ONLINE ONLY JANUARY 6, 2020—EDITORIAL

Shining a Light to Reduce Hospital Falls

Johns Hopkins University School of Medicine, Baltimore, Maryland.

F
all prevention strategies for hospitalized older adults rates, whereas two studies showed no difference in fall rates
include environmental factors such as adequate room among control and intervention groups. In the three studies
lighting and patient-specific factors such as medica- that demonstrated reduced fall rates, standardized fall risk as-
tions. In 2008, the Centers for Medicare & Medicaid sessments were used to identify patient-specific risks for falls.
Services (CMS) implemented a regulatory “shining of the light” Individualized care plans addressed gait and balance disor-
on hospital-acquired falls by eliminating hospital payment for ders, delirium and cognitive deficits, vision and hearing impair-
fall-related injuries. Shorr et al. found that implementation of ments, and toileting needs. For example, physical therapists
the CMS Hospital-Acquired Conditions Initiative was associat- provided instruction on the safe use of walkers for those with
ed with only a modest decline in falls and injurious falls over gait and balance disorders. Patients with delirium and cogni-
the first seven years, with the greatest reduction occurring in tive deficits received some form of staff alert of unsupervised
urban, teaching hospitals.1 These disappointing findings were transfers out of bed, ranging from bed alarms to customized
mitigated only by the finding that the prevalence of physical rubber socks that contained pressure alarms. All three success-
restraints decreased over the seven years of observation from ful intervention studies included patient-centered care plans
1.6% to 0.6%, suggesting that the modest reductions in falls did for toileting.
not occur at the expense of further restricting the mobility of None of the three studies that measured the secondary out-
hospitalized older adults. Shorr et al. concluded that falls may come of fall-related injuries demonstrated impact of interven-
be largely attributable to individual patient risk and may not be tions, although the rates of injurious falls were low in both the
prevented through health system quality and safety programs control and intervention groups (2%-5%).3-5
such as those that have achieved successes in never-events, Since the 2008 CMS policies eliminated hospital payments
including wrong-side surgery and catheter-associated blood for complications of falls, patient-centered models of fall risk
stream infections.2 The authors expressed concern that hos- reduction were widely implemented. The Systems Addressing
pital leaders remain in the dark regarding proven fall preven- Frail Elder (SAFE) Care, designed by Ansryan et al. includes
tion strategies. They question whether hospital-acquired falls nursing, social work, pharmacist, and medical provider assess-
are preventable without restricting the mobility of older adults ments.6 Team huddles occur daily to establish individualized
most at risk for falls. care plans, although as Shorr et al. highlight, without report
Hoff et al. found in their 2011 literature review of the first of outcomes.2 Nurses Improving Care for Healthsystem Elders
three years following implementation of the 2008 CMS hospi- (NICHE) is an New York University-based nursing education
tal payment polices limited evidence-based approaches to ad- and consultation program that has extended to 566 healthcare
dress falls as a spotlighted avoidable hospital-acquired condi- organizations.7 Factors that promote the adoption of organiza-
tion.3 Swartzell et al. reported that at some level, every patient tional interventions such as NICHE have been identified.8 The
admitted to an acute care hospital is at risk for falls. “Patients findings that NICHE is adopted more in larger, urban health-
sick enough to be in the hospital have underlying disease, are care systems are consistent with the findings reported by Shorr
receiving physiologically altering medications and treatments, et al. that fall rate reductions were greater in such hospital set-
and are likely experiencing pain, fatigue, anxiety, sleep distur- tings. Patient-centered care, although time-consuming, may
bance, and other symptoms that interfere with cognitive and promote staff satisfaction and is associated with reductions in
physical functioning. The key to preventing falls among hospi- other hospital-acquired conditions such as delirium.9
talized patients may lie in addressing how the hospital environ- Patient-engaged video surveillance systems are recent tech-
ment creates risk.”4 nological solutions to reduce falls. One staff monitors multiple
In 2017, Avanecean et al. published a systematic review patients for behaviors that risk falls such as unsupervised trans-
of randomized control trials on fall prevention in hospitals.5 fers out of bed. Staff can speak to a patient through the moni-
Three of five studies demonstrated 20%-30% reductions in fall toring system to request the patient to wait for assistance, while
the unit staff are alerted to the fall risk. Bedside caregivers can
activate virtual privacy screens during personal patient care.
Corresponding Author: Michele F. Bellantoni, MD, CMD; ; E-mail: mbellan1@ Shorr et al. appropriately call for studies to further illuminate
jhmi.edu; Telephone: 410-550-0888; Twitter: @MFBellantoni strategies to reduce hospital-acquired falls. A multihospital re-
Received: October 3, 2019; Revised: October 18, 2019; port of fall rates before and after the implementation of SAFE
Accepted: October 18, 2019 Care and NICHE would have sufficient scale to address the im-
© 2020 Society of Hospital Medicine DOI 10.12788/jhm.3345 pact of these patient-centered interventions on injurious falls.

An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine® Published Online Month 2020 E1
Bellantoni | Reducing Hospital Falls

Similarly, patient-engaged video surveillance systems need and fall-risk scores in an acute care setting using the Hendrich II fall risk mod-
el. Medsurg Nurs. 2013;22(3):180-187.
validation from clinical trials. 5. Avanecean D, Calliste D, Contreras T, Lim Y, Fitzpatrick A. Effectiveness of
patient-centered interventions on falls in the acute care setting compared
to usual care: a systematic review. JBI Database System Rev Implement Rep.
Disclosures: Dr. Bellantoni has nothing to disclose. 2017;15(12): 3006-3048. https://doi.org/10.11124/JBISRIR-2016-003331.
6. Ansryan LZ1, Aronow HU, Borenstein JE, et al. Systems addressing frail el-
der care: description of a successful model. J Nurs Adm. 2018;48(1):11-17.
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