ASSESSMENT OF RI SK AND I NCI DENCE OF FALLS I N NEUROSURGI CAL I NPATI ENTS
Solange Diccini1 Pr iscila Gom es de Pinho2 Fabiana Oliv eir a da Silv a3
Diccini S, Pinho PG, Silva FO. Assessm ent of risk and incidence of falls in neurosurgical inpat ient s. Rev Lat ino-am Enfer m agem 2008 j ulho- agost o; 16( 4) : 752- 7.
Neur osur gical pat ient s m ay pr esent m ot or , sensit ive and balance im pair m ent and incr eased r isk of falling. The aim of t his st udy w as t o ev aluat e t he fall r elat ed r isk fact or s and t he incidence of falls in t he pr e and post -oper at iv e per iod of neur osur gical pat ient s. A pr ospect iv e cohor t st udy w it h a r esear ch populat ion of pat ient s under going elect ive neur osur gical pr ocedur es. Ninet y- seven pat ient s t ook par t in t he st udy. Eight ( 8.2% ) have present ed falls wit h a t ot al of 12 falls ( 12.4% ) . I n t wo falls ( 16.7% ) , bed side rails were down, whereas in six falls ( 50% ) , beds had no rails at all. There was no difference am ong fall- relat ed risk fact ors during pre and t he post - operat ive periods. We have concluded t hat m ost falls could have been prevent ed t hrough an im provem ent in t he hospit al int ernal st ruct ure and w it h t he int roduct ion of a falls prevent ion program .
DESCRI PTORS: accident al falls; nur sing; epidem iology ; neur osur ger y
EVALUACI ÓN DE RI ESGO E I NCI DENCI A DE CAÍ DAS EN PACI ENTES DE NEUROCI RUGÍ A
Los pacient es en neurocirugía pueden present ar deficiencias m ot oras, sensit ivas y del equilibrio, lo cual aum ent a el riesgo de caídas. El obj et ivo de est e est udio fue evaluar los fact ores de riesgo y la incidencia por caídas en p acien t es d e n eu r ocir u gía d u r an t e el p r e- op er at or io y p ost - op er at or io. Est u d io d e coh or t e p r osp ect iv o, en don de se in clu y er on pacien t es som et idos a cir u gías in t r a- cr an ean as y r aqu ídeo- m edu lar es. Par t icipar on del est udio nov ent a y siet e pacient es, de los cuales ocho ( 8,2% ) t uv ier on caídas, t ot alizando 12 ( 12,4% ) caídas. En 2 ( 16,7% ) de las caídas, ocurridas durant e el est udio, las barandas no est aban colocadas en la cam a y en 6 ( 50% ) de ellas, la cam a no t enía bar andas. No se evidenció difer encia ent r e los fact or es de r iesgo par a las caídas en los pacient es dur ant e el pr e- oper at or io y post - oper at or io. Concluim os que la m ay or ía de las caídas podr ían haber sido pr evenidas, a t r avés de una m ej or est r uct ur a hospit alar ia, así com o con la im plem ent ación de pr ogr am as de pr ev ención par a caídas.
DESCRI PTORES: acciden t es por caídas; en fer m er ía; epidem iología; n eu r ocir u gía
AVALI AÇÃO DE RI SCO E I NCI DÊNCI A DE QUEDA EM PACI ENTES NEUROCI RÚRGI COS
O pacient e neur ocir úr gico pode apr esent ar déficit s m ot or es, sensit iv os e de equilíbr io, aum ent ando o r isco de queda. O obj et ivo dest e est udo foi avaliar os fat ores de risco e a incidência de queda em pacient es neurocirúrgicos dur ant e o pr é e pós- oper at ór io. Est udo de coor t e pr ospect iv o, onde for am incluídos pacient es subm et idos a cir u r gias in t r acr an ian as e r aqu im edu lar es elet iv as. Nov en t a e set e pacien t es par t icipar am do est u do, sen do que oit o ( 8,2% ) apr esent ar am queda, t ot alizando 12 ( 12,4% ) quedas. Em 2 ( 16,7% ) quedas ocor r idas, nest e est udo, as cam as apr esent av am as gr ades abaix adas e em 6 ( 50% ) delas a cam a não possuía gr ades. Não houv e difer ença ent r e os fat or es de r isco par a queda no pacient e no pr é e no pós- oper at ór io. Conclui- se que a m aioria das quedas poderiam t er sido prevenidas com a m elhoria da est rut ura hospit alar e com a im plem ent ação de pr ogr am a de pr ev enção de quedas.
