Abstract
Background and objectives: Hemodialysis patients are at high risk both for falling and for serious complications associated with falls, but few fall studies have specifically focused on this population. Falls occurring in an outpatient dialysis unit were reviewed to identify contributing factors and implement interventions designed to reduce fall risk.
Design, setting, participants, & measurements: A root cause analysis of all fall incidents occurring at an outpatient hemodialysis center during a 4-year period was conducted. A targeted intervention program to reduce falls was then implemented. Risk of falls in the postintervention period was compared with that of the baseline period.
Results: In the baseline period, a total of 22 falls occurred involving 14 patients and 8 staff members or visitors (incidence of 50 falls per 100,000 dialysis treatments). Root cause analyses identified staff educational deficits and environmental hazards as the most significant risk factors for fall incidents. After an interventional period that focused on formal staff education and environmental modifications, a total of only 3 additional falls (2 patients and 1 staff member) during 21 months of follow-up (14 falls per 100,000 dialysis treatments, P = 0.01) were observed.
Conclusions: Several modifiable risk factors for falls occurring in the high-risk setting of an outpatient hemodialysis unit were identified as a result of this formal analysis of fall incidents. Through a targeted series of interventions, a marked reduction in fall risk was achieved.
Falls remain a significant cause of morbidity and mortality in older adults and contribute a substantial burden to annual health care costs (1,2). The majority of falls, especially those occurring in the healthcare setting, are theoretically preventable and therefore fall reduction is an important focus of public health research. Although patients with ESRD represent a high-risk group for falls and associated complications (3–5), few studies have specifically focused on this population.
The outpatient hemodialysis center is a particularly high-risk location for falls. Among incident dialysis patients, 6.8% are unable to ambulate and 11.2% need assistance with daily activities (6). Furthermore, 6.7% of incident dialysis patients reside in a nursing facility (6). As highlighted in a recent study, this latter group of dialysis patients frequently experiences a profound decline in functional status (7). Common ESRD comorbidities such as diabetic neuropathy, impaired vision, peripheral vascular disease, and cardiac disease all can increase the risk for falls. Treatment-related complications such as postdialysis hypotension and muscle cramping are also contributing factors. In addition, the hemodialysis center's physical environment may be fraught with potential hazards such as loose blood tubing lines, wet floors, and oversized reclining hemodialysis chairs. Finally, the presence of renal osteodystrophy may increase the risk of fracture resulting from a fall (8).
To address fall incidents occurring in our hemodialysis center, we conducted a root cause analysis of all fall incidents occurring during a 4-year baseline period. In this report, we summarize our findings and the results of subsequent interventions aimed at fall reduction in this high-risk setting.
Materials and Methods
The University of Michigan Health System includes two outpatient hemodialysis centers. The center chosen for this study is a community-based hemodialysis center with capacity for 16 patients per shift, with dialysis performed on 6 different shifts. Patient care is provided by dialysis technicians (4:1 patient-to-technician ratio) and nurses (16:1 patient-to-nurse ratio). On average, this center performs more than 11,000 dialysis treatments annually. This study was approved by the University of Michigan institutional review board.
As part of routine quality assurance measures, all fall incidents occurring on the dialysis center's premises are investigated and recorded. In early 2008, a review of all reported falls occurring January 2004 through December 2007 was conducted by an interdisciplinary team consisting of a nephrologist, a physician's assistant, the dialysis nurse manager, the lead dialysis nurse, dialysis technicians, and a renal social worker. This team reviewed standard data elements from the incident report including the location of the fall in the unit, timing relative to treatment, injury sustained, medical follow-up, and contributing factors. Additional input was solicited from biomedical engineering staff, patients, and family members of patients. With use of the technique of root cause analysis, in which an adverse event is examined for all potential contributing causes, the interdisciplinary team identified several potentially modifiable risk factors for falls. On the basis of these findings, a targeted series of interventions was performed between January and March in 2008. Fall incidents continue to be monitored in the postintervention period; we reviewed data from April 2008 to December 2009 for this report.
The demographic and comorbidity characteristics of patients suffering a fall in our dialysis center were recorded. We also examined albumin levels as a surrogate for nutritional status and urea reduction ratio as a measure of dialysis adequacy. The most recently available labs before the fall incident were recorded. The cumulative incidence of falls was calculated for both the baseline assessment period and the postintervention period by dividing the number of falls by the number of dialysis treatments performed for each period. We chose dialysis treatments for the denominator as we believe this best reflects fall-risk opportunities in the center. Risk of falls during the baseline and postintervention periods was compared using Fisher's exact test.
