Policy for the Prevention and Management of Adult In Patient Falls 15210... · 2015-12-08 · a...

Status: Issue 2 Issue date: 02 December 2013 Approved by: Clinical Standards & Policy Group Review by date: 02 December 2016 Owner: Director of Therapies & Health Science ABHB/Corporate/0380

Policy for the Prevention and Management of

Adult In Patient Falls

N.B. Staff should be discouraged from printing this document. This is

to avoid the risk of out of date printed versions of the document. The Intranet should be referred to for the current version of the

document.

Aneurin Bevan Health Board ABHB/Corporate/0380 Policy for the Prevention and Management of Adult In Patient Falls Owner: Director of Therapies

Status: Issue 1 Issue date: 02 December 2013 Approved by: Clinical Standards & Policy Group Review by date: 02 December 2016

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Contents: 1 Executive Summary ................................................................................. p.3 2 Aim of Policy……………………………………………………………………. p.6 3 Definitions……………………………………………………………………….. p.6 4 Roles and Responsibilities……………………………………………………. p.7 5 Falls Bundle………………………………………………………………………. p.12 6 Falls Prevention and Management…………………………………………… p.13

7 Essential patient care following a slip, trip or fall in hospital…………… p.14

8 Management of a patient admitted directly post fall………………………. p.15 9 Education and training…………………………………………………………...p.15 10 Monitoring compliance…………………………………………………………..p.15 11 Equality Statement ……………………………………………………………….p.15 12 References…………………………………………………………………………p.16 13 Appendices…………………………………………………………………………p.17



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1.0 Executive Summary

Patient falls have both human and financial costs. For the individual patient, the consequences range from distress and loss of confidence, to injuries that cause

pain and suffering, loss of independence and, occasionally, death (NPSA 2007).

Falls and falls related injuries are a common and serious problem for older people. People aged 65 years and older have the highest risk of falling, with

30% of people older than 65 and 50% of people older than 80 falling at least once a year (NICE 2013)

Analysis of patient safety incidents reported to the National Reporting and

Learning System (2009/10) indicates that around 200 patients with fractures or

intracranial injury after a fall in hospital experienced some failure of aftercare. Problems included:

delayed diagnosis of fractures, ranging from several hours to several days

after the fall neurological observations not recorded at all or recorded at inadequate

intervals, resulting in delayed diagnosis of intracranial bleeding sling hoists used to move patients despite signs or symptoms of limb

fracture or spinal injury delays in access to urgent investigations or surgery

Prevention of falls, and effective management of patients following a fall, is

recognised as an important patient safety challenge for the Health Board.

The subject of patient falls is complex. Hospital patients are likely to be more

vulnerable to falling due to contributing factors such as: physical illness, disorientation, dementia, mental health, medication, age, as well as

environmental factors. A fall can be the result of a single factor for example: slipping or tripping, however in older or frail people maybe as a result of

multiple, interacting factors.

NICE Clinical guideline 161 states that all people age 65 years or older who are admitted to hospital should be considered for a falls multi factorial assessment

for their risk of falling during their hospital stay. People ages 50-64 who are admitted to hospital and are judged by a clinician to be at a higher risk of falling

because of an underlying condition should also be considered for a falls multi factorial assessment.

Falls prevention via risk assessment and effective risk reduction strategies is

everyone’s responsibility, to reduce harm and create a safer environment.



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In summary: This policy sets out the processes for how Aneurin Bevan Health Board will

prevent and manage Inpatient falls. The Key features are:

All adult patients 18–64 years must be screened for falls as part of the

admission process and appropriate falls prevention care must be commenced (Appendix 1).

All adult inpatients ages 50-64 years judged by a clinician to be at a

higher risk of falling because of an underling condition must have a multi factorial falls risk assessment commenced on admission to hospital.

(Appendix 2).

All adult in patients ages 65 years plus should receive a multi factorial

falls risk assessment commenced on admission to hospital (Appendix 2).

All patients who fall in hospital will be assessed by a registered nurse immediately and assessed by a doctor or equivalent night staff member

within a maximum of one hour following the fall in accordance with Aneurin Bevan Health Board Essential care following a slip, trip or fall

(Section 7 of this policy).

All patient falls will be reported via the Aneurin Bevan Health Board Electronic Accident Incident Management System (DATIX).

All falls resulting in serious injury will require a multi disciplinary Root

Cause Analysis investigation.

1.1 Scope of policy

Whilst this Policy relates to the prevention and management of falls in hospital

settings, it is inextricably linked to the Health Board Community Falls Strategy and 1000 Lives+ mini collaborative: Reducing Harm from Falls in the

Community.

This policy is relevant for all staff caring for adult in patients at Aneurin Bevan Health Board hospitals and is to be used in conjunction with the documents

specified below. Outpatient clinics, Day surgery, Maternity and paediatric areas should be familiar with the general principles for assessing and minimising falls

outlined in this policy and implement them where appropriate. Accident & Emergency departments will be conversant with this policy but will link with the

Community Falls Pathways and use the Community /In patient Falls screening tools and risk Assessment formats as appropriate.



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This policy supports the implementation of:

Standards for Health Services in Wales: Directly:

Standard 3: Health Promotion, Protection and Improvement Standard 7: Safe and Clinically Effective Care

Standard 8: Care Planning and Provision

Indirectly: Standard 6: Participating in Quality Improvement Activities

Standard 10: Dignity and Respect Standard 12: Environment

Standard 22: Managing Risk and Health and Safety

Standard 23: Dealing with Concerns and Managing Incidents

NPSA/2011/RRR001: Essential Care After an Inpatient Fall (appendix 3). This guidance had to be implemented in all organisations by July 2011.