DESCRI TORES: aciden t es por qu edas; en fer m agem ; epidem iologia; n eu r ocir u r gia
1 RN, Adj unct Professor, Federal Universit y of São Paulo, Brazil, e- m ail: [email protected] .br; 2 RN, Hospit al Sírio Libanês, Mast er’s st udent , São Paulo
I NTRODUCTI ON
A
f a l l i s d e f i n e d a s a s u d d e n a n d u n ex plain able ch an ge in posit ion , in w h ich pat ien t s co m e t o t h e f l o o r u n i n t en t i o n al l y( 1 ). Ov er 7 0 % o fin p at ien t s f alls occu r in sid e t h e r oom s, d u r in g t h e change t o bed, chair or wheelchair, and 19% occur in deam bulat ion w hen going and com ing back fr om t he t oilet( 1- 2).
Risk fact or s for falls ar e: being ov er 65( 3- 4), changes in lev el of aw ar eness( 3- 4), use of m edicat ion ( an t idepr essan t s, ben zodiazepin es, an t ih y per t en siv e m edicat ion)( 5- 6), syncope, and post ural hypot ension( 2,4),
b l a d d e r o r b o w e l i n c o n t i n e n c e( 3 - 4 ), b a l a n c e d i st u r b a n ce s( 2 , 4 ), m o t o r i m p a i r m e n t( 2 - 4 ), se n so r y im pairm ent( 2- 4), lack of confidence in t he environm ent( 2-4)
, and pr evious occur r ence of falls( 2- 4).
Am o n g t h e d i s e a s e s m o s t c o m m o n l y associat ed wit h falls, m usculoskelet al lesions have been observed as direct ly relat ed t o it , and neurological and cardiac diseases are indirect ly relat ed t o it( 7).
Ar ound 23% of falls in hospit alized pat ient s result in lesions, and 83% of t hese lesions are bruises, sp r a i n s a n d l a cer a t i o n s, a n d 9 % a r e f r a ct u r es( 1 ). Am ong fract ures, 4% occur in t he bones of t he hips,
and 3.5% in t he bones of t he skull( 2). Falls can lead t o an in cr ease in adm ission len gt h an d in t h e cost of t r eat m ent , as w ell as causing discom for t t o pat ient s, and sk ept icism r egar ding nur sing ser v ices( 8 ).
The im plem ent at ion of m any falls pr event ion
pr ogr am s h av e been su ccessf u l an d t h ey ar e m ade o f t h r e e e l e m e n t s: i d e n t i f y i n g t h e r i sk f o r f a l l s, i n t r o d u c i n g t e c h n i q u e s f o r p r e v e n t i o n a n d reassessm ent of pat ient s t o keep or include new risk f a c t o r s( 4 ). W i t h t h e s e m e a s u r e s i s e x p e c t e d t o decr ease fall r at es and com plicat ions in hospit alized pat ien t s.
Fall is considered as an indicat or of qualit y in n u r si n g ca r e a n d i t i s a l so o n e o f t h e i n d i ca t o r s m onit ored by Qualit y of Care in Hospit al program t hat
aim s at im proving qualit y of care, wit h t he purpose of r eaching ex cellence in hospit al car e( 9).
The obj ect iv e of t his st udy w as t o com par e r isk fact or s for fall in pr e and post oper at iv e per iods, a n d a sse ss t h e i n ci d e n ce o f f a l l s i n n e u r o l o g i ca l pat ient s dur ing pr e and post oper at iv e per iods.
METHOD
A cohort prospect ive st udy, perform ed in t he
n eu r osu r g ical u n it an d n eu r oin t en siv e car e u n it of
Hospit al São Pau lo, f r om Febr u ar y t o Au gu st 2 0 0 6 .
Pat ient s included w er e t hose adm it t ed t o int r acr anial an d sp in al cor d su r g er ies t h at w er e ov er 1 8 y ear s old . Pat ien t s w it h n eu r olog ical d iseases h av e b een ex clu d ed . Dat a collect ion st ar t ed af t er ap p r ov al of
t h e Et h i c a l Re s e a r c h Co m m i t t e e o f t h e Fe d e r a l Univ er sit y of São Paulo, and pat ient s w er e included aft er giv ing t heir w r it t en consent .
