Hospital Practice

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A hospitalist’s role in preventing patient falls

Rachel Keuseman & Donna Miller

To cite this article: Rachel Keuseman & Donna Miller (2020): A hospitalist’s role in preventing
patient falls, Hospital Practice, DOI: 10.1080/21548331.2020.1724473

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Published online: 13 Feb 2020.

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HOSPITAL PRACTICE
https://doi.org/10.1080/21548331.2020.1724473

CLINICAL FOCUS: GERIATRIC MEDICINE

REVIEW

A hospitalist’s role in preventing patient falls

a
Rachel Keuseman and Donna Millerb
a
Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA; bDivision of Hospital Internal Medicine, Division of Geriatrics and
Gerontology, Mayo Clinic,Rochester, MN, USA

ABSTRACT ARTICLE HISTORY

Despite decades of fall prevention efforts, patient falls remain a common cause of harm in hospitalized Received 31 October 2019
older adults. While fall prevention strategies have been historically championed by nurses, hospitalist Accepted 29 January 2020
physicians, nurse practitioners, and physician assistants play a vital role in the multidisciplinary care KEYWORDS
team in ensuring the safety of our patients. Multiple fall risk assessment tools exist, but no one tool has Accidental falls; hospital;
demonstrated excellence in predicting patient falls in the hospital. Any fall risk assessment tool should hospitalist; patient safety;
be complemented by a clinician’s individualized evaluation of patient-specific, situational, and environ- review
mental risk factors. A particular emphasis on medication review is critical, as numerous medication
classes can increase the risk of falls, and medications are a potentially modifiable risk factor. Multiple
studies of individual and multicomponent nursing-based interventions have failed to demonstrate
success in reducing falls or fall injuries. Promising strategies for fall prevention include tailoring
interventions to patient risk factors and individualized patient education. In addition to nursing-based
interventions, the hospitalist’s role in fall prevention is to (1) identify and address potentially modifiable
risk factors, (2) reinforce individualized education to patients, and (3) advise behavior choices that
promote safe mobility. If a patient does sustain a fall, the hospitalist should partner with the multi-
disciplinary care team in post fall care to assess for injury, evaluate underlying causes of the fall, and
determine plans for secondary prevention.

Introduction risk for falling, review literature and guidelines regarding fall
prevention interventions, and review salient aspects of post-
Falls that take place in the hospital are a common cause of
fall care. This review also addresses the practical role of the
significant morbidity and mortality for geriatric patients. The
hospitalist in patient falls. While much of the fall prevention
National Database of Nursing Quality Indicators (NDNQI) defi-
literature surrounds assessment tools and interventions deliv-
nition of a fall is ‘an unplanned descent to the floor with or
ered by nurses, hospitalist clinicians (physicians, nurse practi-
without injury to the patient.’ Fall data is typically displayed in
tioners, and physician assistants) have an important role to
rates, with about 3–5 falls occurring per 1000 patient days in
play on the care team in addressing patient-specific fall risk
the US and UK [1,2]. However, rates displayed as events per
factors and engaging patients in making safe behavior choices
patient days can diminish the true size of the problem. Falls
in the hospital.
occur in about 2% of the hospitalizations [1], and it is esti-
mated that 700,000 to 1,000,000 patient falls occur each year
in hospitals across the US [3]. Falls have direct and psycholo- Methods
gical impacts, including costly physical injuries, loss of confi-
A literature search was conducted using PubMed as well as
dence, and loss of independence. In one study of NDNQI data
Ovid with the search terms ‘Falls, inpatient, geriatric, preven-
from US hospitals, 26% of falls resulted in injury, and 1 in 20
tion, and falls with injury’ dated January 2009 to March 2019.
results in serious injury (e.g. fracture) [1]. The prevalence of
Additionally, a reference librarian did a literature review with
injury from falls can be high as 30–50% [2]. Patient death or
these keywords. The reference sections of several papers were
serious injury associated with a fall while being cared for in
also reviewed to find additional articles.
a health-care setting is considered a ‘Never Event’ by National
Quality Forum (NQF) of the United States, and Centers for
Medicare and Medicaid Services will not reimburse costs asso- Risk factors for falling
ciated with falls in hospitalized patients. Falls are costly and
An important first step in the prevention of inpatient falls is
account for 0.85–1.5% of health-care expenditures within the
knowing what increases a patient’s risk of falling. Risks may be
US, Australia, EU15, and the United Kingdom [4]. This summary
patient specific, situational, and/or environmental. Observational
will review factors that may place patients at increased risk for
and prospective cohort studies in long-term care facilities sug-
falling, describe tools that may be used to assess a patient’s
gest that a history of falling, increased age, impairment in ability

