Falls Injury Prevention Forum Case...

0

Prepared by those with the utmost interest and passion for falls injury prevention!

March 2008

Falls Injury Prevention Forum Case Study

What is/ is not best practice

1

PREVENTION

2

No prevention- what could happen?• Mrs Firstfall visits her GP for her annual

flu vaccine - Lowers herself into the chair using her

arms

- Has had a few near falls of late, but doesn’t think to mention… isn’t that just a normal part of growing old?

- GP reports that she is in tip-top shape

- She grips onto the chair to lift herself to her feet

3

No prevention- what could happen?• A little over a month later…

- Mrs Firstfall loses her balance down a single step and has a fall

- Is taken to the emergency department for a cut that may require stitches

4

Best Practice Prevention• Rewind to the GP consultation…

- GP does a ‘Timed up and go’ test as he noticed her unsteadiness and difficulty getting into the chair

- He tells her a fall isn’t inevitable, with gentle exercise she can regain confidence and improve her strength and balance

- Refers her to a gentle exercise class and will conduct falls risk assessment at her next consultation

5

Best Practice Prevention• GP consultation, continued

- Mrs Firstfall leaves the consultation happy to have talked about her fear of falling and realising that it isn’t something she has to live with

- GP puts a reminder in her notes to prompt follow-up at her next visit

- Mrs Firstfall contacts the gentle exercise group instructor

6

Best Practice Prevention• Fast forward 3 months (rather than having a fall and

ending up at ED…)

- Mrs Firstfall has attended regular exercise classes

- Confidence in her stride is re-emerging

- Plus… she has increased social connections and is sleeping and breathing better

- Occasionally still a little unsteady on her feet, but now confident she can regain her balance

- She has not had a fall

7

ED Journey

8

What can happen in ED!

An independently community living 76 year old woman, Ms Fiona Firstfall from Maitland presents to ED with a laceration that requires sutures.

9

What can happen in ED!

• ED data entry: laceration requiring sutures.

• Mrs Firstfall is asked about her tetanus immunization status

• Wound sutured and referral made to community health to check wound in 3-4 days time.

10

ED Nurse response

• 10 out of 10 triage nurses surveyed asked MrsFirstfall how she had lacerated her leg and then queried the circumstances of the fall.

• 8 out of 10 triage nurses coded the presentation as an injury resulting from a fall.

• 6 out of 10 triage nurses queried the home situation

• 1 nurse reviewed previous ED presentations for falls and also to identify possible cases of elder abuse or history of alcohol abuse.

11

What is best practice in ED!

• Patients assessed for risk of future falls if the ED presentation is related to a fall

• Screening tool used to identify and guide appropriate referral for more detailed assessment

• Preliminary assessment of risk factors in the ED including:

PMHx, falls history, medications, cognition (is it delirium), neurological and cardiovascular system, vision, gait and balance, social circumstances, current level of function.

12

Best Practice ED!• Referral for patients who are identified as an increased risk

of falling to ensure full assessment by appropriate member of the multidisciplinary team

• Referral can include:

ASET

Community Nurse

GP

Physiotherapist

Occupational Therapist

Podiatrist

Medical specialist

13

Best Practice –The Strategic goal

• ED data entry: Coding being reviewed at area level with Primary code being Injury caused by a fall. W19…W19…W19…W19…W19…W19…

• An alert in iPIMs will be activated to refer MrsFirstfall to the Falls Triage Hotline. (fall, lives alone and over 70)

• Wound sutured and tet tox status checked. MrsFirstfall will be advised that the Falls Triage Hotline will call her within 72 hours.

14

HNE Strategic Goal• ED Data entry identifies that the laceration was an injury

caused by a fall, -W19

• That Mrs Firstfall is 76, lives alone, and requires follow-up from the Falls Triage Hotline as she is at risk of future falls.

• Falling is not an inevitable event of old age. The reasons for the fall need to be identified and appropriate referrals made.

• An appropriate and feasible screening tool for use in ED will be identified and appropriate referral responses outlined.

