Risk Management Pitfalls, Medico Legal, Medical Liability, Administration & Operations

Risk Management: Falls in the Emergency Department

Crowded, busy emergency departments seem susceptible to an increased risk of slip-and-fall accidents that keep administrators awake at night. But does the evidence bear out this assumption?

The literature reveals plenty of research on inpatient falls, outpatient falls, falls in geriatrics, and methods of preventing falls in geriatrics. However, there is little data on falls that actually occur in the emergency department. The vast majority of existing literature regarding falls in the ED has been developed and published in nursing journals, but corresponding articles have not filtered into the physician space.

As of 2013, between 700,000 to 1 million patients fall in U.S. hospitals each year.1 Because most of the literature aggregates all falls occurring in the hospital as a whole, it is hard to determine how many of these falls actually occur in the ED. A few studies have quoted fall rates anywhere from 0.152 to 0.2883 per 1000 patients, up to as high as 0.734 per 1000, prior to interventions.

Clearly, falling is bad for patients. It places them at risk for a multitude of injuries, from abrasions or contusions to fractures, head injuries, and even severe disability and death. According to the Joint Commission, 30-50% of falls result in injuries, leading to an average of 6.3 days in increased length of stay and about $14,000 in additional medical costs per admission.5

Analyzing falls in the ED can be a 2-step process. First, how do we identify who is at risk? Second, what do we do once we have identified them?

Identifying patients at risk for falls is harder than it sounds. Some patients are at risk in the short term, such as a patient who is intoxicated or influenced by mind-altering substances. Some patients, such as a demented elderly patient with gait disturbances, will always be considered a fall risk.

There are many fall risk assessment tools available; however, most were developed specifically for inpatient settings. Of all the studies, there are only two fall risk assessment tools that have been designed for the emergency department: the Memorial ED Fall Risk Assessment Tool (MEDFRAT)4 and the KINDER1 Fall Risk Assessment tool.6

The MEDFRAT tool was developed after a two-ED hospital system with a combined annual volume of 140,000 visits evaluated an inpatient tool called the Conley Fall Risk Assessment tool4. The researchers discovered that the inpatient tool identified a dismal 44% of patients who fell. This was consistent with the other inpatient assessment tool that has been evaluated for ED use, the Hendrich II Fall Risk Model evaluated by Terrell et al3 which identified 37% of patients at risk for falls in the ED.

MEDFRAT
The MEDFRAT tool was utilized to assess: confusion/disorientation, intoxication or sedation, impaired gait, use of assistive mobility devices, altered elimination, and history of fall in the past 3 months. The investigators used MEDFRAT for a one-year period with a total sample population of 91,190 patients, 18 years and older, for 110 falls (0.73 per 1000 patient visits). MEDFRAT still only properly identified 43% of patients at risk for falls. The demographics of the patients who fell were similar to previous study statistics with an average of 46 years of age, 62% male and 40% intoxicated. Statistics show 77% of patients who fell had no injuries, while 15% required wound repair, splinting, or radiographs. No patient required casting, traction, surgery, or consults. There were no deaths as a result of the falls. 

KINDER1
The second fall risk assessment tool developed for ED use and the better study was the KINDER1 study6. KINDER1 was developed at a Level 1 Trauma center with 96,000 patient visits per year. Risk factors assessed were age great than 70 years, presentation to the ED for fall, altered mental status for any reason including substance use, impaired mobility, and nursing judgement that patient is at risk for fall. If any one factor was present, the patient was considered a high risk for falls. Investigators retrospectively applied the tool to charts for an almost three-year period, during which time they had 150 reported falls. Of the 150 falls, only 35% had been identified as a fall risk by their previous inpatient tool. Applying KINDER1 retrospectively they identified an additional 49% of falls. In total, they were able to retrospectively identify 84% of the 150 patient falls. After implementation, the KINDER1 screening tool prospectively identified 73% of patients who subsequently fell.

The problem with fall risk assessment tools for the emergency department is the need to take into account that emergency departments are high volume with rapid through-put. Thus, tools should be short and easy to use. Physical Therapy and Physical Medicine and Rehabilitation have spent decades developing many different tests to determine fall risk, but they practice in very different environments from the emergency department, so their tools have been difficult to apply to patients in an ED setting.

