Strategies to reduce risk of fall-related injuries in rehabilitation nursing.

Rehabilitation nurses are in a critical position to lead interdisciplinary team fall prevention management, including injury risk reduction. This article provides an update for rehabilitation nurses on evidence-based strategies to reduce patients'risk of fall-related injuries. This content builds on existing literature by focusing on knowledge to promote patient responses that reduce the risk of falls and ultimately fall-related injuries. Although rehabilitation nurses understand the complex nature of falls, addressing the intrinsic and extrinsic risk factors that increase the risk of fall-related injuries requires both individually based treatment programs and a system-wide commitment. A plethora of literature discusses fall risks and falls, but this article profiles the at-risk patient and describes current and emerging evidence-based interventions to protect patients from fall-related injuries by reducing risk factors. This discussion is limited to exercise, environmental redesign, osteoporosis prevention, and hip protectors.     

Incidence and Characteristics of Fall-related Emergency Department Visits

Abstract. Objective: Unintentional falls are the leading cause of injury and the second most common cause of unintentional injury deaths in the United States, and place a great burden on EDs. In this study, the objective was to describe the incidence and characteristics of ED visits associated with unintentional falls in the United States.
Methods: The authors performed a secondary analysis on data from the National Center for Health Statistics' National Hospital Ambulatory Medical Care Survey for 1992–1994. An ED visit was defined as fall-related if an ICD-9-CM cause of injury code was reported as E880.0–886.9 or E888.
Results: There were an estimated 7,946,000 fall-related ED visits per year, corresponding to an annual rate of 3.1 per 100 persons (95% CI = 2.8 to 3.4). Children under 5 years of age comprised the largest proportion of visits (14%). Among those visits coded with respect to place of occurrence, the rate of visits associated with falls occurring at home (1.7/100; 95% CI = 1.6 to 1.9) was significantly higher than that associated with falls occurring in all other locations combined (1.1/100; 95% CI = 1.0 to 1.2). The mean injury severity score increased significantly with the age of the patient. Fall-related ED visits resulted in an estimated 860,000 hospitalizations, 62% of which involved individuals aged 65 years and older. An estimated $2.45 billion per year was paid for fall-related ED visits. Government sources paid all or part of 41% of visits.
Conclusions: This study reports nationally representative data describing the incidence and characteristics of fall-related ED visits. These data expand what is known about the epidemiology of falls and help to define the burden that fall injuries place on EDs in the United States. The results of this study could serve as a benchmark to evaluate the effectiveness of future fall prevention efforts.     

A hypothesis-generating study to evaluate platelet activity in diabetics with chronic kidney disease

BACKGROUND: The use of antithrombotic agents and falls are independently associated with an increased risk of hemorrhagic injury. However, few studies have delineated the risk of fall-related hemorrhagic complications in persons who are taking antithrombotic therapy. The objective of this study was to compare the rates of fall-related hemorrhagic injury in hospital in-patients who are taking and not taking antithrombotic therapy. METHODS: A 4-year retrospective chart review of consecutive patients who fell during admission to a 500-bed tertiary-care teaching hospital was conducted. Major hemorrhagic injuries including subdural hematomas and major bleeding/cuts, patients' use of antithrombotic medication (warfarin, aspirin, clopidogrel and heparin) and their anticoagulation status at the time of their fall were recorded. RESULTS: A total of 2635 falls in 1861 patients were reviewed. Approximately 10% of falls caused major hemorrhagic injury. One fall resulted in a subdural hematoma. Persons taking warfarin were less likely to suffer a fall-related major hemorrhagic injury compared with persons not taking antithrombotic therapy (warfarin, 6%; no therapy, 11%; p = 0.01). Logistic regression showed that fall-related major hemorrhagic injury was associated with female gender (odds ratio 1.6; 95% CI 1.3, 2.1), use of aspirin (odds ratio 1.4; 95% CI 1.1, 1.8) and use of clopidogrel (odds ratio 2.2; 95% CI 1.1, 4.8), but not with the use of warfarin or heparin, or the intensity of anticoagulation. CONCLUSIONS: In this study, compared with persons taking no antithrombotic therapy, those taking warfarin had lower rates of fall-related hemorrhagic injuries. The absolute rate of the development of fall-related intracranial hemorrhagic injury such as subdural hematomas was low, even in persons taking warfarin. These counter-intuitive results may be due to selection bias, and suggest that physicians are very conservative in selecting patients for warfarin therapy, choosing only those who are sufficiently healthy to be at much lower than average risk of suffering fall-related hemorrhagic injuries. This phenomenon may lead to physicians overestimating the potential for fall-related major hemorrhagic injury in persons taking antithrombotic therapy, with the possible denial of warfarin therapy to many of those who would benefit. This perception may contribute to the care gap between the number of patients who would theoretically derive overall benefit from warfarin therapy and those who are actually receiving it.     

