Risk factors for falls in hospitalized adult patients: an integrative review

Factores de riesgo de caídas en pacientes adultos hospitalizados: revisión integradora de la literatura

Abstracts

Objective: Identifying risk factors for the occurrence of falls in hospitalized adult patients. Method: Integrative review carried out in the databases of LILACS, SciELO, MEDLINE and Web of Science, including articles published between 1989 and 2012. Results: Seventy-one articles were included in the final sample. Risk factors for falls presented in this review were related to patients (intrinsic), the hospital setting and the working process of health professionals, especially in nursing (extrinsic). Conclusion: The systematic screening of risk factors for falls was identified as a contributing factor to the reduction of this injury, helping the non-occurrence of this event that, despite being preventable, can have serious consequences including death.


Accidental falls
; Inpatients; Hospitalization
; Patient safety
; Nursing care
; Review

Objetivo: Identificar los factores de riesgo para la ocurrencia de caídas en pacientes adultos hospitalizados. Método: Revisión integradora de la literatura de artículos publicados entre los años 1989 al 2012 en las bases de datos LILACS, SciElO, MEDLINE y Web of Science. Resultados: La muestra final estuvo compuesta por setenta y un artículos. Entre los factores de riesgo de caídas indicados en esta revisión están los relacionados con el paciente (intrínsecos), con el ambiente hospitalario y con el proceso de trabajo de los profesionales de la salud, especialmente enfermería (extrínsecos). Conclusión: La detección sistemática de factores de riesgo asociados a caídas fue identificada como un factor que contribuye a la reducción de este daño, favoreciendo de esta manera su no ocurrencia, la que a pesar de ser prevenible puede acarrear consecuencias graves, incluyendo la muerte.


Accidentes por caídas
; Pacientes interno
; Hospitalización
; Seguridad del paciente
; Atención de enfermeira
; Revisión

Objetivo: Identificar os fatores de risco para a ocorrência de quedas em pacientes adultos hospitalizados. Método: Revisão integrativa realizada nas bases de dados LILACS, SciELO, MEDLINE e Web of Science, abrangendo artigos publicados entre 1989 e 2012. Resultados: Setenta e um artigos compuseram a amostra final do estudo. Os fatores de risco para quedas apresentados nesta revisão foram relacionados ao paciente (intrínsecos), ao ambiente hospitalar e ao processo de trabalho dos profissionais da saúde, em especial à enfermagem (extrínsecos). Conclusão: A triagem sistemática de fatores de risco para queda foi identificada como fator contribuinte para a redução desse agravo, auxiliando a não ocorrência deste evento que, apesar de ser prevenível, pode determinar consequências graves incluindo o óbito.



Acidentes por quedas
; Pacientes internados
; Hospitalização; Segurança do paciente
; Cuidados de enfermagem
; Revisão

Introduction

The falls of hospitalized patients have a striking effect on health due to the fact of being a problem related to patient safety, in addition to an issue for the quality of care in various health institutions in the world(¹). The falls occurred during hospitalization represent one of the most important instances of the lack of security, and are often responsible for the increase in number of hospitalization days and worse recovery of patients(²).

The World Health Organization (WHO) defines a fall as inadvertently coming to rest on the ground or other lower level, excluding intentional change of position to lean on furniture, walls or other objects(³).

The incidence of falls in the world varies depending on the studied population(⁴-⁶). In 2007, the magnitude of this event in the United States of America (USA) showed that about one million patients had falls in hospitals(⁴). In the years 2008 and 2009, in England and Wales, 283,438 thousand events were reported(⁵). In 2004, in Australian hospitals, 17% of falls occurred in the elderly(⁶).

In Brazil, in 2009, around 320 thousand hospitalizations occurred due to falls, which accounted for nearly 40% of total admissions due to external causes(⁷). In the elderly, the national hospitalization rate for falls reached 27.6%, that is similar to the data of the southern region (26.9%)(⁸).

