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POSTPARTUM

SAFETY:
A Patient-Centered
Approach to

FALL PREVENTION
Suzy Lockwood, RN, PhD, OCN, CHPN, and Kandace Anderson, BSN, RNC
Abstract
Falls in the perinatal setting have received minimal attention and have not been well
documented. Women are at risk for falling following vaginal or cesarean birth, especially
during initial attempts at ambulation. Recently, a womens hospital that averages over 500
births per month recorded a postpartum fall rate that exceeded the national mean for adult
surgical patient falls. A fall prevention team (FPT) of five nurses was formed with a goal to
decrease the incidence of postpartum patient falls to zero within the following 7 months. A
patient-centered fall prevention strategy was developed. The results of this project have laid
the foundation for additional research of a program that will consider not only prevention of
falls in a healthy population but also the development of a risk assessment tool specific to
women in the immediate postpartum period.
Key terms: Accidental falls; Fall prevention; Fall risk assessment; Patient safety; Postpartum
period; Postpartum safety.
January/February 2013

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atient falls account for a significant portion


of injuries in hospitalized patients and are a
major focus of The Joint Commission (TJC)
and Institute of Medicine. Falls in the perinatal setting, however, have received minimal attention and
have not been well documented. As suggested by Simpson
(2010), falls in this specialized setting occur more often
than might be expected, and could be minimized with
patient education and nursing intervention. Women are
at risk for falling following vaginal or cesarean birth, especially during initial attempts at ambulation. This fall
risk can be a result of postbirth fatigue, blood loss, hypotension, weakness, or lack of sensation in lower extremities due to epidural analgesia and side effects of narcotic
medications.

Background
Hook, Devine, and Lang (2008) conducted a systematic
review in an effort to identify the strength of evidence
supporting recommendations for fall risk assessment. In
their review, they used Morses three categories of falls:
anticipated physiological falls (e.g., unstable gait, history
of falling); unanticipated physiologic falls (e.g., seizures,
fainting); and accidental falls (e.g., slipping, tripping).
The category into which postpartum falls belongs is unanticipated physiological falls, defined as falls attributed
to physiological causes but the occurrence could not be
predicted (Morse, 1997). This includes falls occurring in
patients who are recovering from physiological events
and thus are at increased risk for unstable blood pressure,
syncope, and subsequent falling at certain high-risk times.
Relating this to postpartum patients, the physiological
event is cesarean section or vaginal birth, and the highrisk times are after birthing and during the first times out
of bed. Hook et al. (2008) considers this a screenable fallrelated special condition. Based on their review, the most
important factor that influences fall risk particularly in
this category is the patients willingness, or ability, to
actively participate in the fall prevention process.
Fall risk tools are typically designed to predict anticipated physiological falls that represent 34% to 78% of
falls that occur in acute care (Currie, 2008). The Johns
Hopkins Fall Assessment Tool is a nationally recognized and widely used evidence-based approach to fall
risk assessment, fall prevention, and falls management
(Poe, Cvach, Gartrell, Radzik, & Joy, 2005). Although
the John Hopkins tool is useful in the medicalsurgical
population, it does not address the unique characteristics in the immediate postpartum period. When using
the Hopkins Fall Assessment Tool, most postpartum admissions are rated as a moderate fall risk. Interventions
applicable to this category include assisting with bedside
sitting, personal hygiene, and toileting.
The postpartum patient is generally an independent
healthy woman of childbearing age; their hospitalization experience is focused on the birth of a new infant.
Frank, Lane, and Hokanson (2009) recognized the disconnect between the traditional fall risk assessment tools
and the postpartum patients. Using the Morse Falls Scale
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WOMEN are at
risk for falling
following vaginal
or cesarean birth,
especially during initial attempts
at ambulation.
and a Modified Alderete Score, Frank et al. developed
and implemented the Post Epidural Fall Risk Assessment
Score (PEFRAS). The PEFRAS was designed specifically
for postepidural, postpartum patients. The validity and
reliability of PEFRAS have not yet been established, but
this is the first published attempt to address this specialized population.
In the medicalsurgical and geriatric populations,
evidence-based recommendations have been made for
patient safety and fall prevention (Currie, 2008; Fall
Prevention, 2008). In those high-risk populations, research
has been conducted to explore the effectiveness of using
fall risk identification bracelets, signs, stickers, or tags as
an inexpensive and easy intervention (Williams, Young,
Williams, & Schindel, 2011). However, study results have
not indicated that these measures, as isolated interventions,
decreased falls (Bell & Stirling, 2006; Coussement et al.,
2008; Dykes et al., 2010; Oliver, Healey, & Haines, 2010).
The National Patient Safety Goals (NPSG) encourage the
patients active involvement in their own care as a safety
strategy. The Studer Group has recommended that hospitals
hardwire partnerships between nurses and their patients
as part of a fall prevention protocol (Studer, Robinson, &
Cook, 2010).

