Falls among inpatients represent the most common safety incident in acute care settings, with devastating consequences that can include serious injury, increased length of hospital stay, and higher healthcare costs. A multifactorial approach is necessary to mitigate this risk, starting with a comprehensive assessment of both patient-specific and external factors.
Intrinsic (Patient-Related) Risk Factors
These are risk factors related to the patient's own physical and mental condition. They are often compounded by the acute illness that led to hospitalization.
Age and Physiological Changes
Advanced age is a well-established risk factor for falls in hospitalized patients. Older adults may experience age-related declines in balance, muscle strength, and reaction time. Furthermore, the number of comorbidities often increases with age, further elevating risk. The American Center for Disease Control reported that the incidence of falls for those over 85 was four times greater than for those aged 65-74.
Impaired Mobility and Gait Instability
Many hospitalized patients suffer from mobility issues, gait problems, or lower-limb weakness. These can result from the underlying illness, deconditioning due to bed rest, or pre-existing conditions like arthritis or previous stroke. Difficulty with balance and reliance on walking aids are also correlated with higher fall risk.
Cognitive Impairment
Changes in mental status, including agitation, confusion, dementia, and delirium, are significant contributors to fall risk. Patients who are confused or disoriented may try to get out of bed without assistance, while others may overestimate their abilities. Delirium, often induced by the hospital environment, is a major factor for falls in older adults.
Medication Use
Polypharmacy, the concurrent use of multiple medications, is a major risk factor for inpatient falls. Certain medications are particularly problematic, including:
- Sedatives and hypnotics
- Anxiolytics and benzodiazepines
- Antipsychotics
- Antidepressants
- Antihypertensives
- Diuretics
- Opioids
Other Physiological Factors
- Orthostatic Hypotension: A sudden drop in blood pressure when a person stands up can cause dizziness and fainting.
- Urinary Incontinence or Frequency: An urgent need to use the bathroom can lead to hurried attempts to ambulate, increasing the risk of a fall.
- Vision and Sensory Deficits: Impaired vision or hearing can hinder a patient's ability to navigate their surroundings safely.
- History of Falls: A previous fall is a powerful predictor of future falls.
Extrinsic (Environmental and Systemic) Risk Factors
These are external factors in the hospital environment that increase the risk of a fall. Many of these can be modified or managed through hospital protocols.
- Unfamiliar Environment: The layout of a hospital room, including the location of the bathroom and the height of the hospital bed, can disorient patients.
- Clutter and Hazards: Tripping hazards such as loose cords, medical tubing, or clutter on the floor are direct threats to patient safety. Wet or slippery floors also contribute to accidental falls.
- Poor Lighting: Inadequate or dim lighting, especially at night, can increase the risk of falls for patients getting out of bed.
- Call Bell Inaccessibility: If a patient cannot reach their call bell, they may attempt to get out of bed or a chair on their own, leading to a fall.
- Incorrect Equipment: The use of inappropriate or malfunctioning assistive devices like walkers or wheelchairs can be a risk factor.
- Staffing and Communication: Insufficient staffing levels and communication breakdowns during shift changes can lead to less-than-ideal patient monitoring.
Comparison of Intrinsic and Extrinsic Risk Factors
| Feature | Intrinsic Risk Factors | Extrinsic Risk Factors |
|---|---|---|
| Source | Patient's own physical and mental state | The patient's immediate hospital environment and care systems |
| Examples | Age, mobility impairment, cognitive status, comorbidities, medications | Poor lighting, wet floors, bed height, call bell accessibility, staffing levels |
| Influence | Pre-existing or acutely acquired conditions | Modifiable environmental and systemic elements |
| Management | Individualized care plans, medication review, rehabilitation, ongoing monitoring | Universal fall precautions, hourly rounding, staff education, environmental modifications |
| Variability | Can change with patient's health status | Varies with the hospital unit, room, and time of day |
Conclusion
The risk factors for falls in an acute hospital are multifaceted and require a comprehensive approach to mitigation. By addressing both intrinsic factors—such as a patient's age, mobility, cognitive status, and medications—and extrinsic factors related to the hospital environment and care systems, institutions can significantly reduce the incidence of inpatient falls. A proactive, individualized fall prevention plan, combined with ongoing staff education and a culture of vigilance, is essential for improving patient safety and quality of care.
Actionable Prevention Steps
To effectively reduce falls, healthcare providers and patients should implement specific, evidence-based strategies:
- Assess and Reassess: Perform a fall risk assessment upon admission, with reassessments triggered by changes in the patient's condition.
- Optimize Environment: Ensure the room is free of clutter, well-lit, and that personal items and the call bell are within easy reach.
- Manage Mobility: Provide appropriate, well-maintained walking aids and assist with transfers, especially for high-risk patients. Encourage patients to sit on the edge of the bed before standing to prevent dizziness.
- Review Medications: Regularly review and adjust medications that increase fall risk, in collaboration with the medical team.
- Enhance Communication: Use clear flagging systems (e.g., wristbands or door signs) to communicate fall risk status to all staff. Use strategies like safety huddles and improved handover systems.
- Engage Patients and Families: Educate both patients and their families about fall risks and prevention strategies, encouraging active participation in the care plan.
For more detailed information on preventing patient falls, refer to the Agency for Healthcare Research and Quality guidelines.
