These consequences include:

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2 Slide 3 Introduction (Time for this section-10 minutes) These consequences include: Physical Discomfort and pain - caused by skeletal or soft tissue damage Serious injury Hypothermia, pressure-related injuries and infection these can occur in an elderly patient who has a long lie after a fall Reduced functional ability Long-term disability Death. Social Loss of independence Changes to daily routine Decreased quality of life. Psychological Loss of confidence and anxiety Fear of falling - self-imposed restriction on mobility, leading to decreased independence and can contribute to future falls resulting in more serious injuries. This is linked with depression and social isolation Guilt/blame/embarrassment. 2

3 Slide 4 Objectives The overall objective of the training is to help provide information in partnership with the North West Ambulance Service (NWAS) to nursing/care home staff that will increase knowledge and confidence when making the decision on what care pathway to select when dealing with situations (in particular falls) that are not life threatening within the nursing/care home. 3

4 Slide 5 - Definitions Fall: A fall is an event which results in a person coming to rest inadvertently on the ground or floor or other lower level (with or without the loss of consciousness). Slip / Trip: Not only do we need to ask an older person if they have had a history of falls, but also if they are experiencing any slips, trips or stumbles. Slip to slide involuntarily and lose one s balance or foothold Trip an accidental misstep threatening (or causing) a fall Stumble to step awkwardly while walking and begin to fall. Un-explained fall: This is when a fall has not been witnessed, a cause cannot be identified or the person does not know how or why they fell. It is important to note: Repeated slips trips or stumbles, can be warning signs of future falls. We should not wait until a fall occurs before implementing falls prevention strategies. Early intervention could prevent future falls from occurring. It is of high priority that we identify clients who state they have had a weak turn or perhaps fainted / blacked out (unexplained fall). These occurrences may be an indication of an underlying medical problem which will require medical attention. 4

5 Slide 6 Falls Prevention (Time for this section 50 minutes) The number of falls can be cut dramatically through planning and pro-active management. The following section will address actions that can be put in place to help prevent falls within the nursing/care home. Best practice in fall and injury prevention includes implementing standard falls prevention strategies, identifying fall risk, and implementing targeted individualised strategies that are monitored and reviewed regularly. Remember: the most effective approach to falls prevention is likely to be one that includes all staff engaged in a multifactorial falls prevention program. 5

6 Slide 7 Policies on Falls Prevention NICE Guidance Falls: assessment and prevention of falls in older people This guideline offers best practice advice on the care of older people who are at risk of falling. All people aged 65 or older are covered by all guideline recommendations. To access the full guidance document please go online at: 6

7 Slide 8 Policies on Falls Prevention Within this guidance the following recommendations have been identified as priorities for implementation. Case/risk identification Older people should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s. Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance. Multifactorial falls risk assessment Older people who experience recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention. Continues on next page 7

8 The Multifactorial assessment may include the following: identification of falls history assessment of gait, balance and mobility, and muscle weakness assessment of osteoporosis risk assessment of the older person's perceived functional ability and fear relating to falling assessment of visual impairment assessment of cognitive impairment and neurological examination assessment of urinary incontinence assessment of home hazards cardiovascular examination and medication review. Multifactorial interventions All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention. In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors): strength and balance training home hazard assessment and intervention vision assessment and referral medication review with modification/withdrawal. Home hazard and safety intervention Older people who have received treatment in hospital following a fall should be offered a home hazard assessment and safety intervention/modifications by a suitably trained healthcare professional. Normally this should be part of discharge planning and be carried out within a timescale agreed by the patient or carer and appropriate members of the health care team. It Is important to note that home hazard assessment is shown to be effective only in conjunction with follow-up and intervention, not in isolation. Education and information giving Individuals at risk of falling, and their carers, should be offered information orally and in writing about: what measures they can take to prevent further falls how to stay motivated if referred for falls prevention strategies that include exercise or strength and balancing components the preventable nature of some falls the physical and psychological benefits of modifying falls risk where they can seek further advice and assistance how to cope if they have a fall, including how to summon help and how to avoid a long lie. 8

