10
Japanese Journal of Comprehensive Rehabilitation Science (2017)

Original Article

Investigation of factors involved in patient falls during the earlystage of hospitalization in a Kaifukuki rehabilitation ward
Toshio Teranishi, RPT, PhD,1 Izumi Kondo, MD, PhD,2 Yuko Okuyama, RPT,3
Genichi Tanino, RPT, PhD,3,4 Hiroyuki Miyasaka, OTR, PhD, 1,3 Shigeru Sonoda, MD, PhD 3,4,5
School of Health Sciences, Fujita Health University, Toyoake, Aichi, Japan
National Hospital for Geriatric Medicine, Obu, Aichi, Japan
3
Fujita Health University Nanakuri Memorial Hospital, Tsu, Mie, Japan
4
Fujita Memorial Nanakuri Institute, Fujita Health University, Tsu, Mie, Japan
5
Department of Rehabilitation Medicine Ⅱ, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan1
2

ABSTRACT
Teranishi T, Kondo I, Okuyama Y, Tanino G, Miyasaka
H, Sonoda S. Investigation of factors involved inpatient falls during the early stage of hospitalization ina Kaifukuki rehabilitation ward. Jpn J Compr Rehabil
Sci 2017; 8: 10-15.
Objective: To investigate factors affecting the occurrenceof falls during the early stage of hospitalization in a
Kaifukuki (convalescence) rehabilitation ward.
Methods: The subjects were 545 hospitalized patients,
divided into a fall group (having experienced a fallwithin 14 days following admission) and a non-fallgroup. Differences between the two groups in terms of
the Standing Test for Imbalance and Disequilibrium(SIDE) level and in the subscales of the Functional
Independence Measure (FIM) were investigated.
Logistic regression was carried out on items for which
there were significant differences between the groups
as dependent variables and the occurrence of falls as
the objective variable, and the odds ratios werecomputed.
Results: The fall group comprised 36 subjects. Significant
differences between groups were found in the SIDE
level, lower body dressing, bath transfer, stairs, social
interaction, problem solving, and memory. Logistic
regression only identified problem solving as associatedwith the occurrence of falls (odds ratio, 0.288;
p=0.035). For the SIDE level, complete separation of
non-fall subjects was seen at levels of 2b or higher.
Conclusion: Falls in the early stage following
admission do not occur among individuals with good
Correspondence:Toshio Teranishi, RPT, PhD
School of Health Sciences, Fujita Health University, 1-98,
Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192,
Japan. E-mail:teranisi@fujita-hu.ac.jp
Accepted: December 29, 2016.
COI:The authors have no conflicts of interest to declare.
©Kaifukuki Rehabilitation Ward Association 2017
doi.org/10.11336/jjcrs.8.10

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10balance, and problem solving according to the FIM is
involved in falls.
Key words: Kaifukuki rehabilitation ward, fall,
determinant
Introduction
The Kaifukuki (convalescence) rehabilitation ward
is a hospital ward in which a comprehensive team of
specialist healthcare professionals provides intensive
rehabilitation [1]. Less variation is present in theenvironment of the Kaifukuki rehabilitation ward thanin the living environment of the individual, andpatients are able to expand the range of everyday
activities as functional disorders or reduced abilities
improve through rehabilitation in a suitable environ­ment.
The increase in the range of everyday activities
resulting from improved abilities often conflicts withensuring safety, specifically with avoiding falls. Thus,
some variation exists, and falls can occur more readilyin the Kaifukuki rehabilitation ward than in general
hospital wards [2, 3]. During the early stage following
admission to the Kaifukuki rehabilitation ward,
appropriate measures to prevent falls that correspondto the disability status of the patient can be difficult to
put in place while a detailed evaluation from therehabilitation team remains incomplete. In addition,
this is a period in which falls have a greater frequencyof occurrence because the patient is not used to the
new environment or their physical disability [4, 5].
The frequency of falls is reportedly significantly
greater during the first 15 days of hospitalization thanduring any other period, even when adjustments are
made for the number of patients hospitalized [5].
The occurrence of falls can lead to post-fall
syndrome in patients [6], and the resulting fear of
falling again [7] and anxiety can hinder increases in
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Teranishi T et al.: Factors involved in falls in a Kaifukuki rehabilitation ward

