Patients Don't Bounce: Preventing Patient Falls in Ambulatory Settings

By Dale A. Arroyo, RRT, BS, CPHQ, Patient Safety Specialist

Patients at your organization can and will fall. A patient fall can be a life changing event with the potential for serious harm or death as a result.

By implementing an effective fall prevention program, your organization can prevent patient harm and meet new Centers for Medicare and Medicaid Services (CMS) requirements.

Some statistics about falls indicate how serious they can be:

It is estimated that one in three people over the age of 65 experience a fall at least once a year (CDC, 2008). Falls are the leading cause of injury-related deaths and nonfatal injuries in persons over the age of 65.
In the year 2000 alone, falls resulted in nearly 12,000 hospitalizations and 400 deaths among Washington residents age 65 or older. By comparison, fewer than 3,000 hospitalizations statewide resulted from motor vehicle occupant injuries for all ages combined.
Falls are a high cost health care problem in our state. The public pays a very high proportion of these costs. In 1999, Medicare alone paid $68.6 million to treat fractures among Washington’s population age 65 or older. Nearly all of these fractures were due to falls.

CMS requires centers to review risk

A new requirement by the Centers for Medicare and Medicaid Services (CMS) requires all community health centers to provide a detailed review of fall risk for all patients who are Medicare members 65 years of age or older. This requirement falls under the category of Managing Chronic Conditions, which includes how often members with different conditions get certain tests and treatments that help them manage their condition.

Your organization will be rated under the Star system. The Star rating will be based on the percent of patients who had a fall or had problems with balance or walking in the last 12 months (denominator), and who were seen by a practitioner in the past 12 months and who received fall risk intervention from their current practitioner (numerator).

The focus for fall prevention for many years has been on patients who are in an inpatient status. Very little research-based evidence is available that outlines effective ambulatory fall prevention programs. Don't let that fact discourage you from creating your own program tailored to your needs. I personally was involved in a tailored made program for a large ambulatory cancer care center in Seattle. Many of the approaches we used had very little costs involved and proved to be very effective.

New emphasis on fall prevention for ambulatory patients

An effective program must include an assessment of your patient. Table 2 summarizes the intrinsic and extrinsic factors that contribute to patient falls. The list is far from being all inclusive.

Medication management is a key component in fall prevention. During the annual required visit and assessment, providers should work with pharmacy to evaluate the risk to patients who take any of the class of medications listed. Other medications to consider include pain management (narcotics) and diuretics.

Table 2: Factors Contributing to Falls

Intrinsic Factors Based on individual or disease state	Extrinsic Factors Environmental and safety issues
Physical function: Poor vision, muscle weakness, dizziness	Wet or slippery floor
Problems with bladder and/or bowel control	Equipment in the way
Altered mental status (confused or disoriented)	Object on the floor
Gait and/or balance problems	Cane, walker, or crutches out of reach
Previous history of falls	Inadequate lighting in the room
Medications: Antihypertensives, psychotropic, antiepileptics, sedatives and hypnotics, polypharmacy	Poor footwear (nonsupportive, slippers, ill-fitting)

Other simple ways to perform assessments include:

The Timed Up & Go Test (developed by NCPS). Patient is asked to get up from a seated position, walk around a visible object 8 feet away, and sit back down. Times greater than 8.5 seconds are associated with high fall risk.
Front desk observation. Front desk staff are vital. When a patient is called, front desk staff can observe if the patient uses an assistive device, has oxygen or other medical equipment in tow, or is unsteady on their feet.
Footwear observation. Patient footwear such as high heels, open-heeled shoes (such as clogs), or flip-flops all place the patient at higher risk of falling, regardless of age. Patients should be educated on wearing sensible shoes to their appointments.

Simple fall prevention interventions

Interventions for ambulatory patients include:

Provide patient escorts. Staff can escort patients identified as high fall risk to help them navigate through their appointments.
Reduce environmental risks. Ensure that the clinic floors are clean but not wet. Replace worn or torn flooring. Keep hallways and waiting areas free of clutter.
Observe waiting areas. Monitor for children who are unattended.
Educate staff. After deciding upon prevention strategies, give staff appropriate education and training.
Educate patients. Give patients free materials. (See Resources.) Staff can explain the material to patients with literacy issues.
Check for home safety. One-third of adults age 65 or older who live in their own homes fall at least once in a year; 50 percent or more of those age 75 or older will fall. To feel more confident and secure, patients should check their home for safety and make an improvement plan using tools provided by the Washington State Department of Health.

Falls can cause serious to life-threatening injuries. However, people can take steps at home or in a health care facility to reduce their risk of falling. Free materials are available to help patients and health care staff reduce risk: See Resources.

Remember: Our patients aren’t made of rubber and won’t bounce when they fall!