This policy applies to all Hospital-based ABHB staff, including those on bank,

agency or voluntary contracts and should be read in conjunction with:

ABHB Datixweb Incident Reporting Policy and Procedure http://howis.wales.nhs.uk/sitesplus/866/document/229826

http://howis.wales.nhs.uk/sitesplus/866/document/229826 Recognition, Prevention and Management of Aggression & Violence

http://howis.wales.nhs.uk/sitesplus/866/document/232955 ABHB Missing Persons Policy

http://howis.wales.nhs.uk/sitesplus/866/document/232190

Leave of Absence Policy http://howis.wales.nhs.uk/sitesplus/866/document/290221

ABHB CPA Policy and Procedure Currently under development

ABHB Searching Patients Policy http://howis.wales.nhs.uk/sitesplus/866/document/233406

ABHB Locked Doors on Open Wards http://howis.wales.nhs.uk/sitesplus/866/document/290216

ABHB Use of Bedrails and Bedrail Covers Policy http://howis.wales.nhs.uk/sitesplus/866/document/232954

Safe and Supportive Observation of Inpatients in Mental Health & Learning Disability Settings Policy

http://howis.wales.nhs.uk/sitesplus/866/document/253166 ABHB Prevention of Violence to Staff Policy and Procedure


All Wales Policy & Procedure for the Protection of Vulnerable Adults http://howis.wales.nhs.uk/sitesplus/866/document/234384












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Mental Health Act (1983) amended by the Code of Practice for Wales 2007

http://www.wales.nhs.uk/sites3/page.cfm?orgid=816&pid=33960 Mental Capacity Act (2005) code of practice

http://webarchive.nationalarchives.gov.uk/+/http:/www.justice.gov.uk/docs/mca-cp.pdf

Deprivation of Liberty Safeguards code of practice 2008 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicatin

sPolicyAndGuidance/DH_085476 New Mental Health (Wales) Measures (out for consultation)

http://wales.gov.uk/consultations/healthsocialcare/advocates/?lang=en &

http://wales.gov.uk/consultations/healthsocialcare/assessment/?lang=en

& http://wales.gov.uk/consultations/healthsocialcare/care/?lang=en

2.0 Aim of Policy

The aims of this Policy are:

To outline Aneurin Bevan Health Board’s approach to the prevention and

management of falls

To provide a strategy to reduce, as far as is reasonably practicable, the incidence of inpatient and fall – related injuries

To facilitate the continual reduction in the number of avoidable, injurious

slips, trips and falls across the adult, in-patient population through the

appropriate identification and care of people at risk;

To outline key responsibilities in relation to the management of In patient falls;

To increase staff and patient awareness of the risk and impact of falls and

effective prevention strategies.

3.0 Definitions

Fall: An unwanted event whereby an individual comes to rest inadvertently, either on the ground, or lower level with or without loss of consciousness. (NICE

Clinical Guidance 2013)

Un-explained fall: A fall that has not been witnessed, a cause cannot be

identified or the person does not know how or why they fell.

Slip: To slide involuntarily and lose ones balance or foothold

http://www.wales.nhs.uk/sites3/page.cfm?orgid=816&pid=33960



http://wales.gov.uk/consultations/healthsocialcare/advocates/?lang=en

http://wales.gov.uk/consultations/healthsocialcare/assessment/?lang=en

http://wales.gov.uk/consultations/healthsocialcare/care/?lang=en



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Trip: An accidental misstep threatening or causing a fall

Stumble: To step awkwardly whilst walking and begin to fall

Fragility Fracture: A fracture occurring on minimal trauma after the age of 40 years and including forearm, spine, ribs, hips and pelvis. (RCP 2002)

4.0 Roles and Responsibilities

The overall accountability for health and safety of patients and effective

management of risk associated with slips, trips and falls within the Aneurin Bevan Health Board lies with the Chief Executive. The responsibility is delegated

to the Executive Director of Therapies and Health Science.

All staff working within the clinical settings have a responsibility for the safety

of patients, themselves and others. Staff are accountable for their practice in achieving this. The Policy for The Prevention and Management of Adult In

Patient Falls must be implemented at all levels within the organisation to ensure a safe and consistent approach, with the aim of reducing avoidable, injurious

falls and ensuring appropriate management of patients who experience a fall, to include collaboration with Intermediate Care and the Frailty Programme.

4.1 The In Patient Reference Group will:

Report and collate inpatient falls data and monitor and review falls within

the Aneurin Bevan Health Board (ABHB) (particularly related to dementia) in order to inform accurately the nature and prevalence of dementia

related falls.

Develop a Quarterly report on falls and project activity so that a baseline

can be established as at 2012/13 and the group can then track the impact of actions taken.

Act as an interface between inpatients and wider ABHB Divisions,

including Community Resource Teams in order to develop a clearer understanding of falls risk assessment tools used in different settings

(including dementia settings) to understand the nature and prevalence of falls.

Inform and support ABHB strategy and policy development in terms of the

definition, screening assessment and prevention of inpatient falls in dementia – and monitor he impact of initiatives taken.

Keep abreast of best practice guidance with a view to submit for ratification policies that have been tested prior to final approval.



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Undertake audit of ward environments – using in house experience and draw on community staff experience – so as to transfer knowledge and

experience across the division.

Include some local authority representation so that practice developments to monitor and manage falls in the in-patient setting are shared with

multi-agency community teams.

Set up specific task and finish teams from the group membership as needed to progress particular initiatives identified in the work group

project plan as this develops.

4.2 Divisional Directors must ensure:

That risk assessments relating to slips, trips and falls are completed to cover their areas of responsibility, in line with the Health Board’s Occupational

Health and Safety Policy and Strategy.

That serious falls incidents are investigated and managed using the Health Board’s approved incident reporting and management procedure.

That all staff are aware of and implement the NPSA Rapid Response Report

“Essential Care After an Inpatient Fall” (Appendix 3).

Compliance with NPSA, NICE and other national guidelines on falls prevention is audited.

That Falls data, from ‘Safety Crosses’ is analysed and collated at Ward/Dept,

Directorate and Divisional Level.

That there is sufficient equipment available for the prevention and

management of falls.

4.3 Ward Sisters/Charge Nurses must ensure:

All patients are assessed as to their risk of falls on admission, with re-assessment at frequent intervals or when there is a material change in the

patients’ condition.

A detailed risk assessment is completed for those patients identified at risk of a fall and that Transforming Care, specifically Intentional Rounding, is

implemented.

Environmental risks related to slips, trips and falls are identified and

managed appropriately in their area(s) of responsibility.



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That they identify specific staff training needs to ensure that all existing and new staff are trained in Falls Prevention.

All staff are aware of and implement the NPSA Rapid Response Report

“Essential Care After an Inpatient Fall” (Appendix 3).

Fall related incidents, complaints and claims are reviewed and identifying lessons to be learnt and implementing actions locally. Should also identify

learning which should be shared across the organisation.