the range of everyday activities [8], thus delaying the
progress of rehabilitation. It is therefore important tobe able to reasonably estimate the risk of falling in theearly stage following admission to a Kaifukuki
rehabilitation ward, and at the same time propose
methods for managing this risk [5, 9].
To date, numerous attempts have been made toestimate the risk of falls in hospital wards[10-13]. In
many of these studies, the factors involved in falls are
given a numerical weighting, the risk is scored byadding the factors, and a cutoff value is determined.
However, the predictive accuracy of such tools
depends on the environment in which they are applied,
and at least one study has reported that they are
currently no better than the clinical decisions made by
the nursing staff [14]. Such tools thus do not always
give adequate results. Another problem is that thesetools add together fall-related factors that vary innature, so while individuals may have the same
numerical risk score, the combinations of factors
involved in falls may differ. Linking these tools
directly to countermeasures is thus difficult.
The objective of the present study was to investigate
the factors necessary for evaluating the risk of fallingby clarifying the main factors influencing theoccurrence of falls within the first 14 days following
admission to a Kaifukuki rehabilitation ward. For this,the odds ratios were determined through logistic
regression analysis using the explanatory variables ofthe subscales of the Functional Independence Measure(FIM) [15], an evaluation of the degree of independencein activities of everyday life, and the Standing Test for
Imbalance and Disequilibrium (SIDE) [9], which is a
simple evaluation of balance, at the time of admission
to the Kaifukuki rehabilitation ward.
Methods
The subjects were 545 individuals (mean age,
66.7±15.3 years), comprising 301 men (mean age,64.4±14.3 years) and 244 women (mean age,69.5±16.1 years) out of the total of 547 patients
admitted to the 108-bed Kaifukuki rehabilitation ward
during the period between July 1, 2011 and June 30,
2012. Two patients were excluded due to missing FIM
data.
The items surveyed were diagnosis, gender, age on
admission, FIM at the time of admission, SIDE levelat the time of admission, and whether the patient had
fallen within 14 days after admission. The period forsurveying the incidence of falls was set at 14 days (2weeks) because the results in the literature show thatthe incidence of falls is significantly greater in the 15days following admission [5], and also taking into
account specificity for certain days of the week. The
definition of a fall for the present survey was “asituation where part of the body other than the soles ofthe feet makes contact with the floor or the ground11

when this is not intended” [16].
The FIM is an evaluation of the degree of
independence in activities of daily living, comprisinga motor subscale of 13 items and a cognition subscaleof 5 items. The score has 7 steps: 7 indicates complete
independence; 6 indicates modified independencewith concern for time and safety, requiring devices
and time; 5 indicates supervision (patient can carry out
more than 90% of the cognitive items alone); 4
indicates that the patient can carry out over 75% of theitems alone (75-90% of the cognitive items carried out
alone); 3 indicates that the patient can carry out 5074% of the items alone; 2 indicates that the patient can
carry out 25-49% of the items alone; and 1 indicates aneed for total assistance, in which the patient can carryout fewer than 25% of the items alone.
The SIDE is a simple balance evaluation that can beadministered at the bedside. A flow chart for
determining the patient’s level is shown in Figure 1.
The breakdown of diagnoses for the 545 subjects is
as follows: cerebral stroke in 396 (cerebral infarction,
n=195; cerebral hemorrhage, n=171; subarachnoid
hemorrhage, n=30); traumatic brain injury in 17;
spinal cord disorder in 45; lower limb fracture in 44;
and other in 43. Mean scores at the time of
hospitalization were 49.2±24.7 for the total of FIM
motor subscales and 23.0±9.5 for the total of FIM
cognitive subscales. Subjects were divided into a fallgroup, who had fallen within 14 days of admission,and a non-fall group, who had not fallen.
Next, to determine the dependent variables forlogistic regression with the occurrence of a fall as theobjective variable, differences in SIDE level between
the fall and non-fall groups were investigated using
Fisher’s exact test, and differences in FIM subscale
items were investigated using the Mann-Whitney
U-test.
Cutoff values for variables with a significant
difference between the fall and non-fall groups were
determined using the Youden index.
To eliminate the problem of multicollinearity, theKendall rank correlation coefficient between eachvariable was investigated. Where the coefficient was
0.7 or greater, the item having a higher correlation
with the occurrence of falls was selected as a dependent
variable.
In addition, where there was a complete separationof subjects who fell, the variable was eliminated fromthe dependent variables to avoid distorting thelogistic regression results in the same way as themulticollinearity problem [17].
Odds ratios were computed by logistic regression
using the selected dependent variables. Statisticalanalysis was performed using SPSS Statistics Version
23, and the significance level was set at 0.05.
The present study was approved by the Ethics
Committee of Fujita Health University Nanakuri
Sanatorium (Nanakuri Ethics No. 88).
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Teranishi T et al.: Factors involved in falls in a Kaifukuki rehabilitation ward

