1 Policy on Managing Slips, Trips and Falls Document Version number: 1.0 Date Written: October 2007 Author: Job Title: Address: Contact Number: Leszek Bojanowski & Bernadette Kennedy Health & Safety Manager / Falls Co-ordinator (LB) / 4079 (BK) Next Review Date: October 2008 Policy Approved By: Provider Safety Committee October 2007
2 Index 1. Introduction 2. Legal Obligations and Standards 3. Responsibilities 4. Managing Risk 5. Raising Awareness 6. Training 7. Monitoring and Review 8. References Appendix 1 Appendix 2 Appendix 3 Assessment of floor slip risk: HSE methodology. Management of Patients Who Have Fallen Falls Risk Profile for Older Adults: a risk assessment tool Note References are shown in brackets (R) and are listed in section 5. Footnotes shown as [R] are generally used to reference legislation. Abbreviations used HSE Health & Safety Executive NHS LA National Health Service Litigation Authority NICE National Institute for Clinical Excellence NPSA National Patient Safety Agency NSF SSP Support Service Partnership tpct teaching Primary Care Trust
3 Equality Statement This policy takes a positive view of physical disabilities. Otherwise the policy is neutral with regard to equality issues.
4 1. Introduction Falls are a recognised problem both by the Health and Safety Executive (HSE) (1), the Audit Office (2 & 3) and the National Patient Safety Agency (NPSA) (4). The HSE have issued NHS specific guidance (5) as well as run campaigns on fall prevention (6). A fall can have tragic consequence for the person concerned and financial consequences. In recent years the HSE have done much work in developing methodology for quantitatively assessing the slip potential of flooring as well as non-slip safety footwear. This is outlined in Appendix 1. There is also a tpct policy on the use of bed rails (7). There are a number of factors that are associated with the risks of a person falling. These include environmental factors such as slip potential, effects of aging and medical condition. It is recognised that as people get older, after a certain age, their risks of falling increases (8). Patient falls are dealt with in appendix 2 with an assessment form for older patients in Appendix 3. Research has shown that patients with lower limb prosthesis require flooring with a greater slip resistance than for normal people (8). This document does not cover Work at Height Regulations issues; these will be covered by another document. 2. Legal Obligations and Standards The Health and Safety at Work Act  requires the employer to provide safe facilities for both employees and visitors. More specifically the Workplace Regulations  requires flooring to be safe and the Management Regulations  requires the carrying out of risk assessments and management of risks to acceptable levels. Such assessments must be both suitable and sufficient. RIDDOR  requires the reporting of death or more serious injuries to both employees and non-employees which includes patients. The NPSA, in its report on patient falls (4), has produced a scheme for the management of patient falls. The NHS Litigation Authority (NHS LA) recognises falls to be a risk to organisations and to their resources. It therefore has introduced a set of standards ( ) around falls prevention which includes issues such as staff training. Standards for Better Health ( ) have sections on risk assessment and on safe environments: Therefore there are legal as well as NHS risk management obligations to try to prevent falls. This includes employees, patient and visitors. EC / British standards for flooring, safety footware and measurement methodology can be found on:  The Health and Safety at Work Act 1974  Workplace (Health, Safety & Welfare) Regulations 1992  Management of Health & Safety at Work Regulations 1999  Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1985
5 Case Law In 1986 a technical instructor in a large hospital slipped first on wet leaves on an external staircase and then in 1992 on an unmarked wet floor. She had 32 operations to save her leg. The 33 rd was an amputation. The 600,000 for the loss was no compensation for this young mother. South West London and St. Georges Mental Health Trust was fined 7,500 in 2007 following the death of an 88year old visitor as a result of tripping over an 18 inch pot hole in the path. In Ellis v Bristol City Council (2007), the court of appeal ruled that where a floor was slippery when wet and it was foreseeable that the floor was wetted on a regular basis, then this type of flooring was not suitable. Causes of Slips Trips & Falls Environmental: This may due to the state of the floor or ground, any contaminants and the type of footware. Lighting and visual effects may affect ability to see where a person may be trying to walk. Uneven surfaces or irregular features on stairs increase the risks of falling. Handrails and their lack will affect risks of falling. Height of furniture. Physiological: The very young and very old have an increased risk of falling. In the very old, brittle bones make the consequences worst. Eyesight deteriorates in the elderly. Other Patient Factors: These include confusion, medication, general strength which may be associated with a medical condition. 3. Responsibilities Director of Provider Services:- has responsibility for health and safety on the Trust Board. Chief Operating Officer (SSP):- Has responsibility to ensure that tpct owned buildings and their grounds are safe, including control of slip and tripping risk. Also, a there is a responsibility to ensure that all floors conform to HTM 61 ( ), with particular attention to paragraphs. 2.4, and 3.77 to Heads of Estates The head of estates (SSP, Sodexho & Kiers) are responsible for the following: o Ensuring flooring is in a safe condition. o Mapping out the types of floor surfaces in PCT controlled premises.
