Reducing falls in inpatient older adults: Quality improvement initiative

Abstract

Background

Falls and fall-related injuries are common among older adults, adversely affecting their functional independence and quality of life. By 2043, one in three Canadians falls each year, resulting in 85% of hospitalizations, which cost $2 billion annually.

Objective

This study aimed to reduce inpatient falls among older adults with cognitive impairment in a rural Ontario hospital.

Methods

A fall reduction project was implemented at the hospital to improve clinical care since January 2024. The project included fall risk screening, ensuring a fall bundle was in place, and monthly meetings with hospital staff and patient representatives to identify potential barriers and facilitators to the project. The project involved two components: 1) nurses evaluating fall risk using validated tools and 2) implementing a fall prevention bundle. Data was retrieved from the hospital's electronic medical records. The outcome of interest was the fall rate before and after the intervention.

Results

The initiative has reduced the inpatient fall rate from 16.25 falls per 1000 bed days in 2023 to 11.33 falls per 1000 bed days in 2024. Almost 57% of people who fell were cognitively impaired.

Conclusions

The project reduced the inpatient fall rate by 30% within a year. The involvement of patients and their families in the initiative has made the project meaningful to the community. However, no change was observed in the 30-day readmission rate, prompting the research team to conclude that inpatient interventions are insufficient. Further research on collaborative care involving the pharmacy department and community partners is recommended.

Introduction

Hospital patient falls are a significant global concern globally.^1–3 Hospital falls rates vary from 3 to 16 falls per 1000 patient bed days, ² with higher rates observed in geriatric and rehabilitation wards. ⁴ Approximately 30–50% of these falls result in physical injuries ranging from bruises and lacerations to fractures and even death. ² Falling while hospitalized can also add emotional distress to the patient, their caregivers, and the healthcare staff.^5,6 Injuries related to falls significantly burden hospital resources and increase healthcare system costs, as patients who fall have longer LOS than those who do not.^7,8 These consequences highlight the urgent need to reduce falls to enhance patient safety and decrease the financial strain on hospitals.

Fall prevention strategies in hospitals may involve the use of alarms and monitoring devices (such as bed alarms, chair alarms, sensors, and wristbands), implementing environmental safety initiatives (e.g., obstruction-free floors and handrails), conducting risk assessments for falls, ⁹ and reviewing medications.^6,10,11 However, these methods’ impact often has minimal impact on reducing fall rates.^1,12,13 In contrast, patients and staff education on fall risks and prevention strategies and involvement of informal caregivers in fall prevention initiatives have been shown to reduce fall rates among older hospital patients effectively.^4,14–16 Literature identifies several enablers for effective fall prevention education, including shared responsibilities for program implementation, setting clear goals for staff, demonstrating the impact of the program, involving family members to reinforce messaging, designating “falls champions” to train staff, and making resources (such as videos and booklets) easily accessible to patients at all times. ¹⁷ Barriers to implementing fall prevention projects include uncertainties regarding how to conduct staff and patient education, managing delirium and dementia to prevent falls, and documenting incidents of falling in hospitals. ³

However, fall prevention education is not mentioned in all guidelines, and many lacked clarities on implementing patient education.^1,3 There is a growing recognition that organizational and system learning in healthcare emerges from the interactions of various factors that operate at multiple levels, both within and beyond individual care delivery. ¹⁸ While hospitals are responsible for promoting and safeguarding public health, ¹⁹ providing clinical care, including fall prevention education, is just one aspect of decision-making. Sustainability concerns, including human resources, economic factors, and social costs, are critical in determining the longevity and viability of new interventions introduced into the hospital's social ecology. ¹⁹

From the study site perspective, the aging population (65 years and older) in Ontario is primarily concentrated in rural areas (24%) compared to urban areas (17%). ²⁰ The number of older adults hospitalized due to falls increased by 15% from 2006 to 2011, accounting for approximately 85% of injury-related hospitalizations, with costs estimated at $2 billion a year. ²¹ The average LOS for injuries resulting from falls in older adults is around three weeks (approximately 22 days), which is ten days longer than stays for other causes, underscoring the disproportionate healthcare costs associated with fall-related injuries compared to other hospitalization causes among older adults. ²¹ Additionally, Ontario's population is projected to grow significantly shortly, with an increase of 276,000 expected by 2025–26, ²² most of whom will be older adults. ²³ However, as most new international migrants, typically aged between 18–45 years, settle in metropolitan areas, this trend exacerbates the concentration of the aging population in rural areas. ²³

Recognizing the challenges posed by an overburdened healthcare system and underfunded care provisions, a quality improvement initiative following the World Guidelines for Falls Prevention ¹ was launched to reduce falls among older adults with cognitive impairment in inpatient settings at the study site (Erie Shores HealthCare). The project was led by the first author (a co-author of the World Guidelines for Falls Prevention ¹ ) and the second author (a Clinical Nurse Manager with a background in geriatric nursing). This initiative aimed to improve patient outcomes by implementing effective fall prevention strategies.

