POLICY APPROVAL GROUP

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1 POLICY APPROVAL GROUP - Policy Cover Document For use during Policy presentation at the Policy Approval Group (PAG). (Please note that this is a 2- page document Sections 1 12 MUST be completed before submission to the PAG) A - SUMMARY OF POLICY DETAILS 1. Name of Policy: Patient Falls Policy 2. Name of Policy Author: Caroline Joyce 3. Lead Director (Sponsor): Liz Morgan 4. Name of Lead Committee responsible for monitoring the policy and date approved for submission to the PAG: 5. Reason for Policy presentation (Please circle appropriate box) 6. Are the Changes (Please circle appropriate box) New Policy (See Question 7below) Minor (Formatting Amendments Only) 6a. Have the changes been applied to the policy prior to the next scheduled review date)? 6b Has an effectiveness review been undertaken on the policy to establish if the policy is still required and the processes remain unchanged? B - POLICY RATIONALE AND CONTENT 7. NEW POLICIES Reason(s) for new policy Quality and Safety Committee Scheduled Review (See Question 8below) Change due to Legislation/Update (See Question 8below) Major (Amendments to policy content and/or process(es)) Yes (Please go to question 6b). Yes (Please continue to Question 7). No (Please go to Question 7). No (Please review this policy and then continue completing this sheet). Separation from the Health and Safety Policy and expansion of this specific area in order to meet requirements of NHSLA and Rapid Response alert on post falls management. 8. AMENDED POLICIES Summary of main changes (Which MUST be tracked in the electronic version with paragraph/section and page numbers included in this box) C - POLICY CONSULTATION 9. If the Policy has been consulted upon prior to submission to the Policy Approval Group, please list the individuals/committees who have been involved? (If the policy has NOT been consulted upon, please refer to Section 7 & the appropriate Appendices within this document for guidance) Chief Nurse and Director of Education, Deputy and Assistant Chief Nurses, Heads of Nursing, Lead Nurses, Sisters, Practice Educators, Head of Physiotherapy, Head of Occupational Therapy, Nurse Consultant Acute and high dependency care, Nurse Consultant Neurosurgery, Manual Handling 1

2 Trainer/Back Care Advisor, Health and Safety Manager, Governance and Compliance Manager, Nursing and AHP Research Co Ordinator, Head of Radiology, Chief Pharmacist/Head of Biomedical engineering, General Managers, Assistant Head of Quality, Safety and Transformation D - DISSEMINATION 10. Please state the Policy Title which should be used on the Document Library e.g. Policy for the Drafting and Implementation of Procedural Documents 11. Please add a Statement/summary of the policy here so that this can be used within the Trust Newsletter to update staff on the review/development of this policy Patient Falls Policy The patient falls policy sets out the Trust processes for Assessing patients risk of falls Ensuring appropriate mechanisms are put in place to prevent falls Managing falls if they occur Monitoring and learning from incidents of patients falling. 12. Please give a list of key words to be applied to the Document Library for this policy e.g. whistleblowing, and being open (words mentioned in the policy title will automatically be included) Falls Falls risk assessment Bedrails This 2-page Cover Document MUST be completed and provided alongside all policies that are to be presented at the Policy Approval Group. 2

3 Patient Falls Policy This policy is required to meet the requirements of NHS Litigation Authority (NHSLA), Care Quality Commission (CQC), the Health and Safety at work Act 1974, and the NPSA rapid response report NPSA/2011/RRR001 LEAD EXECUTIVE DIRECTOR: Chief Nurse and Director of Education POLICY APPROVED BY: Policy Approval Group DATE POLICY APPROVED: IMPLEMENTATION DATE: 1 st September 2012 REVIEW DATE: July

4 Document Control Sheet Policy Title Purpose of Policy/ Assurance Statement Target Audience (Policy relevant to) Lead Executive Director Name of Originator/ author and job title Version (state if final or draft) Date reviewed (Previous review dates) Circulated for Consultation to (Please list Committee/Group Names): Amendments: Patient Falls Policy The purpose of this policy is to set out the process for prevention, management of patient falls within the Trust. All staff who directly interact with patients doctors, nurses, AHP s, HCA s and clinician s assistants, administrative staff in the clinical setting. Chief Nurse and Director of Education Caroline Joyce Assistant Chief Nurse Quality, Safety and Patient Experience. Final draft Chief Nurse and Director of Education, Deputy and Assistant Chief Nurses, Heads of Nursing, Lead Nurses, Sisters, Practice Educators, Head of Physiotherapy, Head of Occupational Therapy, Nurse Consultant Acute and high dependency care, Kate Owen Manual Handling Trainer/Back Care Advisor, Health and Safety Manager, Governance and Compliance Manager, Nursing and AHP Research Co Ordinator, Head of Radiology, Chief Pharmacist/Head of Biomedical engineering, General Managers, Assistant Head of Quality, Safety and Transformation This policy must be read in conjunction with the following related policies/clinical guidelines: Links to other policies or relevant documentation Trust Health and Safety Policy Moving and Handling Policy Incident Reporting & Management Policy Head injury clinical practice guideline Neurological observation guideline Recording and Responding to Physiological Observations and CEWS policy If draft Draft Number Comments to By [only complete remaining boxes] Final version 4

