Inpatient Falls: Epidemiology, Risk Assessment, and Prevention Measures. A Narrative Review

Abstract

Background

Patient falls are a common inpatient dilemma and comprise the largest category of preventable adverse events in hospitalized patients. These events place a clinical burden on the patient, such as increased morbidity and reduced quality of life, in addition to an economic burden on the hospital system. Fall prevention strategies have the opportunity to decrease inpatient health care costs and length of stay. Several risk factors have been identified that contribute to inpatient falls and several strategies have been identified to minimize this risk. These risk factors are typically characterized as intrinsic and extrinsic factors. Intrinsic factors include characteristics such as age, gender, impaired mobility, and physiological factors (eg, co-morbidities, low muscular strength, visual impairment, poor reaction time, and movement disorders). Extrinsic factors are related to characteristics in the environment, such as slippery surfaces, footwear, bad lighting, and the influence of medications. Risk assessment tools, such as the Hendrich II Fall Risk Model, Morse Fall Scale, and STRATIFY, were developed to help identify those at risk. In utilizing these models and our understanding of predisposing risk factors, prevention strategies may be utilized to mitigate these risks. These strategies are often generalized actions including patient education; however, targeted interventions (ie, patient education) also improve outcomes by interrogating specific risk factors.

Introduction

Patient falls that occur during hospitalization result in patient harm and present a dilemma for health care providers. Implications of inpatient hospital falls include both worsened patient outcomes and costly economic considerations. Epidemiologic studies have identified several risk factors for patients who are predisposed to falling.^1–3 Additionally, scoring methods have been developed to identify those at risk, and post-scoring interventions have been developed to mitigate these risks.⁴ We sought to demonstrate that prevention measures can greatly impact both patient outcomes and inpatient costs.

There is potential to significantly reduce patient harm, improve patient care, and have consequent economic impacts if risk-reduction goals are achieved. In this review, we explore the epidemiology of inpatient falls and examine risk-associated and preventative methods that can be utilized to mitigate the risk. Additionally, we discuss the implementation of these preventive methods within the hospital system.

Methods

The search methodology included articles from the years 1990 to 2024 utilizing the PubMed database. The following search terms were used: inpatient falls, risk factors, fall prevention, assessment tools, and cost. Fifty-three articles were ultimately included in this review after narrowing the PubMed database search to articles on inpatient falls published after 1990, especially prioritizing systematic reviews and randomized control trials.

Discussion

Epidemiology

Patient falls are a common inpatient dilemma and comprise the largest category of preventable adverse events in hospitalized patients.¹ Approximately 700 000 to 1 million patients experience a fall while hospitalized each year. Up to one-third of these falls result in injury, with approximately 10% resulting in serious injury.^2,3 Inpatient falls place a clinical burden on the patient, such as increased mortality and reduced quality of life, and an economic burden on the hospital system.³ In 2023, an economic analysis demonstrated that non-injurious and injurious falls were associated with a $35 365 and $36 776 USD increased cost, respectively.⁵ Most falls occur in the elderly patient population, especially patients who experience agitation, confusion, or impaired judgment.^2,6 Other notable risk factors include adverse medication effects (particularly associated with psychoactive medications), baseline deficits in strength or mobility, acute illness, urinary incontinence, or frequency, impaired balance, and neurovascular instability such as orthostatic hypotension. ^2,7

Health Care Costs

Inpatient falls not only lead to avoidable patient harm but also represent a significant financial burden for health care systems. Falls that occur in the hospital setting often lead to increased health care costs, prolonged lengths of stay, and limitations on reimbursement from the Centers for Medicare and Medicaid Services (CMS). Health care-associated costs of inpatient falls are substantial. In a study by Fields et al, the total cost of imaging related to inpatient falls over a 3-year period at a single academic hospital was $160 897, with 63% ($100 700) attributable to head computed tomography (CT) scans alone.⁸ The authors noted that 85% of head CTs ordered after a fall were negative, raising questions about the necessity and cost-effectiveness of routine imaging following inpatient falls.^9,10 Bates et al estimated that serious fall-related injuries in hospitalized patients result in charges over $4200 higher than for patients who did not fall during their admission. ¹¹ More recently, Dykes et al found that the average total cost of a fall with any injury was $64 526 (the direct cost being $36 776) and that preventing falls through implementing the use of a risk assessment tool saved $22 million over 5 years across 2 health systems.¹² Therefore, fall prevention strategies have the potential to significantly reduce inpatient costs. In addition, the practice of imaging for all patients who fall requires further research.^8,11,12

Inpatient falls also contribute to increased length of hospital stay (LOS).^5,13 For example, Dunne et al found that patients who experienced a fall during their acute care hospitalization had an average LOS of 37.2 days compared to 25.7 days for matched controls who did not fall.¹³ This association between inpatient falls and prolonged LOS was observed regardless of whether the fall resulted in injury.⁵ The additional hospital days related to falls represent a significant cost burden.

