1. What should we do about fall- related injury in the hospital? Hospitalist Best Practice J Rush Pierce Jr, MD, MPH March 13, 2013

2. Disclosures Financial: none Affiliations/biases – I am member of the American Geriatrics Society; AGS helped develop consensus guidelines for evaluation and treatment of elders who fall – 5% of my salary supported by Donald W Reynolds Foundation for education of hospital care of elders – evidence should inform our thinking What should we do about fall-related injury in the hospital? 03/13/20132

3. How we think about falls Most of literature about adult falls is in elderly persons who fall at home or in nursing homes Little literature about patients who fall in the hospital Much of our thinking about hospital falls is extrapolated from outpatient data Hospital falls are considered a “never event” by Medicare What should we do about fall-related injury in the hospital? Source: Inouye: N Engl J Med 2009;360:2390 03/13/20133

4. Roadmap for today Describe case Review some literature about outpatient falls in elderly persons Review literature about inpatient falls Review UNMH experience with inpatient falls Discuss possible system changes at UNMH What should we do about fall-related injury in the hospital? 03/13/20134

5. Learning Objectives 1.Identify at least 3 factors associated with falls in elderly persons. 2.State the most common etiology of falling in elderly persons. 3.Summarize the epidemiology of in-patient falls. 4.Describe an approach for evaluating the in- patient who falls. What should we do about fall-related injury in the hospital? 03/13/20135

6. Case You are providing cross-cover. The 4W nurse calls you at 2 AM because an 84 year old woman fell in her room. The patient 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. What should we do about fall-related injury in the hospital? 03/13/20136

7. Questions you might have How promptly do I need to see this patient? (Can’t this wait until the morning?) If I go to see the patient, how do I evaluate her? (What the #@!! am I supposed to do?) Is there anyway to prevent this? (How do I keep from getting these 2AM calls?) What should we do about fall-related injury in the hospital? 03/13/20137

8. Out-patient falls: literature review

9. Is falling in the elderly a significant health problem? 30 – 40 % of elderly persons fall each year 5 – 6% result in injury significant enough to see a doctor or go to ED 2 – 3 % result in hospitalization (Ave LOS = 8d) Annual cost to Medicare = $19B (est FY2000) 03/13/2013 What should we do about fall-related injury in the hospital? 9 Source: Stevens. Injury Prev 2006;12:290

10. Why do elderly persons fall? In the elderly, syncope is an uncommon cause of falling (0.5%) Common mechanism of falling in the elderly – environmental perturbation (“I tripped”) – impaired neuromuscular reflex systems due to combination of age-related changes and co- morbid illness/medications – 80% of falls in the elderly are “unique to the elderly” What should we do about fall-related injury in the hospital? Source: Rubenstein: Clin Geriatr Med 2002;18:141 03/13/201310

11. 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 What should we do about fall-related injury in the hospital? Source: Rubenstein: Clin Geriatr Med 2002;18:141 03/13/201311

12. Medications associated with falls in the elderly What should we do about fall-related injury in the hospital? Source: Huang: Drugs Aging 2012;29:359 03/13/201312

13. Medications associated with hip fracture in the elderly What should we do about fall-related injury in the hospital? Source: Huang: Drugs Aging 2012;29:359 03/13/201313

14. Evaluating falls in community- dwelling elderly persons What should we do about fall-related injury in the hospital? Adapted from: Panel on prevention of falls in older persons: J Am Geriatr Soc 2011;59:148 03/13/201314

15. What interventions prevent falls in elderly out-patients? Four interventions have shown to be effective – Medication review and adjustment – Environmental changes – Exercise (or physical therapy) – Vit D if deficient (association) Combination of all four (multi-modality) result in relative risk reduction of 10 – 25% What should we do about fall-related injury in the hospital? Sources: Panel on prevention of falls in older persons: J Am Geriatr Soc 2011;59:148. Controversies in geriatrics. J Am Geriatr Soc 2013;61:281 03/13/201315

16. Falls in ambulatory elders (concl.) Falls occur frequently and can result in injury Falls are usually due to inadequate compensatory neuromuscular mechanisms Major risk factors include lower extremity weakness, past h/o fall, female gender, and meds (psychotropics, benzos and narcotics) Interventions can reduce risk of future falls Evidence based guidelines are available What should we do about fall-related injury in the hospital? 03/13/201316

17. In-patient falls: literature review

18. Epidemiology of inpatient falls (Barnes Hospital 2001-2) 1,235 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: Fisher: Inf Control Hosp Epidem 2005;26:822 What should we do about fall-related injury in the hospital? 03/13/201318

