by Gowri Betrabet Gulwadi, Margaret P. Calkins
Published and Funded by: The Center for Health Design and The Coalition for Health Environments Research (CHER)
INTRODUCTION
The phenomenon of falls is a growing concern in various community, workplace, and healthcare settings. When falls occur, three important interrelated aspects demand attention: the health and physical condition of the faller, a risk of fall recurrence, and the immediate and longterm costs associated with a fall. Fall incidents are precipitated by personal (e.g., physiological) and environmental (e.g., type and condition of floor) factors. Interventions aimed at fall reduction vary in their emphasis; some identify and monitor individual conditions of the person experiencing the fall, others seek to alter specific environmental circumstances surrounding the fall incident.
The majority of research focuses on community based falls and addresses factors influencing the safe, independent mobility of people (particularly older adults at risk of recurrent falls) within their homes and surroundings. There have also been some efforts at studying fall prevention measures to maintain worker safety (OSHA, 2007) and create awareness of fall risk factors. For example, O’Dell (1998) discusses fall related workplace concerns among employees who spend long hours on their feet. However, regardless of the location of a fall, many fall related incidents result in at least a visit to a healthcare setting, and often a more extended stay. Given that a previous fall is the number one risk factor for a future fall, healthcare settings must attend to a complex interaction of intrinsic and extrinsic factors that collectively contribute to fall risk and falls among their patients.
Falls occur in various types of healthcare settings—surgical units, perioperative units, labor/delivery/recovery/postpartum units, rehabilitation units, nursing homes, assisted living centers, etc. Although older adults are more prone to fall risk than younger people (Brandis, 1999), falling and fall-related injuries are pervasive phenomena among those younger than 65 as well (Rollins, 2004) and present expensive post-fall healthcare and litigation costs. While some research has examined fall risk factors related to cohorts of individuals with similar conditions, such as lower-limb amputees (Gooday & Hunter, 2002), people in palliative care (Goodridge & Marr, 2002), cancer patients (Holley, 2002), people with dementia (Van Doorn,et al. 2003), and visitors (Sicher, 1995), much of the focus in the literature is on intrinsic factors only. However, the pervasiveness of falls in healthcare settings suggests a need to take a broader perspective. Recognizing that widening the perspective will better define the role of environmental factors in fall detection and prevention, this report explores environmental correlates of falls in healthcare settings.
The Scope of the Problem
In 2005, there were 1.8 million fallrelated nonfatal injuries (e.g., fractures, traumas) that were severe enough to seek medical attention; while in 2003, there were 13,820 fall related fatalities among people 65 years and older (National Center for Injury Prevention and Control, 2006). Approximately 10% (or 180,000) of these fallrelated injuries occurred in healthcare institutions (ECRI, 2006). The Minimum Data Set (MDS) active resident information report indicates that state rates of nursing home residents falling during a six-month period vary from 16.9% to 35% (CMS, 2005), which translates to roughly 593,700 falls. However, there is other evidence that the MDS under-reports falls (Hill Westmoreland & Gruber Baldini, 2005).
Risks of recurrent falls and injuries from falls present both direct insurance costs and legal/liability costs and consequences (National Center for Injury Prevention and Control, 2006; Zinn, 2003). The average healthcare cost for a fall injury (without factoring in physician services) was close to $20,000 (Rizzo et al., 1998) and continues to rise.The direct costs for fall-related injuries in the United States for people 65 and older are projected to reach $43.8 billion by the year 2020 (Englander, Hodson, & Terragrossa, 1996), of which at least $3.6 billion would be associated with falls occurring within a healthcare setting. Thus, there are significant financial reasons why attending to risk factors for falls and injuries from falls is an urgent task at the core of many research efforts.