Falls are responsible for two out of five adverse events in hospitals, and its frequency varies from 1.4 to 13.0 per every 1000 patients per day(⁴). In general, these events aggravate health problems and the main consequences are trauma (fractures, for example); unscheduled removal of catheters, drains and probes; fear of falling again; emotional changes; clinical worsening; and even death. Such events may also increase the length of hospital stay and cost of treatment(⁹).

In the U.S., the costs of treatment of falls totaled 19 billion dollars per year. England and Wales reached 15 million euros annually, which represents 92 million euros per year for every 800 beds(¹⁰). In Brazil, the expenses of the Unified Health System (SUS) with fractures due to falls in the elderly reached 81 million dollars per year(¹¹).

In the elderly, falls may decrease functional capacity, resulting in inability to perform activities of daily living. They may have consequences also for the family and health services, which need to mobilize for the treatment and recovery of this population(⁹).

It is essential that health professionals identify the risk factors for falls in order to avoid this condition(¹). The measurement of the level of risk of patients may influence the choices of preventive interventions.

In clinical practice, there is the need to generate knowledge through studies with quantitative and qualitative approaches, not only regarding risk factors intrinsic to patients that are considered in models of prediction(¹), but also on extrinsic factors, which are commonly related to the outcome of falls.

Given the importance of adopting procedures that eliminate or reduce the risk of falls, a prior knowledge of which individuals have a higher probability for this event is necessary, from the identification of the complex relationship of its risk factors.

This study aimed to identify in the literature the risk factors for falls in hospitalized adult patients.

Method

This is an integrative literature review(¹²), that groups the results obtained in research on a same subject. It was developed in five steps: problem formulation, data collection, data evaluation, analysis and interpretation of data and presentation of results. Its aim is the analysis and synthesis of data in order to develop a more comprehensive explanation of a particular phenomenon(¹²). The formulation of the problem comprised the following research question: what are the risk factors for falls in hospitalized adult patients? The literature search was carried out in Portuguese, Spanish and English, including articles published from 1989 to October 2012. The time frame was defined based on the publication of the first predictive model for falls(¹³), in 1989.

In the review were only included the studies in which the scenario was represented by units of clinical and surgical adult hospitalization because these depict the higher prevalence of the event(⁴-⁵). And also studies that answered the research question, selected by title and abstract of the articles. Publications repeated in more than a database were analyzed only once.

The searched database were the Latin-American and Caribbean Center on Health Sciences Information (LILACS), Scientific Eletronic Library Online (SciELO), MEDLINE and Web of Science, considering the following descriptors: accidental falls, hospitalization, patient safety, risk assessment, nursing process, nursing diagnosis. The keywords falls and hospital were also used adapting to the language, in accordance with the database.

For the data analysis was used a synoptic table containing variables that answered the research question of the study. The topics of interest were: article title, authors, year of publication, location of the study, journal, method, population/sample, results/risk factors of falls.

Figure 1 outlines the process of selecting the articles, starting with the grouping of descriptors, consulted databases, the number of articles that answered the research question and the number of articles selected according to the inclusion criteria. It is noteworthy that the items identified in LILACS are also indexed in SciELO.

Figure 1

Selection of articles by grouping of descriptors in databases. Porto Alegre, RS, 2012

Results

The countries of publication of studies that comprised the sample (n=71) were: United States of America (USA), 23 (32.3%); Australia, eight (11.2%); United Kingdom, seven (9.8%); Switzerland, six (8.4%); Israel, five (7%); Canada and China, with four each (5.6%); Brazil, three (4.2%); Japan, two (2.8%); Bosnia, Portugal, Egypt, Singapore, Colombia, Germany, Italy, Turkey and Serbia had one study each (1.4%).

From the selected studies, Table 1 shows the characterization of the sample according to the period of publication.

Table 1
Sample distribution by period of publication - Porto Alegre, RS, 2012

Period of publication	N(%)
1989├1999	0
1999├2001	1 (1.4)
2001├2003	2 (2.8)
2003├2005	14 (19.7)
2005├2007	6 (8.4)
2007├2009	11 (15.4)
2009├2011	16 (22.5)
2011├┤2012	21 (29.5)
Total	71(100)

The distribution of the sample was carried out according to the types of studies: cross-sectional studies, 23 (32.3%); cohort, 19 (26.7%); case-control studies, nine (12.7%); literature review, 10 (14.4%); randomized controlled trials, five (7.0%); qualitative studies, two (2.8%); and systematic reviews, three (4.2%).

