Circumstances and outcomes of falls in hospital for adults with communication disability secondary to stroke: A qualitative synthesis

1 Introduction

Falls are a significant patient safety concern in hospitals; impacting on the patient and the health service, and accounting for 38% of documented patient safety incidents with up to 65% of patients with stroke falling at least once during their hospital admission (Batchelor et al., 2012; Hill et al., 2007; Walsh et al., 2016). Falls potentially result in a number of adverse consequences to both the patient and health service including; serious injury, loss of functional capacity and reduced confidence and motivation to mobilise; increased length of stay; increased length of stay and can be fatal (Batchelor et al., 2012; Hill et al., 2007).

Communication disability is highly prevalent in people with stroke (O’Halloran et al., 2009), affecting an estimated 64% of this group (Mitchell et al., 2020) and including aphasia, dysarthria, apraxia of speech and cognitive communication impairments. People with communication disability have a three-fold increased risk for adverse events in hospital, including falls, compared to patients without communication disability (Bartlett et al., 2008). However, they are often excluded from falls research (Hemsley et al., 2019) and there is little information about the context of their falls or what would help prevent falls for this population. While a recent systematic review including a meta-analysis (n = 11) found no association between falls and communication disability, studies were limited by not including participants with severe communication disability, or failure to report on the severity of participants’ communication difficulties (Sullivan et al., 2020). In the only study focusing on patients with severe communication disability and their falls following stroke, these patients had twice the risk of falling while in hospital as those who could communicate basic needs (Sullivan & Harding, 2019). Further, Sze et al. (2001) suggested that patients with communication disability who have difficulties expressing their needs may engage in risk taking behaviours such as attempting to mobilise alone. In addition to difficulties communicating their needs, patients with communication disability following stroke may have difficulties understanding and following instructions, such as those required to safely transfer (e.g., sitting to standing). Indeed, Zdobysz et al. (2005) suggest a patient may fall during transferring if “the patient does not understand or remember verbal instructions” (p. 70). Further, Mion et al. (1989) and Nyberg and Gustafson (1995) reported a higher incidence of falls in patients who had difficulties following instructions. With little information available explaining the needs of this population in relation to falls in hospital, it is important to identify from prior research any contributing factors, hazards, and outcome of falls for this vulnerable and under-researched group (Hemsley et al., 2019; Sullivan et al., 2020; Sullivan & Harding, 2019).

Patient safety frameworks provide structure in collecting information about patient safety incidents and consider the interaction between contributing factors or hazards, characteristics of the patient, mitigating factors and outcomes. This can help to identify ways to prevent safety incidents and reduce their negative impacts on patients and health services. The Generic Reference Model (Runciman et al., 2006) is a patient safety framework that can be used to guide the process of collecting and classifying information about patient safety incidents. The model is underpinned by a risk management structure and outlines relationships between contributing factors, the patient safety incident and the outcomes and consequences for the patient and the organisation (see Fig. 1). As this model contains and organises the important elements of a patient safety incident to facilitate the analysis of the incident it was chosen to guide the data analysis and to provide a theoretically sound means of synthesising findings across studies (Walshe & Boaden, 2006).

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Fig. 1

The Generic Reference Model (Runciman et al., 2006). Reproduced from Quality and Safety in Health Care, Runciman.W.B., Williamson, J.A.H., Deakin, A., Benveniste, K.A., Bannon, K., & Hibbert, P.D. volume 15(suppl), i82-i90, copyright 2006 with permission from BMJ Publishing Group Ltd.

In the Generic Reference Model (Runciman et al., 2006), contributing factors and hazards for the incident are grouped into five categories: environmental factors; organisational factors; human factors; subject of incident factors; and drugs, equipment, and documentation. Table 1 provides examples of each of these factor types relating to falls in hospital. In patient safety research utilising this model, the incident is investigated in terms of the demographics of the person involved, timing of the incident, when and how the incident was detected, and preventability of the incident. Outcomes and consequences of the incident are explored for both the patient and the organisation (e.g., the hospital) in relation to the patient’s injury, suffering, and disability; and any impact on organisational resources.