Challenges in Conducting Falls Research
Underreporting and inconsistencies in reporting are complicated by multiple definitions of falls both in literature (Zecevic,Salmoni,Speechley,&Vandervoort,2006) and in hospital and nursing home incident reports. Further, falls are typically unanticipated events, and, thus, are seldom directly observed. As such,most falls are retrospectively recorded in incident reports.This retrospective process has led to the documentation of person-related factors such as physiological or psychological condition and medication, but often insufficient documentation of environmental conditions surrounding the fall. Additional challenges are presented when falls occur outside the purview of a documentation system such as an incident report, e.g., when hospital visitors fall. These types of incidents are likely to be severely underreported in terms of both frequency of occurrence and description of factors that led to the incident. Beyond these challenges, the majority of falls researchers do not conceptualize or include environmental factors as discrete variables in their research, making it virtually impossible to determine the relative role of the built environment on fall and fall risk.
Exploring Fall Risk Factors
Fall risk is clearly a multimodal function. If a person is weak, he or she may fall while trying to get up from bed, even if there is a bedrail. A loose rug or deep threshold at a doorway may cause a fully healthy and ambulatory individual to trip and fall. Most often, it is a combination of factors that leads to a fall. In developing a framework from which to examine fall risk, it is useful to refer back to Lawton and Nahemow’s competence press model (1973). Adapting a model originally developed by Lewin (1951), they suggested that events are the result of individual, environmental, and interactive factors, represented by the equation B = f(P, E, (PxE)).
In this model, B (behavior, or in the case of this paper, falls or fall risk) is the interface between P, the person (intrinsic factors); E, environment (extrinsic factors); and PxE, or the unique interaction between the person and the environment (for instance, how a person performs an activity or views the environment).Thus, to impact B (falls), the most efficacious strategy would be to impact all the elements on the other side of the equation: P, E, and PxE.The charge of this project, however, was to focus specifically on the E factor—particularly the design of the built environment of healthcare settings. By focusing on a detailed, comprehensive, and evidencebased analysis of just E, future projects will be better able to incorporate intrinsic (P) and interactional (PxE) factors to explore both fall risk and intervention strategies.
Environmental factors ranging from lighting levels to type of flooring are significant fall risk factors and can be relatively easily manipulated to create fallprevention and injuryreduction design interventions. However, the first step in developing environmental design interventions is to find evidence-based environmental correlates of falls. This paper presents the findings from a review of 171 fallrelated articles, specifically focusing on environmental factors that were empirically studied, mentioned, or recommended in each article. To further discern the validity and clarity of the environment-related information from each article, a four-tier rating system (described in the next section) was used to provide an easy method for readers to ascertain the level of confidence they should place in the information.
Finding Environmental Correlates of Falls: The Search Strategy
The project’s main goal was to examine and report empirical evidence that links environmental features with outcomes related to falls in healthcare settings, including acute care, assisted living, and nursing home. The gold standard from which evidence-based medicine and practice guidelines are drawn relates to (a) the validity of the information and (b) the clarity of the intervention (de Vet,Touler, & Bouter, 2003). Thus, the literature review focused particularly (but not exclusively) on peer reviewed empirical evidence that is specifically related to the physical environment. Database searches were conducted on Medline, Ageline, CHID/ADEAR, and National Library of Medicine. Initial search parameters included the following terms: falls, injury, healthcare, nursing home, assisted living, flooring, and glare. The most productive search strategy was reviewing the references of previously acquired articles to identify new references.
Articles were included if they met the following criteria:
- Peer reviewed (for the initial search—some non peer-reviewed articles were subsequently included)
- Published in English
- Published in 1980 and after
- Theoretical and/or empirical
- Addressed healthcare settings (includes longterm care and acute care settings)
- Included a conceptualization of the physical environment even if a specific environment or environmental features were not the research focus
Some articles were clearly less relevant than others, having very little information about the physical environment. However, they were included if they presented information on factors that were closely related to the environment or had direct implications for the environment. Some articles pertaining to falls among community dwelling residents were included if they presented relevant instructive information regarding the environment. The articles covered topics on reducing risk of falling, preventing falls, detecting falls, and reducing the risk of injury from falls. While interventions were directed at the intrinsic/individual factors, environmental factors, and interactional or performance of activity factors (Whitney, 1999), included in this report are recommendations that are specifically relevant to the design and use of the physical environment.
| Attachment | Size |
|---|---|
 Download PDF | 4.34 MBpdf | 4.34 MB |