As many nurses are aware, falls are a big problem. They effect not just the health and lives of our patients, but the financial health of our institutions. The experienced nurse has seen this firsthand. The inexperienced nurse is warned of it constantly. Just to be clear, let us look at some statistics.
“Falls account for 70% of accidental deaths in persons 75 years of age and older.” (1)
A 2004 study conducted by JHU found that short term risk of single and recurring falls was three times higher for the two days following a medication change. (2)
“Ten percent of fatal falls for older adults occur in hospitals.” (3)
Goal 9 of The National Patient Safety Goals from JCAHO is to “reduce the risk of patient harm and to implement a fall reduction program“. (4)
These four statistics are enough to ensure that no matter where you work, you have had the pleasure of taking a mandatory course on fall prevention. You have had to fill out paperwork, take quizzes, and document your preventive actions each shift. If you have not been doing this, then your institution is out of compliance and will be implementing these strategies soon.
One of the first things to do is ask them on admission if they have had any falls in the last year. If they have, then they are automatically a high fall risk. (5) Some other more obvious things to assess are visual impairments, use of cane or walker, and urinary urgency or incontinence. One of the less obvious questions would be concerning medication use. If the patient is on a benzodiazepine, then they are at high risk for falls. (5) Any blood pressure, seizure, glucose, or pain medications increases their fall risk. Assess the patient for neuropathies and residual weaknesses from strokes as these can also be contributing factors to loss of balance and weakened gait. Discuss with your new admission the type and frequency of physical activity normal for them. If they are going to be more immobile during their admission than they are at home, then a referral to physical therapy is appropriate to help them maintain a level of ADL capacity for safe discharge home. After you have assessed your patient on admission, your organization will probably have some type of chart for rating their risk. This should easily allow the staff following you to see what you have assessed and follow the appropriate interventions.
For every patient, every shift you work, you will be doing a fall risk assessment. The risk to each patient can vary from hour to hour, and is something that you must become aware of in your daily practice. If a medication has changed, a patient’s level of consciousness has changed, they are experiencing pain or shortness of breath, all of these can change the risk. Imagine you are an older woman who has been placed on a new medication that increases urinary frequency. This is a new problem and you are embarrassed by how often you need to use the call bell. It is likely that you may attempt to go the bathroom independently. Another scenario would be the COPD patient. They may need to stand to urinate, but be weak from their condition. They may misjudge their own capacity and balance.
If your patient is a low risk, then you need to focus on education to keep them at a low risk level. This can be in the form of handouts or verbal reminders. Every patient should be required to notify staff when they are going to be ambulating in their rooms. If a patient has demonstrated safety, then this can be taken on a shift by shift basis. Other things to remind low risk patients about include wearing no-skid slippers or shoes, getting up slowly from supine to upright positions, and any equipment in the room that is on wheels such as tables or poles. If there has been administration of a medication that could change their balance, cognitive functioning, or cardiac response, be sure to warn them. This is especially important with pain medications. Many of us forget that once a patient’s pain is relieved, they may assume that they can resume normal activities, while we may be expecting them to be lying still. Be sure to communicate your expectations and listen to their perceptions of the plan of care.
If your patient is high fall risk, then you need to do as your institution mandates. Some of the more popular interventions include no-slip socks, flags on the chart and doorways, hourly rounding, and bed alarms. Be sure to involve visitors to the patient in this vigilance. Explain to them how dangerous and common falls are so that they truly understand the risk. This will engage them in doing something helpful to the patient and make them feel included in the care plan. Use of personal alarms may be something available to you for the frequently confused patient. These systems can be invaluable in protecting your patient and saving them from injury. Be sure to only use the top two rails of the bed! Anything else is considered a restraint by law and will necessitate following your restraint protocols. Keep commonly used patient belongings within reach, as well as the call bell. It can be helpful to have the patient demonstrate proper call bell use during your initial rounding. This will allow you to assess their ability and give them a motor memory reminder when needed.
When you do get your patients up be sure to use care and caution. Do not hurry them. They are not moving at your pace, ever. You have been whipping around the halls, multitasking, and planning three steps ahead. They have been lying bored in bed or waiting patiently for someone to come and help them. Focus on the task at hand. Remind them to tuck their tailbones under and lift their chins. This causes them to reverse the shuffling hunch that many patients pose. I often joke with my patients when they first stand up to “show me their boobies!” Obviously, you want to be sure that this won’t offend them, but most of them laugh and then stretch their backs into the proper position for correct balance. Many of them will even comment that it feels so good to stand up like that! Notice if your patient is shuffling their feet. This is often a sign of pain or fear. Be sure to address this by establishing trust, making eye contact, keeping a firm steady hand on them, and talking to them about their experience.
Having said all that, it sounds time-consuming, doesn’t it? It isn’t, really. The bottom line is a good assessment at admission, another common sense assessment at rounding each shift, and monitoring the safety measures in place. Combine those with a positive attitude and careful assistance when ambulating your patient, and you will have significantly reduced your patient’s risk of fall, injury, and death.
(1) Am Fam Physician. 2000 Apr 1; 61(7): 2159-68, 2173-4.
(5)Tromp AM et al. Fall-risk screening test: a prospective study on predictors for falls in community dwelling elderly. Journal of clinical epidemiology, 2001, 54:837-844.