5 Table of contents 1.Assurance statement/scope Introduction..6 3.Aims and objectives.7 4.Definitions Duties and responsibilities..8 6.Main body of the policy 9 7.Process for implementation 18 8.Monitoring arrangements 18 9.Standards and Key Performance Indicators (KPI) Equality impact statement Training Other policies of relevance References Appendices

6 1. ASSURANCE STATEMENT/POLICY SCOPE 1.1. This policy is required to meet the requirements of National Health Service Litigation Authority (NHSLA), Care Quality Commission, the Health and Safety at Work Act 1974, and the National Patient Safety Agency (NPSA) rapid response report NPSA/2011/RRR001. This policy sets out the Trust processes for Assessing patients risk of falls Ensuring appropriate mechanisms are put in place to prevent falls Managing falls if they occur Monitoring and learning from incidents of patients falling. This policy does not relate to slips, trips or falls relating to staff or visitors. For the prevention and managing of slips, trips and falls affecting visitors and staff please refer to the Trust Health and Safety Policy. 1.2 The principal legislation dealing with workplace health and safety is the Health and Safety at Work Act The Management of Health and Safety at Work Regulations 1999, Regulation 3 imposes a specific statutory duty on employers to carry out risk assessments. Regulation 12 of the Workplace (Health, Safety and Welfare) Regulations 1992 concerns the condition of floors and traffic routes in a workplace, and requires their surface to be fit for purpose, to have no hole or slope, or be so uneven or slippery as to expose any person to a risk to their health or safety, and every such floor shall, where necessary, have effective means of drainage. Additionally every floor in a workplace and the surface of every traffic route in a workplace shall be kept free from obstructions and from any article or substance which may cause a person to slip, trip or fall. The Work at Height Regulations 2005 deal with falls from height, falling objects and fragile surfaces in workplaces. 2. Introduction 2.1. Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH) is committed to the health, safety and welfare of infants, children and young people, families, visitors and staff who visit the hospital. The Trust seeks to minimise and reduce harm to patients and therefore the risks associated with patient falls Falls in hospital can result in injury and distress to patients and their families, staff and visitors. Falls are seen as a priority area for improvement by the NPSA, as they generate the most incidents reported to the National Learning and Reporting System (NLRS). Approximately 208,000 falls are reported in acute hospitals every year, 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. The immediate annual healthcare cost of treating falls is over 15 million for England and Wales, and in an average acute hospital trust is estimated at 92,000. 6

7 2.3. The causes of falls are complex. Hospital patients are particularly likely to be vulnerable to falling due to medical conditions including delirium, cardiac, neurological or muscular-skeletal conditions, side effects from medication, or problems with balance, strength or mobility. Poor eyesight or poor memory can create a greater risk of falls when someone is out of their normal environment on a hospital ward, especially children, as they are less able to spot and avoid any hazards. In hospital settings falls are also often an ominous red flag symptom indicating the patient s underlying medical condition may have deteriorated, and may merit urgent medical review regardless of injury Traditionally falls have not been seen as a priority for children s hospitals, but evidence from the NPSA indicates that this should not be the case. In a review of paediatric patient safety priorities, patient accidents were the third most commonly reported incident type for children, though less common for neonates, as might be expected. Slips, trips and falls made up over half of the patient accident incidents involving children (54%). This equates to approx 2,500 reports of children falling in hospitals each year; the vast majority of these cause no harm or low harm. Reports are also received of infants accidentally dropped by their parents or carers in inpatient settings. Children with learning disabilities are at increased risk of injury through falling (Sherrard et al. 2001) 2.5. In the year 2011/12 48 children and young people at GOSH suffered a slip, trip or fall causing low or moderate levels of harm. 3. Aims and objectives 3.1. The aim of this policy is to support the safety of patients and engender a culture of falls management and prevention being everybody s business no matter which department/unit/environment the patient is based. The document aims to compliment existing policies and the new strategic direction for falls management within the organisation. The aim of this policy is to: Inform staff of their responsibilities in relation to the prevention and management of patient falls Minimise the risk of falls and harm to patients Set out the Trusts responsibilities for monitoring and acting on Trust wide learning from patient falls. This policy must be read in conjunction with the following related policies/clinical guidelines: Trust Health and Safety Policy Moving and Handling Policy Incident Reporting & Management Policy Head injury clinical practice guideline Neurological observation guideline Recording and Responding to Physiological Observations and CEWS policy 4. Definitions Slip: To slide accidentally causing the person to lose their balance. This is either corrected or causes the person to fall. 7

