implementing an institutional fall assessment and prevention program

by Rein Tideiksaar, PhD

Falls are complex events caused by multiple intrinsic factors related to mobility, sensory perception, cognitive function, medications and co-morbidities, and extrinsic or hazardous environmental conditions. In order to reduce falls, institutions need to take a number of steps. First, the staff must understand the conditions under which falls occur and the most frequent or common factors associated with fall risk. With an increased knowledge of why older people fall and which factors are associated with fall risk, the staff will be able to more easily identify patients and residents at risk and explore appropriate solutions aimed at reducing fall risk. Second, the staff must have in place a formal fall risk assessment program, which consists of assessing risk, communicating risk, and reducing risk.

Where, When and Why Falls Occur
The majority of falls occur from, or near, the patient's/resident's bed, and account for up to half of all falls. Other common fall locations are the bathroom and toilet. Most falls occur during the early period of institutionalization or first 72 hours of stay, during nighttime hours, and post-meal times. The most frequently cited activity at the time of falling includes bed and chair transfers. Other activities commonly associated with falls include toileting and getting up from bedside commodes and wheelchairs.

Falls are generally due to accidental causes (wet/slippery floor surfaces, other environmental hazards, anticipated causes (identified risk factors), and unanticipated causes (falls attributed to factors such as an acute illness that cannot be predicted.) Up to 78 percent of falls are due to anticipated causes.

Fall Risk Factors
The most common fall risk factors include past history of falls, cognitive impairment, elimination or special toileting needs, impaired mobility, and medications. These risk factors form the basis of risk assessment tools.

Fall Risk Assessment Program
It's important that any assessment program is acceptable or "user friendly" to both staff and patients/residents and, most importantly, that the program results in reduced falls.

Assessing Risk
Fall risk assessments/tools, which help to identify those patients/residents at risk of falling, play a crucial role in minimizing the number of falls. The rationale for this assessment is that if patients/residents at high fall risk can be identified, then appropriate interventions can be instituted to minimize this risk. Assessment tools may also assist in stratifying or targeting the urgency and types of interventions required, and play a role in raising staff awareness of the risk of patients/residents falling.

To be effective, assessment tools must be sensitive (correctly identify high risk patients/residents) and specific (correctly identify patients/residents not at risk) and, perhaps most importantly, be easy for nurses to use (embedding the fall risk assessment tool into existing nursing assessments helps with "buy-in" and acceptance of the tool/process). There are several available assessment tools that meet the above criteria: the Morse Fall Scale, the STRATIFY tool, the Hendrich II Fall Risk Model, and the Schmid Fall Risk Assessment Tool.

Baseline fall risk assessments should be completed upon admission (within two hours of admission). Since patients/residents are subject to "a change of condition" (in other words, acuity of illness, medication and co-morbidity changes affecting mobility, cognition, etc.), fall risk factors are subject to change as well. As a result, reassessment of fall risk needs to be an ongoing process and should be completed whenever patients/residents experience a change of condition or medication, daily/every shift in certain high risk patients/residents (for example, recent confusion, taking sedatives, recent fall, temporary acute illness, etc.), and immediately post-fall. The purpose of the post-fall assessment is to identify the circumstances or cause(s) of the fall, identify the presence of new risk factors, and plan appropriate interventions to prevent further falls. Post-fall assessments are beneficial in detecting and eliminating precipitating factors for falls (in other words, remember that falls are a marker of underlying disorders).

Communicating Risk
Once a patient's/resident's risk of falling has been identified, it's crucial that this individual's risk status is communicated to everyone involved (therapists, nurses, nursing assistants, other staff members, and even family members.) Remember that fall prevention is everyone's responsibility. Communication of fall risk can be achieved by means of colored decals (placed on the patient's/resident's chart and/or in his or her bedroom), colored wristbands, and daily shift reports. Formalizing and incorporating the process of "risk communication" into policies or protocols can be very helpful. In this way, everyone in the facility knows that patients/residents wearing a colored wristband are "at risk of falling" or "potential for injury."

Reducing Risk
An assessment program is useful only if there is also an effective treatment or intervention available for patients/residents identified as "at risk". Thus, once assessments are complete and risk factors identified, implementation of preventive strategies is imperative. To be effective, interventions must include a number of different strategies. Interventions are most effective when they are designed to reach those with the greatest risk of falling; combining personalized attention, environmental changes, and medication review.

The concept of universal precautions has been used very successfully by several facilities. This concept acknowledges that all patients/residents, even supposedly "low-risk" individuals, are potentially at certain risk of falling. Thus, low-risk individuals would receive universal precautions (such as setting bed at lowest level, ensuring that patients/residents have necessary items/call bells within easy reach, assessing/eliminating potential environmental hazards, etc.) For those individuals "at-risk", interventions should be more specific and based on identified risk factors (such as maintaining regular toileting, re-orienting confused individuals, and assessing for need of side rails as enablers, need for ambulatory aids, need for sensor alarms, need for hourly rounds or one-to-one nursing, need for room re-location close to nursing station, etc.) It's important to remember that as risk factors change, interventions may have to change as well.

In summary, preventing falls is really about carefully identifying and assessing the needs of each patient or resident. A fall risk assessment program that assesses, communicates and attempts to reduce risk on a regular basis, can be very effective in preventing falls.

Fall and Injury Prevention Devices

October 2005