Research has shown that in-hospital falls can increase morbidities and complications, prolong hospitalizations, and increase healthcare costs. In-hospital falls are problematic for surgeons too because they can lead to wounds bursting open, meaning that patients may require revision surgery or develop wound infections. Although it has been surmised that orthopedic surgeries can put patients at risk for in-hospital falls, few studies have evaluated the risk for these falls in this particular patient group.
New Research on In-Hospital Falls
In the June 2012 Journal of Arthroplasty, my colleagues and I studied in-hospital falls in patients undergoing orthopedic procedures in greater depth using data from AHRQ’s Nationwide Inpatient Sample. The database provides information on nearly 20% of all hospitalizations in the United States. It allows for the appropriate study of relatively rare events—such as in-hospital falls— surrounding surgery.
“Our study data can also be used to design or fine tune in-hospital fall prevention programs.”
We analyzed data between 1998 and 2007 in patients who had undergone a total hip or knee replacement. The rate of patients who fell during in-hospital recovery was 0.85% for the study period, but the rate increased over time, jumping from 0.4% to 1.3% during the 10-year period. This suggests the problem may be growing, perhaps because of more mandatory reporting protocols or because this patient population is getting sicker, which can increase fall risks.
An important aspect of our study was to identify characteristics that put patients at greater risk for in-hospital falls. Patients were more likely to fall if they were male, older, belonged to a racial minority, or underwent a revision joint replacement surgery. Patients were also at risk if they had certain comorbid conditions, including:
Congestive heart failure.
A clotting or bleeding disorder.
Electrolyte or fluid abnormalities.
Recent weight loss.
Pulmonary circulatory disease posed the greatest risk for falls after total hip or knee replacement. Postoperative complications (eg, DVT, pulmonary embolism, and adult respiratory distress syndrome) were also associated with higher fall rates, but it’s unclear if they were the reason for or the consequence of the fall. Obesity, hypothyroidism, uncomplicated diabetes, and cancer were not associated with an increased risk of falling.
Taking Precautions to Decrease Falling Risk
Findings from our study can assist perioperative physicians caring for orthopedic patients by providing them with information about which patients should be considered at risk for in-hospital falls after surgery. This can then be used to take precautions postoperatively when patients are recovering. For example, falls often occur after surgery when patients need to go to the bathroom, but it would probably be unreasonable to put staff members in every room to help with this task. However, it would be feasible to identify smaller groups of patients who are at risk and focus our efforts and attention on those individuals.
Our study data can also be used to design or fine tune in-hospital fall prevention programs. We now have a smaller patient population for which to target interventions. At-risk patients can be given bracelets to increase awareness among staff so that they more carefully watch them for falls. Patients can also be educated about their risk of falling and instructed on how they can prevent falls. Considering the growing prevalence of this preventable problem, efforts to spot patient factors associated with falls may go a long way toward reducing the burden of these events.
Readings & Resources (click to view)
Memtsoudis SG, Dy CJ, Ma Y, et al. In-hospital patient falls after total joint arthroplasty: incidence, demographics, and risk factors in the United States. J Arthroplasty. 2011 Nov 22 [Epub ahead of print]. Available at: http://www.sciencedirect.com/science/article/pii/S0883540311005584.
Clarke HD, Timm VL, Goldberg BR, Hattrup SJ. Preoperative patient education reduces in-hospital falls after total knee arthroplasty. Clin Orthop Relat Res. 2012;470:244-249.
O’Malley NT, Blauth M, Suhm N, Kates SL. Hip fracture management, before and beyond surgery and medication: a synthesis of the evidence. Arch Orthop Trauma Surg. 2011;131:1519-1527.
Sletvold O, Helbostad JL, Thingstad P, et al. Effect of in-hospital comprehensive geriatric assessment (CGA) in older people with hip fracture. The protocol of the Trondheim Hip Fracture Trial. BMC Geriatr. 2011;11:18.
Johal KS, Boulton C, Moran CG. Hip fractures after falls in hospital: a retrospective observational cohort study. Injury. 2009;40:201-204.
Schwendimann R, Bühler H, De Geest S, Milisen K. Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program. BMC Health Serv Res. 2006;6:69.