The prevention of falls in geriatric patients must become a part of the health professionals* intervention strategies as more and more elderly patients are admitted to hospitals. The economic and social impact from serious injury as a result of a fall in this age group can have a devastating effect on the geriatric patient, the family, and the institution. Efforts by health professionals to prevent or minimize this problem are essential.
The development of clinical tools designed towards prevention may be the key to solving this problem. These tools can help caregivers assess elderly patients at risk to fall, provide alternative interventions, and serve as a means to enhance documentation.
The increase in fall rate among geriatric patients in one medical center prompted clinicians from nursing service and nursing education to collaborate in search of possible causes. In a beginning attempt to deal with increased falls, staff inservices were conducted on several nursing units. The purpose of the inservices was directed towards increasing risk awareness to prevent geriatric patients from falling. While the inservices were in progress however, several observations were made. First, there was no recent empirical data to describe the characteristics of patients who were falling in this particular hospital. Second, there was no way other than through generalized statistics to identify who was at risk to fall; and third, there was no standardized universal care plan for preventing injury to this select patient group. The problems became apparent and this article describes the attempt towards solution.
A review of the literature was undertaken to identify the major reasons that contribute to older patients' falling when in hospitals. The older patient is at high risk to fall for several reasons that are often related to physical and psychological changes that occur with advancing age.
Age Related Changes
It has been demonstrated that as the numbers of geriatric patients increase, problems associated with hospitalization of the elderly will also increase, unless innovative ways can be found to prevent or minimize them. In view of these findings, there is a need to focus on the advanced aging process and how it frequently alters body functions, thereby, placing the elderly patient at high risk for falling. One of these changes, failing eyesight, may interfere with the geriatric patient's ability to be protected from environmental hazards. Another, impaired auditory status, may limit this person's ability to hear warning signals. Degeneration of joints, bones, and changes in the center of gravity can also contribute to the older person's high risk to fall.
ASSESSMENT FOR HIGH RISKS TO FALLS
Changes in urination and defecation are major contributing factors to falls among the elderly. Several research studies reviewed indicated that activities related to urination or defecation were in some way involved in the patient's fall.1"9 A study at a VA Medical Center showed that patients who pride themselves in their previous autonomy and wish to maintain their independence in relation to elimination were at high risk to fall while hospitalized.5
Orthostatic hypotension has been shown by many research studies to be a significant cause of falls among the elderly. This type of hypotension can be related to a drug side effect, prolonged immobility, diminished activity, as well as age-related deterioration of the baroreceptors.5,6,8
Changes in mental status are another behavior that consistently impacts on falls in the geriatric population. The changes can occur as a result of certain cardiovascular and neurological diseases, side effects to certain drugs, and as a result of changes in an elderly person's environment.
Polypharmacy among the elderly is not unusual because of multiple physical problems. Aging changes interfere with the ability to absorb or excrete drugs. As a result, there is a toxic buildup which increases the effects and side effects of drugs to levels that impair the elderly person's performance. Nurses often see dramatic changes in the elderly patient's mental status after a few days and nights on tranquilizers and/or hypnotics. General anesthesia can also bring about similar changes in mental status which range from lethargy to disorientation and confusion, thus making the elderly patient a prime candidate for a fall. Research studies have demonstrated an increase in falls among the hospitalized geriatric patients who receive such sedation.7-8
In addition to mental and physical changes, other factors can contribute to the elderly person being at risk to fall. One area often overlooked by staff is the emotional response that can accompany a loss.
Depression, anxiety, and grief decrease the geriatric patient's perception of life. When focusing on a life crisis, the geriatric patient often neglects aspects of personal care and safety. Barbieri 's study demonstrated this to be a possible contributing factor in a few of the patients who fell,5
Medical or surgical conditions that interfere with speech alter the elderly person's ability to communicate. Being unable to communicate with one's caregivers interferes with the geriatric patient's ability to ask for help. Therefore, this type of patient may take chances that can contribute to falling.
Identification of the Problem
Data from the nursing Quality Assurance Division revealed that during one particular month there was a significant increase in the number of falls throughout the hospital. A focused review of incident reports and patients' records was undertaken by two nursing faculty in collaboration with the Quality Assurance nurse specialist within the hospital. This became a great opportunity to jointly problem solve and share resources such as data analysis, computer time, and assistance for the project.