8 Trip: To stumble accidentally, often over an obstacle causing the person to lose their balance. This is either corrected or causes the person to fall. Fall: An event which results in the person or a body part of the person coming to rest inadvertently on the ground or other surface lower than the person, whether or not an injury is sustained. Fall from height: Any level above floor level must be considered a height, which should they fall from could result in serious injury. Examples would include, a patient falling out of bed, climbing out of a window, falling over a balustrade Bedside rail known in the Trust as cot/bedsides these are a device designed to prevent patients falling out of bed (also referred to as cotsides, side rails, safety sides, bed guards or transport sides) 5. Duties and responsibilities The following section outlines the duties and responsibilities of staff and committees in relation to the policy. These duties will be reviewed as part of the policy review process The lead Executive director is the Chief Nurse and Director of Education 5.2. The Chief Nurse and Director of education is responsible for ensuring that all staff (including external contracted staff) are aware of the policy and related guidelines and adhere to the requirements of the policy at all times Directors and Line Managers, including Clinical Unit Chairs, General Managers and Heads of Nursing: are responsible for ensuring the implementation, monitoring and exception reporting of the policy. Managers should encourage incident reporting, monitor incidents, conduct investigations and implement findings Ward Sister/Charge Nurse/Department Head: is responsible for ensuring compliance with the policy and the completion of individual patient risk assessments. They must ensure that all staff have the appropriate knowledge and skills to deliver care in accordance with the policy. They are responsible for ensuring that the local environment under their responsibility is managed in respect to clutter, wet conditions and maintenance risks. Department Heads are responsible for ensuring that all patient falls are recorded on the Trusts incident reporting system (Datix) and for taking a proactive approach to the prevention of slips, trips and falls. These duties may be delegated but the responsibility always remains with them Nurse in Charge/Departmental secondary lead: is responsible, in the absence of the Department head, for ensuring compliance with the policy in their ward/department including completion of risk assessments for each individual patient. They must ensure that care is delivered in accordance with the policy and that incidents are reported, taking a proactive approach to preventing slips, trips and falls Each staff member: that provides care to patients must be fully aware of, and act within the confines of the policy at all times, ensuring that all patients under their care have a risk assessment completed. All staff have a duty to report any incident of patients falling and to taking a proactive approach to preventing slips, trips and falls. 8

9 5.7. The Clinical Emergency Team (CET) are responsible for attending all 2222 calls and implementing emergency treatment in accordance with the relevant resuscitation, head injury, falls policies and guidelines Clinical Site Practitioners (CSPs) are responsible for leading the CET in line with the Resuscitation policy. They will also be aware of the availability of c- spine collars and back boards present on Sky ward. The CSP will also provide expert assistance to all staff who request help in managing a victim of a fall Medical Registrar Cover (MRC) will attend falls victims if requested by clinical staff in line with the un-booked attenders policy. They will examine falls victims and document their finding in the patients/victims clinical record The Moving and Handling Trainer/Back Care Advisor is responsible for delivering training in moving and handling, falls risk assessment and post falls management and use of relevant lifting equipment to all staff. This training incorporates use of the combined manual handing/falls risk assessment form and safe use of bed rails. The Moving and Handling Trainer/Back Care Advisor is responsible for providing advice in relation to beds, bedside rails and accessories and for auditing compliance with risk assessments with support from the Health and Safety team, clinical audit and nursing staff The Biomedical Engineering department is responsible for ensuring that all beds and bed rails are maintained in accordance with agreed maintenance schedules The Facilities Department are responsible for ensuring all broken beds etc are transferred to Biomedical Engineering for repair, and for ensuring all flooring is managed to prevent slips following scheduled cleaning and spillages or heavy rainfall The Health and Safety committee is responsible for all aspects of the prevention, management and monitoring of patient falls. The committee is also responsible for receiving reports and evidence in relation to compliance with maintenance of beds and bed rails. This committee reports to the Quality and Safety committee The Medical Equipment and Supplies Group: are responsible for ensuring the purchasing of safe and effective equipment such as beds and rails. 6. Falls Prevention The aim of this policy is to prevent patient falls where ever possible and minimise the risks of falling. Falls prevention can be grouped into four areas:- The individual The task or activity The immediate environment, and Health and safety team prevention The following is a guide to falls prevention. The following are factors to be considered offering some principles and ideas to prevent, or minimise the risk of falls, this is not an exhaustive list. 9

