Journal of Gerontological Nursing

Is Your Patient About to Fall?

Cynthia Lund, MSN, RN; Marian L Sheafor, PhD, RN

Abstract

Using this profile, Gerontological Nurses can play an important role in predicting patients at risk of falling!

Abstract

Using this profile, Gerontological Nurses can play an important role in predicting patients at risk of falling!

~ lealth care professionals H have long recognized that falls among the elderly pose many concerns. After age 65, falls increase _______ directly with age. If the falls are not fatal, they may cause injury, sap confidence, generate insecurity and fear, and result in decreased mobility and dependence upon others. They may lead to the decline of previously vigorous elderly persons.1

Epidemiological studies have shown the mortality rate for hospital accidents is less than 5%. One-half of the accidents, most of which are falls, result in some type of injury. Patient accidents in general-treatment hospitals range from 18-24 per 10,000 patients days, but older patients fall more frequently.2 Since about 42% of patients in shortstay hospitals are elderly, the aged who fall in these settings present significant health care problems.3 In spite of this, research regarding elderly patients who fall in institutions has been sparse and settings non-comparable. However, all inquiries have concluded that the incidence of falls could be reduced if environmental elements were altered or modified, and patients, families, and/or staff made aware of the aged's characteristics contributing to falls.415

The Study

Most hospitalized elderly patients do not fall and it is not known how those who do fall differ from the elderly who do not fall.2·9" Therefore, the question in this inquiry was, could a profile of risk elements for falling be identified? Since no studies were found regarding elderly hospitalized patients who fell, incorporating a control group of those who did not fall, this investigation appeared warranted.

In this comparison study, the method of data collection was a retrospective incident report and chart review. The setting was a 300 bed short-stay community hospital in which 24% of the inpatients were elderly and dispersed throughout the hospital (with the exception of the pediatric unit). The sample included two groups of records selected from the total population of 1 ,773 agedpatient admissions during 1978. Group I consisted of all (76) elderly patients' records who had documented falls during this year, while Group II was comprised of 76 aged patients' records chosen at random from those with no documented falls.

Data were retrieved on an instrument consisting of the following three sections: 1) Section I: General Information (information regarding whether the subject fell, and if so, how many times during 1978); 2) Section U: Non-comparable Data Regarding Subjects Who Fell (site, time, day of week, shift, activity involved, and factors contributing to the fall); and 3) Section III: Comparable Data Regarding Subjects Who Fell and Subjects Who Did Not Fall.

Environmental factors included the use of restraints, the season, the use of siderails, and the number of transfers from one unit to another. Characteristics of patients included sex, age, number of disease conditions, primary diagnosis on discharge, new diagnosis, anemia, mobility, usage of assistive ambulatory devices, number/types of drugs, and mental status. Parts of the instrument were modified from the work of Pablo and Kalchthaler, both of whom granted their permission to do so.2-8 All data were coded on the instrument, then tabulated.

A pilot study in which three persons each reviewed two charts (a chart of a hospitalized elderly patient who fell and one who did not) revealed that the questionnaire had an inter-rater reliability of 83%, and the information was easily retrieved. Several modifications were made to improve clarity of the instrument after reviewing suggestions of those who participated in this review.

In order to help determine if the investigator was answering questions in a consistent and appropriate manner, another graduate student in nursing independently completed a duplicate questionnaire on every 15th subject in the study. These duplicate questionnaires were compared to those answered by the investigator. Inter-rater reliability was computed and found to be 93%.

Results and Discussion

In regard to frequency of falling, 26% of persons who fell did so a second time within the facility and 9% fell three or more times. The sites where falls most frequently occurred were the bedside and patient room areas (see Table 1).

Aged patients fell more frequently on the evening and night shifts, with peak fall times occurring from 3:00 pm - 7:00 pm (18 falls) and 3:00 am - 7:00 am (19 falls). During the day shift, elderly persons fell most often between 8:00 am - 12:00 Noon (11 falls). Tuesdays and Thursdays were the days of the week on which 41% of all falls occurred.

The most notable of the contributing factors were the use of restraints in 21 falls; getting up without calling for assistance in 15 falls; becoming dizzy.

losing balance, or slipping in U falls; and being under sedation in 10 falls. The activity most frequently involved during a fall was getting in, out, or rolling out of bed.

Table

TABLE 1SITES OF FALLS FOR 76 FALLERS

TABLE 1

SITES OF FALLS FOR 76 FALLERS

Table

TABLE 2ACTIVITIES AMONG 76 FALLERS

TABLE 2

ACTIVITIES AMONG 76 FALLERS

Most falls happened during the first nine days of hospitalization with occurrence steadily diminishing through length of stay (see Table 2).

In regard to comparative environmental factors between aged patients who fell versus those who did not fall, two factors demonstrated statistical significance for increased risk when the test for significant difference between two proportions was applied. These increased risk factors were 1) the season (from September to November) and 2) having three or more unit transfers. The two factors that statistically demonstrated a lower fall risk were 1) being hospitalized in the critical care areas (ICU, CCU) and 2) being hospitalized from March - May.

