Study Points

Falls and Fall Prevention

Course #91660 - $18-

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. How many falls severe enough to require medical attention occur worldwide each year?

    EPIDEMIOLOGY

    Falls and fall-related injuries are common worldwide and have the heaviest impact in low-income communities and communal settings with a preponderance of older adults. Falls can cause severe injury such as hip fractures and head trauma. Among older adults, injurious falls may heighten the risk for further loss of mobility and early death. The World Health Organization estimates that 37.3 million falls severe enough to require medical attention occur each year and notes that falls are the second leading cause of unintentional injury deaths worldwide, after road traffic injuries [7]. Because the number of falls is so high, the resultant loss of disability-adjusted life years (DALYs) is significant—more lives lived with disability than results from transport injury, drowning, burns, and poisoning combined [7]. Not only is the individual economic burden related to falls and fall injuries increasing, healthcare system costs have skyrocketed. Approximately 40% of the total DALYs lost due to falls globally occurs in children [7].

    Click to Review
  2. What are DALYs?

    EPIDEMIOLOGY

    Falls and fall-related injuries are common worldwide and have the heaviest impact in low-income communities and communal settings with a preponderance of older adults. Falls can cause severe injury such as hip fractures and head trauma. Among older adults, injurious falls may heighten the risk for further loss of mobility and early death. The World Health Organization estimates that 37.3 million falls severe enough to require medical attention occur each year and notes that falls are the second leading cause of unintentional injury deaths worldwide, after road traffic injuries [7]. Because the number of falls is so high, the resultant loss of disability-adjusted life years (DALYs) is significant—more lives lived with disability than results from transport injury, drowning, burns, and poisoning combined [7]. Not only is the individual economic burden related to falls and fall injuries increasing, healthcare system costs have skyrocketed. Approximately 40% of the total DALYs lost due to falls globally occurs in children [7].

    Click to Review
  3. Of falls that result in injury severe enough to require medical attention, what proportion require treatment for fracture?

    EPIDEMIOLOGY

    As noted, falls are a common occurrence in the frail older adult population, causing injuries that may result in disability, institutionalization (e.g., long-term care facility admission), or even death. Older adults are particularly prone to falling because of age-associated, gradual onset of lower body muscle weakness, disturbances of gait, and balance deficits. More than 14 million, or 1 in 4, older adults in the United States report falling every year. About 30% of falls result in injury severe enough to require medical attention; of these, approximately 50% require treatment for bone fracture. The most common skeletal fracture sites are the hip, spine, forearm, leg, pelvis, arm, and hand. Hip fractures from falling occur at the rate of about 1 per 100 falls in older adults, a serious complication that requires hospitalization, surgery, and often results in long-term disability. Even in the absence of injury, many older people who fall then develop a fear of falling, which may prompt additional restriction of physical activity, leading to further loss of physical fitness and agility, thereby increasing the risk of falling.

    Click to Review
  4. Pediatric falls are the

    EPIDEMIOLOGY

    Among those 19 years of age or younger, falls are the most common cause of nonfatal injuries each year. Children younger than 6 years of age have the highest proportion of visits for falls, with 1.2 million emergency department visits per year [13]. Falls threaten the safety of children, and they are fourth among causes of unintentional death in children and adolescents. There is concern that childhood falls are under-reported events in health institutions [27].

    Click to Review
  5. What are the three main categories of falls?

    TYPES OF FALLS

    Falls are defined by the World Health Organization as "events that result in a person coming to rest inadvertently on the ground, floor, or other lower level" [7]. Falls can be categorized into three types: physiological anticipated, physiological unanticipated, and accidental. It is important that the types of falls and risks of falling, whether living at home or residing in healthcare facilities, are well understood so appropriate fall prevention measures can be undertaken [9]. Fall prevention strategies designed for community-dwelling persons and healthcare facility inpatients and residents will be discussed later in this course.

    Click to Review
  6. According to the Joint Commission, a sentinel event is best characterized as a/an

    FALL INJURIES AND REIMBURSEMENT

    The Joint Commission (TJC) published a sentinel event alert to assist in preventing falls and fall-related injuries in healthcare settings. A sentinel event is "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof" [10]. Falls resulting in serious injury or death are among the top 10 sentinel events reported to TJC. Of the 465 falls reported to TJC between 2009 and 2015, 63% resulted in death, while the remaining 37% resulted in injuries only [11].

    Click to Review
  7. When did falls become part of the CMS "no-pay" policy?

    FALL INJURIES AND REIMBURSEMENT

    Reimbursement to hospitals and long-term care facility for costs related to fall injuries is no longer covered by the Centers for Medicare and Medicaid Services (CMS) as of 2008 [16]. However, CMS does reimburse for fall risk assessments and fall prevention programs. Falls were not originally included in the CMS no-pay policy, and the addition of falls to the policy was originally questioned due to lack of supporting evidence of fall prevention efficacy. However, the decision was made to add falls to the no-pay policy in hopes of increasing research efforts to further prevent falls. The CMS has stated, "…we believe these types of injuries and trauma should not occur in the hospital, and we look forward to…identifying research…that will assist hospitals in following the appropriate steps to prevent these conditions from occurring after admission" [17].

    Click to Review
  8. Which of the following is an intrinsic fall risk factor?