The following dat a have been collect ed: age,
gender, days of hospit al st ay, m edical diagnoses, risk fact ors for falls, occurrence, and num ber of falls during h ospit alizat ion , place of f all, t y pe an d sit e o lesion a f t er f a l l i n g . Ri sk f a ct o r s f o r f a l l w er e r el a t ed t o
pat ient s, env ir onm ent and t o nur sing.
Risk fact or s r elat ed t o pat ient s w er e: being over 65( 3- 4), changes in level of awareness( 3- 4), use of m edicat ions ( ant idepr essant s, benzodiazepines, ant
i-h y per t en siv e m edicat ion , an d ot i-h er s)( 5 - 6 ), balan ce( 2 , 4 )
, m ot or( 2 - 4 ), an d sen sit iv e im p air m en t ( d ecr eased v isual and/ or audit or y accur acy )( 2- 4), m usculosk elet al diseases( 7), and pr ev ious hist or y of falls( 2- 4).
Th e a s s e s s m e n t o f m o t o r f u n c t i o n w a s perform ed wit h classificat ion of level 0 t o 5( 10). I n t he it em h ist or y of p r ev iou s f all b ef or e ad m ission , t h e reason, place and num ber of falls have been collect ed
t oget her w it h pr esence and t y pe of lesions.
Ri s k f a c t o r s r e l a t e d w i t h e n v i r o n m e n t included: beds w it h side r ail, beds w it hout side r ails, h igh beds, an d call bells ou t of r each f or pat ien t s.
According t o pat ient s, side rails were eit her up or down m ost of t he t im es. Beds w er e consider ed high w hen pat ient s needed a lat her t o clim b up or down t he beds. I n r isk f act or s r elat ed t o n u r sin g w e h av e collect ed: pat ient s r equest ing or not t he help of t he nur sing st aff.
Risk f act or s f or f alls w er e assessed in t h e pr e an d post oper at iv e per iods. Daily dat a collect ion w as per for m ed r egar ding t he occur r ence of fall and n u m ber of pat ien t s/ day. Fall rat e w as calcu lat ed b y dividing t he num ber of falls by t he num ber of pat ient s/ day and m ult iplying it by 1000( 9).
St at ist ical analy sis of r isk fact or s in t he pr e a n d p o st o p e r a t i v e p e r i o d w a s p e r f o r m e d b y Ch i -square t est or Fischer’s exact t est , considering p values < 0.05 as st at ist ically significant .
RESULTS
Table 1 – Dist ribut ion according t o age, gender, days
of hospit al st ay, and m edical diagnoses
s e r u t a e
F Total(n=97)
; s r a e y ( e g
A χ±SD) 48.9 14.8 ) % , n ( r e d n e G e l a
M 49 50.5
e l a m e
F 48 49.5
; s y a d ( y a t s l a t i p s o
H χ±SD) 16 12.8 ) % , n ( s e s o n g a i d l a c i d e M r o m u t l a i n a r c a r t n
I 39 40.2
e k o r t
S 18 18.5
s e s a e s i d d r o c l a n i p
S 16 16.5
s r o m u t l a n i p
S 9 9.3
I B
T 2 2.1
m e t s y s s u o v r e n l a r e h p i r e p e h t n o s n o i s e
L 3 3.1
s i s o c r e c it s y c o r u e
N 3 3.1
s u l a h p e c o r d y
H 2 2.1
I C
S 1 1.0
s e s a e s i d n i a r b r e h t
O 4 4.1
χ, m ean; SD, St andard deviat ion; TBI , t raum at ic brain inj ury; SCT, spinal cord inj ury
Tab l e 2 p r esen t s r i sk f act o r s r el at ed w i t h
neurosurgical pat ient s in pre and post operat ive period.
