Risk Management

Help patients reduce their risk of falling in your office or ASC

ANNE M. MENKE, RN, PhD, OMIC Risk Manager

In response to the high number of older patients injured in falls each year, the Centers for Disease Control (CDC) developed a program called STEADI: Stopping Elderly Accidents, Deaths, and Injuries. Many of the materials are geared to primary care physicians and include strength, balance, and mobility tests. Ophthalmologists in their offices and staff in ambulatory surgery centers (ASCs) are not likely to perform these tests as part of an eye exam or preoperative evaluation. The information in the documents does, however, contain recommendations that can be implemented by the eye care team.

Q We have a busy practice and see many elderly patients. Is there a real-world tool our staff members can use to determine who is at risk of falling?

A Yes. One simple way to screen for fall risk is to ask the patient three questions proposed by the CDC: (1) Have you fallen in the last year? (2) Do you feel unsteady when you stand up or walk? and (3) Do you worry about falling? Some ASCs skip the CDC’s third question about the fear of falling and instead ask if the patient has a history of dizziness or lightheadedness, which can help identify younger patients who suffer vasovagal episodes in medical settings. Staff can either ask the questions and document the answers or include them on forms the patient completes, such as the one identifying who will drive them home after surgery or their emergency contact information. Any yes answer indicates the need for assistance and should be communicated to all members of the team providing care for the patient.

Q What are the signs of gait or balance problems?

A Certain behaviors that are readily observed can point to unsteadiness and increased fall risk. Ask staff to watch for these behaviors and immediately go to the side of any patient who exhibits them. Using one’s hands to push up off a chair, a sign of weak abdominal or leg muscles, could alert staff to stand next to the patient and provide assistance. Holding onto furniture when walking could indicate a fear of falling or weakness in the extremities. Trouble stepping up to a curb could stem from poor depth perception or muscular problems. Many patients experience urinary urgency and may fall while rushing to the bathroom. Offer these patients assistance to the restroom, especially after sedation or anesthesia. Patients who use mobility aids, such as canes, walkers, and wheelchairs, are easy to notice. It can be hard to know when to help, however. Our claims experience shows that some may value their independence and decline offers of assistance. Respect the patient’s choice but stay with the patient and be prepared to help until she has safely moved to where she is going. It might be surprising to learn that patients who are sad or depressed are at increased risk of falling. Perhaps they are less attentive to their environment and don’t notice obstacles or the approach of steps as readily. Will getting answers to these questions and observing these behaviors prevent falls in ophthalmic practices and surgery centers? From the limited information available in the claims files we analyzed of 41 patients who fell, at least 19 of the patients would have been considered at increased risk for a fall based on their histories or behaviors. Asking the patient if he or she worries about falls or feels unsteady or lightheaded could well have identified more.

Q Are we expected to educate patients about their increased fall risk?

A Just as ophthalmologists and ophthalmic ASCs do not conduct formal gait and balance testing, they are not expected to provide extensive education on fall risk. But the eye care team can advise patients of simple ways to keep themselves safe. Consider placing signs with the following reminders in the lobby or examination lanes. Prevent falls that can occur when standing up from a seated position by suggesting: “stand up slowly” and “stand still a minute after you stand up.” When patients are offered sunglasses and prepare to exit into brighter light, remind them to “take your time” and “wait for your eyes to adjust.”

Q Our office does not have equipment to lift or move heavy patients. We are worried that staff may injure themselves by trying to assist bigger patients.

A These fears are well-founded. The CDC website’s section on workplace safety indicates that the healthcare industry has some of the highest reports of musculoskeletal injuries from what it calls “overexertion.” The single greatest risk factor for overexertion injuries is the manual lifting, moving, and repositioning of patients. According to the CDC, mechanical equipment, not staff, should be used to lift and move patients: there is no safe way to manually lift another adult human being. Let the ophthalmologist or head nurse know if you identify a patient who needs lifting or moving. The patient may need to be sent to a facility with the necessary equipment.