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If you have a question about using the Hendrich II Fall Risk Model in your facility check out our Frequently Asked Questions below or Ask AHI by completing and submitting our Ask AHI form.

Frequently Asked Questions

The Hendrich II Risk Factor model does not consider history of falls as an important predictor of falls-Why?

In the previous study completed by Hendrich (Hendrich I Falls Risk Model), history of falls seemed to be significant as other studies have also reported. When the study sample size was increased to 1,135 patients (falls and non-falls) it became clear many of the risk factors reported in previous studies overestimated the importance of certain risk factors. In other words, when large numbers of control patients (non-falls) were tested against patients who fell, the significance of a history of falls became insignificant. History of falls only appeared to be significant because it was always paired with the ‘real’ risk factors-those contained within the Hendrich II Falls Risk Model (HFRM). If someone is falling frequently, the fall risk factors are the true ‘root’ cause of why they are falling-not the fact they have a history of falls.
How often should patients be assessed?

The preferred approach is once a shift or whenever the patient condition changes. In acute care this could be even more frequently if there is a sudden change in acuity. In long-term or residential care, ideally it should be once a day or sooner if the resident’s condition suddenly changes. This change can be pathophysiological (cerebral, coronary etc.) or when medication side effects begin to exhibit themselves as risk factors. The most common side effects of medications include changes in sensorium, gait, elimination patterns, mood, and balance. Therefore, monitoring a patient for these predictive risk factors may eliminate the need to monitor dozens of medication categories.

Why aren't more drugs included as risk factors?

There are two categories of drugs found to be statistically significant related to an increased risk of falls in this study. They include benzodiazepines and antiepileptics. Each of these categories is well validated in the literature. In this large randomized, case-control study, other categories of drugs, in and of themselves, did not increase the statistical risk of falling. This is believed to be true because the risk factors that predict falls are also the most common side effects of medications (orientation, mood, elimination, gait and balance). To state it differently, other than the two categories already mentioned, the fact one is taking other categories of drugs did not seem to increase fall risk if none of the fall risk factors found in Hendrich II Falls Risk Model were positive. This probably helps to explain why risk factors can over-identify certain populations of patients when statistical analysis and sample size is not carefully followed.

Can this tool be used in the various service-lines or case-mixes found in most acute care facilities? (Med-Surg, Emergency, Oncology, Critical Care, Transplant, etc.)

Yes, the research was done in a large, randomized study and so far the feedback is these 8 risk factors can be used generically across the acute-care/skilled care environments as an effective screening tool. When these risk factors are used with environmental safety precautions, and then specific interventions are matched against the identified risk factor, significantly large numbers of falls can be prevented. Since 1989, Hendrich has been advocating a unit-based approach to successful falls programs. The Hendrich II Fall Model risk factors seem to cut across nearly all patient populations. For example, in surgical unit patients returning from acute care surgeries often experience some short term confusion or decreased level of orientation as a result of anesthesia or narcotics. Further, they may have altered gait or get up and go performance due to weakness, pain, and/or side effects of the medications. Elimination may be altered due to catheters, frequency, or bed rest. Within a day or sometimes less, this same patient that would have scored greater than a '5' on the HRFM will have their score drop rapidly. This permits the nurse to take them 'on and off' the protocol saving nursing time, and adding credibility to a falls prevention program. Many surgical units make fall prevention a part of the surgical pathway for all patients returning from surgery. Nurses remove them from pathway once orientation, gait and mobility, return to their baseline.

Based upon further testing of the HFRM tool, these same risk factors work well in identifying falls in ambulatory or out-patient testing areas. For example, when patient comes in to these areas of the hospital (in-patient or out-patient) they often have weakness, and altered elimination due to cathartics or fluid challenges. Should they also have altered gait or dizziness, they will be high risk for falling from carts, chairs, or procedural tables. Observation and assistance is critical for these patients while in ambulatory areas, just like nursing units. Communication is key when high risk patients are arriving from the nursing units so allied health personnel can understand the risk and can help to mitigate injury. These patients should not be left alone in the hallways or observation areas. It is critical to include all personnel in the education and prevention of falls to promote patient safety.

What seems to make a successful fall prevention program?