A Unit-Based Postpartum Fall


Prevention Strategy
Recently, a womens hospital that averages over 500
births per month recorded a postpartum fall rate that exceeded the national mean for adult surgical patient falls.
The national average for adult surgical patient falls per
1,000 patient days during the 12-month time period was
2.79. This mean was used for comparison since there was
no national mean for postpartum falls.
Although actual circumstances varied, the Nursing
Practice Council for the postpartum unit was concerned
that the unsatisfactory fall rate could be due to a lack of
patient education and staff awareness. A preliminary review of post-fall reports revealed that some women were
getting up to the bathroom without calling for staff assistance. Following the fall, women would report to their
nurse that they did not fully understand the effects and
duration of epidural analgesia, and did not realize their
legs were too weak for walking. Although no injuries
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Copyright 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

were sustained from the falls during the 12-month Figure 1. Call for a Helping Hand Patient Letter
period, a need to decrease the fall rate was identified
in order to prevent potential injury and costs.
TO PREVENT A FALL, PLEASE CALL
With approval from Nursing Administration, a
New mothers are at risk for falling, even though they may
fall prevention team (FPT) of five nurses was formed
feel strong and steady.
with a goal to decrease the incidence of postpartum
patient falls to zero within the following 7 months.
What do YOU need to do?
Two months after the FPT was formed, a patient1) Wear the purple arm band until your nurse removes it.
centered approach to fall prevention was impleThis will alert all staff that you are at risk for falling.
mented. A Call for a Helping Hand letter created
2)
CALL
for staff help using your call button or phone before
by the FPT was placed in each patients admission
getting
out of bed.
folder (Figure 1). The letter briefly and simply ex3) Please do not allow your family members or visitors to
plained the risk of falling in the initial postpartum
assist you out of bed.
period. Using low-literacy concepts for developing
educational material for women outlined by Wilson
4) Ask for non-slip socks. These are available at your request.
(2011), the letter instructed the patient to call for
5) Keep foot rail on side of bed closest to the bathroom
assistance before getting out of bed. A Spanish
raised to remind you to wait for staff assistance.
translation of the letter was also available. The admission folder including the letter and a purple fall
We are here for you!
risk armband was to be placed at the bedside when
Dont be shy, ask for help!!
preparing the postpartum room for the patients arrival. The admitting nurse would thus be prompted
to initiate the fall prevention strategy during initial
REMEMBER,
communication and assessment.
When wearing a purple band,
Two weeks prior to implementation all postpartum nursing staff (licensed and nonlicensed) were
Call for a helping hand
educated about the new fall prevention plan. Multiple methods of training were conducted including
Patient___________________________________Date __________
e-mail, staff meeting programs, and mandatory read
and sign packets. Packets included the letter and information on the rationale for the program and deSignificant other__________________________Date __________
tails about the process. All postpartum staff agreed
to participate. Nursing personnel in the newborn
Staff initial __________
nursery and labor and delivery units were informed
of the fall prevention strategy for additional reinReprinted with permission from Baylor All Saints Medical Center
forcement.
When the woman was admitted to the postpar- Andrews Womens Hospital, Fort Worth, Texas, 2012.
tum unit, the admitting nurse and patient reviewed
the letter together. The patient was asked to sign
meet for review of fall reports and intervention evaluation.
it as an agreement to call for assistance. Engaging the
To further increase postpartum unit staff awareness and