CONTACT Rachel Keuseman [email protected] Division of Hospital Internal Medicine, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
© 2020 Informa UK Limited, trading as Taylor & Francis Group
2 R. KEUSEMAN AND D. MILLER

Table 1. Risk factors for falls in hospitalized patients. impairment, and mental status to score patients at low, mod-
Gait instability erate, and high risk of falling [24]. The Hendrich II scale
Lower limb weakness
includes gender, mental/emotional status, dizziness, and med-
Urinary incontinence, frequency, or need for assisted toileting
Previous fall history ications [22]. The Hester Davis Scale is a newer tool, which
Agitation/confusion or impaired judgment includes nine factors including age, time from last fall, mobility
High risk medications, especially centrally acting medications (e.g. hypnotics) limitations, high risk medications, mental status, toileting
Content adapted from Oliver et al. (2004) [9]. issues, hydration needs/volume status, sensory difficulties,
and behavior characteristics [23]. A quick test that hospitalist
to walk, cognitive impairment, visual impairment and decreased clinicians can use at bedside is the ‘Timed Up and Go’ (TUG)
strength increase the risk of falling [5–7]. Common risk factors for test. The patient starts this examiniation from a seated posi-
patient falls in hospitalized settings are included in Table 1. The tion in a chair. The examinier instructs the patient to stand up,
weighted power of each individual risk factor is difficult to quan- walk at a normal cadence to a marker of 10 feet (or 3 m), turn
tify, given the multifactorial etiology of falls and the heterogene- around, walk back to the chair, and sit down again. If the
ity of methods in research on falls. Gait/balance issues and lower entire TUG test takes more than 12 s (a stop watch is helpful),
extremity problems were shown to increase the risk of falls in the patient is identified as having a higher risk of falling, and
a case control study in a large urban academic hospital [8]. further evaluation is necessary [26].
Situational risk factors which increase the risk of falls include
several classes of medications including diuretics, beta- Interventions designed to reduce falls
blockers, sedatives or hypnotics, diabetes medications, psycho-
tropic medications, as well as polypharmacy [6,8–10]. Among Regardless of the tool used, the goal of any fall risk assessment is
newer hypnotic agents, zolpidem has been specifically studied to identify actionable risk factors, which then guide the develop-
in a large retrospective cohort study at Mayo Clinic, a tertiary care ment a patient-centered plan of care to prevent future falls.
center in Rochester, MN USA, and was found to be associated Despite awareness of medical risk factors, the published litera-
with significantly increased fall rates (3.04% vs 0.71%; P < 0.001) ture on fall prevention strategies largely surrounds nursing-
[11]. Additional situational factors including delirium and urine or based assessments and nursing-based interventions. Many of
stool incontinence have been found to be associated with fall risk these studies describe bundled interventions provided to
[8,12]. Environmental hazards such as wet floors, higher than patients identified as being ‘at risk.’ Unfortunately few studies
ideal bed heights, carpeted floors, and clutter may also contri- with interventions aimed at reducing inpatient falls have been
bute [13,14]. Epidemiologic studies suggest that as many as half able to demonstrate significant reductions in falls or fall injuries.
