what should we do about fall- related injury in the hospital? hospitalist best practice j rush...
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How we think about falls Most of literature about adult falls is in elderly persons who fall at home or in nursing homes Little literature about patients who fall in the hospital Much of our thinking about hospital falls is extrapolated from outpatient data Hospital falls are considered a “never event” by Medicare What should we do about fall-related injury in the hospital? Source: Inouye: N Engl J Med 2009;360: /13/20133TRANSCRIPT
What should we do about fall-related injury in the hospital?
Hospitalist Best PracticeJ Rush Pierce Jr, MD, MPH
March 13, 2013
Disclosures
• Financial: none• Affiliations/biases
– I am member of the American Geriatrics Society; AGS helped develop consensus guidelines for evaluation and treatment of elders who fall
– 5% of my salary supported by Donald W Reynolds Foundation for education of hospital care of elders
– evidence should inform our thinking
What should we do about fall-related injury in the hospital?03/13/2013 2
How we think about falls• Most of literature about adult falls is in elderly persons
who fall at home or in nursing homes• Little literature about patients who fall in the hospital• Much of our thinking about hospital falls is
extrapolated from outpatient data• Hospital falls are considered a “never event” by
Medicare
What should we do about fall-related injury in the hospital?
Source: Inouye: N Engl J Med 2009;360:2390
03/13/2013 3
Roadmap for today
• Describe case• Review some literature about outpatient falls
in elderly persons• Review literature about inpatient falls• Review UNMH experience with inpatient falls• Discuss possible system changes at UNMH
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Learning Objectives
1. Identify at least 3 factors associated with falls in elderly persons.
2. State the most common etiology of falling in elderly persons.
3. Summarize the epidemiology of in-patient falls.
4. Describe an approach for evaluating the in-patient who falls.
What should we do about fall-related injury in the hospital?03/13/2013 5
Case
• You are providing cross-cover. The 4W nurse calls you at 2 AM because an 84 year old woman fell in her room. The patient 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.
What should we do about fall-related injury in the hospital?03/13/2013 6
Questions you might have
• How promptly do I need to see this patient? (Can’t this wait until the morning?)
• If I go to see the patient, how do I evaluate her? (What the #@!! am I supposed to do?)
• Is there anyway to prevent this? (How do I keep from getting these 2AM calls?)
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Out-patient falls: literature review
Is falling in the elderly a significant health problem?
• 30 – 40 % of elderly persons fall each year• 5 – 6% result in injury significant enough to
see a doctor or go to ED• 2 – 3 % result in hospitalization (Ave LOS = 8d)• Annual cost to Medicare = $19B (est FY2000)
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Source: Stevens. Injury Prev 2006;12:290
Why do elderly persons fall?• In the elderly, syncope is an uncommon cause of
falling (0.5%) • Common mechanism of falling in the elderly
– environmental perturbation (“I tripped”) – impaired neuromuscular reflex systems due to
combination of age-related changes and co-morbid illness/medications
– 80% of falls in the elderly are “unique to the elderly”
What should we do about fall-related injury in the hospital?
Source: Rubenstein: Clin Geriatr Med 2002;18:141
03/13/2013 10
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
What should we do about fall-related injury in the hospital?
Source: Rubenstein: Clin Geriatr Med 2002;18:141
03/13/2013 11
Medications associated with falls in the elderly
What should we do about fall-related injury in the hospital?
Source: Huang: Drugs Aging 2012;29:359
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Medications associated with hip fracture in the elderly
What should we do about fall-related injury in the hospital?
Source: Huang: Drugs Aging 2012;29:359
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Evaluating falls in community-dwelling elderly persons
What should we do about fall-related injury in the hospital?
Adapted from: Panel on prevention of falls in older persons: J Am Geriatr Soc 2011;59:148
03/13/2013 14
What interventions prevent falls in elderly out-patients?
• Four interventions have shown to be effective– Medication review and adjustment– Environmental changes– Exercise (or physical therapy)– Vit D if deficient (association)
• Combination of all four (multi-modality) result in relative risk reduction of 10 – 25%
What should we do about fall-related injury in the hospital?
Sources: Panel on prevention of falls in older persons: J Am Geriatr Soc 2011;59:148. Controversies in geriatrics. J Am Geriatr Soc 2013;61:281
03/13/2013 15
Falls in ambulatory elders (concl.) • Falls occur frequently and can result in injury• Falls are usually due to inadequate
compensatory neuromuscular mechanisms• Major risk factors include lower extremity
weakness, past h/o fall, female gender, and meds (psychotropics, benzos and narcotics)
• Interventions can reduce risk of future falls• Evidence based guidelines are available
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In-patient falls: literature review
Epidemiology of inpatient falls (Barnes Hospital 2001-2)
• 1,235 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: Fisher: Inf Control Hosp Epidem 2005;26:822What should we do about fall-related
injury in the hospital?03/13/2013 18
Epidemiology of inpatient falls (Barnes Hospital 2001-2)
What should we do about fall-related injury in the hospital?
