Review on prevention of falls in hospital settings

Yuan-Yuan Gu，Koen Balaen，Yiheng Ni，，Jan Ampe，Jan GoffinaDepartment of Geriatri Mediine，The First Hospital Affiliated to Nanjing Medial University，300 Guangzhou Avenue，Nanjing，Jiangsu，210000，ChinaFaulty of Mediine，KU Leuven，Herestraat 49，B-3000，Leuven，BelgiumUniversity Hospitals Leuven，Herestraat 49，B-3000，Leuven，Belgium

Review article

Review on prevention of falls in hospital settings

Yuan-Yuan Gua，b，c，*，Koen Balcaenc，Yicheng Nib，c，Jan Ampec，Jan GoffincaDepartment of Geriatric Medicine，The First Hospital Affiliated to Nanjing Medical University，300 Guangzhou Avenue，Nanjing，Jiangsu，210000，ChinabFaculty of Medicine，KU Leuven，Herestraat 49，B-3000，Leuven，Belgium
cUniversity Hospitals Leuven，Herestraat 49，B-3000，Leuven，Belgium

ARTICLEINFO

Article history：

Received in revised from

27 January 2015

Accepted 19 November 2015

Available online 21 March 2016

Hospital settings

Fall

Fall prevention

Intervention

ABSTRACT

This review will first cover the root causes of falls，identify preventive measures associated with these falls，and provide an overview of best practice of fall prevention at leading institutions.There is significant benefit in instituting a comprehensive program to reduce falls.After analyzing the results from many successful programs，it is apparent that an integrative program that consists of patient evaluations，environmental modification，and staff training can lead to a significant reduction in the overall prevalence of falls.Such programs can be implemented at a low cost and therefore represent an improvement in care with a high return on investment.

?2016 Shanxi Medical Periodical Press.Production and hosting by Elsevier B.V.This is an open access article under the CC BY-NC-ND license（http：//creativecommons.org/licenses/by-nc-nd/4.0/）.

1.Introduction

Falls are defined as“an untoward event which results in the patient coming to rest unintentionally on the ground or other lower surface”and are a common and preventable complication that occurs in a hospital setting.There are 7，00，000-1，000，000 falls each year in hospital settings.1Given the compromised nature of individuals who are in hospital settings，falls often lead to other complications，such as fractures，lacerations，and/or significant internal bleeding.Thus，they increase overall healthcare utilization in a hospital system，drive up costs and adversely affect patient outcomes when a patient is admitted to a hospital.2The average increase in the length of stay for a patient after a fall has been estimated to be 12.3 days.This leads to an average cost increase of 61%.3Given the rapidly aging population in most developed countries，this problem is projected to only increase in the future.Thus，preventing falls represents an important area of hospital care that needs to be addressed to deliver clinically and cost effective care.

One of the more important aspects of preventing falls in a hospital is the use of a integrative care management system in which the design of the facility is taken into account，proper communication between the different healthcare professionals ismaximized，and a systematic review of best practices and mistakes are evaluated at a regular intervals to quantify the risk of certain triggering events for falls and review the actions taken to mitigate this risk.4As healthcare providers，nurses are one of the key components to preventing falls due to the close interactions they have with patients，as well as their role in overseeing the day-to-day operations in a hospital.Often，a nursing staff is far more attuned to the risks of an individual patients than the rest of the staff at a hospital.Thus，theyrepresentthe front line of defense against falls.5

To present a comprehensive overview of the prevention of falls in hospital settings，this review will first cover the root causes of falls and identify preventative measures associated with these falls. It will then provide an overview of best practices of fall prevention at leading institutions.It will thereby be possible to not only understand current state of the art fall prevention methods but also create frameworks by which more comprehensive programs can be formulated and implemented.

2.Root causes of falls

Falls are categorized into three broad categories，accidental falls，anticipated physiological falls and unanticipated physiological falls.6Falls attributed to physiology are due to age，ailments，medications or medical procedures and are reflected in risk assessment scores given tothe patient.Therefore，these falls are the most easily anticipated and，thus，easiest to prevent.Unanticipatedphysiological falls are still due to physiological reasons，but are unforeseen because standard risk assessments did not identify victims of unanticipated falls.The final category，accidental falls，involve individuals who are otherwise not a risk for falls，but who actually do have falls due to environment or operational issues.

http：//dx.doi.org/10.1016/j.cnre.2015.11.002
2095-7718/? 2016 Shanxi Medical Periodical Press.Production and hosting by Elsevier B.V.This is an open access article under the CC BY-NC-ND license（http：// creativecommons.org/licenses/by-nc-nd/4.0/）.

