Overall, the implementation of the multifactorial fall intervention model reduced the incidence of falls in our hospital from 0.31–0.22% and decreased the incidence of falls per 1000 patient-days from 0.29‰ to 0.22‰. In addition, the uninjured rate of falls also increased from 32.99–42.42%.
Compared with our previous fall intervention system, a significant improvement of this model is to prevent falls in high risk patients from multiple aspects, which are composed of not only nurses, but actively involving doctors, patients and family members and care taking staff. Nurses have always been the main force in the prevention and control of falls.(23) However, through analyzing the characteristics of fall patients, we found that falls were closely related to many factors, including doctors' treatment, patients' and their families' consciousness of preventing falls and environmental factors. And the control of these factors is far beyond the ability and responsibility of the nurse, it is more necessary for doctors, patients and their families and care-taking staff to perform their respective duties for these factors. It is important for doctors to pay particular attention to medication for patients at high risk of fall, and to adjust medications according to the result of patient's fall assessment. Previous studies showed that up to 85% of falls occur when patients are alone.(8, 24) A randomized controlled trial demonstrated that providing education to patients enabled them to conduct safe behaviors in hospital and effectively alert staff that they need assistance, especially when alone.(13) Family members' perception of patients' risk of fall is an important factor affecting patients' fall, especially for children, the elderly and patients with cognitive impairment.(25, 26) Hospital falls of elderly patients have been widely reported. As for children, fall is the most common injury mechanism for children, consisting about one-third of accidental injuries.(27, 28) Our study identified that children between the ages of 0 and 6 as having a high risk of falling, which was consistent with previous reports.(29, 30) Falls from furniture and stairs are important causes of children falls in hospital.(30) Therefore, greater awareness of risk factors in family members and medical staffs is required to predict and prevent falls in children.
With regard to environmental factors, many high-quality researches suggested marked reduction in fall risk after physical environmental intervention offered to high risk patients.(31, 32) Our analysis of the characteristics of fall patients in phase 1 showed that 34.42% of falls occurred in the washroom, as the wet floor greatly increased the risk of falling. To specifically reduce the risk factors for falls in the environment, care-taking staff were required to regularly evaluate and improve the patient's physical environment.
Few studies have focused on the importance of continuous improvement measures after falls, but they are effective interventions to further prevent repeated falls. According to the literature report, approximately 10% of elderly patients experienced recurrent falls within a year that posed a subsequent health risk.(33) In our study, 17 out of 474 fall patients had repeated falls at our hospital between 2015 and 2016. Given that falling again will cause more serious physical and psychological harm to the patient, it is crucial to have continuous improvement measures after falls, which organize medical staff to analyze and improve the deficiencies of previous interventions, minimizing the likelihood of a patient falling again. In addition to regular review of fall cases, our continuous improvement measures also include supervision and inspection of fall care by the leading team, aiming at promoting the improvement of fall prevention in hospitals in the long term.
The rate of falls was increased in several departments including D. of TCM, D. of oncology, D. of endocrinology and D. of rehabilitation. Noticeably, the patients in these departments were accompanied by relatively serious diseases, and the burden of medical staff was relatively arduous. To a certain extent, it had increased the difficulty of medical staff in preventing falls and managing falls, so it might cause an increase in the incidence of falls. In addition, the majority of patients in these departments were older patients, who were at higher risk of falling than patients in other departments. Moreover, several patients in the department of endocrinology were involved in hypoglycemia with a higher risk of falls. In the rehabilitation department, there were more patients with physical dyskinesia in urgent need of sports rehabilitation, and their risk of falling was relatively high.
This study has limitations. First of all, we used a before and after intervention control rather than a randomized control over the same time period. We believed that the original fall intervention system had many deficiencies and was not suitable for continued use. Therefore, it’s dangerous to set the original fall intervention system as a control group. In addition, the comparison of results before and after the new intervention system allows us to find changes in the fall of specific departments. To further validate and modify our model, we plan to compare the model with the currently accepted fall intervention systems in subsequent clinical trials. Secondly, our revised system is a multifactorial fall intervention model without specifying the effectiveness of a single intervention. Since falls are associated with many factors, we believe that only by intervening simultaneously from multiple perspectives can we minimize falls. As for its applicability, hospitals can learn from our model and improve upon their existing fall intervention systems. Lastly, the intervention was not conducted blind, which might introduce reporting bias. However, compared with the previous system, the reporting procedure in the revised intervention model was way more stringent. Regular supervision also ensured that falls were reported truthfully.
Our fall intervention model has several advantages. Firstly, compared with the existing fall management systems, our model forms a complete fall intervention work-flow including measures for pre-fall prevention, fall-onset management, and continuous improvement after falls to minimize the incidence of fall. Specifically, few studies pay attention to the continuous improvement after falls. However, this is quite important for learning lessons to improve measures and prevent second fall. Secondly, the approach we used in developing and applying the intervention were easy to implement. For medical staff and care-taking staff, measures for fall risk factor assessment and management are all familiar medical operations. Our model is to form a work flow to fully ensure that their work is orderly and correct. In addition, involving patients and their families in falling interventions in the form of written and oral education is also a common method in medicine to protect patients' health together with medical staff. Thirdly, our fall intervention model was constructed based on a large sample of more than 320,000 inpatients, which reflects the reliability of its effectiveness to some extent.