A Retrospective Cohort Study of Falls in a Psychiatric Inpatient Setting Elizabeth C. Poster, R.N., Ph.D. Luc R. Pelletier, M.S.N., R.N., C.S. Karen
Kay,
M.N.,
R.N.
Severalfactors increase the psychi atric inpatient's risk offalling, in cluding side effects of medications and mental disorders that decrease awareness of environmental baz ards. in this study, rates offalling were determined for a cohort of
4,156 psychiatric inpatients over
34 months.A totalof494falls oc curred among 376 patients. Thir ty-five percent of the patients who fell required medical or nursing intervention. Forty-eight percent of the falls occurred in the over-60 age group. When other results were adjusted for age, neither gender nor diagnosis wasfound to increase the risk offalling, except for de pressed patients under 20 years
old, who were at less risk, and psy chotic patients in their 60s, who were at greater risk. The authors discuss the costs offalls and preven tive efforts instituted in their set ting. Every year thousands of patients are victims of falls suffered during hos pita! stays. While not all falls lead to injury, patient falls are of concern from both quality-of-care and finan cial points ofview (1). In acute care hospitals, between 25 and 89 percent of all incident reports are related to patient falls (2—9), with a corre sponding rate of injury between 23
and 33 percent (4—6).
Plaza, Room 17-364, Los Angeles, California 90024.
Profiles of high-risk patients em phasize increased risk beginning at age 60 to 65; the presence of balance, mobility, and gait problems (1,10); and the use of medications such as diuretics, sedatives and narcotics, an tihypertensives, and psychotropics (1 1). Environmental factors also con tribute to falls, including unstable furniture, wet or glossy floors, and poorly soled or ill-fitting shoes (1). In acute care medical settings, pa tients susceptible to falls have been profiled, and multiple interventions, policies, and procedures have been described (10,1 1). It is remarkable that a survey of the literature revealed no research on falls ofpsychiatric inpatients in dif ferent age groups. Only two studies reported on falls in inpatient gero psychiatric settings (1 1,12). This is particularly surprising because psy chiatric patients have a number of high-risk factors, such as labile men tal status that may alter judgment and lead to maladaptive behavior, use of medications that can affect gait and proprioception, and disor ders that may alter awareness of envi
714
July 1991
Dr. Poster is director of nursing research and education at the University
of California—Los An
geles Neuropsychiatric and
Hospital
Institute
(UCLA-NPI&H)
and assistant clinical professor at the UCLA schools of medicine and nursing. Mr. Pelletier was formerly director of quality man agement
at UCLA-NPI&H
and is
now a regional clinical specialist with Psychiatric Institutes of America, Inc., and assistant cmi cal professor at the UCLA School of Nursing. Ms. Kay is a research assistant at UCLA-NPI&H. Ad dress correspondence to Dr.
Poster at UCLA-NPI&H, Nurs ing Department, 760 Westwood
Vol. 42
No. 7
ronmental and safety hazards. In ad dition, both young children and the elderly, two age groups especially prone to accidents and falls, are seen in the inpatient psychiatric setting. Patient falls are a clinical safety issue, and new standards developed by the Joint Commission on Ac creditation of Healthcare Organiza tions (JCAHO) guide both medical surgical and psychiatric hospitals in developing “¿clinical and administra tive activities designed to identify, evaluate, and reduce the risk of patient injury associated with care (13).
Specific
requirements
charge
the medical staff to identify general areas ofpotential risk in the clinical aspects ofpatient care and safety, to develop criteria for identifying and evaluating specific cases with poten tial risk, to correct problems iden tified by risk management activities, and to design programs to reduce risk in the clinical aspects of patient care and safety (14). Given these JCAHO directives, the lack ofan established data base on patient falls in inpatient psychiat nc units, and recent falls with more serious medical outcomes in the authors' setting, a retrospective co hort study ofpatient falls was con ducted. We wanted to determine the incidence and nature of falls and whether certain characteristics of the patients or setting contributed to falls. We were also interested in the medical outcomes—as opposed to the psychiatric treatment out comes—of patients who fell.
Methods Study design andpopulation. A re trospective cohort design in which characteristics of a defined cohort of patients were obtained from hospital records was used. Members of the cohort who experienced falls were Hospital and Community Psychiatry
identified from other hospital re cords, and comparisons were made between cohort patients who fell and those who did not. For this study the cohort con stituted all admissions to the UCLA Neuropsychiatic Institute and Hos pital (UCLA—NPI&H) who were discharged betweenjanuary 1, 1986, and October 3 1, 1988. UCLA NPI&H is a 209-bed university hos pita! with an average of 39,000 an nual patient-days. The eight in patient units include two adult units, two child units, one gerop sychiatric unit, two adolescent units, and one neurology unit. The majori ty ofpatients are voluntary. The type ofunit and the patient's age, gender, psychiatric diagnosis, and dates of admission and discharge were ob tamed from computerized hospital records. Falls during the 34-month study period were identified from unusual occurrence reports. Incidents in such reports included falls, medication er rors, inj uries, unauthorized absences, confiscation of contraband, treat ment errors, property damage or loss, suicide attempts, physical aggres sion, sexual contact, adverse drug reactions, and death. Definitions. Categories of psy chiatric diagnoses were based on DSM-lIl definitions ( I 5). Four cate gories had enough patients for statis tical analysis, and the analysis was limited to patients in these categor ies. The categories were depression (DSM-III 296.2x, 296.3x, 296.82, 300.5, 309.0, 309. 1, and 3 1 1), de mentia (DSM-III 290.xx, 292.81,
Table 1 Incidence offalls (N=494) by psychiatric inpatients (N=376) overa 34-month period, by age, gender, and clinical
characteristics pa
fell
CharacteristicAll rate1pAgegroup
Kay,
M.N.,
R.N.
