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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 1  |  Issue : 2  |  Page : 21-25

Analysis of incidents of fall in the patients receiving home healthcare services


HealthCare At Home India Pvt. Ltd., Noida, Uttar Pradesh, India

Date of Submission28-Nov-2019
Date of Decision15-Dec-2019
Date of Acceptance14-Jan-2020
Date of Web Publication28-Apr-2020

Correspondence Address:
Dr. Ridhima Pahwa
HealthCare At Home, Tower A, 3rd Floor, Tapasya Corp Heights, Noida - 201 303, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/QAIJ.QAIJ_7_19

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  Abstract 

Background: Incidents of fall remains the major cause of accidental and unintended injury in health care setups. Caring for patients at homecare setting comes with its own challenges and concerns. Methods: The incidents of fall reported over past 18 months in patients availing home care services from Healthcare at home from February 2018 to August 2019 was analysed to identify various risk factors involved in fall and suggestions for fall prevention were laid out in the study. Results: The fall percentage reported was 1.29% of patients served by HCAH during this tenure. The incident of fall was higher in rehabilitation services and lower in nursing services. The results show that prevalence of falling was higher among women than men between the age of 65-84 years. The highest number of falls was reported in patients suffering from neuro disorders, most of the incidents resulted due to external factors where more emphasis needs to be given on creating safe environment in the patient's home. Conclusion: Providing clinical care at home environment even makes it more difficult to control certain factors such as adequate space in the room for safe mobilization or unavailability of grab bars or presence of slippery floors or poor lightening are the majorly contributing to incidents like falls. Thus, identifying underlying risk while admitting the patient in homecare becomes the primary responsibility of the care provider.

Keywords: Fall, home care, incidents


How to cite this article:
Pahwa R, Singh P, Kapoor G, Thukral G, Talukdar P, Joseph P C. Analysis of incidents of fall in the patients receiving home healthcare services. QAI J Healthc Qual Patient Saf 2019;1:21-5

How to cite this URL:
Pahwa R, Singh P, Kapoor G, Thukral G, Talukdar P, Joseph P C. Analysis of incidents of fall in the patients receiving home healthcare services. QAI J Healthc Qual Patient Saf [serial online] 2019 [cited 2020 May 25];1:21-5. Available from: http://www.QAIJ.org/text.asp?2019/1/2/21/283454


  Introduction Top


HealthCare at HOME (HCAH) is one of the most prestigious homecare organizations operating in India. The organization is committed to make quality and patient safety, a top priority throughout the patient's journey. HCAH is a pioneer in bringing personalized and professional home healthcare services to allow quick and convenient recovery within the comfort of one's home. Some of the key medical services offered include setting up intensive care unit at HOME, providing cancer care at HOME, nursing care, physiotherapy services, and holistic stroke rehabilitation along with providing a plethora of clinical procedures at home, thereby delivering almost 70% of all clinical services at home. Caring for patients at homecare setting comes with its own challenges and concerns. Thus, identifying underlying risks while admitting the patient in homecare becomes the primary responsibility of the care provider.

Fall is considered a serious incident both at hospital and at home while the patient is under professional care. It could be due to the medical condition of the patient or negligent attitude of healthcare professionals or could be due to environmental factors. It is a serious incident as it can cause a permanent or a temporary disability for the patient and a financial burden for the family.[1]

We at HCAH view patient falls as an important and a serious incident as it can be a deterrent factor for the organization and leaves an unpleasant situation for the family. Incident reporting in-home healthcare is a challenging task; however, we conduct frequent fall awareness campaigns to improve reporting and parallelly launch mitigation plans to minimize the risk of fall by educating the patient and family and spreading awareness on the consequences of fall.[2]

Need for the study

Incidents of fall remain the major cause of accidental and unintended injury in healthcare setups.[3] According to the WHO, falls are the second most leading cause of mortality worldwide; each year, an estimated 646,000 individuals die from falls globally of which over 80% are in low- and middle-income countries. A report generated by the WHO has estimated that 17 million disability-adjusted life years lost globally due to fall. Falls account for 40% of all injury deaths. According to the WHO among the elderly, nearly 37.3 million falls require medical attention every year. Fall rate increases when age increases, resulting in morbidity, mortality, and loss of independence.[3] Falls is one of the common problems faced by the elderly population, and in preventing falls in India, research has largely focused on the identification and management of risk factors, but the circumstances of the fall and its associated factors are sparsely researched.[4]

We at HCAH realized the need for fall prevention among the patients who receive care through us and added patient falls as one of our quality indicators, which get tracked on a monthly basis.[2] This has also given us an understanding that patient falls are considerably less at home care setup compared to the hospitals, mainly due to 1:1 care being provided at homecare scenario. Nonetheless, analyzing risk factors contributing to the incidents of fall has given us various insights on scope for improvement in reporting and preventing factors contributing to fall.