Assistance with the investigation of serious falls and review the management of patients that have had multiple falls (more than three).

Recording of all falls via the 1000 Lives+ ‘Safety Cross’, illustrating the days between fall incidents on a weekly basis and collating this information on a

monthly basis.

4.4 Registered Nurses must ensure:

A falls risk screening is commenced for all adult in patients within 6 hours following admission.

A bedrail screening is commenced for all adult in patients within 6 hours

of admission

Transforming Care ‘Intentional Rounding’ is to be undertaken for inpatients deemed to be at risk of falls.

The review of a falls risk assessment on any inter hospital ward transfer,

change in clinical condition or review weekly if no change observed.

Falls awareness as to the risks & impact of falls is promoted to

patients/relatives, providing a patient information leaflet (appendix 4).

Patients/relatives have been advised regarding appropriateness of footwear for the hospital environment if problems have been identified on

admission, so that alternatives might be provided as necessary

Observation of the environment identifying and reducing environmental risks where possible.

Lockers, call bells, drinks etc are within patient reach to discourage over

stretching.

The multi disciplinary team is aware of patients who are at a risk of falls

or who have fallen using the Patient Safety at a Glance Board (PSAG) and



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via discussion at patient safety briefings during shift handovers and during referrals. The use of a black dot in the high risk column of the

PSAG Board is to be used to denote a patient is at a high risk of falls

Reporting all fall events via the Health Board Clinical Incident reporting mechanism and via the ‘Safety Cross’.

Compliance with the NPSA Rapid Response Report “Essential Care After

an Inpatient Fall” (Appendix 3).

Compliance with Health Board Policies and Procedures for the prevention and management of patient falls.

Referral to the Community Resource Team/Falls Service as part of discharge planning (as appropriate).

Completion of Falls Prevention and Management Training programme

4.5 Consultants must ensure:

Medical staff have undergone training in Falls Prevention.

Completion of a detailed risk assessment for all patients identified as at

risk of falling, ensuring medication review and delirium assessment.

Patients who have fallen or who are at risk of falls, will have this

described within their discharge plans and will be referred to the

Intermediate Care Team/Frailty falls Team prior to discharge.

Medical compliance with the NPSA Rapid Response Report “Essential Care After an Inpatient Fall” (Appendix 3).

Assistance with the investigation of serious falls and review the

management of patients that have had multiple falls (more than three).

4.6 Medical staff must ensure:

The assessment of patients on admission for any condition that may predispose the patient to a risk of falls and this should be incorporated in

the clerking documentation

The documentation of the patients previous falls history

The clinical review for any condition that may have caused a fall and

review medications that have contributed to the patient’s fall(s)



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Review patients following a fall.

Ensure on discharge that patients at further risk of falls in the community

are referred for appropriate follow up with Intermediate Care Team/Frailty Falls Team prior to discharge.

Completion of training in Falls Prevention

4.7 Physiotherapists are responsible for:

Carrying out an assessment on all patients referred to the service with a

fall/following a fall as an in patient. The assessment will include balance, gait, range of movement, strength, functional ability including transfers

and the need for and provision of a walking aid. The physiotherapy

treatment plan will continue until the patient reaches either their pre admission level of mobility or rehabilitation potential, whichever is the

greater. This will be the responsibility of the physiotherapist in charge of the patient’s care

Providing advice (along with the Back Care Team if appropriate ) to other

members of the multidisciplinary team on the best methods of movement and mobility

Providing patients/relatives with advice of suitable footwear as

appropriate


4.8 Occupational Therapists are responsible for:

Carrying out an assessment on all patients referred to the service with a

fall/following a fall as an in patient.

Ongoing assessment and intervention of activities of daily living and necessary interventions throughout the patients stay, where indicated

Assessment of cognitive function where appropriate

Where indicated, assessment of the patient’s home environment,

identifying the daily activities which place the person at risk of possible falling




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4.9 Pharmacists are responsible for:

The supporting of medication reviews for patients at risk of falls when

requested by the medical or nursing staff


4.10 Portering and Phlebotomy staff:

Portering staff will transport patients and return them to the relevant clinical area in accordance with the falls prevention training received

during the ABHB manual handling training courses

Phlebotomy staff will ensure that they leave the patient at the bedside with the bed at the lowest height, having checked with the nurse in

charge whether bed rails should be left up or down.

5.0 Falls Bundle

All adult patients 18–64 years must be screened for falls as part of the

admission process and appropriate falls prevention care must be commenced (Appendix 1).

All adult in patients ages 50-64 years judged by a clinician to be at a

higher risk of falling because of an underling condition must have a multifactoral falls risk assessment commenced on admission to hospital.

(Appendix 2).

All adult in patients ages 65 years plus should receive a multifactorial falls risk assessment on admission to hospital (Appendix 2).

Certain groups of patients such as those with dementia may be at an increased risk of falling and require more specialised approaches to

manage risk and provide appropriate care in relation to falls. Where possible, specialist areas will make information, such as the 1000Lives

Plus Improving Dementia Care (see page 17 for the link) available which can be read in conjunction with this policy to guide good practice for staff

in relation to specific patient groups.

5.1 The falls Risk Assessment will be reviewed weekly (maximum), or immediately following a fall, a change in the patients condition or ward

move.

5.2 All patients assessed as a lower risk of falls must have the Transforming Care ‘Intentional Rounding’ implemented.



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5.3 All patients assessed as a high risk will be commenced on a 1 hourly “Intentional Rounding.

5.4 Patient safety briefings at the PSAG Board will display black dots in the

high risk column for those patients assessed as being at a risk of falls

5.5 Additional assessments/referrals may be required for individual patients depending on the outcome of the Risk Assessments. These additional

assessment referrals and subsequent intervention must be documented in the patients care plans/notes

5.6 Inappropriate sitting posture can impact on In Patient mobility, comfort

and tissue viability. A chair or bed that is too high will encourage the

patient to slide forward and hence increase the risk of falls as well as reducing independent mobility. The patient’s height of chair and bed

must, therefore, be assessed for suitability (in accordance with NICE guidelines on Pressure Ulcer Assessment and Prevention) and advice

sought from Occupational therapy, Physiotherapy or Aneurin Bevan Health Board Back Care Team/Ward Transfer Specialists as appropriate

5.7 All patients identified as “at risk” will be given the ABHB “Falls Prevention

in Hospital” leaflet (Appendix 4) and have an opportunity to discuss its content with a member of the multi disciplinary team. This will be

documented in the care plan. Where someone has impaired communication or comprehension due to an underlying condition such as

dementia or learning difficulty then an appropriate alternative will be explored if deemed appropriate. For example, discussion with carers/next

of kin.

