Falls in older adults are often serious, resulting in functional decline, reduced quality of life, loss of independence and in severe cases, even death (Rubenstein 2019).
While about 75% of injury-related hospitalisations among older adults (over 65) are caused by falls, hospitalisation is also a major falls risk factor in itself (Roo, Johnston & Petersen 2015; WA DoH 2014).
Falls are among the most common clinical incidents, with the risks only increasing the longer the patient remains in acute care - sometimes even for patients who were not initially at risk of falling (WA DoH 2014).
As a result, older people are also at significant risk of falling post-discharge. It is estimated that about 40% of older adults fall within six months of discharge, with 50% of these incidents resulting in injury (Said et al. 2016).
Despite these alarming statistics, most falls are preventable. In order to prevent post-discharge falls and avoid hospital re-admission for falls injuries, it is important for healthcare staff to provide appropriate education to patients and implement falls-prevention strategies as part of discharge planning (Roo, Johnston & Petersen 2015).
Generally, falls occur due to a combination of both intrinsic (personal) and extrinsic (environmental) factors. The more risk factors that are present, the more likely the patient is to fall (Clay, Yap & Melder 2018). Some common risk factors include:
Intrinsic risk factors
Extrinsic risk factors
Prior history of falls
Acute or chronic illness
Delirium, disorientation or confusion
Use of mobility assistance
Fear of falling
Bathroom location and accessibility
Cords and tubing
Lack of communication with staff
Unfamiliarity with environment
Length of hospitalisation
Time of day
(Clay, Yap & Melder 2018; ACSQHC 2009; Canadian Patient Safety Institute 2015)
Some of these risk factors are static, such as age or baseline health, but hospitalisation may cause additional risk factors to arise or existing risk factors to worsen. (Clay, Yap & Melder 2018). Some examples include:
New or modified medicines or polypharmacy;
New cognitive impairment, or exacerbation of an existing cognitive impairment;
Disorientation due to the unfamiliar and complex acute care environment;
Incontinence or constipation;
Changes to mobility or bathroom habits due to unfamiliar acute care environment;
Malnutrition or dehydration; and
Mobility aids being misplaced during transit.
(WA DoH 2014; Clay, Yap & Melder 2018)
Reducing Post-Discharge Falls Risk
Managing falls risk requires a multifactorial approach that addresses the patient’s modifiable risk factors (Clay, Yap & Melder 2018).
Using an appropriate and validated falls risk assessment tool, vulnerable patients should be identified and appropriate interventions should be put into place. It is likely that multiple solutions will need to be implemented in order to target several individual risk factors (Clay, Yap & Melder 2018).
The Discharge Process
Discharge has been identified as a vulnerable and unsafe stage of the care process due to its complicated and challenging nature (Waring, Marshall, Bishop et al. 2014).
Your communication and planning with the client should be clear and comprehensive during discharge. It is important to ensure the patient and their family understand the implementations and strategies that have been discussed. The patient should be encouraged to maintain physical activity and any fear of falling should be addressed, as this can hinder their recovery (VIC DoH 2015).
You should also ensure that falls prevention is presented to the patient as a means of staying independent, as this will encourage engagement. It is beneficial to involve the patient in the discussion and decision-making process to ensure interventions meet the patient’s preferences and interests (ACSQHC 2009).
The patient’s general practitioner and other relevant services should be provided with documentation about the patient’s falls risk and any strategies that have been implemented. You may need to refer the patient to a speciality falls service for ongoing management (VIC DoH 2015).
It is also important to ensure the patient is discharged to an appropriate location. While some patients are able to return home following discharge, others may require ongoing care and will need to be transferred to another facility. A comprehensive assessment is required in order to determine the appropriate setting for the patient, taking into account their cognitive status, functional ability, decision-making capacity and other factors (Alper, O’Malley & Greenwald 2020).
It is important to note that upon returning to the community or an aged care facility, patients will have a new baseline risk of falls. This is due to the biological, behavioural, social and environmental changes that may have occurred in response to being hospitalised.
Data from 2010 to 2012 indicated that 48% of older adult fall hospitalisations in Victoria were for injuries that occurred in the home, while 22% were due to incidents that occurred at residential facilities. These accidents most commonly occurred in outdoor areas, bathrooms, bedrooms and kitchens (Stathakis, Gray & Berecki-Gisolf 2015).
While acute care staff play an important role in addressing falls risk during hospitalisation and discharge, keep in mind that this responsibility is transferred to community healthcare staff and the patient themselves once the patient has returned home or to a residential facility (Hill et al. 2017).
