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IIR 03-003 – HSR&D Study

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IIR 03-003
Epidemiology and Cost of Falls in Veterans with Spinal Cord Injury
Audrey L. Nelson RN PhD FAAN
James A. Haley Veterans' Hospital, Tampa, FL
Tampa, FL
Funding Period: March 2004 - August 2008

BACKGROUND/RATIONALE:
Patient falls continue to be a significant patient safety problem, detracting from quality of life and increasing the burden of chronic illness, injury, and disability. Fall-related injuries can result in disability or death. While many studies addressed fall risk in ambulatory populations, most have focused on frail elderly populations and very few have focused on adults who use a wheelchair for mobility. Little is known about the conditions surrounding the event, mechanism and nature of the injury, required treatment, risk factors, and consequences of falls for wheelchair users.

OBJECTIVE(S):
The goal of this 3-year multi-site, longitudinal, prospective cohort study was to determine the etiology and risk factors for wheelchair-related tips and falls among community dwelling veterans with spinal cord injury (SCI), and to determine the cost outcomes and consequences of these falls. We obtained supplemental funding to conduct additional analysis resulting in the development of the SCI Wheelchair Fall Risk Assessment Tool.

METHODS:
A convenience sample of 702 wheelchair users from three Veterans Administration Hospitals (Tampa, Boston, and Augusta), living in the community was recruited. Data was collected at baseline and monthly for 12 months, using observation, skill testing, surveys, and interviews. Data included wheelchair user characteristics, health status, health-related behavior, sensation seeking, wheelchair characteristics, wheelchair skills, use of other adaptive equipments, physical environment and descriptive wheelchair falls, tips and injury data. Monthly phone interviews were conducted to capture wheelchair tips, falls and injuries, with a description of the event. A wheelchair-related fall was defined as a wheelchair user accidentally dropping to the floor from the wheelchair or the wheelchair tips over even if the person remains seated. A subsample of 35 participants were interviewed to determine perceived consequences of falls.

FINDINGS/RESULTS:
Two regression models were developed to determine the predictors of falls and fall injury. Results from the cross-validation data indicated that the original predictors were stable. Increased falls were associated with increased pain in previous two months, positive for alcohol abuse, high FIM sub-motor scores, having a previous fall in the past year, fewer years of a SCI and a shorter length of a wheelchair. The predictors of injurious falls included pain in the previous two months, higher FIM sub-motor scores, having a previous fall in the previous year and one's home not being accessible. Data from the qualitative interviews was analyzed using constant comparative analysis. Study participants tended to describe falls as events that "happened without warning" and tended to perceive falls as "inevitable"; they expected falls as a "normal part of living with a SCI".

IMPACT:
Traditional fall risk assessment tools do not predict wheelchair falls in persons with SCI. Our study significantly extends the science about fall risk because the literature typically defines falls as a geriatric syndrome. Data from this study confirm the need to view wheelchair fallers as a unique population, different from older, ambulatory adults who fall. Screening for falls in SCI wheelchair populations should begin early on after impairment, not waiting to begin until age 65. Additionally, since our sample included a range of impairment levels and complete versus incomplete injury, screening is probably indicated for a wide range of SCI wheelchair users. The SCI Strategic Healthcare Group and SCI QUERI are interested in a national rollout of the SCI Wheelchair Fall Risk Assessment Tool. A follow up study [IIR-06-274] is underway to evaluate the effects of wheelchair skills training to reduce wheelchair falls in persons with SCI.


PUBLICATIONS:

Journal Articles

  1. Nelson AL, Groer S, Palacios P, Mitchell D, Sabharwal S, Kirby RL, Gavin-Dreschnack D, Powell-Cope G. Wheelchair-related falls in veterans with spinal cord injury residing in the community: a prospective cohort study. Archives of physical medicine and rehabilitation. 2010 Aug 1; 91(8):1166-73.
  2. Gavin-Dreschnack D, Nelson A, Fitzgerald S, Harrow J, Sanchez-Anguiano A, Ahmed S, Powell-Cope G. Wheelchair-related falls: current evidence and directions for improved quality care. Journal of nursing care quality. 2005 Apr 1; 20(2):119-27.
  3. Gavin-Dreschnack D. Effects of wheelchair posture on patient safety. Rehabilitation Nursing : The Official Journal of The Association of Rehabilitation Nurses. 2004 Nov 1; 29(6):221-6.
Conference Presentations

  1. Fitzgerald SG, Groer S. Wheelchair Features Contributing to Fall Risk. Paper presented at: University of South Florida Transforming Fall Management Practices Conference; 2009 May 7; Clearwater, FL.


DRA: Health Systems
DRE: Prevention
Keywords: Falls, Safety, Spinal cord injury
MeSH Terms: Spinal Cord Injuries, Patient Safety

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