Tab l e 2 – Di st r i b u t i o n o f r i sk f act o r s r el at ed w i t h
n eu r osu r gical pat ien t s in t h e pr e an d post oper at iv e
p er iod s
h t i w d e t a l e r s r o t c a f k s i R s t n e i t a p e v i t a r e p O -e r
P Post
-e v i t a r e p O p
n % n %
5 6 r e v o g n i e
B 16 16.5 16 16.5 1.00 f o l e v e l e h t n i e g n a h C s s e n e r a w
a 9 9.3 10 10.3 0.81 y c a r u c c a l a u s i v n i e g n a h
C 43 44.4 43 44.4 1.00 e g n a h c r o t o
M 45 46.4 41 42.2 0.66 d n a t i a g n i e g n a h C e c n a l a b / r
o 18 18.5 18 18.5 1.00 e v i s n e t r e p y h it n a f o e s U n o it a c i d e
m 46 47.4 45 46.4 0.88 s g u r d c i p o r t o h c y s p f o e s
U 63 65.0 61 62.9 0.88 s e s a e s i d l a t e l e k s o l u c s u
M 5 5.2 5 5.2 1.00 ll a f s u o i v e r p f o y r o t s i
H 21 21.6 21 21.6 1.00
Am ong pat ient s who present ed change in t he
lev el of aw ar eness, sev en ( 77. 8% ) w er e disor ient ed
in t he pr eoper at iv e per iod, and eight ( 80.0% ) in t he
post operat ive period; t wo ( 22.2% ) were wit h let hargy
in t he pr eoper at iv e per iod, and t w o ( 2 0 . 0 % ) in t he
post oper at iv e per iod.
Re g a r d i n g c h a n g e i n v i s u a l a c c u r a c y, 6
( 14.0% ) pat ient s present ed unilat eral am aurosis; t wo
( 4.6% ) had bilat eral am aurosis; five pat ient s ( 11.6% )
present ed diplopia, t hree ( 7.0% ) cat aract ; one pat ient
(2.3% ) had strabism us ; 17 (39.5% ) used corrective lens
for short - sight edness or farsight edness, and 9 pat ient s
( 2 1 . 0 % ) h a d v i su a l a ccu r a cy d ecr ea sed d u e t o
neurological diseases in the pre and postoperative periods.
I n t h e a sse ssm e n t o f m o t o r f u n ct i o n , 4 5
pat ient s ( 46.4% ) in t he pr eoper at iv e per iod, and 41
p a t i e n t s ( 4 2 . 2 % ) i n t h e p o st o p e r a t i v e p r e se n t e d
decr ease in m ot or st r engt h. Hem ipar esis fr om gr ade
1 t o grade 4 was seen in 10 pat ient s ( 22.2% ) in t he
p r e o p e r a t i v e p e r i o d , a n d i n 9 ( 2 2 . 0 % ) i n t h e
post operat ive period; paraparesis grade 1 t o grade 4
in 1 1 pat ien t s ( 2 4 . 5 % ) in t h e pr eoper at iv e an d 1 1
( 26.8% ) in t he post operat ive period; paresis of inferior
lim b gr ade 2 t o gr ade 4 in nine pat ient s ( 20.0% ) in
t h e p r e o p e r a t i v e p e r i o d , a n d 7 ( 1 7 . 0 % ) i n t h e
p ost op er at iv e p er iod ; q u ad r ip ar esis in 1 1 p at ien t s
( 24.5% ) in t he preoperat ive period and 9 ( 22.0% ) in
t he post operat ive period; hem iparalysis in one pat ient
( 2 . 2 % ) in t h e p r eop er at iv e p er iod an d in 1 in t h e
post operat ive period ( 2.4% ) ; paresis in superior lim bs
in 3 pat ient s ( 6.6% ) in t he pr eoper at iv e per iod, and
in 4 pat ient s ( 9.8% ) in t he post oper at ive per iod.
Th e p r e s e n c e o f c h a n g e i n g a i t a n d / o r
balance w as assessed in 18 pat ient s ( 18.5% ) , in t he
pre and post operat ive period. During t he preoperat ive
p er iod , 8 p at ien t s ( 4 4 . 4 % ) p r esen t ed d izzin ess, 5
( 2 7 . 9 % ) h ad at ax ic gait , 2 ( 1 1 . 1 % ) h ad v er t igo, 2
( 1 1 . 1 % ) h ad p ar et ic g ait , an d 1 ( 5 . 5 % ) p r esen t ed
ant algic gait . I n t he post operat ive period, 10 pat ient s
( 55. 6% ) pr esent ed dizziness, 4 ( 22. 2% ) at ax ic gait ,
2 ( 11.1% ) vert igo, and 2 ( 11.1% ) paret ic gait .