9 Slide 9 Risk Assessments To address falls prevention we must: Identify individuals at risk Implement appropriate risk reduction measures. There are two types of risk assessments: 1. Written test 2. Dynamic risk assessment - a continuous process of identifying risk, assessing and coming up with ways to reduce or eliminate risks. It is important that any risk assessments that are undertaken are continually reviewed and changed if needed. 9

10 Slide 10 Risk Factors We must remember that: Falls are not an inevitable part of ageing, but may be the first sign of an underlying health problem. A fall is nearly always due to the presence of one or more risk factors. Recognising then, where possible, removing or altering an individual s risk factors can often prevent a fall. The risk of falling can never be completely removed, but by carrying out a falls risk assessment on a resident, risk factors can be identified and action taken to remove or alter risk where possible. Considering risks within the care home environment is part of this process. There will be cases when an individual remains at high risk of falling despite thorough assessment and management. In these instances, the service can try to reduce the risk of harm from falls by using suitable equipment and alarm systems, and ensure residents take osteoporosis medications as prescribed. The emphasis should be on anticipating and preventing problems rather than simply managing problems once they have occurred. 10

11 Slide 11 Risk Factors Research has identified many risk factors for falls. It is important that we look at both physiological and environmental factors as normally falls occur as a result of both of these. Remember: little factors can add up to big falls. Factors relating to increased physiological vulnerability: Age related changes- reduced mobility, strength, flexibility & eye sight, foot problems Medications Gait & mobility disorders Illness & injury; CVD, Arthritis, Parkinson's Disease, CHD, dehydration, Diabetes, Hypotension (postural). Urinary incontinence Cognitive problems, memory loss, reduced understanding, lack of safety awareness, impulsive behaviour, confusion (acute or chronic) dementia, delirium. Continues on next page 11

12 Increased environmental risks (hazards): poor lighting, especially on stairs low temperature wet, slippery or uneven floor surfaces clutter chairs, toilets or beds being too high, low or unstable inappropriate or unsafe walking aids inadequately maintained wheelchairs, for example, brakes not locking improper use of wheelchairs, for example, failing to clear foot plates unsafe or absent equipment, such as handrails loose-fitting footwear and clothing. Activity Ask the group/think about it yourself: What would you do to reduce the risk of these factors? 12

13 Slide 12 Managing the control of slips, trips and risks Not all falls can be prevented. Some older people will fall, regardless of preventive measures. For these residents, it is imperative to: Assess, plan and organise: minimise the risk of injury by ensuring the environment is as safe as possible implement measures to reduce the risk of a fracture investigate the underlying causes of the incident. Control, record and review: review care plans and risk assessments. 13

14 Slide 13 Show and tell observational tour to identify hazards within the nursing home. Activity Ask staff members to identify what they would define as environmental hazards that might cause people to fall in the nursing home. What can they do to manage and reduce this risk? 14

15 Slide 14 FRAT tool Falls Risk Assessment Tool (FRAT) Falls risk screening is a brief process of estimating a person s risk of falling, classifying people as being at either low risk or increased risk. This can be carried out for all residents and for those identified as high risk a further more detailed assessment and interventions may be put in place. FRAT only involves reviewing up to five brief items and is not designed as a comprehensive assessment. Level of predicted risk: 3-5 yes s Higher risk : conduct a further more detailed risk assessment/refer to the falls team in your local area. Less than 3 yes s Low risk. It is important to note when a falls risk screen is introduced, it needs to be supported with education for staff and intermittent reviews to ensure that it is used appropriately and consistently. 15

16 Slide 15 STEADY tool Falls Risk Assessment Tool (FRAT) The STEADY tool has been developed by the falls team in East Lancashire and is an example of best practice that can be shared. It is best to use this when planning and can be used as a further more detailed risk assessment for residents identified at high risk of falling. 16

