/ CHHS 15/080

Canberra Hospital and Health Services

ClinicalProcedure

Falls Prevention and Management(including safe use of bed rails)

Contents

Contents

Purpose

Alerts

Scope

Section 1 – Falls and Falls Injury Prevention and Management

Step 1 Falls Risk Screening

Step 2 Falls Risk Assessment

Step 3Cognitive Impairment Screening for patients 65years and older or 45years and older if of Aboriginal or Torres Strait Islander background

Step 4 Patient Education

Step 5 Falls Prevention Interventions and Management

Step 6 Falls Reporting and Management Post-Fall in an In-patient Setting

1.Immediate Care

2.Notification

3.Observation

4.Ongoing Care

5.Documentation/reporting

Step 7 Discharge Planning

Step 8 Safe Use of Bed Rails (inpatients only)

Step 9 Measuring Orthostatic Blood Pressure (inpatients)

Implementation

Related Policies, Procedures, Guidelines and Legislation

References

Definition of Terms

Search Terms

Attachments

Attachment A: Falls Risk Screening Tool (Ambulatory/Community Care)

Attachment B: Modified Stratify Falls Risk Assessment Tool (in-patients)

Attachment C: Intrinsic & Extrinsic Falls Risk Factors and Falls Injury Prevention Interventions

Attachment D: Falls Management Process Flowcharts

Attachment E: Bed rail Risk Assessment Matrix

Purpose

This document provides ACT Health with a procedure for reducing falls and injury from falls in all patients, particularly older people aged 65 and over, or 55 years and older for Aboriginal and Torres Strait Islander adults. It is acknowledged, however, that there may be non-preventable falls risks present in adults and children due to a medical condition, cognitive and other disability.

The purpose of this procedure is to:

  • Provide direction to ALL clinical staff to improve the safety of patients by identifying their falls risk through screening and assessment and implementing appropriate falls prevention interventions.
  • Establish a consistent approach to the prevention and management of falls that is in accordance with Australian best practice guidelines.
  • Increase awareness of the importance of being proactive in the prevention of falls and falls related injury.
  • Establish a consistent approach to the safe use of bed rails in accordance with best practice evidence.
  • Clarify the governance infrastructure in place that outlines responsibilities in relation to the prevention and management of falls and falls’ injury.
  • Provide direction to ALL staff to maintain a safe and clean environment.

Scope

Alerts

The alerts throughout this procedure signify a specific patient safety issue that staff must comply with.

Scope

This procedure relates to all ACT Health staff providing care to any patient within Canberra Hospital and Health Services.

This procedure is based onthe Australian Commission on Safety and Quality in Health Care, 2009. Preventing Falls and Harm from Falls in Older People: Best Practice Guidelines for Australian Hospitals 2009.

The procedure includes the following steps in falls and fall-related injury prevention and management:

  1. Falls Risk Screening in designated areas eg ED, Ambulatory and Community Settings;
  2. Falls Risk Assessment;
  3. Cognitive Impairment Screening – Inpatient settings only;
  4. Falls Education for the Patient and their Family and/or Carer;
  5. Falls and Fall-related Injury Prevention Interventions and Ongoing Management;
  6. Falls Reporting and Post-fall Management;
  7. Discharge planning;
  8. Safe Use of Bed Rails; and
  9. Measuring Orthostatic Blood Pressure.

Section 1 – Falls and Falls Injury Prevention and Management

  • Patient Care and Accountability Plan contains:
  • Modified Stratify Falls Risk Assessment
  • Cognitive Impairment Screen
  • Bed Rail Risk Assessment Matrix
  • Falls Prevention Information

Step 1 Falls Risk Screening

Falls Risk Screening (Ambulatory and Community Care)

  • A falls risk screen is conducted for patients on presentationrecognised at being at risk of falling. (Attachment A – Screening tool).
  • For community/ambulatory patients “at risk” consider referral to appropriate services such as the patient’s GP, physiotherapy and/or the Community Falls Assessment and Prevention Clinic if patient is over 65 years.
  • Additional screening tools may be used by allied health.