10 6.1 The individual All infants, children and young people must have an individual manual handling/falls risk assessment completed on admission using the correct, age appropriate, risk assessment tool. Reassessment must be undertaken and documented if the patient s condition, care or treatment changes such that their risk of falls has changed. This is particularly important in the case of patients as they may not be able to identify hazards and risks due to their age, developmental stage and condition. The following are factors to consider when undertaking the risk assessment: Age young children, those who are developmentally delayed or where their physical age does not match their chronological age are particularly at risk of falling due to their developmental state. Infant falls can occur if parents fall asleep in a chair whilst holding the infant. The risk of this increases if the parent/carer is sleep deprived/tired, under stress, or has taken medications or alcohol which affect levels of consciousness. Staff are responsible for ensuring that parents/carers are aware of their responsibilities for supervising their child and any siblings when present, and for encouraging parents/carers to have adequate rest. Clinical condition Confusion and disorientation may increase the risk of falling. Patients with poor/impaired eyesight, neurological conditions or who have had recent general anaesthesia should be considered. Those whose mobility is impaired due to surgery (e.g. plaster casts, limb frames etc) should also be considered at risk. Patients with epilepsy may fall if having a seizure. Protection from falls injury for those with epilepsy may be improved by ensuring the provision and routine use of barriers such as helmets and mouth guards. Staff are responsible for promoting the use of such protective equipment but should be aware that mouth guards may pose a problem during a convulsion (Sherrard et al 2001). Physical mobility - For children and young people who have problems in mobility, falls are the number one injury concern (Gaebler-Spira and Thornton 2002). Consider whether the child needs assistance with mobility, uses a walking aid or wheelchair and whether that increases their likelihood of falling, including falling out of the wheelchair. Staff should ensure that children and young people who have problems with physical and/or cognitive impairment have things placed within easy reach and that the call buzzer is placed beside them so that they do not try to get up alone. Physical activity children and young people may be more prone to falls during physical activities such as play, physiotherapy or occupational therapy. Patients undergoing such treatment should be appropriately supported and supervised at all times when undertaking such activities. Physical activities are extremely beneficial in improving muscle strength, co ordination, balance and other abilities which can help reduce the risk of patients falling, and should be considered for patients who suffer repeated falls where muscle weakness, co ordination or balance are observed to be a contributing factor. Cognitive impairment Falls are the major cause of injury for children and young people with intellectual disability (Sherrard et al 2001). Staff must be aware that children with learning disability may have no sense of danger (Burke and Cigno 2000, Sellars 2002) therefore standard prevention measures such 10

11 as cot-sides, verbal advice, may have little or no impact. Those with behaviours that challenge may exhibit unpredictable behaviour, self-injurious behaviour, inappropriate/excessive running, climbing, or a lack of awareness of environment any of which may increase risk of falling. Sensorineural impairment such as blindness or deafness create significant alterations in negotiating the environment and an increased risk of injury (Gaebler-Spira and Thornton 2002). Medication Any medication which has the potential to affect the conscious level or affect the gait may increase the risk of a fall. These include certain analgesias, anti-convulsants, sedatives etc. Certain eye drops may also impair the vision. Receiving intravenous (IV) fluids may also increase the risk of fall if the patient is mobilising whilst attached to a drip stand and equipment such as an IVAC attached. Footwear and clothing - Footwear plays an important part in preventing slips, trips and falls, both for patients and staff. Staff should ensure that all patients are wearing appropriate footwear. Wearing socks without shoes presents a particular hazard as these can be slippery on surfaces such as linoleum or tiles. Walking barefoot increases the risk of injury caused by stepping on hazards that then precipitate a fall. Non Skid fall management socks can be purchased through procurement for older children and young people to wear to prevent them slipping and falling when moving around the ward near their bed space. Use of bedrails The use of bedrails should be in accordance with the patient s needs. It is the staff s responsibility to ensure the bedrails are in working order, and that they are in place with the cot / bed at its lowest position before leaving the child. Staff should ensure that the use of bedrails are promoted and be aware that children with learning disabilities or disturbed behaviour may climb over cot/bedside. Suitable alternatives should be provided to those children who have a physical or learning disability that require alternative solutions. Staff are also responsible for ensuring that parents are shown how to use bedrails and that they are aware of the risks of not using bedrails or of other harm such as trapping fingers when using bedrails. See Appendix 3 for more detailed guidance on risk assessment and use of bed rails. Previous falls - a history of a previous fall indicates an increase risk of recurrence. The first fall is an accident and therein after should be documented in the patient s Moving and Handling/falls Risk Assessment and Care Plan. Communication Any person with impairment to communication (e.g. use of hearing aids, impaired eyesight, non-english speaking children/families/visitors) may be at an increased risk as they may not understand advice on falls prevention or recognise hazard notices/signs. Staff should ensure that information is provided to patients and their families in a format and language that they understand and ascertain that they have understood the instructions. Falls from height: Staff are responsible for ensuring that children and young people are adequately supervised at all times, either by a member of staff or by the patients parent/carer. Parents should be made aware of their responsibilities for supervising their child and of the risks of falling in hospital. Staff who are responsible for supervising children and young people in the absence of a parent/carer must ensure that they do not climb on furniture or equipment as this increases the risk of falls from height. Children with learning disabilities and/or challenging behaviour may be at risk of climbing and falls from height. Staff should ensure that such patients have had a risk assessment 11

