ASSESSMENT OF RISK AND INCIDENCE OF FALLS IN NEUROSURGICAL INPATIENTS

Neurosurgical patients may present motor, sensitive and balance impairment and increased risk of falling. The aim of this study was to evaluate the fall-related risk factors and the incidence of falls in the pre and postoperative period of neurosurgical patients. A prospective cohort study with a research population of patients undergoing elective neurosurgical procedures. Ninety-seven patients took part in the study. Eight (8.2%) have presented falls with a total of 12 falls (12.4%). In two falls (16.7%), bed side rails were down, whereas in six falls (50%), beds had no rails at all. There was no difference among fall-related risk factors during pre and the post-operative periods. We have concluded that most falls could have been prevented through an improvement in the hospital internal structure and with the introduction of a falls prevention program.


INTRODUCTION
A fall is defined as a sudden and unexplainable change in position, in which patients come to the floor unintentionally (1) .Over 70% of inpatients falls occur inside the rooms, during the change to bed, chair or wheelchair, and 19% occur in deambulation when going and coming back from the toilet (1)(2) .
Among the diseases most commonly associated with falls, musculoskeletal lesions have been observed as directly related to it, and neurological and cardiac diseases are indirectly related to it (7) .
Around 23% of falls in hospitalized patients result in lesions, and 83% of these lesions are bruises, sprains and lacerations, and 9% are fractures (1) .
Among fractures, 4% occur in the bones of the hips, and 3.5% in the bones of the skull (2) .Falls can lead to an increase in admission length and in the cost of treatment, as well as causing discomfort to patients, and skepticism regarding nursing services (8) .
The implementation of many falls prevention programs have been successful and they are made of three elements: identifying the risk for falls, introducing techniques for prevention and reassessment of patients to keep or include new risk factors (4) .With these measures is expected to decrease fall rates and complications in hospitalized patients.
Fall is considered as an indicator of quality in nursing care and it is also one of the indicators monitored by Quality of Care in Hospital program that aims at improving quality of care, with the purpose of reaching excellence in hospital care (9) .

METHOD
The assessment of motor function was performed with classification of level 0 to 5 (10) .In the item history of previous fall before admission, the reason, place and number of falls have been collected together with presence and type of lesions.
Risk factors related with environment included: beds with side rail, beds without side rails, high beds, and call bells out of reach for patients.
According to patients, side rails were either up or down most of the times.Beds were considered high when patients needed a lather to climb up or down the beds.
In risk factors related to nursing we have collected: patients requesting or not the help of the nursing staff.
Risk factors for falls were assessed in the pre and postoperative periods.Daily data collection was performed regarding the occurrence of fall and number of patients/day.Fall rate was calculated by dividing the number of falls by the number of patients/ day and multiplying it by 1000 (9) .
Statistical analysis of risk factors in the pre and postoperative period was performed by Chisquare test or Fischer's exact test, considering p values <0.05 as statistically significant.
There was no statistical difference between patients who fell in the pre and in the postoperative period (p<0.72).Places of fall were: 7 (58.3%) in the preoperative room; 4 (33.3%) in the postoperative room and 1 (8.4%) the fall occurred in the toiled in the postoperative period.Distribution of the ways patients fell was the following: 5 falls (41.7%) when stepping down the bed; 3 (25.0%) in deambulation in the bedroom; 3 (25.0%)when changing position on the bed, and in the 3 cases, the bed did not have side rails, and in 2 cases beds were high; and 1 (8.3%) fall occurred when patient was leaving the toilet bowl.
One patient (8.3%) evolved with subcutaneous bruise in the frontal region after the fall.Table 4 presents reasons referred by patients and by nursing that led to fall during hospital stay.
There was predominance of motor impairment in the pre and postoperative period as the main reason for fall.
Table 4 -Reasons for fall referred by patients and by nursing of the unit during hospital stay Figure 1 assesses the rate of fall per month.
Fall rate of a patient was higher in February with 10.2 falls/1000 patients day.