Some studies indicate that a relationship between fallers and nursing coverage exists.5·6·10·12 One might speculate that nursing staffing practices and falls were somehow also related in this hospital. During the September to November period, newly graduated nurses were assuming charge responsibilities on the evening and night shifts. In March to May, staffing was stable with few orientées. ICU and CCU units had higher staffing ratios than general units at all times.

In regard to unit transfers, Schested and Severin-Nielsen and Kulikowski both speculate that fall risk increases when patients enter new surroundings.13·9

The number of aged persons in restraints were identical in both the group of patients who fell and in the random sample of patients who did not fall. Furthermore, only 1% of all elderly patients admitted to the hospital during 1978 had falls attributed to restraint use (or lack of use), a lower rate than the overall fall rate of 4% for older persons. Results concerning the use of siderails was uninterpretable, as about one-half of the patients who did not fall had no documentation regarding the use of siderails.

In regard to Comparative Patient Characteristics between aged patients who fell versus those who did not fall, three factors demonstrated statistical significance (with the test for significant difference between two independent proportions) for increased fall risk. These increased risk factors were: 1) usage of assistive ambulatory devices (wheelchairs, walkers, canes) 2) taking drugs of the following groups - vitamins and iron, diuretics and hypotensives, or seizure medications and 3) having a cognitive impairment (senility, confusion, or episodic confusion). The factor identified as having a significantly lower fall risk was taking any of the following drugs - preoperative medications, antibiotics, and anticoagulants.

Concerning ambulatory devices, results are not in accordance with those found in Kalchthaler's, et al, study which revealed that older persons in wheelchairs had the greatest amount of falls, whereas those using canes and walkers had the fewest.8 Berry's inquiry found that patients who used assistive devices were more likely to fall.4 However, neither study had control groups. Foerster's inquiry had a nonfallers comparison group and reported that use of assistive devices did not prove significant to the incidence or frequency of falls. But Corless' critique of this inquiry indicates that with proper data grouping, results are not conclusive (see Table 3).17

In regard to why particular medications were significantly different in fallers and nonfallers, one can only speculate. Indeed, Corless in her critique of Foerster's study of falls, deplores the absence of data regarding medications. ,7 The category vitamins and iron is puzzling, as no significant difference was found concerning hemoglobin values of fallers and nonfallers. Diuretics and hypotensives have been cited as drugs taken by patients who fall,13·16 and these findings are supported by the present study. Such medications tend to make some persons weak or dizzy.

Seizure medications were also found to be taken by significantly more persons who fell, supporting Schested and Severin-Nielsen's report that seizures were observed among the elderly who fall.13 The fact that several of our patients with the diagnosis of cerebral vascular accident were taking seizure medication, presents a possible compounding set of factors. This disease category was found to be more prevalent in individuals who fell (see Table 6).

Significantly more nonfallers were taking antibiotics, anti-clotting agents, or had "preps" or preoperative medications. It could be surmised that patients taking such medications are under closer staff supervision or are more "bed bound" due to their illness. As noted previously, these patients who fell were usually "up with assistance" (see Table 4).

Mental status appeared to be a difficult item to assess through a record review. However, cognitive impairment, subsuming senility, confused, and episodic confusion, was significantly related to fall risks within this hospital (Table 5).

Table

TABLE 3AMBULATORY DEVICES USED AMONG 76 FALLERS AND 76 NONFALLERS

TABLE 3

AMBULATORY DEVICES USED AMONG 76 FALLERS AND 76 NONFALLERS

Table

TABLE 4MEDICATIONS TAKEN BY 76 FALLERS AND 76 NONFALLERS

TABLE 4

MEDICATIONS TAKEN BY 76 FALLERS AND 76 NONFALLERS

Table

TABLE 5MENTAL STATUS IN 76 FALLERS AND 76 NONFALLERS

TABLE 5

MENTAL STATUS IN 76 FALLERS AND 76 NONFALLERS

Table

TABLE 6PRIMARY DIAGNOSIS ON DISCHARGE AMONG 76 FALLERSAND 76 NONFALLERS

TABLE 6

PRIMARY DIAGNOSIS ON DISCHARGE AMONG 76 FALLERSAND 76 NONFALLERS

Items that showed no statistical significance concerning comparable patient characteristics included sex, number of disease conditions, primary diagnosis on discharge, anemia, and number of drugs taken. (Table 6).

The average age of patients who fell was 2.4 years older than those who did not fall. The category mobility was difficult to interpret, as the data only accurately described the mobility status of Fallers and when the fall occurred. However, within this group, more falls occurred when patients were getting up with assistance.