12 conducted and that preventative measures are put in place to reduce the risk of falls from height. Parents or siblings sharing beds/cots may increase the risks of falls from height. Staff should also be aware of the risk of babies or infants being dropped by parents. Staff should discourage parents from allowing children to sleep in the parent bed during their admission. 6.2 The task or activity The following should be considered before moving a patient or assisting them to move independently and at all times during the task in order to prevent a fall:- Lifting or carrying patients: when considering lifting or carrying patients staff should consider the weight, size shape, and awkwardness of the patient and refer to the moving and handling policy as necessary. Staff should ensure that they do not obstruct their view when carrying patients and that they use appropriate hoists and prams/pushchairs/wheelchairs/trolleys to lift and move patients, ensuring that they support the patient appropriately at all times. Staff should check the environment around them Staff must not run whilst carrying or moving patients. Staff must not carry infants or children down stairs and should discourage parents/carers from doing the same. Lifts should be used instead unless in an emergency situation e.g. fire evacuation. Staff must not over stretch or balance on one foot to achieve moving or carrying patients. Staff must never work at height when carrying or moving patients Staff must ensure that parents are providing adequate support when holding infants, and are aware of the dangers of sleepiness or alcohol consumption in relation to the risk of infants and children falling. Ensure the task is appropriate for the competency of person undertaking it 6.3 The immediate environment Staff should consider the following when assessing the risk of patient falls in their department:- General clutter: a cluttered environment increases the risk of falls. Keep high traffic areas, particularly corridors, free from obstructions and litter. Trailing leads and cables are a particular risk. Hazards Ensure paths are clear of obstacles. Wet floor signs should be used whenever the floor area is wet or likely to become wet. Liquids or slippery materials on the floor should be removed. Scheduled Cleaning of Floors should be planned where possible during times of lower foot fall and patient activity. A local environmental slips/trips/falls risk assessment is available on wards/areas and should be conducted annually with the Health and Safety team. The risk of falling from windows is managed via the estates department through the installation of restricted opening devices on windows. Flooring: Should be well maintained and use appropriate surface material for the environment (e.g. non-slip flooring in areas likely to get wet such as 12

13 bathrooms). Changes in floor level present a risk and should be highlighted if appropriate (e.g. steps) If an immediate safety hazard then please report immediately to the works department using the CARPS reporting system. Equipment: use equipment appropriately and follow guidelines for use. Ensure equipment does not cause an obstruction or use appropriate signage if it does. Staff should ensure that patients who are alone without a parent/carer have all the equipment that they need close to hand e.g bedside table, call buzzer, television remote control, food and drink so that they do not fall attempting to get something. Lighting: High traffic areas should be well lit. Patients will be in an unfamiliar environment so ensure safety is maintained at night by using night-lights. Lights should be regularly checked and maintained. Non-functioning lights must be reported immediately. Full participation in the Patient Environment Action Plan (PEAT) process to mitigate some of these risks 6.4 Health and Safety Team Prevention A weekly health and safety walkabout monitors the condition of the environment within the Trust in order to help negate the chance of incidents. The work of this group is monitored on a quarterly basis by the Health and Safety Committee. An annual audit is undertaken by the Health and Safety Team of the slip/trip/fall hazards in all Trust areas. Audit results and slips, trips and falls incidents are discussed on a quarterly basis at the Trust Health and Safety Committee and included in reports to wards and departments and included on the risk registers where appropriate for discussion at the local Risk Assurance Groups (RAGs) 6.5 Documentation All infants, children and young people must have an individual manual handling/falls risk assessment completed using the correct, age appropriate, risk assessment tool. Reassessment must be undertaken and documented if the patient s condition, care or treatment changes such that their risk of falls has changed. Reassessment must be undertaken if the patient s condition, care or treatment changes such that their risk of falls has changed. Reassessment must also be documented. This documentation must be stored with the nursing documentation and kept at the bedside at all times. 6.6 Incident Reporting and Investigation All adverse events and near misses involving slips, trips and falls, whether there has been an injury or not, must be reported in line with the Trust s incident reporting policy via Datix. If additional advice is needed, the linemanger should be contacted in the first instance or the CSP (bleep 0313) out of hours. 13