17 Slide 16 Handling Falls (Time for this section 45 minutes) This next section will cover guidelines of what to do when falls do occur within the nursing/care home including advice on observations and monitoring. 17

18 Slide 17 Handling Falls By ensuring that residents who fall are monitored and appropriately referred, further falls may be avoided. It is important that this process takes place even if the resident is not injured. The care plan will also require review. A resident who falls once is at high risk of falling again and an early intervention may prevent serious injury. It is important to investigate incidents thoroughly. Effective accident investigation should look beyond the immediate cause of the incident to the underlying cause. 18

19 Slide 18 MOMAS This is a simple approach to medical assessment. When an elderly person has fallen you should consider the following areas: M Has the patient got mental capacity, can they tell you accurately if or where they are injured and what happened? O Are there any blatantly obvious injuries, broken bones, short or rotated legs, deformity that would need hospital assessment or are the injuries minor and able to be managed in the home or by alternate care providers eg the GP or DN? M Mechanism, what happened, how did they fall what areas of the body might they have damaged? A Clinical assessment, examination of potentially injured areas, observations, co-morbidities, frequency of fall episodes. S Safety Net, referral e.g. to GP/Falls team or alternate care provider, monitoring and review is there a change from their normal range of activities? Offer basic life support and provide reassurance: Check for ongoing danger. Check whether the patient is responsive (e.g. responds to verbal or physical stimulus). Check the patient s airways, breathing and circulation. Reassure and comfort the patient. Continues on next page 19

20 Take baseline measurements: Conduct a preliminary assessment that includes taking baseline measurements of pulse, blood pressure, respiratory rate, oxygen saturation and blood sugar levels. If the patient has hit their head, or if their fall was unwitnessed, record neurological observations(e.g. using the Glasgow Coma Scale). Check for injuries: Check for signs of injury, including abrasion, contusion, laceration, fracture and head injury Observe changes in the level of consciousness, headache, amnesia or vomiting. Move the patient: Assess whether it is safe to move the patient from their position, and identify any special considerations in moving them. Staff members should use a lifting device rather than trying to lift the person on their own. Follow the nursing homes policy or guideline on lifting. Monitor the patient: Observe patients who have fallen and who are taking anticoagulants or antiplatelets (blood-thinning medications) carefully, because they have an increased risk of bleeding and intercranial haemorrhage. Patients with a history of alcohol abuse may be more prone to bleeding. Arrange for ongoing monitoring of the patient, because some injuries may not be apparent at the time of the fall. Make sure that hospital staff know the type, frequency and duration of the observations that are required. Report the fall: Report all falls to a medical officer, even if injuries are not apparent. Document all details in the patient s medical record, including their observations, appearance or response; evidence of injury; location of the fall; notification of medical provider; and actions taken Complete a falls reporting form according to local policy guidelines for all falls, regardless of where the fall occurred or whether the patient was injured. Note any details of the fall for reference in reporting the fall, including the patient s description of the fall, if possible. As a minimum, this should include the location and time of the fall, what the patient was doing immediately before they fell, the mechanisms of the fall (eg slip, trip, overbalance, dizziness), and whether they lost consciousness or had a conscious collapse. 20

21 Slide 19 PHEW The Pre-Hospital Early Warning (PHEW) sore is used by paramedics to assess if a patient needs to go to hospital when they arrive on scene. This can be used by staff members as a guideline to assessing if a person needs to go to hospital. Please note: this should only be used by nursing staff trained to carry out these observations and with the correct equipment. Observations: remember that the patients' normal may already be outside these parameters, e.g. COPD patients may have a normal saturation of Single observations may be pertinent yet elicit only a low PHEWS score e.g. temperature in developing infection. Repeat PHEWS may show that the patient is deteriorating and are a useful tool for monitoring. 21