  Incidents of Fall at Healthcare at Home Top


The incidents of patient fall below are reported between February 2018 till August 2019 in Nursing and Rehabilitation services [Figure 1]:
Figure 1: No. of incidents reported of fall in patients availing nursing and rehabilitation services at healthcare at home

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  Definition of Falls Top


A patient fall is defined as an “unplanned descent to the floor with or without injury to the patient” (WHO Factsheet, 2018). A fall may result in fractures, lacerations, or internal bleeding, leading to increased healthcare utilization. Research shows (WHO Factsheet, 2018) that close to one-third of falls can be prevented.[3]

Below-mentioned factors contributing to the incidence of fall have been taken into consideration in this study.

  • Age
  • Sex
  • Diagnosis
  • Location of fall
  • Mechanism of fall
  • Severity of injury.



  Analysis and Interpretation Top


In a retrospective analysis, conducted for 18 months, i.e. February 2018 till August 2019, approximately, 1.29% falls were reported in patients receiving nursing and rehabilitation services from HCAH.[5]

The percentage of falls is higher in the rehabilitation services as most of the patient falls were reported in the absence of care providers; on the contrary to the fall reporting percentage in patients, availing nursing services is lower as the patient is under constant supervision in most of the cases.[2]

Age

The average age of the patients served by HCAH where falls were reported was 69.38 years, of which 56% were between 65 and 84 years of age and 8% of the clients are above the age of 85 years. In comparison to other studies conducted by Montoux et al., 2009 where 76.5 years is the average age of patients where patients report fall, approximately 50% of falls were reported in patients between 65 and 84 years of age and 28% of patients were above the age of 85 [Figure 2] and [Table 1].[6]
Figure 2: Comparison of Age

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Table 1: Comparison of age

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Gender

In the study, it was found that incidents of fall were reported more in female clients (69%) in comparison to males, which is 31%. Similar trends were noticed in other studies (Cynthia et al., 2017)[7] where the percentage of females reported fall is higher than males [Figure 3] and [Table 2].
Figure 3: Gender wise comparison

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Table 2: Gender wise comparison

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Diagnosis

Patients suffering from neuroconditions such as stroke or other neurodiseases such as Alzheimer's disease and vertigo where the incidents of falls were highest due to poor balance and gait control. Parkinson's disease was more prone to fall in the study, followed by patient's suffering from musculoskeletal conditions such as osteoarthritis of the knee, lumbar spondylosis, and radiculopathy [Figure 4] and [Table 3].
Figure 4: Diagnosis wise comparison

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Table 3: Diagnosis wise comparison

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Location of fall

Most of our patients availing homecare services are fragile and have limited mobility due to which most of the events of falls were located inside patient's home and very less incidents were reported outside the home environment. In our study, it was observed that most falls happened in patient's bedroom or living room (49%), 28% in the washrooms, and 23% of fall happened outside patient's home, i.e., in the park while walking, public areas, or while getting seated in the car [Figure 5] and [Table 4].
Figure 5: Location of fall

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Table 4: Location of fall

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Mechanism of fall

Most common factor responsible for fall, i.e. 41%, was due to external factors such as slippery floor, uneven surface, loose carpeting, or loose clothing; 18% of the falls happened while using assistive devices, whereas 13% clients had a fall due to poor handling by caregiver. Only 8% of the fall resulted due to patient's existing medical condition, and in 20% of cases, patient's and family did not follow adequate fall prevention measures as educated by the staff which resulted in fall [Figure 6] and [Table 5].
Figure 6: Mechanism Of fall

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Table 5: Mechanism of fall

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Severity of injury

The incidents of fall were categorized based on the severity of injury. 10% of the incidents of fall resulted in severe injury where patients were admitted to hospital due to fracture or re-surgery and the services were stopped after the incident. 85% of cases were reported of having moderate injuries where patients were advised cold compression, rest, and visit to the doctor in outpatient setting. In such cases, care plan was altered after the incident and the patient was motivated to follow adequate precautions to minimize chances of recurrent fall in the future. 5% of cases were reported as no injury where the care was not altered and no additional interventions were required post the incident [Figure 7] and [Table 6].
Figure 7: Severity of Injury

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Table 6: Severity of Injury

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Limitation of the study

Data collection remained a challenge, and analyzing the root cause for all reported incidents was difficult in-home setup as it is a distributed environment.

