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Training programs step up efforts to prevent inpatient falls

Necessary precautions include knowing the risk, assessing medications and working closely with nursing staff

From the November ACP Observer, copyright © 2005 by the American College of Physicians.

By Yasmine Iqbal

Michael J. Hersh, MD, a third-year internal medicine resident at Barnes-Jewish Hospital in St. Louis, vividly remembers one elderly patient he encountered during his first month as an intern.

The patient became confused at night, tried to get out of bed and fell, hitting his head. His physicians decided to use restraints, but the same thing happened the next night. Even though the patient wasn't seriously injured, the experience was a sobering one for Dr. Hersh.

"Inpatient falls are one of the most frustrating experiences for residents," he said. "They often happen in the middle of the night, and you always feel like you should have done something to prevent them." As an intern, he said he received no formal education on falls prevention. Instead, techniques to assess patients' risk of falling and to prevent falls "were just things I picked up as I went along."

That all changed when Dr. Hersh completed a 10-day rotation through the hospital's acute care for elders (ACE) unit this past summer. Unit educators stressed the importance of participating in multidisciplinary rounds where geriatricians, nurses, physical therapists and pharmacists discussed falls from different perspectives.

Unit members also covered key topics such as the hospital's specific falls risk precautions, how to assess patients' risk for falls and interventions to help patients stay as mobile and independent as possible. Dr. Hersh also learned key fall-prevention strategies, such as keeping patients' beds as low as possible.

"Residents are usually focused on conditions such as diabetes, hypertension and other acute illnesses," said Kellie Flood, ACP Member, a geriatrician in the Barnes-Jewish ACE unit. "They don't normally think about falls as a medical problem." She's now incorporating a brief lecture on falls prevention into the curriculum for first-year residents and working to increase awareness among all housestaff.

"Even though our lectures focus on elderly patients," she said, "once residents learn the risk factors, assessment techniques and interventions, they can apply them to any patient."

New prevention mandate

According to the Agency for Healthcare Research and Quality, falls account for up to 70% of accidents among hospitalized patients. And the March 23, 2005, Wall Street Journal reported that 1 million patients fall in hospitals every year.

Between 1995 and 2003, fatal falls accounted for almost 5% of the sentinel event reports reviewed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Spurred by these data, JCAHO made falls prevention one of its national patient safety goals for 2005 and 2006.

Beginning this year, JCAHO requires hospitals to assess and periodically reassess patients' risk for falls and to take steps to reduce those risks. Starting Jan. 1, 2006, the agency will mandate that hospitals design a falls-prevention program as a condition of accreditation. Those programs must include procedures for assessing patients' risk; physical, psychological and environmental measures to reduce falls; and education for patients, families and staff.

Partially as a result of JCAHO's mandate, some residents—like Dr. Hersh—are being trained about inpatient falls in more formal settings, attending multidisciplinary conferences and lectures on falls prevention during mandatory geriatric rotations.

Others may still be picking up tips on falls prevention as they go along. But no matter how they learn, experts say residents play a key role in preventing inpatient falls. Here are tips they recommend:

  • Know the risks. Age, a history of falls, cognitive impairment or confusion, and mobility issues are just some factors that predispose patients to falls. (See "Falls risk factors.") Assess patients for all risks and note risk factors on patients' charts. Tell nursing staff about those risks and take all precautions recommended by your facility's falls-prevention program.

    Medicine residents at Boston University School of Medicine in Boston find out about those risks during a month-long geriatrics rotation.

    "All our residents are taught to ask every patient whether they've fallen before," said Sharon A. Levine, MD, an associate professor of medicine and the director of education for the geriatrics section. "We also have them do a functional neurological exam including the 'Timed Get Up and Go' test to assess for falls risk."

    John J. Ryan, ACP Associate, a first-year resident at Boston University, said that falls risks are also discussed on a case-by-case basis during ward rounds. "Formal teaching sessions are helpful, but when you see a high-risk patient, who was perhaps brought in because of a fall, you tend to personalize and remember the information more."

  • Consider all patients to be at risk. It might be a no-brainer to tag an elderly patient with dementia and a history of falls as high risk. But don't overlook younger, healthier patients who may not realize they've lost some strength.

    Teenage bone marrow-transplant patients, for example, are at particularly high risk, according to Patrice Tims, RN, quality improvement coordinator for Detroit Medical Center in Detroit. "These patients have a strong desire to be in control and independent," she said. "They're not going to let you know if they feel unsteady." Postpartum patients, weak from blood loss and hours of labor, are also at high risk, she said.

  • Educate patients. If patients can understand instructions, educate them about their risk of falling, said Christopher R. Phillips, ACP Associate, a first-year internal medicine resident at Barnes-Jewish who recently attended Dr. Flood's falls-prevention lecture. "Explain to patients that they may not be as strong as they're used to being, and emphasize that they need to call someone before they get out of bed." You can also ask family members to stay close by, especially if the nursing staff is particularly busy.

  • Keep patients as active as possible. One of the ACE-rotation lessons that stuck with Dr. Hersh was the need to get elderly patients some physical therapy as soon as possible. "Patients tend to get weaker in the hospital," he said. "They're more likely to fall after a few days in bed." At Barnes-Jewish, all residents are encouraged to promote mobilization in all patients—and to call for a physical therapy consult for patients who need assistance. Mobility and/or physical therapy help patients maintain muscle strength during their stay.

