Read Full Text: Preventing Falls in Hospitalized Patients
Journal: Clinics in Geriatric Medicine
Year Published: 2019
CEU Podcast: #47: OT and Falls Prevention with Pooja Patel (CE Course)
Falls are complex.
That makes fall prevention a perfect goal for occupational therapy!
This week, we’re looking at an article that explores “the state of the science” on preventing falls in hospitalized patients. The authors walk us through:
- The scope of the problem
- The science (or lack thereof) supporting various interventions
While many of the interventions sound simple (like “gripper socks” and alarms), the article reminds us that there’s no “silver bullet” to prevent falls.
That said, this paper will serve as an excellent overview of the latest research. Whether you’re looking to up your therapy game or improve the quality initiatives at your facility, you’ll learn what the evidence says—and why investing in patient and staff education is crucial to your efforts.
Introduction to falls in acute care
Patient falls are the MOST COMMON adverse event reported at hospitals.
The number of falls in hospitals each year is decreasing overall, but the statistics continue to be staggering.
Each year, roughly 700,000 to 1 million falls occur in United States hospitals. These falls result in about 250,000 injuries—and up 11,000 deaths.
An estimated 2% of patients fall during a hospital stay.
Who pays for these falls?
In addition to the significant physical (and emotional) burden of falls, they take an economic toll on both patients and facilities.
In 2008, the Centers for Medicare and Medicaid Services (CMS) stopped reimbursing for fall-related injuries, as they deemed them preventable. The annual cost of falls is estimated to be 30 BILLION dollars.
What is being done?
Given the massive cost, hospitals have been seeking a “silver bullet” to this problem.
This has resulted in the rollout of fall prevention programs that typically entail:
- Identifying patients at a high risk of falling
- Using clinical judgment to decide which strategies should be used accordingly to prevent falls
Unfortunately, there is considerable variation to these programs, as clinical judgment is typically used in place of decisive research.
While there’s a growing body of research on fall prevention in the community-dwelling elderly, these findings do not necessarily translate to the unique circumstances of hospitals…which leads us to this paper.
What was the intent of this paper?
Given the above information, the authors say it is imperative to examine fall prevention strategies specific to the hospital setting. They break their exploration into three main categories:
- Study designs being used
- Evidence behind individual fall prevention interventions
- Evidence behind multifactorial fall prevention interventions
Study designs in fall prevention
The authors give a brief overview of the types of research studying fall prevention. (I’m pretty sure this was done to illustrate why stronger evidence is needed.)
Quality improvement studies
Many studies on fall prevention take the form of quality improvement studies. They typically follow a “before and after” design, without using a control group—e.g., were there fewer falls on the unit after the fall prevention program was implemented?
The authors emphasize that studies like this should NOT be viewed as evidence, because one cannot determine if the cause of the improvement was the actual program or some outside factor.
Randomized studies
Randomized control trials (RCTs) provide a much stronger study design. Randomization can occur at the patient or unit level. The authors highlighted the benefit of a stepped wedge study design.
The evidence behind individual fall prevention strategies
Ok, now let’s look at specific fall prevention strategies, and where the evidence stands for each.
Fall risk identification
There is a lack of evidence supporting the use of fall prediction tools. This led The National Institute for Health and Care Excellence to recommend AGAINST the routine use of fall prediction tools. Instead, they advise that all inpatients older than 65 should be considered at high risk for falls.
The Agency for Healthcare Research and Quality also asserts that it’s more important to identify and address patients’ specific risk factors for falls, rather than spending time calculating fall risk numbers.
To be clear, it is important to distinguish between:
- Fall risk assessments: checklists identifying risk factors
- Fall prediction tools: calculations of fall risk scores based on known risk factors
Alarms
There is now strong evidence that alarms are ineffective in fall prevention.
Additionally, alarms cause a host of their own problems, including:
- Contributing to confusion and agitation for cognitively impaired patients
- Restricting mobility and independence
- Creating “alarm fatigue” for staff
The authors do note that just because alarms are ineffective in their current form (sounding loudly when people get up from bed or out of a chair), that does not mean we should discount future tech developments. For example, wearable alarm systems could prove more effective than the current models used on beds and chairs.
