Transcript Fall Risk Assessment - Ohio Public Health Association

Christian Wuescher, MD
University of Toledo Medical Center
Physical Medicine and Rehabilitation
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Falls and the healthcare industry
Assessment of fall risk in the inpatient setting
Disposition assessment and options for
reducing fall risk including rehabilitation
Role of Inpatient Rehabilitation
Qualifying for an Inpatient Rehabilitation stay
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Falls are the leading cause of injury among
people aged 65 years and older
Over 80% of all adverse events among
hospital patients are associated with falls
◦ 30-40% suffer injuries and 6-8% are severe which
include fracture, subdural hematomas and death
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Falls are ranked sixth in the rating of sentinel
events published by the Joint Commission in
2010
Morbidity and mortality from falls are a high
risk, high volume and high cost challenge for
health care facilities
◦ By 2020 annual costs of injuries from falls may
reach over 40 Billion Dollars
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Consequences are physical and psychological
◦ Result in injuries that limit function and
independence
◦ Produce fear of recurrence and loss of self
esteem
◦ Leads to a loss of quality of life
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Identify those factors that can be used to
assess fall risk both in the hospital setting as
well as in the home
Based on this assessment, make
recommendations to patients and families on
measures to improve safety, the level of
assistance the patient will require and any
disposition options
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70 year old female with a history of recent
stroke with associated right hemiplegia and
aphasia. She can transfer with help and has
been ambulating 5 feet but with moderate
assistance. Past history of mild dementia,
high blood pressure and anxiety for which
she takes medication. She previously
functioned independently with use of a cane.
She lives with her husband who has back
issues in a 1 story home with 5 stairs to
enter.
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What is her fall risk?
What measures can be done to reduce fall
risk while in the hospital?
What are her options for improving her safety
for an eventual discharge home?
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Cognition
Impulsivity
Muscle Strength, Sensation and Coordination
Functional Assessment
Bowel and Bladder Status
Visual disturbance
Medications
Support System
Home Setup
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Alert and Oriented X 4
Assess short term memory
◦ Remember three random items
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Avoid making determination based on ability
to answer basic questions appropriately
Speech Therapy Evaluation
◦ Identify more subtle cognitive deficits that may
pose a fall risk
◦ GOAT Score - Post Traumatic Amnesia
◦ Identify need for 24 hour supervision
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Act on impulse rather than thought
High association with Brain Injury
◦ Frontal Lobe
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Evaluate for impulsive behavior both in
speech and action
◦ Verbal or physical outbursts, poor judgment and
disinhibition
◦ Review therapy notes for evidence of impulsivity
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Formal Strength Exam with 5 point scale
◦ Proximal Weakness – Difficulty with raising from seated
position or stairs
◦ Distal Weakness / Foot Drop – Limb clearance during
swing phase
 Occupational therapy evaluation, orthotic
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Sensation: Light touch and Proprioception
◦ Sensory ataxic gait – Patients have difficulty knowing
location of limb in space and on ground
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Coordination / Cerebellar Dysfunction and Ataxia
◦ Deceivingly good strength exam
◦ Finger to nose testing
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Consider activities of daily living
Review of the physical and occupational
therapy evaluations and devices used
◦ Ambulation and Transfers: Walker, Transfer Board
◦ Toileting: Raised Toilet Seat
◦ Dressing and Grooming: Long Shoe Horn
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Assistive device needs and previous use
◦ Standard vs. Wheeled Walker
◦ Patient willing and able to utilize appropriately
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How would patient be toileting at home?
