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FALLS PREVENTION AND MANAGEMENT—THE HOSPITALIST’S OPPORTUNITY

Key Clinical Questions

  • image Why is prevention of falls and management important in hospitalized adults?

  • image How can the hospitalist identify the patient at risk of falling with injury?

  • image What assessment can be performed at the bedside to identify patients at high risk for falling in hospital?

  • image What interventions reduce the incidence of falls and injuries?

  • image What is the bedside approach to the fallen patient?

CASE STUDY

An 85-year-old woman was admitted to the hospital 2 days ago after suffering a fall complicated by a left proximal humerus fracture. She subsequently fell in her hospital room after she stood from the bed and leaned forward to answer the phone located on the bedside table just out of her reach. She struck her forehead on the corner of the bedside table and twisted her right arm which she was using to grasp the bedrail and steady herself. Nurses report that she has been delirious, with episodes of restlessness and frequent attempts to get out of bed. Her past history includes macular degeneration in the left eye, osteoporosis, hypertension, mild cognitive impairment and recurrent falls at home. At the time of the fall in the hospital, her medications included: trimethoprim/sulfamethoxazole for a urinalysis suggestive of urinary tract infection; metoprolol for hypertension and irregular heart rhythm; calcium carbonate with vitamin D; subcutaneous enoxaparin for prophylaxis against thromboembolism; aspirin; hydrocodone for severe shoulder pain; and trazodone for sleep. The previous night she received 50 mg orally of quetiapine because of her restlessness and calling out for help.

At the bedside, this patient is awake, crying for help, lying prone on the floor by the bed and with her left arm in a sling under her. She has a bleeding laceration that will require suturing over the right zygomatic bone and a large hematoma forming over her right eye. She tells you her right hand and arm hurt.

This case illustrates risk factors for falls as well as common risk factors contributing to an in-hospital fall with injury (Table 87-1). Hospitalists have opportunities to improve the quality of patient care so as to reduce the risk for subsequent falls and fall-related injuries. This chapter provides a framework for efforts to prevent future falls and injuries and for the hospitalist’s targeted evaluation of the fallen patient.

Falls are the most common type of adverse event in acute care hospitals. Estimates suggest that 700,000 to 1 million falls occur in hospitals each year. Defined as an unplanned descent to the floor, the ground or any lower level, a fall may be further classified as injurious or noninjurious. A fall is considered injurious if it results in any injury (such as bruising or fracture) that leads to reduced physical function and an evaluation by a health care professional. An injurious fall is further characterized by the severity of injury or level of harm brought about by the fall ...

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