Case Presentation:
A 70‐year‐old woman with a history of emphysema and recurrent deep venous thrombosis was admitted to the hospital with dysuria and acute renal failure. Physical exam was notable for mild fluid overload, and laboratory studies revealed an elevated creatinine and an INR of 2.7 on warfarin. On admission, the bedside nurse initiated standard fall precautions based on a Schmid fall risk assessment and because the patient required assistance with activities of daily living at home. By hospital day 3, she was clinically improving, and fall precautions were lifted based on an improved Schmid score. However, the patient had difficulty sleeping during her stay, and Zolpidem was ordered at bedtime. That night, a few hours after receiving the sleep medication, the patient's husband was wakened by the sound of his wife crying out from severe hip pain, and he found her on the floor. Immediate evaluation by the nurse and covering physician prompted placement of a bed alarm and treatment with a nonopioid analgesic. When the primary team arrived in the morning, they ordered a left hip x‐ray that showed an intertrochanteric fracture. The patient required surgical intervention and after a postoperative course complicated by delirium, was discharged on hospital day 19 to a skilled nursing facility.
Discussion:
Falls are common in hospitalized patients and associated with significant morbidity and increased length of stay. Fall risk, as in this case, can fluctuate throughout the hospital course depending on changes in clinical condition or effects from newly prescribed medications. Aggressive utilization of fall prevention strategies, such as early involvement of physical therapy, avoidance of sedatives, and the adoption of a nonpharmacologic sleep protocol may have mitigated this patient's fall risk. The mnemonic ABCS can identify patients at highest risk for injury from a fall: very advanced Age, Bones weakened by osteoporosis or multiple metastatic lesions. Coagulopathy or anticoagulants, and postoperative/postsurgical status. Our patient was at high risk for injury from a fall given her elevated INR. Finally, all patients who suffer falls in the hospital should be managed with a standardized postfall assessment. This tool embraces a multidisciplinary approach that uses standardized protocols to guide providers about recommended imaging, monitoring, and documentation. In our case, a standardized postfall assessment may have prompted a more timely diagnosis of the patient's hip fracture with imaging ordered at the time of the fall.
Conclusions:
Falls can be devastating to patients and challenging to both prevent and manage for providers. Adopting standardized risk assessment tools, identifying patients who are at high risk for injuries from falls, and developing a postfall assessment tool are key components of a comprehensive fall prevention program.
Author Disclosure:
E. Murphy, none; C. Graf, none; N. Sehgal, none.