of falls occur when hospitalized patients are not within arms- A large systematic review of the literature and meta-analysis
reach of caregivers and many falls occur around toileting [15]. evaluated randomized controlled trials in residential/nursing
While many factors may increase a patient’s risk of falling, some care facilities (71 studies), or hospitals (21 studies) which utilized
patients are more likely to be seriously injured. Factors shown to interventions designed to reduce falls in older patients [27].
increase the risk of injurious fall include a history of fall with Additional physiotherapy beyond standard care was not shown
injury, osteoporosis, anticoagulant or antiplatelet therapy, to reduce fall rates in the hospital, based on pooled data from the
increased age, agitated confusion, frequent urination, lower review. Bed exit alarms were also shown to be ineffective in
limb weakness, and loss of consciousness [16–18]. Toileting is reducing fall rates or risk of falling. Review of medication appro-
an important situational factor increasing the risk of both non- priateness in 114 older adults in a subacute hospital setting in
injurious and injurious falls [15]. Germany utilizing a quasi-cluster randomized trial showed
a reduced fall rate per 1,000 patient-years for the intervention
group (1.5 ± 8.3) compared to the control group (10.6 ± 25.4, p <
0.004) [28]; however, Cameron and colleagues concluded that
Tools utilized for fall risk assessment
there was no compelling evidence for a reduction of the rate of
Screening tools are often implemented in hospital settings to falls after adjustment for clustering [27]. The analyzed pooled
alert staff to a patient’s increased fall risk. There are several data did suggest a significant positive impact of multifactorial
validated, standardized, numeric tools that can be used to interventions in hospitals which reduced the rate of falls. There
categorize patients into fall risk categories such as low, mod- was variation in effectiveness when looking at individual trials.
erate, or high. Unfortunately, while validated to identify risk Notably, a cluster randomized trial involving 46,245 admissions
factors, few of these tools have demonstrated success in pre- patients (average age 67) in 16 medical and 8 surgical wards
dicting actual patient falls in hospitals [2]. The Hendrich II Fall using multifactorial interventions was unsuccessful in reducing
Risk Model and Morse Fall Scale have been recommended as falls. Investigators evaluated the effectiveness over usual care of
standardized and validated tools by The Joint Commission what the authors defined as a ‘6-Pack’ intervention over a 12-
[19]. There are numerous fall risk assessment tools, including month period in multiple medical/surgical wards. The ‘6-Pack’
the Hester Davis Scale, St. Thomas’s Risk Assessment Tool involved individualized interventions which could include a fall
(STRATIFY), and Conley Scale [20–25]. These tools use different alert sign, bathroom supervision, patient proximity to walking
criteria to predict fall risk and can be integrated into the aids, a toileting regimen, low beds with exit alarms, and ensuring
patient’s medical record. The Morse Fall scale calculates risk patients were within arms-reach when ambulating. Rates of falls
based on factors including history of falling, presence of and fall injuries were similar between the intervention and con-
a secondary diagnosis, ambulatory aid, IV access, gait trol group [29].
 HOSPITAL PRACTICE 3

