According to a published medical article from 2019:
The use of fall risk prediction tools is widespread, but their value in hospital fall prevention interventions is questionable. First, it is important distinguish between fall risk assessments and fall prediction or screening tools. Risk assessments usually consist of a checklist of risk factors for falls, but do not provide a score or value for the patient’s fall risk. Predictive tools use these known risk factors to calculate a score for the patient’s risk of falling, with established cutoffs to identify risk level.
Some tools have demonstrated acceptable sensitivity and specificity in single studies, but the reported predictive values of these tools vary by study design, setting, and population. Further, a patient’s risk for falling is transitory, requiring periodic reassessment. Few tools have been validated specifically with older hospital patients, and a systematic review concluded that existing tools do not have sufficient specificity and sensitivity to be effectively used in this population.
The lack of evidence supporting the use of predictive tools led to 2013 National Institute for Health and Care Excellence (NICE) guidelines which explicitly recommended against the routine use of fall prediction tools, instead advising that all inpatients over the age of 65 be considered at high-risk. The Agency for Healthcare Research and Quality (AHRQ) cautions that it is more important to identify and address a patient’s specific fall risk factors than to determine their risk for falling. Despite this, fall risk screening tools are frequently used to identify patients for intervention, often, relying on “home-made” tools without established psychometric properties. While these tools have the potential to tailor fall prevention strategies to specific patient risk factors, they predict falls no better than nursing judgment.
Alarms
Alarm systems are designed to reduce falls by alerting staff when patients attempt to leave a bed or chair without assistance. They can also function as a reminder to patients to call for assistance before getting up. There are several types of alarm systems in use, including pressure mats, infrared movement detectors, cord-activated alarms, and wearable devices. Alarms are disruptive and may be especially disturbing to cognitively impaired patients, contributing to confusion and agitation. They also restrict mobility and independence; in US nursing homes, alarms are considered a type of restraint and facilities can be penalized for indiscriminate use of the devices.
There is now strong evidence that alarms are ineffective as a fall prevention maneuver in hospitals.
Sitters
Sitters, also known as companions or ‘specials’, are a potentially effective yet costly fall prevention strategy. Sitters provide one-to-one surveillance for patients deemed at high risk for falls and may additionally provide therapeutic care. Guidelines for the use of sitters and their duties, qualifications, and training vary among hospitals.
There is indirect evidence of sitter effectiveness, but no RCTs of sitters as a single intervention have been performed to date. The evidence supporting effectiveness of sitters has been limited to small observational studies conducted in a single hospital—each with its own definition of what constitutes a sitter. In addition to the limited evidence of effectiveness, there is the possibility that sitters may have an adverse effect on patient care; for example, to save on costs, existing staff may be utilized as sitters, potentially placing other patients at risk. Despite the lack of evidence, sitters are recommended in numerous fall prevention guidelines.
Intentional Rounding
In an effort to increase patient satisfaction and reduce patient harm, many hospitals have instituted intentional rounding. Rounding is a proactive approach to meeting patient needs that involves bedside checks at regular intervals, usually every one to two hours. The quality of evidence for rounding is weak, with most of the literature consisting of QI studies. Difficulties with adherence and sustainability of rounding initiatives are widely reported, and introduction of the practice is often perceived as a top-down approach which restricts staff autonomy. Other barriers include increased workload, competing priorities, poor documentation, inadequate education, and lack of staff buy-in. Thus, even if stronger evidence supporting the effectiveness of rounding is produced, the feasibility of the strategy as a sustainable fall prevention practice is uncertain.
Patient Education
There is some evidence that education is an effective component of multifactorial interventions, but the body of evidence on their effectiveness as a single intervention is limited. Haines et al. performed an RCT of a multimedia education intervention combined with one-on-one follow up from a health professional. While the intervention did not significantly reduce fall-related outcomes overall, subgroup analysis of cognitively intact patients who received the intervention showed a 50% reduction in fall rates. When the same intervention was tested in a cluster RCT in 8 hospital rehabilitation wards, a significant reduction in rates of falls and falls resulting in injury. These results may be explained by the fact that patients in rehabilitation wards tend to be more cognitively intact than those in acute settings. Thus, although patient education is potentially effective in reducing hospital falls for certain patients, it is not suitable for patients with cognitive impairment—a common risk factors for inpatient falls.
Physical Modifications
The physical environment can be an important contributor to falls. Of a total of 538 hospital falls resulting in death or permanent loss of function that were reviewed by The Joint Commission, 209 (39%) identified the physical environment as part of the root cause. Small studies have explored the impact of a variety of environmental modifications. One RCT found fewer falls occurred on vinyl flooring compared to carpet, but the findings were limited by a small sample size and low fall rate during the 9-month trial. A cRCT found no evidence that low-low beds reduced rates of falls or injuries from falls. Other interventions have included visual cues (e.g. signage, wristbands), lighting, and the use of special rooms for high-risk patients. Some of these fall prevention efforts have resulted in patient harm; for example, in 2005 the FDA issued a recall of enclosed beds after reports of patient injury and death from entrapment.
Physical Restraints
There is considerable controversy surrounding the use of physical restraints in hospital settings. Patients who require restraints suffer a loss of dignity and autonomy; furthermore, restraints may also cause agitation, delirium, pressure ulcers, deconditioning, strangulation and death. Data suggest that restraints may not protect, but actually increase risk of falling, or sustaining an injurious fall.
On the part of both health professionals and patients, there is a perception that restraints reduce the risk of falling, and they are often employed as a “last resort” to protect patients from falling. This perception of physical restraint effectiveness as a strategy to prevent falls has persisted despite the increasingly restrictive regulations and standards from CMS and The Joint Commission limiting their use.
Non-Slip Socks
Non-slip socks are often provided to hospitalized patients under the assumption that they will provide additional traction to prevent patient falls. In contrast to manufacturers’ claims, research has cast doubt on the slip-resistant properties of these products. The small body of research on non-slip socks has not provided evidence of their efficacy as a fall prevention strategy. Further, non-slip socks carry the risk of spreading drug-resistant infection in hospitals. Given the lack of evidence of effectiveness and potential to spread infection, a patient’s own footwear remains the safest option for fall prevention.
If you or a family member were injured (or worse) as a result of a fall in a hospital in the United States, you should promptly find a medical malpractice attorney in your state who may investigate your hospital fall claim for you and represent you or your family member in a hospital fall case, if appropriate.
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