Fall prevention and mitigation of patient injury if a fall does occur is a critical part of a hospitalized patient’s plan of care. Having a comprehensive strategy in place to prevent in-hospital falls has grown challenging in recent years. Patients are getting older and sicker, the nursing workforce is aging, and of course, hospitals and caregivers are wrestling with the enormous pressures and limitations created by the pandemic. To work around these obstacles, the healthcare industry must become more aggressive in its approach to fall prevention and improving patient outcomes.
Patient falls continue to be a common adverse event reported in hospitals. Every year, between 700,000 and 1 million people fall while being treated in the hospital. It is also estimated that up to 11,000 U.S. patients die annually due to injuries sustained from a fall during hospitalization.
Not only is the cost of these falls to the healthcare system enormous—$20 billion annually—but the Centers for Medicare and Medicaid Services (CMS) is no longer reimbursing providers for treating patient injuries resulting from falls in a hospital.
For patients, the long-term effects of falls can be debilitating. Caregivers are also equally impacted. From a personal perspective, during my time working at the bedside on a MedSurg unit, I have personally experienced two patients falling during my watch. It is something I will never forget from an emotional perspective, and how draining it was on both the individual and team morale on the unit. My current clinical work today is in the hope that no other nurses or patients have to endure another patient fall.
Today, the criticality of patients is increasing. Nurses are seeing sicker patients than ever before. Patients are also living longer, with those 65 years and older representing nearly 40 percent of hospitalized adults. Nurse-to-patient ratios have also gotten out of balance, which can lead to fatigue, burn-out, and mistakes. In my experience, on any given night, a Med/Surg nurse could have up to eight patients at one time in his or her care. When you couple this with the fact that the nursing workforce is aging, a potential shortage could also pose big problems. The onset of COVID-19 has also presented its set of challenges.
For nurses, the restrictions that caring for a patient in the COVID “bubble” has placed on them–from donning and taking off PPE to the limited interaction they can have with patients–is something very new and hard to navigate. These protocols can leave patients susceptible to falls. Additionally, there are concerning reports that many COVID patients experience delirium, which also elevates the risk level for falls.
There are a number of ways hospitals can address these challenges to help improve patient outcomes.
One of the most important is improving bed technology—including standardization and interoperability. One studyshowed that 79% percent of falls were unassisted. In addition, 85% of falls occurred in the patient’s room. The problem is many hospitals today use multiple generations of beds, all with varying degrees of technology and options. This makes training on beds much more challenging. Hospitals should consider standardizing their beds to one specific kind, as this helps support a nurse’s interaction with the bed becoming a hardwired process and promotes easier decision-making. Thankfully, technology has arrived to help achieve these ends.
Stryker, for example, just came out with a new bed, the first of its kind, that can connect wirelessly to any nurse call system and can be used for all acuity levels. Called ProCuity™, this “intelligent” hospital bed not only helps alert nurses if a patient is out of position or has left the bed, it also eliminates difficult tasks like ensuring a nurse call cable is properly plugged in. By streamlining usability, training, and maintenance, technological advancements like this help hospitals make their beds work better for patients and staff.
With wireless technology, hospital beds can be connected to any nurse call system.
Another important fall prevention strategy is data analysis. Numbers don’t lie and so one of the best ways to ensure a hospital’s fall prevention strategy is on track is to routinely monitor and analyze data around fall rates. By determining the cause and type of falls that occur, hospital administrators have a 360-degree view of the issue and can take forward-thinking action to prevent reoccurrence.
Communication is also paramount. When a fall occurs, all appropriate stakeholders in charge of a patient’s care should conduct post-fall huddles to assess all the factors that contributed to the accident and plan an appropriate mitigation strategy. Effective after-action review may also improve team performance by 20-25%. Likewise, nurses should communicate with their patients—what I call teach-back education. By asking open-ended questions about their well-being and state, nurses can help identify potential fall risk problems beyond just finding a shaky grab bar in the bathroom.
When it comes to fall prevention, there is no one size-fits-all-plan. But as the pandemic and other healthcare challenges have shown us, we can no longer be reactive in our planning. With better technology, more data, and increased education and communication, we can more quickly reach our desired outcomes—improving the safety of our patients and caregivers.