DISCUSSION
Fall is the most common side effect in hospitalized patients, and 70% of the accidents occur inside the hospital (11) .Among patients, 2% fall during hospital stay (1) .
Elderly patients are at risk for fall, and 53% of falls occur in patients over 65 (5) .In neurological and neurosurgical wards, the risk of fall is regardless of age (1) .In this study, we have assessed that 25% of falls occur in patients who were over 65 years old.
Among the most common risk factor in neurological patients is muscular weakness, strongly

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associated with this type of fall and to fall generally speaking.A survey conducted with inpatients showed that muscular weakness was present in 80.9% of patients who fell (5) .Motor impairment was found in 4 patients (33.3%) who fell in the pre-operative period, and 2 (16.7%) in the postoperative; visual impairment associated with balance and/or gait disturbance was found in 3 patients (25%) who fell in the postoperative period.
Risk factors for fall are present in hospital patients in neurological and surgical units.However, the risk of fall is greater in psychiatric, neurological and/or neurosurgical wards (1) .In these wards, patients present several risk factors, such as level of awareness, hindered mobility, orthostatic hypotension, vesical or intestinal disturbances, sensory deficits, and previous history of falls.Falls among neurology patients occur twice as much as in other units (1) .
In risk factors associated with hospital environment, both problems of structure and process were assessed.High beds and those without side rails are related to problems with the structure of the hospital.Beds with side rails that remained lowered and not requesting nurse's assistance are related to failure in the process.
A survey assessing risk factors related to the presence of fall demonstrated that 56.1% of patients that fell had the side rails of their beds lowered.
Additionally, 44 (44.9%) of them referred they requested nurses' assistance sometimes, whereas only 11 (11.2%) said they always asked for nurses' assistance (11) .In this study, the number of patients that referred not requesting nurses' assistance was 16 (16.5%) in the preoperative period, and 8 (8.2%) in the postoperative period.In 2 falls (16.7%), the beds had their side rails lowered, and in 6 of them (50%), beds did not have side rails at all.
In this study, 8.2% of patients fell, which shows that in addition to risk factors related to patients, the difficulties found regarding structure and process may have contributed to the occurrence of falls.The rate of lesions caused by falls was 28% in neurological/neurosurgical wards (1) , whereas in other wards, this rate was 33.6 % (12) .We have observed in this study that 8.3% of falls caused lesions but no fracture.In another study 2% of patients had fracture (1) .
The rate of fall was 6.12 falls per 1000 patients day in a neurology ward (5) , while in this study, rates ranged from zero to 10.2 falls per 1000 patients day.
Factors related to structure and process contribute to these rates.
For these preventable falls, current beds have to be replaced by beds with side rails and height

CONCLUSIONS
There was no difference between risk factors for fall found in the pre and post operative period of neurosurgery.Rate of fall was 12.4%, and 6 falls (50%) could have been prevented with the improvement of hospital structure, 2 (16.7%) with the introduction of a program to prevent fall, and 4 (33.3%) if there was adherence of patients to request help for the nursing staff before performing any activity.

Falls have been divided
according to the period they occurred, pre or postoperative.Seven of the falls (58.3%) occurred in the preoperative period, and 5 (33.3%) in the postoperative.When risk factors were assessed, 4 patients (4.2%) who presented motor impairment in the pre-operative period did not present it in the postoperative.
adjustment.In addition to these measures, at hospital admission, there should be an assessment of the risk of falls, to determine prevention action during hospital stay.This assessment should also be periodical, since risk factors change.It is also important to involve Continuous Education of the hospital to educate the nursing team.

Table 1
presents features regarding age, gender, days of hospital stay and medical diagnosis.

Table 1 -
Distribution according to age, gender, days of hospital stay, and medical diagnoses

Table 2
presents risk factors related with neurosurgical patients in pre and postoperative period.

Table 2 -
Distribution of risk factors related with

Table 3 -
Distribution of risk factors related to the