Patient falls are not patient accidents, a common misconception. The definition of "accident" from The American College Dictionary is "an undesirable or unfortunate happening; casualty; mishap; anything that happens unexpectedly, without design, by chance." Patient falls rarely occur by chance. Instead, they are complex phenomena that take place because of multiple, often unrelated, highrisk factors that compromise the individual's situation.
A three-part study conducted at the San Diego Veterans Administration Medical Center (SDVAMC) identified the demographics of patient falls, the personal characteristics of the individuals who fell, and the risk factors that were interrelated. This was accomplished by a retrospective audit of 420 incident reports (Figures I and 2), field observation in three clinical areas, and 25 patient interviews within 24 hours of a fall (Figures 3 and 4).
The problem under study was to identify the characteristics of the individuals who had fallen and to determine and examine the relationship among their risk factors. AU individuals studied were inpatients at SDVAMC and had an incident report completed by a member of the nursing staff and a physician following a fall.
The primary dependent variables studied were the number and types of patient falls that occurred. The independent variables studied were the location, time, patient's age, diagnosis, medications patient was receiving, mental status, and blood pressure. Additional independent variables for the third part of the study, included number of days since admission, presence or absence of sensory deficits, urinary problems, ADL status, fit of shoes, patient's utilization of nursing personnel prior to the fall, use of restraints and/ or siderails, and previous history of falls.
The sample included 420 incident reports filed between January 1, 1980 and December 31, 1980 for Part I. Part II consisted of field observation of the ward environments, nursing staff, patients, and a review of the patient's medical record on three services. The three areas selected for field observation had the highest incidence of falls at any given hour. Seven falls occurred on the acute psychiatric ward between 7 am and 8 AM, and six falls occurred between 5 PM and 6 PM. Surgical specialty ward patients (GU, ENT, Eye) had 18 of their 37 falls evenly dispersed between 6 AM and 10 AM. There were 1 1 falls in the orthopedic-rehab ward between 8 PM and 10 AM. 12 falls between 4 PM and 6 PM, and 12 falls between 6 PM and 8 PM. The sample for Part III included interviews with 25 patients from three surgical wards, three medical wards, one neurological ward, one psychiatric ward, and 1 nursing home care unit that was housed on two wards.
A data collection tool was developed that contained all criteria expected on the incident report for Part I. Field observation notes were maintained and data from patient care plans were collected for Part II. A second data collection tool, entitled "Patient Interview Following a Reported Fall," was developed for Part III (see Figure 5).
The highest incidence of falls occurred between 6 am and 10 AM and between 4 PM and 8 PM,- 173 falls (44.8%). Those most affected were patients over the age of 75 (8 1 falls); 118 patients with neurologic diseases, 57 of whom were not on the neurology service; patients experiencing falls involving 137 bathroom activities; 96 patients who were receiving hypnotics/ tranquilizers; and 48 patients with mental deficits.
Clinical observation revealed that all but four patients had problems relating to safety on their care plans. Clinical areas all were covered adequately at change of shift and report time. Of the 37 falls in the surgical unit during peak hours, the highest incidence occurred among cancer patients, who experienced 22 (59.4%) of the falls. Of the 35 falls in the orthopedic-rehab ward, 13 (37.1%) were experienced by patients with previous fractures and 10 (28.5%) by patients with neurologic disorders. Of these 45 patients, 25 (55.5%) were receiving diuretics, pain medications/barbiturates, and/ or hypnotics/ tranquilizers. Twelve (26.6%) were receiving two or three of these medications. On the psychiatric ward, medications are administered one to one and one-half hours prior to mealtime, possibly adding hypoglycemia and weakness to the preexisting risk of hypotension. Hypotension/black-outs were experienced by five (38.4%) of the 1 3 patients who fell during the peak hours; three of these patients were receiving Trilafon.
All three areas observed were noted to have a high gloss on the floors, which produced a glare, particularly in areas where sunlight was reflected. All grab bars in patient bathrooms Were horizontal.
Profiles of high-risk patients established from 25 interviews in Part III of the study included individuals who pride themselves on previous autonomy and who desire to remain independent; individuals preoccupied with life crises; and individuals who do not seek help, have knowledge regarding reasons for falls, and hold the belief that falls are inevitable. These patients all had multiple combinations of risk factors.
Thirteen of the 25 falls (52%) had something to do with the need to urinate and the patients' attempts to complete the task independently. Six of these 13 patients (46.1%) were receiving diuretics.
