Inpatient falls are a significant cause of hospital acquired conditions (HACs)(AHD, 2015). The Agency for Healthcare Research and Quality estimates the U.S. national incidence of fall-related HACs to have been approximately 260,000 in 2010. The interim U.S. national estimated incidence of fall-related HACs remained unchanged at 260,000 in 2014 (AHRQ, 2015).
This course introduces the scope of this patient safety risk. The reported inpatient fall rate varies widely in the literature. A recent, significant study of the inpatient fall rate found that rates varied within and among hospitals with a range from 1.3 to 8.9 falls/1,000 patient days depending upon the type of hospital and the hospital unit (Degelau et al., 2012).
A second study found patient characteristics, nursing unit, hospital culture, environment, equipment and procedures influenced the rate of patient falls. Fall rates ranged from 0.2 to 13.3 falls per 1,000 patient days in medical nursing units. They classified these units as low and high-fall units. A significant difference between the low and high-fall rate units was found to be the patient turnover rates. High-fall rate units had higher patient turnover rates. They found that more time was spent by nursing personnel on admissions and discharges and that those units with higher patient turnover rates tended to be physically larger with increased distance between nursing stations and patient rooms. Hospitals with greater than 300 beds were found to have a 6% lower fall rate than smaller hospitals. (Staggs et al., 2015)
A study of 8915 units using 2008 statistics, reported the following fall rates by unit type:
Of the patients who fall, 3% to 20% will sustain an injury, 6% to 44% of those injuries are serious, such as fractures, subdural hematomas, excessive bleeding all of which can lead to a death. Even minor injuries can cause delay in recovery (Oliver et al., 2010). Not only are the patient, family and community affected by falls, but everyone bears the expense of rising healthcare and hospital costs.
Increased hospital costs can vary depending on the extent of injury from a fall: one hospital fall without serious injury has been shown to increase costs by $3500; two or more falls without serious injury can lead to a $16,500 increase in cost; falls with serious injury can cost an additional $27,000 (Wu, et al., 2010).
The U.S. health care industry is beginning to respond to this economic challenge. The Agency for Healthcare Research and Quality (AHRQ) reported in its handbook, Patient Safety and Quality: An Evidence-Based Handbook for Nurses), every year inpatient falls resulted in 90,000 serious injuries and 11,000 deaths in American hospitals (Hughes, 2008).
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in their first set of National Patient Safety Goals in 2003 included the goal of reducing the risk of patient harm resulting from falls. The evaluation of effective steps toward the achievement of this standard is part of their accreditation review (JCAHO, 2006). The Joint Commission continues to review hospital standards for preventing fall. A description of their recommendation for fall prevention is discussed later in this course (JCAHO, 2015). http://www.jointcommission.org/assets/1/18/SEA_55.pdf)
In 2008, the Centers for Medicare & Medicaid Services published the final rule for their Inpatient Prospective Payment System (IPPS) in compliance with the Deficit Reduction Act of 2005. Falls and fall related injuries are considered preventable conditions. This addresses the fractures, dislocations, intracranial injuries, crushing injuries, burns and electric shock associated with hospital falls and trauma. http://www.cms.gov/HospitalAcqCond/01_Overview.asp#TopOfPage. http://www.cms.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp.
According to Medicare, following October 1, 2008, “hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present.” http://www.cms.gov/HospitalAcqCond/01_Overview.asp#TopOfPage. http://www.cms.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp.
For example if a patient comes to the hospital because of a myocardial infarction (MI) but falls while in the hospital, fracturing a wrist, Medicare will reimburse the hospital for the treatment of the MI but not the treatment of the wrist fracture. It is common for private payers to follow Medicare’s lead in payment policies. Anthem Blue Cross and Blue Shield has posted the following payment policy:
When a Hospital Acquired Condition does occur, all inpatient acute care hospitals shall identify the charges and/or days, that are the direct result of the HAC. Such charges and/or days shall be removed from the claim prior to submitting to the Health Plan for payment. Current and valid Present on Admission (POA) Indicators (as defined by CMS) must be populated on all inpatient acute care hospital claims. In no event shall the charges or days associated with the HAC be billed to either the Health Plan or our members. https://www.anthem.com/provider/noapplication/f1/s0/t0/pw_e170997.pdf?
Additional policies have been promulgated that effect Medicare reimbursement.
It must be noted that in some instances the fall rates of hospitals have increased due to intrinsic patient factors, i.e. older, sicker patients, and also because of extrinsic factors like improved accident reporting and systems that focus on fall prevention and Medicare reporting requirements (Weil, 2015).