In 2008, the CMS stopped reimbursing hospitals for costs associated with fall-related injuries, considering them a preventable hospital-acquired condition.¹⁴ This policy change has incentivized hospitals to implement fall prevention programs to avoid financial penalties. However, the CMS policy has been criticized for failing to adequately promote evidence-based strategies to reduce inpatient falls and for not including falls that do not result in injury, which still contribute substantially to hospital costs.¹⁴ A study assessing the impact of this policy using data collected from 4 hospitals over a 5-year period showed that nurses were more likely to perform at least 1 fall-related intervention (primarily the use of bed alarms) after the policy was implemented. However, it was unclear whether those changes were influenced by the CMS policy change directly or by the organization.¹⁴

Efforts to reduce inpatient falls and associated costs should prioritize patient engagement and education and target evidence-based interventions. ^5,12,15 Radecki et al interviewed hospitalized patients and found that patient beliefs about their own fall risk were often linked to their perceived ability to walk independently.¹⁶ These authors suggested that fall prevention programs need to shift from being clinician-centric to patient-centric, with nurses developing relationships with patients to understand their individual needs and perspectives. Dykes et al specifically studied fall prevention programs that targeted patients and families and found an overall adjusted decrease in falls by 15% after implementation.¹⁵ They also reported a reduction in fall injuries in their large patient population (n = 37 321). Efforts to mitigate patient harm and costs associated with patient falls should focus on implementing evidence-based, patient-centered fall prevention strategies that engage patients as active participants in their care. This may include an initial assessment by a member of the health care team identifying relevant risk factors followed by the development of an individualized prevention plan tailored to specific areas of risk.¹⁵

Risk Factors

Several risk factors are associated with inpatient falls, with these risk factors characterized as either intrinsic or extrinsic factors. Intrinsic factors include characteristics such as age, gender, impaired mobility, and physiological factors (eg, co-morbidities, low muscular strength, visual impairment, poor reaction time, and movement disorders). Extrinsic factors are related to characteristics in the environment, such as slippery surfaces, footwear, bad lighting, and the influence of medications.¹⁷ In general, falls result from a combination of both intrinsic and extrinsic factors, but patients with more intrinsic factors appear to be at a higher risk.^17,18

There is controversy as to whether age by itself is an independent risk factor for falls, or if factors commonly associated with advanced age (impaired mobility, impaired balance, and cognitive impairment) are the reason for an apparent increased risk of falls in older patients. Both Hitcho et al and Najafpour et al reported that age was not significantly related to increased falls in the hospital setting.^19,20 However, researchers have shown age to be a risk factor for fall-related injury.^20,21 Notably, Hitcho et al found that patients under 65 were just as likely to suffer fall-related injury as those over 65, but the small number of patients who suffered injury in their study precluded multivariate analysis.¹⁹

Cognition has also been implicated in playing a large role in contributing to hospital fall risk. Coupled with disorientating unfamiliar hospital environments and impaired mobility, cognitively-impaired elderly patients may find themselves considerably more confused. In a meta-analysis to identify associations between cognitive frailty (defined as the co-existence of physical frailty and cognitive impairment in the absence of dementia) and hospital falls, the authors concluded that 36.3% of patients who had fallen had cognitive frailty.²² Assessing cognition in elderly patients upon admission may be a valuable tool for determining which patients may require extra assistance ambulating during their stay.

