Milton Keynes Professionals Falls Pathway As at March 2013

Transcription

1 Milton Keynes Professionals Falls Pathway As at March 2013 Refer to A3 sheet for diagram of services Box 1: Presents with a fall A fall is defined as an event whereby an individual comes to rest on the ground or another lower level with or without loss of consciousness (National Institute of Clinical Excellence 2004). A fall is an unintentional change in position causing an individual to land at a lower level on an object, the floor and the ground other than as a consequence of sudden onset paralysis, epileptic seizure or overwhelming external force (Tinetti et al 1988). Box 2: South Central Ambulance Service (SCAS) 999 call to emergency services by person, family member, member of public, carer or community alarm service. Provide emergency care post-fall including treatment of any injuries; assist person from the ground. If the person does not require face to face immediate assistance, SCAS Clinical Support Desk (CSD) clinicians may give telephone advice or make onward referrals at the point of call without sending a face to face response. CSD clinicians can also offer clinical advice to operational ambulance clinicians, particularly with reference to care pathways available locally. Emergency Care Practitioners (ECP s) are able to offer extended assessment and management of injuries in the community (e.g. wound closure, treatment of minor infections etc). Person may be transported to hospital or remain in own accommodation and referrals made as appropriate: MKCHS Falls Service RAIT if urgent input required enabling the person to remain at home or have a short stay rehab bed in the community direct referral via telephone. Clinical Report Form left with person to pass on. GP for further advice and treatment referred by any ambulance clinician verbally, formal GP Triage process in place. Clinical Report Form left with person to pass on. MKUCS Person can be transported to or advised to attend the Urgent Care Centre. If GP OOH advice is required this follows the same process as above, but via MKUCS (OOH call taking will be superseded by 111). ASCAT if increase in care required by direct telephone referral to the duty desk (usually only CSD clinicians or Emergency Care Practitioners will undertake such referrals). If a vulnerable adult ambulance clinicians will complete a SCAS form and submit to Social Services vulnerable adults via fax. Information about people who have fallen is held by the SCAS Performance Information Team. Page 1 of 13

2 Box 3: MK Council Community Alarm and Telecare Service Person or carer uses community alarm to seek assistance Dialogue between control centre staff and individual to ascertain the problem Control centre staff may call person s contacts to aid the person or mobile warden may visit Assist person from the ground if no injuries Call to SCAS when there is an indication of possible injury, this could be verbal confirmation from service user or if mobile warden has attended and has concerns Referred to MKCHS Falls Service whenever mobile warden attends a falls incident or if a telecare assessment is carried out and consent to refer is gained Age UK for home safety check Community OT for assessment and provision equipment and rails Housing Department if unsuitable accommodation Sensory services if issues with sight and hearing loss which may impact on mobility Social work teams for possible home care, lunch club or day centre Information about people who have fallen is held on the alarm centre database and telecare assessment form where applicable. Information received may originate from a referrer to the service, an alarm call in from the service user or in conversation with the service user when a visit is carried out. Box 4: GP Analyses people at risk of falling from their client records Refers to MKCHS Falls service for initial contact, assessment and referral on to relevant community based falls prevention service Person or family member alerts GP at a later date that the person has fallen Referred to services Information about people who have fallen is held on practice computer system Box 5: ExtraCare Retirement Village Person or carer alerts staff that assistance is needed using pull cords or pendant alarm May alert staff at a later date that have fallen Assist person to get themselves up from the ground if able and no obvious injury or if unable and/or injured, call SCAS Management Report completed within 7 days following report of Accident, Injury, Incident or Dangerous Occurrence. Falls monitored at month end by Team Leader and Wellbeing Advisor. Individual Falls Risk Assessment forms kept in folder in Care Office; copies in Wellbing Office. Copies of RIDDOR falls/accident Forms/Osteoporosis Risk Assessment/Falls Screening Assessment/Individual Risk Assessment for Slips Trips & Falls sent to ExtraCare Head Office for monitoring DOH Fracture Project. Page 2 of 13