Recommendations to prevent fall

There are several measures that homecare professionals can take to reduce a homecare client's risk of falling, irrespective of age, gender, diagnosis, and severity of risk:

  • Conduct a fall risk assessment to identify factors which could contribute to incidents of falls in the home
  • Observe the environment for potentially unsafe conditions and provide suggestions for assuring a safe home environment
  • Review the patient's history of falling
  • Review all medications taken by the patient, including over-the-counter medication and home remedies. When applicable, discuss with the physician
  • Monitor the patient's cardiovascular status, heart rate, rhythm, and blood pressure for cardiac arrhythmias and orthostatic hypotension
  • Encourage adequate hydration and nutrition
  • Evaluate the patient's gait and balance
  • Evaluate the strength and function of a patient's lower extremities
  • Review the patient's use of, or need for, an ambulatory aid or other assistive devices
  • Provide gait training and strength training as needed
  • Establish a home exercise program with balance training
  • Identify home environmental hazards that could contribute to falls and make recommendations for modifications
  • Instruct the patient to wear nonskid footwear or properly fitting shoes
  • Ensure that the pathway to the restroom is free of obstacles and properly lighted
  • Ensure the hallways are clear of obstacles
  • Place assistive devices, such as walkers and canes, within a patient's reach
  • Include the patient, family members, and any homecare aids in the development of an individualized home safety plan
  • Consider the patient's cognition and other fall risk factors when planning care
  • Educate the patient and/or family members regarding a plan of care to prevent a fall in the home
  • Collaborate with the patient's family to provide assistance, as needed, while maintaining the patient's independent functioning
  • Recommend a sitter or companion to the patient or family to provide one-to-one observation with the patient and to maintain a safe environment
  • Communicate and document the patient's “fall risk” status and risk factors with other homecare staff who may be involved with the patient's care.



  Discussion Top


The aim of the study was to analyze various factors responsible for falls among patients availing homecare services. A total of 4585 patients were served from February 2018 till August 2019. The results show that the prevalence of falling was higher among women than men between the age of 65 and 84 years. The highest number of fall was reported in patients suffering from neurodisorders; most of the incidents resulted due to environmental factors where more emphasis needs to be given on creating a safe environment in the patient's home using antiskid mats, grab bars, and removing loose carpeting on the floor.

Modified Morse fall risk assessment tool has been implemented in the system for timely identification of risk factors, resulting in fall such findings to be considered while formulating care plan for patients at higher risk of fall.

Regarding fall-related injuries, around 10% of falls result in serious injury to the elderly, such as hip fracture, hematoma, head trauma, and a variety of other injuries that require hospitalization. Most of the injuries resulted due to fall were treated with ice application, rest, and medication to relieve pain.[8]


  Conclusion Top


In conclusion, patient fall can lead to moderate-to-severe injury in majority of the cases leading to discomfort, temporary, or permanent disability to the patient and financial burden on the family. Healthcare providers are expected to keep the above-mentioned suggestions and recommendations in mind while giving care the patients. This will surely bring down the percentage of falls and improve the effectiveness of care provided. At HCAH, we constantly strive hard to keep “zero” fall incidents as it is an indicator to gauge the quality of our services.

Acknowledgments

We thank all our clinical staff, clinical excellence team, and quality and training team for their contribution and mentorship for the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Asiri FY, Alshahrani A, Aseeri MA, Alam MM, Ataalla SM, AlMohiza MA, et al. Fall risks factors among home-based health care patients in the Aseer province: Observational study. Biomed Res 2018;29:2640-5.  Back to cited text no. 1
    
2.
Joseph A, Kumar D, Bagavandas M. A review of epidemiology of fall among elderly in India. Indian J Community Med 2019;44:166-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Pitchai P, Dedhia HB, Bhandari N, Krishnan D, D'Souza NR, Bellara JM. Prevalence, risk factors, circumstances for falls and level of functional independence among geriatric population - A descriptive study. Indian J Public Health 2019;63:21-6.   Back to cited text no. 3
[PUBMED]  [Full text]  
4.
HealthCare At Home India Pvt. Ltd. L3-65 Standard Operating Procedure for Incident Management V6.  Back to cited text no. 4
    
5.
HealthCare At Home India Pvt. Ltd. L0-03 Continual Quality Improvement Program V2.  Back to cited text no. 5
    
6.
Lewis CL, Moutoux M, Slaughter M, Bailey SP. Characteristics of individuals who fell while receiving home health services. Phys Ther 2004;84:23-32.  Back to cited text no. 6
    
7.
Phelan EA, Mahoney JE, Voit JC, Stevens JA. Assessment and management of fall risk in primary care settings. Med Clin North Am 2015;99:281-93.  Back to cited text no. 7
    
8.
WHO Fall Report Factsheet, 2018. Available from: https://www.who.int/news-room/fact-sheets/detail/falls. [Last accessed on 2020 Jan 02].  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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  In this article
   Abstract
  Introduction
   Incidents of Fal...
  Definition of Falls
   Analysis and Int...
  Discussion
  Conclusion
   References
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