Running head: IMPROVING FALL RATES

Improving the Fall Rates in Patients with Dementia in the Acute Care Setting
Kim Foos, BSN, RN

IMPROVING FALL RATES

2
Abstract

Falls in the acute care setting of patients with dementia symptoms have increasingly
became a challenge facing hospitals today. Regulations now adjust financial
reimbursements to hospitals based on the ability or inability of the facility in
preventing falls. Furthermore, the aging population is growing in volume each year
and is forecast to continue to grow, which will also increase the amount of
hospitalized patients with dementia related symptoms. The current strategies to keep
this patient population safe from falls during hospitalization can be costly and use
valuable nursing resources. Currently, there is a lack of research regarding the
effectiveness of evidence based interventions on the specific population of
hospitalized patients with dementia. This study is designed to determine the
effectiveness of implementing evidence based interventions targeted to special high
fall risk populations, such as patients with dementia to current intervention sets. The
study shows a correlation to including these evidence based interventions that
identify patients that are at high risk for fall and also promote collaboration among
all hospital staff in lowering fall rates among patients with dementia related
symptoms. It is essential for the nursing profession to develop efficient methods to
prevent patient falls. The findings of this study indicate the need for further research
of the implementation of evidence based interventions and its effectiveness on fall
risk patients with cognitive impairments.

IMPROVING FALL RATES

Improving the Fall Rates in Patients with Dementia in the Acute Care Setting
Preventing falls in hospitalized patients has been a significant challenge for
health care organizations, with one of the most challenging populations being those
patients with dementia-related disease processes. Hospitals struggle with keeping
these patients safe from falls, due to the increased level of confusion present, the
inability to educate these patients regarding associated fall risks, the impulsiveness
of this population, and other age-related factors. Further complicating the problem
is the strict criteria for payment reimbursement implemented by Centers for
Medicare and Medicaid Services (CMS), that financially penalizes facilities by nonpayment for medical tests or treatment related to inpatient falls. Evidence-based
interventions have been effective in decreasing fall rates of patients in the acute care
setting, however, there is limited research regarding the effects of these interventions
on patients with dementia.

Routinely, nursing staff perceive the problem as

inadequate staffing and often feel helpless in preventing falls within this population
without the assistance of additional staff (Chakravarty, 2013). Unfortunately, with
the current nursing shortage and financial cutbacks experienced by many health care
facilities, additional staffing is not always possible and more viable solutions need to
be examined.
There have been multiple studies conducted regarding the implementation of
evidence-based interventions in reducing the fall rates of hospitalized patients.
However, there has been limited research studies that determine the effectiveness of
current evidence based interventions on hospitalized patients with dementia. Most
fall prevention strategies incorporate multiple interventions to prevent falls

IMPROVING FALL RATES

including: appropriate assessment of fall risk factors, specific identification of

patients at risk for falls, patient and family education of fall risk, hourly rounding,
staff awareness of fall risk patients, utilization of specialty equipment, removal of
environmental risks, improved communication and collaboration among nursing and
ancillary staff, and efficient safety huddles conducted each shift (Spoelstra, Given,
Mei, & Given, 2012). Some of these interventions rely on the ability to properly
educate and direct the patient at risk for falls. However, in the population of patients
with dementia, education and redirection of the patient are often difficult or even
impossible.
To compensate for this, some hospitals have implemented some interventions
directed at this patient population, with which have had an exhausting effect on
nursing staff or resources, yet have not proven to improve the fall rates. One
intervention utilized is the assignment of additional nursing staff that remain with
the at-risk patient at all times during hospitalization in an effort to keep them safe.
This role is identified as a safety attendant, and is in addition to regular staffing
assignments (Wiggins, Welp, & Rutledge, 2012). However, the utilization of safety
attendants can cost hospitals thousands of dollars each week and exhaust valuable
staffing resources. There is also no evidence to support that the safety attendant role
has decreased the fall rates in patients with dementia (Degelau, et al., 2012). Other
hospitals have used specialty equipment, such as bed and/or chair alarms for patients
at risk for fall. However, many hospitals have reported alarm fatigue in those units
who have a large population of fall risk patients (Daniels, 2014). The bed
alarms/chair alarms are designed to sound when a patient makes a movement to get