5.8 Next of kin/carers must be informed of the findings of the patient Falls

Risk Assessment and advised of any issues that require attention whilst the patient is an in-patient. e.g. provision of suitable footwear, availability

of spectacles, etc.

5.9 Prior to the patient’s discharge, the patient/next of kin/carers must be given a copy of a leaflet about falls prevention in the home (Age UK:

Staying Steady booklet). Ward staff can obtain the booklets free of charge from Age UK. This intervention must be documented in the care plan

5.10 Patients assessed as being at risk of falls following their discharge from

hospital must be reviewed for their need to have a home assessment prior to their discharge. In some cases it may not be appropriate to provide a

home or environmental assessment. This is a clinical decision which is

made by the Occupational Therapy Team depending on individual patient need.



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5.11 The discharge summary sent to the patient’s General Practitioner (GP) on their discharge , must clearly identify when a high risk of falls is identified

during a hospital stay, so that the patient can receive additional support in the community as required (e.g. referral to Locality Frailty Team/ Falls

Service as per Community Falls pathways and referral criteria). Please contact the Community Falls Co-ordinators for the Community Falls

Pathways.

6.0 Falls Prevention and Management

Awareness on preventing and reducing the number of falls occurring in Aneurin Bevan Health Board adult in patient clinical areas is provided

through a variety of avenues including:

Monitoring incident trends on falls and feeding back learning to relevant

committees i.e. In patient Falls Reference Group, ABHB Falls Delivery and Steering Groups.

Providing ward data on falls via the use of Safety Crosses, the Nursing

Dashboard and DATIX incident reporting

Provision of Falls staff training to all relevant staff groups

Providing information to patients, relatives and carers about assistance they can give to help minimise falls occurrences whilst an inpatient in

hospital

Completion of annual environmental checklists to encourage staff to think about and evaluate their clinical areas in terms of falls risk and prevention

measures

7.0 Essential patient care following a slip, trip or fall in hospital (Appendix 3)

7.1 Once a patient has slipped, tripped or fallen, a suitably qualified clinician should make visual and first aid assessment of the patient, observing for

potential fracture or injury before the patient is moved.

7.2 Ensure that the immediate environment is safe for staff and the patient.

7.3 If serious injury such as a fracture or head injury is suspected then clinicians and medical staff should follow the Rapid Response Report and

Falls Flow diagram for patients who are prescribed anticoagulants (Appendix 5 & 6)



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7.4 If a spinal injury is suspected, a spinal board and hover jack can be used `to raise the patient. However it must be stressed that staff must be

competent to apply the spinal board and use the hoverjack safely.

The manual lifting of a person is high risk and considered as a last resort. In life threatening or emergency situation, when there is no other option

available, a total of 7-8 people will be required to assist depending on the situation (Resuscitation Council 2009).

Once satisfied that there is no obvious injury that requires medical

intervention, the patient can move or be moved. If able, the patient should be verbally encouraged to raise themselves using surrounding

furniture as support. If the patient is unable to move themselves they

should be hoisted or lifted using the hoverjack air cushion available in acute sites.

7.5 The patient should be asked to account for how they slipped, tripped or

fell. A clear account of the fall, if known, should be clearly documented for future reference in their nursing notes.

7.6 The patient should be referred to the appropriate medical or/and

therapies clinician if further assessment of falls is required.

7.7 A review of the patient’s bed position in the ward should be carried out and, if necessary, moved into easy observation points if necessary.

7.8 The next of kin should be informed of the incident and appropriate

reassurance/Information provided.

7.10 Any lessons learnt following the investigation of a fall should be shared

with all ward staff at team meetings.

8.0 Management of a patient admitted directly post fall

8.1 Patients admitted to hospital directly following a fall should be nursed in

an easy observation part of the ward until all assessments have been completed

8.2 On admission a detailed history of mobility and previous falls should be

documented to inform the patient’s multi disciplinary team of existing and potential problems to be addressed.

8.3 The patient should be thoroughly examined for evidence of trauma i.e.

fractures, swelling, unexplained injuries, bruising, head injury etc.



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8.4 If the patient has a suspected head injury then medical and nursing staff should follow the rapid Response Report and the Falls flow diagram for

patients who are prescribed anti coagulants. (Appendix 5&6)

8.5 If the patient has sustained a head injury, the patient should be placed on neurological observations as per medical advice.

9.0 Staff Education and Training

An on-line training programme is available to raise awareness of the prevention and management of patient falls in Hospital, accessible via

Learning@NHSWales under the Clinical Category. Users must establish an account.

10.0 Monitoring and Effectiveness

10.1 The Policy will be reviewed annually or when national guidance changes.

11.0 Equality Statement

This policy has undergone an equality impact assessment screening process using the toolkit designed by the NHS Centre Equality & Human

Rights. Details of the screening process for this policy are available from the policy owner.

12.0 References

National Patient Safety Agency (2007) Slips, trips and Falls in hospital Patient Safety Observatory, 3rd Report NPSA, London.

National Patient Safety Agency (2011) essential care after a Fall in

Hospital in Hospital .NPSA, London.