Sitters
Sitters provide 1:1 surveillance for patients, and they may also provide therapeutic care.
There are only small, non-randomized studies that support the use of sitters. And, they represent a considerable expense, often not reimbursable by third-party payers. Many hospitals discourage their use.
Intentional rounding
Intentional rounding is a proactive approach to meeting patient needs, involving regular bedside checks performed every 1-2 hours.
The quality of evidence for rounding is weak; of note, studies performed have been quality improvement studies.
Rounding also carries its own downsides, potentially including:
- Perception of a top-down approach, restricting staff autonomy
- Increased workloads
- Competing priorities
- Poor documentation
- Lack of staff buy-in
Patient education
There is some evidence that patient education is effective in reducing falls for cognitively intact patients. But it is not suitable for patients with cognitive impairment, which is a common risk factor for inpatient falls.
Environmental modifications
The physical environment can be an important contributor to falls. One study specifically looked at falls that resulted in death or permanent loss of function. 39% of such falls identified the physical environment as part of the root cause.
One RCT found that fewer falls occur on vinyl floors as opposed to carpet.
Another study found NO evidence that “low-low” beds reduced the risk of falls.
Physical restraints
Unfortunately, there remains a perception (both on the part of health professionals and patients) that restraints reduce the risk of falls. In many facilities, they are still considered a viable last resort for preventing falls.
Data from this and this and this study suggest that restraints may not prevent, but instead increase, the risk of falling.
Restraints can also cause:
- Agitation and delirium
- Pressure ulcers
- Deconditioning
- Strangulation
- Death
Non-slip “gripper” socks
The small body of research on non-slip socks has not provided evidence of their efficacy as a fall prevention strategy.
Given the lack of evidence, a patient’s own footwear remains the safest option for fall prevention.
Multifactorial interventions
Given the many factors contributing to falls, it makes sense that multicomponent approaches would be most effective.
There are a few important readings if you are exploring this option.
The 6-PACK program has been the largest researched fall prevention program to date. But despite a successful rollout, there was not a reduction in falls.
That said, a recent cochrane review concluded: “Multifactorial interventions may reduce rate of falls, although subgroup analysis suggests this may apply mostly to a subacute setting.” So, there’s still plenty of time to research whether this finding holds true in acute settings.
Author summary
Although fewer falls have been reported over time, hospital falls remain a significant safety problem. There’s an urgent and ongoing need for well-designed research studies of hospital fall prevention.
Takeaways for OT practitioners
(Please note: These are my personal takeaways. They are not mentioned specifically in the article.)
1. This was surprising on one hand, but not the other.
Anyone who has worked in acute care is probably familiar with all of the interventions mentioned. They are so commonplace that it was surprising to read the lack of evidence supporting their use.
On the other hand, we OTs also recognize that there is not one simple answer to such a complex problem.
2. There is still a lot of concrete advice out there to follow.
While there’s no “silver bullet,” when it comes to fall prevention, we’re not starting from scratch. We now know that many of the commonplace interventions simply do not have strong evidence behind them. And many carry significant costs and downsides.
These seem to be the most important resources out there for learning about falls prevention and multifactorial interventions:
- Interventions for preventing falls in older people in care facilities and hospitals
- Preventing Falls in Hospitals Toolkit from AHQR
3. Patient and staff education are the best use of resources at this time.
New research continues to clarify that patient and staff education are the most compelling options for fall prevention.
When possible, our patients and their families should understand the increased fall risks associated with being in the hospital.
Likewise, staff members need to take the time to understand what is safest for their individual clients. There truly is no one-size-fits-all “gripper sock” solution!
Here’s the full APA citation for this article:
LeLaurin, J. H., &; Shorr, R. I. (2019). Preventing falls in hospitalized patients. Clinics in Geriatric Medicine, 35(2), 273–283.
Earn one hour of continuing education by listening to the podcast on this article!!
In this podcast episode, we dive even deeper into this topic, with OT (and Club member!), Pooja Patel. You may be eligible for continuing education credit for listening to this podcast. Please read our course page for more details!
But, no job openings right now…)