IMPROVING FALL RATES

up, however the alarms sound even when a patient makes a simple movement such
as changing positions slightly. The danger associated with this is the exposure of
nursing staff to false alarms, which can lead to slower responses due to alarm
fatigue.
Patients with dementia symptoms are, many times, at the highest risk for falls in
the acute care setting. In addition to the increased risk for falls, these patients are
also one of the most difficult fall risk populations in which to prevent falls. As
mentioned before, the inability of the patient to be educated by nursing staff or to
follow directions appropriately places the patient at higher risk. The cognitive
impairments that go along with the disease process also increase the impulsiveness
and anxiety in these patients, which can also hinder many fall prevention strategies
(Hrlein, Halfens, Dassen, & Lahmann, 2011). With the increasing number of the
elderly population with dementia and the impending nursing shortage, it is essential
for the nursing profession to develop better strategies to prevent falls and decrease
fall rates in this fragile patient population.
The Joint Commission requires facilities to establish a protocol to address fall
risks for hospitalized patients (Quigley, & White, 2013). To comply, most hospitals
utilize a tool to help identify patients who are at risk for falls, and then apply
interventions to help prevent falls in those patients who are at risk. These patients
are identified through use of a fall risk tool such as the Morse Scale, Hendrich II,
STRATIFY, and the Downton index (Rosario, Kaplan, Khonsari, & Patterson, 2014).
These tools can be extremely useful in identifying fall risk patients and even the
degree of risk. When utilizing a tool such as the Morse Fall Risk Scale, all patients

IMPROVING FALL RATES

who score 45 or higher on the fall risk scale are considered a fall risk.
The Morse Fall Scale scores patients risk on six components. These include: a
history of falling, having a secondary diagnosis, the use of an ambulatory aid or
nurse assistance to ambulate, intravenous therapy or heparin lock, assessment of
patients gait, and the patients mental status (Baek, Piao, Jin, & Lee, 2014). For
instance, if a patient has a history of falling this results in a score of 25. The other
scores are as follows: and existence of a secondary diagnosis results in score of 25,
the use of an ambulatory aid or nurse assistance results in a score of 15-30,
intravenous therapy or a heparin lock IV scores 20, a weak or impaired gait results
in a score of 10-20, and a patient who overestimates abilities or forgets limitations
receives a score of 15. (See Appendix A) These scores are added together to reach
the fall risk score of a patient. As mentioned earlier, a score of 45 or higher will
identify the patient as a fall risk. This accounts for a significant percentage of all
hospitalized patients to be identified as a fall risk (Rosario, et al., 2014). When the
high fall risk patients with dementia are identified in the same method as all other
fall risk patients, there is the potential for nursing staff to become somewhat immune
to the severity of the fall risks associated with some of the highest risk patients, and
therefore make it more challenging to prevent falls. Creating an easily visual
method to further identify those patients at highest risk for falls and promoting
education and awareness of nursing and ancillary staff may be effective in
decreasing the fall rates in this population. An appropriate alert or sign that
differentiates a significantly higher fall risk patient from other fall risk patients may
be effective in preventing falls in patients with dementia (Ganz, et al., 2013).

IMPROVING FALL RATES

Despite an increased focus on strategies to decrease the fall rates in hospitalized

patients, little research has been done to examine the effectiveness of these strategies
on any subgroup of high fall risk patient populations. Elderly patients with dementia
pose a significant fall risk because of cognitive and age-related factors, and as our
elderly population continues to grow these issues will become much more prevalent
in health care. Falls in the acute care setting costs hospitals on average $13,000
more per patient due to fall-related medical expenses (Wong, et al., 2011). One in
three patients over the age of 65 in the United States fall each year (Ganz, et al.,
2013). Although, these statistics represent all individuals over the age of 65, the fall
risks of the elderly patient with dementia may potentially be even higher. As the
elderly population continues to increase, it is essential to determine more efficient
and effective ways to prevent falls.
The purpose of this study will be to improve the safety of patients hospitalized
with dementia without an increase in staffing using evidenced based interventions to
prevent falls. This will be done by implementing evidence-based practice
interventions that may help identify patients at highest risk for falls, such as patients
with dementia, and may reduce the fall rates of this specific patient population. This
includes creating signs to be placed on the doorway of those patients with dementia
who are at highest risk for falls and educating all staff members about the
significance of these signs.
Literature Review
Falls continue to be the primary cause of all hospital acquired injuries and
typically complicate and lengthen hospital stays for patients in the acute care setting