Methods

The study site, Erie Shores HealthCare (ESHC), is a 72-bed rural Ontario acute-care facility serving 470,000 people. The target population was older adults admitted to the hospital. The setting was ESHC inpatient units. The study design was a case series. The intervention was a comprehensive fall prevention bundle that included training nurses on reliable fall risk assessment (Morse Fall Scale (MFS), ²⁴ Confusion Assessment Method (CAM), ²⁵ Montreal Cognitive Assessment (MoCA), ²⁶ and Time “Up & Go” test (TUG) ²⁷ ) as part of their regular monthly training sessions and providing a fall bundle to the admitted patients. Those who had a score of >25 in MFS were considered at risk of falling. Since the hospital uses MFS as a routine screening test for fall risk in all admitted patients, the research team used the tool for practicality.

The site provided the intervention from admission to discharge from January-December 2024. The fall bundle included 1) monitoring patients by alerting hospital security and having sitters (personal support workers, family members, security personnel, registered practical nurse) near the patient room and installing bed alarms; 2) modifications to a patient's bed by bed height and bed-rail adjustments based on clinician's recommendations; 3) identification of high-risk patients with door-sign and color-coded bracelets so that hospital staff were aware of their fall risk; 4) safety practices with clutter-free environment; 5) educating patients and caregivers on falls risk, providing them with relevant resources for fall prevention, and connecting with local stakeholders working on falls prevention (Alzheimer's Association, Canadian Mental Health Association); and 6) interpretation services during the patient and family education activities. The hospital is in the Municipality of Leamington, home to Spanish-speaking migrant agricultural workers and a low German-speaking Mennonite population. One of the local stakeholders, the Migrant Worker Community Program, involved their Spanish and low-German interpreters during this activity.

Monthly meetings with hospital staff and patient representatives were not just about sharing the project's progress report, but also about fostering a sense of collaboration and shared responsibility. This activity was instrumental in identifying possible barriers/facilitators to the project, allowing the research team to modify the activities if needed. For example, at the beginning of the project, there were visible door signs for those at risk of falling. It was noticed that a few fell in the cafeteria, and the food servers were unaware that those patients were at fall risk. During the monthly meeting, a patient representative suggested a color-coded wristband for those with fall risk, and the site adopted that idea. This collaborative approach, independent of clinical care staff, led to the creation of a data safety monitoring board to regularly monitor hospital data and provide unbiased directions. The board comprised of representatives from the hospital's Office of Research, Health Information and Decision Support, and Patient and Family Advisory Council.

Results

One hundred and thirteen clinical staff (n = 113, registered practical nurses, n = 53 and registered nurses, n = 62) were trained through regular Education Days (once a month) using simulated scenarios based on actual events to assess fall risk since January 2024. Those scoring 25 and over in MFS were identified as at fall risk (n = 1437) and were provided with a fall bundle. The hospital data revealed that the inpatient fall rate in 2023 was 16.25 (±4.33) falls per 1000 bed-days in 2023 and 11.33 (±4.79) falls per 1000 bed-days in 2024, a 30% reduction within a year (4.917 ± 6.33 less falls with 95% confidence interval of 0.89–8.93, one sided p value of 0.01) (Figure 1: Comparison of inpatient fall rate from 2023 to 2024 at the ESHC). The total number of fallers was 136, with an average age of 77 years and predominantly male (54%). Around 56% (n = 76) of all patients at fall risk had cognitive impairment (MoCA = 22 ± 2), and around 36% (n = 47) were confused (CAM = 72 ± 3). Around 17% (n = 23) of the fallers had mobility issues (TUG = 15 ± 2). The demographic snapshot of the fallers is presented in Table 1.

Figure 1.

Comparison of inpatient fall rate from 2023 to 2024 at the Erie Shores Healthcare.

Table 1.

Demography of fallers at Erie Shores HealthCare (January-December 2024).