3 MKCHS Falls Service when new falls or when thought further assistance needed GP when any health related issues Age UK to help individual stay independent e.g. home support, home visiting, foot care service District Nurse if health related issues identified and unable to attend the surgery Community OT for aids and adaptations Information about people who have fallen is held on wellbeing drop-in card and on incident forms in team office Box 6: Residential/Nursing Care (Excelcare) Incident form completed and care plan and risk assessment updated/reviewed Assist person from the ground if no injuries once checked over and appropriate to do so Call to SCAS when sustain any head injury and on a residential unit/or any concerns relating to immediate health GP for review on next visit to ascertain any underlying cause for fall; or sooner if presenting with any pain/bruising, but no obvious breaks/fractures District Nurse when any dressings need changing/ assessing following an injury such as a skin tear MKCHS Falls Service when a person has recurrent falls and there is no apparent underlying medical cause/reason Information about people who have fallen is held on ABLYSS system (Electronic care plans) Quality Control system Box 7: Willen Hospice Inpatient Unit Provide immediate nursing care; assist person from the ground if no injuries apparent using equipment where required. Incident form completed by Nursing Staff and forwarded for assessment and completion by Doctor. Falls risk assessment reviewed and care plans updated: Medical staff review contributory factors Nursing staff review patient safety Referred to physiotherapy when a risk of falls identified which could be improved by intervention Completed incident form forwarded to In Patient Unit Nurse Manager for review. Reviewed at Clinical Effectiveness Committee and categorised for level of harm; reviewed at Clinical Governance and Health & Safety Committee. Information about people who have fallen is held by Administrative staff and recorded for CQUINs and National Patient Safety Thermometer. On admission people are asked about falls and this information is held on ADL sheet and Falls/manual handling care plan. Moving and handling assessment completed on admission. Page 3 of 13

4 Box 8: Windsor Intermediate Care Unit (WICU) Assist person from the ground if no injuries, observations checked, falls risk assessment recalculated and care plan reviewed, reviewed by the unit doctor on next visit. Person assessed for suitability to use a falls sensor, assess if the patient needs to move rooms to be closer to the central area, look at possible cause of fall, and address e.g. offer use of the toilet regularly. Observe for signs of infection e.g. ward test urine Unit has implemented a clip on the call bells to help the patient to be able to reach them and call for assistance Visual signs are in place to act as a reminder to use the call bell With consent, Next of Kin informed about the fall Tally chart completed for monthly records of the number of falls occurring within the unit Incident form completed and submitted following MKCHS policy Call to SCAS when any injury is suspected that needs acute hospital intervention Continue rehab at WICU Information about people who have fallen is held within the patient paper notes and electronically on RiO; monthly reports are held on the G drive of the computer. These reports are collated by clinical governance (those who fall at WICU) Box 9: (The Older People's Assessment Service) TOPAS Incident form completed and risk assessment and care plan reviewed and updated where appropriate. Fall entered onto entered into Rio progress notes. Ward doctor informed and/or asked to attend where nursing staff are concerned but assess that an attendance at A&E is not required. Assist person from the ground if no injuries and client is willing to get up. Call to SCAS when client injured, and/or in pain, and unable to get up from the floor. Do Vital Signs check and call SHO if client able to get up Continue rehab at TOPAS Refer to Falls Service when falls are becoming frequent Update Falls Risk Assessment and care plan Information about people who have fallen is held on Rio system. Box 10: Milton Keynes Hospital Foundation Trust (fallen on ward) Provide immediate nursing care; assist person from the ground Incident form completed on electronic incident reporting system alert sent to nominated receivers Falls risk assessment reviewed Multi professional team review contributory factors Nursing staff review patient safety Referred to pharmacy for medication review if 2 or more falls in a week Page 4 of 13

5 Investigated by ward sister/charge nurse Lessons learnt are shared within the team Information about people who have fallen is held in patient records Box 11: Urgent Care Service Treat presenting problem MKCHS Falls Prevention Service Information about people who have fallen is held in patient records Box 12: Orchard House Incident form completed and falls risk assessment completed and if needed care plan revised Assist person from the ground if no injuries and the person wishes or insists on getting up; complete basic observations and inform RAIT nurse Call to SCAS when person unable to get up from ground or are injured Continue rehab at Orchard House People identified as high risk have falls sensor in situ GP review Information about people who have fallen is held in file and sent to MK Council health and safety team (those who fall at OH) Box 13: Accident and Emergency Person attends A&E following a fall Initial assessment completed dependent on status of patient Treatment and investigation Referred on to appropriate source T&O Medical team RAIT etc dependent upon outcome of investigation or required medical management plan Box 14: Milton Keynes Hospital Foundation Trust (Inpatient stay) Individual patient assessment and referral in hospital to physiotherapy if unsteady when mobilising RAIT to assist supporting discharge and when reablement required MKCHS Falls Service if indicated by Geriatrician/Physiotherapy Information provided to person about Age UK Information about people who have fallen is held in nursing records Box 15: WICU Referrals from health and social care professionals Assessment of need from which interventions include provision of equipment, environmental assessment and improving safety, balance and strengthening exercises, medical review Podiatry if foot care issues identified Community alarm and telecare to facilitate safety in home environment Intermediate Care for further rehabilitation in home environment Page 5 of 13

