System Factors and Patient Falls in Emergency Departments

As recommended by Terrell et al,1 emergency department–specific fall risk models need to be developed to account for key differences that relate to emergency departments. However, it is necessary to recognize that beyond the primary patient-related factors, there are a number of inherently unique system-related factors that exert a diffuse but equally significant influence on the overall fall risk profile in this environment.

Physical environment factors such as the dimensions of cubicles and distances between ED beds and toilets, as well as functional factors such as lines of sight and the general sensory environment, all influence the overall risk of falls in an area. High-stimulus environments may elevate confusion, agitation, and wandering among at-risk patients. Large distances from patient beds to toilets (and a lack of way-finding cues) may further raise the risk of falls. Human factors are another critical consideration. Stretched resources during periods of peak load make the completion of comprehensive risk assessments, the provision of adequate supervision, and the management of identified risk all the more challenging.

It is suggested that addressing these issues may improve the effectiveness of patient-specific fall prevention strategies in emergency departments. For example, high-stimulus environments may be counterbalanced by preferential placement of patients at risk of confusion (or agitation) away from high-activity or main transit areas. The judicious use of surfacing materials with dampening properties could also be explored. Fall risks associated with access to detached toilets could be managed by the use of directional floor tape leading from each cubicle to the closest toilet.

A significant gap in the literature currently exists on the relationship between patient fall risk and larger system issues. As a consequence, these influences are poorly accounted for in existing predictive models, which may be a reason for disappointing sensitivity and specificity outcomes when trialed away from initial validation sites. It is suggested that research into how system factors interact and influence overall fall risk in an ED environment is the next step from both a fundamental perspective (for improving predictive models) and applied perspective (for developing durable solutions).