Shielding or caging? Healthcare staffs’ views on fall risk and protection in Stockholm

Aim.  To describe Registered Nurses' and enrolled nurses' views and reasoning on falls, fall risk, use of physical restraints and patients' safety and security in nursing homes.
Background.  Nursing home patients frequently suffer from diseases which require medication. Both Registered Nurses and enrolled nurses must make decisions about how to protect patients from falls and fall-related injuries. Physical restraints are frequently used. When patients are unable to understand or do not wish to limit their freedom of movement, staff must consider each decision carefully.
Method.  A qualitative approach was used. Data were analysed using a thematic content analysis method.
Findings.  Staff have sufficient knowledge about which pathologically related conditions lead to fall risk. An insufficient number of staff on duty jeopardizes patient safety. Wheelchairs with safety belts, and bed rails, are sometimes used. For Registered Nurses it was not an easy decision to use restraints. Enrolled nurses' actions were based on standard procedure, to protect and supervise patients.
Conclusion.  Staff often use restraints to protect their patients, even though this may mean compromising the patient's integrity.
Relevance to clinical practice.  Nurses, occupational therapists, physiotherapists and physicians should plan the care together. Restrictive measures should be adapted to each individual patient.     

Fall risk factors in older people with dementia or cognitive impairment: a systematic review

Title.  Fall risk factors in older people with dementia or cognitive impairment: a systematic review.
Aim.  This paper is a report of a review conducted to identify and summarize specific risk factors for falls in older people with dementia or cognitive impairments as documented by prospective or case–control studies.
Background.  People with dementia have a doubled to threefold risk for falls, but the reasons for this have not yet been fully explained. Several integrative literature reviews discuss possible specific fall risk factors. However, there is lack of a systematic evaluation of studies.
Data sources.  The CINAHL, PubMed, EMBASE and PsychInfo databases were searched for the period between 1980 and May 2007.
Review methods.  A systematic review was conducted. Cohort or case–control studies published in English or German were included if they investigated risk factors for falls or fall-related injuries in a sample consisting of participants with dementia or cognitive impairment. Two reviewers independently assessed study quality.
Results.  Six prospective studies were included in the review. These differed concerning samples, settings, follow-up periods and examined variables. Therefore, meta-analysis was not possible. Eight categories of risk factors emerged: disease-specific motor impairments, impaired vision, type and severity of dementia, behavioural disturbances, functional impairments, fall history, neuroleptics and low bone mineral density.
Conclusion.  There is lack of sound studies examining fall risk factors in cognitively impaired elders. Well-known risk factors such as motor impairment show particular characteristics in people with dementia. In addition, behavioural disturbances contribute to their high risk for falls. Further prospective studies are needed.     

Falls in somatic and dementia wards at Community Care Units

Introduction:  Falls and fall injuries are common problems for patients at nursing homes in Sweden. Impaired cognitive function, a poor sense of orientation and a high intake of medicine, can lead to an increase in falls among older people.
Aim:  The objective of this study was to investigate the associations between falls and: fall risks, fractures, the use of physical restraints and the use of certain medications in somatic and dementia wards, respectively.
Method:  The study design is ecological, and aggregated data regarding falls, fall risk assessments, fractures, the use of physical restraints and medication were collected between 2000 and 2003. The Pearson correlation analysis and regression analyses were used to investigate associations between fall risks, medication, fractures, wheelchair-bound situations, bed rails and falls.
Results:  The total number of reported fall incidents was 2651; of these, 737 incidents were registered in dementia wards and 1914 in somatic wards. Dementia wards and somatic wards differed regarding falls and fractures, as it was only in dementia wards that falls were associated with fractures. There was also a significant correlation between falls and assessed risk of falling, the use of certain medication, and physical restraints such as wheelchairs and bed rails in dementia wards. Falls at somatic wards were associated with the use of sleeping pills with benzodiazepines.
Conclusion:  For dementia wards there were associations between falls and fractures, physical restraints and the use of certain medications. Fractures were associated with the use of neuroleptics, sleeping pills and sleeping pills with benzodiazepines. At somatic wards, falls correlated with the use of sleeping pills with benzodiazepines, and with the use of wheelchairs and bed rails.     