Figure 1. Flowchart to determine the level of SIDE.
The levels are arranged in order of difficulty; more levels should not be included once a subject
loses balance at a certain level and requires assistance. As the level of difficulty in the test
increases, the risk of falling increases.
Level 0: A standing position with a wide base cannot be maintained without assistance. Support
provided by grasping something or being assisted by a caregiver is always required to maintaina standing position.
Level 1: A standing position with a wide base can be maintained without assistance, but standing
with a narrow base cannot be maintained for more than 5 s. Balance is lost in a standing
position with a narrow base: bringing the legs close together such that the feet are in contact
with each other medially at both the heel and forefoot.
Level 2a: A standing position with a narrow base can be maintained for more than 5 s, but atandem standing position cannot be maintained for more than 5 s with either leg position. The
tandem standing position involves standing with the heel of one foot placed at the toe of theother foot, in a straight line (either foot may be in front).
Level 2b: A tandem standing position can be maintained for more than 5 s with one but not theother leg in the leading position.
Level 3: A tandem standing position can be maintained for more than 5 s with either leg in front,
but standing on one leg is difficult to maintain for more than 30 s with either leg.
Level 4: A position of standing on one leg can be maintained for more than 30 s with either leg.
Results
Of the 545 subjects, 36 subjects experienced a fallwithin the first 14 days following admission (fallgroup). The non-fall group thus comprised 509
subjects, and the rate of fall occurrence was 36/545×
14 (4.72 ‰).
The differences between the two groups in SIDE
level and FIM subscale items are shown in Table 1.
Significant differences were found in the SIDE level(p=0.021) and in the following FIM subscale items:
lower body dressing (p=0.018), bath transfer (p=0.010), stairs (p=0.012), social interaction (p=0.018),
problem solving (p=0.01), and memory (p=0.07).
Cutoff values for the 7 items showing significant

differences between groups were determined using theYouden index. For the SIDE level, the cutoff was
between 2a and 2b. For the FIM subscale items, thecutoff values were: lower body dressing, between 5 and
6; bath transfer, between 4 and 5; stairs, between 3 and4; social interaction, between 4 and 5; problem solving,
between 3 and 4; and memory, between 5 and 6.
To eliminate the problem of multicollinearity in thelogistic regression, the correlation between the 7 itemswith significant differences between groups and theoccurrence of falls was investigated using the Kendall
rank correlation coefficient. The results are shown in
Table 2.
The only items with a correlation coefficient of ≥0.7
were lower body dressing/bath transfer (0.715). The

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3 (3)
3.3 (1.8)5 (6)4.2 (2.2)
0.01
4 (6)
4.4 (2.0)5 (4)5.0 (2.2)
0.02
4 (2)
4.4 (1.8)5 (4)4.8 (2.0)
0.10

2 (1)
2.8 (1.7)4 (4)4.0 (2.3)
0.00

Socialinteraction

13

variable showing a higher correlation with theoccurrence of falls was bath transfer, which wastherefore selected for use as a dependent variable.
With the SIDE level, complete separation of nonfall subjects was seen at level 2b and higher (Figure 2).
As a result, SIDE level was excluded from thedependent variables.
Logistic regression was carried out with the 5 FIM
items of bath transfer, stairs, social interaction,
problem solving, and memory binarized by the cutoff
value as dependent variables and occurrence of falls as
the objective variable. The results are shown in Table
3. Of the 5 variables, only problem solving statisticallyaffected the occurrence of falls (odds ratio=0.292; p=0.038).