A closer look at trials which did show effective interventions In conclusion, the two areas that have the strongest evi-
suggests that a personalized approach with an emphasis on dence base for effectiveness in preventing falls in the hospital
patient engagement and education may contribute to success. are (1) patient-centered plans of care based on the identifica-
A prospective randomized controlled trial of 1822 patients in an tion of specific risk factors and (2) individualized patient edu-
acute care hospital in Singapore targeted patients at risk for cation and engagement strategies. Figure 1 displays a
falling based on Hendrich II Fall Risk Model. They compared practical framework for the hospitalist’s role in fall risk factor
usual care with a multi–intervention approach which added identification and management, as well as how a hospitalist
patient education (family education if the patient was con- can partner with the care team in engaging the patient in safe
fused). Education was provided about individualized risk factors behavior choices.
along with strategies that the patient could act on such as
getting up slowly to prevent dizziness. The relative risk of falling
was 0.29 (95% CI: 0.10–0.87) in favor of the intervention group
Post fall care
[30]. Another cluster-randomized study of the Fall TIPS inter- Early recognition and treatment of fall-related injuries is as
vention included 10,264 patients in 4 urban US hospitals col- important as prevention strategies. When injury is present,
lected data on fall rates over a 6-month period [31]. A fall rapid assessment is crucial to improve outcomes. The
prevention toolkit was integrated into existing workflow utiliz- National Patient Safety Agency (now a part of NHS
ing software which would tailor interventions to address Improvement of the United Kingdom) released a guide called
patients’ specific fall risk factors. Recent falls, multiple medical ‘Essential care after an inpatient fall’ [33]. They emphasized
issues, need for gait aids, IV therapies, gait impairment, and that care after a fall is often inadequate and results in delays in
mental status changes were considered risks and illustrated diagnosis of serious injury such as fracture or intracranial
icons prompted bedside alerts to stakeholders with appropriate hemorrhage. Recommendations included evaluating patients
interventions customized to patient-specific sources of fall risk. at the time of injury before moving them if possible. If signs of
Fall rates per 1000 patient days were significantly higher in the serious injury are present or if the patient is more vulnerable
control group (4.18, 95% CI, 3.45–5.06) compared to the inter- (for example, a head injury in a patient on anticoagulation),
vention group (3.15, 95% CI, 2.54–3.90 P= .04). In another study, rapid evaluation by a clinician is necessary. For head injuries,
a stepped-wedge cluster-randomized controlled trial including patients should be closely monitored and any new or evolving
3606 admissions (1983 control, 1623 intervention, mean age 82 neurologic symptoms or drop in Glasgow coma score (GCS),
years) was performed [32]. In this study, individualized multi- increasing headache, persistent vomiting, agitation, or con-
media education provided by a physiotherapist was associated cerning behavior should be noted. If any of these concerning
with a reduction in the rate of falls (adjusted rate ratio 0.60, features are present this should prompt rapid assessment by
95%, CI 0.42–0.94, p = 0.003) and reduction in the rate of the supervising doctor. National Institute for Health and Care
injurious falls (adjusted rate ratio 0.65, 95% CI 0.42–0.88) com- Excellence of the United Kingdom (NICE) guidelines suggest
pared to the control group. The rate of falls in the intervention minimum documentation after head injury to include GCS,
vs control group was 7.8 vs 13.8 per 1000 patient, respectively. pupil size and reactivity, limb movements, a complete set of

Figure 1. Strategies for hospitalist to partner with the team to reduce patient falls.
4 R. KEUSEMAN AND D. MILLER