Falls in elderly patients--assessment of falls with reference to etiology and prevention

Falls have been identified as a major risk factor for disability. There is an increasing risk of falls and fall-related injuries in the elderly due to a decline in mobility and due to multimorbidity. Intrinsic and extrinsic factors lead to falls with and without syncope. Among nursing-home residents intrinsic factors are the main cause of falls, whereas community-dwelling elderly are more likely to fall because of environment (extrinsic) factors. Assessment of falls must be detailed, multidimensional and function-orientated, and aimed at identifying the causes of the index fall and risk-factors for further falls. As the risk of falling increases linearly with the number of abnormalities contributing to decreased mobility (mental status, mood, decline in sensory inputs, neurological and musculosceletal affections), identifying all risk factors increases the chance of successful intervention. Prevention of fall-related sequalae and further falls is the major goal of therapy. Primary prevention should be included in the scope of future strategies. The basis of successful intervention is fall-assessment, risk-factor assessment, causative therapy, if possible, as well as individually adapted function-orientated therapy programs, and, if at all possible, endurance and resistance training.     

Characteristics of falls and recurrent falls in residents of an aging in place community: A case-control study

BackgroundFalls and fall-related injuries remain an ongoing and serious health problem in older adults. Many clinical and environmental factors have been implicated in falls and recurrent falls, including sleep disturbances, sensory deficits, balance problems, incontinence, comorbid conditions, and certain categories of medications. We undertook this study to determine if there was an association between these factors and falls or recurrent falls in older adult residents of an aging in place community.MethodsOur retrospective case-control study compared residents who did and did not fall in an aging in place community, as well as those who experienced recurrent versus single falls in a single year.ResultsA total of 50 residents met the criteria for inclusion in this study, with 30 participants (60%) having experienced one or more falls during the observation period. Of the 30 participants who fell, 21 (70%) experienced more than one fall in a single year. Variables associated with falls included marital status and bowel incontinence; variables associated with recurrent falls included self-reported sleep difficulty, balance with sitting to standing and surface-to-surface transfer, use of a walker, and use of antidepressant medications.DiscussionOur study supports the existing nursing research that falls, and recurrent falls are the result of multiple, interrelated factors. Further research is needed into preventative measures for both falls and recurrent falls, particularly in the context of aging in place.     

Fear of falling in stroke patients: relationship with previous falls and functional characteristics

The objectives of this study were to determine the relationship between fear of falling and functional characteristics of patients after stroke as well as to determine what characterizes fallers who score high fall-related self-efficacy, and nonfallers who score low fall-related self-efficacy. Patients (n=140) treated in a stroke unit during a 12-month period were included. On follow-up, fallers were identified and patients answered the questions in the Falls Efficacy Scale, Swedish version (FES-S). Assessments of motor capacity, functional mobility and balance were also made. In univariate analysis, low fall-related self-efficacy was significantly associated with increased age, female sex, earlier falls, visual and cognitive impairment, low mood and impaired physical function. In multivariate analysis, only earlier falls and physical function remained significant. Twenty percent of the patients scored low fall-related self-efficacy without having experienced a fall, and 11% who experienced a fall scored high fall-related self-efficacy. Impaired physical function was significantly associated with scoring low fall-related self-efficacy, for both fallers and nonfallers. Fear of falling is significantly associated with poor physical function and earlier falls. Falls Efficacy Scale, Swedish version could add useful information to a fall risk analysis. Patients scoring low fall-related self-efficacy should be offered fall prevention measures whether they have fallen or not.     

An analysis of falls occurring in patients with stroke on an acute rehabilitation unit.

Falls are a common occurrence in stroke patients admitted to a rehabilitation unit. This study evaluates the effect of current fall risk screening and prevention strategies on the number of falls in stroke patients admitted to an acute rehabilitation facility. All stroke patients admitted to a designated acute rehabilitation unit were considered at risk for falls by virtue of their diagnosis. These patients were studied retrospectively during a 24-month period. Wheelchair lap belts and bedrails were provided to all patients admitted to the unit. Further measures consisting of bed and chair alarms, enclosed beds, and placement in rooms close to the nursing station were implemented with high-fall risk patients. One hundred seventeen (15.5%) of the 754 patients in this study fell. The fall index rate was 8.2 falls, based on patient care days during the study period. No injury was observed in 143 of 159 fall cases (90%). In 13 cases (8%) there were only minor injuries, and 3 falls (2%) resulted in serious injuries. Current preventive strategies decrease the number of falls and the severity of fall-related injuries. Patients who do fall are cognitively impaired on admission and have lower ambulation speed.     

