OVERNIGHT FALL, REPORTED BY CROSS-COVER

 

William Dale MD, PhD

 

 

 

Teaching Trigger:

 

Patient on service fell overnight, reported by cross-cover.

 

I.     Clinical Question:

 

What are the consequences of falls in the aging patient?

 

Teaching Points:

 

• Falls are a classic geriatric syndrome, characterized by the loss of reserve or injury along many functional and physiological dimensions resulting in a common outcome. 
• Older patients in the hospital are at risk to fall, causing preventable injuries, increasing length of stay, and raising a legal risk. 
• The risk of a fall over the last year among people over the age of 65 is 30-40%, and 20% of these will require medical attention, primarily fractures. 
• One of the largest risk factors for injuries from falls is restraint use in the hospital, even though restraints are often placed to prevent wandering and “prevent falls.” 
• Patients with osteoporosis, which is much more common in older patients, are especially likely to be injured by a fall.

 

II.          Clinical Question:

 

What is the relationship between restraint use and falls in the older hospitalized patient?

 

Teaching Points:

 

• Elderly patients in the hospital are at high risk to fall and be injured from a fall, especially due to the use of formal restraints (like posey vests, wrist restraints, and bed rails) and informal restraints (like foley catheters, oxygen nasal cannula, and IV lines). 
• Patients with osteoporosis, which is much more common in older patients, are especially likely to be seriously injured by a fall. 

 

III.         Clinical Question:

 

What history and exam items are most important in assessing fall risk in the hospitalized older patient?

             

Teaching Points:

 

• Always ask at the time of admission whether a patient has fallen in the past. 
• Ask whether they usually use an assistive walking device such as a cane or walker.
• Ask patients if they have osteoporosis or take alendronate (Fosamax). 
• On exam, assess patients for visual and hearing losses, balance difficulties, and lower extremity weakness. 

 

IV.         Clinical Question:

 

What are some interventions to prevent falls in the older hospitalized patient?

 

Teaching Points:

 

• Avoid formal restraints whenever possible, and minimize unnecessary informal ones.
• Keep beds low to the ground, keep at least one bed rail down for easy bed access, always lock the wheels of the bed, and make bathroom easily accessible (with scheduled toileting). 
• Have usual assistive devices available near the bed. 
• Move patients at high fall risk nearer to nursing station for improved surveillance, and enlist the help of family to monitor patient.

 

V.          Clinical Question:

 

List three important teaching points on falls in the aging hospitalized patient.         

 

Teaching Points:

 

• Always ask about a history of falls in the last year.  It is the strongest predictor of future falls.
• Avoid restraints, both formal and informal.
• Targeted interventions are effective in reducing future falls, while untargeted ones are not.  It is important to work closely with the physical therapists for targeting rehabilitation therapy.