NICE (2006) and the Social Care Institute for Excellence (SCIE)

Guidelines to Improve Care of People with Dementia http://www.nice.org.uk/guidance/index.jsp?action=download&o=30323

NICE (2013) Clinical Guideline 161 Falls: Assessment and Prevention of

falls in Older People, www.guidance.nice.org/cg161

Royal College of Physicians (2012) implementing Fallsafe:Care Bundles to

reduce Inpatient Falls. www.rcplondon.ac.uk/projects/fallsafe

http://www.nice.org.uk/guidance/index.jsp?action=download&o=30323

http://www.guidance.nice.org/cg161

http://www.rcplondon.ac.uk/projects/fallsafe



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1000Lives Plus (2010) Improving Dementia Care.

http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/How%20to%20%2815%29%20Dementia%20%28Feb%202011%29%20Web.pdf

Resuscitation Council, 2009. Guidance for safer handling during

resuscitation in healthcare settings, Resuscitation Council, London

15 Appendices

1 Falls Risk Assessment Screening Tool

2. Falls Multi Factorial Risk Assessment Tool

3. Essential Care following a fall - Rapid Response Report

4. Falls Prevention in Hospital – Patient Information Leaflet

5. Falls flow diagram for patients who are prescribed anticoagulants



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Falls Risk Screening Tool - Guidance The screening tool should be used as a guide to more detailed falls assessment and subsequent targeted interventions. Falls Risk screening should occur within 6 hours of an adult being admitted to hospital All adult In Patients aged 50- 64 years judged by a clinician to be at a higher risk of falling because of an underlying condition, should have a full Multifactorial risk assessment completed on admission to hospital (NICE 2013). This screening tool should NOT be used on this patient group All adults aged 65 years+ should have a full Multifactorial risk assessment completed on admission to hospital (NICE 2013). This screening tool should NOT be used on this patient group This falls risk screening tool should be completed by a member of the multi disciplinary team who understands the process, can administer the screening tool, interpret the results and make referrals as appropriate When the threshold of the screening tool is exceeded (scoring of 2 or more) A Falls multi factorial risk assessment and care plan should be undertaken as soon as possible. When scoring 2 or less the patient will be considered at a low risk of falls and the ward should ensure their Falls Prevention policy and procedures are in place. When completing this screening tool consider all patient falls risks, including falls from heights (e.g. from beds, stairs etc) Repeat the screening tool if the patient condition changes in a way that may increase their falls risk (e.g. new onset confusion or incontinence. Mobility decreased following an operation) Outcomes of the screening tool should be documented and discussed with other members of the care team and where appropriate the patient and family

APPENDIX 1

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Adult In Patient Falls Risk Assessment Screening Tool

PATIENTS NAME__________________HOSPITAL & WARD:_____________ HOSPITAL NO:____________

Admission Week

1 Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Date 1 Did the patient present to hospital with a fall or have they fallen on the

ward since admission (Yes =1 No = 0)

Do you think the patient is: 2

Agitated? (Yes =1 No = 0)

3 Visually impaired to the extent that their everyday function is affected? (Yes =1 No = 0)

4 Needing to use the toilet frequently? (Yes =1 No = 0)

5 Gait Pattern Unable to walk/stand without major prompting & help (Yes =0) Mobile/Independent with minimum assistance but unsteady (Yes =1) Independently and safely mobile with or without a walking aid (Yes =0)

Total Score Name, Job title & Signature of assessor

Aneurin Bevan Health Board IN PATIENTS MULTI-FACTORIAL FALLS RISK ASSESSMENT

Patient’s Name: Date of Birth:

Ward: NHS No

Address:

This assessment checklist should be completed if: The patient is over 50 years of age and deemed at a risk of falls by a clinical practitioner The patient is 65 years+ Assess the priority of completing this checklist as part of patients overall admission assessment process. The checklist MUST be completed as soon as possible following the patient’s admission. Work through the Falls Risk Assessment questions below. Please turn over the page for guidance on care planning actions and referrals to ‘YES’ responses

Yes No

A Has the patient a history of falls in the previous year? (include any falls during current hospital admission) Number of falls in past 12 months: Approx date of last fall:

B Does the patient have a history OR ongoing ill health which may contribute to the risk of falls e.g.: UTI, LRTI, COPD Exacerbation etc

C Medications – Ward Dr to be informed of any YES answers

Is the patient taking 4 or more medications per day?

Is the patient on any of the following: Anti-depressants, sedatives and hypnotics, psychotropic drugs, anti-hypertensives, diuretics? (If nurse / pharmacist is unsure refer to ward Doctor for advice)

Is the patient on Anticoagulant (Warfarin therapy)?

D Loss of consciousness

Has the patient reported or observed to have had a loss of consciousness? Do they report dizziness?

E Cardiac & Neurological

Does the patient report previous cardiac or neurological conditions or ongoing symptoms?

F Postural Hypotension

Does the patient have a history of or complains of postural dizziness or light-headedness? Lying BP after 5 mins of rest Standing BP after 1 minute and 3 mins (If yes record above BP checks)

G Confusion/Disorientation

Does the patient have a history OR at present is confused, disorientated or has difficulty with comprehension. Does the patient have a history OR at present show signs of anxiety or depression? Is there a history of memory problems?

H Alcohol

Is there a history of alcohol or substance abuse? Does the patient exhibit withdrawal symptoms or signs?

I Nutrition and hydration

Follow the All Wales Nutrition Pathway? N/A N/A

J Osteoporosis Risk Factors.

Is the patient over 65 years of age?

Has the patient experienced previous/current fractures?

K Continence

Does the patient suffer from urgency, frequency and/or continence issues?

Does the patient need to use the toilet 3 or more times during the night?

L Vision

Does the patient have a problem or is observed to have a problem with their vision?

M Hearing

Does the patient have difficulty with hearing conversational speech?

N Footwear/Foot care

Does the patient have difficulty with foot care or inappropriate footwear that is affecting their mobility?

O Balance, Transfers and Walking

Does the patient have difficulty with walking, balance or transfers?

P Reduced confidence/Coping strategies

Does the patient demonstrate anxiety when mobilising with or without a walking aid?

Q Pain

Is the patient in pain?

R Environmental Risk Factors

Does the ward environment negatively impact on the risk of this patient falling (i.e. tripping hazards, inadequate lighting, obstructive walkways, difficulty standing from low seating)?

APPENDIX 2

19

Comments Please write any further information here that supplements or is not covered by the risk assessment checklist

Assessor Name: Ward: Assessor Signature: Date:

20

MULTI-FACTORIAL FALLS RISK ASSESSMENT CARE PLANNING GUIDANCE

Risk Factor Practical Care Planning Referral for further assessment A. History of Falls

Commence a falls care plan to address risk factors identified on Falls risk assessment checklist

Consider referring risk factors not able to be addressed by ward staff for further assessment

Discuss completed care plan with patient

Review any falls patient has experienced on the ward

All falls incidents to be recorded on DATIX

Ensure the completed Falls risk assessment and care plan accompanies the patient if moved to another ward/hospital/team on discharge

B. Ill Health

Consider any ill health issues the patient has and their contribution to the risk of the person falling whilst in hospital

Bring to the attention of the Ward Dr. current and historical ill health issues that may impact on the patient’s risk of falling whilst in hospital

C. Medications

REFER TO WARD DOCTOR/NURSE PRESCRIBER to

Identify Falls susceptible medications and prescribing patterns

Consider risk of bleeding from falls (Warfarin)

Review all medication and compliance

Ask patient about symptoms of dizziness & consider sleep disturbance & implications

Ward Dr/Nurse prescriber to ensure medication plan is communicated to the nursing team.

