Elsevier

Australian Critical Care

Volume 24, Issue 3, August 2011, Pages 167-174
Australian Critical Care

The incidence of falls in intensive care survivors

https://doi.org/10.1016/j.aucc.2011.06.001Get rights and content

Summary

Background

Falling among adults in acute care is an important problem with falls rates in tertiary hospitals ranging from 2% to 5%. Factors that increase the risk of falling, such as advanced age, altered mental status, medications that act on the central nervous system and poor mobility, often characterise individuals who survive a prolonged intensive care unit (ICU) admission.

Purpose

To measure the incidence of falls and describe the characteristics of fallers among intensive care survivors.

Methods

A comprehensive retrospective chart review was undertaken of 190 adults who were intubated and ventilated for ≥168 h and survived their acute care stay. Using a standardised form, several variables were extracted including falls during hospitalisation and risk factors such as age, severity of illness, and length of stay in intensive care and hospital.

Findings

Thirty-two (17%, 95% confidence interval 11.5–22.2%) patients fell at least once on the in-patient wards following their ICU stay. Compared with non-fallers, fallers were younger (53.2 ± 17.9 vs. 44.1 ± 18.3 years; p = 0.009) and had a shorter duration of inotropic support in ICU (84 ± 112 vs. 56 ± 100 h; p = 0.040). The majority of fallers were aged less than 65 years (84%). Both fallers and non-fallers had similar APACHE II scores (20 ± 8 vs. 21 ± 7; p = 0.673), length of stay in intensive care (14.2 ± 8.7 vs. 14.0 ± 9.7 days; p = 0.667) and hospital length of stay (43.9 ± 33.1 vs. 41.0 ± 38.8 days; p = 0.533).

Conclusion

Falling during hospitalisation is common in intensive care survivors. Compared with non-fallers, fallers were younger and required inotropes for a shorter duration. Those who survive a prolonged admission to an ICU may benefit from specific assessment of balance and falls risk by the multidisciplinary team.

Introduction

Falls are consistently the most commonly reported adverse event in hospitals accounting for as many of 41% of patient safety incidents.1, 2, 3 Falls in hospital have been associated with other negative consequences including injury in as many of 30% of cases,4, 5 anxiety, loss of confidence and depression,5 increased hospital length of stay and cost, worse rehabilitation outcomes, and greater risk of requiring residential care.6, 7, 8, 9, 10, 11 Falls rates, related injuries, and circumstances of in-patient falls vary across clinical areas.12, 13, 14 Specifically, falling is more common in geriatric and internal medicine patients compared with those admitted to the surgical wards.12, 14 Although rates range from 2 to 18 falls per 1000 bed-days,4, 5, 14 these are likely to underestimate the true incidence as in-patient falls are under-reported.4, 15 The aetiology of falls is multi-factorial and includes intrinsic and extrinsic factors.16 Commonly identified risk factors for in-patient falls include gait instability, altered mental state (such as delirium), urge incontinence, a history of falls, use of sedatives and hypnotics, use of restraints, and an unfamiliar environment to an acutely ill patient.5, 17 Individuals who survive an admission to an intensive care unit (ICU) are likely to be characterised by some, if not all of these risk factors.

Healthcare costs associated with an admission to an ICU are substantial. The primary focus of multidisciplinary care in this setting is to optimise survival and relatively few studies have attempted to describe the morbidity and mortality of patients who survive an ICU admission. Preliminary studies suggest that following discharge from ICU, survivors experience fatigue, difficulty concentrating, sleep disturbances and impaired health-related quality of life.18 Cox et al.19 demonstrated that functional outcomes were worse among patients who required prolonged mechanical ventilation, defined, in their study, as the need for tracheostomy and mechanical ventilation that exceeded four days. Given the increased recognition of skeletal muscle weakness20, 21, 22 and delirium observed among ICU survivors23, 24, 25 it is reasonable to suspect that this patient group are at a high risk of falling during their in-patient stay. However, little is known about the proportion of people who fall following an ICU admission, particularly those with prolonged ventilation requirements. Therefore, the main aim was to document the incidence of falls among ICU survivors following a period of prolonged mechanical ventilation. These data were collected as part of a larger study that aims to examine the ambulation status in people who survive a period of prolonged mechanical ventilation. For the purpose of this study, we defined prolonged mechanical ventilation as intubation and ventilation for ≥7 days.26 A large international prospective study that collected data across 361 ICUs, from 20 countries in more than 15,000 patients demonstrated that the upper quartile for the duration of mechanical ventilation in ICU was seven days.27 Therefore, using this threshold as our definition of prolonged mechanical ventilation ensured that we were likely to capture those with the longest requirements for invasive mechanical ventilation. These data are likely to be of interest to clinicians who are involved in the functional rehabilitation of ICU survivors.

Section snippets

Design

A comprehensive retrospective review was completed of the medical records pertaining to 190 patients sequentially admitted to an 23-bed Level 3 ICU28 at a metropolitan tertiary hospital [Sir Charles Gairdner Hospital (SCGH)]. This facility is the state's principal hospital for neurosurgery. The sample was identified by screening all patients admitted to the ICU over a two-year period.

Study criteria

Inclusion criteria comprised: (i) admitted to the ICU at SCGH between January 1st 2007 and December 31st 2008,

Results

A total of 2590 individual patients were admitted to the ICU at SCGH during 2007 and 2008. Of these, 190 fulfilled the study criteria (Fig. 1). The characteristics of the sample are summarised in Table 1. Of the 190 patients included in our sample, the number of indigenous Australians was 10 (5%). Fifteen (8%) patients were documented as ‘not-for-resuscitation’ at some stage during their admission. In keeping with the inclusion criteria of intubation and ventilation for ≥7 days, 143 (75%) of

Discussion

This retrospective review of medical records revealed a falls incidence of 17% among those patients who were intubated and ventilated for at least seven days and survived their acute care stay. Our sample size allows us to be 95% confident that the true proportion of fallers among patients who meet these criteria lies between 11.5% and 22.2%. Considering all patients admitted to a tertiary hospital, reported falls rates range from 2% to 5%.12, 30, 31 Therefore our data suggest that those who

Limitations

The limitations of this study are related primarily to those inherent of retrospective chart reviews. That is, the validity of the results is dependent on accurate and consistent documentation of the variables of interest by the health care team. A hospital-wide falls risk assessment tool was in use at the time of the admission period covered by this retrospective chart review, but engagement and compliance was fairly minimal in most clinical areas. Hill et al.15 reported that approximately 92%

Conclusion and future directions

The incidence of falls among those who required mechanical ventilation in ICU for at least seven days and survived the acute care stay was 17% or 3.8–4.1 falls per 1000 bed-days. All recorded falls occurred outside of the ICU. Compared with non-fallers, fallers were younger and required a shorter duration of inotropic support. There was a trend for fallers to have less co-morbid conditions and be more likely to be admitted to the ICU with a neurological insult. The age distribution of fallers

Acknowledgements

The authors gratefully acknowledge the following:

  • Adjunct Assoc/Prof Jeff Tapper, Head of Physiotherapy Department, Sir Charles Gairdner Hospital, for his support and facilitation of this project.

  • Tracy Hebden-Todd and Lisa Marsh, (senior ICU physiotherapists) for their general collaboration and assistance with independent reviews of the data extraction.

  • Brigit Roberts, Sir Charles Gairdner Hospital ICU research coordinator, for support and access to the ICU admissions database.

  • Leigha Sherwood,

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