IMPROVING FALL RATES

(National, 2014). Yearly, in the United States there are between 700,000 and
1,000,000 patient falls reported in the hospital setting (Ganz, et al., 2013). The
Center for Disease Control and Prevention, (CDC) estimated, that in 2005, between
3 and 20 percent of all hospitalized patients fell at least once during their hospital
stay. Those falls have resulted in additional injuries, increased length of inpatient
stay, malpractice lawsuits, and associated health care costs of over $4,000 in excess
charges per patient fall, during hospitalization (Inouye, et al., 2009). According to
the Joint Commission, hospitals operational cost were increased an average of over
$13,000 dollars per serious fall related injury, and also resulted in an increased
length of stay of 6.7 days (Wong, et al., 2011). With this information, the CDC
estimates that patient falls resulted in a cost of $34 billion dollars in 2013 and may
rise over $50 billion by the year 2020. Inpatient falls are preventable, and because
of this, the Centers for Medicare and Medicaid Services (CMS), the Center for
Disease Control and Prevention (CDC), the Joint Commission, the Agency for
Healthcare Research and Quality (AHRQ), the National Quality Forum (NQF), and
the Institute for Health Improvement (IHI), have each taken steps to prevent hospital
acquired falls (Quigley, et al., 2013). This has resulted in new provisions by CMS
that no longer reimburse for hospital expenses incurred as the result of a hospital
acquired fall (Inouye, et al., 2009). Despite the increased costs and utilization of
health care resources associated with falls in the hospital setting, the physical,
mental, and financial costs to patient themselves, their families, and surrounding
community are also significant.
Currently there exists approximately 4.2 million individuals in the United States,

IMPROVING FALL RATES

who have dementia, and worldwide those numbers grow to an astonishing 35 million
(Hurd, et al., 2015). The baby boomers started reaching the age of 65 in 2011, and
by the year 2030, it is estimated by the CDC that one in five individuals will be over
the age of 65 in the United States (Matthews, 2013). This has many implications on
health care in the United States, as well as current health, quality, and safety
initiatives in the health care industry. As people are living longer, and the baby
boomer population transitions to senior citizens, it may likely increase the incidence
of dementia, as well. There is a significant need for continued research regarding
fall risk factors, evidence based interventions, and health care guidelines in elderly
patients with dementia.
As mentioned earlier, there have been numerous studies conducted regarding
patient fall risk factors, evidence based interventions to prevent falls, and guidelines
designed to prevent patient falls. However, there is limited research regarding
patient falls in the cognitively impaired or dementia patient within the hospital
setting and how effective evidence-based interventions are in this patient population.
These interventions include: appropriate assessment of fall risk factors using a fall
risk tool, specific identification of patients at risk for falls, patient and family
education of fall risk, hourly or purposeful rounding, awareness of all staff of fall
risk patients, utilization of specialty equipment, removal of environmental risks,
improved communication and collaboration among nursing and ancillary staff, and
efficient safety huddles conducted each shift (Spoelstra, et al., 2012). In a study
conducted during the years 2005-2007 in German hospitals, it was found that 12.9
percent of elderly patients with a cognitive impairment fell during hospitalization,