vital signs (including oxygen saturation) every 30 min for 2 h, One-to-one patient education should be provided with review
every hour for 4 h and every 2 h thereafter as long as GCS by a trained professional. There should also be a standardized
remains stable. After a fall, secondary prevention should be hand-off communication process between caregivers regarding
undertaken with assessment of modifiable patient specific and a patient’s specific risk and interventions. The Joint Commission
environmental risk factors [34]. also emphasized the importance of a post-fall huddle involving
Following assessment of injury, the care team should con- all levels of staff to assess factors that contributed to the fall,
duct a post fall huddle. The post fall huddle is an opportunity preferably with a standardized tool. Reporting and analyzing fall
for the multidisciplinary team to gather, discuss the circum- data with an aim to improve fall prevention strategies and
stances of the fall, the underlying causes of the fall, and reduce falls must be a continued effort [19].
strategies to prevent future falls. Addressing the precipitating
fall risk factors and ensuring patient engagement in the safety
plan of care are critical. Ideally, the post fall huddle will occur Implications for practice
within minutes after the fall and will include the patient, Hospitalist physicians, nurse practitioners, and physician assis-
nursing staff, primary team provider, and/or any family/visitors tants play a vital role in the multidisciplinary care team in
or ancillary staff (e.g. physical therapy) who were present at ensuring the safety of our patients. The literature clearly
the time of the fall. Participation in post fall huddles may demonstrates that nursing-based screening and interventions
reduce the risk of future falls and can promote positive per- alone are insufficient to prevent falls and fall-related injuries in
ceptions of teamwork and safety culture [35]. The Agency for the hospital; multidisciplinary partnership is required. While
Healthcare Research and Quality of the United States (AHRQ) fall prevention has typically been largely championed by our
published a Preventing Falls in Hospitals Toolkit which pro- nursing colleagues, there are several specific actions that we
vides excellent resources for practical aspects of fall preven- can and should undertake to partner with the care team and
tion program, including a tool for the post fall assessment [36]. keep our patients safe in the hospital (Figure 1). Central to our
role is to identify and treat potentially modifiable fall risk
Additional resources: toolkits/roadmaps/guidelines factors, and to provide individualized counseling to patients
to promote safe behavior choices.
Hospitalist clinicians looking to reduce falls and falls with
injury at their local institutions, the IHI released a ‘How-to-
Guide’ in 2012 which suggests evidence-based changes to Take-away points
reduce serious injuries from falls in hospitalized patients and
● Know your patient’s fall risk factors and fall history. Fall
shares helpful resources/tools [37]. Several points are empha-
sized. The first recommendation is to utilize a standardized risk assessment tools can be utilized but should also be
screening tool to assess fall risk with documentation of fall complemented by a clinician’s individualized evaluation
history at admission, and screening for risk factors of serious of patient-specific, situational, and environmental risk
injury. For those at risk, perform an in-depth fall risk assess- factors.
● Reduced use of medications is known to increase the risk
ment. Communication between care providers about patient-
specific fall risk at shift changes is very important. Additionally, of falls. Sedative hypnotics should not be used to treat
it is vital to educate patients and family members with ‘teach insomnia in the hospital. Use caution with any medica-
back’ on risks for falling and what patients can do themselves tion that can affect mental status (pain medications,
to prevent falls. Hospital-wide and patient level safety sedating medications, etc.). Antihypertensives can cause
improvements should be implemented to eliminate environ- orthostatic hypotension, and orthostatic vital monitoring
mental hazards. Frequent rounding every 1–2 h to address should be considered. Assess the necessity or timing of
patient needs of pain relief, toileting, and repositioning is diuretics and laxatives which increase patients’ need for
recommended. For those at highest risk of falling, there toileting, or strategize safety plans of care that anticipate
should be an increased intensity of observation, personal toileting urgency or frequency.
● Educate patients by acknowledging their fall risk, encou-
devices to reduce falls, and interventions to reduce medica-
tion side effects [37]. rage early assisted mobility, reinforce safety plans, and
There is a great opportunity for physicians, nurse practi- communicate with nursing.
● Perform post-fall evaluation promptly to assess for
tioners, and physician assistants to become leaders for change
and quality improvement within their institution. The Joint injury, evaluate the underlying causes of the fall, and
Commission, the not-for-profit accreditation group for health- determine plans for secondary prevention. Complete
care organizations in the United States, implores health-care a post-fall huddle with available stakeholders and docu-
groups to support efforts to raise awareness about fall safety ment appropriately.
at all levels of clinical and non-clinical staff. A multidisciplinary
falls prevention team should be established within an institu- Declaration of interest
tion. As in the IHI toolkit mentioned above, The Joint
Commission recommends hospitals adopt a standardized fall The contents of the paper and the opinions expressed within are those of
the authors, and it was the decision of the authors to submit the manu-
risk tool which would preferably be incorporated into the med- script for publication.
ical record. An individualized plan of care should be made Peer reviewers on this manuscript have no relevant financial or other
for patients with strategies to address specific risk factors. relationships to disclose.
 HOSPITAL PRACTICE 5

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