Chart 1 presents the different types of study of this integrative review summarized, showing the evolution of knowledge about the topic of study.

Chart 1

Summary of studies and its risk factors - Porto Alegre, RS, 2012

Chart 2 shows the use of rating scales for risk for falls among adults in the hospital context, more specifically in clinical/surgical inpatient units, in 10 studies (14%).


The risk factors for falls presented in this review are related to the patient (intrinsic), the hospital environment and the working process of health professionals, especially in nursing (extrinsic).


Chart 2

Predictive scales for falls and its risk factors - Porto Alegre, RS, 2012

Discussion

Considering the number of studies on risk factors for falls included in this integrative review, among which 23 were published in the USA (32.3%), followed by Australia with eight studies (11.2%) and the United Kingdom with seven (9.8%), it is noteworthy that the subject of patient safety had a great impact in the late 1990s in the U.S., from the publication of the report called Toerrishuman: building a safer health system by the Institute of Medicine. This report estimated that between 44,000 and 98,000 Americans die each year due to preventable errors in healthcare(⁸⁵). This concern also gained ground in countries like Australia, UK and Latin America (Brazil, Colombia)(⁸⁵).

Among the 18 countries of studies, Brazil is in eigth place in terms of publication, with three papers (4.2%).

In the early twentieth century came a conducive environment for the incorporation of actions for safety in health care and, consequently, for the development of scientific research on this issue in Brazil. One of these actions was the creation of the National Health Surveillance Agency (ANVISA), in 1999, by the government of Fernando Henrique Cardoso, to ensure the health safety of products and services(⁸⁶-⁸⁷).

In October 2004, the Ministry of Health launched the National Alliance for Patient Safety (Aliança Nacional para a Segurança do Paciente), with the aim of spreading knowledge and solutions found to improve care processes involved in patient safety(⁸⁸). In this context, by initiative of the Pan American Health Organization, was established the Brazilian Network of Nursing and Patient Safety – REBRAENSP, in May 2008. This was a strategy adopted by a group of nurses for the articulation and cooperation between institutions of health and education, aiming at strengthening the safety and quality care(⁸⁷).

As a result of the global movements related to this problem, scientific studies have been carried out in order to identify and understand the errors and adverse events, take corrective and proactive measures, analyze systemic failures and its causal factors, as well as to develop strategies that ensure a safe practice(⁸⁹).

The number of publications progressively increases, showing the increasingly imminent need of approaching issues related to the knowledge and safety of risk factors for falls in the hospital setting. The term called patient safety is defined as the reduction to a minimum acceptable level/degree of unnecessary risk of harm during the health assistance(⁹⁰).

The development of studies related to the risk of unnecessary harm, in particular to falls in inpatient and/or surgical units, is distributed in 23 cross-sectional studies (32.3%), highlighting the number of 19 cohort studies (26.7%), nine case-control studies (12.7%) and five randomized clinical trials (7%). It is observed that studies of higher level of evidence are developed in smaller numbers, which demonstrates the need for researchers to carry out robust jobs that best characterize predictors of falls.

Risk factors related to patients represent the majority of predictors of falls identified in the reviewed studies, in which several terms used to assess the level of consciousness of patients were identified, such as disorientation, confusion, dementia, organic mental disorder, cognitive impairment, delirium and even agitation.

Another risk factor that is approached in different ways includes assessing the mobility of patients that is described as changed, with loss of balance, difficulty in gait and sensory disabilities(¹⁶,³⁸,⁶⁶).

It was found that reports of the identification of the sensory and mobility of patients, especially at the time of the fall, are uncommon. One of the possible reasons is the lack of assessment records of patients on the outcome or, when these are available, are also often inaccurate(⁹¹). The different terms used may indicate the complexity of the evaluation of these aspects.