6 o o Ensuring that risks arising from contaminants likely to increase slip risk are kept to a minimum. Ensure that sufficient rock salt is available for icy weather and that there is a means of applying it to areas at potential risk. Managers:- Managers have the following responsibilities: o Monitoring the areas under their control for any incidents or near misses of slips trips and falls and ensuring that any falls are reported on the tpct AIR form . o Report to Estates and / or the Safety Office any areas where lighting appears to be insufficient. o Where it is known that water or other contaminants can cause the floor to be slippery either exercising direct control or reporting it to the appropriate estates department . o Ensuring that staff in their control, are aware of the importance of managing slips trips & falls. o Ensuring that staff in their control, wear the correct footware. This may need to be provided, in certain circumstances under the Personal Protective Equipment Policy. o Carrying out regular inspections, and where necessary, further assessment of areas that they control. o Managers of staff visiting patients at home need to ensure that an assessment of safety in the home and the approaches is carried out (normally by staff) and any risk management controls are conveyed to staff. The family and / or social services may also need to be informed of significant risks. Managers of Patient Areas o For patient falls, carrying out an assessment. See [Appendix 3]. Falls Risk Profile for Older Adults. o Ensuring that provision and assessment of bed rails is in line with the PCT s Use of Bedrails Policy ( ). o Monitor patient footware & advise patient and / or relative with regard to any risks and how to reduce these. All staff Have a responsibility to report spillages and potential trip hazards. 4. Managing Risk General:- Certain smooth lino and stone floors can become slippery when wet. The type of sole on footware also may be a contributory factor. Since footware is generally difficult to control, it is important to try and control water contamination. This includes water ingress from outside and spillages. External entrances:- There needs to be suitable matting to absorb any water over areas where people walk. If the extent of matting is not suitable or sufficient then the relevant estates department needs to be contacted (CC to the PCT s Safety Office.) Spillage Control:- Where spillages are foreseeable then they must be managed. This is particularly important in areas inhabited of accessed by elderly patients. Spillages may occur as a  Accident & Incident Form. Ref.  Sodexho for QMH, Kiers for St.John s, St.G&SWLMH Trust for Springfield & Barnes and the SSP for the rest of the tpct.
7 result of mishandling by drinks containers by patients and occasionally incontinence. Where a spillage service is not available (eg QMH) then managers need to ensure that there is access to some means of dealing with the spillage. Spillages often also occur in the proximity of vending machines. At QMH, a spillage team is operated by Sodexho. Trip hazards:- It is important that all potential slips and trips are minimised. Outside this can apply to uneven or damaged paving. Inside trip hazards can arise out of bags, bundles of notes and other hazards being left in passageways. Also badly placed furniture restricting access can increase the risk of falling. Poor lighting can increase the risk of falling. Snow / Ice:- Snow and ice are likely to make certain areas more slippery. Rock salt will reduce the risk of slipping. A trip accident A dental nurse was bringing back a tray of instruments back into the office. She tripped over a bag left in the middle of the room by someone else as her view was obscured by the tray. The dental nurse was off work for 4 days as a result of the accident. 5. Raising Awareness Wandsworth PCT aims to raise awareness and prevent slips, trips and falls in the following ways: Both the Health and Safety Manager and the Falls Advisor actively promote the risks regarding falls throughout the Trust. Through the Falls Awareness Group At Corporate Induction Through incident reporting 6. Training Training regarding slips, trips and falls is covered at the Health and Safety for Managers Training session and is also covered in the Health and Safety slot at Corporate Induction. All managers should receive this training once. 7. Monitoring and Review This policy will be reviewed annually by the Provider Safety Committee. Statistics and issues regarding slips, trips and falls will regularly be presented at the Provider Safety Committee in order to learn from incidents and ensure improvements are made. 8. References (1) HSE website:- (2) Health & Safety in NHS Acute Hospital Trusts in England, NAO, 1996 (3) A Safer Place to Work, NAO, 2003,
8 (4) Slips trips & falls in hospital, NPSA, 2007, (5) Slips & trips in the health services, HSE Information Sheet No.2. (6) Reducing slips and trips risk in the health services: 2 year campaign. and (7) Use of Bedrails Policy (Draft). WtPCT. (8) HSE Research Report 382, Identifying human factors associated with slip and trip accidents, System Concepts, (9) Overjero T, Dura JV, Aleantara E. The Required Friction Coefficient for Disabled People.