patient in signing the letter confirmed understanding and
compliance, monthly fall statistics were posted as well as
created the nurse/patient partnership in fall prevention as
a sign indicating the number of days since the last patient
suggested by Studer et al. (2010) and Hook et al. (2008).
fall. The fall prevention program and progress on meeting
The letter was left at the bedside as a visual reminder.
the goal of zero falls was discussed at monthly staff meetFor additional emphasis, the purple fall risk armband
ings. Since implementation of the postpartum fall prevenwas placed on each womans wrist upon arrival to the
tion program, the womens hospital has decreased their
postpartum unit. The purple armband was later refall rate by 50% and maintained a postpartum fall rate
moved when the patients postpartum nurse assessed that
below the 50th percentile for the national mean of adult
she was able to safely and independently walk. Nonslip
surgical patient falls per 1,000 patient days.
socks, as discussed in the letter, were also placed at the
Clinical Implications
bedside upon admission.
By combining staff awareness of fall risk with a patientCompliance with implementing the fall prevention
centered approach, caregivers and patients became enstrategy was monitored through leadership rounding.
gaged together in the fall prevention process. Although
Postpartum nurses and patient care technicians were rean improvement was demonstrated in the postpartum
minded to answer calls for bathroom assistance promptly
fall rate, continuous review, evaluation, and reinforceand to frequently remind patients to Call for a Helping
ment is essential for the safe care of obstetrical patients
Hand. The importance of hourly rounding and inclusion
and to ensure compliance with the NPSG of reducing risk
of the woman in discussing her fall risk during bedside
of patient harm from falls.
shift report was also emphasized. The FPT continued to
January/February 2013

MCN

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17

Suggested Clinical Implications


Traditional Fall Risk Scales do not address the unique
characteristics of the postpartum period.
Postpartum patients have short-term increased fall
risks.
Patient-centered education immediately following birth
that includes active involvement and visual cues about
risk for falling makes a difference.
Further research is needed to define fall risk factors in
the postpartum population.

Opportunities abound for research as a result of this


initial project. Investigation to establish common criteria
associated with those patients that did experience a fall
can facilitate the development of a fall risk assessment
tool that would be specific to the postpartum population.
Although a reduction in fall rate occurred, further data
could be collected to look at how various types of anesthesia, amount of blood loss, or other birthing factors relate to the incidence of falls. Additionally, the influence of
patient participation or engagement in education on the
fall risk prevention could lead to its inclusion in evidencebased practice guidelines.
Until now, the focus of fall prevention strategies has
been in the adult medical hospitalized or frail elderly
population. There are other populations however that
have gone unrecognized but yet are at a risk for fall and
injury. TJC has called for the development of programs
to reduce the number of falls and assess for fall risk in all
populations. The experience at this facility has laid the
foundation for additional research of a program that will
consider not only prevention of falls in a healthy population but also the development of a risk assessment tool
that is specific to women in the immediate postpartum
period.
Suzy Lockwood is a Professor of Nursing at Texas Christian UniversityHarris College of Nursing & Health
Sciences, Fort Worth, TX. She can be reached via e-mail at
s.lockwood@tcu.edu.

Kandace Anderson is a Nurse Supervisor, Postpartum


at Baylor All Saints Medical Center, Andrews Womens
Hospital, Fort Worth, TX.
The authors declare no conflict of interest.
DOI:10.1097/NMC.0b013e31826bae4b
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