19. Epidemiology of inpatient falls (Barnes Hospital 2001-2) What should we do about fall-related injury in the hospital? Source: Fisher: Inf Control Hosp Epidem 2005;26:822 03/13/201319

20. Source: Fisher: Inf Control Hosp Epidem 2005;26:822 What should we do about fall-related injury in the hospital? 03/13/201320

21. Epidemiology of fall-related injury in the hospital 9 hospitals in Midwest, 2001 – 2003 7,082 falls 40% falls associated with toileting 42% assoc w/injury, 2.4 % serious injury Increased age, fall in location other than pt room and unassisted fall assoc with injury What should we do about fall-related injury in the hospital? Source: Krauss: Infect Control Hosp Epidemiol 2007;28:544 03/13/201321

22. Epidemiology of in-patient falls National Database of Nursing Quality Indicators (NDNQI) from 2006 – 2008 315,817 falls in 1263 hospitals Conclusions: – 3.56 falls/1000 patient days – 26% injury rate – Rate of falls and fall-related injury higher on medical than surgical floors What should we do about fall-related injury in the hospital? Source: Bouldin: J Patient Saf 2012:Epub 03/13/201322

23. Epidemiology: UNMH in-patient falls study 298 PSN’s reporting falls in 2010 Exclude pts < 18 y/o (2), pregnant pts (3), pts with no matching MR (7) 286 falls, 251 pts 152 males (61%), 99 females (39%) 63 falls with injury (25%); 11 (4%) serious injury (laceration requiring sutures, fracture, subdural) What should we do about fall-related injury in the hospital? 03/13/201323

24. Falls by unit What should we do about fall-related injury in the hospital? 03/13/201324

25. Fall related to toileting What should we do about fall-related injury in the hospital? 03/13/201325

26. Falls with injury What should we do about fall-related injury in the hospital? 03/13/201326

27. Predictors of fall with injury What should we do about fall-related injury in the hospital? 03/13/201327

28. Documentation, all falls What should we do about fall-related injury in the hospital? 03/13/201328

29. Documentation, falls with injury What should we do about fall-related injury in the hospital? 03/13/201329

30. Epidemiology: medication use and in-patient falls What should we do about fall-related injury in the hospital? Source: Prakash; J Hospital Med 2013:8:1 03/13/201330

31. Cost of hospital fall-related injury Case reports: delayed recognition of fall- related injury can result in liability risk 3 Midwestern hospitals, 2004 – 2006 – 57 inpatient with serious fall-related injury – $13,316 and 6.3 days more than case controls NHS Litigation claims – 668 claims – 60% payments, mean = $30K What should we do about fall-related injury in the hospital? Souces: Wong: Joint Comm J Qual Patient Saf 2011:37:81; Oliver: Qual Saf Health Care 2008;17:431 03/13/201331

32. 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 = 73%, specificity = 42% What should we do about fall-related injury in the hospital? Sources: Beauchet: J Nutr Health Aging 2011;15:933; da Costa: Plos One 2012;7:e41061 03/13/201332

33. What single interventions do not prevent inpatient falls? Bedrails Exercise Staff training Patient education Medication review/adjustment Bed alarms What should we do about fall-related injury in the hospital? Sources: Shorr: Ann Intern Med 2012;157:692; Cameron: Cochrane Database Syst Rev;2012:CD005465 03/13/201333

34. Do multi-modality interventions prevent inpatient falls? Very limited data – two observational studies show 20-25% reduction with bundle 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 What should we do about fall-related injury in the hospital? Source: Cameron: Cochrane Database Syst Rev;2012:CD005465 03/13/201334

35. 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. What happens at UNMH? What should we do about fall-related injury in the hospital? 03/13/201335

36. What should we do about fall-related injury in the hospital? 03/13/201336

37. In-patient falls (conclusions) Result in serious injury in 2 – 6% of patients More common on med/surg units and frequently related to toileting Falls and especially delayed recognition of fall- related injury poses significant liability risk Our ability to predict and prevent falls is very limited Regulatory agencies expect hospitals to monitor and address this problem What should we do about fall-related injury in the hospital? 03/13/201337

38. Conclusions Outpatient falls and inpatient falls are probably different epidemiologically About 5% of in-patients who fall in the hospital will suffer significant injury Evidence-based guidance about assessment is lacking UNMH physician documentation of falls is poor More study is needed What should we do about fall-related injury in the hospital? 03/13/201338

39. What should we do about fall related injury in the hospital? - Possible actions at UNMH - Use/review the checklist for evaluating pts who fall Limit use of zolpidem in patients at risk Decrease narcotic use in the hospital Other What should we do about fall-related injury in the hospital? 03/13/201339