Causes and Patterns of Injury from Ladder Falls

Objectives: To review all ladder fall injuries seen in a community ED and to identify patterns of injury, factors that contribute to falls, and what pre-event and event factors could have reduced the likelihood of a fall or a resulting injury.
Methods: This was a retrospective, observational study involving patients who presented to a community hospital ED from January 1993 through December 1995 with injuries from a ladder fall. The medical records of all patients were reviewed. Patients then underwent a structured telephone interview to provide additional information about the circumstances of the fall.
Results: There were 59 patients who sustained injuries relating to ladder falls. All were adults, aged >18 years (mean 42.9 ± 16.2 years), were predominantly male (93%), and had fallen a distance of 1–15 feet (mean 7.2 ± 3.6 feet). Thirteen percent were admitted to the hospital, and there was 1 death. Fractures were observed in 21 patients (36%) and usually involved an extremity (77%). There was no relationship between the distance fallen and the occurrence of fracture. Other primary injuries included sprain (27%), contusion (24%), laceration (10%), abrasion (3%), and subdural hematoma (2%). Of the 59 patients, 42 (71%) were contacted directly. Most falls (79%) resulted from excessive reaching or incorrect ladder placement. Fifty percent of the described falls were occupationally related.
Conclusions: Falls from ladders, both in the occupational and nonoccupational settings, often result in significant injury. Simple safety measures may have prevented the majority of falls in this study. Public health efforts should emphasize education on safe ladder practices and techniques to reduce the possibility of injury in the event of a fall.     

Minnesota Hospital Association Statewide Project: SAFE from FALLS

Since 2007, the Minnesota Hospital Association (MHA) has developed, managed, and promoted a statewide fall and injury reduction program to reduce inpatient falls and injuries, SAFE from FALLS. Because of statewide success in reducing falls from 2007-2010, the MHA set the goal in 2010 to eliminate serious fall-related injuries, especially head injuries. The outcomes that large-scale, multifacility health care organizations can have in reducing hospital-based falls resulting in serious injury (25% reduction) are presented, along with lessons learned.     

Pattern of fall injuries in Pakistan: the Pakistan National Emergency Department Surveillance (Pak-NEDS) study

Background

We aimed to analyse the frequency and patterns of fall-related injuries presenting to the emergency departments (EDs) across Pakistan.

Methods

Pakistan National Emergency Departments surveillance system collected data from November 2010 to March 2011 on a 24/7 basis using a standardized tool in seven major EDs (five public and two private hospitals) in six major cities of Pakistan. For all patients presenting with fall-related injuries, we analysed data by intent with focus on unintentional falls. Simple frequencies were run for basic patient demographics, mechanism of falls, outcomes of fall injuries, mode of arrival to ED, investigations, and procedures with outcomes.

Results

There were 3335 fall-related injuries. In cases where intent was available, two-thirds (n = 1186, 65.3%) of fall injuries were unintentional. Among unintentional fall patients presenting to EDs, the majority (76.9%) were males and between 15-44 years of age (69%). The majority of the unintentional falls (n = 671, 56.6%) were due to slipping, followed by fall from height (n = 338, 28.5%). About two-thirds (n = 675, 66.6%) of fall injuries involved extremities, followed by head/neck (n = 257, 25.4%) and face (n = 99, 9.8%). Most of the patients were discharged from the hospital (n = 1059, 89.3%). There were 17 (1.3%) deaths among unintentional fall cases.

Conclusion

Falls are an important cause of injury-related visits to EDs in Pakistan. Most of the fall injury patients were men and in a productive age group. Fall injuries pose a burden on the healthcare system, especially emergency services, and future studies should therefore focus on safety measures at home and in workplaces to reduce this burden.

     

Falls in the nursing home: preventable or inevitable?

1. Falls in the elderly are frequent occurrences and are usually a result of the complex interaction of environmental, physiological, and pathological variables. Fall-related injuries happen much less frequently. 2. Physical restraints have not been found effective in preventing falls and may be associated with increased risk of fall-related injury. 3. Because of the complex nature of falls in the elderly, fall prevention programs must emphasize the critical assessment of each resident's risks for falling with targeted interventions.     

How to Prevent Falls and Fall-Related Injuries: A Virtual Breakthrough Series Collaborative in Long Term Care

Abstract

Aims: To reduce preventable falls and fall related injuries in State Veterans Homes (SVHs), we conducted a virtual breakthrough series (VBTS) quality improvement collaborative.

Methods: Participating teams attended educational calls, received coaching, and submitted reports on process changes. Outcomes for the project included fall rates (total number of falls divided by the total number of census days reported) and fall injury rates (total number of falls with any injury divided by the total number of census days reported). Outcomes were tracked 6?months before, during, and after the project and compared using a Poisson regression model.

