REDUCING F ALLS AND F ALL-RELATED
INJURIES IN ACUTELY AND CRITICALLY
ILL P ATIENTS
Clinical Evidence Review
By Margo A. Halm, RN, PhD, ACNS-BC, and Patricia A. Quigley, PhD, MPH, ARNP, CRRN
F
alls are a major public health problem around
the world, and are the number 1 adverse event
in the hospital. From 3% to 20% of inpatients
fall at least once, with injury prevalence ranging from
30% to 51%.
1
Of these, 6% to 44% experience simi-
lar injuries such as fractures, subdural hematomas, or
excessive bleeding that may cause death. Certain to
affect morbidity and mortality, injury falls are “never
events” that also cut reimbursement. Adjusted to
2010 dollars, a fall without serious injury costs an
additional $3500, whereas 2 or more falls without
serious injury cost $16 500. Falls with serious injury
are the costliest, with additional costs of $27 000.
2
Interventions to prevent falls and fall-related
injuries require multidisciplinary support for program
adoption and reliable implementation for specific
at-risk and vulnerable subpopulations, such as frail
elderly persons and those at risk for injury. The pur-
pose of this clinical evidence review is to address the
effects of fall and injury risk assessment and targeted
interventions on fall and injury rates in acutely hos-
pitalized patients.
Methods
The search strategy involved CINAHL and
MEDLINE with the following key words: falls, fall
prevention, injury prevention and reduction, acute and
critical care. The search was limited to the past 10
years. All forms of evidence were considered.
Results
Eleven reports focused on in-hospital fall pre-
vention in a variety of settings (medical/surgical, neu-
rological, geriatric, all units). The reports included 1
A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced
in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an
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meta-analysis, 2 randomized controlled trials, 2
observational studies, and 6 quality improvement
studies. The interventions to prevent falls that were
evaluated are noted in Table 1. Fall metrics were
assessed in the studies for periods from 6 months
to 5 years.
The meta-analysis
9
did not reveal significant
reductions in fall-associated metrics (level A evidence
in Table 2). However, examination of the results of
individual studies shows that the fall rate per 1000
patient-days decreased in 4 studies,
6,8,12,13
including
1 study with older patients.
13
The relative risk of
falling was reduced by 23% to 29% in 2 studies.
4,8
Significant reductions were also realized in the injury
rate in 2 studies.
6,10
Other investigators found a
reduction in both minor and serious injuries, includ-
ing fractures.
3,5,7
Collectively, these findings represent
level B-C evidence (Table 2).
Recommendations for Practice
Falls are rare events in progressive and critical
care settings owing to higher patient acuity and
staffing ratios. However, falls do still occur and are
devastating to patients, their families, and nurses.
Nurses manage competing priorities for these
patients, dealing with medically acute conditions
and unexpected acute/emergent situations and
complications while ensuring the patient’s safety.
These safety needs include protecting patients from
falls and fall-related injuries, and nurses must be
sensitive to the geriatric population.
15
The Ameri-
can Association for Critical-Care Nurses’ scope and
standards document
16
provides the framework for
specialty practice and these fall prevention practice
recommendations: assessment, diagnosis, out-
comes management, planning, implementation,
and evaluation.
©2011 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2011606
480 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2011, Volume 20, No. 6 www.ajcconline.org
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