22 Slide 20 Assessment Checklist for Falls The SCP Assessment checklist for falls is used by paramedics to assess if a patient needs to go to hospital when they have had a fall. This can be used by staff members as a guideline to assessing if a person needs to go to hospital. Please note: this should only be used by nursing staff trained to carry out these observations and with the correct equipment. 22

23 Slide 22 Alternative Care Pathways The following information highlights alternative pathways that NWAS would recommend using (when appropriate) in the event of a resident falling, rather than calling an ambulance. Self-care pathways If a nursing home or care home resident has fallen over but when assessed by an NWAS clinician either satisfies the self-care pathway or elicits an amber outcome using Pathfinder when a care plan or referral scheme is available, then the patient does not need to be conveyed to hospital. Normally, amber outcomes would be conveyed to hospital. To fulfil a Self-care Pathway for falls, neck injuries or minor head injuries and minor injuries, a patient must show no signs of confusion, which unfortunately means that if a patient has Alzheimer s or dementia, they will probably not fulfil them and would need to be conveyed. Throughout the North West, there are various options available to support self-care, improve quality of individual care, whilst avoiding falls in the future. These include Community Care (see next section). Continues on next page 23

24 Community care pathways and Individual care plans Community care pathways and individual Care Plans support frequent fallers and their carers to manage their individual care needs and avoid repeat falls in the future. A Community Care Pathway (CCP) may have been developed by the appropriate Clinical Commissioning Group for frequent fallers. Patients who suffer from frequent falls will be identified by the GP or lead clinician/healthcare professional (typically the Community Matron but can also include occupational therapists and physiotherapists) and an individual Care Plan will be produced for the patient. The Care Plan will be retained by the Nursing Home or Care Home or within the Patients own home for reference and an alert placed on the Patient on ERISS (Electronic Referral and Information Sharing System). When and if a subsequent call is made to 999, leading to an ambulance being despatched, NWAS clinicians will be advised that a Care Plan is in place for the patient and available to view on scene. When on scene, the care plan will be reviewed. The plan will include the patient s baseline observations and enables NWAS clinicians to assess the patient using Pathfinder. If the patient s outcome is amber and a care plan is in place, or doesn t fulfil a self-care pathway then a clinician to clinician referral should be made in accordance with the referral instruction detail, contained on the patients Care Plan. Please note: an example of the care plan is on the next slide. Falls Referral Schemes Schemes are in place throughout the North West which NWAS Clinicians can actively refer into, via Carlisle. When attending a patient who fulfils the self-care pathway but is not already on a scheme, Crews are actively encouraged to refer patients via Carlisle, directly into existing schemes within the local area. By referring falls patients, we aim to provide improved overall care to help maintain independence, wellbeing and facilitate better long-term management of their conditions, thus ensuring best practice for the patient. The Falls Referral Scheme should be used for any patient who fulfils the appropriate Self Care Pathway (SCP) criteria, using the appropriate Paramedic Pathfinder, and who is not conveyed to hospital. Patients would benefit from a multi-disciplinary falls assessment. If the patient meets the criteria and consents to their information being shared, the NWAS clinician must contact the Carlisle Support Centre to make a referral. Once the information has been received by the Support Centre, it will be recorded using the new Electronic Referral Information Sharing System (ERISS) and will be sent securely to the appropriate Falls Team. 24