Of these three root causes，anticipated physiological falls are the most common，accounting for 78%of all falls.Accidental falls represent the second most common category，accounting for 14%of falls.7From these statistics，it is clear that the majority of cases involve situations in which the risk of falls could be foreseen and therefore prevented.This review will focus primarily on physiological falls because it is the largest category.They are also entirely preventable with careful monitoring and precautions，which allows to achieve the greatest reduction in falls at a minimum cost.

Physiologically attributable falls can be due to either intrinsic or extrinsic factors，which as listed in Table 1.Intrinsic factors involve factors that relate to the current physical fitness or level of impairmentofagivenpatient.Forexample，issuessuchasage，acuteillness，issues with vision，balance，injury from previous falls or musculoskeletal issues are factors that can lead to falls.8Extrinsic factors are environmentalfactorssuchasclutterandpoorlighting.Whilethese are not necessarily specific to a patient，they do act as exacerbating factors that magnify the risk brought on by intrinsic factors.Thus，they play a role in the overall risk profile of patients.Therefore，reducingextrinsicriskfactorsalsoplaysasignificantroleinreducing falls in hospitals.However，while these factors should reduce the prevalence of falls，robust studies have not been conducted to identifythelevelbywhichtheyarereduced.Thisprimarylimitation instudiesisbecausetheydonotidentifyorquantifythesizeofanatrisk population，whereas studies on intrinsic risk factors do.

Intrinsic risk factors can be easily assessed from the medical history of a given patient and should，therefore，trigger immediate preventive actions that would，in most cases，reduce the risk of falls for these individuals.The primary shortcoming in mitigating the risk of these falls is lack of communication between differenthealth care providers that interact with the patient，as well as a lack of standard operating procedures when these patients have been identified as having significant risks of falls.Hospital systems in which communication is improved and standard operating procedures are implemented have been observed to have a significantly decreased fall incidence.In many cases，the reduction of falls can be greater than 60%.9

3.Evaluation of fall prevention

An analysis of existing trials studying fall prevention has been inconclusive.Various studies have shown different levels of reduction，while other studies have shown no significant reduction in an overall rate of falls.However，it should be noted that these studies only encompass situations in which fall prevention programs have been instituted.Therefore，they are poorly controlled for the type of programs that have been instituted.Furthermore，additional complications arise from an assessment of the success of a program.While most evaluations focused on the number of falls per N patient years，other studies focused on if programs instituted led to a lower incidence of complications due to falls.10

In general the reduction in fall ranged from 19%to 77%in the studies that reported a reduction in the number of falls.11While these results are inconclusive，a formal meta-analysis has shown that the implementation of a formal falls prevention program does，in fact，reduce falls by a statistically significant amount，though the overall magnitude remains questionable.11However，while the magnitude of the effect may be in question，with a more careful analysis of these studies，it is possible to determine which factors exist that lead to successful falls reduction programs.

After examining 12 different studies and meta-analyses，our conclusion is that one of the most critical aspects that lead to a reduction of falls is the use of a patient-risk assessment.The presence of a risk assessment procedure was found to be the most significant factor that led to a reduction in the number of falls because it allowed a hospital or nursing home care team to devote additional attention to individuals who were at risk of falling.This alone was found to reduce the rate of falls by approximately 19%.10

Trialsthatshowedagreaterreductionintheriskoffallsgenerally combined risk assessment strategies with integrative communication within a care team and standard operating procedures for dealing with patients who were at a higher risk of falling.