In this sense, the construction of conceptual and operational definitions for risk factors could help to understand the different terms used to express the same situation.

Regarding the use of drugs, those with potential depression of the central nervous system are related to falls, such as benzodiazepines(,,,,,,,,,), antipsychotics(²⁶,³³,³⁸,⁴⁴,⁴⁹,⁵⁶,⁵⁹,⁷⁶), antidepressants(³⁷,⁴³,⁵⁹), narcotics/opiate(³³-³⁴,⁷¹), barbiturate(³³-³⁴,⁷¹), barbitúricos(¹⁴,¹⁶,²⁷,³²,³⁷,⁴⁷-⁴⁸), antihistamines(³¹,³⁶,⁷¹), anticonvulsants(³¹,³⁶,⁴⁴,⁵⁹,⁶⁰) and sedatives(²⁰,²⁷,³⁷) in general. Medicines that may cause hypotension are also associated with risk of falls (antihypertensives)(¹⁶,²⁶,³⁵,⁴⁹,⁶⁰), in addition to diuretics(¹⁶,²⁶,³⁶-³⁷,⁵⁹,⁷⁴). Laxatives were mentioned in a few studies(³⁷,⁷²,⁵⁹). However, the antidiabetics that have excelled in only one case-control study(³¹) and another cross-sectional(⁴⁹), and the antiarrhythmics(²⁶,⁴³) and anticoagulants(⁴⁴), that were mentioned in this integrative review only in literature reviews, do not seem to show strong enough evidence to be associated with the outcome.

These evidences reinforce the need for professionals knowing the risk factors for falls, and the criteria to identify and evaluate them in patients, because only few instruments checked for risk assessment of falls were tested in different scenarios, such as the Morse Fall Scale(⁹²-⁹³), the St Thomas Risk Assessment Tool in Falling Elderly Inpatients(⁹⁴-⁹⁵) (STRATIFY) and the Heindrich II Fall Risk Model(⁹⁶), instruments that vary in terms of sensitivity and specificity(⁹⁴). There is also the Dowton’s Risk of Falls Scale(⁹⁷), which groups only intrinsic risk factors. This scale has not shown to be accurate in the prediction of falls either(⁹⁷), or has been used in an adapted form with the inclusion of some risk factors of the nursing diagnosis Risk of falls among its components(⁹⁸). Other scales such as the Johns Hopkins(⁸³), the Harrogate Assessment, the RAFS II and the FRASE(⁸⁴) were also mentioned in this review, but did not show validation tests in different contexts.

This corroborates that extrinsic, environmental factors or related to the work-process, together or not with intrinsic risk factors, are crucial for risk identification, as mentioned in studies that associate infection risks to factors related to work and professional qualification(⁹⁹). From the view of health problems related to hospital infections such as the prevalence of infections and multidrug-resistant organisms, there is published evidence(⁹⁹) establishing associations between such events and the staff-patient relationship.

However, from the analysis of risk factors in the hospital environment, a gap was identified in knowledge by producing a small number of research related to staff-patient questions and how it is linked to the risk of patients suffering falls. And even intrinsic aspects such as fear of falling, were not mentioned in the different types of study of this integrative review, despite having shown to be important risk factors(¹⁰⁰).

Conclusion

This integrative review identified risk factors for falls of hospitalized adult patients, especially in inpatient clinical and/or surgical units. The intrinsic risk factors are important in predicting the risk of falls, as demonstrated in the studies. However, factors related to work processes, such as the staff-patient relationship, are also key. From the studies analysis it was found a gap on risk factors, especially those related to the work process as an additive outcome.

Regarding the diversity of studies presented in this integrative review, we can not fail to mention that the risk factors, according to the methodological rigor of each study, may have different weights in the prediction of the event.

With this work, we hope to have contributed to the expansion of knowledge about issues of patient safety and clinical practice of health professionals, especially in nursing, helping with the non-occurrence of falls, which despite being a preventable event can cause death.

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Publication Dates

• Publication in this collection
  June 2014

History

• Received
  30 Aug 2013
• Accepted
  29 Mar 2014