Step 2 Falls Risk Assessment

Falls Risk Assessment (in-patients)

  • All patients admitted will have a Falls Risk Assessment (Modified Stratify Risk Assessment Tool- Attachment B) completed on arrival and documented on the Patient Assessment & Accountability Plan. If they are deemed at being a “High Risk” of falls (score of 3 or more) a minimum of three appropriate prevention strategies must be implemented and documented immediately after assessment is completed.
  • Other assessment tools may be used in other clinical areas.
  • Timely referrals are made to allied health professionals according to risk factors, for further assessment and provision of falls risk mitigating strategies.
  • For inpatients identified at high risk of falls a medication review is required. (Refer table page 14 and 15).
  • A documented falls risk assessment should be repeated daily, as soon as possible following a fall, when patient’s condition or environment changes, and on discharge.
  • Some inpatient areas such as Mental Health may have patients who are ambulant and mostly independent and therefore may be excluded from the daily falls risk reassessment. However reassessment must be completed if their condition changes.

Alert: Staff must be alert to the risk of bleeding following a fall for any patient on anticoagulants(refer to Haematology Department for advice).

Step 3Cognitive Impairment Screening for patients 65years and older or 45years and older if of Aboriginal or Torres Strait Islander background

  • A four (4) question cognitive screen and clock drawing test has been included on the Patient Assessment and Accountability Plan and must be completed on admission to inpatient services.
  • If the patient is unable to answer any of the questions correctly or draw a clock as instructed, the screen is positive and the Cognitive Impairment policy should be followed.

Step 4 Patient Education

  • After screening and/or assessment, information regarding falls risks, prevention and interventions should be discussed with patient and family and/or carer.
  • Provide patients and/or carer with information brochures and relevant fact sheet. This is to be documented in the clinical record/care plan.
  • For inpatients, if it is deemed safer for the patient to use a walking aid, the appropriate health professional will educate the patient, family and/or carer as to why the equipment is needed and how to use it correctly. If identified as “at risk” then explain the need for referral to other health professionals, as required.
  • Maintain appropriate levels of mobility.
  • Ensure patient/carer understands the reasons for using the “Falls Risk” sign that is placed above the bed.
  • Involve patient/carer in bedside handover.

Step 5 Falls Prevention Interventions and Management

  • A multi factorial and team approach is needed to achieve a significant reduction in falls and falls related injury.
  • Interventions should address both the intrinsic (individual) and extrinsic (environmental) risk factors as indicated from assessment (Attachment C).
  • Interventions and a plan of care will be determined by the falls risk assessment and the identified falls risk factors.
  • Individual falls prevention programs and interventions should be flexible enough to accommodate the patient’s needs and circumstances.
  • The falls risk level and management plan must be documented and handed over to other care providers for ongoing care at transfer and/or discharge.
  • Falls injuries can include fractures. Management of osteoporosis should be addressed in those who are at risk to minimise the risk of fractures.

Step 6 Falls Reporting and Management Post-Fall in an In-patient Setting

1.Immediate Care

  • Basic Life Support (D-danger, R-respond, S-send for help. A-airway, B-breathing, C-circulation, D-defibrillation)
  • Conduct baseline vital signs (full MEWS) and reassure the patient.If patient meets the MET Criteria -Dial 8 and activate Code Blue for in-patients. Continue with hourly observations on all patients who have fallen including neurological observations if head injury is suspected (Glasgow Coma Scale)
  • Do not move the patient initially - call for assistance.
  • If an inpatient, notify medical officer.
  • Stabilize the patient before moving. Immobilise the spine if head and neck pain is reported.
  • Observe for any changes in condition i.e. increased pain, reduced mobility or change in vital signs.
  • Clean and dress any wounds.
  • If fall is not witnessed consider further imaging if clinically indicated.
  • If the fall occurs in the community, refer to the GP for a medical review or call an ambulance if injury suspected.

Alert: Staff must be alert to the risk of bleeding following a fall for any patient on anticoagulant.

