Inpatient Fall Prevention Programs as a Patient Safety Strategy

Abstract

Falls are common among inpatients. Several reviews, including 4 meta-analyses involving 19 studies, show that multicomponent programs to prevent falls among inpatients reduce relative risk for falls by as much as 30%. The purpose of this updated review is to reassess the benefits and harms of fall prevention programs in acute care settings and to identify factors associated with successful implementation of these programs. We searched for new evidence using PubMed from 2005 to September 2012. Two new, large, randomized, controlled trials supported the conclusions of the existing meta-analyses. An optimal bundle of components was not identified. Harms were not systematically examined, but potential harms included increased use of restraints and sedating drugs and decreased efforts to mobilize patients. Eleven studies showed that the following themes were associated with successful implementation: leadership support, engagement of front-line staff in program design, guidance of the prevention program by a multidisciplinary committee, pilot-testing interventions, use of information technology systems to provide data about falls, staff education and training, and changes in nihilistic attitudes about fall prevention. Future research would advance knowledge by identifying optimal bundles of component interventions for particular patients and by determining whether effectiveness relies more on the mix of the components or use of certain implementation strategies.

Prevention of falls in hospital

“…Systematic reviews have consistently suggested that multifactorial assessments linked to appropriate interventions may reduce falls in hospital by 20-30%. [7][8][9] The optimal combination of components is not, as yet, clearly defined but the assessment of mobility, toileting and continence needs, medication review, vision, confusion (dementia and delirium) and orthostatic blood pressure are important. Similarly, the provision of mobility aids (sticks and walking frames), minimising clutter, clear (pictorial) signage coupled with attention to appropriate footwear, spectacles and hearing aids are simple ways of reducing the potential impact of environmental risk factors.…”

“…3 However, a systematic review suggests a number of key quality improvement themes are important features of successful schemes. 9 The engagement of front-line staff is critical and requires effective leadership at both ward and board level. Multiprofessional education and training helps to invalidate any prevailing nihilism and promote positive attitudes with respect to falls prevention.…”

Not All “Continuous Femoral Nerve Blocks” Are Equivalent

“…[2][3][4] It is a limitation of studies using administrative databases that important information, such as practice management strategies, is often lacking. The lack of association between PNB and in-patients falls in our study may very well relate to systems issues and perhaps selection bias: those hospitals that have had previous problems with falls or lack training in the safe use of PNB may be less likely to use PNB for arthroplasty patients; and those hospitals that use PNBs regularly for arthroplasty may have systems in place to make them work while keeping patients safe, including multidisciplinary fall prevention programs.…”

“…In a meta-analysis of three randomized, placebo-controlled trials involving femoral and posterior lumbar plexus catheters for TKA and total hip arthroplasty, respectively, Ilfeld et al found that no subjects receiving perineural saline (n = 86) fell (0%) while there were seven falls (7%) in patients receiving perineural ropivacaine (n = 85; p = 0.01), strongly suggesting a causal relationship between the continuous blocks and falling. 3 Since there were no falls in the placebo group, an odds ratio cannot be calculated; but, if even just a single fall occurred in this group, the odds ratio would be 5.5 (therefore, the actual odds ratio is at least 5.5, but possibly higher). Finally, an additional metaanalysis including 4 randomized, controlled trials and one retrospective cohort study, Johnson et al calculated an odds ratio of 3.9 (p < 0.01) of falling for subjects with a continuous femoral or posterior lumbar plexus block of greater than 12 h (incidence = 2.2%) compared with subjects with either no block, a single-injection block, or a perineural infusion of less than 12 h (incidence = 0.5%).…”

“…Given that falls with 4-day continuous PNB occur not only in the two days following surgery, but postoperative days 3 and 4 as well-after patients have successfully ambulated multiple times during physical therapy-there is a high probability that patients become more confident and do not continue to take the same precautions as during early ambulation attempts. 3 To support this supposition, the majority of falls in patients with continuous PNB occur when patients are unaccompanied/unassisted and going to the restroom, often in the middle of the night. 5 Therefore, while I agree with the authors' statement that their, "data should provide encouragement to not shy away from the use of PNB;" it should also not lull healthcare providers into a false sense of security regarding the risks of continuous PNB.…”