare Matrix-2010

RCTs to Reduce In-hospital FallsRCTs to Reduce In-hospital Falls8 Trials Since 19668 Trials Since 1966– Only two were exclusively acute care hospitalsOnly two were exclusively acute care hospitals

1993 RCT of bed alarms1993 RCT of bed alarms– Very small trial (35 patients in each arm)Very small trial (35 patients in each arm)– Non-significant reduction of fallsNon-significant reduction of falls

2006 Quasi-experimental multi-component trial2006 Quasi-experimental multi-component trial– Reduction in pts with recurrent falls Reduction in pts with recurrent falls

20% versus 56%20% versus 56%– No reduction in first falls No reduction in first falls

12.6% versus 11.8%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 1993;60:522-527Schwendimann R. Fall prevention in a Swiss acute care hospital setting. J Gerontol Nurs 2006;32:13–22.

Findings of Systematic Review and Findings of Systematic Review and Meta-AnalysisMeta-Analysis

No conclusive evidence that hospital fall No conclusive evidence that hospital fall prevention programs can reduce the number of prevention programs can reduce the number of falls or fallersfalls or fallers

More studies are needed to evaluate trend More studies are needed to evaluate trend towards efficacy of actively targeting patient’s towards efficacy of actively targeting patient’s most important risk factorsmost important risk factors

No evidence demonstrates acute care fall No evidence demonstrates acute care fall prevention programs reduce injuriesprevention programs reduce injuries

Coussement J. Interventions for Preventing Falls in Acute and Chronic-Care Hospitals: A Systematic Review and Meta-Analysis. JAGS 2008;56:29-36

Cochrane ReviewCochrane Review

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

lengths of staylengths of stay

Cameron ID. Interventions for Preventing Falls in Older People in Nursing Care Facilities and Hospitals. Cochrane Databse Syst Rev 2010;20(1):CD005465

Final ThoughtsFinal Thoughts