Assessing hospital patients who have fallen

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Assessing hospital patients who have fallen

• J Rush Pierce Jr, MD, MPH
• Section of Hospital Medicine
• University of New Mexico School of Medicine
• March 01, 2011

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Case

• You are providing cross-cover. The 4W nurse calls
  you at 2 AM because an 84 year old woman fell in
  her room. She was admitted two days ago with
  pneumonia and is receiving IV antibiotics and
  oxygen. The nurse says the patient fell when
  trying to get to the toilet. The nurse says the
  patient seems okay but thinks that maybe you
  should come see the patient.

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Questions you might have

• How promptly do I need to see this patient?
  (Cant the primary team take care of this in the
  morning?)
• How should I evaluate this patient?
• How am I going to remember all this stuff?

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General facts about falls

• Most of literature about falls is in elderly
  patients who fall at home or in nursing homes
• Little literature about patients who fall in the
  hospital
• Nonetheless, hospital falls are considered a
  never event by Medicare

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Why do patients fall?

• In the elderly, syncope is an uncommon cause of
  falling (0.3) if present suggests orthostatic
  hypotension, cardiac arrhythmia, or seizure
• Common mechanism of falling in the elderly
• impaired neuromuscular reflex systems due to
  combination of age-related change
• co-morbid illness/medications
• environmental perturbation (I tripped)

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Epidemiologic factors associated with outpatients
falls in the elderly

• Age (gt80)
• Cognitive impairment
• Female gender
• Past history of fall (second largest effect)
• Lower extremity weakness (largest effect)
• Balance difficulty
• Arthritis
• Meds neuroleptics, sedatives, antidepressants,
  antihypertensives

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Epidemiology of inpatient falls (Barnes Hospital
2001-2)

• 1235 falls by 1082 pts (3.10 falls/1000 pt days)
• 89 single fall, 11 more than once
• 40 related to toileting
• Serious injury (laceration requiring sutures,
  loss of consciousness, fracture, SDH) 6
• Death 0.2 (both in patient with more than 1
  fall)

Source Inf Control Hosp Epidem 200526822
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Can we predict which pts will fall?

• Outpatient - Best clinical predictors are
  previous fall in past 6 months and Timed
  Up-and-Go (TUG) test
• Inpatient Falls risk tools (Morse, STRATIFY,
  Hendrich II, Conley)
• Not very good, best sensitivity 60,
  specificity 51

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What interventions prevent falls? (outpatient
data)

• Four interventions have been shown to be
  effective
• Medication review and adjustment
• Environmental changes
• Physical therapy
• Vit D if deficient
• Combination of all four (multi-modality) result
  in relative risk reduction of 10 25

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What interventions prevent falls? (inpt data)

• Very limited data two observational studies
  show 20-25 reduction with bundle of services
• 3 RCT of bundle in acute care hospitals
• one showed no reduction in falls
• one showed reduction for those with recurrent
  falls
• One showed reduction of falls in elderly, but no
  reduction in fall-related injury

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Case

• You are providing cross-cover. The 4W nurse calls
  you at 2 AM because an 84 year old woman fell in
  her room. She was admitted two ago with pneumonia
  and is receiving IV antibiotics and oxygen. The
  nurse says the patient fell when trying to get to
  the toilet. The nurse says the patient seems
  okay but thinks that maybe you should come see
  the patient.
• How promptly do I need to see this patient?

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How soon do you need to evaluate the patient?

• Ask the following 7 questions
• Was the fall unwitnessed?
• Did the patient hit his/her head?
• Did the patient experienced loss of
  consciousness?
• Is the patient confused?
• Is there any obvious laceration?
• Is there inability to bear weight or obvious new
  extremity deformity?
• Does the patient complain of pain?
• Delayed (within 24 hours)

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How soon do you need to evaluate the patient
(contd)?

• If answer to ANY of the seven is yes evaluate
  the patient urgently
• If answer to ALL is no, may defer to primary team
  in the morning
• Evaluate all patients within 24 hours and
  DOCUMENT your evaluation
• Ask nurse to document these elements and report
  fall to hospital incident reporting system

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Case

• You are providing cross-cover. The 4W nurse calls
  you at 2 AM because an 84 year old woman fell in
  her room. She was admitted two ago with pneumonia
  and is receiving IV antibiotics and oxygen. The
  nurse says the patient fell when trying to get to
  the toilet. The nurse says the patient seems
  okay but thinks that maybe you should come see
  the patient.
• How should I evaluate this patient?

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What evaluation should we do after a fall occurs?
3 step approach

• Assess for syncope
• Assess for injury
• Assess opportunity to prevent the second fall

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Step 1. Assess for syncope (or syncope mimic such
as seizure)

• Ask the patient and any possible observers
• Ask the patient did you pass out
• Ask the family did he/she pass out
• Ask the roommate did he/she pass out?
• Ask the nurse did you observe syncope
• If yes, remember common causes for syncope
  (orthostatic hypotension, cardiac arrhythmia, or
  seizure) think about meds that can cause
  orthostasis, consider telemetry

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Step 2. Assessing for injury
Injury Clues Possible Interventions
Laceration Pain, exam Steri-strip, suture
Head injury Hit head, LOC, scalp laceration, new confusion Additional imaging, scheduled serial neurologic exams
C-spine fracture/injury Risk (RA), other fx, mid-line post neck tenderness, focal neurologic signs C-collar, additional imaging (CT scan preferred)
Extremity fracture Refusal to ambulate, limb deformity, tenderness or crepitance on limb movement Additional imaging, splint/cast/surgery
Rib fracture Chest wall tenderness, sternal compression test CXR for pneumothorax
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Step 3. Review opportunity to prevent subsequent
falls

• This part should usually be done by primary team
• Can tethering devices be stopped? (Foley, IV,
  telemetry, Sequential compression devices)
• Is the patient getting physical therapy?
• Can some medications be stopped (especially
  neuroloeptics, sedatives, drugs with
  anticholinergic effects, narcotics)
• Could the patient have delirium?

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Case

• You are providing cross-cover. The 4W nurse calls
  you at 2 AM because an 84 year old woman fell in
  her room. She was admitted two ago with pneumonia
  and is receiving IV antibiotics and oxygen. The
  nurse says the patient fell when trying to get to
  the toilet. The nurse says the patient seems
  okay but thinks that maybe you should come see
  the patient.
• How am I going to remember all this stuff?

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How am I going to remember all this stuff?

• The nurses will help you they are your friends!
• Use a check list!
• Reminds you of what to do
• Helps you organize your brain
• Can use it to provide documentation
• Provides record for primary team

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Questions?