ASSESSMENTAND INTERVENTIONS FOR PATIENTS AT RISK TO FALLS
The retrospective study showed that the elderly patient is at high risk to fall for multiple reasons. Five main areas for the study of "fallers" included: demographics, diagnosis, sensory deficits, mobility deficits, and medications. Environmental- and hospital-related factors such as location of the fall and time of day were also explored. Findings, for the most part, were consistent with the existent literature on those at risk to falling in an acute care setting. After having established a profile of those patients most likely to fall, it was important to incorporate those findings into a tool to assess the individual patient.
Development of Clinical Tools
Based on the review of the literature, and the focused review of records, an assessment for those elderly patients at high risk to falls was designed. The assessment data chosen was based on the behaviors seen in geriatric patients that seem to contribute to a high rate of patient falls. The original assessment tool was long and complex. Because of the time pressures and workload of the staff, the tool was shortened and the criteria simplified.
Staff inservices were presented to all shifts and the Assessment for High Risk to Falls was piloted on two nursing units that implemented primary nursing. The purpose of the pilot was to elicit feedback from the staff in order to modify the tool. Areas of concern consisted of clarity of the tool, workload of the staff, and feasibility. The assistance and support of the clinicians on each unit was significant in accomplishing the project's goals.
Results of the pilot indicated that the following risk areas were exhibited by the majority of the patients assessed: history of previous falls, mental status changes, debilitation or weakness, mobility deficits, communication deficits, sensory deficits, multiple medications, urinary alterations, and evidence of emotional upsets or loss of a significant other. Although improper fitting footwear and orthostatic hypotension were not assessed in this pilot, they were included in the assessment tool since previous studies showed these two items to be high risk factors (see Figure 1).
On the units involved in the pilot, the majority of the patient population exhibited several high risk areas. It was recognized that while the Assessment for High Risk to Falls would be used as a guide to fall prevention, ratings would depend on the professional nurse's judgment. It was decided that the RN, preferably the patient's primary nurse, would perform the risk assessment. After trying various locations, it was also determined that the best place to keep the assessment tool was with the patient's hospital data base on the patient's chart.
The pilot showed that the assessment tool was workable. The next step was to develop a plan of care based on the nursing diagnosis, "potential for injury." This plan of care contained risk factors from the Assessment for High Risk to Falls and appropriate nursing interventions to meet the patient's safety needs (see Figure 2).
The objective was to reduce falls through the intervention of a standardized nursing care plan based on particular risk factors. The application of such a standard consequently becomes the tool for measuring nursing care. The standard has since been modified for use by prioritizing risk areas and allowing for individual patient differences.
A standardized nursing diagnosis, "potential for injury," with intervention strategies is currently kept on file on each nursing unit. As a patient is admitted to the unit, an Assessment for High Risk to Falls is performed. When it is decided by the primary nurse that this patient is at risk to falling, an individualized care plan to prevent falls is initiated.
Further Tool Development
Looking for ways to provide tools that are accessible and useful to staff make evaluation and revision an ongoing process. Because flowsheets at the patient's bedside are used successfully at this institution, another tool was created which incorporated the most critical components of the first two tools, and was designed to be filled out on every shift (see Figure 3). The flowsheet also helps foster interventions that may serve to promote safety and meet an overall goal of geriatric patients remaining free of injury during the hospital stay.
Since flowsheets are a part of the patient's permanent record, they serve as an additional source of documentation. Due to the legal implications of this form if it is implemented in an institutional setting, it needs to be piloted and approved for use in each individual institution.
A final way to increase awareness among care providers is with a Safety Alert Sticker (SAS). This sticker can be attached to the geriatric patient's care plan, chart, or affixed at the patient's bedside (see Figure 4).
Future plans involve the development of a booklet. The booklet will focus on safety guidelines for the hospitalized elderly patient, with a major emphasis on how to prevent falls. It will be shared with the patient and family when the elderly patient is admitted to the hospital.
FALL PRECAUTIONS CHECK LIST PREVENTION AND INTERVENTION
The implications for nursing are very important. Safety for the geriatric patient who is hospitalized is a major concern for the nursing staff. For this reason, it is very important that the elderly patient be assessed regarding a history of previous falls on admission to the acute care setting. This action has proven to be an excellent predictor for those geriatric patients who are most likely to fall while in the hospital.