No matter what area of the healthcare facility (ambulatory, procedural, or in-patient) the key to prevention of falls is:

Assessment of patients with statistically significant risk factors

Make the environment safe for all patients with core environmental safety practices (lighting, footwear, bed height, floor surfaces, call lights, patient education, bed exit monitors)

Match interventions against the fall risk factors identified. For example…

Poor gait and balance+ confusion = Constant monitoring and assistance for transfers, ambulation, and movement

Reassessment of patient risk on a frequent basis

Make this part of an interdisciplinary clinical practice model (MD, RN, PharmD, Allied Health)

Involve the patient, family and significant other with education on the importance of risk, prevention, and communication with staff

What if the patient is in critical care and is comatose or if the patient cannot get up without assistance? How is the tool used?

Critical care patients may exhibit many of the risk factors during highly acute periods. However, if they are comatose and/or on a ventilator or simply not able to rise at all without assistance they do not have an opportunity to fall even though there are risk factors. They should be assessed the same and risk factors documented, and just as SOON as they have a potential to attempt to get up they should be placed on a protocol for fall prevention. Interventions should always be matched against the risk factors when the patient has a potential to fall. In critical care falls are rare, but when they do occur they can be very serious. These falls often occur when patients awaken from comatose states or in the early days of mobility attempts without staff’s knowledge.

In severely compromised or debilitated patients they often have many risk factors but are simply unable to rise without considerable assistance of one or more personnel. These patients are often more at risk for falls from bed and/or side rail entrapments than actually falling while upright. In either case, one must be very cautious in assuming what can or cannot occur with individual patients. All patients deserve to have appropriate assessments and safety interventions performed on a regular basis. This patient will benefit from constant environmental assessments as well as risk factor identification.

Can this tool be used with pediatric patients?

To date, the tool has not been tested in acute care pediatrics. Falls are rare in hospitalized pediatric patients. Often, developmental falls (accidental) occur in the first few years of life and those related to the environment are most common. Hospitalized children often climb from beds or cribs seeking to be next to their parents and it can result in falls. Parents may often fall asleep at their bedside with the rails down and then the child falls from the bed. The second type of fall seen in hospitalized, very ill, children seems to be related to physiologic risk factors, similar to adults. In these few cases, weaknesses and impaired gait and mobility were present. Further testing and research is needed to prospectively test the specificity and sensitivity of the HFRM in this highly specialized population.

Are there interventions that seem to work better than others?

Yes, 80+% of hospitalized falls occur in the patient room, while the patient was attempting to go to the bathroom, or felt elimination needs. These patients have underlying fall risk factors that make them high risk for falling. If they call for assistance and attempt to go alone, many will fall. This is often not related to the number of staff, but rather what the staff is doing at the time the patient has a need that goes unmet. For example, if the call light goes unanswered the patient’s risk of falling also goes up. If the call light is answered and the patient has assistance, or if a bed alarm alerts the staff the patient is about to take a risk, the patient's risk will be averted. Proactively toileting patients that can't express their needs, or assisting those who require ambulation help due to poor gait and mobility meet elimination needs, reduces their overall risk of falling. Adding toileting to 'core' interventions can reduce falls in half in most facilities.

How can we add fall prevention to an already challenged nursing staff?

All nurses care about the prevention of falls no matter how busy they are. Professional practice models that retain staff have characteristics of shared decision-making, research-based practice, innovation and measurement of patient outcomes. Fall prevention can be incorporated into a professional practice model and the assessment adds less than 1-2 minutes of nursing time. What can be more important than preventing a fall, a fracture, a head injury, or loss of life? Our greater challenge is to identify what is wasting nursing time in indirect care or “hunting and gathering” Hendrich, 2004 IOM publication Keeping Patients Safe: Transforming the Work Environment of Nurses. Nurses must be returned to direct care and have time for clinical interventions that make a difference in patient outcomes. Fall prevention programs work best when they are incorporated into existing clinical practice committees with direct care givers who own the process, and who have open access to fall data for their unit and organization. This contributes to an environment and culture of patient safety.

How many falls can be prevented?

This is difficult to generalize. It depends upon many factors described above. However, remember in this large study the tool was tested against all of the fall patients and 75+% would have been correctly identified with just the 8 risk factors contained in the HFRM. Potentially this means at least 75% of all falls can be prevented in your hospital or healthcare facility.