Implications for Nursing

The results of this study revealed a high-risk profile of elements for falls in elderly patients within this short-stay community hospital which included:

1. Being hospitalized during September, October, or November;

2. Having three or more unit transfers;

3. Using assistive ambulatory devices (wheelchairs, walkers, canes);

4. Taking one or more of the following drugs: vitamins and/or iron, diuretics and/or hypotensives, anticonvulsants;

5. Having a cognitive impairment (senility, confusion, or episodic confusion).

In addition, three fall low risk factors were found including:

1. Being hospitalized during March, April, or May;

2. Being hospitalized in intensive or coronary care units;

3 . Taking one or more of the following drugs - "preps" or pre-operative medications, antibiotics, anticoagulants.

Due to the fact that a profile of high risk elements was identified in this facility, it appears that nursing interventions to reduce fall risk could be initiated.

Patients could be identified as needing assessment for fall risk if they had one or more of the identified high risk elements (with the exception of season). If necessary, preventive strategies to reduce fall risk could be planned.

While planning such care, nurses might wish to use descriptive data from this study concerning falls, such as fall sites, contributing factors, and activity and mobility status in designing nursing interventions to reduce fall risks. Asking the patient and his family to help develop such a plan would enable all to actively participate in attempts to reduce fall risk.

Nursing administration could also attempt to promote safety by providing inservice for new graduates concerning fall risk immediately prior to their acceptance of charge responsibility. In this hospital that usually occurs during high risk months and on the evening and night shifts. In addition, administration might want to consider staggering personnel hours to ensure sufficient staffing during high risk times.

Future studies might evaluate if such in-service education and staffing patterns as those suggested are effective in reducing falls. Nursing administration and nursing staff might also want to investigate why Tuesdays and Thursdays account for 4 1 % of all falls in their elderly population. If reasons could be identified, interventions might be implemented to reduce hazards during these days.

Variables in this study not previously found to be researched in relation to fall risks include: unit transfers, episodic confusion, new diagnosis, and anemia. In addition, the categories regarding primary diagnosis on discharge and the kinds of drugs taken have not been studied in depth. In order to corroborate the elements constituting fall risk, further studies, which include a control group or a replication of this study, are needed.

Reference

  • 1 . Accident mortality at older ages. Statistical Bulletin. Metropolitan Life Insurance Co, 1974; 55:6-8.
  • 2. Pablo R: Patient accidents in a long-term facility. Can J Public Health 1977; 3:237-247.
  • 3. Stat. Abstract of the U.S.-U.S. Bureau of Census, 103 ed.. Washington D. C. 1982-1983.
  • 4. Berry G, Fisher RH, Lang S: Detrimental incidents, including falls, in an elderly institutional population. J Am Geriatr 1981; 22(7): 322-324.
  • 5. Fine W: Fits and falls. Gerontologia Clinica 1967; 7:270-284.
  • 6. Foerster J: A study of falls: The elderly nursing home resident. J NYSNA 1981: 12(2): 9-16.
  • 7. Gibbs J: Bed area Falls: A recent report. The Australian Nurs J 1982; 1 1( 10): 34-37.
  • 8. Kalchthaler T. Bascon RN. Quintas V: Falls in the institutionalized elderly. J Geriatr Am Soc 1978; September 424-428.
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  • 10. Lynn FH: Incidents - need they be accidents'? Am J Nurs 1980; June: 1098-2001 .
  • 11. Morris EV. Isaacs B. Bristen W: Falls in the elderly in hospital. Nursing Times 1981: August 26: 1522-1524.
  • 12. Odetunde Z: Fell walking! Nursing Mirror 1982; February 24: 33-36.
  • 13. Schested P. Severin-Nielsen T: Falls by hospitalized elderly patients. Causes, prevention. Geriatrics 1977; 32(4): 101-108.
  • 14. Swartzbeck EM. Milligan WL: A comparative study of hospital incidents. Nurs Management 1982: 13(1): 39-43.
  • 15. Walshe A. Rosen H: A study of patient falls from bed. J Nurs Admin 1979; May: 31-35.
  • 16. Rodstein M: Accidents among the aged. In Reiche! W (ed): Clinical aspects of aging. Baltimore: The Williams & Wilkin Co.. 1978. ? 505.
  • 17. Corless IB: A Critique. J NYSNA 1981; 12(2): 30-32.

TABLE 1

SITES OF FALLS FOR 76 FALLERS

TABLE 2

ACTIVITIES AMONG 76 FALLERS

TABLE 3

AMBULATORY DEVICES USED AMONG 76 FALLERS AND 76 NONFALLERS

TABLE 4

MEDICATIONS TAKEN BY 76 FALLERS AND 76 NONFALLERS

TABLE 5

MENTAL STATUS IN 76 FALLERS AND 76 NONFALLERS

TABLE 6

PRIMARY DIAGNOSIS ON DISCHARGE AMONG 76 FALLERSAND 76 NONFALLERS

10.3928/0098-9134-19850401-11

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