Transcript Avoiding Hospital Falls

What should we do about fallrelated injury in the hospital?
Hospitalist Best Practice
J Rush Pierce Jr, MD, MPH
March 13, 2013
Disclosures
• Financial: none
• Affiliations/biases
– I am member of the American Geriatrics Society;
AGS helped develop consensus guidelines for
evaluation and treatment of elders who fall
– 5% of my salary supported by Donald W Reynolds
Foundation for education of hospital care of elders
– evidence should inform our thinking
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How we think about falls
• Most of literature about adult falls is in elderly
persons who fall at home or in nursing homes
• Little literature about patients who fall in the
hospital
• Much of our thinking about hospital falls is
extrapolated from outpatient data
• Hospital falls are considered a “never event”
by Medicare
Source: Inouye: N Engl J Med 2009;360:2390
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Roadmap for today
• Describe case
• Review some literature about outpatient falls
in elderly persons
• Review literature about inpatient falls
• Review UNMH experience with inpatient falls
• Discuss possible system changes at UNMH
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Learning Objectives
1. Identify at least 3 factors associated with falls
in elderly persons.
2. State the most common etiology of falling in
elderly persons.
3. Summarize the epidemiology of in-patient
falls.
4. Describe an approach for evaluating the inpatient who falls.
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Case
• You are providing cross-cover. The 4W nurse
calls you at 2 AM because an 84 year old
woman fell in her room. The patient was
admitted two ago with pneumonia and is
receiving IV antibiotics and oxygen. The nurse
says the patient fell when trying to get to the
toilet. The nurse says the patient “seems
okay” but thinks that maybe you should come
see the patient.
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Questions you might have
• How promptly do I need to see this patient?
(Can’t this wait until the morning?)
• If I go to see the patient, how do I evaluate
her? (What the #@!! am I supposed to do?)
• Is there anyway to prevent this? (How do I
keep from getting these 2AM calls?)
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Out-patient falls: literature
review
Is falling in the elderly a significant
health problem?
• 30 – 40 % of elderly persons fall each year
• 5 – 6% result in injury significant enough to
see a doctor or go to ED
• 2 – 3 % result in hospitalization (Ave LOS = 8d)
• Annual cost to Medicare = $19B (est FY2000)
Source: Stevens. Injury Prev 2006;12:290
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Why do elderly persons fall?
• In the elderly, syncope is an uncommon cause
of falling (0.5%)
• Common mechanism of falling in the elderly
– environmental perturbation (“I tripped”)
– impaired neuromuscular reflex systems due to
combination of age-related changes and comorbid illness/medications
– 80% of falls in the elderly are “unique to the
elderly”
Source: Rubenstein: Clin Geriatr Med 2002;18:141
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Epidemiologic factors associated
with outpatients falls in the elderly
•
•
•
•
•
•
•
Age (>80)
Cognitive impairment
Female gender
Past history of fall (second largest effect)
Lower extremity weakness (largest effect)
Balance difficulty
Arthritis
Source: Rubenstein: Clin Geriatr Med 2002;18:141
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Medications associated with falls in
the elderly
Source: Huang: Drugs Aging 2012;29:359
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Medications associated with hip
fracture in the elderly
Source: Huang: Drugs Aging 2012;29:359
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Evaluating falls in communitydwelling elderly persons
Adapted from: Panel on prevention of falls in older persons: J Am Geriatr Soc 2011;59:148
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What interventions prevent falls in
elderly out-patients?
• Four interventions have shown to be effective
– Medication review and adjustment
– Environmental changes
– Exercise (or physical therapy)
– Vit D if deficient (association)
• Combination of all four (multi-modality) result
in relative risk reduction of 10 – 25%
Sources: Panel on prevention of falls in older persons: J Am Geriatr Soc
2011;59:148. Controversies in geriatrics. J Am Geriatr Soc 2013;61:281
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Falls in ambulatory elders (concl.)