Malnutrition may also play an important role in influencing patients' fall risk. However, the relationship between malnutrition and fall risk is poorly understood. For example, Lackoff et al aimed to elucidate the association between malnutrition (defined by the authors as BMI < 18.5 kg/m2 in addition to the use of a validated nutrition assessment tool, which includes the patient’s weight history, diet, physical assessment, etc) and inpatient falls through a study that involved performing malnutrition audits over a 12-year time span.²³ In this study, they found a 32.4% prevalence of malnutrition in patients who experienced an inpatient hospital fall, and that patients with malnutrition were approximately 8 times more likely to have a fall with injury.²³ Ishida et al also reported that malnourished patients at the time of admission had a higher incidence of falls with their multivariate analysis revealing a 2.78-fold higher hazard ratio.²⁴ Therefore, it appears that malnutrition should be carefully considered when stratifying risks of inpatient falls.

Medications, specifically those acting on the central nervous or cardiovascular systems, are a significant risk factor for in-hospital falls. An increased incidence of falls and fall-related injuries was reported in patients taking drugs such as benzodiazepines, antipsychotics, antihypertensives, and antiepileptics.^20,25 Castaldi et al found that antipsychotics, antidepressants, and diuretics were the drug classes associated with the highest increased risk of falling.²⁵ Further support of medication-related fall risk was reported in a study by O’Neil et al in which they examined a wide variety of drug classes.

This study found hydantoin and benzodiazepine anticonvulsants, tricyclic antidepressants, and haloperidol most strongly associated with an increased risk of falls.²⁶ O’Neil et al also found insulin, due to hypoglycemic episodes, may be associated with an increased risk of falls.²⁶

Naturally, polypharmacy is also linked with a risk of inpatient falls, as it is common for hospitalized patients to be on drugs from multiple classes, which also increases the risk of falls. Ming and Zecevic found that polypharmacy (defined as the use of 4 or more prescription medications) resulted in a 1.5 to 2 times higher possibility of recurrent falls in adults.²⁷

Patients with a history of stroke have a higher risk for future falls. In a study examining the prevalence of a positive stroke history in patients who have fallen, Kumagai et al found an increase in falls in patients with a history of stroke in their retrospective cohort study.²⁸

Osteoporosis has also been implicated in the prognosis of patients with hospital falls, but osteoporosis appears to be linked to the seriousness of injury and potential high mortality rate more than the risk or cause of the fall. Lewiecki et al found early identification of osteoporosis and severity classification proved useful when stratifying patients for fracture risk.²⁹

Difficulty with balance, previous history of falls, and the need for walking assistance devices have also been correlated to higher fall risk depending on the age group being studied, with these risk factors often occurring simultaneously. ^{17,19,20,30,31} Repeat falls are often caused by the same predisposing factor, indicating that proper history-taking is important when inquiring about fall risk.²⁰ Moreover, recurrent falls are often an indicator of an underlying problem such as impaired balance.²⁰ Limited access to assistive devices and lack of familiarity with hospitals’ assistive devices are also possible contributors to the increased fall risk in patients requiring walking assistance.²⁰

Risk Assessment Tools

Fall-risk assessment tools identify the patients’ risks for falling and allow for staff to make recommendations to reduce patient risk. Commonly used fall risk assessment tools are Hendrich II Fall Risk Model, Morse Fall Scale, and STRATIFY. The Hendrich II Fall Risk Model (HIIFRM) assesses 8 fall risk factors making one of its main strengths its brevity along with its ease of being incorporated into electronic medical records.³² The 8 factors assessed by the HIIFRM are disorientation, symptomatic depression, altered elimination, dizziness, gender, administered anticonvulsants, administered benzodiazepines, and ability to rise from a chair. Any score greater than or equal to 5 is considered a high risk for a fall.³³ These 8 factors were determined to be significantly and independently related to inpatient falls via a stepwise logistic regression.³⁴ The HIIFRM also provides the opportunity to diagnose the root causes of fall risks and add them to the medical problem list, so they become part of the comprehensive cross-continuum care plan.³² The HIIFRM has been validated with a specificity of 64.07% and sensitivity of 78.72% via a retrospective analysis of patient data from 9 hospitals over 3 years including a total of 214 358 patients.³² The main limitation of the HIIFRM is its use in rehabilitation departments of hospitals or long-term care facilities, as the cutoff of 5 points is not as predictive in specialized patient scenarios. Specifically, HIIFRM may not be as effective in orthopedic, neurologic, and pulmonary rehabilitation cases.³³

