Inpatient falls

Falls are generally defined as ‘an unexpected event in which the participant comes to rest on the ground, floor, or lower level’.² They are the most common type of safety incident reported by acute hospitals.³ More than 240,000 falls are reported in acute hospitals and mental health trusts in England and Wales each year,⁴ although under-reporting may mean the true incidence of falls is higher.^5,6 Falls are most common in patients aged 65 years or older, representing 77% of inpatient falls.³ The majority of falls result from multiple interacting causes, most commonly age-related physiological changes, medical causes, medications and environmental hazards.⁷

Overall, 28% of inpatient falls result in some level of harm and patients aged 65 years or older are more likely to be harmed.³ The proportion of falls resulting in any fracture ranges from 1% to 3%, with reports of hip fracture ranging from 1.1% to 2.0%.⁶ In 2015–6, inpatient falls in England resulted in 2500 hip fractures.⁸ Outcomes for patients who acquire hip fractures in hospital are far worse than for those in the community who acquire hip fractures, with significant differences in mortality [relative risk (RR) = 3.00; 95% confidence intervals (CIs) 1.05 to 8.57], discharge to long-term high-level nursing care facilities (RR = 2.80; 95% CIs 1.10 to 7.09), and return to preadmission activity of daily living status (RR = 0.17; 95% CIs 0.06 to 0.44).⁹

Even where no physical harm occurs, falls can lead to fear of falling and associated loss of confidence.^5,8 They can result in slower recovery,⁸ even when physical harm is minimal, and can have longer-term consequences for the patient’s health, as fear of falling may lead to restriction of activity and associated loss of muscle and balance function, increasing risk of falling.⁵ Falls can also be a cause of significant distress for families and staff.^6,8 Falls in hospital are a common cause of complaints¹⁰ and can be a source of litigation.¹¹ They are also associated with increased length of stay and greater amounts of health resource use.⁶ NHS Improvement (now part of NHS England) estimated inpatient falls cost the NHS and social care an estimated £630 million annually.³ It is therefore a priority to reduce the number of patients who fall, and their risk of injury, in acute hospital settings.

Falls risk assessment

The traditional approach to managing falls in acute hospitals is to complete a falls risk prediction tool, sometimes referred to as falls risk screening tools or falls risk scores (such as STRATIFY¹²). Such tools typically provide a list of falls risk factors, assign a numerical value to the presence or absence of the risk factor, and then sum the numerical values together to represent the individual’s risk of falling (high, medium, low).¹³ Interventions are then used to target individuals at high risk.¹⁴ There are issues with the predictive validity of such tools; a systematic review of falls risk prediction tools found only moderate accuracy, comparable to the accuracy of nursing staff clinical judgement.¹³ Consequently, such tools may either provide false reassurance about patients identified as low risk or result in most patients on a ward being identified as high risk.¹⁴ Such tools are often completed only once, typically on admission, while a patient’s risk of falling can vary over time. There is also concern that their use gives false reassurance something is being done, even if no action to address falls risks has been taken. Additionally, with a tool of this kind, actions tend to be linked to the score and can lead to a ‘one size fits all’ approach even though the issues and needs of individual high-risk patients can be very different.¹⁴ A stepped-wedge cluster randomised controlled trial (RCT) showed removing the risk score component from falls risk prediction tools does not negatively impact falls outcomes and can reduce time spent completing paperwork.¹⁵

In light of the limitations of falls risk prediction tools, the NICE guideline on falls in older people states they should not be used and instead a MFRA should be undertaken.¹⁶ The recently published World Falls Guidelines, for falls prevention and management for older adults, also recommend patients in hospital should receive a MFRA and advise against using falls risk prediction tools.¹⁷ A multifactorial approach to falls risk assessment identifies individual risk factors for each patient, which may make them at risk of falling and that can be treated, improved, or managed during their stay (what tend to be referred to in the falls research literature as ‘modifiable’ risk factors). MFRAs, unlike risk prediction tools, do not include unmodifiable risk factors (i.e. cannot be treated, improved, or managed) such as age and sex. The NICE guideline includes the following modifiable risk factors: cognitive impairment; continence problems; falls history, including causes and consequences (e.g. injury and fear of falling); unsuitable or missing footwear; health problems that may increase a patient’s risk of falling; medications that increase the risk of falls; postural instability, mobility problems and/or balance problems; syncope syndrome; and visual impairment. The NICE guideline states that a MFRA should be undertaken for all inpatients 65 years or older and inpatients aged 50–64 years judged to be at higher risk of falling due to an underlying condition. Based on this assessment, a multifactorial intervention should be provided for the patient, tailored to their individual risk factors. For example, if visual impairment is identified, it might be decided that an optician visit should be arranged if the patient has lost their glasses or, if there is no known reason for poor eyesight, an ophthalmology referral is made.¹⁸ In this way different patients, who have different risk profiles, will receive different interventions to reduce their risk of falls.

Preventing inpatient falls completely would only be possible with unacceptable restrictions to patients’ independence, dignity and privacy, such that some falls may be considered an inevitable consequence of promoting rehabilitation and autonomy.^6,10 Thus, there is a need to balance the risk of harm from falls and the risk of deconditioning. Nonetheless, it is estimated introduction of MFRA and tailored interventions, as recommended by the NICE guideline, could reduce the incidence of inpatient falls by 25–30% and the annual cost of falls by up to 25%.³ Despite the NICE guideline being updated to include these recommendations in 2013, the 2022 National Audit of Inpatient Falls (NAIF) report noted that 34% of Trusts are still using falls risk prediction tools and, while there has been improvement in the proportion of patients receiving documented assessment for components of the MFRA included in the NICE guideline, there has been a reduction in the proportion of patients assessed for delirium.¹⁹ Documented vision assessment (52%) and lying and standing blood pressure (LSBP, 39%) remain concerningly low. In interventions, a mobility care plan was in place for 90% of patients who required one, a continence care plan for 78% of patients who required one, and a delirium care plan for 61% of patients who required one. This suggests variation in the extent to which the NICE guideline is being followed and opportunities are being missed to reduce the likelihood of inpatient falls.

Given these findings, it is necessary to understand the contextual factors that support and constrain use of MFRA and tailored falls prevention interventions in acute hospitals, to improve practice.