After the Fall

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Barbara Levin BSN LNCC ONC is a clinical scholar at Massachusetts General Hospital, a position that recognizes her dedication to patient care and contributions to education of the nurses with whom she works. She is an active member of the National Association of Orthopaedic Nurses, and has presented several programs in the past years. She published a chapter in the NAON core curriculum on complications in Orthopaedics and this content has been incorporated into the ONC exam. She is a certified orthopaedics nurse and expert witness.

Barbara answered these questions:

How do you define a fall?

Is an assisted fall really a fall?

How many falls occur each year?

How much money does the Centers for Medicare and Medicaid pay out each year because of falls?

What are some of the ways that a nurse could identify somebody who is at risk for falls?

Is there one standard falls risk assessment that facilities should be working towards implementing?

When you have got a high risk population on a nursing unit, what are some of the strategies useful for reducing the risk of falls?

What are the benefits of hourly rounds?

Why do older people tend to have poor outcomes after a fall has occurred?

What are the financial consequences for falls that occur in hospital settings?

How does documentation affect the analysis of liability after a fall occurs?

What are facilities doing to modify the environment to make it safer?

What is the role of a sitter?

What are the common types of fractures?

How does the type of fall affect the fracture that results?

Is there any outside window that the surgeon can wait before it becomes too late to attempt a surgical closure of a fractured hip?

How are closed reductions performed?

What are some of the postoperative risks following surgery for fractures? Aren’t these “never events”?

Could you comment about some of the controversies regarding surgical site infections?

Could you comment about pressure sores developing in people who've had surgery to repair a fracture?

Are you seeing less use of Foley catheters in patients after they have had hip fractures repaired?

One third of patients who suffer a serious fracture die within a year. Why?

Extracted from Barbara Levin BSN LNCC ONC and Howard Yeon MD JD, “Orthopaedic Medical Records” in Patricia Iyer, Barbara Levin and Mary Ann Shea (Editors), Medical Legal Aspects of Medical Records, Lawyers and Judges Publishing Company

Attorneys and other legal professionals are called upon to review medical records of patients who sustain musculoskeletal injuries for several reasons. When injuries result from a motor vehicle collision, assault or workplace accident that generates a tort claim, attorneys need to cull several key pieces of information from the medical record including the cause of the patient’s injuries, the breadth and seriousness of the injuries, the extent of medical or surgical treatment necessary to address the injuries, and the resultant long-term disability associated with the injuries. In other cases, attorneys representing insurance companies or employers review medical records to ascertain whether patients are receiving the appropriate level of disability benefits. Finally, when there is a question of medical malpractice, plaintiffs’ and defendants’ attorneys review the written medical record to determine whether the appropriate standard of care was met. Attorneys reviewing the record in the context of tort injury or disability claims should focus on this evidence as it is germane to causation. The mechanism of injury may be documented in multiple places in the written record including the on-scene report of the emergency medical transport (EMT) team and the history written by the admitting physician or nurse.

Once a fracture is confirmed radiographically, the most significant first assessment is whether the fracture is “open” or “closed” – or in other words, whether the fracture is associated with a break in the skin. A useful and ubiquitously used classification system is the system of Gustilo and Anderson. Under this system, a Grade I open fracture is described as having an associated open wound less than 1 cm with minimal soft tissue injury and a clean wound bed; these open fractures are generally thought to result from a sharp spike of bone penetrating the skin from inside to out. Grade II injuries have an open wound greater than 1 cm in length with a moderate associated soft tissue injury, and the wound bed is moderately contaminated. Grade III open fractures generally have wounds greater than 10 centimeters in length, but these injuries are further subclassified as type “A” – with minimal stripping of the soft tissues surrounding the bone, type “B” – with extensive soft tissue stripping probably requiring a soft tissue flap to close or cover the wound, or type “C” – with an associated major vascular injury.

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