How to Monitor Hospitalized Patients for Falls
Implement systematic fall risk screening at admission by asking all older patients about falls in the past year, followed by observational gait testing (Get Up and Go Test), and establish continuous monitoring through patient supervision by nursing staff, supplemented by video monitoring technology for high-risk patients. 1
Initial Screening and Assessment
Universal Screening Protocol
- Ask every older patient under your care at least once yearly about falls 1
- For hospitalized patients, conduct this screening at admission
- Document fall history as part of routine intake
Observational Gait Assessment
After identifying any fall history:
- Perform the "Get Up and Go Test": observe the patient stand from a chair without using arms, walk several paces, and return 1
- Patients demonstrating difficulty or unsteadiness require comprehensive fall evaluation
- Those with no difficulty need no further immediate assessment
Comprehensive Fall Evaluation for High-Risk Patients
When patients report recurrent falls, present after a fall, or show gait/balance abnormalities, conduct a full evaluation including 1:
History Components:
- Detailed fall circumstances
- Complete medication review (especially psychotropic medications)
- Acute and chronic medical conditions
- Current mobility levels
Physical Examination:
- Vision assessment
- Gait and balance testing
- Lower extremity joint function
- Neurological examination: mental status, muscle strength, peripheral nerves, proprioception, reflexes, cortical/extrapyramidal/cerebellar function
- Cardiovascular status: heart rate, rhythm, postural pulse and blood pressure, carotid sinus stimulation response if appropriate
Ongoing Monitoring Strategies
Primary Monitoring Method: Patient Supervision
The key falls prevention strategy in hospitals is direct patient supervision by nursing staff 2. However, this approach has significant limitations:
- Creates substantial workload burden on nurses 2
- Constrains ability to share responsibility across multidisciplinary teams 2
- May be less effective during high-acuity periods
Technology-Enhanced Monitoring
Video monitoring shows the most consistent evidence for reducing fall rates in hospitalized patients 3:
- Particularly effective for nighttime falls 3
- Reduces need for one-to-one observation 3
- Perceived as effective by patients, nursing staff, and monitor technicians 4
- Protects patient safety in other high-risk situations beyond falls 4
Assistive Device Monitoring
Consider bed alarms, though evidence shows these work best as part of multifactorial interventions rather than in isolation 1
Critical Implementation Considerations
Common Pitfalls to Avoid
Documentation Burden:
- Workload pressures can reduce assessment to "tick-box exercises" 2
- Ensure assessment tools support clinical practice rather than just audit requirements 2
Risk Categorization Issues:
- Avoid relying solely on high/low risk categories to determine supervision 2
- Individual risk factors matter more than composite scores 5
- Scored screening tools are no longer recommended 5
Communication Gaps:
- Nursing staff often lack time to explain fall risks to patients 2
- Provide brief, sensitive communication strategies to prevent patient actions that increase fall risk 2
- Consider how other staff members can contribute to patient education 2
Medication Monitoring
Pay particular attention to patients taking:
- Four or more medications 1
- Psychotropic medications (neuroleptics, benzodiazepines, antidepressants) 1
- Review and reduce medications as appropriate 1
Evidence Limitations
Important caveat: Despite widespread implementation, there are no adequate randomized controlled trials of multifactorial intervention studies to reduce falls among hospital inpatients 1. The recommendations are extrapolated from community and long-term care settings, combined with observational hospital data and quality improvement studies.
The evidence base for hospital-specific monitoring is weaker than for other settings, requiring clinical judgment in implementation 2, 6.