Some of the patients' remarks illustrate the profiles identified: "I was coming from the bathroom and got up too fast." "I'm afraid I will be an invalid and have to slow down for life like some of these others." "They thought I was crazy and tied me up. I tried to get up to go to the bathroom. " "I got cocky and overdid it, I should have known I was tired and used my crutches." "I didn't want to wet the bed and bother the nurses. They had to change it three times the other night and that's not fair to them." "I prefer to do things for myself." "I have Paget's Disease, scoliosis, arthritis, and can do everything for myself. When I fall the cops always come and pick me up and I've never hurt myself yet." An 87-year-old, debilitated patient stated, 'Tm in good shape, IVe walked for years."
Three of the 25 patients actively were grieving the death of a spouse. One patient focused on his essential problem of loneliness, his perceived abandonment by his children, and his inability to eat properly or socialize since the death of his wife. He had cardiovascular disease, hypertension, some confusion coupled with a hearing deficit, and was receiving diuretics. He was most certainly a multiple risk patient. Two others were preoccupied with their own impending deaths. AU three of these patients focused on their immediate life crises and were unable to concentrate on aspects of their care and safety.
Twenty four (96%) of those interviewed were knowledgeable regarding the cause of their fall. Ten (40%) of the falls were caused by a sudden change in body position. Seven patients stated, "I got up too fast." Three others either turned or bent over. One patient stated, "I forgot to put my rubber-soled slippers on and transferred to bed, I mean the floor, in my Ted-hose." Falls occurred when eight (32%) were barefooted; four (16%) additional patients who had mental deficits and were receiving diuretics did not remember if they were barefooted.
None of the 25 patients interviewed sought help before their falls. Five patients believed that nothing that could be done to prevent this from happening and expected to fall again. One 80-year-old patient who had had multiple falls at home, an erratic response to diuretics, a history of venous ligation, weakness of legs, and cardiovascular disease resisted suggestions of a cane, walker, use of a urinal, or any assistance from his wife. He intended to do everything himself.
COMPARISON WITH THE LITERATURE
Comparing the findings of this study with those documented in the literature revealed the following. Walshe and Rosen found that 39.6% of patients with a primary cardiovascular diagnosis and 22.6% of patients with a secondary cardiovascular diagnosis had sustained falls.1 This investigator found that 48% of patients had a primary or secondary cardiovascular diagnosis. Walshe and Rosen also reported that 43.4% were receiving diuretics, 32.0% were receiving sedatives, and 13.2% were receiving analgesics.1 This investigator found 44% receiving diuretics, 36% receiving hypnotics/ tranquilizers, and 36% receiving pain medications/ barbiturates. In 30.2% of Walshe and Rosen's sample, the patient was attempting to go to the bathroom. In this study, 33.8% attempted to go to the bathroom before they fell.
Brown and Kiss, in an audit of falls by cancer patients, found the greatest number of falls occurred on the day shift (45%).2 This was contrary to findings in other studies. In this study, the incidence of falls was 37.5% of 386 and 32% of 25 on the day shift. Of the 13 falls in which significant injuries occurred, 10 (76.9%) were on the day tour. Brown and Kiss also found the largest number of falls, 16 (40%), occurred within the first six days of admission, and 1 0 (25%) occurred within the first three days. This investigator found that seven (28%) of 25 falls occurred in the first six days, and that 24% of the patients involved in these falls were over the age of 65. Brown and Kiss found that a high incidence of falls (10 or 25%) occurred during the third week of hospitalization.2 This was not validated by this study. In another peak period during the second and third months of hospitalization, seven (28%) of 25 falls occurred. One may speculate that the length of stay and types of problems for which one is hospitalized vary in an acute-care, private hospital and a veterans' hospital.
MacDonald and MacDonald studied the use of barbiturate hypnotics in relation to the time of day 390 patients sustained femoral fractures.3 Ninety-three percent of the patients who suffered nocturnal fractures were taking barbiturate hypnotics, compared with 6% on the day tour and none on the afternoon tour. In this study, 49.7% were receiving hypnotics/ tranquilizers and 23.8% were receiving pain medications/ barbiturates at the time of 193 reported falls.
Schested and Severin-Nielsen also found that most falls occurred during the first week of hospitalization and during the interval when hospital personnel density was greatest - 134 (51%) occurred between 7 AM and 3 PM. and 65 (25%) occurred between 3 PM and 7 PM. Tranquilizers had been administered to patients involved in 42% (1 1 1 of 51 1) of falls.4 They also identified 28 falls resulting from lack of friction between shoe and floor, 2 1 resulting from a patient changing position to reach a low-lying object, and 14 resulting from the movement of an expected support point, suchas a bedside table. This investigator identified that 13 (52%) of 25 patients fell because of ill-fitting shoes or slippers, 37 (9. 1 %) of 405 patients fell while reaching for something, and 26 (6.4%) of 405 patients fell when something was in their way, often a bedside table or wheelchair.