14 The appropriate manager should investigate all incidents and ensure that any necessary preventive action is taken to prevent recurrence. The Quality Safety and Transformation team will provide an overview of learning from incidents. 6.7 Guidance for clinical staff in the event of a fall Safety is the priority. Physical assessments should only be undertaken by appropriately trained staff. Assess the situation and condition of the fallen person ( victim ). Reassure the victim and explain to them and their family/parents what you are doing and why. Do not move the victim if there any sign of severe bony injury, especially to the head or neck unless the victim and/or yourself are in immediate danger (e.g. from fire, electrical hazard etc). If there is any suspicion that there may be serious injury, including spinal or neurological injuries the clinical emergency team (2222) should be activated. The Clinical emergency team should follow the PICU head injury management guideline and refer to National Institute for Health and Clinical Excellence NICE) Guidance CG56 for further guidance on management of patients with head injuries if required. All victims should be assessed for bony injuries following a fall, paying particular attention to the spine and hips. The combination of pain during straight leg raise, pain in groin and pain on rotation of the hips gives a very strong indication of the presence of a hip fracture. If in doubt, or if the patient is confused, there should be a low threshold for obtaining an x-ray of the relevant area. If the injuries are not felt to be serious/life-threatening (e.g. the victim says they are not injured and the fall was onto a soft surface etc), they should be assisted to a bed or chair. The TILE framework (Task, Individual, Load and Environment) can be used to undertake an emergency risk assessment. The fallen person maybe able to get onto all fours then sit and stand with the aid of furniture. The use of a hoist should be considered if the victim is unable to weight-bear. Appropriate first aid, such as dressing wounds, should be administered to victims with non-serious injuries. The MRC (bleep 0520) and CSP (bleep 0313) should be contacted if additional support is needed. If first aid is administered to a visitor or relative, the unbooked attenders policy should be followed. All patients who have fallen should have a full set of vital signs and Children s Early Warning Score (CEWS) recorded. Neurological observations should be taken using the 15 point Glasgow coma scale (GCS) if there is any suspicion that there may be an injury to the head or neck. They must then be fully examined by a doctor or other designated professional, paying particular attention to head/neck injuries and any potential fractures. This must be documented fully in the healthcare record. The scene should be made safe e.g. by removing obstructions and drying wet surfaces 14

15 6.8 Suspected spinal injury In the event of suspected spinal injury Compared to an adult all infants and young children are at risk of neck or spinal injuries if they fall. Their head is relatively large compared to their body, and they have immature vertebral bodies (with less tensile strength) through which the spinal cord travels, strong elastic intravertebral ligaments, flexible joint capsules and easily compressible soft tissues in the neck. As these structures are pliable, injury to the cervical spinal cord may occur without radiographic abnormality being seen. This also holds true for the rest of the spine. Although spinal cord injury is uncommon, the cervical spine must be immobilised along with the rest of the spine until spinal cord injury can be clinically evaluated by neurological examination Signs of spinal injury Severe multiple injuries Significant trauma to the head, neck and back Any trauma associated with high deceleration forces Falls from heights Conscious children may complain of pain in the affected area Assessment When assessing whether a patient has suffered a spinal injury the 6 P s should be evaluated: Pain Position Paralysis Paresthesia (pins and needles) Priapism (erection) Ptosis (drooping of the upper or lower eyelids) If pain swelling or tenderness are located in the spinal area then spinal cord injury must be ruled out even in the absence of neurological signs. The cervical spine should be immobilised and an MRI undertaken Treatment Stabilisation of airway, breathing and circulation (ABC) is the priority for all patients before attention to other injuries. In the event that a spinal injury is suspected the MRC (bleep 0520) and CSP (bleep 0313) should be contacted to review the patient. If there is any suspicion that there may be a serious head or spinal injury the clinical emergency team (2222) should be activated. The Clinical emergency team should follow the PICU head injury management guideline and refer to NICE Guidance CG56 for further guidance on management of patients with head injuries if required. 15

