Hospital Falls and Falls that Lead to Hospitalization The Inpatient Perspective

1. Hospital Falls and Falls that Lead to HospitalizationThe Inpatient Perspective Ethan Cumbler MD, FACP Associate Professor of Medicine Director UCH Acute Care For Elderly Service University of Colorado Denver 2010

2. Disclosures • None

3. Objectives 1: Teach actionable risk factors for falls leading to admission with emphasis on interventions which can be initiated in the inpatient setting 2: Identify strengths and weaknesses of risk stratification tools for the in-hospital fall 3: Critically appraise the quality of evidence for interventions to reduce falls in the acute care hospital

4. Clinical Case #1Outpatient Fall Leading To Admission • PMH • Mild Alzheimer's Dementia • HTN • Urge incontinence • Depression • Insomnia • Medications • Clonidine 0.1 mg bid • Aspirin 81 mg daily • Sertraline 50 mg daily • Amitryptiline 50mg at night Gertrude is an 88 y/o woman admitted for back pain after a fall stepping off a curb outside her assisted living Xray demonstrates thoracic compression fracture. Admit for pain control, inability to ambulate.

5. IMPACT • 30-40% of people over age 65 will have a fall each year • In an elderly patient who has fallen, the risk of having a second fall within a year rises to 60% Rao SS. Prevention of Falls in Older Patients. AAFP 2005;72:81-88

6. Consequences • 5-10% of community dwelling elderly who fall will suffer a serious injury • Up to 20-30% of elderly patients overall • Falls increase risk of going to nursing facility • 3 fold increase for falls without injury • 10 fold increase for falls with serious injury • 8% of people > 70 come to ER for falls each year • 1/3 will be admitted Rubenstein LZ, Josephson KR. Falls and Their Prevention in the Elderly. Med Clin N Amer 2006;90:807-824 Tinetti ME,et al. Falls, Injuries Due to Falls, and the Risk of Admission to a Nursing Home. NEJM 1997;337:1279-84

7. Injuries • Fractures • 1% of falls in the elderly lead to hip fx • 20-30% mortality in the year after hip fx • ¼ to ¾ of patients do not recover prior level of ADLs Rubenstein LZ, Josephson KR. Falls and Their Prevention in the Elderly. Med Clin N Amer 2006;90:807-824

8. Injuries • Other Fractures • Humerus • Rib • Subdural Hematoma • Prolonged lie-half of all elderly patients who fall are unable to get back up • 2o rhabdo, dehydration/ARF, pressure injury Tinetti ME et al. Predictors and Prognosis of Inability to Get Up after Falls among Elderly Persons. JAMA 1993;169:65-70

9. Post Fall Anxiety Syndrome“Fallophobia” Self-limiting activity, worsening deconditioning, social isolation • Picture the geriatric fall as a node on a decline spiral

10. Falls are a Prototypical Geriatric Syndrome Multifactoral Rubenstein LZ. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin N Am. 2006;90:807-824 Tinetti ME, Speechley M, Ginter SF. Risk Factors for Falls Among Elderly Persons Living in the Community. NEJM 1988;319:1701-8

11. A Brief Diversion • In Malcolm Gladwell’s book on cognition “Blink”, he describes a fascinating psychology experiment. • A sample table is set up at two grocery stores for customers to try a sample of jam. • On table has 6 varieties of jams, the other has 24 selections. • Which table do you think sold more jam?

12. Multiple Alternatives Bias • Table with only 6 varieties sold 10X more jam • The reason lies in the human psyche. • Faced by too many choices, customers freeze up and make no decision at all.

13. A New Conceptual Framework • Fall risk has specific components: • Latent risk for fall • Physiologic changes of aging • Disease and medications • Behavioral traits • Environmental trigger • the “accident” • Underlying frailty • Vulnerability to injury • EACH COMPONENT HAS CONCRETE ACTIONS TO REDUCE RISK OF FUTURE INJURY

14. OPPORTUNITY FOR INTERVENTION 1) Physical Therapy 2) Ambulation/Gait assists 3) Sensory Aids 4) Remove Problematic Medications 5) Bed Alarms for dementia with impulsivity ↓Baroreceptor Sensitivity ↓Balance from vestibular and proprioception ↓vision (esp night) ↓reflex speed for correction Fall Risk Benzodiazepines Psychotrophics Anticholinergics Antihypertensives Parkinsons Neuropathy Arthritis Podiatry problems ↑impulsivity (esp in dementia) Environmental Trigger “Accident” 6) OT Home Safety Eval -rugs -cords -lighting -rails Fall Frailty Osteoporosis Decreased muscle speed to deflect injury 7) Calcium+Vitamin D/Bisphosphonate 8) ? Hip protectors INJURY

15. What about Tests? • Orthostatic Vital Signs • Vitamin D levels • Vitamin D deficiency associated with falls and osteoporosis • CBC, Chem7, Urinalysis are reasonable • B12 levels and TSH if driven by other clinical cues • Brain imaging if neurologic findings on exam or if fall caused head injury • Echo is only indicated if exam suggests valvular disease • EKG/holter monitoring- low yield without syncope, chest pain, or palpitations • Syncope is estimated to cause only 0.3% of falls Broe KE, et al. A Higher Dose of Vitamin D Reduces the Risk of Falls in Nursing Home Residents: A Randomized, Multiple-Dose Study. JAGS 2007;55:234-239 Rubenstein LZ et al. Falls and Their Prevention in the Elderly. Med Clin N Amer 2006;90:807-824