median (interquartile range)mean (standard deviation)
Non-Fall group (n=509) median (interquartile range)mean (standard deviation)
p-Value－

3 (1)3.4 (1.3)4 (4)3.8 (2.1)
0.11

1 (2)
2.0 (1.3)2 (4)2.8 (1.9)
0.01

3 (1)
2.9 (1.1)3 (4)
3.5 (2.0)
0.15

1 (1)
1.7 (1.1)1 (3)
2.6 (1.9)
0.01

5 (3)
4.5 (1.8)5 (4)5.0 (1.9)
0.06

Discussion

Fall group (n=36)

ToilettransferBathtrunsfer

Ambulatory

StairsCognitive
comrehension

Expression

ProblemsolvingMemory3 (1)3.6 (1.1)4 (3)3.9 (2.0)
0.13
3 (5)
3.6 (2.4)5 (6)4.3 (2.6)
0.12
3 (4)
3.5 (2.3)5 (6)4.2 (2.7)
0.17
2 (3)
2.6 (1.7)3 (4)
3.4 (2.3)
0.05
2 (3)
2.5 (1.7)3 (6)3.5 (2.3)
0.02
3 (4)
3.0 (1.7)4 (6)3.7 (2.2)
0.05
2 (2)
2.3 (1.6)2 (4)
2.9 (2.1)
0.12
5 (6)
4.1 (1.9)5 (4)4.3 (2.2)
0.44
5 (2)
4.8 (1.8)5 (4)4.8 (2.2)
0.35
0 (1)
－
1 (3)
－
0.01
median (interquartile range)mean (standard deviation)
Non-Fall group (n=509) median (interquartile range)mean (standard deviation)
p-Value－
Fall group (n=36)

Upper body
dressing
Bathing
Grooming
Eating
SIDE level

Table 1. Comparison of SIDE level and subsale items of FIM between Fall group and Non-Fall group.

Lower body
dressing

Toileting

Bladdermanagement

Bowel
management

Bed
trunsfer

Teranishi T et al.: Factors involved in falls in a Kaifukuki rehabilitation ward

A large proportion of stroke patients were in thehospital ward in the present study, comprising 398 of
the 545 subjects (73%). With regard to efforts toprevent falls, the need to determine permitted actions
and the need for monitoring, sensors, or restraints is
discussed and decided by a team of specialists.The
rate of fall occurrence within 14 days of hospitalization
was 4.72% in the present study, lower than the 13.9%rate of fall occurrence in Kaifukuki rehabilitation
wards reported by Tsuchida [18].
SIDE and FIM, which were used as explanatory
variables in the present study, are methods of testingwith clear criteria. The reliability and validity of thesetools have been verified. SIDE is a method devised fordiscriminative evaluation of the ability to maintainbalance in a static standing position that allows simple
assessment of a patient immediately after admission toa ward [9]. On the other hand, FIM was developed as
an evaluation of the ability to carry out activities ofdaily living, and the assessment requires a grasp of thestatus of everyday activities. The assessment ofcognitive items in particular included a period of
observation, and took several days following admission.
FIM motor subscales with significant differences
between the fall and non-fall groups were lower body
dressing, bath transfer, and stairs. These items have ahigh degree of difficulty, and are also items for which
the score is affected by the ability to maintain balance.
In the FIM cognition subscales, social interaction,
problem solving, and memory showed significant
differences between the two groups. Falls likely
involved the metacognitive ability to “understand theinfluence of your own words,” which is included in thesocial interaction subscale; “How do you deal withyour needs?” which is included in problem solving;and “Do you remember the agreement on limits tobehavior?” which is included in the memory subscale.
In addition, a significant difference in SIDE level was
found between the fall and non-fall groups. Although
there was one case with missing values, none of the
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Teranishi T et al.: Factors involved in falls in a Kaifukuki rehabilitation ward

Table 2. Correlation between Variables (Kendall rank correlation coefficient).