• By decreasing the risk factors and early identification, the risk of falling is reduced.

15

Community Journey- Part A

16

What can happen in Community Health!

• The Community Nurse visits 4 days later and notes good wound healing.

• No follow up of the falls risk occurs

• Due to lack of follow up Ms. Firstfall may be placed at even higher risk of further falls.

17

Best Practice in Community Health

• ED makes referral to Falls Triage hotline.

• Falls Triage hotline staffed by EN’s contact Mrs Firstfall the day after her ED presentation.

18

Best Practice in Community Health

This tool has been developed by the presenters as an example of the type of screening questions that could be asked.

19

Difference in Outcome

• With best practice, referral was made from ED to Falls Triage hotline

• Risk assessment priorities are identified through phone call from Falls Triage hotline.

• This identifies that this was her first fall from a trip over a step and her leg caught the edge of a rock, causing the laceration.

20


• This results in identification as a moderate falls risk

• A falls risk alert is placed in CHIME

• A referral is completed to community nursing for a wound status check due to potential wound infection risk.

• The referral will also request a Quick screen assessment which is an example of a more comprehensive falls risk assessment.

21

Community Journey-Part B

22

What could happen!

• Relief community nurse (CN) unaware of CHIME falls risk alert prior to visiting Mrs Firstfall.

• Notes wound is healing well.

• This results in lack of follow up in regards to falls risk, for example Allied Health referral.

23

Best Practice

• CN note the CHIME falls risk alert prior to completing home visit

• The CN therefore has an awareness of the need to undertake an opportunistic screening assessment such as the Quick screen assessment

24

Best Practice

25

Best Practice

• Results from Quickscreen assessment are entered into CHIME

• Follow up appointment scheduled with General Practitioner(GP).

• CHIME generates a letter to Mrs Firstfall’s GP highlighting the following risk factors:

Need for medication review

Referral to physiotherapist to assess home based exercise program to improve gait stability and balance as well as potential walking aids

26

More Best Practice

Recommendation for attendance at a relevant community exercise group, e.g. Beaming Balancers (balance and strength program) auspice by HNE health Promotion as part of Active Over 50s program.

OT referral to assess possible house and yard modifications, possible adaptive equipment and falls hazard risk assessment.

Education booklet on falls prevention issued and explained to Mrs Firstfall at time of home visit.

Note of the healing wound.

27


• Following basic standard of care Mrs. Firstfall did not receive any follow up in regards to her falls risk which may have an impact on her risk of future falls.

28


• Under best practice-Mrs. Firstfall would have an opportunistic fall

screening assessment completed-This would then identify risk factors that are

highlighted to her GP and other health professionals in a letter

-Mrs Firstfall is contacted with appointment times for OT and PT.

-Mrs Firstfall. is an active member of the community exercise group

29


• Appropriate follow up, assessment and referral has meant Mrs. Firstfall is likely to have a significant reduction in her future falls risk.

30

Acute Journey

31

What can happen in hospital!

• Mrs. Firstfall’s neighbours concerned

• Mrs. Firstfall is found on the floor

Second time faller

On floor several hours

• Road trip to hospital

32


• Bedside rails up to prevent her getting out of bed

• Pressure relieving mattress

• Bed in high position

To attend”Cares”

Call bell on locker

Room at end of corridor

33


• Mrs. Firstfall tries to get out of bed

• Falls over top of bedside rail

• Hits head on locker

“No apparent injury”

Placed back in bed

“Quiet”

34


• Night Registered Nurse noticed (Rt.) pupil fixed, dilated

• Medical Officer called

Laboured respirations noted

Hourly observations commenced

Status declines

35

What can happen in hospital!• CT Scan following morning

• Intracranial bleed

• Permanent brain damage

• Not suitable for rehabilitation

36


• Mrs Firstfall now requires permanent RACF placement

37

Residential Aged care journey

38

What can happen in Residential Aged Care!

• Transferred to a Residential Care facility

• Minimal staff

39

What can happen in Residential Aged care!

