Falls Prevention in Hospital

Andrea Németh, MA, Managing Editor, Geriatrics & Aging.

Introduction
Australian researchers who conducted a randomized controlled trial of a targeted multifactorial intervention to prevent falls among hospitalized older adults have found that the approach was not effective for those with relatively short hospital stays.¹ Researchers gathered falls data from 24 acute and older adult rehabilitation wards in 12 Sydney, Australia, hospitals between October 2003 and October 2006. Investigators paired wards on the basis of type (acute care or rehabilitation), fall rates, length of stay, and patient age before randomization: each ward was studied for 3 months. All patients in the ward at the time of the study were included, and data were collected on the health, medication, and physical function of each patient from their medical records. A total of 3999 patients, mean age 79 years and with a median hospital stay of 7 days, were included in the study.

Method
A part-time nurse and a part-time physiotherapist delivered select interventions during the 3-month study. The interventions used were selected from published recommendations^2-4 that could be implemented with the available resources (additional staff time and alarms) of the study. The study nurse assessed patients; provided education to patients and their families; arranged for appropriate walking aids (together with the physiotherapist), eyewear, modifications at bedside, and increased patient supervision; and worked with other staff regarding the necessity of changing medications, managing confusion, and the possibility of foot problems. The study nurse also provided education to groups of staff and individual staff members.

The study physiotherapist saw those patients who were referred by the study nurse and other ward staff. She led patients, individually or in groups, through exercises designed to enhance balance and ability with functional tasks, and practiced safe mobility with patients around the ward.

Ambulant patients assessed to be at high risk of a fall due to delirium or cognitive impairment were fitted with a custom-designed alarm in the form of a neoprene rubber sock with a pressure switch under the heel and a small loudspeaker in a pocket in the sock. The alarm emitted a loud, high-pitched tone when weight was put on the pressure switch, indicating that the patient was standing and required support.

Results
Among the 24 hospital wards (12 acute and 12 rehabilitation), 3,999 patients were studied; the average total number per ward during the 3-month study period was 167 overall, 233 (range 113-332) for the acute wards and 100 (range 56-170) for rehabilitation wards.

During the study period, 381 falls occurred, with an overall rate of falls of 9.2 per 1,000 bed days. The authors saw no difference between the rate of falls in acute care wards (9.4 per 1,000 bed days) and rehabilitation wards (9.0 falls per 1,000 bed days), nor did they find a differing rate of falls in the intervention versus control wards during the period studied. The mean fall rate in the intervention wards was 9.26 per 1,000 bed days, while the control wards saw 9.20 falls per 1000 bed days.

The intervention was also found to have no effect on the rate of injurious falls, for which the unadjusted incidence rate ratio was 1.12 (95% confidence interval 0.71 to 1.77).

The study authors posit that previous falls prevention studies^5,6 may have demonstrated a positive effect of intervention due to the relatively long length of stay in those studies (30 days and 20 days). In this study, the median length of hospital stay for patients was just 7 days. The investigators suggest that prevention interventions such as exercise require longer than a few days to take effect. They conclude that preventing falls among older adults in the hospital may require innovative approaches, including better ways to assess cognitive impairment, the use of low beds and hip protectors for preventing injury, a redesign of wards so that high-risk patients are easily seen at all times by staff, continual supervision of those patients at highest risk of falling, and a system-wide approach to falls prevention led by ward staff themselves.

References

1. Cumming RG, Sherrington C, Lord SR, et al. Cluster randomized trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ 2008;336:758-60.
2. Shanely C. Putting your best foot forward: preventing and managing falls in aged care facilities. Sydney: Centre for Education and Research on Ageing, 1998.
3. Lord SR, Sherrington C, Menz H. Falls in older people: risk factors and strategies for prevention. Cambridge: Cambridge University Press, 2001.
4. Australian Council for Safety and Quality in Health Care. Preventing falls and harm from falls in older people. Best practice guidelines for Australian hospitals and residential aged care facilities. Canberra: Australian Council for Safety and Quality in Health Care, 2005.
5. Haines TP, Bennell KL, Osbourne RH, et al. Effectiveness of targeted falls prevention programme in subculture hospital setting: randomized controlled trial. BMJ 2007;334:82-7.
6. Healey F, Monro A, Cockram A, et al. Using a targeted risk factor reduction to prevent falls in older in-patients: a randomized controlled trial. Age Aging 2004;33:390-5.