Assessing hospital patients who have fallen J Rush Pierce Jr, MD, MPH Section of Hospital Medicine Univ New Mexico School of Medicine 10/04/2010

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.

Questions you might have How promptly do I need to see this patient? (“Can’t 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?

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 UNMH will roll-out a multidisciplinary falls prevention program in October, 2010

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 Most common mechanism of falling in the elderly is impaired neuromuscular reflex systems due to combination of age-related changes plus illness/medications, precipitated by environmental perturbation (“I tripped”)

Epidemiologic factors associated with outpatients falls in the elderly Age (>80) Cognitive impairment Female gender Past history of fall (second largest effect) Lower extremity weakness (largest effect) Balance difficulty Arthritis Meds: neuroleptics, sedatives, antidepressants, antihypertensives

Epidemiology of inpatient falls (Barnes Hospital ) 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 2005;26:822

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%

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%

What interventions prevent falls? (inpt data) Very limited data – two observational studies show 20-25% reduction with bundle of services 2 RCT in acute care hospitals – no sign reduction in first fall; one showed reduction for those with recurrent falls

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?

How soon do you need to evaluate the patient? Ask the following 7 questions: 1.Was the fall unwitnessed? 2.Did the patient hit his/her head? 3.Did the patient experienced loss of consciousness? 4.Is the patient confused? 5.Is there any obvious laceration? 6.Is there any obvious new extremity deformity? 7.Does the patient complain of pain? Delayed (within 24 hours)

How soon do you need to evaluate the patient (contd)? If answer to ANY of the seven is “yes” – evaluate the patient within one hour If answer to ALL is no, may defer to primary team in the morning. Evaluate all patients within 24 hours and DOCUMENT your evaluation.

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?

What evaluation should we do after a fall occurs? 3 step approach 1.Assess for syncope 2.Assess for injury 3.Assess opportunity to prevent the second fall

Step 1. Assess for syncope 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

Step 2. Assessing for injury InjuryCluesPossible Interventions LacerationPain, examSteri-strip, suture Head injuryHit head, LOC, scalp laceration, new confusion Additional imaging, closer observation C-spine fracture/injuryRisk (RA), other fx, mid-line post neck tenderness, focal neuro signs C-collar, additional imaging Extremity fractureRefusal to ambulate, limb deformity, tenderness or crepitance on limb movement Additional imaging, splint/cast/surgery Rib fractureChest wall tenderness, sternal compression test CXR for pneumothorax

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 (esp narcotics, sedatives, drugs with anticholinergic effects) Could the patient have delirium?

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?

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

UNM’s Checklist

Questions?