Frequently Asked Questions

If you have a question about using the Hendrich II Fall Risk Model in your facility, check out our Frequently Asked Questions below. For all other inquiries, please contact us directly.

Why doesn't the Hendrich II Fall Risk Model consider history of falls as an important predictor of falls?

This is one of the most common questions the study considered. In the initial study completed by Hendrich (Hendrich II Fall Risk Model), history of falls seemed to be a significant predictor, as other studies had reported. When the study sample size was increased to 1,135 patients (falls and non-falls), it became clear that many previous studies overestimated the importance of certain risk factors. In other words, when large numbers of control patients (non-falls) were tested against patients who fell, the predictive ability of a history of falls became insignificant. History of falls only appeared to be significant because it was always paired with the “real” risk factors – those contained within the Hendrich II Fall Risk Model. If someone is falling frequently, the fall risk factors are the true root cause, not the fact he/she has a history of falls.

How often should patients be assessed?

The preferred approach is once per shift or whenever the patient condition changes. In acute care, assessment could be even more frequent if there is a sudden change in acuity. In long-term or residential care, assessment should be performed based the policies of the organization or national recommendations and guidelines. Often these patients remain with some facilities over a long period of time, and the goal is to not only accurately assess the patient’s condition, but to address changes in the patient's condition related to fall risk over time. This will help staff recognize and then address these changes which often are subtle in nature. These changes can be pathophysiologic (cerebral, coronary, etc.) or the result of medication side effects that emerge as risk factors.  The most common side effects of medications include changes in sensorium, gait, elimination patterns, mood, and balance. Therefore, monitoring a patient for these predictive risk factors may eliminate the need to monitor dozens of medication categories.

Why aren't more drugs included as risk factors?

There are 2 categories of drugs found to be significantly related to an increased risk of falls in this study. They include benzodiazepines and antiepileptics. Each of these categories is well validated in the literature. In this large, randomized, case-control study, other categories of drugs, in and of themselves, did not increase the statistical risk of falling. This is believed to be true because the risk factors that predict falls are also the most common side effects of medications (orientation, mood, elimination, gait, and balance). To state it differently, other than the 2 categories already mentioned, the fact that a patient was taking other categories of drugs did not seem to increase fall risk if none of the fall risk factors found in the Hendrich II Fall Risk Model were positive. This probably helps to explain why risk factors can over-identify certain populations of patients when statistical analysis and sample size are not carefully followed.

Can this tool be used in the various service-lines or case-mixes found in most acute-care facilities (e.g., med-surg, emergency, oncology, critical care, transplant, etc.)?

Yes. The research was done in a large, randomized study and so far, feedback suggests that the Hendrich II Fall Risk Model can be used generically across the acute-care/skilled-care environments as an effective screening tool. When the 8 risk factors are used with environmental safety precautions, and specific interventions are matched against the identified risk factor, a significant number of falls can be prevented. Since 1989, Hendrich has been advocating a unit-based approach to successful fall prevention programs. The Hendrich II Fall Risk Model risk factors seem to cut across nearly all patient populations. For example, patients returning from acute-care surgeries often experience some short-term confusion or decreased level of orientation as a result of anesthesia or narcotics. Further, they may have altered gait or get-up-and-go performance due to weakness, pain, and/or side effects of the medications. Elimination may be altered due to catheters, frequency, or bed rest. Within a day or sometimes less, this same patient who would have scored greater than a 5 on the Hendrich II Fall Risk Model will show a rapid score drop. This permits the nurse to take the patient on or off the protocol, as appropriate, saving nursing time and adding credibility to a fall prevention program. Many surgical units make fall prevention a part of the surgical pathway for all patients returning from surgery. Nurses remove patients from the prevention pathway once orientation, gait, and mobility return to baseline. Based upon further testing of the Hendrich II Fall Risk Model, these same 8 risk factors work well in identifying falls in ambulatory or out-patient testing areas. For example, when a patient arrives in these areas of the hospital (inpatient or outpatient), he/she often has weakness and altered elimination due to cathartics or fluid challenges. If the patient also has altered gait or dizziness, he/she will be high risk for falling from carts, chairs, or procedural tables. Observation and assistance are critical for these patients while in ambulatory areas, just as in nursing units. Communication is key when high-risk patients arrive from the nursing units, so allied health personnel can understand the fall risk and help to prevent injury. These patients should not be left alone in hallways or observation areas. It is critical to include all personnel in the education and prevention of falls to promote patient safety.

What makes a successful fall prevention program?

No matter what area of the healthcare facility (ambulatory, procedural, or inpatient), the keys to fall prevention are to: • Assess patients with statistically significant risk factors for a fall. • Make the environment safe for all patients by using core environmental safety practices (e.g., lighting, footwear, bed  height, floor surfaces, call lights, patient education, and bed exit monitors). • Match interventions against the fall risk factors identified. For example: Poor gait and balance + confusion = Constant monitoring and assistance for transfers, ambulation, and movement. • Reassess patient risk on a frequent basis. • Make this part of an interdisciplinary clinical practice model (e.g., including MD, RN, PharmD, and Allied Health). • Involve the patient, family, and significant other with education on the importance of risk, prevention, and communication with staff.

What if the patient is in critical care and is comatose or if the patient cannot get up without assistance? How is the tool used?