Of t he 63 pat ient s ( 65.0% ) using psychot ropic
dr u gs in t h e pr eoper at iv e per iod, 4 9 ( 7 7 . 8 % ) u sed
an t icon v u lsan t s, 8 ( 1 2 . 7 % ) an t id ep r essan t s, an d 6
( 9.5% ) benzodiazepines. I n t he post operat ive period,
6 1 ( 6 2 . 9 % ) u se d p sy ch o t r o p i c, a n d 4 8 p a t i e n t s
( 7 8 . 7 % ) u s e d a n t i c o n v u l s a n t s , 6 ( 9 . 8 % ) u s e d
ant idepr essant s, and 7 ( 1 1 . 5 % ) benzodiazepines.
Mu scu losk elet al diseases w er e pr esen t in 5
pat ient s ( 5.2% ) in t he pr e and post oper at iv e per iod,
and 2 pat ient s ( 40% ) had ost eoart hrit is, 1 ( 20% ) had
a m p u t a t i o n o f i n f e r i o r l i m b , 1 ( 2 0 % ) h a d p e l v i c
m u scles h y p er t r op h y, an d of in f er ior lim b s, an d 1
pat ient ( 20.0% ) was put on a cast due t o fract ure of
left infer ior lim b.
Tw e n t y - o n e p a t i e n t s ( 2 1 . 6 % ) r e p o r t e d
pr ev ious fall befor e adm ission, t he causes w er e: 11
( 5 2 . 3 % ) d e cr e a se i n m o t o r st r e n g t h , 4 ( 1 9 . 0 % )
b alan ce im p air m en t , 3 ( 1 4 . 3 % ) d u e t o seizu r e, 1
( 9.6% ) due t o sy ncope and 2 ( 9.5% ) did not r epor t
t he r eason. Places of fall w er e: 13 ( 62.0% ) pat ient s’
h ou seh old ; 4 ( 1 9 . 0 % ) on t h e st r eet s, 1 ( 4 . 7 % ) in
hospit al before t his adm ission, 1 ( 4.7% ) at work and
pr esent ing falls, 12 ( 57. 0% ) pr esent ed t he follow ing
lesion s: 7 ( 3 3 . 3 % ) h ad sk in ab r asion s, 3 ( 1 4 . 3 % )
b r u ises, 1 ( 4 . 7 % ) ab r asion s an d b r u ise, 1 ( 4 . 7 % )
br uise and fr act ur e of super ior r ight lim b. Regar ding
t he num ber of falls, 17 pat ient s ( 81. 0% ) had fallen
once, 1 pat ient ( 4.7% ) had fallen t wice, 1 ( 4.7% ) t hree
t im es, and 2 ( 9.6% ) had fallen 4 t im es or ov er. Of t he
21 pat ient s ( 21.6% ) t hat pr esent ed falls pr ev ious t o
hospit al st ay, 3 ( 14.3% ) had falls dur ing t he cur r ent
hospit al st ay.
Tab le 3 p r esen t r isk f act or s r elat ed t o t h e
environm ent and nursing in t he pre and post operat ive
p e r i o d . A l l p a t i e n t s r e p o r t e d t h e n u r s i n g t e a m
answ er ed t o t heir r equest s w hen t hey r equir ed.
Table 3 - Dist r ibu t ion of r isk f act or s r elat ed t o t h e
e n v i r o n m e n t a n d t o n u r s i n g d u r i n g p r e a n d
post oper at iv e per iod
e h t o t d e t a l e r s r o t c a f k s i R g n i s r u n d n a t n e m n o r i v n e e v i t a r e p O -e r
P Post-Operative
P
n % n %
s d e b e h t n o s li a r e d i S s li a r e d i s o
N 54 55.7 56 57.8 5 5 . 0 p u e r e w s li a r e d i
S 28 28.9 31 32.0 n w o d e r e w s li a r e d i
S 15 15.4 10 10.2 s d e B f o t h g i e H h g i
H 71 73.2 72 74.2 7 8 . 0 w o
L 26 26.8 25 25.8 s ll e B ll a C h c a e r ' s t n e it a p t
A 83 85.6 89 91.8 6 2 . 0 h c a e r ' s t n e it a p f o t u
O 14 14.4 8 8.2 e c n a t s i s s a g n i s r u n d e t s e u q e R d e r e w s n a s a w d n
a 81 83.5 89 91.8 0.14 g n i s r u n r o f k s a t o n d i D e c n a t s i s s
a 16 16.5 8 8.2 0.13
Dur ing hospit al st ay, 8 pat ient s ( 8. 2% ) fell,
of a t ot al of 1 2 f alls ( 1 2 . 4 % ) . Tw o pat ien t s ( 2 5 % )
w er e ov er 65. I n t he pr eoper at iv e per iod, 5 pat ient s
( 62. 5% ) fell, and 2 pat ient s ( 25. 0% ) pr esent ed t w o
falls, on a t ot al of 7 falls in t he pr eoper at iv e per iod
( 58.3% ) . I n t he post oper at iv e per iod, 3 pat ient s fell
( 37.5% ) , however, 1 pat ient ( 12.5% ) present ed 3 falls,
in a t ot al of 5 falls in t he post operat ive period ( 41.7% ) .