Results
During the 4-year baseline period, a total of 14 falls occurred among 12 different patients. During that same period, our center performed 43,630 dialysis treatments, giving a 4-year cumulative fall incidence of 32 (95% confidence interval [CI] 15 to 49) falls per 100,000 treatments. The characteristics of patients who fell are summarized in Table 1. Age, comorbidities, and laboratory values are similar to those of our overall dialysis unit population. Half of the patients experiencing a fall had some degree of impaired mobility. Two (17%) patients had a documented history of at least one previous fall.
Characteristics of hemodialysis patients that experienced a fall (n = 12)
Of the 14 falls during the baseline period, 6 occurred postdialysis, 7 occurred predialysis, and 1 occurred during dialysis. Three patients had been hospitalized within 60 days preceding their fall, whereas the remaining patients (9 of 12, 75%) had not been hospitalized for at least 6 months preceding their fall incident. The most common locations for falls were at the dialysis chairside (5 of 14, 35.7%) and at the scale (4 of 14, 28.6%). Most (8 of 14, 57.1%) falls did not result in significant injury or require acute medical attention, but there were 2 patients who suffered minor head trauma and 1 patient pelvic fracture. The 1-year mortality of patients suffering a fall was 33.3%, compared with a mortality rate of 15.5% among patients that did not fall during the baseline period (P = 0.09).
In addition to patient-related falls, during the baseline period there were 7 falls involving staff members and 1 involving a family member. None of these incidents resulted in significant injury, need for further medical evaluation, or time missed from work. Taking these incidents into account, the cumulative incidence of falls during the baseline period was 50 (95% CI 29 to 71) falls per 100,000 dialysis treatments.
Root cause analyses identified several common contributing risk factors for falls, which were categorized as follows: (1) a high-risk patient population; (2) a lack of formal staff education on fall-risk reduction; and (3) presence of environmental hazards. Examples of environmental risk factors included slippery floors from water spillage or leakage, low ambient lighting limiting vision (often because of patient preference for sleep during treatment), and an elevated scale that posed a tripping hazard (Figure 1A). In addition, frequent cleaning because of infection control concerns also contributed to wet or slippery floors.
(A) Original elevated platform scale. (B) Newly constructed in-ground scale.
The identified risk factors and our targeted interventions are summarized in Table 2. To address our high-risk patient population, we provided fall-prevention education to all center staff involved in direct patient care. The educational program involved a presentation by fall-reduction educators from the local visiting nurse association, which focused on identifying high-risk patients, eliminating potential risk factors (both in-center and in the home setting), and educating patients. We also developed and implemented a fall-risk assessment tool (Table 3) to identify patients at high risk for falls or fall-related complications. High-risk patients were required to have a documented action plan such as mandatory staff assistance with transfers, use of a wheelchair while in-center, staff assistance with postdialysis weighing, and/or use of a lift device. All high-risk patients received counseling about fall risk from direct care staff; in addition, the renal social worker met individually with each dialysis patient to talk about fall risks and provide written information. After this initial patient education, we followed up with an in-center bulletin board display and more educational handouts outlining fall-risk reduction. To address modifiable environmental risk factors, we required that full lighting be used during patient shift change periods. Tractable floor mats were placed around all sink areas, and we provided dedicated hand towels for each dialysis machine to wick potential leaked fluid. In addition, the elevated scale was replaced with an in-ground scale (Figure 1B) to eliminate the tripping hazard.
Summary of targeted interventions for in-center fall reduction
Patient fall risk assessment tool
No fall incidents occurred during the 3-month intervention period. Subsequently, in 21 months of follow-up, there were three additional patient-related fall incidents reported. The first incident was characterized as a “near-miss” in which a patient became unsteady because of leg weakness while ambulating postdialysis and required assistance to sit down; notably, two staff members had already been assisting her because of concerns for her fall risk. In the second incident, a patient slumped to the ground while trying to enter his car after dialysis; this occurred after the patient had refused assistance offered by staff members. In the third incident, the patient fell out of her dialysis chair during dialysis after feeling lightheaded. No significant injury was reported in any of these instances, and no further medical intervention was required. Therefore, if the first incident where no actual fall occurred is excluded, there were 2 patient-related falls in the postintervention period, a reduction in fall incidence to 9 (95% CI 0 to 21) falls per 100,000 dialysis treatments (P = 0.06).