D. Loss of Consciousness

REFER TO WARD DOCTOR in first instance for medical review

Ward Dr. will consider appropriate onward referrals for further investigation

E. Cardiac & Neurology

REFER TO WARD DOCTOR in first instance for medical review

Ensure nursing care plan includes any neurological observations recommended by Dr.

Ward Dr. will consider appropriate onward referrals for further investigation

F. Postural Hypotension

REFER TO WARD DOCTOR if postural Systolic blood pressure drops by 20mmHg and / or Diastolic drop by 10mmHg.

Discuss with patient how to stabilise self when moving from lying to sitting to standing

Encourage oral hydration

Request medication review

Care plan to indicate appropriate manual handling assisting techniques if staff assisting patient to walk or/and transfer

Referral to ward physiotherapist for further advice to be provided to patient regarding stabilising self during transfers

Referral to Occupational Therapist if further mobility equipment assessment is required

G. Confusion /Disorientation

Complete AMTS screen or MOCA (if AMTS < than 7)

Inform ward doctor of concern

Investigate cause of acute confusion e.g. infection (Follow delirium pathway)

Check EPEX to see if patient is known to mental health team, if yes, make contact with case manager

Ensure patient’s care plan reflects mental health team advice and current social/nursing plan as appropriate

Refer to ward doctor for medical review if practical care planning considerations do not address patient’s mental health condition

H. Alcohol

Consider/Discuss with the patient pre admission alcohol /drug consumption patterns

Inform ward Doctor of any concerns re alcohol/drug consumption/withdrawal symptoms

Ensure patient’s care plan reflects ward Dr advice and current social/nursing plan as appropriate

Ward Dr. will consider appropriate medical intervention or onward referrals for further investigation

I. Nutrition and Hydration

Follow All Wales Nutrition Pathway Automatic referral to dietician if flagged up during the pathway assessment

J. Osteoporosis

Undertake the patients weight, height & BMI then

REFER TO WARD DOCTOR for osteoporosis risk factor assessment with use of the FRAX tool

Ward Dr will consider appropriate medical intervention or onward referrals for further investigation e.g. DEXA scan /bone medication

K. Continence

Undertake routine urinalysis to discount infection

Note patients usual toileting programme and any issues staff may need to be aware of in patient’s care plan (in particular night routine)

REFER TO WARD DOCTOR if continence/infection is an issue for the patient

Ensure any actions highlighted in the care plan for: medication (B),postural hypotension(E) vision and hearing(K&L), feet & Footwear (M),Balance, transfers and walking(N), reduced confidence &coping strategies(O),Pain(P), Environmental hazards(Q) are implemented

Consider a referral to the continence service if appropriate for the patient to receive further assistance and advice on discharge

21


Risk Factor Practical Care Planning Referral for further assessment L. Vision

Check if patient usually wears spectacles, if yes, are they on the ward, clean & in good repair?

Note in patient’s care plan when patient usually requires spectacles

Consider the effect the ward environment may have on a patient’s existing eye conditions; e.g. lighting, contrast, blurring, misinterpretation of shapes and note difficulties in patient’s care plan

Ensure any actions highlighted in the care plan for Environmental hazards(Q) are implemented

If required request relatives/visitors bring to the ward appropriate spectacles or/and vision accessories normally used by the patient

REFER TO WARD DOCTOR any unresolved sight issues highlighted during the patient’s admission to the ward

M. Hearing

Check if patient usually wears a hearing aid (s), if yes, is it on the ward, clean & in good repair?

Are the hearing aid batteries insitu &working

Is the hearing aid correctly fitted?

Note in patient’s care plan when patient usually requires the hearing aid and what ear it is worn on

Consider the effect the ward environment may have on a patient’s existing hearing conditions; e.g. televisions, room echoes and note difficulties in patient’s care plan

REFER TO WARD DOCTOR if tinnitus, dizziness and excess ear wax has been highlighted during the patients admission discussions

If required request relatives/visitors bring to the ward appropriate hearing aid(s)or/and hearing accessories normally used by the patient

REFER TO WARD DOCTOR any unresolved hearing issues highlighted during the patient’s admission to the ward

N. Foot care/Footwear

Check feet condition e.g. length of toe nails, corns, painful bunions. Undertake essential nursing ca of the patient’s feet as appropriate and note actions required in the care plan Check patient’s foot wear is flat, well fitting with backs on the shoes/slippers. Shoes are preferable to slippers.

Note in the patient’s care plan what footwear the patient wears as part of the daily routine

If patient has diabetes or a medical condition (e.g. fungal infection) that affects skin care/tissue viability or mobility, refer to hospital podiatry and Ward Doctor for essential foot care E.g. cutting of toe nails and medical treatment

If the patient is presenting with footwear that is in poor repair or/and loose fitting or/and backless, request that a visitor or relative replace the footwear for the patient

O. Balance, Transfers and Walking

Ensure any actions highlighted in the care plan for medication considerations(C),postural hypotension(F) vision and hearing(L&M), foot care & Footwear (N), reduced confidence & coping strategies(P),Pain(Q), Environmental hazards(R) are implemented.