Kirkpatrick and Pearson studied 71 fatal cerebral injuries based on a medical examiner's records.5 Falls represented almost two-thirds of the injuries, and occurred in the infirm and/ or alcoholic elderly. Eleven of the patients were hospitalized at the time of the fatal injury. Skull fractures occurred in one half of the cases and subdural hematoma occurred in two-thirds of the cases, frequently opposite the site of impact. The greater incidence of subdural hematoma is attributed to atrophy of the brain in older patients, with greater movement and tension of the bridging veins that pass from the brain to the dural sinuses. Epidural hematomas are almost nonexistent. This investigator found that 43 (10.6%) of the minor injuries, lacerations, abrasions, hematomas, and sutures occurring in a sample of 405 involved the head.
Kalchthaler, Bascon, and Quintos reported that residents with three to six concurrent chronic diseases and those treated with more than three drugs had the greatest number of falls.6 Peak frequencies of falls occurred from 4 PM to 5 PM. 7 PM to 8 PM. and 6 AM to 7 AM. Residents over the age of 85 were at greatest risk for major falls. Kalchthaler et al suggest that the number of drugs that a patient received represented the multiple pathological disorders in these patients, and increased their underlying risk. They also reported that alert, wheelchair-bound patients were at higher risk because of their mobility, whereas those who used assistive devices (walkers, canes, crutches) were at the lowest risk. The shuffling gait, shift in the center of gravity, hip and knee flexion, and decreased proprioception experienced by old people predisposes them to falling. It is believed that assistive devices increase proprioception, coordination, and redistribute weight. This study validates their findings.
FfGURE 1 DISTRIBUTION OF PATIENT FALLS RELATED TO AGE TYPE OF FALL AND MEDICATIONS RECEIVED FIGURE 2
DISTRIBUTION OF PATIENT FALLS RELATED TO AGE, DIAGNOSIS, MENTAL STATUS AND BLOOD PRESSURE
Gordon reported on 16 patients with undetected cardiac arrhythmias that presented with neurologic dysfunction and falls.7 He found patients misdiagnosed with "cerebral atherosclerosis, vertebrobasilar insufficiency, senility, and chronic ear disease." He used the Holter monitor to diagnose transient cerebral ischemic attacks and confirmed that cardiac events often can be implicated in CNS dysfunction, which can be corrected by pacemaker insertion and /or medication. With appropriate treatment, the CNS symptoms disappeared. This investigator found that seven (28%) and 12 (48%) of a sample of 25, and 1 18 (39.8%) and 23 (7.7%) from a sample of 296 had neurologic and cardiovascular disease, respectively.
The quality of care of the older patient can be increased and the incidence of falls reduced by completing a risk assessment (Figure 6) designed to pinpoint those patients at greatest risk. The assessment must begin at the time of admission and must be followed by patient education regarding the principles of safety and the physiologic changes that make them more vulnerable to falls and subsequent injuries. The prescribing of medications, particularly combinations of diuretics, pain medications/ barbiturates, and hypnotics/ tranquilizers, must be limited and reviewed frequently as to the number of drugs and the time sequence in which the patient is receiving them. Barbiturates, hypnotics, and tranquilizers rarely should be prescribed for the older patient.
DISTRIBUTION OF FALLS RELATED TO AGE OF PATIENT
DISTRIBUTION OF FALLS RELATED TO HIGH RISK PROFILE OF VISUAL, AUDITORY, URINARY, MOBILITY, DEBILITY AND INADEQUATE SHOES
The primary goal of the VA Nursing Service is the CARE of the veteran patient. Recommendations from this study are made under the CARE categories - Clinical, Administrative, Research and Education.
1. Reassessment of medications, specifically diuretics, pain medications/barbiturates, and hypnotics/ tranquilizers, by pharmacist, MD, and RN.
2. Develop a patient education program on safety for all newly admitted patients with risk factors, specifically all patients with a primary or secondary diagnosis of cardiovascular, neurologic, and oncologic diseases or fractures.
3. Develop a standard care plan and a patient fact sheet for high-risk patients that will be available on admission.
4. Include fall diagnosis on patient's problem list.
5. Continue patient interviews, preferably within 24 hours after a fall, with a primary focus on assessment of risk factors, and rehabilitative and gerontologie needs of the patient.
6. Increase the emphasis on prevention of falls with movement therapy aimed at increasing coordination, dexterity, and compensating for physical deficits within recreation, physical, and occupational therapy programs.
1. Reassess staffing patterns between the hours of 6 AM and 10 AM and 4 PM and 8 PM, specifically in relation to the number of patients with high-risk factors and their needs.
2. Obtain overbed tables with wheels that lock to reduce the incidence of falls that occur when patients reach or lean on a movable object. Also obtain half-side rails to reduce the incidence of falls that occur when patients climb over the full-side rail or the foot of the bed. The half-side rail also will enable patients to hold onto a secure object when bending or reaching.