In the postintervention period there was one additional non–patient-related fall that involved a staff member in the maintenance department who was not included in the original fall education intervention. When this event is included, the total fall risk in the postintervention period was 14 (95% CI 0 to 29) falls per 100,000 dialysis treatments, a significant decrease from the baseline period (P = 0.01) (Table 4). The relative timing of falls is graphically illustrated in Figure 2.
Fall risk during the baseline and postintervention periods
Time course of patient and staff/visitor falls.
Discussion
Falls are a major source of morbidity in older adults, and falls in the hemodialysis population represent a significant but understudied subset. We conducted an analysis of fall incidents occurring in our hemodialysis center and implemented targeted interventions to reduce the risk of falls. With these interventions, we observed a clinically and statistically significant decrease in overall fall incidents during 21 months of follow-up.
The median age of incident hemodialysis patients is now 64.4 years (9), and hemodialysis patients are among the highest risk population for falls because of patient comorbidities and treatment factors. Several studies have attempted to achieve fall reduction through patient-centered interventions such as strength and gait training (10–12). Such studies have not typically included hemodialysis patients, and successful physical rehabilitation presents additional challenges among this population. Interestingly, our analysis did not identify patient characteristics that could be used to distinguish fall patients from the general dialysis center population, although the low number of falls does not provide enough statistical power to detect small differences. Still, the characteristics of patients suffering a fall were clinically similar to those of our center's general population. Additionally, falls were equally likely to occur before or after dialysis, suggesting that treatment may not have been a significant risk factor. Instead, common environmental factors appeared to represent the most significant risks. This finding is highlighted by the observation of falls among staff and family members during this study. A targeted approach to modifying these factors has proven successful in our center. Although patient-centered approaches remain an important long-term target for intervention, environmental modifications can provide immediate impact and may be more cost-effective.
In addition to the clinical implications, our study has important administrative and regulatory significance. In late 2008, new Centers for Medicare/Medicaid Services (CMS) coverage rules were implemented under which reimbursements may be withheld because of the occurrence of preventable hospital-acquired adverse events, one of which was identified as patient fall-related injury (13). Given that the majority of dialysis patients receive Medicare coverage, it is conceivable that such policies may be extended to dialysis centers in the future. In the meantime, CMS regulations require dialysis centers to develop active quality assurance and performance improvement (QAPI) programs, and patient falls are specifically mentioned in the interpretive guidelines of these regulations (14). As such, we present this study as a model of the type of QAPI process mandated by CMS. In addition, the updated Conditions for Coverage specify that all new patients in a dialysis center be evaluated as to their fall risk as part of the initial nursing assessment.
We chose to focus our study only on falls occurring within our dialysis center as opposed to including all episodes of falls for several reasons. This approach allowed us to thoroughly evaluate each incident to identify risk factors; inclusion of off-site falls would have required a screening approach and would have been highly subject to recall bias. Importantly, our emphasis on in-center falls provided specific targets for intervention that could potentially benefit all patients (plus staff and visitors). Therefore, our approach proved to be both efficient and practical, and was validated by the additional reduction observed in staff-related falls. Furthermore, we believe that our emphasis on fall reduction in the hemodialysis center will result in benefits outside the center by raising patient awareness and providing education on general fall reduction measures.
Our study has several limitations. First, the results are somewhat specific to the characteristics of our dialysis center. However, we suspect that several of the environmental risk factors identified in our analysis are common in other hemodialysis centers, and therefore our interventions may be broadly applicable. Second, our retrospective approach to reviewing fall incidents was limited to information provided in incident reports and staff member recollections. Thus, some patient-specific information such as visual impairment or medication usage that may affect fall risk was not available as part of this review. It is also possible that fall incidents occurred that were not reported. However, an ascertainment bias would presumably decrease the magnitude of our findings by underestimating the incidence of falls in the baseline period; conversely, fall reporting in the postintervention period was heavily emphasized and it is unlikely that fall incidents were missed. Lastly, the overall low number of fall events observed provides limited precision to our results and longer follow-up will be required to confirm the magnitude of risk reduction in the postintervention period.
By conducting a quality improvement review of fall incidents, we were able to identify important risk factors contributing to fall occurrences in our hemodialysis center. Through focused educational efforts and environmental modifications, we successfully achieved a significant reduction in fall risk. Our study suggests that an emphasis on environmental factors may be productive in reducing falls, and we encourage other centers to conduct similar analyses to confirm these findings.
Disclosures
None.
Footnotes
Published online ahead of print. Publication date available at www.cjasn.org.
- Received February 19, 2010.
- Accepted May 18, 2010.
- Copyright © 2010 by the American Society of Nephrology
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