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].
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].
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.
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].
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.
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].
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].
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].
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].
