Falls prevention in hospital

Falls are a complex problem with multiple causes and risk factors. Preventing falls in hospital is not easy, but there are many things we can do to help reduce the risk.

Some hospitals may routinely use some or all of the following strategies to prevent falls. Please note that not all strategies have been proven to work for all patients in all settings.

We should choose strategies in consultation with our care teams, considering all clinical and organisational factors.

Identify falls risk

• Use falls risk identifiers, for example coloured signs or traffic light symbols, to communicate level of falls risk.
• Ensure staff understand what the identifiers mean and what strategies they should be implementing.
• Explain what the identifiers mean to the patient and their visitors.

Intentional rounding

Consider undertaking regular rounds (for example hourly or two hourly) to check on patients to ensure fundamental needs are being met. Note that while there is evidence to suggest that rounding is associated with improved patient experience, the impact on falls is less clear.

Low-low beds

Consider using low-low beds for patients at risk of falling or rolling out of bed. Consult with all team members, considering the following aspects:

• Is the patient at risk of rolling out of bed? Would they benefit from a low-low bed with an adjacent floor mat?
• Is the use of the low-low bed a form of restraint? It may be inappropriate to use a low-low bed for patients who are mobile.
• Does the patient have enough strength to stand up but has poor balance or walking and has risk taking behaviour (such as decreased awareness of ability, perceptual difficulties, delirium, dementia)? A low-low bed may be contraindicated in this case.
• Is the use of a mat next to the bed a trip hazard for staff and other patients/carers?
• The availability of one low-low bed for three standard beds may contribute to a decrease in the rate of serious fall-related injuries¹ whereas providing one low-low bed per 12 beds does not seem to effect rate of falls.²
• Where is the low-low bed placed? If it is close to the wall but there is space between the wall and the bed, this can be a hazard.
• What height is appropriate? For example, low when resting, raise bed for transfers and care activities.

Bed or chair alarms

Consider using bed or chair alarms for patients who do not ask or wait for assistance or who require supervision to mobilise.Note that there is high level evidence indicating that the use of bed or chair alarms as a single strategy has no effect on the rate of falls.

Clinical judgement should be used in deciding whether to use a bed or chair alarm, considering factors such as:

• patient characteristics: can and will the patient use their call bell?
• staffing: are there enough staff to respond? Is there a risk of ‘alarm fatigue’: have staff become desensitised to alarms?

Non-slip socks

Many hospitals have introduced non-slip (red) socks to identify individuals at risk of falls and focus attention on prevention strategies. Note there is no published high-level evidence to suggest that non-slip socks prevent falls in the hospital setting.

For patients with bone conditions

Patients with conditions such as osteoporosis, previous fracture and metastatic bone disease are at greatest risk of fracture following a fall. For these patients consider the following:

• hip protectors (worn at all times)
• low-low bed (low when resting, raised for transfers and care activities)
• evaluation of osteoporosis.

For patients with bleeding disorders

Patients with bleeding disorders due to use of anticoagulants or an underlying clinical condition are at increased risk of haemorrhage following a fall. For these patients consider the following:

• evaluate use of anticoagulation medication, including considering risk vs benefit
• use of a low-low bed (low when resting, raised for transfers and care activities)
• use of protective helmets for some patients.

For surgical patients

Surgical patients are at increased risk of falls. For these patients, consider the following:

• pre-op education
• post-op reinforcement about using call bell
• toileting prior to providing centrally acting pain medication.³

Referral to other health professionals

Consider whether the patient should be referred to other health professionals such as physiotherapists, occupational therapists or pharmacists. On completion of a comprehensive assessment, all health professionals should work with the patient and their family to develop an intervention plan.

Multifactorial interventions

Multifactorial interventions have been shown to work in some, but not all, settings^4,5. This type of intervention refers to strategies to address risk factors identified in a comprehensive falls risk assessment. It can include a combination of interventions such as:

• treatment of delirium and agitation
• improving continence, for example through regular toileting, treating constipation, referral to a continence nurse specialist, urinalysis to check for infection
• footwear: ask family and carers to bring in supportive shoes or slippers
• foot problems: provide foot care and refer to podiatrist
• visual impairment: ensure patient has the right glasses and they can reach these easily
• poor balance: refer to physiotherapist, consider using a gait aid, assist or supervise the patient when walking to the toilet
• stay with patients who require assistance on the toilet or while showering
• medication review: consider medications known to increase falls risk such as sedatives, centrally acting analgesics, psychotropic medications
• treat postural hypotension
• ensure nutritional needs are met and consider referral to a dietitian
• exercise program: strength and balance training may be effective in reducing falls and improving awareness of risk.

Educate the patient, their family and carers

Provide personally tailored falls prevention education to the patient and their family and carers. Talk to them about their knowledge and perceptions of falls risk, their goals for their hospital stay, and things they can do to reduce the risk of falls. Encourage patients to ask for assistance. Remember, simply providing a brochure on falls prevention is not enough: talking to the patient and their family and carers is essential.

On each shift, we can:

• orientate new patients to the ward, including to the toilet, and provide regular reorientation for patients with cognitive impairment
• place the call bell within reach
• reduce clutter around the bedside
• position the gait aid within reach
• provide easy access to objects according to patient’s needs and preferences, for example the TV control, glasses, magazines
• lock wheels on the bed and other equipment
• help the patient put on appropriate footwear and clothing
• ensure adequate lighting
• encourage the patient to walk regularly, even for short distances
• provide assistance or supervision for walking as needed
• keep hallways clear, provide safe seating opportunities.

1. Barker, A., et al., Reducing serious fall-related injuries in acute hospitals: are low-low beds a critical success factor? Journal of Advanced Nursing, 2013. 69(1): p. 112-121.

2. Haines, T.P., R.A.R. Bell, and P.N. Varghese, Pragmatic, Cluster Randomized Trial of a Policy to Introduce Low-Low Beds to Hospital Wards for the Prevention of Falls and Fall Injuries. Journal of the American Geriatrics Society, 2010. 58(3): p. 435-441.

3. Boushon B, Nielsen G, Quigley P, Rita S, Rutherford P, Taylor J, Shannon D, Rita S. Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls, 2012. Institute for Healthcare Improvement: Cambridge, MA.

4. Cameron, I.D., et al., Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews, 2012. 12.

5. Oliver, D., et al., Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ, 2007. 334(7584).