Source: Fisher: Inf Control Hosp Epidem 2005;26:822
03/13/2013 19
Source: Fisher: Inf Control Hosp Epidem 2005;26:822What should we do about fall-related
injury in the hospital?03/13/2013 20
Epidemiology of fall-related injury in the hospital
• 9 hospitals in Midwest, 2001 – 2003• 7,082 falls• 40% falls associated with toileting• 42% assoc w/injury, 2.4 % serious injury• Increased age, fall in location other than pt
room and unassisted fall assoc with injury
What should we do about fall-related injury in the hospital?
Source: Krauss: Infect Control Hosp Epidemiol 2007;28:544
03/13/2013 21
Epidemiology of in-patient falls
• National Database of Nursing Quality Indicators (NDNQI) from 2006 – 2008
• 315,817 falls in 1263 hospitals• Conclusions:
– 3.56 falls/1000 patient days– 26% injury rate– Rate of falls and fall-related injury higher on
medical than surgical floors
What should we do about fall-related injury in the hospital?
Source: Bouldin: J Patient Saf 2012:Epub
03/13/2013 22
Epidemiology: UNMH in-patient falls study
• 298 PSN’s reporting falls in 2010• Exclude pts < 18 y/o (2), pregnant pts (3), pts
with no matching MR (7)• 286 falls, 251 pts• 152 males (61%), 99 females (39%)• 63 falls with injury (25%); 11 (4%) serious
injury (laceration requiring sutures, fracture, subdural)
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Falls by unit
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Fall related to toileting
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Falls with injury
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Predictors of fall with injury
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Documentation, all falls
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Documentation, falls with injury
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Epidemiology: medication use and in-patient falls
What should we do about fall-related injury in the hospital?
Source: Prakash; J Hospital Med 2013:8:1
03/13/2013 30
Cost of hospital fall-related injury• Case reports: delayed recognition of fall-related injury can result in liability risk• 3 Midwestern hospitals, 2004 – 2006
– 57 inpatient with serious fall-related injury– $13,316 and 6.3 days more than case controls
• NHS Litigation claims– 668 claims– 60% payments, mean = $30K
What should we do about fall-related injury in the hospital?
Souces: Wong: Joint Comm J Qual Patient Saf 2011:37:81; Oliver: Qual Saf Health Care 2008;17:431
03/13/2013 31
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 = 73%, specificity =
42%
What should we do about fall-related injury in the hospital?
Sources: Beauchet: J Nutr Health Aging 2011;15:933; da Costa: Plos One 2012;7:e41061
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What single interventions do not prevent inpatient falls?
• Bedrails• Exercise• Staff training• Patient education• Medication review/adjustment• Bed alarms
What should we do about fall-related injury in the hospital?
Sources: Shorr: Ann Intern Med 2012;157:692; Cameron: Cochrane Database Syst Rev;2012:CD005465
03/13/2013 33
Do multi-modality interventions prevent inpatient falls?
• Very limited data – two observational studies show 20-25% reduction with bundle
• 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
What should we do about fall-related injury in the hospital?
Source: Cameron: Cochrane Database Syst Rev;2012:CD005465
03/13/2013 34
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.
• What happens at UNMH?
What should we do about fall-related injury in the hospital?03/13/2013 35
What should we do about fall-related injury in the hospital?03/13/2013 36
In-patient falls (conclusions)• Result in serious injury in 2 – 6% of patients• More common on med/surg units and frequently
related to toileting• Falls and especially delayed recognition of fall-
related injury poses significant liability risk• Our ability to predict and prevent falls is very
limited • Regulatory agencies expect hospitals to monitor
and address this problem
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Conclusions• Outpatient falls and inpatient falls are probably
different epidemiologically• About 5% of in-patients who fall in the hospital
will suffer significant injury• Evidence-based guidance about assessment is
lacking• UNMH physician documentation of falls is poor• More study is needed
What should we do about fall-related injury in the hospital?03/13/2013 38
What should we do about fall related injury in the hospital? - Possible actions at UNMH -
• Use/review the checklist for evaluating pts who fall
• Limit use of zolpidem in patients at risk• Decrease narcotic use in the hospital• Other
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