How often should patients be assessed for falls?
In acute care, patients should be assessed on admission, once per shift and whenever the patient’s condition changes.
Hospitalized patients or those in free-standing surgical centers can have frequent changes in acuity and complexity. Reassessment assures these changes in conditions do not go undetected while providing an opportunity to change modifiable risk factors.
In senior living, assisted living, or residential care, assessment should be part of daily rounding and reassessments completed similar to acute care. Any change in the resident’s state of mind should indicate reassessment for fall risk.
Risk factors can change quickly and can include underlying pathophysiologic causes, such as cognition, dehydration, sepsis, and arrhythmia, or be the result of medication side effects. The most common side effects of medications include changes in sensorium, gait and balance, blood pressure, and mood. Therefore, monitoring a patient or resident for predictive risk factors, like those in the Hendrich study, provides an efficient and effective way to incorporate fall risk screening into daily practice.
What makes a successful injurious fall reduction program?
Healthcare systems and continuum of care sites can benefit from the following elements known to prevent injurious falls while improving the care of the person. These key elements include:
- Assess and screen patients or individuals with an evidence-based risk assessment to guide care pathways for modifiable risk factors. Intrinsic risk factors account for the largest percentage of injurious falls.
- Make the environment safe for all individuals. For example, lighting, footwear, bed height, floor surfaces, call lights, and patient engagement and education.
- Assess patient or individual on admission, once per shift, and whenever the patient’s condition changes.
- An interprofessional care team approach is often required to modify risk factors. This includes pharmacy, medicine, therapies, and community/home health.
- Injurious fall prevention requires a continuum of care approach to address and promote independence and healthy aging.
- Involve the patient or individual, their family, and their significant other with education on the importance of risk factors and the interventions necessary to avoid loss of independence and injury.
- Interprofessional care teams should have input on how to adopt and integrate risk factors into their daily practice to generate optimal outcomes for the system and the individual.
- Leadership teams must enable a safety culture to foster injurious fall reduction while building an age-friendly healthcare system.
What does a patient fall mean?
The most widely used definition of a patient fall comes from the National Database of Nursing Quality Indicators (NDNQI):
“A patient fall is an unplanned descent to the floor or extension of the floor, with or without injury to the patient.”
Another way to look at what a fall means is through the eyes of a person whose independence, mobility, and fear of falling again may be affected for the foreseeable future. The majority of injurious falls are preventable.
What is an injurious fall?
An injurious fall is one that causes harm to the patient or individual. Various scales and degrees of injury can be used to quantify the severity of the injury. The Agency for Healthcare Research Quality (AHRQ), National Database of Nursing Quality Indicators (NDNQI), and others provide the severity of injury classifications that can be helpful within event reporting systems to connect outcomes with fall events.
The risk of falling does increase with age, but keep in mind encouraging someone to be immobile to prevent a fall will only increase their overall risk of falling.
Who is at risk for falls?
Anyone can be at risk of falling regardless of age. While it is true that a history of falling and age look to be correlated with the risk of falling, they are not necessarily predictive risk factors. The key to preventing injurious falls is to focus on evidence-based risk factors that can be used for assessing and interventions aimed at reducing modifiable risk factors.
What are the types of falls?
There are three types of falls:
- Intrinsic falls
- Extrinsic falls, also known as environmental falls
- Non-predictable falls (i.e., stroke, seizure, fainting, etc.)
Intrinsic falls are the result of pathophysiological causes that can often be modified, such as dehydration, medication side effects, confusion, and altered elimination. Extrinsic, or environmental falls, are the result of objects, clutter, slips and trips, improper footwear, and slippery floors. It’s important to note, extrinsic falls often only account for a small number of injurious falls. In acute care, non-predictable falls, such as those caused by a stroke, seizure, or fainting, can account for as much as 10-15% of the total number of falls and are nearly unforeseeable.
What causes falls?
The cause of falling in multidimensional. It can be an interaction between intrinsic and extrinsic risk factors, a rapid change in condition, side effects of medications, poor gait and balance, a loss of hearing or vision or disease progression.
The Hendrich II Fall Risk Model® includes statistically significant risk factors known to predict falls. These risk factors can be modified with interventions to lower injurious fall risk.
What is a fall risk assessment?
Fall risk assessments are tools used by healthcare professionals to assess a patient’s or person’s risk of falling. A fall risk assessment should be evidence-based and include valid and reliable risk factors.
Who is behind the Hendrich II Fall Risk Model®?
The author and researcher of the Hendrich II Fall Risk Model® is Ann Hendrich, Ph.D., RN, F.A.A.N. Ann is a national expert in quality, safety, nursing, care models, and organizational change. She has led the industry for more than 25 years as an author, editorial board member, speaker, panel expert, health services researcher in predictive modeling, patient safety, health services research, federal advisory panels, and nursing.
Her publications include text, journals, and scientific papers that include the Hendrich II Fall Risk Model®, patient safety, leading complex organizational change, medical liability, value-based purchasing, and hospital-acquired infections.
Her time and motion study evaluated “how nurses spend their time” in the largest multi-site study in the literature reporting results from more than 20,000 hours and 36 hospitals from coast to coast.
Why was the Hendrich II Fall Risk Model® developed?
The Hendrich II Fall Risk Model® was developed from an Institutional Review Board (IRB) approved study with concurrent study participant enrollment, and it remains one of the largest studies in the literature to date. More than six-hundred risk factors were evaluated in fall and non-fall patients to create the Hendrich II Fall Risk Model® that has since been replicated in dozens of studies.