4.Risk assessment

Risk assessments are the cornerstone of any falls prevention program because they allow for a more efficient use of resources as well as focusing the attention of an individual's care team when they are at a high risk of falling.The process of risk assessment consists of scoring each patient with various scales to identify those who are at a high risk of falling.The two most common scales are the Morse fall scale and the St.Thomas Risk Assessment Tool in Falling（STRATIFY）.While there are other scales，12this review will focus only on the Morse fall scale and the STRATIFY scale because they are the most widely used in clinical and research settings.13，14

In terms of assessing risk，the most widely used metric is the Morse fall scale.The Morse Fall scale has the advantage of being a relatively simple instrument to administer.It has been shown to be effective in gauging the risk of falls in a variety of different settings.

Table 1Examples of risk factors associated with falls.

Briefly，the scale evaluates a patient's previous history of falls，number of additional diagnoses a patient has，which reflects the severity of the current condition.It also evaluates if a patient can currently move without aid or requires IVs or other therapies involving physical impediments and his or her current gait status and mental state.These essentially enumerate the various intrinsic factors that may lead to falls.

Another commonly used scale is the STRATIFY scale.This scale is less generalizable than the Morse fall scale and focuses specifically on older individuals in a hospital setting.However，although it is less generalizable over different environments and age groups，it has been shown to have a greater statistical sensitivity for predicting falls in a geriatric population，while maintaining comparable statistical specificity.15

Based on the scores on the different scales，a patient can be grouped into a low，medium or high risk category.These categories will then determine how the patient is handled in the hospital.One important aspect of this process is that the score needs to be communicated to each of the individuals on the patient's care team. It should be noted that these scale do not assess the contribution of external environmental factors.They only allow patients to be assessed relative to one another.A secondary process of calibration is needed to make the scales applicable to a specific institution to which a patient has been admitted.16

After the scales have been calculated for each patient by a healthcare professional，the cutoffs for the low，medium and high risk categories must be calibrated to the conditions of the specific care facility.For example，an acute care environment would warrant a lower cutoff than a more general hospital environment.Aspects to take into account during the calibration process are the presence of obstacles，overall lighting situation，presence of staff，and need for an individual patient to move.This calibration process needs to be handled by an integrative fall prevention team because the scale and corresponding risk categories are specific to the specific institution and the calibration process needs to be dynamic to account for falls occurring at the institution.

5.Fall prevention after risk assessment

After the overall risk of the patient has been calculated，a standard operating procedure needs to be implemented to ensure treatment consistency and identify environmental issues that need to be addressed to minimize a systemic risk of the hospital environment.While there has been a great deal of variability in the reported success of individual prevention programs，looking at successfully implemented procedures can provide some guidelines for the most effective interventions.

The first area that can be improved to reduce the number of falls is the use of assistive devices for patients.Hospitals should instruct patients assessed in the moderate-to-high risk categories on howto easily request assistance（i.e.，placing call buttons within easy reach of all the places a patient would spend any significant amount of time）.1Second，patient should be issued footwear that would minimize the risk of a falls，provided with assistive devices such as walkers and canes，or，when there is a significant need to move，provided with assistance from staff and non-skid footwear.8

While not directly associated with a patient's intrinsic risk for falls，the general environment should be well lit and free of obstacles.Furthermore，care should be taken that means for support，such as side rails，handholds，etc.，are within easy reach.Therefore，when patients feels they are at risk for a fall，they can easily reach these devices and prevent the fall.17Additionally，simple and easily overlooked factors，such as the height of furniture and positioning furniture for easy access，can be addressed.While this may be thought of in the context of preventing foreseeable falls，it also has an impact on unforeseen falls.

Other than environmental factors，specific interventions can be made to the direct care of a patient.For example，taking into account the pharmacodynamics for individual drugs when scheduling actions that require the patient to be moved may decrease the impact of drugs that increase the risk for falls.4Second，given that most patients on medications that increase the risk of falls require long-term treatment，implementing an effective communications strategy to notify all individuals on the care team about the risk of falls has also been shown to greatly decrease the percentage of falls. This follows the same logic of having a formalized risk assessment process to decrease falls（i.e.，it focuses the vigilance of different individuals on a patient's care team on patients who have the greatest fall risk）.