  • Assess medications. Certain medications—including psychotropics, benzodiazepines and other sedative-hypnotics—are known to increase falls risk, a fact Dr. Phillips learned to appreciate after attending Dr. Flood's falls prevention lecture. "I realized that this is one of the areas where I can really have an impact on a patient's falls risk," he said. He now takes more care evaluating dosage and side effects of potentially sedating medications, and routinely questions the use of those drugs in patients at high risk for falling.

  • Collaborate with nursing staff. Nurses are at the forefront of fall prevention programs and are key players in managing inpatient falls. According to Eileen Costantinou, MSN, RN, a falls prevention consultant at Barnes-Jewish, a recent study conducted at the hospital indicated that when the patient-to-nurse ratio goes above five to one, a patient's risk of falling almost triples.

    Residents and nurses need to communicate about at-risk patients and to determine patient-specific interventions. Barnes-Jewish recently launched a medical student shadowing program where medical students shadow a nurse for a day to learn more about nurses' roles and issues they face, including managing patients at risk for falls.

  • Know your hospital's alert systems and precautions. Chances are your facility has multiple falls alert and prevention systems in place. At Detroit Medical Center, for example, patients wear different colored wristbands that indicate their level of falls risk. Other hospitals put signs on patients' doors or labels in their charts to designate falls risk. Both Barnes-Jewish and Boston Medical Center use bed alarms that sense movement and alert nurses when high-risk patients try to leave their beds.

    According to Ms. Tims, patient safety education has traditionally been geared to nursing staff. To encourage physicians to learn about prevention precautions, the Detroit Medical Center is developing medical safety education modules that will be offered to physicians for continuing medical education credit.

  • Use environmental precautions. After examining patients in their rooms, Dr. Hersh recommended taking the following precautions to minimize falls risk:

    • Make sure the IV pole is on the same side of the bed as the bathroom.
    • Lower the bed as much as possible.
    • Put down the side rail at the foot of the bed closest to the bathroom.
    • Make sure patients can easily access all their personal belongings, such as eyeglasses and water cups, as well as the call bell.
    • Give patients nonskid footwear.
    • Order a bedside commode, if necessary.

    Boston Medical Center's Dr. Ryan added that, especially for elderly, fragile patients who may become confused, it's important to create as quiet and peaceful an environment as possible. (See "NO FALLS.")

     

  • Avoid restraints. According to Erica Bernstein, MD, PhD, a geriatrician at Boston University, residents sometimes get a jarring introduction to the use of restraints when they get called in the middle of the night by a nurse telling them a delirious patient is trying to get out of bed. In the past, she said, residents might have felt pressured to order restraints, but Boston Medical Center has taken extensive measures to show that restraints do nothing to reduce patients' risk of falling—and are especially inappropriate for frail and elderly patients.

    "Restraints never fully restrain someone," Dr. Bernstein said, "and they actually increase the risk of harm in some cases. Patients can slide into positions where they can choke or cause other injuries to themselves—so restraints should be used only in cases where patients pose an extreme and immediate danger to themselves or staff, and should be used for only a very short period."

    Clare Wohlgemuth, APRN, nursing director for the geriatrics section at Boston Medical Center, presents a lecture to all residents on the proper use of restraints. During the lecture, she always asks a resident to volunteer to be placed in restraints to provide an all-too-real perspective of what this feels like.

    "We're gradually getting rid of restraints at our hospital," she said, "and we're teaching residents that it's their responsibility to assess the patient and address the root causes of the falls risk, such as delirium."

  • Follow up on outpatient risks. If you think patients may be at risk for falls after leaving the hospital, find out what resources—such as falls and balance clinics and physical therapy—may be available to them.

    At Boston Medical Center, residents are taught to do a falls risk evaluation when creating a discharge plan. "I thought I'd died and gone to heaven," Dr. Levine said, "when a resident recently told me he'd never discharge an elderly patient from the hospital or emergency room without seeing that patient walk."

    The Association of Program Directors in Internal Medicine is currently sponsoring a pilot project to teach residents about the risks of outpatient falls. Catherine R. Lucey, FACP, the internal medicine program director at Ohio State University College of Medicine and Public Health in Columbus, Ohio, is leading the project, which will involve giving residents a simple card that lists falls risks and screening tools for the outpatient.

    "The goal of the project is to examine whether the card can increase residents' awareness of falls and to remind them to screen patients and refer them to proper resources," she said.

    Because most residents will be involved in some incident related to a patient falling, said Boston Medical Center's Dr. Bernstein, those types of interventions can't come too soon. "We have to bring residents into the fold early," she said. "We can't wait to educate them until after the fall occurs."

Yasmine Iqbal is a freelance health and science writer in Philadelphia.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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Falls risk factors

  • History of falls
  • Older than age 65
  • Functional or mobility issues
  • Cognitive impairment or confusion
  • Being attached to equipment, such as EKG leads, IVs, oxygen, chest tubes and sequential compression boots
  • Incontinence/urinary frequency or urgency
  • Postural hypotension or dizziness/vertigo
  • Medication regime
  • Depression
  • Visual/hearing deficits
  • Decreased peripheral sensation/neuropathy

Source: Joint Commission on Accreditation of Healthcare Organizations, 2005

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