16. Antidepressants 68% increased risk Neuroleptics/Antipsychotics 59% increased risk Sedative/Hypnotics 47% increased risk Antihypertensives 24% increased risk NSAIDS 21% increased risk There is usually a reason patients were placed on a medication Patients and physicians may be resistant to change It is incumbent on us to try to reduce problematic medications when adverse events are occurring. The Hard PartMedications Woolcott JC, et al. Metaanalysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Int Med 2009;169:1952-60

17. InpatientOutpatient

18. Transient Ischemic Attack versus Geriatric Fall

19. Case #2The In-hospital Fall • 74 y/o previously independent man admitted for GIB • Felt most consistent with hemorrhoids • Admit for observation overnight • Double occupancy room with another patient

20. There are Some Who Think the Hospital is a Fancy Hotel

22. Fall Risk Stratification • Physician assessment as “Low” (binary) fall risk • “Moderate” risk per nursing assessment • The patients roommate is rated “High” risk

23. The Fall • Patient incontinent and attempting to reach toilet using walker. • Nursing aid assists patient to toilet • While on toilet roommate’s bed alarm sounds • Imminent risk of falling out of bed • Nursing aid leaves bathroom to assist roommate • Bed alarm also summons nurse to room

24. The Fall • Returns to find patient has fallen in bathroom • Scalp laceration • Humerus + Radius fracture • Subdural hematoma

25. Outcome • Patient transferred to ICU • Fails swallow evaluation • Declines PEG tube • Aspirates in hospital • Death

26. Circumstances 20% with toileting 34% from bed 38% while ambulating Hospital Falls2-12% of patients will have a fall in the hospital 10-20% of in-hospital falls are recurrent events Chelly JE. Risk Factors and Injury Associated with Falls in Elderly Hospitalized Patients in a Community Hospital. Journal of Patient Safety 2008;4:178-183 Schwendimann R, et al. Falls and Consequent Injuries in Hospitalized Patients. BMC Health Ser Research 2006;6:69

27. 30% with minor injury 4% with major injury Lacerations/bleeding Hematomas Fractures/dislocation Traumatic brain injury  hospital charges  LOS Consequences Litigation • Serious injuries • Failure to follow procedures to prevent recurrent falls • Delays in injury recognition Half of all patients with hip fracture from in-hospital fall will be dead within the year -Twice the rate seen in the community Risk of injury from in-hospital fall rises by 19% for each decade of age Schwendimann R, et al. Falls and Consequent Injuries in Hospitalized Patients. BMC Health Ser Research 2006;6:69 Bates DW. Serious Falls in Hospitalized Patients: Correlates and Resource Utilization. Am J Med 1995;99:137-143 Johal KS. Hip Fractures after Falls in Hospital: A Retrospective Observational Cohort Study. Injury 2009;40:201-204 Oliver D. Do Falls and Falls-Injuries in Hospital Indicate Negligent Care- and how big is the risk? Qual Saf Health Care 2008;17:431-436

28. The Challenge of the In-hospital Fall • Falls in the hospital are rarely witnessed • Only 8% of hospital falls have staff present • Witnessed falls are still difficult to catch • Falls are widely underreported • 44% of falls not reported as incident reports Bradley SM. Predictors of serious injury among hospitalized patients evaluated for falls. JHM 2010;5:63-68 Sari AB. Sensitivity of Routine System for Reporting Patient Safety Incidents in an NHS Hospital. BMJ 2007;334:79

29. Regulatory Environment • Injuries from hospital falls are “Never Events” • --Medicare will no longer pay for them • Hospital falls with significant injury are JCAHO reportable • --sentinel events • Falls with injury in the hospital pose malpractice risk

30. Risk Assessment- Physicians • How do physicians assess fall risk? • For the most part, physicians pay little or no attention to this issue. • A simple physician falls screen: • “Have you fallen in the last 6 months or are you afraid of falling?” • Get-Up-And-Go test • You learn a lot about strength, balance, and gait in 30 seconds. Fernandez HM. House Staff Member Awareness of Older Inpatients’ Risk for Hazards of Hospitalization. Arch Intern Med 2008;168:390-396

31. Fall Risk Scoring Tools • Screening tools are available to target interventions to high risk patients • STRATIFY Score • Downton Score • Morse Falls Scale • Hendrich II • Using the standards of EBM, even the best of these tools has poor test performance • Sens 67% Spec 51% • Predictive accuracy of 43.2% to 60% • ACTION on modifiable risk factors is far more important than risk stratification Oliver D, et al. A Systematic Review and Meta-analysis of Studies Using the STRATIFY Tool for Prediction of Falls in Hospital Patients. Age and Aging;37:621-627 Coussement J et al. Interventions for Preventing Falls in Acute and Chronic Care Hospitals: A Systematic Review and Meta-Analysis. JAGS 2008;56:29-36 Oliver D. Falls Risk-Prediction Tools for Hospital Inpatients. Time to Put Them to Bed? Age and Ageing 2008;37:248-250

32. The literature provides little guidance as to how the probability of injury should be incorporated into hospital fall policies as a modifier of the risk of a fall itself.