Ther e w as no st at ist ical differ ence bet w een pat ient s
w h o f ell in t h e pr e an d in t h e post oper at iv e per iod
( p < 0 . 7 2 ) . Pl a ce s o f f a l l w e r e : 7 ( 5 8 . 3 % ) i n t h e
pr eoper at iv e r oom ; 4 ( 3 3 . 3 % ) in t h e post oper at iv e
r oom and 1 ( 8.4% ) t he fall occur r ed in t he t oiled in
t h e p ost op er at iv e p er iod . Dist r ib u t ion of t h e w ay s
pat ient s fell w as t he follow ing: 5 falls ( 41.7% ) w hen
st epping down t he bed; 3 ( 25.0% ) in deam bulat ion in
t he bedr oom ; 3 ( 25. 0% ) w hen changing posit ion on
t he bed, and in t he 3 cases, t he bed did not have side
r ails, and in 2 cases beds w er e high; and 1 ( 8. 3% )
fall occurred when pat ient was leaving t he t oilet bowl.
One pat ient ( 8.3% ) evolved wit h subcut aneous bruise
in t he front al region aft er t he fall.
Table 4 present s reasons referred by pat ient s
and b y nur sing t hat led t o fall dur ing hospit al st ay.
Ther e w as pr edom inance of m ot or im pair m ent in t he
pr e and post oper at iv e per iod as t he m ain r eason for
f all.
Table 4 – Reasons for fall referred by pat ient s and by
nursing of t he unit during hospit al st ay
Figure 1 assesses t he rat e of fall per m ont h.
Fall rat e of a pat ient was higher in February wit h 10.2
falls/ 1000 pat ient s day.
10
0 2
4.6 4.8 0 0 2 4 6 8 10 12
Feb Mar Apr Mai Jun Jul
Fa ll s pe r 1 0 0 0 pa ti e n ts d a y Months
Figure 1 – Rat e of Pat ient s’ fall / 1000 pat ient s day
DI SCUSSI ON
Fa l l i s t h e m o s t c o m m o n s i d e e f f e c t i n
hospit alized pat ient s, and 70% of t he accident s occur inside t he hospit al( 11). Am ong pat ient s, 2% fall during
hospit al st ay( 1).
Elderly pat ient s are at risk for fall, and 53% of f alls occu r in pat ien t s ov er 6 5( 5 ). I n n eu r ological
and neurosurgical wards, t he risk of fall is regardless
of age( 1). I n t his st udy, we have assessed t hat 25% of falls occur in pat ient s w ho w ere over 65 years old.
A m o n g t h e m o s t c o m m o n r i s k f a c t o r i n
neur ological pat ient s is m uscular w eak ness, st r ongly l l a F r o f n o s a e
R Pre-Operative Post-Operative
n % n %
t n e m r i a p m i r o t o
M 4 33.3 2 16.7 e c n a b r u t s i d t i a g r o / d n a e c n a l a
B 2 16.7 -
-h t i w d e t a i c o s s a ( n o i s u f n o C l a t n e M ) t i c if e d r o t o
m 1 8.3 -
-h t i w d e t a i c o s s a ( t n e m r i a p m I l a u s i V ) e c n a b r u t s i d t i a g r o / d n a e c n a l a
associat ed w it h t his t y pe of fall and t o fall gener ally
speaking.A sur vey conduct ed w it h inpat ient s show ed
t h at m u scu lar w eak n ess w as p r esen t in 8 0 . 9 % of
pat ient s who fell( 5).Mot or im pairm ent w as found in 4
pat ient s ( 33.3% ) who fell in t he pre- operat ive period,
and 2 ( 16.7% ) in t he post operat ive; visual im pairm ent
associat ed w it h balance and/ or gait dist ur bance w as
found in 3 pat ient s ( 25% ) who fell in t he post operat ive
p er iod .