Severalfactors increase the psychi atric inpatient's risk offalling, in cluding side effects of medications and mental disorders that decrease awareness of environmental baz ards. in this study, rates offalling were determined for a cohort of
4,156 psychiatric inpatients over
34 months.A totalof494falls oc curred among 376 patients. Thir ty-five percent of the patients who fell required medical or nursing intervention. Forty-eight percent of the falls occurred in the over-60 age group. When other results were adjusted for age, neither gender nor diagnosis wasfound to increase the risk offalling, except for de pressed patients under 20 years
old, who were at less risk, and psy chotic patients in their 60s, who were at greater risk. The authors discuss the costs offalls and preven tive efforts instituted in their set ting. Every year thousands of patients are victims of falls suffered during hos pita! stays. While not all falls lead to injury, patient falls are of concern from both quality-of-care and finan cial points ofview (1). In acute care hospitals, between 25 and 89 percent of all incident reports are related to patient falls (2—9), with a corre sponding rate of injury between 23
and 33 percent (4—6).
Plaza, Room 17-364, Los Angeles, California 90024.
Profiles of high-risk patients em phasize increased risk beginning at age 60 to 65; the presence of balance, mobility, and gait problems (1,10); and the use of medications such as diuretics, sedatives and narcotics, an tihypertensives, and psychotropics (1 1). Environmental factors also con tribute to falls, including unstable furniture, wet or glossy floors, and poorly soled or ill-fitting shoes (1). In acute care medical settings, pa tients susceptible to falls have been profiled, and multiple interventions, policies, and procedures have been described (10,1 1). It is remarkable that a survey of the literature revealed no research on falls ofpsychiatric inpatients in dif ferent age groups. Only two studies reported on falls in inpatient gero psychiatric settings (1 1,12). This is particularly surprising because psy chiatric patients have a number of high-risk factors, such as labile men tal status that may alter judgment and lead to maladaptive behavior, use of medications that can affect gait and proprioception, and disor ders that may alter awareness of envi
714
July 1991
Dr. Poster is director of nursing research and education at the University
of California—Los An
geles Neuropsychiatric and
Hospital
Institute
(UCLA-NPI&H)
and assistant clinical professor at the UCLA schools of medicine and nursing. Mr. Pelletier was formerly director of quality man agement
at UCLA-NPI&H
and is
now a regional clinical specialist with Psychiatric Institutes of America, Inc., and assistant cmi cal professor at the UCLA School of Nursing. Ms. Kay is a research assistant at UCLA-NPI&H. Ad dress correspondence to Dr.
Poster at UCLA-NPI&H, Nurs ing Department, 760 Westwood
Vol. 42
No. 7
ronmental and safety hazards. In ad dition, both young children and the elderly, two age groups especially prone to accidents and falls, are seen in the inpatient psychiatric setting. Patient falls are a clinical safety issue, and new standards developed by the Joint Commission on Ac creditation of Healthcare Organiza tions (JCAHO) guide both medical surgical and psychiatric hospitals in developing “¿clinical and administra tive activities designed to identify, evaluate, and reduce the risk of patient injury associated with care (13).
Specific
requirements
charge
the medical staff to identify general areas ofpotential risk in the clinical aspects ofpatient care and safety, to develop criteria for identifying and evaluating specific cases with poten tial risk, to correct problems iden tified by risk management activities, and to design programs to reduce risk in the clinical aspects of patient care and safety (14). Given these JCAHO directives, the lack ofan established data base on patient falls in inpatient psychiat nc units, and recent falls with more serious medical outcomes in the authors' setting, a retrospective co hort study ofpatient falls was con ducted. We wanted to determine the incidence and nature of falls and whether certain characteristics of the patients or setting contributed to falls. We were also interested in the medical outcomes—as opposed to the psychiatric treatment out comes—of patients who fell.
Methods Study design andpopulation. A re trospective cohort design in which characteristics of a defined cohort of patients were obtained from hospital records was used. Members of the cohort who experienced falls were Hospital and Community Psychiatry
identified from other hospital re cords, and comparisons were made between cohort patients who fell and those who did not. For this study the cohort con stituted all admissions to the UCLA Neuropsychiatic Institute and Hos pital (UCLA—NPI&H) who were discharged betweenjanuary 1, 1986, and October 3 1, 1988. UCLA NPI&H is a 209-bed university hos pita! with an average of 39,000 an nual patient-days. The eight in patient units include two adult units, two child units, one gerop sychiatric unit, two adolescent units, and one neurology unit. The majori ty ofpatients are voluntary. The type ofunit and the patient's age, gender, psychiatric diagnosis, and dates of admission and discharge were ob tamed from computerized hospital records. Falls during the 34-month study period were identified from unusual occurrence reports. Incidents in such reports included falls, medication er rors, inj uries, unauthorized absences, confiscation of contraband, treat ment errors, property damage or loss, suicide attempts, physical aggres sion, sexual contact, adverse drug reactions, and death. Definitions. Categories of psy chiatric diagnoses were based on DSM-lIl definitions ( I 5). Four cate gories had enough patients for statis tical analysis, and the analysis was limited to patients in these categor ies. The categories were depression (DSM-III 296.2x, 296.3x, 296.82, 300.5, 309.0, 309. 1, and 3 1 1), de mentia (DSM-III 290.xx, 292.81,
Table 1 Incidence offalls (N=494) by psychiatric inpatients (N=376) overa 34-month period, by age, gender, and clinical
characteristics pa
fell
CharacteristicAll rate1pAgegroup