2.Notification

  • Call a “huddle”, a multidisciplinary meeting immediately following the fall to discuss what had happened and how it can be prevented in the future.
  • Contact medical officer for review. The medical officer is to complete the Post Fall Medical Assessment Form 35557 found on the Clinical Forms Register on the Intranet
  • Notify registrar/consultant (if required).
  • Notify CNC/Team Leader and JMO.
  • Inform relatives/carer of the fall and, where appropriate, discuss ongoing management plan. Document interaction with relatives/carer.

3.Observation

  • Record vital signs hourly for 4 hours then review and continue as per medical orders and clinical condition (MEWS score)
  • Notify Medical Officer immediately if any changes in patient observations or condition
  • Observe for signs of bleeding if on anticoagulants.

4.Ongoing Care

  • Review environment(e.g. high-low bed, position of locker/belongings, call bell, and mobility aids).
  • Review of clothing to ensure long gowns, socks and footwear are not contributing to falls.
  • Reassess the patient and arrange any additional interventions that may be required such as hip protectors, physiotherapy or a specialist review.
  • Plan interventions using a multidisciplinary approach which may include:
  • Medication review
  • Geriatrics/Rehabilitation review
  • Nutrition review
  • Physiotherapy review
  • Occupational Therapy review
  • Optometrist, podiatry, social worker, Vision Australia or other specialist
  • Community Falls Assessment and Prevention Clinic on discharge

5.Documentation/reporting

  • Document the fall in the clinical record, including any injuries and observations. Include in the progress notes the Post Falls Sticker to easily identify when a fall has occurred.
  • For a patient who has sustained a significant injury, a “Significant Fall Incident Review” document must be completed.
  • Complete a RiskMan report, including the extension module, record Riskman incident number on care plan. A RiskMan should be completed within the community/ambulatory settings if the fall occurs while staff member is present.
  • Manager should provide follow up information into RiskMan (investigations and controls) with the outcome from the fall.
  • Handover appropriate information to all staff caring for the patient.
  • Complete the Post Falls Audit and take appropriate action from findings.
  • A family member/carer/guardian must be notified after any fall.

For patients who fall in the community, arrange for review with GP or emergency department if injury is suspected.

NOTE: For inpatients, a post fall analysis should be conducted to identify why the fall occurred and include changes to management. If serious injury or death has occurred as a result of the fall an in-depth clinical review of the fall must be conducted.

Step 7 Discharge Planning

  • For patients at risk of falls, include interventions to reduce the risk of falls and harm from falls in discharge planning. Planning for discharge should commence at admission.
  • Include specific falls information in all discharge, transfer and referral information for all patients at risk of falls or who have fallen.
  • For inpatients, including the physiotherapist and occupational therapist as an integral part of the discharge plan enables a home safety assessment, at discharge, to be done.
  • Allow adequate time for equipment availability and education of patient and carer to prevent any delays in discharge from inpatient settings.
  • Consider a referral, where appropriate, to the Falls Assessment and Prevention Clinic and other community services. Referrals can be made via CHI.

Refer to the flowcharts at Attachment D for a summary of these procedures.

Step 8 Safe Use of Bed Rails (inpatients only)

Bed rails may be used to reduce the risk of a patient accidently slipping, sliding, falling or rolling out of bed. Bed rails will not prevent a patient from leaving their bed and falling elsewhere and should not be used for this purpose (restraint). Patient risk assessment must be carried out and the result documented in the care plan with regard to the decision to not use (or use) bedrails prior to their use. This decision will be reviewed in line with changes to the patient’s condition.

  • On all occasions, the default position is bed rails DOWN, unless clinically indicated through risk assessment.
  • All patients will be assessed using the Bedrail Risk Assessment Matrix (Attachment E).
  • The decision to use or not use bedrails will be documented on the care plan.
  • All patients will be assessed for the appropriateness of use of bedrails on admission and reviewed in response to changes in their condition.
  • Whenever possible the decision to use or not use bedrails will be communicated to all staff/carers responsible for the care of the patient.

Alert:

Default position for bed rails is down unless a bed rail risk matrix is completed.