• Waiting

40


• Preferences

41


• GP unavailable

42


• The nurse’s minute

43


• Gait aid

44


• Facility Manager/RN/physio/OT/Social worker etc

45


• Group exercise program – no balance focus!

46


• Footwear – they’re comfy

47


• More comfy footwear

48


• Bed Rails to keep the resident ‘safe’

49


• Night time – confusion, dark, fear

50


• Here we go again!

51


• Another life changing experience!

52

Best Practice in Residential Aged Care

• Transferred to a residential care facility

• Plenty of staff and a GP available within 24hrs

53


• Welcomed by staff

54


• Family

55


• Preferences!

56


• Assessed by physiotherapist

57


• Individual exercise program with a focus on balance!

58


• Group exercise programs with a focus on balance

59


• Hip Protectors

60


• Gait aid

61


• FRAT

Falls Risk

Assessment

Tool

HOW TO USE THIS FORM: - Complete Parts 1 & 2 of this FRAT to establish ‘Fall Risk’. Using Parts 1, 2 & 3 document in the progress notes and care plan the appropriate fall prevention strategies for this resident PART 1 AUTOMATIC HIGH RISK STATUS IF one of the following is ticked: (tick HIGH risk below)

Dizziness Postural hypotension present Recent change in functional status and/or medications, which may affect safe mobility.

PART 2 RISK SCORE ASSESSMENT Recent Falls History: - including number of falls and possible contributing circumstances _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________

Risk Factor Level Risk Score RECENT FALLS (To score this, complete recent falls history above)

none in last 12 months one or more between 3 - 12 months ago one or more in last 3 months one or more in last 3 months whilst inpatient/resident

2 4 6 8

MEDICATIONS (Sedatives, Anti-Depressants Anti-Parkinson’s, Diuretics, Anti-hypertensives, hypnotics)

not taking any of these taking one taking two taking more than two

1 2 3 4

PSYCHOLOGICAL (Anxiety, Agitation, Depression, Withdrawn, Decreased Cooperation, Decreased Insight or Decreased Judgement esp. re mobility)

does not appear to have any of these appears mildly affected by one or more appears moderately affected by one or more appears severely affected by one or more

1 2 3 4

COGNITIVE STATUS Align to cognitive assessment tool used for this resident

PAS Cognitive Impairment Scale Standardised Mini Mental Status PAS=0-3 m-m score 24 or more Intact PAS=4-9 m-m score 24 – 15 mildly impaired PAS=10-15 OR m-m score 15 – 9 OR mod impaired PAS=16-21 m-m score 9 or less severely impaired

1 2 3 4

FALL RISK STATUS Low 5 - 11 (Document Fall Status in the Care Plan) Medium 12 - 15 High 16 - 20 IMPORTANT: IF HIGH RISK, COMMENCE A FALL ALERT PROTOCOL FLOW CHART PART 3: RISK FACTOR CHECKLIST Tick and Explain Vision

Reports/observed difficulty seeing objects/signs/finding way around

Mobility

Mobility status unknown or is unsafe/impulsive/forgets walking aid

Transfers

Transfer status unknown or is unsafe i.e. over-reaches, impulsive

Behaviours

Observed or reported agitation, confusion, outbursts of anger, disorientation, difficulty following instructions or resistive with care, constant walking or pacing

ADL’s

Observed or reported risk-taking behaviours Observed unsafe use of equipment Unsafe/inappropriate footwear or clothing

Environment

Difficulties with orientation to environment i.e. areas between bed/bathroom/dining room

Nutrition

Underweight/low appetite

Continence

Reported or known urgency/nocturia/accidents

Other

Osteoporosis, history of fracture/s, signs/presence of pain, restraint

Name: MRN: Attach Resident Label Here Address: DOB: M.O.