Does the patient usually use a walking aid – stick or frame? Is it on the ward with the patient? Is it in a good state of repair

If the patient usually has a walking aid but it is not available or in poor state of repair consider short term manual handling & mobilising implications until the ward physiotherapist/visitors can assist with the correct/replacement walking aid. If the patient is presenting with balance and walking problems of a sudden onset, discuss with ward doctor and consider short term manual handling & mobilising techniques, noting change of dependency in the patient’s care plan

If the patient is admitted to the ward with a history of poor balance and mobility and has no accompanying walking aid. Consider manual handling assisting techniques to help the patient to walk and transfer until the ward doctor and ward physiotherapist have undertaken further assessments. Record all assisting techniques and equipment required in the patient’s care plan. Ensure this is reviewed on a daily basis

If there are issues with a patient’s walking aid an urgent referral is to be made to the ward physiotherapist

If there is an issue with the manual transferring of a patient, then a referral is to be made to the ward occupational therapist

Consider a referral to the ward physiotherapist for further assessment of balance and walking issues

22


Risk Factor Practical Care Planning Referral for further assessment P. Reduced Confidence/Coping Strategies

Check if the patient is usually anxious or/and has poor confidence when walking or transferring Provide the patient with reassurance by considering assisting/accompanying walking techniques as per manual handling training. Ensure the patient has access to a call bell and knows how to use it if requiring staff assistance on mobilising Record in the patient’s care plan manual handling techniques/equipment to be used with the patient and review daily until further assessment by a physiotherapist

Consider a referral to the ward physiotherapist for further assessment of balance /walking/confidence issues

Q. Pain

Assess the patient’s pain level during essential movement using the appropriate pain assessment used in the patient’s ward Undertake skin care bundle Consider the patient’s warmth, seating, comfort and use of manual handling techniques for his/her duration on the ward Record in the patient’s care plan the assessment outcomes and pain treatment plan for the patient

Refer to the ward doctor to review analgesia during the patient’s medication review

R. Environmental Hazards

If ,considering bedrails for the patient, follow the Trust Bedrail policy and assessment Consider placing patients who are vulnerable to falls near the nurses station/ward toilet/dining/sitting areas Ensure, where appropriate, patients have access to call bells and know how and when to use them.

Consider a ward environmental hazards check. This can easily be undertaken by walking the daily routes your patients will take around the ward checking for hazards, obstacles and clutter. Be mindful of patients who have vision, hearing, balance and walking difficulties Report to the ward manager any ward items requiring repair or removal

23

ACTION PLAN FOLLOWING FALLS RISK ASSESSMENT Please file in patient notes or records

Patient’s Name: Date of Birth:

Ward: NHS No

Address:

Document interventions and referrals made following assessment

Date/Time

Actions Taken Referred to (If applicable)

Signature

Assessors Name (Please Print): Designation: Assessors signature Date:

24

Essential care after an inpatient fall Issue

Each year around 282,000 patient falls are reported to the NPSA from hospitals and mental health units. A significant number of these falls result in death, severe or moderate injury including around 840 fractured hips, 550 other types of fracture, and 30 intracranial injuries.

Evidence of harm Analysis of patient safety incidents reported to the National Reporting and Learning System (in the 12 months prior to 25 March 2010) indicates that around 200 patients with fractures or intracranial injury after a fall in hospital experienced some failure of aftercare. Problems included:

delayed diagnosis of fractures, ranging from several hours to several days after the fall;

neurological observations not recorded at all or recorded at inadequate intervals, resulting in delayed diagnosis

of intracranial bleeding;

sling hoists used to move patients despite signs or symptoms of limb fracture or spinal injury;

delays in access to urgent investigations or surgery.

Reducing the risk of harm When a serious injury occurs as a result of an inpatient fall, safe manual handling and prompt assessment and treatment is critical to the patient’s chances of making a full recovery. This RRR aims to ensure that local protocols and systems help staff to consistently achieve this.

For IMMEDIATE ACTION by all NHS organisations that have inpatient beds. The deadline for ACTION COMPLETE is 14 July 2011.

NHS organizations with inpatient beds should ensure that:

1. They have a post-fall protocol that includes:

a) checks by nursing staff for signs or symptoms of fracture or potential for spinal injury before the patient is moved;

b) safe manual handling methods for patients with signs or symptoms of fracture or potential for spinal injury*;

c) frequency and duration of neurological observations for all patients where head injury has occurred or cannot be excluded (e.g. unwitnessed falls) based on National Institute for Health and Clinical

Excellence (NICE) Clinical Guideline 56: Head Injury; d) timescales for medical examination following a fall (including fast track assessment for patients with

signs of serious injury, or high vulnerability to injury, or who have been immobilised). 2. Their post-fall protocol is easily accessible (e.g. laminated versions at nursing stations). 3. Their staff have access to clear guidance and formats for recording neurological observations using a 15

point version of the Glasgow Coma Scale (GCS) and that changes in the GCS that should trigger urgent medical review are highlighted.

4. Their staff have access at all times to special equipment (e.g. hard collars, flat-lifting equipment, scoops)* and colleagues with the expertise to use it, for patients with suspected fracture or potential for spinal injury.

5. Systems are in place allowing inpatients injured in a fall access to investigation and specialist treatment* that is equal in speed and quality to that provided in emergency departments and conforms to NICE Clinical Guideline 56: Head Injury.

* Community hospitals and mental health units without the equipment or expertise may be able to achieve this in collaboration with emergency services

. Further information Supporting information on this Rapid Response Report is available at www.nrls.npsa.nhs.uk/alerts. For further queries contact [email protected]; Telephone 020 7927 9500

Gateway ref: 15328

© National Patient Safety Agency 2011. Copyright and other intellectual property rights in this material belong to the NPSA and all rights are reserved. The NPSA authorises UK healthcare organisations to reproduce this material for educational and non-commercial use.

NPSA/2011/RRR001

13 January 2011

APPENDIX 3

25

http://www.nrls.npsa.nhs.uk/alerts

mailto:[email protected]

Patient/Carer Information Leaflet Reducing Patient Falls in Hospital

This leaflet is to tell you how we try to prevent falls, and what you

and your visitors can do to help.

As a patient you can help us reduce the risk of falling by doing the following:

Be honest with the nurses if you feel anxious about moving around or are scared of falling.

Be careful when standing up or getting out of bed.

Do not use hospital furniture, such as tables, to help you stand up.

Wear lightweight non-slip shoes or well fitting slippers.

If you have a walking aid, use it when you are moving around.

Take your time when moving.

Listen to the advice the staff give you.

Remember the hospital is not as familiar to you as your home.

Remember to keep your personal items within easy reach. If you are a patient in hospital we request that you:

Let us know if you have fallen at home within the past 12 months.

Use the call bell for assistance if you feel weak, unsteady or dizzy.

Do not get up in the dark alone, use the call bell for help.

Keep everything you need within easy reach.

