The Next Era in Preventing Injurious Falls
For the last several decades, nursing has had primary responsibility for preventing falls and the fall risk assessment often “sits aside” the overall care plan, rather than being integrated with it. The main interventions or standards have focused on summing risk scores and documenting them with less nursing time going to interventions aimed at reducing modifiable risk factors that cause the person to fall in the first place.
Significant amounts of nursing time still go to simple methods of identification of fall risk, bed monitors, and protecting patients from falling. Limiting the mobility of hospitalized patients, even for a few days, can have unintended consequences. Immobility can create a whole new set of risks for preventable, hospital-acquired conditions, delirium, and functional decline, potentially increasing the patient’s risk of falling in the future. A positive development is that we are now seeing broader adoption of programs that encourage mobility and ambulation, demonstrating that reducing fall risk must involve protocols that advance or sustain mobility for the person at all levels of acuity.
While reducing injurious falls is still the safety goal, it must be balanced against “what matters to the person” and taking small risks that preserve independence. If we are to prevent needless injurious, we can’t “oversimplify fall risk”. Falls are multifactorial, and we should shift nursing and care giver time to how risk factors are part of the problem list with a continuum of care focus. This should not add care giver burden if we shift time and reorganize the workflow with the electronic record as an enabler. This can be facilitated by adopting the *“4M framework”—What Matters, Medication, Mentation, Mobility—for age-friendly care.
The Hendrich II Fall Risk Model® has used the 4M categories to build evidenced-based care plans that are relational and longitudinal to guide the reduction of modifiable risk factors whenever possible. The acronym “ERA” reminds us of the three pillars that can launch a new culture and practice for any adult at risk of falling.
E=Electronic Health Record Integration
The record should incorporate valid and reliable fall risk assessments with the nursing and medical problem list with an intent to reduce modifiable risk factors with standards and collaborative practice.
Mobility during hospitalization, and in all environments, must be elevated to receive the same attention and focus as any other medical intervention
R=Valid and reliable risk factors
Falls are multifactorial in nature unless it is an accidental “slip or trip”, so it’s important to avoid oversimplification. Such a “reluctance to simplify” is a central tenet of high reliability science and a driver of progress in the patient safety work. Use a fall risk assessment tool based on valid and reliable risk factors from large, diverse, populations. Avoid the temptation of departmentalizing risk factors based on hospital units when most injurious falls are intrinsic in nature and travel with the person. Helping the person understand the importance of their own risk factors and how-to self-monitor, for all who can, or having a support system if they cannot do it alone, will be vital to sustaining or improving their opportunity for mobility and independence
A=Assessments and continuum of care plans that are based on the risk factors
Establishing interventions to correspond with validated risk factors will ensure the next era of injurious fall reduction is balanced with healthy aging and independence whether at home or in the hospital or a special care facility. While we know medicine, nursing, pharmacy, and allied health must partner to create the longitudinal care plan during hospitalization for stronger care transitions we are still not there. Ongoing assessments for the 4Ms, with baseline documentation in an open access record is central to sustaining independence by detecting small changes or improvements based on the risk factors and care plan for providers and the person and/or family