Step 9 Measuring Orthostatic Blood Pressure (inpatients)

Postural hypotension or orthostatic hypotension is defined as the ‘reduction in systolic blood pressure of ≥ 20mmHg or a reduction in diastolic blood pressure of ≥ 10mmHg during the first 3 minutes of standing’ from lying down (1). This is typically associated with autonomic failure and can be multi-factorial.(2)This is a common cause of patients falling and needs to be included in the risk assessment for a patient who has sustained a fall as multiple strategies can be employed to reduce the subsequent risk of falls and related injury in these patients.

Postprandial hypotension is defined as a reduction of systolic blood pressure of ≥ 20mmHg 1 hr post meal (3).

Alert: Any type of chemical or physical restraint should not be used as a falls prevention intervention.Refer to ACT Health Policy (DGD11-080) –Restraint of Patients and Health Directorate SOP (DGD11-081) – Restraint of Patients.

Alert: In-patient settings –any environmental or equipment hazard that compromises patient safety and increases falls risk must be attended to immediately and reported through appropriate channels.

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Implementation

Information contained in this document will be disseminated to staff via educational forums, falls champion workshops and via e learning modules.

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Related Policies, Procedures, Guidelines and Legislation

Legislation

  • Work Health and Safety Act (2011)
  • Patient Health and Safety ACT (2003)
  • Human Rights Act (2004)

Related Policies

  • Restraint of Patients Policy(DGD11-080)SOP (DGD11-081)
  • ACT Health RiskMan Incident Reporting Policy (CED07-032)
  • ACT Health Occupational Health & Safety (OH&S) Policy (CED08-066)

Standards

  • Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 10: Preventing Falls and Harm from Falls (October 2012). Sydney. ACSQHC, 2012.

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References

Australian Commission on Safety and Quality in Health Care. 2009. Preventing Falls and Harm from Falls in Older People: Best Practice Guidelines for Australian Hospitals. Available at the commission website

The Royal Children’s Hospital Melbourne Falls Prevention Clinical Guidelines

Centre for Rural Health Website: Falls Prevention University of Tasmania

Queensland Stay on your Feet Website – Preventing falls in older Queenslanders

The definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. J Auton Nerv Syst 1996; 58:123-4.

Freeman R, Neurogenic orthostatic hypotension N Engl J Med 2008; 358:615-24.

Fisher A et al, Postprandial Hypotension Predicts All-Cause Mortality in Older, Low-Level Care Residents J Am Geriatr Soc. 2005 Aug;53(8):1313-20.

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Definition of Terms

A fall: An event which results in a person coming to rest inadvertently on the ground or floor or other lower level.

A paediatric fall:Paediatric falls should be considered in the context of normal physical growth and cognitive development. Children are likely to experience falls as they become more active and begin to explore their environments. However, some falls are preventable along the growth and development continuum. Newborns are at risk of falling from high surfaces such as a change table, bed or lounge, so care must be taken to keep one hand on newborns when they are not in their crib or cot. Mobility increases in the first year of life, including crawling, rolling and standing. Infants at this stage of development should not be left unsecured in a high chair or on any elevated surface, and when placed in their cot the sides must be elevated and secured. Further, stairways should be secured with doors or gates to prevent a fall which could result in significant injury. Gross motor skills improve when infants become toddlers, allowing them greater mobility, including moving chairs to counters or railings. Therefore, close supervision is required to keep them from falling from high surfaces. Children of preschool age are able to function more independently and they often engage in adventurous activities. They may need constant reminders to modify these behaviours, such as running or climbing. School aged children and adolescents sequentially reach greater levels of independence, becoming less risk adverse, so falls prevention is also relevant in this older age range (Ball, Bindler & Cowen, 2012).

ED: Emergency Department

Interventions can be described as:

Single intervention: an intervention targeting one risk factor, such as a balance and strength exercise program or medication adjustment.

Multifactorial intervention: an intervention made up of a set of single interventions that are intended to address some or all of the specific risk factors that were identified through an individual’s fall injury risk assessment. This is ideally provided by a multidisciplinary team.

MEWS: Modified Early Warning Score

JMO: Junior Medical Officer

Patient:Any person, client or consumer of Health Directorate services