9 Appendix 1 Assessment of floor slip risk: HSE methodology. The main website dealing with slips and trips can be found on: Essentially there are two methodologies that can be used for the evaluation of a floor s slip potential: the pendulum test which measures the dynamic coefficient of friction and is conducted in dry and wet conditions, and the micro-roughness meter. The micro-roughness meter measures the peak to trough distance in micro-meters and combined with the HSE software Slip Assessment Tool (SAT) gives a grading of a low, medium and high slip risk. The HSE have allocated a similar 3 point grading for the coefficient of friction results. There is about 80% agreement between the two methodologies with the pendulum method being regarded as the Gold Standard. For further information see Evaluation of the Slip Resistance of Flooring: A technical information sheet ( ). The PCT uses a micro-roughness meter made by Taylor Hobson. The Health and Safety Laboratory (part of the HSE) also uses the ramp methodology to measure the dynamic coefficient of friction. Using this methodology they have been able to grade the slip potential of different footwear.
10 Appendix 2 - Management of Patients who have Fallen Introduction Approximately 30% of people over the age of 65 years fall at least once a year and those who fall are more likely to fall again (Liu-Ambrose et al., 2004; O Loughlin, 1993). Falls are the leading cause of injury-related hospitalisation in this population (Lord & Sherrington, 2001), accounting for 14% of emergency admissions and 4% of all hospital admissions (Close, 2005). Falls are also associated with a significantly increased morbidity and mortality with up to a third of fallers suffering injuries that reduce mobility and increase the risk of premature death (Tinneti et. al., 1989). Over 40 risk factors for falls have been identified, from the systemic review of interventions Gillespie concluded that protection against falling may be maximized by interventions that target multiple risk factors in individual patients and that health care professionals should consider screening of older people who are at risk for falls, followed by targeted interventions. In addition there is acknowledgement that population groups within different studies are widely different and that effective interventions in community settings cannot just be transferred to hospital settings. Within Wandsworth tpct a wide variety of different health professionals provide services to this population at home, in clinics and health centres and within hospital settings. The provision of inpatient treatment is within a community hospital model and as such the service users are not expected to be medically unwell ( if this occurs patients are transferred to an Acute Hospital). The underlying ethos for a Trust that provides health services in a variety of settings is to provide equitable standards as care after a fall in hospital should be comparable to aftercare for people who fall in the community NPSA p56. However, at the same time the effective prevention tools used in the community have been modified so that it can be implemented at Queen Mary s Hospital (a rehabilitation hospital). It is recognised that the population group in rehabilitation hospitals do not present with some of the risk factors evident on an acute hospital ward, and that in essence this group transcend the 2 groups that have been extensively studied. For this reason it has been deemed more appropriate to modify the community tool. Aims Reduction in unnecessary/emergency hospital admissions / transfers Identify people over 65 years of age who have fallen and or are at high risk of falls, refer them to the appropriate services to address the risk or provide them with strategies to minimise risk. Provide relevant falls prevention and management literature to people over 65 years and their carers and relatives. Provide an extensive local services directory in order to address depression and isolation issues Ensure that service users are accessing the appropriate specialist assessments and specific treatments in order to reduce their risk of falls Ensure that all staff are clear about what they should do after a patient has fallen
11 Definition A fall may be defined as an untoward event, which results in the patient coming to rest unintentionally on the ground or other lower surface (Morris et al, 1980). Specific Detail Due to the complexity of the reasons for falls an initial identification of the location and type of fall allows a differentiation of whether the falls are linked to an acute illness/specific environment or whether the patient is at risk of falls irrespective of these components. 