Ensure you have your glasses, hearing aids and dentures.

Wear clothes that are not too long or too loose to help prevent you from tripping.

Report any problems such as spills, trailing wires or cables to staff.

APPENDIX 4

26

If you are a relative, carer or friend you can help by doing the following:

Share any information you may have on previous falls the patient may have had.

Please replace anything that you have moved during your visit and leave the bedside uncluttered

Inform nursing staff that you are leaving and ensure that the patient realises you are leaving

Place the call bell near the patient as you leave

If possible, bring in well fitting clothing and supportive footwear for the patient to wear

Bring in any walking aids, which may have been left at home, as well as items such as glasses and dentures.

Remember to inform the nursing staff of any concerns you have

If a patient is at high risk of falling we may:

Put the bed in a different position

Move the patient’s position within the ward

Use safety sides on the bed

Use a different bed

Carefully monitor the patient

Use other falls prevention aids as directed by the nursing staff.

If you go into hospital, you can expect that:

If you are at risk of falling out of bed, the staff will discuss bedrails with you.

If you are well enough, you will decide whether you want bedrails or not.

The staff will know how to use bedrails safely.

Special bedrails or bedrail covers will be provided for you if you might injure your legs with standard bedrails.

Please remember

This leaflet shows the ways we try and protect the patient from falling and injury. Some patients will still fall even if we have tried o do all of the things mentioned in this leaflet. We want to work together with you, to reduce falls.

Further information If you have any concerns regarding falls please do not hesitate to ask a member of staff

27

Aneurin Bevan Health Board

FALLS FLOW DIAGRAM FOR PATIENTS WHO ARE PRESCRIBED ANTICOAGULANTS

ALL PATIENTS SHOULD RECEIVE NEURO OBSERVATIONS FOLLOWING A FALL WHERE A HEAD INJURY

IS SUSPECTED

PATIENT FALL/FOUND ON FLOOR

CAN YOU EXCLUDE HEAD INJURY? - Patients Account of Fall - Witness Account of Fall

- Examination of Head for Bruises/ Lacerations

YES

PERFORM AND RECORD NEURO OBSERVATIONS EVERY 30 MINUTES UNTIL GCS = 15

No

Are the anticoagulants prescribed from the list below:

LMWH Rivaroxaban (Xarelto) Dabigatran (Pradaxa)

Apixiban Clopidogrel

Other anti platelet drugs

Perform an urgent INR and coagulation screen check

If INR>3 Urgent CT Scan If INR >1.5 Timing of CT Scan

based on clinical findings. Sometimes a delay of a few hours

is advisable if there are no abnormal neurological features.

SEEK SENIOR ADVICE

Discuss reversal of anticoagulation urgently with senior and haematologist on call if CT Scan positive or if INR outside of

normal range. Refer to ABHB Policy for the reversal of

warfarin with PCC Usual dose of Vitamin K =5mg

Contact haematologist on call for dosing of PCC (max 3000iu)

Perform an urgent coagulation screen although this may be

normal. Contact the Haematologist on call

for advice There are currently no reversal

agents for the newer oral anticoagulants

If coagulation abnormal or has had drug within 4 hours needs

Urgent CT Scan

Sometimes a delay of a few hours is advisable if there are no abnormal

neurological features. SEEK SENIOR ADVICE

Continue to observe the patient for 24 hours even if they have a normal CT Scan

APPENDIX 5

28

Essential Care after an Inpatient Fall (Adult) This protocol must be followed by all nursing staff in the event of a patient fall

Patient Falls in Hospitals

29

STOP & THINK For All Falls

ABC Check (airway/ breathing/ circulation)

Before Movement -Patient to be checked for fracture, limb deformity, loss of sensation possible spinal or head injury

Maintain immobilisation until full clinical assessment & risk assessment completed Following clinical & risk assessment move patient using the correct safe manual handling (MH) methods

Ensure patients dignity is maintained

Ensure explanation is given to the patient at all times

Record observations using NEWS

Use clinical judgement to ensure on-going assessment & monitoring

If spinal injury is suspected

(Neck pain, or tenderness, paraesthesia in the extremities. Focal neurological deficit, reduced conscious level

Contact A&E immediately who will attend & advise on patient movement and handling using appropriate safe system of work

Community Hospitals to contact emergency 999 ambulance

Fast track for urgent medical review / investigations

If fall is witnessed and no head injury sustained

If fall un-witnessed or patient has sustained head injury (hit head or sustained laceration/ trauma)

Request medical review

Record neurological observations half hourly using 15 point Glasgow Coma Scale (GCS) until GCS = to 15.

When GCS = 15, minimum frequency after the initial assessment should be - Half Hourly for 2 hrs

- Then hourly for 4 hrs - Then 2 hourly thereafter If GCS deteriorates observations should revert to half hourly

Any changes in GCS refer again for urgent medical review

Fast track for investigations if indicated

Consider patients normal cognitive state

Move patient using appropriate safe system of work

If signs of limb fracture (limb deformity, severe pain)

Request Urgent medical assessment /examination


Fast track for investigations

Community hospitals to contact emergency 999 services for transfer to A & E dept

Additional Actions To Be Undertaken For All Falls

Review Falls risk & identify any underlying risk factors

Identify patients on anticoagulation therapy

Implement relevant plan of care

Ensure safe environment, patient call bell at hand, suitable footwear

Inform Relatives of risk status & incident

Request medication review

Report fall onto the DATIX system. Provide full details of incident and after care. To include how patient fell, if fall was witnessed injury sustained, observations, how patient was moved following the fall, review by Doctor.

FOR SEVERE HARM CASES/SERIOUS INCIDENT Notify the Consultant, Senior Nurse, Directorate Manager and Clinical

Incident Manager

Ensure appropriate support to patient, their family and staff involved.

Risk assess clinical area to identify whether any immediate actions are needed to reduce risk of re-occurrence.

Follow steps in both green boxes


Refer To

NEWS Guidance

Moving & Handling – Safe systems of work

Incident reporting policy

Resuscitation policy

Management of Serious concerns policy.

References: Rapid Response Report NPSA /2011, Essential care after an Inpatient Fall National Institute for Health and Clinical Excellence (NICE) 2007 CG 56 Head Injury

NPSA Protocol v4 March 2012

APPENDIX 6

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