IMPROVING FALL RATES

10

however only 4.2 percent of hospitalized patients over the age of 65 with no
cognitive impairment experienced a fall (Hrlein, et al., 2011). Current research and
literature indicates that there are many evidence based interventions that may be
applied in the hospital setting which has been significant in reducing the rate of
patient falls. However, there is limited information regarding the effectiveness of
these interventions in hospitalized patients with dementia.
The challenges many organizations face when implementing evidence-based
interventions to prevent falls is nursing's perception of ineffectiveness in the high
fall-risk patient such as the dementia population. Nursing staff routinely cite
inadequate staffing levels as the primary reason falls cannot be prevented in this
population. Nursing staff have the perception that a twenty-four hour attendant or a
decreased nurse to patient ratio is the only acceptable solution in reducing falls.
However, there is little research that correlates this suggestion. Health care
organizations, on the other hand, are challenged to find other viable solutions
because of the excessive costs associated with the preventive measures such as a
safety attendants, and lack of nursing resources available. As the population of
elderly individuals continue to rise in proportion with the existing and future nursing
shortage, this has become a challenging health care issue.
This research is of high importance, not only because of the fiscal cost associated
with falls within the hospital setting, but also because of the risks of bodily injury or
even death of this patient population as the result of hospital acquired falls.
Consideration must also be given to potential financial costs, as well as the use of
valuable resources in providing twenty-four hour safety attendants to those patients

IMPROVING FALL RATES

11

with dementia who may be at highest risk for fall injuries.

Methodology
The study includes an extensive data collection and quality improvement
initiative. The quality improvement initiative is conducted for the months August
2015 through December 2015 in an acute care hospital setting located in midwestern United States. The study is carried out on a 500 bed medical facility.
Data regarding fall rates in patients with dementia is collected for the year 2015
prior to the initiation of the study and is again compared when the study is complete.
The framework that is utilized to guide this study is the evidence implementing and
evaluating approach and the quality improvement model.
Using the quality improvement model, the process of preventing falls in patients
with dementia-related symptoms is examined for potential improvements. An
examination of current practice and how it applies to this population is conducted. A
study of how the fall prevention protocol works and any variations in the process is
also performed. Extensive research and literature review of scholarly articles is
conducted to determine evidence-based interventions. Using the research data, an
evidence-based intervention is selected to implement in the effort of reducing fall
rates in this population. This will include a uniform fall risk sign to be hung on the
door frame of all fall risk patients with symptoms of dementia. Hospital staff are
made aware of the need for change and information is presented to staff throughout
the hospital to educate about the change prior to the evidence-based intervention
being added to the current fall prevention protocol. Once evidence-based
interventions are in place, then ongoing data collection and analysis occurs.

IMPROVING FALL RATES

12

Evaluation of results may determine falls among hospitalized patients with

dementia-related symptoms will be reduced.
Patients who score 25 or above on the Morse fall scale are categorized as patients
who are at risk for falls in the hospital setting. Patients who score 45 or above on the
scale are considered high fall risks. Within the facility participating in the study,
these patients are identified by a yellow armband that identifies them to be at risk for
falls, as well as no skid yellow socks. They are asked to sign a safety agreement on
admission and watch a video aimed at educating patients and families about fall
prevention. A Call, dont Fall sign is also placed in the patients room.
Additionally, patients who are a high fall risk, and are also non-compliant will be
identified further with a high fall risk sign on the doorway that is uniform
throughout the hospital and will continue to use a bed and chair alarm. Noncompliance is defined in this setting as patients who are not able to follow
directions. This includes patients who are not able to follow directions because of
confusion, cognitive impairments, or patients who refuse to cooperate. Noncompliance will capture patients with dementia-related symptoms because of the
level of confusion present, cognitive impairments, and the impulsive characteristics
of this population.
In preparation for this study, the problem recognized with identifying all patients
categorized as a fall risk by the yellow armband is the difficulty of all staff to be able
to quickly and efficiently identify patients at risk. For those patients with dementia
symptoms, the inability of nursing staff to readily identify these patients may result
in a failure or delay to assist a high fall risk patient in need. The implementation of