60% of hospital admissions are through St Georges Hospital where STRATIFY is used to risk score on the acute ward. Differentiation of fall practice Evidence base/ref Patient falls whilst actively participating in treatment. Patient falls whilst under the care of Wandsworth pct but not during treatment/rehabilitation Patient has fallen whilst under the care of another team. This period prior to transfer can be hours or weeks. Patient has been referred to your service / specifically admitted to hospital because of a fall Patient referred to service for another reason but when questioned reports 1 or more falls in the previous 12 months Immediate action and follow up observations at scene of fall as documented in local service guidelines reemergency procedures. Complete AIR. Liaise with other Wandsworth tpct health professionals to ensure a falls risk profile is completed and shared amongst teams Summary of all falls included in the transfer summary to Wandsworth tpct. Any falls risk tools to be copied in. Complete Falls Risk Profile if not done. STRATIFY completed during acute hospital stay. Falls Risk Profile completed prior to d/c or on transfer to Wandsworth tpct service. Completed Falls Risk Profile NPSA NICE 2004 NSF 2001 NICE 2004 NPSA 2007 NICE 2004 NICE 2004 NSF 2001
12 Duties of: Integrated Falls Service Facilitator The Integrated Falls Service Facilitator is responsible for developing and leading integrated falls management across Wandsworth, thereby contributing to achieving standard six of the NSF for Older People. In addition to influencing services Trust wide the Integrated Falls Service Facilitator provides weekly one-stop clinics for people who have fallen. These are open access clinics Falls Risk Assessment Tool The single tool in place for Wandsworth tpct health professionals is the Falls Risk Profile. This tool is based on the NICE requirements and has been developed locally through collaborative work between the Integrated Falls Service Facilitator and the Geriatricians in Secondary Care. This tool has not yet been validated but a paper is currently in progress locally comparing this tool to the FRAT (Falls Risk Assessment Tool) References Slips trips & falls in hospital, NPSA, 2007, Close, J. T. C. 2005: Prevention of falls a time to translate evidence into practice. Age and Ageing 34, Department of Health (DH) 2004: Better Health in Old Age: Resource Document from Professor Ian Philp, National Director for Older People s Health to Secretary of State for Health. London: DH Department of Health 2001: National Service Framework for Older People. London: Department of Health. Gillespie, L., Gillespie, W., Robertson, M., Lamd, S., Cummings, R. and Rowe, B. 2003: Interventions for preventing falls in elderly people. The Cochrane database of Systemic Reviews. Cited by Wiens, C., Koeba, T., Jones, A. and Feeny, D. 2006: The Falls Risk Awareness Questionnaire: Development and Validation for Use With Older Adults. Journal of Gerontological Nursing 32, (8), Liu-Ambrose, T., Khan, K. M., Eng, J. J., Janssen, P. A., Lord, S. R. and Mckay, H. A Resistance and Agility Training Reduce Fall Risk in Women Aged 75 to 85 with Low Bone Mass: A 6-Month Randomized, Controlled Trial. Journal of the American Geriatrics Society 52, (5), Lord, S. R., Sherrington, C. and Hylton, B. M. 2001: Falls in older people: Risk factors and strategies for prevention. Cambridge: Cambridge University Press. Morris, E.V. & Isaacs B. (1980) The prevention of falls in geriatric hospital. Age and Ageing, 9,
13 Appendix 3 Falls Risk Profile for Older Adults: a risk assessment tool
14 Falls Risk Profile for older adults PATIENT NAME: D.O.B: GENDER: M / F NHS NUMBER: Increased falls risk Patient Profile(Date+ Initials) Action (Date+ Initials) Action Results (Date+Initials) Number of falls in last 12 months Context and characteristics of fall(s) Number of fractures since age wrist vertebrae hip ankle 50 other Osteoporosis risk factors yes no Osteoporosis medication yes no Number of medications in total List: sedatives psychotropics cardiac drugs diuretics antihypertensives Weight normal underweight overweight Vitamin D risk yes no Concerned about falling? yes no What activities are limited? yes no Describe Unable to get off the floor Able unable Mobility and balance: none stick frame wheelchair Walking aid (details) other 180 turn> 5 steps TUAG > 17 secs foot problems yes no describe BP-Lying to standing Postural drop>20mm/hg yes no
15 Falls Profile cont Patient profile (Date+Initials) Action (Date+ Initials) Action Results(Date+Initials) Do you ever feel sad / low? no yes sometimes yes often describe Memory problems no yes, short term yes,long term Recent deterioration of vision yes no Date of last eye test Deterioration of hearing no yes, describe Hearing aid perscribed? no yes, is it worn? Continence issues yes no Query UTI? yes no Any history of: Other relevant medical history: Dizziness / blackouts Cardio respiratory Osteoarthritis Peripheral vascular disease Chronic lung disease Thyroid dysfunction Diabetes Stroke Parkinson's Patient housebound? yes no Socially isolated? yes no Alcohol units per week (1 unit =1/2 pint lager, 25ml spirit, 125ml wine) Smoking history no yes,describe Environmental issues at home no yes,describe Problematic footwear? no yes,describe Local resource information issued Completed by : Name Signature Initials Department Date
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