Factors within or intrinsic to patients with stroke (e.g., their impairments, activities or personal factors) are multifactorial and include balance impairments, increased dependence for activities of daily living tasks, and hemi-neglect (Batchelor et al., 2012; Campbell & Matthews, 2010; Walsh et al., 2016). When considering the Generic Reference Model (Runciman et al., 2006), little is known about other contributing factors for the falls of patients with communication disability after stroke including aspects of the environment and the patient’s activities on the ward. Understanding more about the circumstances and outcomes of falls in hospital patients with stroke and communication disability could provide useful information to identify appropriate prevention strategies and thus reduce the risk or incidence of falls in this vulnerable patient group.

Therefore, the aim of this review was to provide a secondary analysis of the literature located in a prior systematic review and meta-analysis, on the circumstances and outcomes of falls in hospital patients with communication disability secondary to stroke, including factors leading up to, occurring during, or following a fall. The prior systematic review (Sullivan et al., 2020) sought to identify any association between communication disability following stroke and falls and involved the same population and search terms suitable for the present review^. Given the high rates of exclusion of people with communication disability in the falls literature (Hemsley et al., 2019), the studies within the prior systematic review provided an opportunity to understand more about the nature of falls in cohorts of hospital patients known to include people with communication disability following stroke. Reviewing these studies with a focus on the contextual factors surrounding falls could help to identify ways to reduce the risk of falls, and to inform the design and analytic framework of future falls risk and prevention research and patient safety programs that are inclusive of this population.

3 Results

The PRISMA flow diagram, depicting the screening and selection of studies, is presented in Fig. 2.

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Fig. 2

Study Selection Flowchart.

Of the 16 studies included in the prior systematic review (Sullivan et al., 2020), 15 met the expanded inclusion criteria for this review (see Table 2). Despite being selected due to known inclusion of patients with communication disability, none of the included studies specifically provided results on the circumstances and outcomes of falls for this population. The Generic Reference Model (Runciman et al., 2006) guides the reporting of the results with a focus on patient safety and the results are discussed specifically in relation to patients with stroke and communication disability.

4 Discussion

This review synthesised evidence on the reported circumstances and outcomes of falls in patients with stroke in hospital, in studies where at least one participant with communication disability was included. The Generic Reference Model (Runciman et al., 2006) provided the theoretical framework for the analysis. Falls are one of the most common complications to occur after stroke (Verheyden et al., 2013) and despite the relatively low occurrence of severe injury associated with falls, the continued occurrence of falls is a persistent and challenging problem. The majority of falls in people with stroke described in studies included in this review occurred at the patient’s bedroom or bedside, and were unwitnessed, is of concern; considering that patients spend the majority of their time during hospitalisation in their bedroom and alone (West & Bernhardt, 2012). That the most common activity being performed prior to a fall was transferring (e.g., from bed to wheelchair) is also important, considering that transfers are an activity that patients often undertake on any hospital ward and are an important goal of rehabilitation (Baetens et al., 2011).

Although this body of literature was selected due to known inclusion of patients with communication disability, none reported on factors, circumstances, or outcomes of falls specifically in relation to this population. This is an unfortunate limitation in the literature that the studies included in this review did not yield further insights or help explain the increased risk of falls in patients with stroke and communication disability in hospital. In a recent systematic review of 61 studies on falls of adult hospital patients with communication disability, Hemsley et al. (2019) found that despite two thirds of the studies identifying communication disability as a contributing factor for falls, patients with communication disability were actively excluded from participation by the recruitment methods or data collection and results across all studies rarely mentioned any participants with communication disability who had been included.

The majority of studies in this review aimed to identify the intrinsic risk factors associated with falls in people with stroke, an essential element required to mitigate these patient safety incidents. Beyond this, the studies reviewed provide little insight into other factors such as environmental and organisational factors (e.g., staffing ratios) surrounding falls in patients with stroke that could inform strategies designed to reduce the risk of falls in stroke patients with communication disability. The identification of intrinsic risk factors such as balance impairments informs the development of falls prevention interventions, however, identification of these factors alone is unlikely to prevent a fall (Taylor & Hignett, 2016).