FALLS RISK ASSESSMENT TOOL

13 / 20

62

Best Practice in Residential Aged Care‘Fall Alert’ Protocol Flow Chart

Commence resident on fall alert check form:

o Day o Night o Day & night o Other______________

To monitor for: o Pain/comfort o Need to change location o Need to toilet o Need for food & drink o Behaviour suggesting

an unmet need o Other_______________

Commence resident on a

“Log of Falls”

form

Place green sticker on appropriate locations to alert staff of high fall risk:

o Bed head o Care plan o Progress notes o Handover sheets o Communication sheet/book o Mobility aid o Dining room table o Resident’s chair o Bathroom if appropriate o Inside wardrobe door o Other___________________

Commence resident on movement alarm/alert system:

o Day o Night o Day and night o Other_______________

Resident identified as “HIGH” Risk Falls using a Falls Risk Assessment Tool

Initiate ‘Fall Alert’ Strategies

Highlight below the Fall Alert Strategies that are to be implemented for this resident

Keep on file with the Resident Mobility Care Plan and review as part of the Mobility Care Plan and after a reassessment with a ‘Falls Risk Assessment Tool’ as per facility protocol


Injury Prevention StrategiesIs the resident using:

o Vitamin D o Hip protectors

Fall Alert Strategy

63


• Falls Log Aim: This log is to be completed for residents for whom it has been determined that there is a benefit from logging a falls record for further analysis of their falls history Page Number:___________ Date

Time

Location

of Fall

Description

Describe what the resident was doing at the time of the fall, include possible contributing factors and whether hip

protectors were being worn

Injuries from fall

Referred

to GP

Falls Prevention Strategies

What falls prevention strategies have been implemented as a result of the fall

Signature

Name: MRN: Attach Residents Label Here Address: DOB: M.O.

Log of Falls

64

Best Practice in Residential Aged CareFall Alert Check Form

How to use this form: This form is to be used to record the ‘checks’ that occur for a resident who is high risk for falling and been assessed as requiring frequent monitoring as a strategy of their falls prevention intervention Frequency or times for ‘checks’ _______________________________________________

Date

Time

What was the resident doing / where were they?

Comments


•Fall Alert

•Check

65


• GP Communication

66


• Easy to find, comfy footwear

67


• Information on

safe footwear

Safe Footwear Checklist The requirement for safe, well-fitting shoes varies depending on the individual and their level of activity. The features outlined may assist in the assessment of an appropriate shoe. This is a general guide only. Some people require the specialist advice of a podiatrist for the prescription of appropriate footwear for their individual needs. The shoe should have the following features:

Safe Feature Tick

Heel

Low & broad (<2.5cm)

Straight through sole

Firm heel collar to provide support

Sole

Cushioned, flexible, non-slip

Weight

Lightweight

Adequate width, depth & height for natural spread of toes

Toe box

Have a one centimetre space between longest toe and end of shoe

Fastenings

Laces, buckles elastic or velcro that hold securely

Accommodating material

Uppers

Smooth seam-free interior

Safety

Protect feet from injury

Shape

Same shape as the feet, without causing pressure or friction on the foot

Purpose

Appropriate for the activity being undertaken

Orthoses

Comfortably accommodating orthoses

Podiatrist or physiotherapist advice

Recommendations /Plan:


This checklist may be used in the resident’s admission package or to assess safety of current footwear or purchase of new footwear.

68


• New safer footwear

69


• Bed mobility

70


• Vision assessment, single lens glasses

71


• Settling in…

72


• A life changing experience!

73


• An unbalanced load

74


• Balancing that load!!

75

Acute Journey-Best practice!

76

Best practice in Hospital!

• Post operative confusion anticipated• Increased risk factors for delirium targeted• Given room near nurses station• Bed in lowest position when not receiving direct

care• Bedside rails down• Use of “Special” considered for 1:1 monitoring

77


• Volume depletion

noted in OT

• Resident consulted to

increase IV rate

78


• Falls prevention management plan commenced• Sign above bed indicating falls risk

• Falls arm band in place

• Noted in handover as “High Falls Risk”

79


• Consult with Dementia/Delirium CNC

• Post operative delirium suspected• Check hydration• Fluid intake and out put• Bowel function• Appetite• Pain / relief scheduled• Infection

80


• By treating risk factors post op delirium resolving :• Less confused

• Physiotherapist able to commence exercises

• Non-slip socks placed over TED stocking

• Mrs. Firstfall able to stand out of bed

81


• Gradually Mrs. Firstfall regains strength

• Increased participation in self care

• Suitable for Rehabilitation

• Transferred to Rehabilitation unit ten days later

82

Rehabilitation journey!