16 Airway obstruction is common in patients with a serious neck/spinal injury and jaw thrust may be required without moving the c spine. Full immobilisation with the correct hard collar, spinal board and 2 head blocks should be utilised to prevent permanent neck injury (Management of the patient who falls whilst in hospital appendix 1) Safe Manual handling methods to be used in the event a patient is showing signs or symptoms of fracture or potential for spinal injury. It is imperative that patients who have suspected neck or spinal fractures/ injuries are moved using specialist equipment and suitably trained staff. The potential harm from sling hoisting patients with neck or spinal fractures/injuries is thought to be a very under-recognised risk. To avoid such risks alternative flat-lifting equipment and expertise must be sought (See post fall protocol flowchart appendix ) Lifting equipment in the event of a fall and suspected spinal injury. Specialised lifting equipment including hard collars, spinal boards and head blocks are located on Sky ward (Level 6, Octav Botnar Wing). 6.9 In the event of suspected head injury Head injuries are a common occurrence when patients fall All patients presenting with a head injury should be assessed by a registered nurse or doctor member competent in undertaking neurological observations within a maximum of 15 minutes. Part of this assessment should establish whether they are high risk or low risk for clinically important brain injury and/or cervical spine injury, using the guidance on patient selection and urgency for imaging (head and cervical spine). All patients who have fallen should have a full set of vital signs and Child Early Warning Score (CEWS)recorded. Neurological observations should be taken using the 15 point paediatric Glasgow coma scale (GCS) if there is any suspicion that there may be an injury to the head or neck. If there is any suspicion that the patient has sustained a serious head injury or the GCS is 8 or less the clinical emergency team (2222) should be activated. The Clinical emergency team should follow the PICU head injury management guideline and refer to NICE Guidance CG56 for further guidance on management of patients with head injuries if required Frequency and duration of neurological observations for all patients where head injury has occurred or cannot be excluded (e.g. unwitnessed falls) is based on NICE Clinical Guideline 56: Head Injury As the risk of an intracranial complication is highest in the first six hours after a head injury, observations should have greatest frequency in this period Observations should be performed and recorded on a half-hourly basis until GCS equal to 15 has been achieved. The minimum frequency of observations for patients with GCS equal to 15 should be as follows: half-hourly for 2 hours 16

17 then 1-hourly for 4 hours then 2-hourly thereafter. Should a patient with GCS equal to 15 deteriorate at any time after the initial 2- hour period, observations should revert to half-hourly and follow the original frequency schedule. CT should be requested immediately in all patients with any of the following risk factors: GCS less than 13 at any point since the injury. GCS equal to 13 or 14 at 2 hours after the injury. Suspected open or depressed skull fracture. Any sign of basal skull fracture (haemotympanum, panda eyes, CSF otorrhoea, Battle s sign). Post-traumatic seizure. Focal neurological deficit. More than one episode of vomiting (clinical judgement should be used regarding the cause of vomiting in those aged 12 years or younger, and whether imaging is necessary). Amnesia for greater than 30 minutes of events before injury. The assessment of amnesia will not be possible in pre-verbal children and is unlikely to be possible in any child aged under 5 years. CT should be performed within one hour of request received in radiology department and analysed (Nice, 2007) Any of the following examples of neurological deterioration should prompt urgent reappraisal by the supervising doctor. Development of agitation or abnormal behaviour. A sustained (that is, for at least 30 minutes) drop of one point in GCS (greater weight should be given to a drop of one point in the motor response score of the GCS). Any drop of three or more points in the eye-opening or verbal response scores of the GCS, or two or more points in the motor response score. Development of severe or increasing headache or persisting vomiting. New or evolving neurological symptoms or signs, such as pupil inequality or asymmetry of limb or facial movement. To reduce inter-observer variability and unnecessary referrals, a second member of staff competent to perform observation should confirm deterioration before involving the supervising doctor. This confirmation should be carried out immediately. Where a confirmation cannot be performed immediately (for example, no staff member available to perform the second observation) the supervising doctor should be contacted without the confirmation being performed. Please see Hospital Guidelines for neurological observations found on the clinical guidelines section of the intranet 17