    FALL RISKS

    Personal fall risks can be organized into two categories: those associated with environmental (extrinsic) hazards and those related to age, general health, and mobility (intrinsic factors). Extrinsic factors include poor lighting, lack of personal ambulation aids (if needed), loose carpets, slippery floors, low objects (e.g., low toilets), steps, cords, or improper footwear. Intrinsic factors are those associated with aging, intoxication, and/or chronic disease, such as weakness, disturbances of gait and balance, declining vision, and medication side effects. Examples of intrinsic factors that lead to an increased risk of falling are gait abnormalities associated with Parkinson or vestibular diseases; bradycardia from beta blockers; drowsiness associated with sedative medication; reduced visual acuity from retinopathy or cataracts; hypotension (postural, medication induced, or hypovolemic); delirium and orthostatic instability related to acute infection and febrile states; and general loss of functional capacity associated with aging [2,12].

    Click to Review
  9. For inpatients or residents, fall risk assessment and preventive interventions should start

    FALL RISK SCREENING, ASSESSMENT, AND INTERVENTION

    Fall risk assessment and preventive interventions should start at initial admission to the hospital or long-term care facility. Within hospitals, bed alarms, sitters, and physical restraint orders have been used in the past to reduce the likelihood of patients falling [17]. However, restraints have been noted to pose an increased risk for severe injury (and aspiration) and are used only very rarely. Restraints must have 1:1 observation and a physician order [28]. While employing a bedside sitter seems a reasonable precaution, one study found that evidence is inconclusive whether the presence of a sitter decreases the number of falls [16].

    Click to Review
  10. Which of the following tasks is the responsibility of the STEADI safe mobility champion?

    FALL RISK SCREENING, ASSESSMENT, AND INTERVENTION

    SUGGESTED TASKS FOR SAFE MOBILITY AND FALL PREVENTION PROGRAM TEAM MEMBERS

    Team MemberSuggested Tasks
    STEADI safe mobility champion (from any profession)
    Proactively encourage early mobilization of patients to reduce fall risks during hospitalization
    Work with team to incorporate the safe mobility and fall prevention program into the patient care workflow
    Work with available unit-based or hospital educators to establish a training program for current and future employees
    Be available to troubleshoot issues during implementation
    Provide feedback to team members
    Monitor and report results of program implementation
    Communicate with hospital leadership about the program
    Assign and train staff to discuss fall prevention strategies with patients and caregivers
    Nurse and/or certified nursing assistant
    Screen patients for fall risk using a screening tool (e.g., Stay Independent checklist, three key questions, STRATIFY Risk Assessment Tool)
    Perform gait testing (e.g., Timed Up and Go Test, 30-Second Chair Stand Test, or 4-Stage Balance Test)
    Check orthostatic blood pressure
    Educate patients about orthostatic hypotension and related fall risk
    Discuss fall prevention strategies with patients and caregivers
    Perform vision assessment (e.g., Snellen eye chart)
    Counsel about using single distance lenses when walking outside (e.g. avoid bifocals)
    Assess feet and footwear
    Conduct cognitive assessment (e.g., Mini-Cog)
    Ensure each patient has optimal independence in instrumental activities of daily living (IADLs) and activities of daily living (ADLs) during hospital stay
    Mobilize patient at least three times a day as tolerated
    Give patient appropriate STEADI patient educational materials
    Follow up during their hospital stay to ensure patients are making progress as part of fall prevention care plan
    Physician, nurse practitioner, physician assistant, clinical nurse specialist
    Take a fall history, including circumstances of previous falls
    During physical exam include an observation of gait to identify medical issues that could increase fall risk (e.g., cardiac or neurologic disease)
    Review results of fall risk assessments performed by other team members
    Avoid prescribing and manage medications that increase fall risk (collaborate with pharmacists)
    Order appropriate labs and imaging specific to fall risk
    Recommend and provide referrals specific to fall risk
    Discuss fall prevention strategies with patients and caregivers
    Engage patients and caregivers in developing and implementing individual fall prevention care plans
    Avoid issuing bed rest orders or discontinue them as soon as not clinically indicated
    Discontinue tethers (IV lines, urinary catheters, etc.) as soon as not clinically indicated
    Recommend community exercise or fall prevention programs
    Pharmacist
    Review medications to identify those that increase fall risk
    Notify safe mobility and fall prevention program team of any medications that might increase fall risk and set up alerts to providers for those medications
    Make recommendations for dose reduction or safer alternatives for medications that increase fall risk
    Raise awareness about medication-related fall risks
    Discuss fall prevention strategies with patients and caregivers
    Physical therapist
    Assess or inquire about baseline functional status
    Discuss fall prevention strategies with patients and caregivers
    Perform detailed gait and balance testing
    Design a rehabilitation care plan or exercise program to improve mobility and balance during hospitalization
    Educate patients about community-based fall prevention programs, such as tai chi classes or Stepping On
    Occupational therapist
    Discuss fall prevention strategies with patients and caregivers
    Educate patients about home trip hazards (e.g. throw rugs, stairs)
    Recommend fall prevention safety features (e.g., grab bars, lighting, railings)
    Educate patients and caregivers about behavioral and functional changes that impact fall risk
    Click to Review

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.