The emergency department (ED) presents a set of unique challenges for patient care, not the least of which is unstable patients who are at great risk for falls. I once heard a nurse educator proclaim: “Everyone is a fall risk in an ED.” From the elderly to the acutely ill, most patients in the department are at possible risk of falling, whether due to their age, their complaint, or the medications and treatment they are receiving. Additionally, many EDs do not have bed or chair alarms available for gurneys to assist with patient falls. Fall prevention is almost solely in the hands of the busy ED nurse.
Here are six ways you can help prevent patient falls in the emergency setting.
1. Use universal falls precautions.
All patients—from the 30-year-old with abdominal pain to the 65-year-old post–total knee replacement—are at risk of falling. In your own practice, using universal falls precautions can be helpful. Treating all patients as though they have the same risk for falls is a good start. Additionally, performing individual fall risk assessments on each patient at the beginning of his or her visit is important to both assessing risk and documenting that risk in the medical record. If completing a falls risk assessment is not mandatory at your facility, consider printing out the Morse Fall Scale and attaching it to your ID badge for quick reference. A standardized tool can help you quickly quantify the risk of patient falls so you can intervene accordingly.
2. Plan your interventions.
My personal favorite fall prevention intervention is the call light. On patient care whiteboards in the ED rooms, I write my name and the phrase, “Please use your call bell for ANY reason” on the board. I orient patients to the call bell immediately and make sure that it is in reach. I explain to them why both side rails need to stay up. Additionally, you may place fall risk socks (or grippy non-skid socks) on your patient as soon as you get them undressed into a gown. Use a fall risk yellow arm band if they’re available to you.
3. Orient your patient.
“I’m going to be your nurse today, and the best way we can work together is for you to help me keep you safe.” I remind patients that even if they feel fine, that trying to get up after laying down or after receiving high-risk pain medications can cause them to feel weaker or dizzier than they might imagine. I encourage patients to use the call bell so I can help assist them out of bed for any reason, but it is also important to set expectations. “It may take me a few minutes to respond, but I will be there as soon as I can.” Try to point out IV lines and oxygen tubing to patients as well as their EKG cables and monitoring leads to remind them that they will need to stay in bed and cannot get up without assistance.
4. Active toileting.
One of the biggest reasons that patients fall is because they have to use the bathroom. For male patients I always place “just in case” urinals at the bedside, and I encourage female patients to use the call bell as soon as they think they have to use the restroom. It is also recommended that you offer toileting as frequently as possible so that you are able to prevent the “have to go right now” urge that draws patients out of their beds.
5. Teamwork works.
It would be impossible for a nurse to be able to be in all of his or her patients rooms at all times, especially within the environment of the ED. If you have a patient who is a high fall risk, who perhaps has dementia or is uncooperative, notify your charge nurse and your colleagues on the unit. Try to move the patient to a room in sight of the nurses’ station or near a hallway. Keep the curtains to the room open if possible to allow as much sight as possible from passersby. If staffing allows, perhaps you could request a safety sitter to help watch the patient to keep them safe.
6. Speak up.
If there are conditions on your unit that continually put patients at risk for falls, report them to your manager and supervisors. It is everyone’s responsibility to help prevent patient falls.
Whether you’re working in a hospital, a rehab facility, an assisted living care facility, or doing home health care, chances are that, at some point, you will come across patients who are at a high risk for falling.
According to the Centers for Disease Control and Prevention (CDC), more than 700,000 patients each year are hospitalized because of a fall injury—and most often, this is because of either concussions or hip fractures. In addition, one out of every five falls tends to result in a serious injury such as broken bones or a head injury of some sort. Annually, the medical costs for these fall-related injuries are approximately $34 billion, with two-thirds of that being hospital costs.
These types of patients aren’t the only ones at risk for falls, though. Other diseases, medical conditions, and various medications can also put patients at risk for falling. The key for nurses is to help patients prevent falls as much as possible.
Even if you’ve received training to deal with this patient type, there are always more actions steps you can take and tips to keep in mind. Especially with fall-risk patients, you can never be too careful.
Evaluate and Assess
“In the hospital, the first thing that should be done is an evaluation of the fall risk. Your patient assessment will clue you in on how much of a fall risk your patient is,” says Sherae Durham, BSN, RN, TCRN, the trauma coordinator for education, injury prevention, and outreach at Osceola Regional Medical Center in Kissimmee, Florida. “Different facilities approach this differently, but in the end, your interventions will be based on the individual’s fall risk.”
