Assessing hospital patients who have fallen

J Rush Pierce Jr, MD, MPHSection of Hospital Medicine

University of New Mexico School of MedicineMarch 01, 2011

Case

• You are providing cross-cover. The 4W nurse calls you at 2 AM because an 84 year old woman fell in her room. She was admitted two days ago with pneumonia and is receiving IV antibiotics and oxygen. The nurse says the patient fell when trying to get to the toilet. The nurse says the patient “seems okay” but thinks that maybe you should come see the patient.

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Questions you might have

• How promptly do I need to see this patient? (“Can’t the primary team take care of this in the morning?”)

• How should I evaluate this patient?• How am I going to remember all this stuff?

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General facts about falls

• Most of literature about falls is in elderly patients who fall at home or in nursing homes

• Little literature about patients who fall in the hospital

• Nonetheless, hospital falls are considered a “never event” by Medicare

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Why do patients fall?

• In the elderly, syncope is an uncommon cause of falling (0.3%) – if present suggests orthostatic hypotension, cardiac arrhythmia, or seizure

• Common mechanism of falling in the elderly– impaired neuromuscular reflex systems due to

combination of age-related change– co-morbid illness/medications– environmental perturbation (“I tripped”)

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Epidemiologic factors associated with outpatients falls in the elderly• Age (>80)• Cognitive impairment• Female gender• Past history of fall (second largest effect)• Lower extremity weakness (largest effect)• Balance difficulty• Arthritis• Meds: neuroleptics, sedatives, antidepressants,

antihypertensives6Assessing hospital patients who fall

Epidemiology of inpatient falls (Barnes Hospital 2001-2)

• 1235 falls by 1082 pts (3.10 falls/1000 pt days)• 89% single fall, 11% more than once• 40% related to toileting• Serious injury (laceration requiring sutures,

loss of consciousness, fracture, SDH) – 6%• Death – 0.2% (both in patient with more than

1 fall) Source: Inf Control Hosp Epidem 2005;26:822

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Can we predict which pts will fall?

• Outpatient - Best clinical predictors are previous fall in past 6 months and Timed Up-and-Go (TUG) test

• Inpatient – Falls risk tools (Morse, STRATIFY, Hendrich II, Conley)– Not very good, best sensitivity = 60%, specificity =

51%

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What interventions prevent falls? (outpatient data)

• Four interventions have been shown to be effective– Medication review and adjustment– Environmental changes– Physical therapy– Vit D if deficient

• Combination of all four (multi-modality) result in relative risk reduction of 10 – 25%

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What interventions prevent falls? (inpt data)

• Very limited data – two observational studies show 20-25% reduction with bundle of services

• 3 RCT of bundle in acute care hospitals –– one showed no reduction in falls– one showed reduction for those with recurrent

falls– One showed reduction of falls in elderly, but no

reduction in fall-related injury

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Case• You are providing cross-cover. The 4W nurse

calls you at 2 AM because an 84 year old woman fell in her room. She was admitted two ago with pneumonia and is receiving IV antibiotics and oxygen. The nurse says the patient fell when trying to get to the toilet. The nurse says the patient “seems okay” but thinks that maybe you should come see the patient.

• How promptly do I need to see this patient?

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How soon do you need to evaluate the patient?

• Ask the following 7 questions:1. Was the fall unwitnessed?2. Did the patient hit his/her head?3. Did the patient experienced loss of consciousness?4. Is the patient confused?5. Is there any obvious laceration?6. Is there inability to bear weight or obvious new extremity deformity?7. Does the patient complain of pain?

• Delayed (within 24 hours)

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How soon do you need to evaluate the patient (contd)?

• If answer to ANY of the seven is “yes” – evaluate the patient urgently

• If answer to ALL is no, may defer to primary team in the morning

• Evaluate all patients within 24 hours and DOCUMENT your evaluation

• Ask nurse to document these elements and report fall to hospital incident reporting system

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Case• You are providing cross-cover. The 4W nurse

calls you at 2 AM because an 84 year old woman fell in her room. She was admitted two ago with pneumonia and is receiving IV antibiotics and oxygen. The nurse says the patient fell when trying to get to the toilet. The nurse says the patient “seems okay” but thinks that maybe you should come see the patient.

• How should I evaluate this patient?

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What evaluation should we do after a fall occurs? 3 step approach

1. Assess for syncope2. Assess for injury3. Assess opportunity to prevent the second fall

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Step 1. Assess for syncope (or syncope mimic such as seizure)

• Ask the patient and any possible observers– Ask the patient “did you pass out”– Ask the family “did he/she pass out”– Ask the roommate “did he/she pass out?”– Ask the nurse “did you observe syncope”

• If yes, remember common causes for syncope (orthostatic hypotension, cardiac arrhythmia, or seizure) – think about meds that can cause orthostasis, consider telemetry

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Step 2. Assessing for injuryInjury Clues Possible Interventions

Laceration Pain, exam Steri-strip, suture

Head injury Hit head, LOC, scalp laceration, new confusion

Additional imaging, scheduled serial neurologic exams

C-spine fracture/injury Risk (RA), other fx, mid-line post neck tenderness, focal neurologic signs

C-collar, additional imaging (CT scan preferred)

Extremity fracture Refusal to ambulate, limb deformity, tenderness or crepitance on limb movement

Additional imaging, splint/cast/surgery

Rib fracture Chest wall tenderness, sternal compression test

CXR for pneumothorax

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Step 3. Review opportunity to prevent subsequent falls

• This part should usually be done by primary team– Can tethering devices be stopped? (Foley, IV,

telemetry, Sequential compression devices)– Is the patient getting physical therapy?– Can some medications be stopped (especially

neuroloeptics, sedatives, drugs with anticholinergic effects, narcotics)

• Could the patient have delirium?

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Case• You are providing cross-cover. The 4W nurse

calls you at 2 AM because an 84 year old woman fell in her room. She was admitted two ago with pneumonia and is receiving IV antibiotics and oxygen. The nurse says the patient fell when trying to get to the toilet. The nurse says the patient “seems okay” but thinks that maybe you should come see the patient.

• How am I going to remember all this stuff?

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How am I going to remember all this stuff?

• The nurses will help you – they are your friends!

• Use a check list!– Reminds you of what to do– Helps you organize your brain– Can use it to provide documentation– Provides record for primary team

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Questions?