18 In the case of a patient who has had a normal CT scan but who has not achieved GCS 15 after 24 hours observation, a further CT scan or MRI scanning should be considered and discussed with the radiology department. Patients who sustain any form of head injury during their visit/ admission to the hospital should not be discharged until they have achieved GCS equal to 15, or normal consciousness in infants and young children as assessed by the paediatric version of the GCS. 7 Process for implementation The policy will be uploaded through the intranet, and staff will be made aware of it and patient falls prevention and reduction strategies through targeted e mails and presentation to relevant staff groups and meetings, staff to be made aware of it at induction and update moving and handling training. 8 Monitoring arrangements A weekly health and safety walkabout monitors the condition of the environment in the Trust in order to help negate the chance of incidents. The work of this group is monitored on a quarterly basis by the Health and Safety Committee. To bolster this process an annual audit is undertaken by the Health and Safety Team of the slip/trip/fall hazards in all Trust areas (See Appendix 1). Audit results and slips, trips and falls incidents are discussed on a quarterly basis at the Trust Health and Safety Committee and included in reports to wards and departments and included on the risk registers where appropriate for discussion at the local Risk Action Groups. Action plans will be developed in response to audit results where areas of practice are not compliant with the process. Action plans will be presented and approved through relevant committee s. This policy will be reviewed on a two-yearly basis and the duties will be reviewed as part of this. Monitoring plan Element to be monitored Number/ location/ severity/outcome /remedial action (if necessary) of falls. Lead Tool Frequency Reporting arrangements Assistant Chief Nurse Quality, Safety and Patient Experience Incidents reported on Datix Monthly Collated and reported to NHS London Reported to Health and Safety Committee quarterly Reported as part of Trusts harm index in monthly zero harm reports to management board. Acting on recommendations and Lead(s) The health and safety team Investigation begins within 72 hours of a falls incident being reported via the DATIX incident reporting system. The Health and Safety committee are responsible for acting and leading on improvement work in relation to patient falls. Change in practice and lessons to be shared Falls incidents and lessons learned will be disseminated via the appropriate risk action groups, other relevant staff meetings and the Quality, Safety and Transformatio n team newsletter. 18

19 Annual audits to be conducted on the compliance with completion of the moving and handling/falls risk assessment Moving and Handling Trainer/ Advisor Revised moving and handling/falls risk assessment audit tool Annual Reported to Health and Safety Committee The Health and Safety committee are responsible for acting and leading on improvement work in relation to patient falls. Falls incidents and lessons learned will be disseminated via the appropriate risk action groups and other relevant staff meetings. Summary review of mechanisms for raising awareness of reduction and prevention on patient slips trips and falls Assistant Chief Nurse, Quality, Safety and Patient Experience Health and Safety and Quality and Safety annual reports Annual Reported to Health and Safety and Quality and Safety Committees The Health and Safety and Quality and safety committees are responsible for acting and leading on improvement work in relation to patient falls. Action plan created and signed off by relevant committee Annual review of compliance with with falls training requirements Review manual handling/falls risk assessment tool and biannually Patient Environment Lead for Education and Training Moving and Handling Trainer/ Back Care Advisor Facilities Risk and Governance Officer Annual report Annual Reported to the Health and Safety Committee Moving and handling/ falls risk assessment tool Biannually Health and Safety Committee PEAT Tool Quarterly Health and Safety Committee The Lead for Education and training and the Moving and Handling/Back Care Advisor will address any gaps in training requirements The Health and safety Committee are responsible for ensuring the risk assessment tool is reviewed biannually Estates (maintenance) Facilities (Housekeeping) Action plan created and signed off by relevant committee Revised tools will be issued with key learning points and changes identified if required. Action Plans are created and signed off by relevant committee 9 Standards and Key Performance Indicators (KPI) Monthly falls data is collated and fedback to NHS London, via the National Reporting and Learning System and presented quarterly at the Trust Health and safety committee. 10 Equality impact statement This policy applies to all patients irrespective of age, disability, gender, race, religion or sexual orientation. An equality impact assessment can be seen in appendix 11 Training Preventing slips trips and falls is covered in the mandatory moving and handling training. The staff groups who receive this training are described in the Statutory and Mandatory Training Policy which used a training needs analysis to identify the types of training required by different staff groups. Training Needs Analysis (delivered on a 2 year rolling programme) 19

20 Training on taking Neurological Observations Removal and retrieval of suspected skeletal fractured patients: Manual handling training Hard collar Spinal board Head blocks Lifting equipment Bed/Cot Fault finding STAFF GROUP/ROLE Nursing SKY Ward Band 5 Nurse (SKY Ward) Band 6 Nurse (SKY Ward) Band 7 Nurse (Sky Ward) Band 8+ Nurse (Sky Ward) PULSE Bank Nurse (Sky Ward) Student Nurse (Sky Ward) Nursing Pan Trust Health Care Assistants Band 5 Nurse Band 6 Nurse Band 7 Nurse Band 8+ Nurse CSP s PULSE Bank Nurse Student Nurse AHP's & Clinical Support Physiotherapist Occupational Therapist Non-Clinical Portering Staff Medical Consultants on clinical emergency team Junior Doctors on clinical emergency team 12 Other policies of relevance Trust Health and Safety Policy Moving and Handling Policy Incident Reporting & Management Policy 20