Patient falls pose a significant risk in hospitals, resulting in bone fracture, traumatic head injury and visceral organ contusion, among other serious complications.
“Implementation of preventive strategies for in-hospital falls is an important issue in health care,” said Colleen R. Walsh, DNP, RN, president of the National Association of Orthopaedic Nurses and clinical assistant professor of nursing at the University of Southern Indiana, in Evansville. “By identifying at-risk patients, utilizing concepts of safe patient handling and encouraging communication between providers, we can reduce falls, along with hospital length of stay and medical expenses.”
Speaking at the 2017 Interdisciplinary Conference on Orthopedic Value-Based Care, she noted that the most important step in falls prevention is identification of at-risk patients. Patients older than 65 years of age and those with poor functional status before surgery (American Society of Anesthesiologists physical status ≥III) are at increased risk.
“Nutritional status is important, too,” she said. “Low protein and albumin levels are contributing factors.”
Chronic conditions, such as arthritis, diabetes, stroke, Parkinson’s disease, incontinence and dementia, also increase the likelihood of falls. “Recognizing early signs of delirium and intervening quickly can minimize risk.” Toileting needs may play a role as well. “A Foley catheter for the first 12 to 13 hours may decrease this risk, but the literature indicates that most patients fall after that 24-hour period,” she observed.
Opioid-Naive Versus Opioid-Tolerant Pathways
Although clinical pathways are commonly used within total joint replacement programs, there are dangers in assuming a one-size-fits-all approach, according to Dr. Walsh.
“Pathways are great for standardization and data collection, but should be modified and individualized for each patient,” she said. “There need to be adequate opportunities for health care providers to use narratives to discuss patient or pathway variances.”
In opioid-naive patients, for example, it is critical to monitor response to medications. “Don’t assume that restlessness indicates pain. Restlessness may be a result of medications given to prevent pain.”
In opioid-tolerant patients, on the other hand, preoperative assessment and planning is required and needs to be individualized to the patient. Postoperative agitation due to inadequate pain control is another risk factor for falls, she reported.
For opioid-tolerant patients, possible protocols may include IV acetaminophen; direct intra-articular bupivacaine injections; anticonvulsants, such as gabapentin; nonsteroidal anti-inflammatory drugs; peripheral or regional nerve blocks; and opioids, as needed.
“Whether the patient is opioid tolerant or naive, however, there should be only one prescriber of pain medicine during the hospital stay,” said Dr. Walsh, who stressed that the pain management plan needs to be communicated to all other specialists. “Be aware of silos in the preoperative, perioperative and postoperative periods for total joint replacement surgery that prevent communication.”
Strategies for Falls Prevention
Although multiple risk assessment tools are available, the most widely used are the Hendrich II Fall Risk Model and the St. Thomas’s Risk Assessment Tool in Falling Elderly Inpatients. Regardless of which tool is employed, however, careful falls risk assessment should begin in the preoperative phase when surgery is planned, and results must be consistently communicated throughout the entire episode of care.
“People can be great at risk assessment and documenting what needs to be done but then fail to do it,” Dr. Walsh explained. “If you have a protocol, follow it.”
Providers should assess a patient’s readiness to ambulate by looking at vital signs, mental status, pain level and distal neurovascular status, she said, especially in patients who have had a femoral nerve block. They also should ensure there are enough personnel to facilitate a safe transfer. Moreover, when transferring patients, the use of safe-handling equipment, such as mobilization beds and ceiling lifts, prevents injury to patients and health care personnel.
In addition, physical therapy needs to be part of the protocol of the PACU team in order to assist in proper transfer and ambulation techniques.
“Patients who are ambulating in the PACU should be working with a physical therapist,” she said. “Physical therapists are more likely to use proper techniques to prevent complications, especially in the total hip arthroplasty population. And this evaluation needs to be shared.”
Finally, all services required for a patient’s episode of care need to be integrated to ensure continuity of care. “Help break down the silos,” she concluded.
Zeev N. Kain, MD, MBA, FAAP, president of the American College of Perioperative Medicine; Chancellor’s Professor of Anesthesiology, Pediatrics and Psychiatry; and chair of the Department of Anesthesiology and Perioperative Care at UC Irvine Health, commented that “value-based care will align the incentives of all clinicians involved in the care of the patient, regardless of their specialty.
“This will result in anesthesiologists being more concerned with issues such as fall prevention that typically happens on the ward after the patient left the operating room,” said Dr. Kain, who is a member of the Anesthesiology Newsadvisory board.