Patients with communication disability following stroke may have unique intrinsic factors that contribute to their falls due to difficulties communicating with health professionals involved in their care (Simmons-Mackie & Kagan, 2007; Sullivan et al., 2020, Sze et al. 2001). These difficulties could impact a patient’s ability to understand and follow the instructions required to transfer, use equipment and ambulate safely, resulting in a fall (Mion et al., 1989; Nyberg & Gustafson, 1995; Zdobysz et al., 2005). Thus, staff providing instruction or assisting with tasks such as transferring might need to make adaptations to their communication to meet the patient’s communication needs (e.g., for understanding information and following instructions) in order to minimise the risk of a fall.

Further, environmental factors (e.g., floor surface, and placing items such as the call bell in reach of the patient) are modifiable and may have a significant impact on the safety of patients during their hospitalisation (Taylor & Hignett, 2016). Problems for people with communication disability gaining attention in hospital (Balandin et al., 2001; Hemsley et al., 2013) may lead patients to have difficulty in alerting staff to their basic needs and potentially increase patient risk taking behaviour to access food, toileting, and personal care (Sullivan & Harding, 2019, Sze et al. 2001). None of the studies reviewed provided a comprehensive evaluation of all these factors in the circumstances leading up falls, in prioritising attention to the intrinsic factors.

The finding that the presence of family members or visitors may be a protective factor for falls in this population (Baetens et al., 2011; Bugdayci et al., 2011; Byers et al., 1990; Chaiwanichsiri et al., 2006; Ullah et al., 2019) might help to explain the finding that falls occur while patients are alone as it is possible that family members and visitors are acting to prevent falls (e.g., by providing assistance to reach items or instructing to wait for nursing assistance or use the call bell) (Hemsley et al., 2013). However, two studies also suggested that family members and visitors may provide inappropriate assistance or supervision and contribute to a fall (Czernuszenko & Czlonkowska, 2009; Tsur & Segal, 2010), suggesting that family members and visitors should receive instruction regarding appropriate assistance and supervision needed for patients with stroke, including specific communication strategies to support patients with communication disability in hospital; and that family members and visitors should be included in falls risk policies in hospitals so that their role in preventing falls is made clear. Although studies did not specify recommendations relating to patients with communication disability, it is likely that the involvement of family and visitors in hospital could be supportive of their interactions with hospital staff (Hemsley et al., 2013).

Communication between patients and healthcare providers is essential to the provision of good healthcare (Sherman et al., 2009) and poor communication with patients with communication disability is associated with increased rates of adverse events, including falls (Bartlett et al., 2008; Hemsley et al., 2013; Hemsley & Balandin, 2014). Whilst augmentative and alternative communication, such as the use of picture boards, may help patients with communication disability communicate more effectively in hospital, these strategies are not universally applicable to every patient with communication disability (Lasker & Garrett, 2008). Communication partners such as nurses and allied health professionals, continue to play an essential role in supporting effective communication for patients with communication disability in hospital. Adapting communication to use short sentences, single step instructions, and specific language (e.g., using words such as ‘put your foot next to mine’ rather than ‘put it here’) could help to support comprehension of the safety requirements of the task, and eliminate the risk of other human factors in a fall as described in Czernuszenko & Czlonkowska, (2009) and Tsur & Segal (2010). Additionally, given the large proportion of people with stroke who have difficulties with language (O’Halloran et al., 2009) or cognitive function (Renjen et al., 2015) any preventative strategies undertaken should take into consideration the special requirements of this population.

5 Conclusion

This synthesis review of 15 studies, located and selected using systematic search procedures, provides scant insights on the hospital falls of adults with communication disability following stroke, highlighting a glaring gap in the falls prevention literature. The findings suggest that falls commonly occur in the patient’s bedroom or bedside, during transfers, during the day, and when the patient is alone. Although severe injury is uncommon, one outcome of these falls is a significantly increased length of stay in hospital. However, limitations in the reporting of the incident characteristics or the circumstances of the fall, other contributing factors in the environment, and lack of specific data relating to patients with communications disabilities after stroke indicates a need for further research on the falls in this population. Such research should not only increase focus on the patient’s communication skills and impairments, but also take more than the patient’s intrinsic factors into account to include examination of environmental factors and outcomes to falls for this vulnerable patient group.