Fatima Naqvi, MD, is Geriatric Fellow, State University of New York (SUNY) Stony Brook School of Medicine, Stony Brook, New York.

Susan Lee, MD, is Assistant Professor of General Medicine and Geriatrics, Stony Brook School of Medicine.

Suzanne D. Fields, MD, is Geriatric Fellowship Director and Chief, Division of Geriatrics and General Internal Medicine, Stony Brook School of Medicine.

ABSTRACT

Although falling may seem like a simple event, in reality it is a complex medical issue leading to serious injuries including fractures, lacerations, soft tissue and traumatic brain injuries, and even death. The Nurses Improving Care for Health System Elders (NICHE) guideline for falls prevention in acute care unit was formulated by incorporating recommendations from systematic reviews of the literature and advice from expert consensus. Recommendations include pre-fall risk assessment, utilization of a post-fall assessment tool, follow-up monitoring for 48 hours, and implementation of an individualized, multidisciplinary plan of care to address treatable problems that contributed to the fall and to prevent future falls. The guideline also calls for staff education.

Naqvi F, Lee S, Fields SD. An evidence-based review of the NICHE guideline for preventing falls in older adults in an acute care setting. Geriatrics. 2009;64(3)10:13, 26.

Key words: falls, risk factors, fall assessment and management

Drugs discussed: aspirin, clopidogrel, lorazepam, risperidone, warfarin, and general references to anticoagulants, antidepressants, antihistamines, antiarrhythmics, antithrombotics, benzodiazepines, opioids, psychotropics, sedatives

Case scenario: An 80-year-old widowed woman with a history of severe dementia presented to the emergency department after a fall that resulted in a right hip fracture. According to the assisted living staff, she had been having auditory hallucinations and wanderd the hallways for several nights prior to the fall. She had multiple other chronic medical problems, including diabetes mellitus, arthritis, and depression. Medications included lorazepam and risperidone for psychiatric symptoms.

In the emergency room, the patient was confused and disoriented. The following day, she underwent an internal fixation of her hip fracture without surgical complications. On postoperative day 2, however, she developed delirium after receiving narcotic analgesics. While confused, she attempted to get out of the bed to go to the bathroom without assistance. In the process, she fell on the floor and was entangled in her intravenous (IV) tubing and Foley's catheter bag. She complained of pain in her left shoulder.

What measures could have been taken to prevent this patient's fall in the hospital?

The population of US adults 65 years and older will double during the next 25 years. By 2030, it will number 71 million, comprising 20% of the population.¹ Approximately one-third of persons 65 years and older experience one or more falls each year.² Falls are the leading cause of nonfatal injuries and hospital admission for trauma services in this segment of the population. Further, there were 15,800 deaths in 2005 from injuries related to unintentional falls.² About 1.8 million people 65 years and older had emergency department visits related to nonfatal injuries resulting from falls.³ The physical trauma from a fall causes the elderly to harbor a fear of falling, thereby discouraging them from physical activity, leading to functional decline and escalating the risk of future falls.⁴

The purpose of this article is to review and summarize the Nurses Improving Care for Health System Elders (NICHE) guideline on preventing falls in acute care.⁵ The guideline was formulated by an expert panel that reviewed the medical literature pertaining to falls and analyzed the evidence, including systematic reviews and published meta-analyses. Panel members rated the evidence for each recommendation contained in the guideline, ranging from level I evidence (evidence derived from systematic reviews) to level VI evidence (opinions of respected authorities/consensus panels).

Clinical specialties targeted to use the guideline include physicians, nurses, nurse practitioners, physician assistants, and physical and occupational therapists. The targeted population to benefit from the guideline is older adults who fall in a hospital setting or who are at risk for falling based on established intrinsic and extrinsic factors, medical comorbidities, and the hospital environment. Falls prevention is achieved by identification of older adults at risk for falls, implementation of an individualized fall management plan, and careful monitoring.

The guideline has been subjected to peer review but the validation process is not described. The scope of the guideline is the prevention of falls and serious injuries that result from a fall in a hospital setting.