Durham stresses that you must remember that patients’ risk levels can change throughout their time with you. She gives the example of a low-risk patient becoming a high-risk one after a procedure or receiving certain medication.
“Our go-to strategies include hourly rounding, which ensures, among other things, that each patient has the assistance they need, such as moving from the bed to the chair, to the bathroom, or to change positions,” explains Suzanne Tercyak, RN-BC, MSN, the assistant chief nursing officer at Largo Medical Center in Largo, Florida. “We also screen each patient for risk for falls using the Morse Falls Scale, and based on the screening results, we add additional safety measures.”
Tercyak says that some of these measures include identifying patients who are at-risk for falls by having them wear non-skid yellow socks and a yellow falls-risk bracelet on them. “This strategy is important and works well as all staff can identify a [fall-risk] patient once they are off their assigned unit,” she says. For example, if the patient needs to go to the imaging department, the staff there will immediately know that the patient needs assistance. “In addition, we oftentimes move the at-risk patient into view of the staff; ask a family member to stay with the patient, and/or utilize a bed alarm for quick notification that the patient is moving off the bed,” Tercyak says.
Another go-to strategy for patients is to provide standby assistance if someone is a fall risk—no matter if that risk is low or high, says Daisy Cruz, RN, director of nursing for BrightStar Care of Stamford, Connecticut.
“A main go-to strategy is to listen and/or observe the client to determine the motivation or cause for the fall. This will always work,” says Michelle Davis, PT, DPT, the program director of rehabilitation at Harrogate CCRC, in Lakewood, New Jersey. “Look for a pattern to the falls relative to timing of the day, actions being performed prior to the fall, etc.”
Education is Key
For fall-risk patients, providing them with education is absolutely crucial. “Education is always key to prevention because the more you know, the better you are,” says Cruz. “Making recommendations about their house like taking out a loose rug or adding a nonslip mat or shower chair in the bathtub can go a long way.”
“Being in the hospital increases everybody’s risk for falling, and people do not always realize this,” says Durham. “It is always easier to get cooperation when people know what is going what is going on and understand the situation.”
Before informing family members or friends, though, “make sure you are operating in accordance with HIPAA guidelines,” says Davis.
Tips to Reduce Falls
While a patient is in the hospital or a facility, use alarms to alert the staff members’ attention if the patient tries to get out of bed, says Julianna Harmer, RN, charge nurse at the Harrogate Health Care Center in Lakewood, New Jersey. “Keep bells within reach [of the patient],” she says, so that they can get help if and when they need it.
Sometimes preventing falls can be as simple as “Keeping a confused patient oriented to their surroundings, and keeping the bed low, paths cleared, and things within reach,” says Durham. “For others, it can require constant supervision, and that person may need a hired sitter or a family member to be with them at all times.”
When discharging a patient or if working with patients at their homes, be sure to give them tips that can help them keep from falling. “I suggest preventing falls by minimizing clutter in the home and ensuring there is a clear path for walking. Using rug pads to secure throw rugs on the floor, providing proper lighting on stairs and common rooms, and using night lights or stick-on lights for darker areas also decreases the chance of slipping,” explains Alicia Schwartz, RN MSN, PCC, CMM, RN, a registered nurse for VNSNY CHOICE Health Plans in New York, New York. “Make sure hand rails and bathroom grab bars are installs and are secure. Proper shoes are also important—avoid heeled shoes, slippers, and sandals without straps.”
Exercise is also important for fall prevention, says Schwartz. “Exercises can be performed while sitting, standing, and/or lying down. Mobilizing our joints helps to increase overall body function, which will directly reduce the risk of falls,” she says.
Some other tips Schwartz suggests are to clearly mark edges of steps and use non-slip treads on wooden ones. In addition, store food, dishes, and cooking equipment at the waist or counter level. If patients have to reach up or down too far, they may be more prone to fall.
Remember to give this kind of information to patients, families, and caregivers during discharge. “The fall risk doesn’t necessarily end once the patient leaves the hospital,” says Durham. “Patients may go home with alterations in motor function, on medication that alters their mentation and balance, and sometimes with unfamiliar, special equipment. We need to make sure that patients and caregivers are able to be safe in their homes after discharge as well.”
