Inpatient falls prevention

A hospital setting is associated with an increased risk of falling. Falls are one of the most frequently reported clinical incidents in hospitals around the world, including in WA.

Falls in hospital are associated with increased:

• length of stay
• use of health resources
• rates of discharge to a nursing home.

Existing risk factors for a fall are compounded by a variety of new factors on admission to hospital. Those who were not initially at risk of a fall may develop a falls risk.

Factors which compound existing falls risk or introduce a falls risk where none previously existed are:

• illness
• injury
• surgery
• new medications or changes to existing medications
• a variety of unfamiliar and complex environmental hazards, which have to be navigated whilst compromised by deteriorated health conditions. 

In addition:

• cognitive functioning can become impaired
• pre-existing cognitive impairment can be exacerbated.

This can severely affect a patient’s capacity to:

• judge and manage their own falls risk
• remember what staff have discussed with them about their falls risk and how to manage this in hospital. 

Systematic reviews have shown that:

• risk factors for falls in hospital inpatients are multivariate there is limited evidence to support any one intervention, however interventions targeting multiple risk factors can reduce falls in hospital.

In Australia, the assessment and management of inpatient falls is governed by evidenced based guidelines including:

• National Safety and Quality Health Service (NSQHS) Standard 10 (external site)
• Preventing Falls and Harm from Falls in Older People Best Practice Guidelines for Australian Hospitals 2009 (external site)

In order to facilitate the incorporation of the practices outlined by both Standard 10 and best practice guidelines, the Falls Risk Assessment and Management Plan (FRAMP) has been developed for use in the general adult population in Perth metropolitan hospitals.

The FRAMP:

• centralises and simplifies core requirements into one form
• guides staff through the essential screening, assessment and management processes.

There are also patient education tools designed for use in inpatient settings and these include:

• The Preventing falls – your hospital stay (Healthy WA) provides general advice for patients on how to prevent falls in hospital and also when they return home from their hospital stay. This can be ordered as a brochure from the Online Publication Ordering System (external site)
• The Health advice following a fall flyer (PDF 186KB) should be given to patients who are being discharged from hospital and have had a recent fall. It outlines symptoms to watch out for in case of further problems.

Patients who were identified at increased risk of falling during their admission may continue to be at increased risk of falling after discharge. In conjunction with the multidisciplinary team discharge planning should include consideration of referral to appropriate services. Falls risk and falls history should be included in discharge reports and any referrals.

Some inpatient groups have fall risk profiles which differ from adult patients in the general hospital population. These groups include children, mental health patients and obstetric patients.

Given the multifactorial nature of falls, a multidisciplinary approach to assessment and management is vital. All professions have a role to play in falls prevention.

Collaboration with staff at other facilities is an efficient way to:

• keep up-to-date with local patient safety initiatives and projects
• reduce duplication when implementing quality improvements.

It also provides a means to:

• share the latest evidence based practice
• consult with other specialists in the field. 

Types of collaboration include:

• The WA Falls Prevention Community of Practice for hospital settings which commenced in 2009. This group provides a support network to a variety of staff involved in falls prevention and works collaboratively to standardise key processes at a statewide level. The FRAMP development was a collaboration of the Community of Practice.
• The Falls Prevention Health Network (external site) which connects people with an interest in falls prevention to share their knowledge and expertise to improve health outcomes in WA.

Information about the variety of collaborative projects that have been undertaken in WA to reduce the risk of falls for patients can be found on Falls prevention initiatives. Perhaps you:

• have an idea for a project
• would like to see what projects or initiatives:
  • are happening in your area of interest
  • can assist you in your daily practice.

References

• Pekka Kannus, Karim M Khan and Stephen R Lord. Preventing falls among elderly people in the hospital environment. Med J Aust 2006; 184 (8): 372-373.
• Your Safety in Our Hands in Hospital. An Integrated Approach to Patient Safety Surveillance in WA Hospitals, Health Services and the Community: 2012 Delivering Safer Care Series Report Number 1. Government of Western Australia Department of Health. Perth.
• Bates D, Pruess K, Souney P, et al. Serious falls in hospitalized patients: correlates and resource utilization. Am J Med 1995;99:137–43.
• Hill KD, Vu M, Walsh W. Falls in the acute hospital setting—impact on resource utilisation. Aust Health Rev 2007;31(3):471–7.
• Murray GR, Cameron ID, Cumming RG. The consequences of falls in acute and subacute hospitals in Australia that result in proximal femoral fracture. J Am Geriatr Soc 2007;55(4):577–82
• Department of Health, Western Australia. Falls Prevention Model of Care. Perth: Health Strategy and Networks, Department of Health, Western Australian; 2014.
• Miake-Lye IM, Hempel S, Ganz D, Shekelle PG. Inpatient Fall Prevention Programs as a  Patient Safety Strategy. A Systematic Review Ann Intern Med. 2013;158:390-396.