83

What can happen in Rehabilitation

• 10 days post op Mrs Firstfall is transferred to a rehabilitation unit in Maitland

• She appears well and staff note that assessments from acute care had been attended and utilise these same assessments to plan her care.

• No falls risk identification or individual plan is put into place

84


• Mrs Firstfall does not want to call the nurses for assistance to go to the toilet.

• Her bed is a bit high due to staff attending to her hip dressing a few moments before.

• As she attempts to get from sitting to standing she slides forward for her feet to touch the floor and with her TED stockings on she continues to slide when her feet meet the linoleum.

85


• She falls to the floor on her non surgical side and she hears a crack.

• Staff assess Mrs Firstfall and note the external rotation of her foot and shortening of her leg

• She is hoisted to the bed and awaits X-ray

86


• X-ray reveals a fractured NOF which requires surgery.

• Mrs Firstfall requires major surgery for the second time in less then two weeks

• No IIMS record is made and there is little documentation made in the notes pertaining to the fall.

87


• Due to her weakened state, blood loss and dehydration, she arrests during surgery and cannot be resuscitated.

• This results in a coronial inquest.

88

Best Practice in Rehabilitation• On admission to rehabilitation Mrs Firstfall has a

comprehensive multidisciplinary assessment completed

Nursing-initial patient assessment includes:

1.Falls risk screen

2.Review of vision and hearing

3.Mobility assessment eg: sit to stand and aid used

4.Hydration and nutrition

5.Orientation and cognition

89

Best Practice

6.ADL function- manual dexterity, limb movement and education based on surgical requirements

7. Medication management and

pain management review

8.Continence

90

Best Practice

• Falls screen denotes Mrs Firstfall as a high falls risk

• Strategies that are put in place include:

1.Attaching arm band that denotes falls risk

2.Educating Mrs Firstfall on falls prevention and restrictions to her mobility, including footwear

3.Orientating Mrs Firstfall to the new area she is in, including call bell use

4.Having all equipment within reach

91

Best Practice

5.Locating Mrs Firstfall close to nurse desk and close to ward bathroom

6.Instituting falls care plan and documenting risks

7.Educating family members on falls risk

8.Frequent checks on Mrs Firstfall,supervision and encouragement with her mobility

92

Best Practice

9.Pain management

10.Adding a night light to increase night vision

and

Highlighting risks to other staff at handover

93

Best Practice

Multidisciplinary team falls prevention• Occupational therapy- assess cognition, self care,

home assessment.

• Physiotherapy- assess mobility, bed mobility, transfers, strength and balance, and gait.

• Social work- social situation, service provision and emotional state.

94

Best Practice

• Medical- review of medication management including pain medication and commencing Vitamin D and calcium if appropriate.

• Dietician- assess nutritional status and provide education.

• Pharmacist- review of medications and instruct patient on use.

95

Best Practice

• Mrs Firstfall becomes more independent with her mobility aide each day and her strength and balance improve considerably.

• Mrs Firstfall is sent for bone density testing and is commenced on a bisphosphanate.

• She is competent in self medication, small meal preparation and requires supervision with self care.

96

Best Practice

• A home visit is attended by the OT at Maitland who suggests some rails be put in the bathroom and toilet and front entrance, the height of the bed adjusted and removal of floor hazard.

• The OT will refer to community Physiotherapy(TACP) for ongoing mobility safety and allow for Mrs Firstfall to regain independence both indoor and outdoor.

97

Best Practice

• Towards end of time in rehab Mrs. Firstfall’s son comes to visit from WA in order to meet with staff to ascertain what is required to enable Mrs. Firstfall to return home

• It is decided that her son will return home with her to see how she is managing.

98

Best Practice

• Referrals are made to TACP for ongoing review of patient care needs .