IMPROVING FALL RATES

13

a bright yellow fall risk sign, that is to be attached to the door frame of patients who
are a fall risk and also non-compliant, will improve this process.
All hospital staff are educated about the elevated fall risks and non-compliance
associated with these signs, to further aid in preventing falls. In addition, there are
designated ambassadors who serve as fall prevention champions placed on each unit
to help improve the acceptance and participation of all staff. Ongoing assessment of
hospital falls and staff participation in evidence based interventions occur
throughout the study, and are evaluated for adjustment needs. Six months following
the implementations, an analysis and comparison occurs. It is expected that the
number of falls related to dementia symptoms will decrease after the specific
interventions have been implemented. An evaluation and analysis will then be
conducted to determine the effectiveness of the additional signage in preventing falls
in patients with dementia. The aim of the study is to show that fall rates will
decrease with the use of evidence-based interventions and the inclusion of signs to
identify those patients hospitalized with dementia.
The standard for fall rates, which is the benchmark set by the Joint Commission
is 3 falls per 1000 patient days, with none of those resulting in serious injury. Fall
rates are determined by the number of patient falls per month multiplied by 1000
and then divided by patient days determined by the type of unit. Patient days are
determined adding the total of hours of all patients stay and then divide the sum by
24. This will give the rate of falls per 1000 patient days (Ganz, et al., 2013). By
decreasing the number of falls experienced by patients with dementia, it is also
expected to have an impact on overall fall rates throughout the facility.

IMPROVING FALL RATES

14

Data analysis for this study occurs in two stages. An initial data analysis has
been conducted to determine the fall rate for 2014 and 2015 within the facility for all
patients. The additional intervention of signage for high fall risk patients who are
also non-compliant is implemented in August throughout the hospital. Data analysis
also occurs for the months August through December of 2015, following the
implementation of new interventions that have been added to specifically prevent
falls in patients with symptoms of dementia. First, a comparison is made of the total
falls of all patients before and after the study specific implementation of evidence
based interventions. Additionally, all falls for the year 2015 are analyzed to
determine how many patients with dementia symptoms experienced a fall. A report
is generated for all falls that have occurred throughout the hospital. Another report
is generated for all patients with a dementia related diagnosis. These two reports are
compared to determine the number of patients, who have experienced a fall and also
have a dementia related diagnosis. These totals are compared to determine if there is
a decrease in the number of falls occurring as a result of dementia symptoms
following the implementation of the new signs.

Results
The fall rate throughout the facility in 2014 for all patients was 3.74, which is
above the benchmark set by the Joint Commission. For the months, January through
June there were a total of 202 patient falls. Of those 202 falls, 42 falls were
experienced by patients with dementia symptoms. This is 20.7% of the falls within
the facility. From the months August through October there were 85 falls, and 10 of

IMPROVING FALL RATES

15

these falls were due to dementia symptoms. The total falls for the month of August
are 32, with 5 of these resulting due to dementia-related symptoms. October has a
total of 28 patient falls, with only 3 of them being due to dementia. This is 8.5% of
the falls during the months of August through October. The fall rate so far for the
year 2015 for all patients in the facility has dropped to 2.71. This indicates that the
targeted interventions have had a significant impact on the falls of patients with
dementia throughout the facility.
Table 1
Comparison of Falls Pre and Post Intervention
Time of Collection
Fall Rate
Percent of Dementia Falls
Pre-intervention
3.74
20.7%
Post-intervention
2.71
8-5%
Note. Fall rate is for all patients throughout the hospital measured per patient 1000
patient days.
Discussion
The findings form this study indicate the importance of collaboration and
effective communication between nursing and staff from other departments, in
preventing falls. It also indicates that a quick and uniform method of identifying
patients, such as a bright sign on the door frame of those patients at highest risk for
falls, may have a significant impact on improving fall rates among patients with
symptoms of dementia. Further implications include the importance of teamwork
among nursing staff in preventing falls.
There are several limitations that have been identified throughout the course of
this study. One limitation of the study is that there is not a complete year of data for
a more accurate comparison. It would be more efficient to compare the year prior to

IMPROVING FALL RATES

16

the interventions to a year of data after the intervention. Another limitation is that
the study took place in only one facility, and a similar study throughout multiple
facilities in varying demographic and geographic locations may be more relevant.
Another limitation is that the analysis and reports depend on accurate charting of
dementia or history of dementia related symptoms in order for the reports to be
accurate. Though, there is promising evidence that the specific interventions along
with the intervention set are successful in decreasing fall rates among patients with
dementia, there is a need for further research to validate the relevance of the study.

