what should we do about fall-related injury in the hospital?

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


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


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.


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.


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?)


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)

03/13/2013 What should we do about fall-related injury in the hospital? 9

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”


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


Source: Rubenstein: Clin Geriatr Med 2002;18:141

03/13/2013 11

Medications associated with falls in the elderly


Source: Huang: Drugs Aging 2012;29:359

03/13/2013 12

Medications associated with hip fracture in the elderly


Source: Huang: Drugs Aging 2012;29:359

03/13/2013 13

Evaluating falls in community-dwelling elderly persons


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%


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


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)


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


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


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


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)


Falls by unit


Fall related to toileting


Falls with injury


Predictors of fall with injury


Documentation, all falls


Documentation, falls with injury


Epidemiology: medication use and in-patient falls


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


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%


Sources: Beauchet: J Nutr Health Aging 2011;15:933; da Costa: Plos One 2012;7:e41061

03/13/2013 32

What single interventions do not prevent inpatient falls?

• Bedrails• Exercise• Staff training• Patient education• Medication review/adjustment• Bed alarms


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


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?


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 problemWhat should we do about fall-related


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? - 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


what should we do about fall-related injury in the hospital?

Documents

fallrelated injury

injury significant

injury prev

adult falls

outpatient datahospital

literature reviewis

fallsmost of literature

w nurse