The Morse Fall Scale (MFS) is an approximately 2-minute fall risk assessment used in hospital settings.³⁵ It groups the patients into low, medium, and high-risk fall categories.³⁵ This assessment scale ranks history of falls, secondary diagnosis, ambulatory aids, IV/heparin lock, gait/transferring ability, and mental status.³⁵ This scale was shown to have 73.2% sensitivity and 75.1% specificity.⁴ The main limitation of the MFS is the variable organization-specific cut-off value to determine if a patient is at risk of a fall. Therefore, individual analysis by each organization is required to determine optimal cut-off and periodic re-evaluation to ensure continual optimal cut-off.³⁵

The St Thomas Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) is a fall risk assessment used in hospital settings.³⁶ The STRATIFY takes approximately 3 minutes to complete and assigns the patient a score of 0 to 5, with a score of 2 or greater indicating a risk of falling. STRATIFY evaluates the history of falls, agitation, visual acuity, frequency of toileting, and transfer/mobility of the patient. The STRATIFY risk assessment tool has been shown to have a sensitivity of between 73.7% and 93% with a specificity of 68.3%.^36–38 STRATIFY is not considered ideal for traumatic brain injuries, and its accuracy in acute geriatric settings is also controversial with 1 systematic review stating STRATIFY may not be optimal for identifying high-risk individuals for fall prevention.^36–38 However, according to 2 studies, STRATIFY achieved greater diagnostic validity compared to MFS and HIIFRM.^36–40 All 3 risk assessments are considered self-report and evaluate the state of illness of the individual. Thus, there have been proposals following systematic literature reviews of fall risk assessment tools to combine these types of risk assessments with a test that evaluates physical ability to provide greater accuracy in identifying patients at risk in various contexts.³⁷

General Measures for Fall Prevention

At present, there is not a universally accepted standard for preventing falls in hospitals, although hospitals implement various measures with the aim of reducing the risk of falls. Common prevention measures include bed-locking and alarms, handrails, accessible call bells, scheduled toileting, sitters, non-slide socks, bracelets, and organized patient rooms.^41,42 Additionally, patient and family education plays a crucial role. For example, a cross-sectional study by the National Institute of Health revealed that the typical identification method for patients who are at risk of falling involved leaving their door open and placing a sign on the door.⁴¹ This study showed that 73% of providers implement bed practices including locking and lowering the bed and having a bedside toilet.⁴¹ Additionally, assisting the patient during toileting and rounding hourly were believed to be the most successful monitoring practices.⁴¹ For quality measures, most hospitals used postings of fall rates and nurse huddles.^41,42 In a systematic review performed by Morris et al in 2022, the only intervention that was significantly associated with a reduced fall rate was patient and staff intervention and education.⁴³ In contrast and in addition to this study, Miake-Lye et al found that a combination of leadership, staff engagement, and implementation of committees on fall prevention guidance contributed significantly to the prevention of falls.⁴⁴ In summary, it appears that education of the staff and patients is an important factor to prevent falls, but more research on the effectiveness of multifactorial interventions may be needed.

The Agency for Healthcare Research and Quality (AHRQ) offers training to hospitals to implement their fall prevention program. Use of this program reduced hospital falls and fall-related injuries by 15% and 34%, respectively.⁴⁵ The AHRQ focuses on the 5 P’s of fall precautions: pain, personal needs, position, placement, and preventing falls.⁴⁵ Ensuring the patient’s needs are met (eg, toileting) and assistance is within easy reach (eg, their phone) are among the most essential ways to prevent falls.

Targeting Specific Risk Factors

Specific risk factors can be targeted to reduce the risk of falls. The following section discusses these selected measures and highlights the importance of targeting these risk factors. As described above, fall risk assessment tools such as the Hendrich II Fall Risk Model, Morse Fall Scale, and STRATIFY scale can aid in the prediction and, therefore, the prevention of inpatient falls.^32,35,36 High-risk category patients receive targeted fall-prevention programs in addition to general prevention measures in which there are defined measures geared toward specific risk factors.