The intent was to provide an assessment tool for clinical practice to test the hundreds of risk factors, published in the peer-reviewed literature, and build a model with statistical accuracy that is practical for the reality of the complex care environment.
A statistical valid instrument, like the Hendrich II Fall Risk Model®, is more relevant to clinical practice and conserves scarce resources by allowing the talents of professional nurses to be used more effectively and efficiently to assess fall risk and administer targeted interventions. These interventions reduce modifiable risk factors to promote independence, preserve what matters most to the person, and act to support an age-friendly environment – now closely connected to quality, safety, external facility/practice rankings, and value-based purchasing.
How was the Hendrich II Fall Risk Model® developed?
The model was developed over a two-year study enrollment period with 355 patients who fell and 780 non-fall patients (sample size=1,135). Each study participant was assessed concurrently by four registered nurses who used validated standardized instruments to measure gait/mobility, elimination, cognition, depression, medications, balance, hearing/vision, and history of falls. Additionally, a randomized sample of patients was evaluated by a second research nurse to assure the accuracy of the physical and historical data collection.
The clinical pharmacist categorized and evaluated all medications. Statistical measures used to generate the model included manual stepwise logistic regression, two-way interactions, 2 Log L chi-square statistic, and sensitivity and specificity. Additionally, once the model was built, it was retrospectively tested in the study fall population (74.9% falls correctly identified / 73.9% non-fall correctly identified).
The value the Hendrich II Fall Risk Model® brings is that it is a predictive assessment compared to other fall risk assessments that merely correlate risk factors from small sample sizes and retrospective chart reviews.
Is the Hendrich II Fall Risk Model® a valid and reliable fall risk assessment?
The Hendrich II Fall Risk Model® is widely validated and tested across the care continuum for more than 20 years with numerous replicated studies in the US and abroad. Since the Hendrich II Fall Model® risk factors were scientifically identified as intrinsic predictors of falling, these risk factors travel with the person – they are not dependent on location.
While environmental falls are certainly a contributor to falling, intrinsic risk factors (physiological) are often the root cause of injurious falls. Slips and trips can be prevented by environmental safety, but intrinsic risk factors must be modified by specific interventions, such as deprescribing high-risk medications that are not medically indicated, promoting balance, strength training, gait, and addressing altered elimination concerns. This lends itself very well for electronic health record forms to continually guide the provider toward evidence-based interventions that make a difference.
Where do most falls occur in the older adult?
Regardless of age, falls can occur in any environment due to intrinsic (risk factors) or extrinsic (environmental) causes. Additionally, there is a small percentage of falls that are non-predictable and occur secondarily to an unexpected event, such as a stroke, transient ischemic attack, or arrhythmia.
One of the most common myths is that age is an independent risk factor to predict falls. While age is often associated with injurious falls, the root cause is the “true risk factor” that causes the fall not the age of the person falling. For example, poor balance, gait, and strength can change with aging and that is the “true risk factor” not age alone.
Bear in mind, small studies that only look at falls and do not adhere to scientific methodology and evaluation methods, such as incorporating control groups into the study, tend to falsely identify age as an independent risk factor. This inaccurate assumption is likely because many hospitalized patients are over the age of 65. Valid fall studies, like the Hendrich II study, use statistical tests to identify a minimal data set of significant risk factors needed to predict falls and include control groups.
What are long-term effects of falling?
Injurious falls can have a devastating impact on the person for a very long time. Fractures, head injuries, and severe blunt force among many other consequences introduce complications, loss of independence, financial burden, and family stress. Even without these devastating consequences, the fear of falling again can have just as much impact on the person. Furthermore, the loss of immobility and independence can lead to disease, loss of balance and strength, and depression.
This cycle can cause a downward decline, known as fall event cascade, unless the individual, an interprofessional care team, and/or the primary provider build a care plan for prevention and improved health. Community resources must also be aligned where the person lives in their community or facility.
What are the major risk factors for falls?
While there are hundreds of risk factors identified in the peer-reviewed literature, the Hendrich II fall study objectively tested which risk factors were necessary to predict falls. Once a person is identified as high risk, based on the weighted risk factors included in the Hendrich II Fall Risk Model®, more testing may be required to diagnose and treat modifiable risk factors, such as delirium vs. dementia. From this, an individualized care plan can be used to effectively reduce modifiable risk factors.
If risk factors are not addressed, many individuals suffer unintended consequences in as little as 30 days, such as being readmitted to the hospital and treated in an emergency department for a fall. Falls are now one of the most common reasons for safety and quality of care concerns in the older adult in the U.S.
How can falls be prevented?
You cannot fully prevent all falls, but here are 5 things you can do to best reduce the risk of injurious falls within your sites of care:
- Have a valid and reliable way to asses fall risk factors with frequent reassessment when conditions change.
- Use evidence-based interventions based on the fall assessment with modifiable risk factors to reduce injury risk.
- Promote early and constant gait, strength, and mobility in all populations and understand some risk taking is warranted. Otherwise, keeping someone who has poor gait and mobility inactive only worsens their future risk. Assisted falls or falls without injury does not mean your program is not effective.
- Build the fall risk factors into existing workflow and the electronic record to minimize “add-ons”. This approach should be part of any assessment, safety huddles, and rounding.
- Align appropriate skills and education with providers within a safety culture supported by focused data collection for continuous evaluation of “who is falling’ and “why” with case reviews or root cause analysis when needed.