The following are some universal precautions that healthcare staff can take to reduce falls risk once patients return to their home or residential facility:
Ensure effective communication between staff;
Ensure the patient is familiar with their environment;
Ensure the patient knows how to use any call lights or alert devices;
Ensure personal belongings such as glasses are in reach;
Answer call lights as soon as possible so that the patient does not need to ambulate unnecessarily;
Keep the floors clean, dry and free of clutter, and clean any spills as soon as possible;
Use bright lighting and nightlights to increase visibility;
Encourage the patient to wear non-slip footwear;
Keep the patient’s bed at an appropriate height (their feet should be able to touch the floor with their hips, knees and ankles at a 90-degree angle) and lower it while they are resting;
Keep bed and chair breaks on;
Mobilise the patient at least two times per day;
Ensure toileting is safe and regular;
Ensure patients know how to use mobility and assistive devices;
Avoid restrictive practices;
Establish a bowel and bladder function care plan;
Consider frequent vital sign observations;
Ensure patients and staff are properly informed about any medicines, including instructions, dosage and any side effects; and
Ensure the patient is not taking unnecessary medicines.
(Performance Health 2019; ACSQHC 2009; Canadian Patient Safety Institute 2015)
Depending on their individual risk factors, patients may require specific interventions in addition to universal precautions. Some examples include:
Modifiable risk factor
Fear of falling
Encourage the patient to verbalise their feelings
Encourage the patient about their capabilities and strengthen their self-efficacy for ambulation
Regular monitoring of the patient’s cognitive status
Implement a behavioural approach
Strength or balance impairment
Strength and balance training
Provide assessment and referral if necessary
Ensure aids or devices are being used and are suitable
Ensure frequently-used items are in a consistent place
Incontinence and toileting issues
Individual bladder/bowel management plan
Encourage adequate fluids and fibre
Laxatives, if required
Urinal bottle or commode chair
Poor hydration or nutrition
Referral to dietitian
Address reasons for poor food or fluid intake
Modify medicines if necessary (upon review)
Switch, decrease or stop medicines if necessary (upon review
Modify or remove hazards
Review bed rails
Adjust bed and bedside table height
Provide clocks or calenders
Use personal belongings to make the patient’s space familiar
(Canadian Patient Safety Institute 2015; WA DoH 2018)
Barriers to Post-discharge Falls Prevention
Despite their heightened vulnerability post-discharge, some older adults have been found to lack awareness of their own falls risk or the effectiveness of prevention strategies. Others engage with and acknowledge prevention strategies but encounter unexpected issues such as difficulty taking medicines, pain or poor diet.
Furthermore, while patients often respond positively to tailored education, there is a lack of evidence suggesting that education on its own is enough to reduce post-discharge falls risk (Naseri et al. 2018).
Some other identified barriers include:
Patients with a high falls risk not receiving a comprehensive risk assessment;
Lack of accurate handover of the patient’s falls risk during discharge;
Failure to assess certain risk factors, preventing the corresponding strategies from being implemented;
Risk-taking behaviour being undertaken by older adults in an effort to maintain independence; and
Lack of conversations between patients and community healthcare staff about falls risks.
(Said et al. 2016; Hill et al. 2017)
Falls occur due to an intersection of intrinsic and extrinsic risk factors, many of which develop with age. Hospitalisation is likely to worsen these risk factors and create new ones, compounding the risk further.
Therefore, it is crucial to address and modify these risk factors both during hospitalisation and upon discharge so that the patient does not fall and severely injure themselves after returning to the community.
Hill et al. 2017, ‘Reducing Falls After Hospital Discharge: A Protocol for a Randomised Controlled Trial Evaluating an Individualised Multimodal Falls Education Programme for Older Adults’, BMJ Open, vol. 7 no. 2, viewed 12 August 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5293998/
Naseri et al. 2018, ‘Impact of Tailored Falls Prevention Education for Older Adults at Hospital Discharge on Engagement in Falls Prevention Strategies Postdischarge: Protocol for a Process Evaluation’, BMJ Open, vol. 8 no. 4, viewed 12 August 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914781/
Waring J, Marshall F, Bishop S, et al. 2014, 'An Ethnographic Study of Knowledge Sharing Across the Boundaries Between Care Processes, Services and Organisations: the Contributions to ‘Safe’ Hospital Discharge', NIHR Journals Library, viewed 12 August 2020, https://www.ncbi.nlm.nih.gov/books/NBK259995/