Critical care patients may exhibit many of the risk factors during highly acute periods. However, if they are comatose and/or on a ventilator, or simply not able to rise at all without assistance, they do not have an opportunity to fall, even though there are risk factors. They should be assessed in the same manner, and risk factors should be documented. As soon as they have a potential to attempt to get up, they should be placed on a protocol for fall prevention. Interventions should always be matched against the risk factors when the patient has a potential to fall. Falls are rare in critical care, but when they do occur they can be very serious. These falls often occur when patients awaken from comatose states or in the early days of mobility attempts without staff knowledge. Severely compromised or debilitated patients often have many risk factors but are simply unable to rise without considerable assistance of 1 or more personnel. These patients are often more at risk for falls from bed and/or side rail entrapments than for actually falling while standing. In either case, one must be very cautious in assuming what can or cannot occur with individual patients. All patients deserve to have appropriate assessments and safety interventions performed on a regular basis. This patient will benefit from constant environmental assessments as well as risk factor identification.

Can this tool be used with pediatric patients?

To date, the Hendrich II Fall Risk Model has not been tested in acute-care pediatrics. Falls are rare in hospitalized pediatric patients. Often, developmental falls (accidental) occur in the first few years of life; falls related to the environment are most common. Hospitalized children often climb from beds or cribs seeking to be next to their parents; this can result in falls. Or parents may fall asleep at their child's bedside with the rails down and then the child falls from the bed. The latter type of fall seen in hospitalized, very ill children seems to be related to physiologic risk factors, similar to adults. In these few cases, weaknesses and impaired gait and mobility were present. Further testing and research is needed to prospectively test the specificity and sensitivity of the Hendrich II Fall Risk Model in this highly specialized population.

Are there interventions that seem to work better than others?

Yes, 80% or more of hospitalized falls occur in the patient room, while the patient was attempting to go to the bathroom or felt elimination needs. These patients have underlying fall risk factors that make them high risk for falling. If they call for assistance without success, and attempt to ambulate alone, many will fall. This is often not related to the number of staff, but to what the staff are doing at the time the patient has a need that goes unmet. For example, if the call light goes unanswered, the patient’s risk of falling increases. If the call light is answered and the patient has assistance, or if a bed alarm notifies the staff that the patient is about to take a risk, the patient's risk will be averted. Proactively toileting patients who cannot express their needs or assisting those who require ambulation help (due to poor gait and mobility) meet elimination needs reduces their overall risk of falling. Adding toileting to “core” interventions can reduce falls by half in most facilities.

How can we add fall prevention to an already challenged nursing staff?

All nurses care about the prevention of falls, no matter how busy they are. Professional practice models that retain staff have characteristics of shared decision making, research-based practice, innovation, and measurement of patient outcomes. Fall prevention can be incorporated into a professional practice model, and the assessment adds less than 1 to 2 minutes of nursing time. What is more important than preventing a fall, a fracture, a head injury, or loss of life? The greater challenge is to identify what is wasting nursing time in indirect care or “hunting and gathering” (Hendrich, 2004; Keeping Patients Safe: Transforming the Work Environment of Nurses. Institute of Medicine). Nurses must be returned to direct care and have time for clinical interventions that make a difference in patient outcomes. Fall prevention programs work best when they are incorporated into existing clinical practice committees with direct caregivers who own the process, and who have open access to fall data for their unit and organization. This practice contributes to an environment and culture of patient safety.

How many falls can be prevented?

The answer to this question depends upon many of the factors described above. However, remember that the comprehensive Hendrich et al., (2003) study tested the Hendrich II Fall Risk Model against all fall patients and 75% or more would have been correctly identified with just the Hendrich II Fall Risk Model 8 risk factors. Potentially, therefore, at least 75% of all falls could be prevented in the hospital or healthcare facility environment.

Falls in obstetrics are rare, but do they occur?

Women expecting multiple births often spend weeks or months on continual bedrest. Large abdominal girths and excessive weight related to the pregnancy can make them high-risk for falls. The recently delivered mother often feels faint or weak the first few times she gets up. Frequently, this doesn't occur until she gets into the bathroom. Cesarean mothers may have residual effects of epidural anesthesia that causes numbness in the legs or incomplete motor control. In rare instances, falls occur while the mother is holding or walking with an infant, causing injuries to one or both. Toxemia can further increase the mother's risk of falling due to seizures and drug therapies such as magnesium sulfate.

Were pediatrics included in the study?

Few, if any, studies of falls have been completed in pediatrics. We have included interventions within the education component of the Upright® Fall Prevention Program computer-based educational program to address pediatric fall risk in children admitted to the hospital. If an adolescent’s developmental level is within normal limits, the Hendrich II Fall Risk Model can be used to assess fall risk. The same adult risk factors account for most falls in this young adult population as well, e.g., impaired gait and mobility, altered elimination, confusion and or dizziness. The side effects of drug therapies are included in the intrinsic risk factors with the exception of the benzodiazepine and antiepileptic medications. Your fall data collection team should closely monitor the adolescent population to determine if there are any unusual findings, such as risk factors that are not in the Hendrich II Fall Risk Model. Unique Circumstances in the Pediatric Population There are two kinds of falls seen in the pediatric population: a) developmental, and b) pathophysiological, or intrinsic, falls. Falls occur rarely among this population, but when they do occur, they can result in similar if not the same injuries as those that occur with adults.


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