Also of note, several fall risk tools give points for impaired gait but not necessarily enough points to automatically make them a fall risk in the emergency department. For example, another tool, which happens to be the one my department uses, is the Johns Hopkins Fall Risk Assessment Tool (JHFRAT)8. JHFRAT gives 2 points for unsteady gait and 2 points for needs supervision for mobility, transfer, or ambulation. It takes 6 points to make patients a moderate fall risk and 14 points to make them high risk. Logically, an impaired or unsteady gait should automatically place a patient at high risk for a fall.

It remains clear that existing tools are not optimal for identifying falls in the emergency department. While they seem to be improving with the development of emergency department focused tools, it remains that even the best study identified only 73% of falls when implemented prospectively. This leads me to believe we need more studies on how we can best identify fall risks in the emergency department.

The second component of our assessment shifts from identification of risk to management of it. At St. Joseph’s University Medical Center, a bundle of items was created to easily identify fall risk patients to any employee working with the patient. All items in the bundle are bright yellow. The bundle includes socks, blanket, a star to hang on the wall and a fall risk wristband. It also includes a sign-out sheet that goes with the patient to other departments. The sign-out sheet alerts transport and employees in other departments that the patient is a fall risk.

The original plan for my study was to compare number of falls before and after implementation of this bundle. However, this was where the study fell apart. There is different software for reporting incidents than our ED Electronic Medical Records (EMR) software so when we checked the falls reports, the incident reports did not always match up with the EMR. Those that were a match had suboptimal reports, often just documenting a fall without specifying what happened or whether there were injuries. In the ED record, there was not always documentation of the fall. One could assume that if the fall resulted in injuries or required that the patient received extra care, it would have been documented, but such assumptions do not make for good research. Thus this project met its end.

From the available literature evaluated, many hospitals are also taking extra precautions and are implementing fall risk prevention protocols similar to our yellow fall risk bundle. However, from the available literature it is unclear if these bundles actually make a difference. So once again, further studies are needed. We need to know once we identify these patients that our interventions are actually minimizing the risk of falls.

Acknowledgements: I would like to thank Richard E. Schultz, RN, CEN, MICN, who originally conceived this project, Marianna Karounos, DO, MS, for the hours attempting to make this work, and Chris Carpenter, who steered us in the right direction and kindly pointed out its flaws.


References

1. Agency for Healthcare Research and Quality. Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. Available online.
2. Dukes IK, Grant MK, Pathakji GS. Accidents in the accident and emergency department. Arch Emerg Med. 1990;7(2):122-124.
3. Terrell KM, Weaver CS, Giles BK, Ross MJ. ED Patient Falls and Resulting Injuries. J Emerg Nurs. 2009;35(2):89-92.
4. Flarity K, Pate T, Finch H. Development and implementation of the Memorial Emergency Department Fall Risk Assessment Tool. Adv Emerg Nurs J. 2013;35(1):57-66.
5. The Joint Commission. Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert. 2015.
6. Alexander D, Kinsley TL, Waszinski C. Journey to a safe environment: Fall prevention in an emergency department at a Level 1 trauma center. J Emerg Nurs. 2013;39(4):346-352.
7. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “get-up and go” test. Arch Phys Med Rehabil. 1986;67(6):387-389.
8. Johns Hopkins. Fall Risk Assessment Tool. Accessed March 7, 2018.
9. Harrington L, Luquire R, Vish N, Winter M. Meta-analysis of fall-risk tools in hospitalized adults. J Nurse Adm. 2010;40(11):483-488.
10. McCarty CA, Woehrle TA, Waring SC, Taran AM, Kitch LA. Implementation of the MEDFRAT to promote quality care and decrease falls in community hospital emergency rooms. J Emerg Nurs. 2018;44(3):280-284.
11. Southerland LT, Slattery L, Rosenthal JA, Kegelmeyer D, Kloos A. Are triage questions sufficient to assign fall risk precautions in the ED? Am J Emerg Med. 2017;35(2):329-332.
12. Townsend AB, Valle-Ortiz M, Sansweet T. A successful ED fall risk program using the KINDER 1 fall risk assessment tool. J Emerg Nurs. 2016;42(6):492-497.

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