Approaches targeting “safety in numbers” optimize progressive functional mobility independence while reducing fall risk.

by Jennifer Biggs, RN, MSN, CNRN, and Lisa D’Aurio, PT, MS, MHA

After brain injury, not only do risk factors for falls in the inpatient setting increase, the consequences of falls increase dramatically. There are multiple policies in place to minimize fall risk at Craig Hospital, a 93-bed rehabilitation hospital that provides care exclusively for patients with spinal cord injuries and brain injuries. Helping support those policies is an emphasis on the importance of being aware of unavoidable risk factors, anticipating an increased fall risk, and building a plan of care accordingly. A few factors that increase fall risk include impaired balance, agitation, confusion, elimination issues, visual impairments, and certain medications. Patients with brain injury frequently suffer from many or all of these challenges.1


Deficits associated with brain injury not only increase a patient’s risk for falls, they increase vulnerability for trauma from a fall. Patients with brain injury have a number of medical complications related to secondary injury and trauma. A few of these drastically increase the risk for further severe injury with the occurrence of a fall. For example, after trauma, patients have an increased risk for blood clots, which can lead to use of anticoagulation medications that thin the blood. Although this reduces the risk for clots, it increases the risk for bleeding. A fall for these patients can cause internal bleeding anywhere in the body, including the brain. In addition, many patients have undergone a craniotomy, in which a piece of the skull is removed to allow the brain to swell and expand during healing. If a fall occurs without the skull in place, the brain can be severely damaged. These are just two scenarios that exemplify this patient population’s increased vulnerability and the importance of fall prevention.

Research shows that patients who fall and sustain injury or need follow-up services will have an average of hospital charges more than $4,200 higher than patients who do not fall.1 Among the brain injury population, this number could be significantly higher because of potential needs for surgical intervention.


As clinicians in the brain injury rehabilitation setting, it is essential to have policies that help ensure falls do not occur. Or, if falls do occur, they are controlled. Studies have shown that fall risk assessment tools are not a reliable way to prevent falls.2 In the brain injury population, most fall risk assessment tools show that anyone with a brain injury is at higher fall risk. For this reason, the clinical staff at Craig Hospital does not use a fall risk assessment tool. Staff uses clinical judgment to determine that anyone with a brain injury is at higher risk and all are placed on fall precautions. Clinical judgment also determines the level and the number of safety interventions each patient will have. The nurses, techs, and entire interdisciplinary team are part of this decision-making process, and it is constantly evaluated.

The fall rate per 1,000 patient days on the Craig Hospital brain injury units has always been below the national benchmark. There is always need for improvement and examination of current policies to ensure they are meeting the needs of the organization. The graph in Figure 1 depicts the fall rate per 1,000 patient days on one of Craig Hospital’s brain injury units, 2 East, compared to NDNQI national benchmarks. It shows a linear decrease over the past 2 fiscal years, underscoring the facility’s efforts at consistent improvement and goal setting.

Craig’s success is multifaceted and involves a staff that is committed to patient safety. It is the job of staff members to implement safety interventions, which may include the use of safety devices such as releasable seatbelts, camera monitoring systems, and bed alarms. For patients at higher risk, interventions might include one-to-one behavior attendants and, as a last resort, restraints. Restraints are used when a patient has demonstrated impulsivity and safety devices have proven ineffective in preventing the impulsive behavior. Because impulsivity along with agitation is so unpredictable, utmost precaution is taken when restraints and safety devices are removed. All patients who demonstrate impulsivity at the facility are required by policy to be a 2-person transfer when outside of therapy. This ensures that if a fall does occur, it is controlled and the risk for patient injury is reduced.


Initial mobilization of a patient once admitted to Craig Hospital is an interdisciplinary effort. The team works together to prevent falls and begin the rehabilitation process. Nursing completes an intake with the patient, paying close attention to factors that increase the patient’s risk for falls; physical therapy evaluates the patient for an appropriate wheelchair and assesses the safest transfer out of bed; occupational therapy assesses the patient’s transfer on and off the toilet and evaluates the patient’s needs for showering; speech therapy provides guidance to all disciplines for the best and most productive ways to communicate and interact with patients and their families. Clinical care managers provide the interdisciplinary team with important background information about the patient and family in addition to providing information about discharge plans. Neuropsychology provides the team with valuable insights about the patient and family for maximizing the patient’s safety and rehabilitation potential. Each member of the team plays an integral role in the patient’s recovery, and all team members are focused on individualizing the patient’s program to maximize safety and independence, working to align goals and expectations, with the goal of returning the patient to the previous level of function.


The goal of rehabilitation is to return the patient to the previous level of independence. All team members offer valuable input about the patient and that information is used by team members, specifically, physical therapists and occupational therapists, to progress the patient’s functional mobility. OTs and PTs complete evaluations that may include range of motion, manual muscle testing, sensory testing, proprioceptive testing, assessment of balance, coordination testing, vision screening, and perceptual testing. The disciplines work together to determine the safest technique for mobility. The therapists critically analyze the patient’s ability to complete activities of daily living, move around in bed, transfer, manage a wheelchair, and gait, as appropriate. The team works together to develop a plan of care that focuses on maximizing safety and progressing functional mobility independence while incorporating the patient’s goals and limiting the risk for falls.

Adjunct therapies are available to assist the team in maximizing a patient’s safety and functional mobility outcome. Orientation classes, cognitive skills groups, cooking groups, group exercise classes, pool therapy, and interdisciplinary outings provide patients with additional opportunities to facilitate recovery and practice mobility skills in a safe environment.

Technology is available and offers the patient additional training opportunities to maximize functional mobility and increase safety. Patients can be scheduled for functional electrical stimulation (FES) bikes for the upper or lower extremities, elliptical training with FES, body-weight supported treadmill, or over ground training with robotic assistance and/or manual assistance available to appropriate patients. Balance systems offer therapists valuable insight into patient deficits and guide treatment programs to improve balance to decrease the likelihood of falls.


The focus on fall prevention does not stop once a patient is discharged from inpatient rehabilitation. In order to minimize the risk of falls in the home environment, OTs and PTs work with clinical care managers and patients and families to make the environment as safe as possible, while allowing patients the most independence. A home evaluation is completed, with therapists visiting the patient’s home, if possible, and recommendations are provided for what is needed to make the environment as safe as possible. This may include removing throw rugs, ramping entrances and exits, adding rails to stairways, and/or simply moving commonly used items to a more easily accessible location.


Prior to discharge, the patient may receive written programs from therapists that focus on activities to facilitate continued progress and safety. Home therapy may be recommended to set up a safe home environment and a structured daily routine that allows the patient the best opportunity for continued recovery with maximal safety. Outpatient therapy may be the most appropriate setting for the patient to continue to work toward increased functional mobility independence and safety. Community wellness or fitness centers for people with disabilities may be an option, offering the individual the opportunity to exercise in an accessible setting with knowledgeable staff available to guide ongoing programs that promote continued functional recovery.

Patient falls can be costly and are largely preventable with a well-coordinated interdisciplinary team approach to patient care. Every member of the team is responsible for assisting patients to meet their goals of independence while maximizing their safety. Keeping patients safe is everyone’s responsibility. RM

Jennifer Biggs, RN, MSN, CNRN, has worked at Craig Hospital since 2003. She holds a bachelor of nursing degree from Regis University and a master of leadership in health care systems from Regis University.

Lisa D’Aurio, PT, MS, MHA, is supervisor of physical therapy on the Brain Injury Unit at Craig Hospital. She has worked at Craig since 2000. For more information, contact [email protected].