◦ Indwelling or intermittent catheterization
◦ Bedside commode
◦ Standard bathroom
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Urinary urgency or frequency
◦ May pose fall risk if voiding frequently or urgently
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Subtle deficits may be difficult to determine
Higher clinical suspicion w/ certain
diagnoses:
◦ Stroke
 Homonymous hemianopsia
◦ Brain Tumor
◦ Multiple Sclerosis
◦ Diabetes
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Important to assess peripheral vision
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Medications associated with high fall risk:
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Cardiovascular: Anti-arrhythmic, HTN, Diuretics
Anti-Anxiety: Benzodiazepines
Anti-Psychotics: Typical and Atypical
Seizure Medication
Opiods
Anti-Parkinsons Medications
Psychotropic and benzodiazepine use is the
most consistently associated with falls
Medications associated with high fall
morbidity:
◦ Coumadin, ASA, Plavix, Heparin
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Who lives at home with the patient:
◦ Alone
◦ Lives with other
 Absent most of the day
 Present but not able to provide significant assistance
 Present and able to assist
◦ Resident at an assisted living center w/ help if
needed
◦ Resident at an extended care facility w/ nursing and
therapy care
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One or Multiple level home
◦ Available for 1 story set up
◦ Bedroom and Bathroom location
◦ Elevator or chair-lift available
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Stairs to enter the home
Other Barriers
◦ Areas of the home that are incompatible with use of
mobility or assistive devices
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Identifying those that are at increased risk
◦ Daily risk assessments / Fall Risk Scales
◦ Self assessment measures, fall committees
 When falls occurring, were measures in place,
diagnoses that represent highest percentage of falls
◦ Patients with speech therapy consults considered
high fall risk until cleared
◦ Informing staff on admission of patients w/
cognitive deficits, not oriented or w/ prior falls
◦ Bracelet or patient room labels of fall risk, Kardex
precautions
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Interventions on at risk patients:
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Closer to nursing station
Bed and wheelchair alarms
1:1 Direct Supervision
Non-Slip Socks
Fall Runway mats
Hourly checks on patient
Toileting every 2 hours
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Home
Home with outpatient or in-home therapy
Subacute rehabilitation
Acute inpatient rehabilitation
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Goals of inpatient rehabilitation:
◦ Restore functional deficits and independence
through an aggressive and comprehensive
approach
◦ Educating patients and families on methods to
improve safety with activities of daily living
◦ Assessing functional status and barriers to return
home
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Multi-disciplinary Approach
◦ Nursing care
◦ Physical, occupational and speech therapy 3 hr /day
 Assistive device needs, home evaluations, swallow eval
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Counseling
Neuropsychology evaluations
Recreation Therapy
Physical Medicine and Rehabilitation Physicians
Meet weekly to evaluate patients progress
and determine appropriate disposition plan
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Who is a candidate for inpatient rehab?
◦ Able to tolerate the aggressive rehabilitation
program (3 hours per day)
◦ Have enough functional goals to justify the patient
would require an inpatient stay
◦ Have a reasonable anticipation of a discharge home
after 1-3 weeks of therapy
 Based on home set-up and support system
◦ Have a qualifying diagnosis
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Common qualifying diagnoses for an
inpatient rehabilitation stay:
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Spinal Cord Injury
Traumatic Brain Injury
Cerebral Vascular Accident
Multiple Sclerosis
Parkinson’s Disease
Multiple fracture, Joint Replacement
Debility
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Subacute Rehabilitation
LTAC Facilities
Home with in-home or outpatient therapy
Home without therapy needs
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Focused fall risk assessment is an important
tool for improving patient safety as well as
determining an appropriate rehabilitation
program and disposition plan for patients.
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Johnson, Joyce, PhD, RN. Breaking the Fall. The Journal of
Nursing Administration. 41 (12): 538-545. 2011
Aranda-Gallardo, Marta. Instruments for assessing the
risk of falls in acute hospitalized patients: a systematic
review protocol. Journal of Advanced Nursing. 2012 Aug
9.
Braddom, Randall, MD. Physical Medicine and
Rehabilitation. Third Edition. 2007.
Divakara, Kedlaya, MBBS. Assistive Devices to Improve
Independence. eMedicine. Oct 2011
Huang, Allen. Medication-Related Falls in the Elderly.
Drugs & Aging. 29.5: 359-376. May 2012
Nursing Staff at University of Toledo Medical Center