Results: Twenty-six SVHs participated and implemented 27 unique interventions. The most commonly implemented interventions included post fall huddles, staff education, and intentional rounding. There was significant improvement in the fall related injury rate (injuries per 100 census days), decreasing from 7.4 before, to 6.6 during (p?=?0.009) and 5.6 after (p?=?0.005) the VBTS. The minor injury rate (minor injuries per 100 census days) decreased significantly from 6.4 during the VBTS to 5.8 (p?=?0.000) after the VBTS. There was no statistically significant decrease in total fall rates or major injury rates.

Conclusion: Lessons learned may be of interest to other SVH facilities seeking to improve their falls prevention program.     

Falls sustained during inpatient rehabilitation after lower limb amputation: prevalence and predictors

OBJECTIVE: The purpose of this study is to identify risk factors for falling and fall-related injury among a group of inpatients undergoing rehabilitation after major lower limb amputation. DESIGN: Retrospective cohort. RESULTS: Out of 1267 patients, 260 (20.5%) fell at least once. There were a total of 374 falls, 67 (17.9%) of which resulted in one or more injuries. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated for factors significantly associated with falling, including age of > or =71 yrs (OR = 1.40, 95% CI = 1.02-1.89), lengths of stay of 22-35 days (OR = 2.97, 95% CI = 1.14-7.72) or >5 wks (OR = 6.07, 95% CI = 2.34-15.71), four or more comorbidities (OR = 1.93, 95% CI = 1.09-3.41), cognitive impairment (OR = 1.68, 95% CI = 1.02-2.78), two or more as-needed medications (OR = 1.81, 95% CI = 1.02-3.21), benzodiazepines (OR = 2.22, 95% CI = 1.24-3.96), and opiates (OR = 5.76, 95% CI = 3.29-10.09). Factors significantly associated with fall-related injuries included bilateral amputation (OR = 3.68, 95% CI = 1.49-9.05) and falls during the day shift (OR = 2.63, 95% CI = 1.24-5.57). CONCLUSIONS: One in five patients with lower limb amputation will likely experience at least one fall during inpatient rehabilitation, with 18% sustaining an injury. Ongoing research is required to develop appropriate intervention strategies to ameliorate the risk of falling during inpatient rehabilitation.     

Potentially inappropriate urinary catheter indwelling among long-term care facilities residents

Purpose  To evaluate the prevalence of long-term urinary catheter (UC) indwelling and potentially inappropriate urinary catheterization among residents of long-term care facilities (LTCFs) in Taiwan.
Method  From January to March of 2007, residents with long-term urethral UC indwelling of LTCFs in northern Taipei were invited for study and were enrolled when the informed consent was obtained. For every subject, UC was removed by home care nurses, and self-voiding (SV) status was determined after a 4-hour observation period. Residual volume (RV) was measured when the UC was re-indwelled. Potentially inappropriate UC indwelling was defined by the concomitant presence of SV and the RV less than 150 mL.
Results  In total, 252 residents from eight LTCFs were screened and 45 out of 62 residents with long-term UC indwelling were enrolled (mean age = 80.4 ± 8.9 years, 40% were males, 95.6% were severely disabled). SV was noted in 86.7% (39/45) of study subjects, and 71.8% (28/39) self-voided subjects had their RV less than 150 mL. By definition, the prevalence of potentially inappropriate UC indwelling in this study was 62.2%. The mean RV was significantly lower in subjects with SV (101.3 ± 66.1 vs. 221.7 ± 154.1 mL, P  = 0.002) and subjects with SV were more prone to have the RV less than 150 mL ( P  = 0.018).
Conclusion  The prevalence of long-term UC indwelling among Taiwanese LTCF residents was high and a high proportion of their UC may be removable. A national audit and introducing a practice guideline for continence care in LTCFs may help to promote quality of care for institutionalized older people in Taiwan.     

Older people's perspectives on fall risk and fall prevention programs: a literature review

Despite evidence supporting fall prevention methods, fall-related injury and death rates continue to rise. Understanding older people's views on fall risk and prevention will help nurses and other health professionals in the design of fall prevention strategies that will broaden their scope, reach and adoption. This literature review synthesised 19 qualitative and quantitative studies examining older people's perspectives about fall risk and prevention using a social-ecological framework. Three themes emerged about fall risk; fearing vulnerability, maintaining autonomy and independence and interpreting risk. Four themes emerged about fall prevention programs: influence of participant and program characteristics, need for personal relevance and preference, maintaining autonomy and independence and increased support for and access to programs. Implications for practice include individual, interpersonal, organizational and community level considerations for improving fall prevention efforts.