Falls are an important consideration in patients attending cardiac rehabilitation (CR) because exercise training is needed to optimize cardiac health, but it can also temporarily expose the patient to increased risk of falling.1 This risk is particularly high in older adults with cardiovascular disease and frailty due to multidimensional physical impairments.2,3 Exercise training requires stability, balance, and coordination to improve stability and gait.4,5 Despite these competing concepts and the potential for CR to help reduce falls overall, falls in CR are an underinvestigated topic and data are scant. As such, this study aimed to assess the incidence and patterns of falls in patients who participated in phase II and III CR.
METHODS
This was an observational cohort with quality improvement project that was conducted in Baystate Medical Center, a large, urban-based, tertiary teaching hospital in Springfield, Massachusetts. The details of the population characteristics are outlined in another study,6 with majority of enrolled patients being White (73%), males (69%), and with a mean age of 64 +/- 12.6 yr. Because this was a quality improvement project, institutional review board approval was not needed.
We identified all adult patients who participated in phase II and phase III CR. All falls were reported starting from January 2015 to May 2022 using our Safety Reporting System: an open access, anonymous, reporting forum of adverse events such as falls, medication mistakes, and communication errors. Detailed report of the falls, including timing, description of the event, and resulting outcomes, was included in the Safety Reporting System.
Beginning in July 2020, we began a quality improvement project to decrease falls following a fall event that resulted in hospitalization in late 2019. As this overlapped with COVID-19 lockdown, public health safety measures such as spacing out exercise equipment and increasing staffing to patient ratios were naturally implemented. However, other measures such as eliminating high-step treadmills, and performing risk assessment on all new patients using the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) tool kit, were added. The STEADI initiative is a coordinated approach developed by the Centers for Disease Control and Prevention to prevent falls.7 It incorporates a 12-question screening tool, with a score of >=4 suggesting an increased risk of fall.
In May 2022, we pulled all events from the Safety Reporting System and analyzed patterns in falls and any that resulted in harm. Potentially serious falls included all falls that required medical attention without the need of hospitalization, while harmful falls were ones that led to hospitalization. Incidence was calculated by dividing the number of falls by the total volume of annual exercise sessions. The sum of events in the pre- and post-periods of intervention was added to calculate one estimate of risk for each period and then Poisson regression was utilized to estimate the rate ratio.
RESULTS
For more than 7 yr, there were 34 total falls, 24 of which resulted in no harm, 11 of which required brief treatment and monitoring in CR, and 1 which resulted in a hospitalization but with no lasting permanent harm (Table). Compared with the average patient in the program, those who fell were of similar race and sex (65% White; 71% male) but were 12 yr older (76 +/- 10 yr). Based on a total volume of 175 748 sessions of CR, the estimated incidence was 2.0, 0.60, and 0.06/10 000 sessions in CR session for total, potentially serious, and harmful falls, respectively. Most falls occurred in phase II (75%), and the plurality occurred while transferring on or off exercise equipment (29%), followed by tripping/slipping while training (29%). Other reported falls happened while standing (15%), ambulating (15%), transferring training equipment (6%), or sitting/adjusting position from chair (6%). The average fall risk was low (STEADI score of 2.8 +/- 2.8), but 30% of patients were considered at risk of falling. After implementation of our fall reduction program, falls decreased from 2.05 falls/10 000 sessions to 1.21 falls/10 000 sessions with a rate ratio of 0.59 (95% CI, 0.18-1.93; P = .38).
DISCUSSION
Consistent with our clinical experience, we found that falls in CR are rare, but their occurrence can result in harm. Implementation of risk-stratifying scores such as STEADI, and measures to improve exercise training environment, may result in reduction in the number of falls.
Although patients and physicians often worry about falls with exercise training, these concerns are inconsistent with studies of actual risk.8 For example, a systematic review of 17 trials of exercise interventions in older adults found that all falls, including falls that produced major injuries, were reduced with exercise training.9 This is in keeping with other studies, which also reported that exercise programs are effective in decreasing falls, particularly among older adults.10 Nevertheless, data remain inconclusive about falls in CR as no prior studies were conducted in these settings with particular attention to the unique attributes of patients with cardiac disease.
The study was limited by the short assessment time after quality improvement measures were implemented. The small number of falls makes it difficult to know with statistical certainty whether our quality improvement program made a difference. Our efforts to reduce falls overlapped with COVID-19 lockdown and a three-time closure of the CR Program resulting in a lower total phase III volume, which could also confound the results. More studies are needed to further establish the incidence and patterns of falls in CR.
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