33. Acute Post-Fall Evaluation • First priority is evaluation for injury • Obvious and occult • Head to toe examination • Palpation of spine, pelvis and ROM of extremities • Fractures between occiput and C2 more likely in elderly • Immobilize neck pending CT scan if neck injury suspected • Head injury prompts CT scan • Up to 10% of elderly pts with ICH lack focal deficits • Scheduled neuro checks prudent Touger M. Validity of a Decision Rule to Reduce Cervical Spine Radiography in Elderly Patients with Blunt Trauma. Ann Emerg Med 2002;40:287-293 Gangavati AS. Prevalence and Characteristics of Traumatic Intracranial Hemorrhage in Elderly Fallers Presenting to the Emergency Room without Focal Findings. J Am Geriatr Soc 2009;57:1470-1474

34. Pts with none of these factors are low risk for significant injury and do not require imaging. Mower WR. Developing a Decision Instrument to Guide Computed Tomographic Imaging of Blunt Head Injury Patients. Journal of Trauma-Injury Infection & Critical Care 2005;59:954-959 Touger M. Validity of a Decision Rule to Reduce Cervical Spine Radiography in Elderly Patients with Blunt Trauma. Ann Emerg Med 2002;40:287-293

35. There is No Better Sign of the Next Fall….Than the First Fall Institute Secondary Prevention Measures

36. What Interventions Reduce Falls?

37. Interventions to Reduce FallsOutpatient and Long Term Nursing Homes • Expedited cataract surgery • One trial showed benefit, two did not • Cardiac pacing for cardio-inhibitory carotid sinus sensitivity • Home safety evaluation in patients with prior falls • Vitamin D supplementation • Exercise/balance programs • Medication withdrawal Tinetti ME, et al. The Patient Who Falls. JAMA 2010;303:258-266

38. Cumming RG. BMJ 2008; 336: 758–760 von Renteln-Kruse. J Am Geriatr Soc 2007;55:2068-2074 Healey F. Age and Ageing 2004;33:390-395 Haines TP. BMJ 2001;328:676-681

39. Observational Trials of Hospital Fall Reduction Protocols • 2004 Observational trial • 25% reduction in fall rates • 2004 RCT in Community Hospital • 21% reduction in falls • No difference in fall related injuries

40. Falls Prevention Programs Effective…. According to Less Rigorous Scientific Standards Of course by these standards….lots of things are plausible Loch Ness Monster Sasquatch

41. 2006 Observational Trial of Interdisciplinary Fall Prevention Program No reduction in falls No reduction in fall related injuries Schwendimann R et al. Falls and Consequent Injuries in Hospitalized Patients: Effects of an Interdisciplinary Falls Prevention Program. BMC Health Serv Research 2006

42. Identified Problems • Incomplete predictive power of screening tools • Limited exposure time for intervention impact • LOS in days vs. months to years • Incomplete adherence to fall reduction protocol • Prior research demonstrates 43% non-adherence rates • Our investigation found 64% non-adherence to bed alarms Bakarich A. The Effect of a Nursing Intervention on the Incidence of older Patient Falls. Aust J of Adv Nurs 1997, 15:26-31 Lampignano DW. Using rare inpatient accidents to evaluate and improve the system-based practice: an example in process mapping and the Vanderbilt Healthcare Matrix-2010

43. RCTs to Reduce In-hospital Falls • 8 Trials Since 1966 • Only two were exclusively acute care hospitals • 1993 RCT of bed alarms • Very small trial (35 patients in each arm) • Non-significant reduction of falls • 2006 Quasi-experimental multi-component trial • Reduction in pts with recurrent falls • 20% versus 56% • No reduction in first falls • 12.6% versus 11.8% Tideiksaar R. Falls Prevention: The Efficacy of a Bed Alarm System in an Acute-Care Setting. Mt Sinai J Med 1993;60:522-527 Schwendimann R. Fall prevention in a Swiss acute care hospital setting. J Gerontol Nurs 2006;32:13–22.

44. Findings of Systematic Review and Meta-Analysis • No conclusive evidence that hospital fall prevention programs can reduce the number of falls or fallers • More studies are needed to evaluate trend towards efficacy of actively targeting patient’s most important risk factors • No evidence demonstrates acute care fall prevention programs reduce injuries Coussement J. Interventions for Preventing Falls in Acute and Chronic-Care Hospitals: A Systematic Review and Meta-Analysis. JAGS 2008;56:29-36

46. Cochrane Review • In hospitals, multi-factoral interventions reduced the rate of falls and risk of fallers. • Results most robust for patients with longer lengths of stay Cameron ID. Interventions for Preventing Falls in Older People in Nursing Care Facilities and Hospitals. Cochrane Databse Syst Rev 2010;20(1):CD005465

47. Final Thoughts