Christian Wuescher, MDUniversity of Toledo Medical Center

Physical Medicine and Rehabilitation

Falls and the healthcare industry Assessment of fall risk in the inpatient

setting Disposition assessment and options for

reducing fall risk including rehabilitation Role of Inpatient Rehabilitation Qualifying for an Inpatient Rehabilitation

stay

Falls are the leading cause of injury among people aged 65 years and older

Over 80% of all adverse events among hospital patients are associated with falls◦ 30-40% suffer injuries and 6-8% are severe which

include fracture, subdural hematomas and death

Falls are ranked sixth in the rating of sentinel events published by the Joint Commission in 2010

Morbidity and mortality from falls are a high risk, high volume and high cost challenge for health care facilities◦ By 2020 annual costs of injuries from falls may

reach over 40 Billion Dollars

Consequences are physical and psychological◦Result in injuries that limit function and

independence◦Produce fear of recurrence and loss of self

esteem◦Leads to a loss of quality of life

Identify those factors that can be used to assess fall risk both in the hospital setting as well as in the home

Based on this assessment, make recommendations to patients and families on measures to improve safety, the level of assistance the patient will require and any disposition options

70 year old female with a history of recent stroke with associated right hemiplegia and aphasia. She can transfer with help and has been ambulating 5 feet but with moderate assistance. Past history of mild dementia, high blood pressure and anxiety for which she takes medication. She previously functioned independently with use of a cane. She lives with her husband who has back issues in a 1 story home with 5 stairs to enter.

What is her fall risk?

What measures can be done to reduce fall risk while in the hospital?

What are her options for improving her safety for an eventual discharge home?

Cognition Impulsivity Muscle Strength, Sensation and

Coordination Functional Assessment Bowel and Bladder Status Visual disturbance Medications Support System Home Setup

Alert and Oriented X 4 Assess short term memory

◦ Remember three random items Avoid making determination based on

ability to answer basic questions appropriately

Speech Therapy Evaluation◦ Identify more subtle cognitive deficits that may

pose a fall risk◦ GOAT Score - Post Traumatic Amnesia◦ Identify need for 24 hour supervision

Act on impulse rather than thought High association with Brain Injury

◦ Frontal Lobe Evaluate for impulsive behavior both in

speech and action◦ Verbal or physical outbursts, poor judgment and

disinhibition◦ Review therapy notes for evidence of impulsivity

Formal Strength Exam with 5 point scale◦ Proximal Weakness – Difficulty with raising from seated

position or stairs◦ Distal Weakness / Foot Drop – Limb clearance during

swing phase Occupational therapy evaluation, orthotic

Sensation: Light touch and Proprioception◦ Sensory ataxic gait – Patients have difficulty knowing

location of limb in space and on ground Coordination / Cerebellar Dysfunction and Ataxia

◦ Deceivingly good strength exam◦ Finger to nose testing

Consider activities of daily living Review of the physical and occupational

therapy evaluations and devices used◦ Ambulation and Transfers: Walker, Transfer

Board◦ Toileting: Raised Toilet Seat◦ Dressing and Grooming: Long Shoe Horn

Assistive device needs and previous use◦ Standard vs. Wheeled Walker◦ Patient willing and able to utilize appropriately

How would patient be toileting at home?◦ Indwelling or intermittent catheterization◦ Bedside commode◦ Standard bathroom

Urinary urgency or frequency◦ May pose fall risk if voiding frequently or urgently

Subtle deficits may be difficult to determine Higher clinical suspicion w/ certain

diagnoses:◦ Stroke

Homonymous hemianopsia◦ Brain Tumor◦ Multiple Sclerosis◦ Diabetes

Important to assess peripheral vision

Medications associated with high fall risk:◦ Cardiovascular: Anti-arrhythmic, HTN, Diuretics◦ Anti-Anxiety: Benzodiazepines◦ Anti-Psychotics: Typical and Atypical◦ Seizure Medication◦ Opiods◦ Anti-Parkinsons Medications

Psychotropic and benzodiazepine use is the most consistently associated with falls

Medications associated with high fall morbidity:◦ Coumadin, ASA, Plavix, Heparin

Who lives at home with the patient:◦ Alone◦ Lives with other

Absent most of the day Present but not able to provide significant assistance Present and able to assist

◦ Resident at an assisted living center w/ help if needed

◦ Resident at an extended care facility w/ nursing and therapy care

One or Multiple level home◦ Available for 1 story set up◦ Bedroom and Bathroom location◦ Elevator or chair-lift available

Stairs to enter the home Other Barriers

◦ Areas of the home that are incompatible with use of mobility or assistive devices

Identifying those that are at increased risk◦ Daily risk assessments / Fall Risk Scales◦ Self assessment measures, fall committees

When falls occurring, were measures in place, diagnoses that represent highest percentage of falls

◦ Patients with speech therapy consults considered high fall risk until cleared

◦ Informing staff on admission of patients w/ cognitive deficits, not oriented or w/ prior falls

◦ Bracelet or patient room labels of fall risk, Kardex precautions

Interventions on at risk patients:◦ Closer to nursing station◦ Bed and wheelchair alarms◦ 1:1 Direct Supervision◦ Non-Slip Socks◦ Fall Runway mats◦ Hourly checks on patient◦ Toileting every 2 hours

Home Home with outpatient or in-home therapy Subacute rehabilitation Acute inpatient rehabilitation

Goals of inpatient rehabilitation:◦ Restore functional deficits and independence

through an aggressive and comprehensive approach

◦ Educating patients and families on methods to improve safety with activities of daily living

◦ Assessing functional status and barriers to return home

Multi-disciplinary Approach◦ Nursing care◦ Physical, occupational and speech therapy 3 hr

/day Assistive device needs, home evaluations, swallow

eval◦ Counseling◦ Neuropsychology evaluations◦ Recreation Therapy◦ Physical Medicine and Rehabilitation Physicians

Meet weekly to evaluate patients progress and determine appropriate disposition plan

Who is a candidate for inpatient rehab?◦ Able to tolerate the aggressive rehabilitation

program (3 hours per day)◦ Have enough functional goals to justify the

patient would require an inpatient stay◦ Have a reasonable anticipation of a discharge

home after 1-3 weeks of therapy Based on home set-up and support system

◦ Have a qualifying diagnosis

Common qualifying diagnoses for an inpatient rehabilitation stay:◦ Spinal Cord Injury◦ Traumatic Brain Injury◦ Cerebral Vascular Accident◦ Multiple Sclerosis◦ Parkinson’s Disease◦ Multiple fracture, Joint Replacement◦ Debility

Subacute Rehabilitation LTAC Facilities Home with in-home or outpatient therapy Home without therapy needs

Focused fall risk assessment is an important tool for improving patient safety as well as determining an appropriate rehabilitation program and disposition plan for patients.

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Divakara, Kedlaya, MBBS. Assistive Devices to Improve Independence. eMedicine. Oct 2011

Huang, Allen. Medication-Related Falls in the Elderly. Drugs & Aging. 29.5: 359-376. May 2012

Nursing Staff at University of Toledo Medical Center