• Falls occur frequently and can result in injury
• Falls are usually due to inadequate
compensatory neuromuscular mechanisms
• Major risk factors include lower extremity
weakness, past h/o fall, female gender, and
meds (psychotropics, benzos and narcotics)
• Interventions can reduce risk of future falls
• Evidence based guidelines are available
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In-patient falls: literature review
Epidemiology of inpatient falls
(Barnes Hospital 2001-2)
• 1,235 falls by 1082 pts (3.10 falls/1000 pt
days)
• 89% single fall, 11% more than once
• 40% related to toileting
• Serious injury (laceration requiring sutures,
loss of consciousness, fracture, SDH) – 6%
• Death – 0.2% (both in patient with more than
1 fall)
Source: Fisher: Inf Control Hosp Epidem 2005;26:822
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Epidemiology of inpatient falls
(Barnes Hospital 2001-2)
Source: Fisher: Inf Control Hosp Epidem 2005;26:822
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Source: Fisher: Inf Control Hosp Epidem 2005;26:822
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Epidemiology of fall-related injury
in the hospital
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•
•
•
•
9 hospitals in Midwest, 2001 – 2003
7,082 falls
40% falls associated with toileting
42% assoc w/injury, 2.4 % serious injury
Increased age, fall in location other than pt
room and unassisted fall assoc with injury
Source: Krauss: Infect Control Hosp Epidemiol 2007;28:544
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Epidemiology of in-patient falls
• National Database of Nursing Quality
Indicators (NDNQI) from 2006 – 2008
• 315,817 falls in 1263 hospitals
• Conclusions:
– 3.56 falls/1000 patient days
– 26% injury rate
– Rate of falls and fall-related injury higher on
medical than surgical floors
Source: Bouldin: J Patient Saf 2012:Epub
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Epidemiology: UNMH in-patient
falls study
• 298 PSN’s reporting falls in 2010
• Exclude pts < 18 y/o (2), pregnant pts (3), pts
with no matching MR (7)
• 286 falls, 251 pts
• 152 males (61%), 99 females (39%)
• 63 falls with injury (25%); 11 (4%) serious
injury (laceration requiring sutures, fracture,
subdural)
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Falls by unit
UNMH 2010 falls by unit
60
50
40
30
20
10
0
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Fall related to toileting
Fall related to toileting
24%
28%
No
Yes
Not recorded
48%
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Falls with injury
Extent of injury
250
200
count
150
100
50
0
1
2
3
4
percentage
77.9
18.2
2.4
1.4
count
223
52
7
4
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Predictors of fall with injury
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Documentation, all falls
Physician documentation, %
100
90
80
70
60
No
50
Yes
40
30
20
10
0
MD Special note
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MD Progress note
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D/C summ
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Documentation, falls with injury
Physician documentation, %
90
80
70
60
50
no
yes
40
30
20
10
0
MD Special note
03/13/2013
MD Progress Note
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D/C summ
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Epidemiology: medication use and
in-patient falls
Source: Prakash; J Hospital Med 2013:8:1
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Cost of hospital fall-related injury
• Case reports: delayed recognition of fallrelated injury can result in liability risk
• 3 Midwestern hospitals, 2004 – 2006
– 57 inpatient with serious fall-related injury
– $13,316 and 6.3 days more than case controls
• NHS Litigation claims
– 668 claims
– 60% payments, mean = $30K
Souces: Wong: Joint Comm J Qual Patient Saf 2011:37:81;
Oliver: Qual Saf Health Care 2008;17:431
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Can we predict which pts will fall?
• Outpatient - Best clinical predictors are
previous fall in past 6 months and Timed Upand-Go (TUG) test
• Inpatient – Falls risk tools (Morse, STRATIFY,
Hendrich II, Conley)
– Not very good, best sensitivity = 73%, specificity =
42%
Sources: Beauchet: J Nutr Health Aging 2011;15:933;
da Costa: Plos One 2012;7:e41061
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What single interventions do not
prevent inpatient falls?
•
•
•
•
•
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Bedrails
Exercise
Staff training
Patient education
Medication review/adjustment
Bed alarms
Sources: Shorr: Ann Intern Med 2012;157:692; Cameron:
Cochrane Database Syst Rev;2012:CD005465
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Do multi-modality interventions
prevent inpatient falls?
• Very limited data – two observational studies
show 20-25% reduction with bundle
• 3 RCT of bundle in acute care hospitals –
– one showed no reduction in falls
– one showed reduction for those with recurrent
falls
– One showed reduction of falls in elderly, but no
reduction in fall-related injury
Source: Cameron: Cochrane Database Syst Rev;2012:CD005465
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Case
• You are providing cross-cover. The 4W nurse
calls you at 2 AM because an 84 year old
woman fell in her room. She was admitted
two ago with pneumonia and is receiving IV
antibiotics and oxygen. The nurse says the
patient fell when trying to get to the toilet.
The nurse says the patient “seems okay” but
thinks that maybe you should come see the
patient.
• What happens at UNMH?
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In-patient falls (conclusions)
• Result in serious injury in 2 – 6% of patients
• More common on med/surg units and
frequently related to toileting
• Falls and especially delayed recognition of fallrelated injury poses significant liability risk
• Our ability to predict and prevent falls is very
limited
• Regulatory agencies expect hospitals to
monitor and address this problem
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Conclusions
• Outpatient falls and inpatient falls are
probably different epidemiologically
• About 5% of in-patients who fall in the hospital
will suffer significant injury
• Evidence-based guidance about assessment is
lacking
• UNMH physician documentation of falls is poor
• More study is needed
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What should we do about fall
related injury in the hospital?
- Possible actions at UNMH • Use/review the checklist for evaluating pts
who fall
• Limit use of zolpidem in patients at risk
• Decrease narcotic use in the hospital
• Other
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