Falls in the Intensive Care Unit: A Retrospective Cohort Study to Describe the Incidence, Risk Factors and Outcomes
CCCF ePoster library. Trumble D. Nov 2, 2016; 150974; 93
Dr. Drayton Trumble
Dr. Drayton Trumble
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Topic: Retrospective or Prospective Cohort Study

Falls in the Intensive Care Unit: A Retrospective Cohort Study to Describe the Incidence, Risk Factors and Outcomes


Trumble, Drayton E1; Meier, Michael, MD1,2; Doody, Maryellen, RN MSc2; Wang, Xiaoming, PhD3; Bagshaw, Sean M, MD MSc1,2
1Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB
2General Systems Intensive Care Unit, University of Alberta Hospital, Alberta Health Services, Edmonton, AB
3Research Facilitation, Alberta Health Services, Edmonton, AB


Grant acknowledgements:
This project was supported by a summer studentship award from Alberta Innovates – Health Solutions (AIHS)

Abstract:

INTRODUCTION
Falls among hospitalized patients contribute to avoidable morbidity and prolonged hospital stay. There has been a paucity of data specifically exploring the occurrence and circumstances of patient falls in the intensive care unit (ICU).
OBJECTIVES
Our primary objective was to describe the incidence, risk factors, and outcomes associated with falls among adult ICU patients. Additionally, we sought to evaluate the circumstances surrounding falls, the impact of ICU operational parameters, and if the falls were considered avoidable.
METHODS
We conducted a retrospective cohort study of all patients over the age of 18 years admitted to the General Systems ICU at the University of Alberta Hospital between January 1, 2013 and April 30, 2016. We searched for 'fall' events documented in eCritical/TRACER, a provincial bedside clinical information system and data repository. A fall was defined as a sudden, unexpected descent from a standing, sitting, or horizontal position, including slipping from a chair to the floor, a patient found on the floor, or an assisted fall.1 Each event was independently adjudicated by two intensivists to: 1) confirm a fall did occur; and 2) determine if the fall was avoidable. Inter-rater agreement was assessed using the intra-class correlation coefficient (ICC). Data were extracted on socio-demographics, diagnoses, chronic diseases, APACHE II scores, and mechanical ventilation for the entire ICU cohort. Fall event data extracted included delirium (i.e., Intensive Care Delirium Screening Checklist [ICDSC] scores), restraint use, and operational parameters (i.e., time of day, ICU discharge delay, nurse shift change, nurse break coverage). Data were descriptively analyzed. We generated a matched cohort (1:5) to evaluate the impact of falls on ICU and hospital length of stay.
RESULTS
Of 31 events identified, 26 (84%) were adjudicated as a fall (ICC 1.0 [exact agreement]) for an estimated incidence of 5.2 per 1000 ICU admissions (95% CI, 3.4-7.6). Of these, 23 (89%) were judged as avoidable (ICC 0.69; 95% CI, 0.37-0.85). Three patients (12%) fell twice. Among patients who fell, mean (SD) age was 54.5 (17.4), 20 (77%) were male, mean (SD) APACHE II score was 20.2 (5.4), and 12 (46%) were surgical admissions (8 [31%] for major trauma). Prior to a fall, patients had a median (IQR) ICU stay of 10.6 (6.2-15.0) days, an ICDSC score of 3.5 (1.0-6.0) with 17 (65%) having a score ≥4, and 25 (96%) having had soft restraints applied at some point. At the time of the fall, 4 (15%) were mechanically ventilated, while 8 (31%) were classified as 'ward ready.' Only 11 falls (42%) were witnessed, 12 (46%) occurred after hours, of which 9 (35%) were delirious. A total of 7 (27%) occurred within 2 hours of nursing shift change, and 11 (42%) during nursing break coverage. The ICU stay after a fall was 2.2 (1.2-2.9) days. In a matched cohort, patients who fell had a longer ICU stay (12.0 [8.3-18.6] vs. 5.0 [3.0-8.4] days, p=0.001), a non-significant difference in transfer delay from ICU (23.2 [6.4-44.7] vs. 13.1 [7.4-40.9] hours, p=0.334), and a longer hospital stay after ICU discharge (13.9 [6.9-27.9] vs. 7.7 [2.3-23.8] days, p=0.050).
CONCLUSION
Falls in the ICU are infrequent and generally judged as avoidable. Falls were commonly among those with delirium, occurred at night, and went unwitnessed. Falls were also associated with transfer delays, nursing shift changes, and during cross coverage.


References:

1. Hitcho EB et al. 'Characteristics and circumstances of falls in a hospital setting: A prospective analysis.' J Gen Intern Med 19.7 (2004): 732-739.
 



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