Reply to ‘Seasonal ambient changes influence inpatient falls’ Magota et al.

Dear Sir,

Magota et al. [1] recently reported in this journal temporal patterning of 464 recorded falls by inpatients of a secondary emergency medical facility. Fall rate was higher during the night than day, particularly between October and February, the months of longest nighttime darkness, with greatest fall rate around dawn in association with morning bathroom activities.

Hospital falls are a major challenge, because they reduce patient quality of life, in part due to loss of autonomy and independence, and increase morbidity and consequentially length of stay and health expenditures [2]. Falls are the outcome of complex interactions between identified intrinsic (biological and behavioural) and extrinsic (socioeconomic and environmental) risk factors. Some of these are modifiable, e.g. lifestyle and housing design, maintenance and lighting, and some are not, e.g. age, chronic medical conditions and medication adverse effects [3]. Effective intervention programs, even when addressing only a single risk factor, can reduce fall occurrence and associated injury [4].

The variable of fall occurrence time is ignored in most investigations of causality. This information is important because it enables exploration of temporal relationships of such events with scheduled inpatient activities according to intrinsic and extrinsic risk criteria and also clock time and shift schedule-dependent patterns of fatigue, oversight and staffing of healthcare personnel [5–7]. We [6–8] previously reported prominent time-of-day, day-of-week and month-of-year variation in fall occurrence using time series study methods and analyses [9]. One of these [7] involved five Italian non-university hospitals in which a fall prevention program had been initiated. It revealed 24-h (main peak at ~05:30 h) and seasonal patterns (main peak March–April) in elderly falls. Categorisation of the clock-time of events according to the assessed intrinsic and extrinsic risk factors resulted in more precise understanding of their epidemiology and ultimately improvement of the instituted prevention program, e.g. based on knowledge bathroom falls are most frequent at ~06:30 h, hospital corridor falls are most frequent at ~11:450 h, and falls from bed due to failure of staff to position bedrails are most frequent at ~01:45 h as opposed to falls from bed with proper staff-positioned bedrails that are most frequent at ~05:30 h—around wake-up time [7].

Although the design and investigative methods of the Magota et al. [1] and our [7] study differed, the time-of-day pattern of falls is similar; falls were greatest at dawn in association with wake-up bathroom toileting and hygienic activities. Nonetheless, further studies employing a time series approach are required to better understand the role during the 24 h of patient intrinsic and residential extrinsic fall risk factors, staffing number, schedule of routine duties—bedsheet changes and patient bathing, meal positioning, between-unit transfers, etc—and fatigue/sleepiness, attention and cognitive functioning [6].

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