Taking the mystery out of falls

Donna M. Miller, MD, ACP Member, offered advice on diagnosing and preventing falls at the Mayo Clinic Hospital Medicine 2017 conference.

Treating a patient who has fallen is like solving a crime, Donna M. Miller, MD, ACP Member, told attendees at the Mayo Clinic Hospital Medicine 2017 conference.

“Evaluating a patient fall, we need to put our detective hats on and get the who, what, where, when, and why, because that's what's going to be the key to help us identify what are the underlying risk factors that are potentially modifiable to prevent falls moving forward,” said Dr. Miller, who is a geriatrician and hospitalist at Mayo Clinic in Rochester, Minn. “Most people . . . aren't having those falls every day, so what was it that was different about today as to why they fell?”

The first step is to investigate a couple of known offenders. “If there are two things that we should always do on any patient who has fallen from standing height, it's 1) a thorough medication review, and 2) orthostatic vital signs,” she said.

Dr Miller
Dr. Miller

The medication review should include not just a list of the patient's medications but also a look into the timing of doses prior to the fall. It's also important to get specific in the questioning about medications, Dr. Miller recommended. “[For] a lot of patients who take Tylenol, it's only if I ask them that I find out that it's oftentimes the Tylenol PM version,” she said.

Research has shown that orthostatic hypotension increases in prevalence with age and that many patients might not notice they have it, Dr. Miller reported. “Only about half of patients experienced symptomatic dizziness,” she said.

Vision difficulties, whether age-related or situational, are another frequent cause of falls. “In fall incident reviews, both in the outpatient and inpatient setting, inadequate lighting is a common theme,” Dr. Miller reported.

Bifocal glasses can cause problems climbing stairs or crossing thresholds, and age-associated decreases in color contrast perception can also increase fall risk. “Somebody is in the bathroom where they've got a white toilet and white floors and white wall and maybe . . . misjudge where their bottom is supposed to land and instead land on the floor,” she said.

Along with these likely causes of falls, there's one explanation that hospitalists should not be using. “We shouldn't be calling things mechanical falls. That actually doesn't mean anything other than maybe that it wasn't syncope,” Dr. Miller said.

In addition to explaining falls, hospitalists need to apply themselves to preventing them, particularly while a patient is in the hospital. “A lot of us will institute our institution's fall precaution protocol. What exactly is that? I think we have this idea in our head that they like bubble-wrap the patient and don't let them get out of bed and they always 24 hours a day have somebody there to help when they get out of bed,” said Dr. Miller. “But unfortunately, in hospitals across the country, we're seeing this happen all the time—tons and tons and tons of falls and tons of falls with major injuries. This has been a really tough nut to crack.”

Interventions that have been tried and failed include bundled nursing interventions that involve supervision, fall risk signs, low beds, and bed and chair alarms. “Unfortunately, there have been numerous studies in the literature that have demonstrated that despite these really good ideas and good things, we're not moving the needle significantly on falls,” she said.

Fall-risk prediction tools, even those validated in studies, have also proven ineffective. “Unfortunately, the literature would suggest that despite the validity of these tools for looking at risk factors, they're not very good at predicting who is going to fall in the hospital,” said Dr. Miller.

But amid these failures, there is some hope. “There is emerging literature that would suggest that promising concepts include 1) tailoring patient-specific interventions, and 2) patient engagement,” she said.

To tailor an intervention, hospital staff members work with patients to determine their particular fall risk factors. “That helps us with our critical thinking about what might then be some creative interventions. Somebody with heart failure who we know is going to need to get up and use the restroom quite a bit, they might need a more tailored toileting schedule,” said Dr. Miller.

In a pilot effort at Mayo Clinic on patient engagement in fall prevention, patients were educated on their individual risk factors for falls and made a verbal agreement with a nurse regarding each of their roles in preventing falls in the hospital.

“What we found is that the patients' understanding that this is an issue significantly increased,” she said. For example, when asked what they would do if they wanted to get out of bed, more patients said they would use the call light instead of getting up on their own. Early results of the trial also suggested a reduction in falls and falls with injury.

Encouraging patients to ambulate, while known to speed recovery of function, might be expected to increase fall risk, but a recent trial at Johns Hopkins Hospital in Baltimore, published in the Journal of Hospital Medicine in 2016, found just the opposite.

“They were able to significantly increase the time that people were spending walking, and there was a significant reduction in length of stay, by about half a day, and a trend toward a decrease in injurious falls,” said Dr. Miller. “Just the degree of ambulation a patient is doing does not correlate with an increase in falls, and it might actually be the other way around.”

Her hospital has similarly engaged in initiatives to create a “culture of mobility,” including a nurse-driven activity and mobility algorithm with daily goals for patient activity that progress based on the patient's functional abilities. Patients who are medically stable and can get out of bed, for example, should have a goal of getting up and into a chair at least three times a day, she said.

Patients with even less ability to move get smaller goals, ideally ones that fit easily into nursing workflows. “When they're rolling in bed to have their linens changed and their gown changed, we're trying to get them to physically participate in the rolling and increasing their independence,” said Dr. Miller.

These interventions are mainly implemented by nurses, but hospitalists play a key role in motivating patients to participate, she said. “We talk to our patients about a prescription of physical activity. I tell patients, ‘Your spending more time out of bed and sitting up in a chair at the bedside is just as important in your ability to quickly recover from this illness as the antibiotics that we're prescribing.’”

Hospitalists should also be involved in the discussion of fall risk and activity goals. “If we do that together, with nursing, the patient, and us in the room, I think it holds each other, all of us, accountable for addressing an issue that would sometimes be easy to miss,” said Dr. Miller.