Risk f act or s f or f all ar e pr esen t in h ospit al
pat ient s in neur ological and sur gical unit s. How ever,
t he r isk of fall is gr eat er in psy chiat r ic, neur ological
and/ or neurosurgical wards( 1).I n t hese wards, pat ient s
p r e s e n t s e v e r a l r i s k f a c t o r s , s u c h a s l e v e l o f
awareness, hindered m obilit y, ort host at ic hypot ension,
vesical or int est inal dist urbances, sensory deficit s, and
p r e v i o u s h i st o r y o f f a l l s. Fa l l s a m o n g n e u r o l o g y
pat ient s occur t wice as m uch as in ot her unit s( 1).
I n r i s k f a c t o r s a s s o c i a t e d w i t h h o s p i t a l
environm ent , bot h problem s of st ruct ure and process
were assessed. High beds and t hose wit hout side rails
ar e r el at ed t o p r ob l em s w i t h t h e st r u ct u r e of t h e
hospit al. Beds w it h side r ails t hat r em ained low er ed
and not r equest ing nur se’s assist ance ar e r elat ed t o
failur e in t he pr ocess.
A survey assessing risk fact ors relat ed t o t he
presence of fall dem onst rat ed t hat 56.1% of pat ient s
t h at f ell h ad t h e sid e r ails of t h eir b ed s l ow er ed .
Ad d i t i o n a l l y, 4 4 ( 4 4 . 9 % ) o f t h e m r e f e r r e d t h e y
r eq u est ed n u r ses’ assi st an ce so m et i m es, w h er eas
only 11 ( 11. 2% ) said t hey alw ay s ask ed for nur ses’
assist ance( 11). I n t his st udy, t he num ber of pat ient s
t h at r efer r ed n ot r equ est in g n u r ses’ assist an ce w as
16 ( 16.5% ) in t he preoperat ive period, and 8 ( 8.2% )
in t he post oper at iv e per iod. I n 2 falls ( 1 6 . 7 % ) , t he
beds had t heir side r ails low er ed, and in 6 of t hem
( 50% ) , beds did not have side rails at all.
Am ong pat ient s adm it t ed t o a neur ological/
neur osur gical w ar d, 5.8% fell dur ing hospit al st ay( 1).
I n t his st udy, 8.2% of pat ient s fell, which shows t hat
in ad d it ion t o r isk f act or s r elat ed t o p at ien t s, t h e
difficult ies found regarding st ruct ure and process m ay
hav e cont r ibut ed t o t he occur r ence of falls.
Falls hav e been divided according t o t he period
t h ey occu r r ed , p r e or p ost op er at iv e. Sev en of t h e
falls ( 58.3% ) occurred in t he preoperat ive period, and
5 ( 33.3% ) in t he post operat ive. When risk fact ors were
assessed , 4 p at ien t s ( 4 . 2 % ) w h o p r esen t ed m ot or
im pairm ent in t he pre- operat ive period did not present
it in t he post oper at iv e.
The r at e of lesions caused by falls w as 28%
i n n eu r o l o g i cal / n eu r o su r g i cal w ar d s( 1 ), w h er eas i n
o t h e r w a r d s, t h i s r a t e w a s 3 3 . 6 %( 1 2 ). We h a v e
observed in t his st udy t hat 8.3% of falls caused lesions
but no fract ure. I n anot her st udy 2% of pat ient s had
fr act ur e( 1 ).
The rat e of fall was 6.12 falls per 1000 pat ient s
day in a neur ology w ar d( 5), w hile in t his st udy, r at es
ranged from zero t o 10.2 falls per 1000 pat ient s day.
Fact ors relat ed t o st ruct ure and process cont ribut e t o
t hese r at es.
For t hese prevent able falls, current beds have
t o b e r ep laced b y b ed s w it h sid e r ails an d h eig h t
adj ust m ent . I n addit ion t o t hese m easures, at hospit al
adm ission, t here should be an assessm ent of t he risk
of falls, t o det erm ine prevent ion act ion during hospit al
st ay. This assessm ent should also be periodical, since
r isk f act or s ch an ge. I t is also im por t an t t o in v olv e
Cont inuous Educat ion of t he hospit al t o educat e t he
nur sing t eam .