25 Slide 21 Care Pathways and Planning An example of the community care plan is on the next slide. 25

26 Slide 23 Blackpool Teaching Hospitals NHS Foundation Trust - Care Home Support Teams An example of a project that has been undertaken across the North West to reduce the number of calls to the ambulance service from nursing/care homes. Blackpool Teaching Hospitals NHS Foundation Trust has recently commissioned a 12 month pilot, working in collaboration with Care Home Managers, Residents and their families. This is called The Care Home Support Team the Community Matron and 3 case managers manage a caseload of approx. 600 residents, within 15 identified care homes in the Blackpool CCG footprint. Within the 15 care homes, residents are assessed and a care plan produced. Risk assessments are also undertaken to identify potential risk of the patient being taken to hospital, alongside providing guidance and support to the care home staff. The residents may also be referred to other multi-disciplinary teams for medication reviews etc. Safety audits are undertaken every month, with potential safety issues identified and discussed with the care home manager and action plans put in place to reduce incidents. Care Plans are reviewed every 3 months. A hard copy of the care plan is left at the Care Home and should the patient fall, and then the care plan should be reviewed prior to calling the Care Team or lead GP instead of calling 999. The care plan is used not just for falls but also in relation to other identified health issues and acts as a support for care staff and other readers- the care plan directs any concerns to the care coordination team which is working out of Whitegate Drive locally or the lead GP; the Care Home Support Team are not a reactive team to ill health, unfortunately due to time constraints. However they do review the care plan to see if they can do anything post event on a month to month basis. 26

27 Slide 24- Pennine Care Falls Prevention Scheme An example of a project that has been undertaken across the North West to reduce the number of calls to the ambulance service from nursing/care homes. A falls prevention and rapid intervention scheme was commissioned earlier this year, by Pennine Care NHS Foundation Trust and Bury Council (crisis response). Patients in Bury, Oldham and Rochdale, who are aged over 65 and have fallen at home, can now avoid being taken to hospital unnecessarily. If 999 is called and an ambulance is dispatched, NWAS clinicians assess every patient on the scene. If referral to community-based care is appropriate for the patient s needs, NWAS clinicians can refer the patient directly to Pennine Care s community services. Following the referral, a package of care and support will be developed and agreed based on the patient s needs, and this can be delivered by a range of health professionals, including nurses, occupational therapists and physiotherapists. When necessary, care can be provided within two hours of the referral, for example if the patient has an urgent medical need or is very distressed following their fall and can t be left alone. If immediate input is needed, i.e. a first time faller or a frequent faller who has fallen again then a rapid response intervention is also available. A key aspect of this scheme is to reduce the risks of recurrent falls, which are common. This would include reviewing medication, organising exercise classes if appropriate, to improve balance and generally provide patients with the right care and support, at the right time in the right place. 27

28 Slide 25- Record Keeping The proper recording of individual and environmental assessments is a key element in effective falls management. This can take various forms (for example, records relating to medication review; environmental check sheets; supervisory audits of cleaning contractors and training records). These records all show that appropriate action is being taken and help to maintain management control. All accidents, including falls, suffered by a resident should be recorded in the appropriate accident book. It is also good practice to keep a falls register for each resident so that multiple falls and patterns can be identified. Periodic review will help to identify trends. For example, a resident may demonstrate unsteadiness at particular times of the day that may be associated with medication, meal times or particular activities. Long-term review may identify that there are environmental factors that need attention but which only arise at certain times of the year (for example, high contrasting light levels during the summer, low sun causing glare on a floor surface during winter). Continues on next page 28

29 Example questions to assist with this include: What was the type of fall (e.g. slip, trip, bumping into or falling on an object)? What was the activity at the time of the fall (e.g. attempting to stand, walking)? Does the patient depend on a carer, aids or hospital staff? If the patient has a high risk of falls, what steps have they taken previously to reduce falls risk and injury risk? Is there any relevant information about the patient s clothing, footwear, eyewear and mobility aids used at the time of the fall? Were any restraints being used? Did the patient have any recent change in medications that might be associated with their falls risk? Was there staff supervision at the time of the fall? Where there any external factors that may have contributed to the fall, such as environmental conditions (e.g. floor, lighting, clutter) or staffing levels? What was the patient s status after the fall (e.g. baseline observations, injuries)? What interventions will be implemented after the fall, and what medical treatment is required? What was the patient s perception of the fall, including their description of any preceding sensations or symptoms, and what do they think might have prevented the fall? 29

30 Slide 31- More Information These information sources have been used and are referenced throughout this document. 30