Fall or Non-Fall
SIDE level
Lower body dressing
Bath trunsfer
StairsSocial interaction
Problem solving
MemoryFall or Non-Fall

SIDE level

1.000- 0.148**
1.000

Lower body
dressing

Bathtrunsfer- 0.132**
0.583**
1.000- 0.131**0.592**
0.715**
1.000

Stairs- 0.131**0.661**
0.620**
0.614**
1.000

Scial
interaction

Provlemsolving- 0.130**
0.229**
0.303**
0.281**
0.277**
1.000- 0.201**
0.349**
0.445**
0.389**
0.353**
0.664**
1.000

Memory- 0.136**0.290**
0.414**
0.365**
0.316**
0.644**
0.603**
1.000**p<0.01, *p<0.05.

nnFigure 2. SIDE level of Fall group and Non-fall group.

Table 3. Logistic regression analysis for fall event.

Lower body dressing
StairsSocial interaction
Problem solving
MemoryConstant

Wald

p-Value

Odds ratio

1.006
1.190
0.001
4.316
0.141
55.691

0.316
0.275
0.970
0.038
0.708
0.000

0.319
0.526
0.985
0.292
0.745
0.155

95% Confidence interval of Odds ratio
Lower

Upper

0.034
0.166
0.450
0.092
0.160

2.973
1.668
2.155
0.933
3.469

Hosmer-Lemeshow test, χ2=2.76, p=0.838.

subjects with a SIDE level of 2b or higher experienced
a fall. This suggests that individuals with a high SIDE
level are less likely to fall.
In the logistic regression analysis, problem solving
was identified as a factor affecting falls, and there is alikely involvement of problem solving items relating
to metacognition and behavioral control disorders,such as “ask for the necessary care when making
transfers,” “ask for help to clean up spilt milk,”“realize that you will fall if you attempt to get out of
the wheelchair unaided,” “use the call button whenhelp is needed,” “ask to be taken to the toilet if you
want to go when sitting in bed,” and “remember
agreements.” Studies to date that have investigatedfactors involved in falls using FIM subscales havereported the involvement of moving and problem
solving [4, 19], and the results of the present study
support such findings.
The causes of falls can generally be classified into
internal factors relating to the patient’s physical andmental condition, such as paralysis, visual impairment,or reduced ability to maintain balance, and external
factors relating to the environment, such as footwear
that comes off easily, steps, slippery floors, etc.
However, the internal factors of physical and mental
function play a greater part in an environment
optimized for rehabilitation training, such as the
Kaifukuki rehabilitation ward. Among the internal
factors relating to falls, the ability to maintain balanceis considered of paramount importance [20]. For

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Teranishi T et al.: Factors involved in falls in a Kaifukuki rehabilitation ward

example, even a patient with dementia will not fall if
their balance is good. In the present analysis, although
values were missing for one case, no falls were seenamong patients with an SIDE level of 2b or higher(patients able to maintain the tandem stance for≥5 s).
Patients with good balance do not readily fall, implyingthat such patients may be able to be excluded from theevaluation of falling risk.
In addition, a tendency to fall was seen amongindividuals who did not know what actions they could
safely perform without causing a fall because ofdeteriorated metacognition regarding their own
balance ability, which is a problem-solving criterion
for carrying out daily activities without falling. There
was likewise a tendency to fall among individuals with
reduced cognitive abilities regarding their environment,
individuals who were unable to abide by agreementson behavior restriction, and individuals for whomconstraints were ineffective even though they
understood the danger.
To reduce falls during the early stage of
hospitalization, there is a need for an assessment toolthat combines a simple evaluation of the ability tomaintain balance with a simple evaluation that allows
measurement immediately after admission of
metacognition relating to the ability to maintainbalance and control of impulsivity, which are includedin the FIM problem solving subscale.
A limitation of the present study was theretrospective nature of the study undertaken only at asingle facility. In addition, the number of variables in
the logistic regression was somewhat large in relation
to the number of events, so the results may not berobust. Thus, there is a need for a prospective study at
multiple facilities in the future.
Acknowledgments
The authors would like to thank the rehabilitation
stuffs of the Nanakuri Memorial hospital.
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