PATIENT INTERVIEW FOLLOWING A REPORTED FALL
3. Recommend matte, specklefree, solid color floor covering so that spills can be seen easily and glare is reduced. Recommend that rubberbacked area carpets be placed in front of sinks in patients' rooms, at the bedside, and in front of patients' toilets in areas with the greatest number of high-risk patients - orthorehab, neurology, and ENT services.
RISK ASSESSMENT: FALLS
4. Request physical therapy and occupational therapy personnel to evaluate the grab bars located near patients' toilets. Recommend installation of a perpendicular bar, in addition to horizontal bars, if indicated.
5. Review incident reports for all required data.
1 . Continue to investigate the correlation between cardiovascular and neurologic deficits in relation to patient falls.
2. Audit incident reports for a one-year period beginning three months after the implementation of the recommendations of this study.
3. Conduct 25 patient interviews after the implementation of the risk assessment, patient education safety program, fact sheet, and standard care plan.
4. Continue to investigate the correlation between the use of diuretics, pain medications/ barbiturates, hypnotics/tranquilizers, and patient falls.
1 . Teach risk assessment as part of the gerontological nursing program. Presenting the program on closedcircuit television may maximize the number of nursing staff attending. Develop case studies.
2. Provide educational programs for nurses and physicians on the interrelationship of medication usage, disease states, and the incidence of falls among high-risk patients. Discuss physiologic changes in the nervous system that make the elderly more susceptible to fatal head injuries.
3. Reinforce learning for nursing staff on the documentation of incident reports and use of overbed tables with side-rails up for bed patients.
4. Provide training in activities of daily living for nursing staff and patients, emphasizing safety and toilet transfers. Stress awareness of preoccupation with personal life crises and its effect on patients' ADL status.
The task of improving the quality of life and the health of our older patients is a common goal. By increasing the patient's level of knowledge regarding safety and improving his/her ADL skills in the hospital will reduce the incidence of falls and injuries in the home. Nurses must continue to study this multifaceted problem and seek innovative solutions.
- 1. Walshe A, Rosen H: A study of patient falls from bed. J Nurs Admin 1979; 79:31-35.
- 2. Brown MH, Kiss ME: A problemfocused approach to nursing audit: Patient fails. Cancer Nursing 1979; 79:389391.
- 3. MacDonald JB. MacDonald ET: Nocturnal femoral fractures and continuing widespread use of barbiturate hypnotics. Br Med J 1977;2:483-485.
- 4. Shested P, Severin-Nielsen T: Falls by hospitalized elderly patients: Causes, prevention. Geriatrics 1977; 77:101-108.
- 5. Kirkpatrick J, Pearson J: Fatal cerebral injury in the elderly. J Am Geriatr Soc 1987; 26:489-494.
- 6. Kalchthaler T, Bascon RA, Quintos V: Falls in the institutionalized elderly. J Am Geriatr Soc 1978; 26:424-428.
- 7. Gordon M: Occult cardiac arrhythmias associated with falls and dizziness in the elderly: Detection by holter monitoring. Journal of the American Geriatrics Society. 1978; 26:418-423.
- Ashley MJ. Gryfe Cl, Amies A: A longitudinal study of falls in an elderly population: Some circumstances of falling. Age Ageing 1977;6:211-220.
- Brocklehurst JC1 Exton-Smith AN, Barber SM, et al: Fractures of the fe mur in old age: A two-centre study of associated clinical factors and the cause of the fall. Age Ageing. 1978; 7:7-15.
- Gould G: A survey of incident reports. Journal of Gerontological Nursing 1975; 15:23-26.
- Gryfe CI, Amies A, Ashley MJ: A longitudinal study of falls in an elderly population: Incidence and morbidity. Age Ageing 1977; 6:201-210.
- Howton K, Leopoldt H: Accidents in a psychiatric hospital. Br J Psvchiatrv 1978; 133:224-227.
- Holding TA, Barraclough BM: Psychiatric morbidity in a sample of accidents. Br J Psychiatry 1977; 130:244-252.
- Overstall PW, Exton-Smith AN. Imms FJ, et al: Falls in the elderly related to postural imbalance. Br Med J 1977; 1:262-264.
- Witte N: Why the elderly fall. Am J Nurs 1979; 79:1950-1952.
- Our patients slip, slide and crawl but rarely fall -A study of accidents in a hospital. Unpublished study. Columbia, SC, Veterans Administration Medical Center, 1977.
- The author wishes to thank the many staff nurses, head nurses and supervisors who participated in this project. A special acknowledgment is given to Susan H. Harris. MSN, Associate Chief Nursing Service/ Education. and Marcella Z. Davis, DNSc. Associate Chief Nursing Service/ Research, and to Janet Julian and Kurt Smolen of the Medical Media Service for their assistance and encouragement during this study.
RISK ASSESSMENT: FALLS