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Literature review says no

When Terry Clyburn, MD, set out last year to review the literature on elderly falls in acute-care settings, he expected to find overwhelming evidence that seniors fall in hospitals more often than at home. After all, they are in unfamiliar surroundings, perhaps heavily medicated, their gait unsteady, their vision hampered and their pathway from the bed cluttered with equipment and tubing. What he and co-author John Heydemann, MD, uncovered instead was ìquite surprising,î Clyburn acknowledged.

ìThe fact is that although the fall rate is higher in the hospital than it is at home, it's only marginally higher,î said Clyburn, an orthopedic surgeon at the University of Texas Health Sciences Center in Houston. ìWhat that seemed to indicate is that we must be doing something that's effective to reduce the incidence of fall.î

But what?

Now, here's the kicker: ìUnfortunately, there's very little data that shows effectiveness of anything in the acute-care setting,î Clyburn continued. ìAt this point, we really don't have a very good explanation for why the rate of falls in the hospital is not significantly greater than it is at home. We just haven't done the necessary studies that may show statistical significance.î While there has been proven success in long-term care facilities for some fall-prevention measures, he said, those same measures in hospital settings for short stays of five to seven days aren't proven to be effective at all.

The upshot is that there's only so much a hospital can do to prevent seniors from falling, and they're going to fall anyway – at a rate anywhere from 3 percent to 20 percent. According to research presented in 2009 in Critical Care Nurse Quarterly and the New England Journal of Medicine, that 3-to-20 percent rate of elderly hospital falls correlates with Centers for Disease Control statistics on the rate of elderly falls in all settings. The CDC estimates that the cost of all senior falls annually will reach $54.9 billion by 2020. In hospital settings, senior falls on average add $4,000 to the bill.

ìI don't know that we can ever prevent every fall in the hospital. If a fall happens, it's not always that somebody is to blame. Sometimes people make mistakes that contribute to a fall, but a lot of time it really isn't anybody's fault,î said Mara Aronson, director of nursing services at Spaulding Nursing & Therapy Center, North End, in Boston. Aronson is also a national consultant to healthcare providers through her company, AGE: Association for Gerontologic Education.

Aronson's experience backs up what Clyburn found in his research. ìThere are no absolutes. There are several tools that hospitals often use that are supposed to identify patients at fall risk, and they're not tremendously reliable,î she said. Those tools include identification bracelets unique to patients who are fall risks, yet a randomized trial cited in Clyburn's literature review found that ID bracelets don't reduce the number of falls. If nothing else, the bracelets do serve as reminders to nurses to take special care and be aware, Aronson said.

Hospitals increasingly take more precautions to prevent falls, especially since payment provisions were revised in 2008 by the Centers for Medicare and Medicaid Services. Falls in hospitals today are classified as ìnever eventsî by CMS, and hospitals are responsible for the costs associated with treating fall injuries. Changes hospitals are making and policies they are employing to prevent senior falls include:

• ID bracelets,

• bed rails,

• bed alarms,

• lower bed and toilet heights,

• rubber-soled socks,

• specialty flooring and

• exercise and balance training.

Yet, Clyburn noted that no studies have found that any of those measures work. ìThe only thing that we know of that probably reduces the rates of fall – and in the studies, the reduction in the rate of falls was not statistically significant – is control of delirium. Trying to avoid medication-induced delirium in patients does have an effect,î he said.

Some measures, in fact, have increased the risk of falls. Clyburn said some hospitals have actually brought in optometrists to fit fall-risk patients with better glasses. ìGuess what? They actually fell more frequently because they had new glasses, and they weren't used to them,î he said.

Clyburn added that ìreasonable studiesî have also shown that the rate of falls does not decrease with the use of bed alarms that sound when a patient gets up unattended. That's because most patients don't fall, and if they do, the nurse usually can't be there in time to prevent the fall anyway.

Aronson said that when she counsels hospital personnel about the care of elderly patients, she stresses ìself-evidentî factors. Are the patient's reading glasses within reach? Is the patient toileted frequently? Does the patient receive regular assistance to reposition in the bed, so that he or she isn't too close to the edge? She said her quality reports conclude that there are two times of the day when falls are most frequent. The first is early morning, when patients first wake up. ìThey're not going to wait for you,î she said. The second is during the afternoon shift change, when nurses are distracted by reporting requirements and the noise level rises. Aronson suggested that hospitals ìlook for patterns and address them.î
At her facility in Boston, Aronson said there's a ìhuddleî each time a patient falls, and anyone who's cared for the patient recently is paged immediately to talk about the patient's care and pinpoint whether the fall could have been prevented. ìWe know we can't prevent every fall. The only way to do that is to sedate everybody to the point of stupor, and they can't move. That's about the only option you have,î she said.

And that's obviously not an option at all.

In fact, Clyburn has come to the conclusion that ìit's really unfairî to hold hospitals accountable for senior falls when ìthey are truly not preventable and there's no technique that hospitals can use to prevent them.î While it's obvious that the next step would be rigorous studies on potentially preventive measures, the possibility that these studies will happen is remote, he said. Such studies would require that a group of senior patients would be the control, and what Institutional Review Board would OK admitting fall-risk seniors to a hospital and not identifying them as a risk?

I thought this was going to be uninteresting when I started studying it, but actually it is interesting,î Clyburn said. ìHere we are in this phase of the development of medicine in this century. We have technology that's absolutely phenomenal, and yet we're really chasing our tail putting blobs of rubber on the bottoms of socks. We just really, really don't know what we're doing when it comes to fall prevention.

Tags:

, Dr. Terry Clyburn, Hospital fall prevention, hospital senior care, Mara Aronson, never events

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