References

IMPROVING FALL RATES

17

Baek, S., Piao, J., Jin, Y. & Lee, S.-M. (2014). Validity of the Morse Fall Scale
implemented in an electronic medical record system. Journal of Clinical
Nursing, 23(17), 24342441. doi: 10.1111/jocn.12359
Chakravarty, A., (2013). A survey of attitude of frontline clinicians and nurses
towards adverse events. Medical Journal Armed Forces India, 69(4), 335-340.
Daniels, K., (2014). Fighting bed alarm fatigue in orthopedic units. Nursing, 44(9),
66-67.
Degelau, J., Belz, M., Bungum, L., Flavin, P. L., Harper, C., Leys, K., Lundquist, L.,
& Webb, B., (2012). Prevention of Falls (Acute Care). Institute for Clinical
Systems Improvement, (3), 1-43.
Ganz, D. A., Huang, C., Saliba, D., Shier, V., Berlowitz, D., Lukas, C.V.,
Pelczarski, K., Schoelles, K., Wallace, L. C., Neumann, P. (2013). Preventing
falls in

hospitals. A toolkit for improving quality of care. Agency for

Healthcare Research and Quality, Rockville, MD. Retrieved from:

http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fal
lpxtoolkit/index.html
Hrlein, J., Halfens, R. J., Dassen, T. & Lahmann, N. A. (2011). Falls in older
hospital inpatients and the effect of cognitive impairment: a secondary analysis
of prevalence studies. Journal of Clinical Nursing, 20: 175183. doi:
10.1111/j.1365-2702.2010.03460.x
References

IMPROVING FALL RATES

18

Hurd, M. D., Martorell, P., & Langa, K. (2015). Future monetary costs of dementia
in the United States under alternative dementia prevalence scenarios. Journal of
Population Aging, 8(1-2), 101-112.
Inouye, S. K., Brown, C. J. & E. Tinetti, M. E. (2009). Medicare nonpayment,
hospital falls, and unintended consequences. The New England journal of
Medicine, 360: 2390-2393. doi: 10.1056/NEJMp0900963
Matthews, S. E. (2013). How the aging population is changing the healthcare s
system. Senior Helath,

http://www.everydayhealth.com/senior-health/aging-

and-health/pressures-on-he

althcare-from-

booming-senior-population.aspx
National Center for Injury Prevention and Control. (2014). Falls among Older
Adults: An Overview. Retrieved from: http://www.cdc.gov/injury/index.html
Quigley, P., & White, S., (2013). Hospital-based fall program measurement and
improvement in high reliability organizations. The Online Journal of Issues
in Nursing 18,(2), doi: 10.3912/OJIN.Vol18No02Man05
Rosario, E. R., Kaplan, S. E., Khonsari, S. & Patterson, D. (2014), Predicting and
assessing fall risk in an acute inpatient rehabilitation facility. Rehabilitation
Nursing, 39: 8693. doi: 10.1002/rnj.114

References

IMPROVING FALL RATES

19

Spoelstra, S.L., Given, B., Mei, Y., & Given, C. W. (2012). The contribution falls
have to increasing risk of nursing home placement in community-dwelling older
adults. Clinical Nursing Research, 21(1),24-42.
Wiggins, A., Welp, C., & Rutledge, D. (2012). Reconceptualizing patient safety
attendants. Nursing Management, 43(5), 25-27.
Wong, C. A., Recktenwald, A. J., Jones, M. L., Waterman, B. M., Bollini, M. L.,
Dunagan, W. C. (2011). The cost of serious fall-related injuries at three mid
western hospitals. The Joint Commission Journal on Quality and Patient Safety,
37(2), 81-87.

Appendix A

IMPROVING FALL RATES

20
The Morse Fall Scale

The Morse Fall Scale is a tool that is used to quickly and accurately assess a
patients likelihood of falling. It consists of six components that are quick and easy
to score. These components have been shown to be valid predictors of a patients
risk for falls, and have been proven reliable. It is widely used in acute care settings.

IMPROVING FALL RATES

21

IMPROVING FALL RATES

22