Hospital falls are an important patient safety issue, and much attention in the interest of developing fall prevention strategies has been devoted to predicting which patients are most likely to fall.2,27,28
Despite several decades of clinical research, hospital falls have remained relatively stable in the United States. Some have expressed the opinion that prevention strategies should focus on fall injury rather than on falls per se, and several risk factors on the basis of expert opinion have been proposed.14,15
This retrospective study of adult medical/surgical patients provides little evidence to help distinguish those likely to sustain an injury in the event of a hospital fall.
Within this cohort of 784 fallers, 29% sustained some type of injury, and 5% sustained injury classified as moderate to severe, with four of these related to an inpatient death. In previous hospital studies in the United States, the proportion of fallers having any type of injury range from 23% to 42%, and the proportion of those sustaining moderate to severe injuries range from 1.5% to 8%.4,16–20
The wide variation in results is likely due to study design differences, including settings, classification of injury severity, ascertainment of falls, ascertainment of fall injury, variable selection, data collection procedures, and comparison group (for example, nonfallers versus noninjured fallers).
We examined a number of intrinsic, situational, and extrinsic factors that may distinguish those likely to sustain a fall injury, few of which were significant. Several medication classes were associated with an increased risk for fall injury: SSRIs, concomitant use of two classifications of antipsychotic medications, opiates, and diuretics for other than hypertension management. Of four hospital-based studies that examined the association of medication classes with fall injury, no medications were found to be statistically significant.4,17,19,20
However, our findings of an increased risk of fall-injury reflect those found in community- and nursing home–based studies for those on SSRIs,29–33
For a number of years, the Beers Criteria for potentially inappropriate medications (PIMs) has designated benzodiazepines, conventional antipsychotics, and opiates as PIMs because of increased risk of falls, fall injury, and delirium for older adults.37
During this time, geriatricians had recommended SSRIs as first line therapy for depression.38
Because of the growing body of evidence indicating the increased risk for falls and fall injuries with SSRIs, independent of depression, the updated 2012 American Geriatric Society Beers Criteria designates SSRIs as a medication to avoid unless safer alternatives are not available.39
The finding of white race as a predictor of fall injury is puzzling because neither advanced age nor sex was associated with racial distribution. Nor did we find advanced age or being female to be associated with fall injury; indeed the influence of age, sex, or race is inconsistent among previous hospital studies.4,16–20
The finding of wheelchair use as protective may likely be a result of falling from a lower height. Others have postulated that falling from greater heights has greater fall impact that could contribute to injury,40,41
although one clinical trial of very low beds failed to reduce hospital fall injuries.42
One other hospital-based study found that height of fall may have an association with fall injury; Bradley and colleagues reported that patients who had an activity order for ambulation were at increased risk for fall injury.17
Discharge disposition, practice patterns, and hospital resource utilization other than use of imaging procedures did not differ among fallers with no injury and those with injury.
A major strength of the study was the use of multiple methods for data collection: Chart abstraction, hospital administrative databases, nurse interviews, patient interviews, and targeted examinations. However, despite the standardized approach using multiple data sources, there were still a number of patients for whom data were not available, a limitation that has plagued many hospital-based fall studies. A second limitation is that there are likely unmeasured confounders, including work environment issues such as staffing. Finally, the study was limited to one large urban hospital, limiting the generalizability of the findings. Nevertheless, our approach is, to our knowledge, the most comprehensive to date.
The major result of this study is what we did not
find, despite using a liberal definition of “fall injury” and not adjusting for the multiple comparisons. Identifying salient risk factors that are generalizable across varying acute patient populations is difficult. Several meta-analyses have demonstrated that fall risk scales have moderate predictive accuracy at best and often do not perform significantly better than clinical nursing judgment.2,27,28
Given the multifactorial etiology of falls (intrinsic, extrinsic, situational, and organizational factors), this is not surprising. We found that 79% of the patients who sustained a fall injury had been classified as high fall risk, which means that one fifth of fall-injured patients had been classified as low risk. We believe that predicting fall injury among hospitalized patients will face the same issues as trying to predict those likely to fall, bringing into question the utility of further efforts and resources devoted to development and validation of fall-injury risk scales.2,28,29
Single-intervention hospital strategies aimed at preventing falls are ineffective; rather a multicomponent strategy and/or targeted approach shows promise.2,13,43,44
Recent studies designed to implement multiunit, multicomponent, patient-specific strategies in acute care hospitals have had mixed results.45–47
There is a need to examine both patient- and organization-specific interventions. The approach to hospital fall prevention should center on commonly known risk factors for falls, such as postural instability and select medications, and apply intervention(s) to reverse or at least modify the associated risk.2
Further, it may be that successful organizational strategies are those at the unit rather than hospital level, accounting for unit variation in physical design, patient population, nursing workload, and care delivery models.8,12,48–50
In November 2011 The Joint Commission Center for Transforming Healthcare launched a multisite project using Robust Process Improvement™
(RPI) methods and tools to develop solutions to prevent falls that occur in health care facilities and result in injury to patients.51
As evidence accumulates of successful approaches to prevent hospital fall injuries, clinical and administrative leadership will be better able to determine sustainable and cost-effective strategies to implement within their settings.