This was a prospective cohort study using an historical control group to analyze fall incidence, risk factors associated with falls, and costs arising before and after implementation of a FPP. We conducted this study in a 91-bed elective orthopaedic hospital. The majority of this hospital’s inpatient volume (approximately 80%) is elective admissions for orthopaedic procedures, including THA and TKA. A minority of patients (approximately 20%) are transfers from an affiliated trauma center mainly consisting of patients with orthopaedic trauma who have undergone surgery and are awaiting placement in rehabilitation. The study population included all patients hospitalized within a 5-year period preintervention from January 1, 2003, to December 31, 2007, and for 1 year postintervention from July 1, 2008, to June 30, 2009.
We used administrative data to identify variables relating to the entire population during the study period, including age, length of stay, and reason for admission. Fall incident report forms, which are handwritten at the time of the incident, were reviewed to identify patients who fell during the 6-year study period (JGG, RTM). The falls incident report form is a standardized document that has a checklist for information relating to a fall event, including date, time, location, circumstance, use of devices, and any injuries received. This form has a section that must be filled out by the nurse who discovers the patient who fell. This form also has a section that must be filled out by the in-house doctor. This means that a doctor must review the patient after any fall regardless of how innocuous a fall may seem. In this section, the doctor gives his or her clinical impression of the fall, likely injuries if present, and a plan for further management. The decision to order radiologic investigation is based on the clinical judgment of the doctor reviewing the patient. It is based on mechanism of the fall, findings on physical examination, previous orthopaedic procedures, and clinical suspicion of injury. We analyzed the medical records of all patients who fell to identify risk factors associated with falls, fall-related injuries, and all related costs for the year preintervention and the year postintervention. This project was reviewed by our institutional ethics board, which waived the need for approval.
In February 2008, a multidisciplinary task force was established to develop a FPP with the aim of creating a safe environment for inpatients and to reduce the incidence of falls and consequent injuries. The various elements of the plan were introduced in stages during a 6-month period and the FPP was fully operational by July 1, 2008 (Table ).
The Falls Prevention Program
Starting July 1, 2008, all patients, on admission to the ward, received a falls risk assessment from the nurses. Patients deemed at high risk of a fall were placed in designated beds on that particular ward next to the nursing station where they could be closely monitored. Falls assessment was performed using the Falls Risk Assessment Scale for the Elderly (FRASE) risk assessment tool. This tool was selected because it has been prospectively validated [7
Staff education and training were priorities in the FPP. An initial 1-hour structured education session on the fall prevention interventions was provided for all staff. Specific roles were highlighted for the different health workers, including nursing staff, support staff, occupational therapy, and physiotherapy staff. Information on patient transfer, provision of mobility devices, and provision of adequate footwear were among the topics discussed. Voiding was highlighted as a major risk in falls and focus was placed on this aspect of patient care. In addition to patient assessment and staff training, changes to the infrastructure of wards also were implemented. The falls prevention committee, representing the involved healthcare professionals, was installed to audit the progression of the FPP every 2 months.
We (JGG, ARM, JSB) identified all costs relating to falls for the 2-year study period. The cost of falls was subdivided into its major components: acute ward costs, operating room costs, nonoperating room treatment costs, transfer costs, and investigations performed. Ward expenses were computed with the aid of the financial department. We used patient charts, nursing notes, and operation notes where applicable to identify all costs relating to a fall episode. Using these data, the individual total cost incurred in the treatment of each patient was calculated. We also calculated the cost of the FPP. They were subdivided into staff and infrastructure costs. Initial staff-related costs resulting from protected time for training and audit meetings were calculated by matching pay grades to the numbers of hours spent by all staff in training. We calculated infrastructure costs from the accounting department relating to provision of new equipment, repairs, and labor costs.
Between January 1, 2003, and December 31, 2007, 19,057 orthopaedic patients were admitted to our hospital resulting in 118,865 bed days. A test for homogeneity of annual fall rates was performed using a chi square test through contingency tables. This showed no significant difference between years when comparing the falls incidence from 2003 through 2007 (p = 0.245), before formulation of the FPP (Table ). Therefore, for further analysis, we grouped these observations together to make a more powerful inference with respect to the effects of the intervention implemented in 2008.
Fall rates among preintervention years
Frequency distributions and summary statistics, including count (percentage) and mean ± SD, were used to describe patient characteristics, prevalence of patient falls, and associated risk factors. We applied one-sided and two-sided z-tests for statistical analysis where appropriate using SPSS, Version 16.0 (SPSS Inc, Chicago, IL). p Values < 0.05 were considered to be statistically significant.