CONCLUSI ONS
There was no difference bet ween risk fact ors
for fall found in t he pre and post operat ive period of
neurosurgery. Rat e of fall was 12.4% , and 6 falls ( 50% )
could hav e been pr ev ent ed w it h t he im pr ov em ent of
hospit al st ruct ure, 2 ( 16.7% ) wit h t he int roduct ion of
a program t o prevent fall, and 4 ( 33.3% ) if t here was
adherence of pat ient s t o request help for t he nursing
st aff befor e per for m ing any act iv it y.
REFERENCES
1. Rohde JM, Myers AH, Vlahov D. Variat ion in risk for falls by
cl i n i ca l d e p a r t m e n t : I m p l i ca t i o n s f o r p r e v e n t i o n . I n f e ct
Con t r ol Hosp Ep id em iol 1 9 9 0 ; 1 1 : 5 2 1 - 4 .
2. Rubenst ein LZ, Pow ers CM, MacLean CH. Qualit y indicat ors
f or t h e m an ag em en t an d p r ev en t ion of f alls an d m ob ilit y
p r o b l e m s i n v u l n e r a b l e e l d e r s . A n n I n t e r n M e d
2 0 0 1 ; 1 3 5 : 6 8 6 - 9 3 .
3. Cohen L, Guin P. I m plem ent at ion of a pat ient fall prevent ion
p r og r am . J Neu r osci Nu r s 1 9 9 1 ; 2 3 : 3 1 5 - 9 .
4 . Hit ch o EB, Kr au ss MJ, Bir ge S, Du n agan WC, Fisch er I ,
Johnson S, et al. Char act er ist ics and cir cum st ances of falls
in a hospit al set t ing. J Gen I nt er n Med 2004; 19: 732- 9.
5. Vassallo M, Vignar aj a R, Shar m a JC, Br iggs R, Allen SC.
Pr edict or s for falls am ong hospit al inpat ient s w it h im pair ed
m obilit y. J R Soc Med 2 0 0 4 ; 9 7 : 2 6 6 - 9 .
m edicam ent os psicoat ivos e seu r elacionam ent o com quedas
en t r e idosos. Rev Saú de Pú blica 2 0 0 0 ; 3 4 : 6 3 1 - 5 .
7 . Fa b r íci o SCC, Ro d r i g u e s RAP, Ju n i o r MLC. Ca u sa s e
con seqü ên cias de qu edas de idosos at en didos em h ospit al
pú blico. Rev Saú de Pú blica 2 0 0 4 ; 3 8 : 9 3 - 9 .
8 . Mar in HF, Bou r ie P, Saf r an C. Desen v olv im en t o d e u m
sist em a d e aler t a p ar a p r ev en ção d e q u ed as em p acien t es
h o sp i t a l i za d o s. Re v La t i n o a m En f e r m a g e m 2 0 0 0 ; 8 : 2 7
-3 2 .
9 . N A G EH . M a n u a l d e I n d i c a d o r e s d e En f e r m a g e m .
Pr o g r a m a CQH. Sã o Pa u l o ( SP) : APM/ CREMESP; 2 0 0 6 .
Recebido em : 13.11.2007 Aprovado em : 2.7.2008
1 0 . Diccin i S, Wh it ak er I Y. Ex am e Neu r ológ ico. I n : Bar r os
ALBL e cols. An am n ese e Ex am e Físico. São Pau lo ( SP) :
Ar t m ed Edit or a; 2 0 0 2 , p. 9 5 - 1 1 1 .
1 1 . Kr auss MJ, Ev anoff B, Hit cho E, Ngugi KE, Dunagan C,
Fischer I , et al. A case- cont r ol st udy of pat ient , m edicat ion,
and care- relat es risk fact ors for inpat ient s falls. J Gen I nt ern
Me d 2 0 0 5 ; 2 0 ( 2 ) : 1 1 6 - 2 2 .
1 2 . Sch w en dim an n R, Bü h ler H, Geest SD, Milisen K. Falls
and consequent inj uries in hospit alized pat ient s: effect s of an
int er disciplinar y falls pr ev ent ion pr ogr am . BMC Healt h Ser v
