Nurses are trained in patient safety, where they can make a difference. That responsibility includes efforts to prevent falls in the hospital. From the first days in nursing school to working as a licensed professional, proactively and continuously working to prevent falls among patients is a fundamental part of a nurse's job. While all patients are cared for implementing what nursing professionals know as universal fall precautions, patients deemed at high risk for falls will trigger additional nursing interventions integrated into the plan of care. In 2020, falls caused more than 36,000 deaths of people 65 and older, according to the Centers for Disease Control.
Consequences come in many forms
Why do we pay so much attention to the surveillance and prevention of falls? Falls in hospitals occur at an alarmingly high rate. Approximately 700,000 to 1 million people fall in hospitals each year in the U.S., according to the Agency for Healthcare Research and Quality. And more than one-third of patient falls that occur in hospitals result in serious injuries such as fractures and head trauma. Hip fracture is most common with seniors, said Jennifer E. Voorlas, MSG, CMC, gerontologist and care advocate, CEO of Geriatric Care Consultants, LLC, a private case management business located in Malibu, Calif. "Once that happens, the quality of life is never the same and the person has an ongoing fear of falling again, which can impact ability to rehab properly," she said. "This results in non-ambulatory patients, which can lead to muscle wasting, weight gain, depression, and increased stroke risk."
In addition to the human cost of pain and suffering for patients that can result from falls, the monetary costs to hospitals are considerable -- in the tens of thousands per incident and in the millions per year for a hospital.
Direct and indirect costs of falls
Allison Lieberman, PT, MSPT, GCS, clinical manager of acute physical and occupational therapy at the JFK Johnson Rehabilitation Institute in Edison, N.J., explains the direct and indirect costs of falls. Direct costs of falls include surgery, testing, treatment, medication, and physician fees. Indirect costs of falls include disability, caretaker time, and a reduced quality of life. For hospitals, a high rate of falls can result in a hit to their reputation. So that is another reason it is important to prevent falls in hospitals. "We are living in an era of value-based purchasing," said Lieberman. "What this means is that individuals have access to certain types of data which will help influence their decision in choosing a healthcare provider. When data such as falls becomes publicly accessible, that may play a role in which type of consumers or patients choose to be part of your organization. So, keeping falls to a minimum and minimizing risk in the hospital is extremely important."
While some falls are not avoidable, one study concluded 20% to 30% of falls are preventable when fall risk is continuously assessed, and the appropriate fall prevention interventions are implemented.
Because many falls are preventable, the Centers for Medicare and Medicaid Services considers a fall in the hospital -- and its subsequent injuries and trauma -- a hospital-acquired condition for which they will not reimburse payment.
Identifying patients at a higher risk of falling
Multiple factors can increase a patient's risk for falling while in the hospital. They include:
- Generalized weakness and a lack of lower body strength at baseline or because of current illness or surgery
- Having a balance disorder
- Advanced age (> 65)
- Having a previous fall
- Medication side effects
- Medical devices that impede movement (IV poles, catheters, etc.)
- Cognitive issues and delirium
- Vitamin D deficiency
- Vision problems
- Improper shoes/slippers
- A cluttered environment
- Wet floors
Universal fall precautions in hospitals
Every hospital has its own set of policies about conducting fall risk assessments with the use of a specific fall risk assessment tool, fall prevention strategies, and reporting and treatment procedures when falls occur. However, universal fall precautions form the backbone for programs to prevent falls in the hospital. The AHRQ described universal fall precautions as "universal because they apply to all patients regardless of fall risk. Universal fall precautions revolve around keeping the patient's environment safe and comfortable." The basics of fall prevention strategies that nurses own and are taught in nursing school and on the job are:
- Orient patients to their room.
- Ensure the call light is accessible and each patient knows how to use it.
- Keep the patient's personal possessions handy so they can easily reach them.
- Maintain the lowest height position of the bed -- only raise the height when you need to provide care.
- Place side rails in the upright and locked position when a patient is in bed.
- Keep the brakes of wheelchairs and beds locked, unless you need to move patients to another location while they're in their wheelchair or bed.
- Follow your facilities' protocols for the safe moving, transferring and ambulating of patients.
- Continuously monitor patient rooms for clutter and remove or relocate clutter deemed unsafe for increasing the risk of slips and falls.
- Assess each patient's slippers/shoes for proper fit and the appropriate non-skid features.
Specific steps for fall prevention in hospitals
Nurses can take other steps to prevent falls in hospitals. Constant reassessment of medication changes, pain level, psychological distress, vision deficits (especially visual spatial deficits), fear of falling because of a previous fall, and other elements also can help reduce risk, Voorlas said. Lieberman said after a patient is found to be at risk for falls, nurses also can use colored arm bands or socks to designate fall risk -- and there are plenty of other steps nurses can take. "We can place individuals who have a high fall risk closer to the nursing station so that individuals can keep a better eye on them," she said. "We can put them in beds that are very low to the ground so at least if they were to fall out of the bed the chance of injury is minimalized. And we can consider using floor mats so, once again, if they were to fall out of the bed or slip out of the chair they can land on a more comfortable soft surface minimizing the chance of injury." Nurses can communicate fall risk in electronic medical records, huddle boards, or at the bedside, Lieberman added. Educating patients orally and in writing about fall risk and prevention and using teach-back strategies are important. So is teaching patients how to avoid a fall and what to do if they do fall, Lieberman said. For instance, do they know where the call buttons are located throughout the patient room? Nurses also want to keep a lookout for any unsafe conditions or equipment such as:
- Unstable handrails in bathrooms, patient rooms, and hallways
- Nonfunctioning lights in rooms and hallways
- Wet floors
Report these and other hazards immediately and prevent access to any areas affected until the issues are resolved.
Thorough reporting of all falls and near misses
Some patients or family members may not think of an incident as a fall or a big deal -- but it is. "Let's say a patient is in the bathroom," Lieberman said. "They may lose their balance and fall on to the commode or on to the sink. That should be considered a fall." If a patient loses his or her balance but is caught by a caregiver or family member, that may be called a near fall or a near miss. "Near falls and near misses should be treated as true falls by the hospital staff because the factors that contributed to that near miss could potentially happen again," said Lieberman. "For care planning we want to take these near misses into account and conduct constant patient reassessment."
Leveraging technology to prevent falls in hospitals
In addition to the invaluable observation and intervention skills of nurses and other healthcare professionals, sensor technology that triggers an alarm to notify staff when a patient exits a bed can also help reduce the number of falls. One study which analyzed the efficacy of sensor technology, saw just over a 54% reduction in falls when bed sensors were installed for high risk patients, enabling staff to intervene quickly. Some hospitals use iBed Wireless technology, which is compatible with many information management systems and helps prevent patient falls via an enhanced ability to monitor risk and respond in a timely manner. Another method to monitor patients at high risk for falls is using video monitoring and employing a monitor technician for remote, ongoing observation. One study concluded the use of video monitoring reduced inpatient fall rates by a significant rate -- 35%. The study also noted a reduction in the need for one-on-one sitters/chaperones. Budgets need to extend to more training across all settings upon admittance, during the hospital stay, and upon discharge," said Voorlas. "Training is integral and measures for fall risk and reassessment continuously need to be a part of the care plan." Editor's Note: This blog post was originally published in December 2020 and has been updated. For more information on interventions nurses can take to promote patient safety, see our continuing education on reducing hospital-acquired conditions like falls.