• Mrs Firstfalls son and daughter are educated on her mothers care requirements and informed of service providers and the referral system.

• Mrs Firstfall is aware that her GP will have information pertaining to her admission sent to him and to see her GP within one week of d/c.

99

Best Practice

Mrs Firstfall is discharged home with her daughter and son who will assist community services to increase their Mums independence

The referral made to community services in Maitland will assess and identify what services will be required for Mrs Firstfall to live independently

100

Community Journey c)

101

Support to return home

• CAPAC Services

• TACP

• Client Journey

102

CAPAC Umbrella• CAPAC

HITHHAHPre-Hospital

Health / COPsPartnership

6 week program

TACPPost - AcuteEnablement /

ACFavoidance

12 week program

•Anticoagulation•Cellulitis IV•Other Orthopaedic•Elective Orthopaedic•Falls Risk•Heart Failure•COPD•Other

103

CAPAC-Why?

• Goal to prevent admission to hospital and facilitate early discharge by providing:

“front end” care to avoid ED presentations and unplanned admissions (HAH)

Quick turn around at the Emergency Department (HITH)

Early discharge (Acute)

104

CAPAC

Follow-up to prevent representation (Post-acute / TACP)

Multidisciplinary team-based approach

Holistic approach

Seamless and integrated care, complementary to existing services

• As effective as in-patient care for selected conditions

105

TACP- overview•Jointly funded program by both the Commonwealth and State Governments

•Only for current inpatients (5 local public hospitals)

•Slow-stream rehabilitation,

Capturing elderly patients in an acute/subacute setting who have the potential to be rehabilitated to the point where they can care for themselves in the home; or

Can be admitted to an Aged Care Facility at a higher level of functioning and independence

Funding for 12 weeks with potential for a 6 week extension

106

TACP Process• Mrs. Firstfall identified as suitable for enablement by

multidisciplinary inpatient team

• Referral to TACP attended via CAPAC phone intake

• Reviewed / assessed by clinician (CAN / CAAH) whilst in Rehabilitation

• ACCR completed for transitional care (valid for 4 weeks )

107

TACP Process• Mrs. Firstfall agrees to enter Transitional Aged Care Program and

is willing to enter into an agreement, which may include making a financial contribution

• GP informed at time of discharge

• She is visited daily for the first week and goals established, contact is reduced depending upon need (multidisciplinary)

• Review at 4 and 8 weeks

108

Primary Goals for TACP• Ensure that client and family are actively involved in goal

setting and planning for clients treatment

• Improve clients mobility and physical functioning generally and assist in returning to daily living skills following hospitalisation

• Enable the client to remain at home wherever possible.

• Work toward establishing community services to be organised to meet the clients ongoing care needs upon discharge from the program

109

Goals Identified for Mrs Firstfall

• Shower and dress independently

• Attend to small meal preparation, light domestic tasks.

• Return to independent mobility indoors and walk to local shops

110

Program for Mrs Firstfall

Reconditioning and mobility were the major focus of rehabilitation

• Initially daily visits.

• TACP nurse - personal care enablement and medication supervision.

• TACP Physio – home based exercise program and outdoor mobility.

• TACP OT -Follow up with home modifications, encouragement to remove floor hazards, initial meal prep supervision,encourage socialisation.

111

Outcome• Physio identified that Mrs Firstfall was continuing to improve

with intensive therapy and an extension of 6 weeks on the program would enable her to fully return to her previous level of functioning.

• Mrs Firstfall is encouraged to attend the local Active over 50s program

• OT encouraged socialisation and Mrs Firstfall joined the local charity group and spends time with her friends.

• Community Options have been arranged to assist with transport and heavy domestic chores.

112

Outcome• Mrs Firstfall discharged from programme at an increased

level of independence.

- Independent with personal care.

-Independent with light domestic tasks and meals.

-Independent with indoor mobility and uses a cane for outdoor mobility.

-Increased socialisation and exercise tolerance.

113

Best Outcome!!

Falls Injury Prevention Forum Case...

Documents

Transcript of Falls Injury Prevention Forum Case...