Demography of fallers at Erie Shores HealthCare (January-December 2024)
Total number of patients at fall risk	1437
Total number of fallers	136
Average age	77
Sex (Male)	73
Number of patients with cognitive impairment	71
Number of patients with diagnosed dementia	5
Number of patients with confusion	47
Number of patients with mobility issue	23

Every month, a thorough analysis of falls was conducted as a group to understand the possible facilitators and barriers. This approach allowed identification of trends and taking measures in real-time to prevent future falls. The analysis revealed that most falls occurred when patients were in the washroom (n = 29) and outside their room (n = 41), with a majority of falls (n = 90) occurring after hours (06:01 PM-5:59 AM). Confusion (n = 48), balance (n = 31), clutter (n = 27), wandering behaviour (n = 26), and bed rail adjustment (n = 4) were identified as possible facilitators of falls. Out of 136 falls, only seven patients sustained an injury resulting in prolonged hospitalization by a day. This thorough analysis underscores the site's commitment to patient safety and their ability to address potential issues. Following the monthly data review, four issues were identified: 1) a need for a color-coded wristband for patients at fall risk, 2) limited presence of after hour observers, 3) family members not being aware/connected with community programs targeting fall reduction in cognitively impaired older adults, and 4) a need for a comprehensive medication review and counselling that may increase the risk for adverse drug reactions and falls. The project implemented two measures six-months after the project start date: 1) color-coded wristbands to identify those at fall risk and 2) involvement of security personnel as sitters after hours to detect/prevent falls for patients wandering in the hospital corridors.

Discussion

The implementation of the intervention (fall prevention bundle) at the ESHC was a learning experience. A significant reduction (30%) was observed in the inpatient fall rate before and after the intervention. However, caution is advised in interpreting this result due to the wide 95% confidence interval. This reduction also led to a substantial decrease in hospital costs, saving roughly $89000 in terms of prolonged hospital stay. These results demonstrate the potential for effective fall prevention strategies in clinical settings. The project outcomes aligned with the CDC developed the STEADI initiative ²⁸ and the World Guidelines for Falls Prevention ¹ in terms of comprehensive approach in inpatient fall reduction.

Since the post-pandemic era, the site has experienced increased patient volumes and acuity, most likely due to a 15% increase in the migrant population, the closure of a local Urgent Care Center, and a lack of access to primary care, ²⁹ forcing the site to operate at a 150% capacity. Each year, on average, 2017 fall-related injuries accounted for 33% of all injury-related emergency visits in Windsor-Essex County (the site's catchment area). ³⁰ Those hospitalized in Windsor-Essex from 2004–2013 for a fall-related injury spent an average of 13.0 days in the hospital, costing each patient $104,000 for their hospital stay. ³⁰ The average inpatient fall rate in Ontario hospitals was 7.98 per 1000 bed-days in 2016, ³¹ whereas the fall rate in our hospital was 16.25 falls per 1000 bed-days in 2023. In Canada, healthcare is decentralized and under the responsibility of each province and territory based on the organizational structure, resource allocation and payment mechanisms as they see fit, given their respective priorities. ³² The proportion of total health spending covered by the Canada Health Transfer (i.e., from the federal government) has fallen from an original 50% to about 23% in 2019. ³³ However, additional federal funding is available for lower hospital stay and readmission rates. ³²

Ontario healthcare facilities have adopted several fall reduction strategies ³⁴ over the years. However, the fact that fall-related injuries are still the leading diagnosis for hospital readmissions underscores the critical need for greater attention to transitional prevention strategies to avoid post-discharge falls.^3,11 Disability, chronic illness, functional limitation, and cognitive impairment have also been identified as factors for readmission,^35–38 which are separately associated with fall risk. No change in the 30-day readmission rate was noticed at the hospital, doubting the sustainable effect of this initiative. The possible limitation of this project was a non-existent coordinated and comprehensive fall prevention strategy at ESHC. For example, the need for a color-coded wristband and involvement of security personnel as sitters after hours were identified during the project. The results may have been different if those measures were in place from the beginning of the project. Moreover, not informing/connecting the patient's family members with community programs targeting fall reduction in cognitively impaired older adults was identified as another limitation of this project reflecting no change in the 30-day readmission rate.

The site's pharmacy department informed the research team that older patients also disproportionately use a higher number of prescription and non-prescription drugs, increasing the risk for adverse drug reactions and falls, echoing the published literature. ¹⁰ Large-scale studies consistently show that the risk of falls and fall-related injuries leading to hospitalization is practically double in older patients taking sedative-hypnotics. ³⁹ Falls can result in fear of falling, leading to anxiety, depression and reduction in activities, with a negative impact on general well-being, leading to repeated falls. ⁴⁰ Literature also shows that pharmacist-led medication counselling could reduce hospital readmissions by 48.3%.^41–43 Therefore, not providing a comprehensive medication review and counselling was identified as a limitation of the fall bundle intervention.

Further research with comprehensive medication counselling and post-discharge follow-up phone calls involving caregivers combined with fall screening and bundling may shed light on a sustainable effect of fall reduction.