According to the National Institute for Health and Care Excellence, guidelines for assessing the risk and prevention of falls in older people, all patients aged 65 and older, should be categorized as high-risk.⁴⁶ Among many of the recommended interventions to prevent falls in these high-risk populations, evaluating and adjusting the inpatient environment, including flooring and furniture, was highlighted as a reliable prevention method.⁴⁶

Malnutrition is a significant predictor of in-hospital falls with risk increasing with age. A cross-sectional study confirmed the relationship between falls and malnutrition, with malnutrition defined as unintentional weight loss of more than 10% of body weight in the past 6 months or more than 5% body weight in the past month.⁴⁷ Recommendations emphasize dietary intervention to optimize bone health, muscle strength, and physical function in nutrient-deficient adults.⁴⁷ Current evidence linking malnutrition with in-hospital falls primarily focuses on patients who are already nutritionally deficient before their hospitalization. However, there is a lack of research on how in-hospital nutrition affects fall risk during the same hospitalization and the timeframe for when the benefits of improved nutrition on fall risk begin to appear. The fall risk assessment tools mentioned previously do not specifically address malnutrition; however, the AUTUM (Assess fall risk, Utilization Tool including Medical Nutrition risk factors) falls instrument described by Julius et al is currently being created and does specifically address nutrition in relation to fall risk, with findings that show an increased risk of falls associated with history of anemia.⁴⁸ Assessing a patient’s nutritional needs can be done with assistance from placing an inpatient nutrition consult for a more individualized approach.

Given the frequency of alterations in medications throughout a patient’s hospital stay, it is important to be aware of the specific medications that increase the likelihood of falls. In a case-crossover study by Shuto et al, certain medications contribute to inpatient falls among high-risk patients.^49,50 It is imperative for physicians to recognize these medications and use caution when initiating them in inpatient settings for high-fall risk patients. Recommendations include initiating low but effective doses of these medications alongside careful monitoring of patients following initiation of these medications.⁶

Among the conditions that place patients at increased susceptibility to falling during their hospital stay, stroke is a leading candidate-risk factor. A study evaluating unique interventions for inpatients who suffered a stroke examined the benefits of exercise, changes in glasses, brain stimulation, and robotic rollators (a walker device with technology to provide assistance when walking).⁵⁰ This study revealed that these interventions significantly improved fall risk; and, therefore, emphasis should be placed on close monitoring and other general fall-risk prevention strategies for patients who have suffered strokes while they remain in the hospital. ⁵⁰ Additionally, conditions such as a stroke that cause difficulty in balance, loss of proprioception, or result in the need for a walking assistant device should have general fall-prevention interventions as described previously.⁵⁰

Implementation Considerations and Barriers to Effective Implementation of Fall Prevention Programs

Tailoring prevention measures toward patients with specific risk factors is resource-consuming by most hospital systems.⁴⁵ Hospitals often lack the staff necessary to adequately monitor patients, which is essential for reducing the frequency of falls. In a qualitative review by Heng et al, the main barriers to implementing fall prevention measures included inconsistencies in guidelines across different hospital systems, patients' lack of awareness regarding their fall risk, and limited interprofessional communication concerning patient falls.⁵² Therefore, it is important to consider other factors that impede the proper utilization and execution of prevention measures, such as the fast-paced nature of the hospital and lack of patient education. Patients are often relocated multiple times during their hospital stay. Thus, efforts to reduce inpatient falls require that prevention measures be implemented each time a patient transitions to a different environment.⁴⁵

Research conducted by McConville and Hooven revealed patients' reluctance to engage in rehabilitation efforts was attributed to factors such as lack of insurance coverage or willingness to try, thereby contributing to their ongoing risk of instability.⁵¹ Additionally, patients expressed reluctance to seek assistance for fear of burdening their caregivers.⁵² Therefore, prevention strategies must be implemented to lower the fall risk, even in these intractable cases.

Conclusion

Inpatient falls are complex but preventable adverse events that can result in patient harm, negatively affect patient outcomes, and result in increased health care costs. These falls increase morbidity and injuries and prolong hospitalizations, increasing health care costs and leading to worsening outcomes for patients. Risk factors for falls include factors associated with advanced age, cognitive impairment, polypharmacy, and medical history. Current testing scales do not include an assessment of malnutrition, despite its prevalence in elderly patients and apparent link to fall risk. Assessments developed to target those at risk include the Hendrich II Fall Risk Model, Morse Fall Scale, and STRATIFY. When we combine these models with our understanding of predisposing risk factors, we are able to identify patients that will benefit from prevention strategies to mitigate these risks. These strategies are often generalized actions including patient education; however, targeted interventions also improve outcomes by interrogating specific risk factors. Implementation of such interventions is often deemed difficult due to varying guidelines and limited resources. Nevertheless, a consensus that focuses on patient, patient's family, and staff education is imperative to the implementation of basic preventative measures to prevent falls and improve patient outcomes in health care efficiency.

Funding Statement

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare-affiliated entity.