A third intervention shown to be important is providing educationtothefamilyofapatient.Thisinvolvesinformingfamiliesabout a plan of care，risks involved，and how to prevent falls.It has been shown that often falls occur during visiting periods outside the direct supervision of hospital staff.Training the family and informing them on the risk of falls allows a patient to be continuously monitored by individuals actively engaged in preventing falls.10

One under-appreciated aspect of fall prevention is the impact of physical fitness.Patients who stay in a hospital for a long period of time are at risk of significant muscle atrophy.This has a two-fold effect：the loss of stabilizing muscles increases the risk of falls，18and the lack of physical fitness prevents a patient from being able to brace themselves during a fall event.Finally，it has also been shown that lacking physical fitness decreases protective qualities，such as bone density.Therefore，in cases in whom a fall cannot be prevented，individuals are more resilient to the effects of the falls.

The last procedure shown to play a significant role in reducing the rate of falls is the incorporation of a post-fall analysis.A post-fall analysis includes all the individuals on a patient's care team.They assess factors that led to the fall.This identifies shortcomings in the current standard operating procedures and identifies additional signs that could have been missed in a patient's assessment.19Reviewing the events that resulted in a specific fall and identifying the shortcomings in the currently instituted processes can create a policy that is unique for a given institution.

Additionally，the use of the post-fall analysis allows a care team to better understand their own responsibilities，such as communicating clearly on the needs and current status of the patients，to their patients and to other members of the care team.Raising awareness of an individuals'responsibility in preventing falls greatly decreases the probability of overlooking the key signs of a patient's risk of falling.Therefore，preventative action can be taken. The overall schematic of the process that needs to occur is shown in Fig.1.

6.Implications for nurses

As the individuals who most directly interact with patients，nurses are at the forefront in the efforts to prevent falls in hospitals. Therefore，nurses must be given the relevant training and tools to analyze the effect of specific actions and programs.Instituting a training procedure，such as quality and safety in nursing，and establishing standard operating procedures with which to manage high risk patients allows best practices to be implemented outside and addresses any immediate risk factors present in an institution. However，because each individual institution will have its own differences，nurses must be given the ability to innovate and suggest alternatives that are more applicable.Thus，there needs to be a method by which nurses can propose and test new procedurespreventing falls.They must also have necessary informatics systems to capture and quantify outcomes.

Giving nurses the necessary autonomy by which to formulate new methods as well as perform evaluations in real time allows for the establishment of a culture of safety.This culture of safety is more than just the incorporation of standard operating procedures and necessary training.It also includes the desire to bring continuous improvement to patient safety.9All of the previously mentioned methods were first implemented at institutions that had a culture of safety and the necessary procedures by which suggestions could be implemented，evaluated，and disseminated to the rest of the institution.Because nurses work so closely with the individual patients，it is important to provide them with a stake in the overall culture，rather than focusing solely on more senior figures in the hospital. for the implementation of any successful program，nurse must be given the proper training to recognize patients who are at risk of falls and given the autonomy to implement and assess the benefits of different preventative measures.This is the only way to implement a comprehensive culture of safety in a hospital and for a systemic reduction of falls to be seen.

Conflicts of interest

All contributing authors declare no conflicts of interest.

Acknowledgments

Y.-Y.Gu gratefully acknowledges the support from the China Scholarship Council.

References

7.Conclusions

Falls in hospitals are events that can lead to significant secondary complications for individual patients.Furthermore，theyare easily preventable，for the most part.Thus，they represent an attractive target to increase the quality of care and lower the cost of overall medical treatment.While the benefits of instituting a formal falls prevention program are highly variable，common themes exist in successful implementations.The first component is the use of assessments to identify patients who are at a high fall risk.These can be done inexpensively and effectively using scales such as the Morse fall or STRATIFY scale.After the patients have been identified，standard procedures that focus on minimizing the risk of falls，such as reducing the period of time that a patient has to walk and providing assistive devices，can be implemented.Second，proceduresthatincreasecommunicationbetweendifferentindividuals on a patient's care team should be implemented.Finally，there needs a culture of safety needs to be incorporated so continuous improvements can be made and tailored to the needs of a specific institution.

As the individuals who interact with patients the most，nurses play an important role in the overall prevention of falls.Therefore，

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24 January 2015

*
Corresponding author.
E-mail address：38551492@qq.com（Y.-Y.Gu）.
Peer review under responsibility of Shanxi Medical Periodical Press.