It is very important for nursing to establish a data base that addresses safety issues. In addition to a history of previous falls, routines of toileting and activity should also be included. For example, the frequency with which the elderly person uses the bathroom at night and the assistance required at home are necessary base line data. Orientation to the hospital room, bathroom, call lighting system, and ?? signaling for assistance is very important on admission. The family can also be incorporated to reinforce the necessary reminders to aid safety.
SAFETY ALERT STICKER
Siderails on beds of geriatric patients can work both positively and negatively. Most of them are not accustomed to rails in the home environment. When they are in a hurry to use the bathroom, it is likely that they will manage to get out of bed with siderails still in place. If siderails are not going to serve as a deterrent to falls, then it is necessary for the staff to be aware of this and use additional strategies.
The floors of a hospital usually are not carpeted and can often be slippery for geriatric patients. Tables and chairs will often move when grabbed for support and beds can give way when not locked. All of these areas need to be addressed when providing a safe hospital environment for elderly patients.
It is not unusual for geriatric patients to become disoriented when placed in a new and different environment- It is critical that during the first 24 hours of hospitalizaron and especially the first night of admission, that geriatric patients are given extra surveillance. Such activities as pushing a button to call for help, contending with siderails, or walking on a slippery floor are not customary practices in the home. An unfamiliar hospital environment at night can add to temporary confusion and disorientation for the elderly patient.
Medications are another major contributor to changes in the mental status of the hospitalized elderly. It is necessary for the nurse to be aware of the medications that the geriatric patient is receiving and carefully monitor their effects and side effects. Diuretics and laxatives have been demonstrated to increase urgency for toileting and thus have contributed to falls. Anticipation of these needs can often aid in preventing a crisis situation.
Elderly patients who are admitted to an acute care setting are often weak or fragile, may already have a history of falls at home, and become high risk for repeat falls when hospitalized. These patients may have been accustomed to functioning independently and wish to continue with such behavior, forgetting or not recognizing a weakened condition. It is particularly important for geriatric patients to be given instructions to sit on the bed for a few minutes before getting up to walk. Those assessed at high risk to fall should be assisted with walking.
While working in a large metropolitan medical center, nursing faculty and clinicians recognized that there was a dramatic increase in falls among the geriatric population. A review of literature was undertaken to identify the aging-related changes that contribute to elderly patient falîs. A focused review of patient records and incident reports helped to identify reasons for falls and establish a profile of "fallers." Based on the review of literature and the retrospective study, clinical tools were developed to aid nurses help prevent falls. For the elderly patient, providing safety and protection from injury while in the hospital environment should be every nurse's goal.
The nursing profession is responsible for continually expanding and improving its practices. Patients1 falls adversely impact on the quality of nursing care and generate a negative image in the community. The development of safety standards is important because these formulated criteria serve as guidelines for nursing practice.5
- 1 . Morris EV, Isaacs B. Breslen W: Falls in the elderly in hospitals. Nursing Times 1981; 77:1522-1524.
- 2. Innés EM, Turrnan WG: Evaluation of patient falls. QKB 1983; 9:30-35.
- 3. Catchen H: Repeaters: lnpatient accidents among the hospitalized elderly. Geronioiogisi 1983; 23:273-276.
- 4. Rainville NG: Effect of an implemented fall prevention program on the frequency of patient falls. QRB 1984: 10:287-291.
- 5. Barbieri EB: Patient falls are not patient accidents. J Geromol Nurs 1983: 9:165*173.
- 6. Riffle KL: Rills: Kinds, causes, and prevention. Geriatric Nursing 1982; 3:165-169.
- 7. KalchthaterT. Bascon RA, Quintos V: Falls in the institutionalized elderly. J Am GeriatrSoc 1978; 26:424-428.
- 8. Sehested P, Severin-Nielsen T: Falls by hospitalized elderly patients: Causes, prevention. Geriatrics 1977; 32:101-108.
- 9. Fife DD, Solomon P, Stanton M: A risk/falls program: Code Orange for success. Nursing Management 1984; 15:50-53.