6 RAIT for further rehabilitation in home environments is required MKCHS Falls Service for education to reduce risk of falls Information about people who have fallen is held on assessment paperwork Box 16: MKCHS Falls Service Referrals from health and social care professionals, the individual and their family. FRAT score 1 and 2 triaged to Safer Steps; FRAT score 3 or more offered multi factorial assessment. Key components: medical; falls history; mobility assessment; environmental; functional abilities; foot check; osteoporosis risk; fear of falling; visual impairment; hearing impairment; cognition; continence; medication; lifestyle. Assessment of need from which interventions include provision of equipment, improving safety, balance and strengthening exercises, medical review, falls programme (otago home exercise) Podiatry if foot care issues identified that are impacting on mobility Community alarm and telecare to facilitate safety in home environment RAIT for admission avoidance Age UK for any services identified at assessment that would be beneficial Intermediate Care for admission avoidance Hearing assessment if problems identified Optician if no recent eye test (within the last year) COT if equipment not related to falls risk identified and/or specialist intervention required Domiciliary Physiotherapy if longer term physiotherapy management and treatment programme GP for review of medication Neuro-rehab unit if require specialist neurological intervention and/or prolonged rehabilitation that cannot be met through falls programme Neurological Clinical Specialist Team for specialist advice related to condition Extra Time for ongoing physical activity to improve strength and balance; may or may not have attended falls programme Reactivate for ongoing physical activity to improve strength and balance; likely to have attended falls programme Information about people who have fallen is held on assessment paperwork scanned into RiO and on referral scanned into RiO Box 17: MKCHS District Nursing Service Referrals accepted from all disciplines including members of general public. Dependant on nature of fall, when it occurred and severity, referrer may be guided towards alternative discipline ie ambulance service or GP for assessment. Referrals often taken as second line intervention ie client has been assessed by ambulance service as sustaining no injury where attendance to hospital is required but has tissue injury where wound care and follow up intervention Page 6 of 13

7 required. A full assessment process would then be undertaken looking at all aspects of nursing intervention and patient safety. GP for reassessment of health status and medication review. RAIT for OT and physiotherapy to avoid admission Intermediate Care and Social Services for assessment or reassessment of short and long term care provision MKCHS Falls Service Community Alarm for provision of alarm or additional equipment Community Matrons for assessment long term conditions or suitability for teleheath Specialist nurses/ncst as applicable e.g. Parkinson s Clinical Specialist, Diabetes Age UK Referrals would be dependant on patient need/choice and what provision was already in place. It may be that disciplines already involved in the provision of care and support would need to be alerted. Box 18: RAIT Referrals from health and social care professionals Service remit to facilitate hospital discharge or prevent an admission to hospital through assessment of need from which interventions include provision of equipment, environmental assessment and improving safety, balance and strengthening exercises MKCHS Falls Service if reason for fall is unclear and/or the person would benefit from further balance and strengthening exercises Information about people who have fallen is on RiO scanned overview assessment Box 19: Orchard House Referrals from health and social care professionals Assessment of need from which interventions include provision of equipment, environmental assessment and improving safety, balance and strengthening exercises MKCHS Falls Service if reason for fall is unclear, or if person would benefit from overview which cannot be provided whilst within the service, or is due to be discharged soon and may not be suitable to be referred to other ICT services Information about people who have fallen is on scanned overview assessment on Frameworki and on care needs assessment Box 20: GP Page 7 of 13

8 Box 21: Safer Steps Referrals from MKCHS Falls Service (FRAT 1 and 2) and by individuals direct to service Provide a Well-being assessment, advice and information on home safety and produce a Health Action Plan. Wellbeing assessment similar to MKCHS Falls Service s multi factorial assessment to provide equity of service provision GP if health issue that needs addressing; for referral to physiotherapy Community OT for equipment provision Extra Time & Extra Time+ and Safer Steps Otago exercise programme to improve strength, balance and confidence. Other local health care providers e.g. audiology or optician services Age UK for information and advice (referral given leaflet if required) ASCAT for social care issues requiring specific intervention Community alarm and telecare to facilitate safer home safer environment British Legion for ex service personnel to access safety equipment e.g. installation of key safe and community alarm. Information about people who have fallen is held on Safer Steps database and paper notes Box 22: MKHFT Physiotherapy Referrals accepted from ward staff Provide walking aids as appropriate; strength and balance exercise programme; complete an outcome measure (normally tinetti) RAIT if urgent safety check and/or equipment provision to facilitate discharge home Domiciliary Physiotherapy if longer term physiotherapy management and treatment programme MKCHS Falls Service if require falls management and prevention?? Age UK for home safety check MKC community alarm and telecare service if alarm system needed Information about people who have fallen is held in the medical notes Box 23: OT (MKHFT based) Referrals made by ward staff for Occupational Therapy Intervention. Assessment of need from which interventions include provision of equipment, strength and mobility exercises, environmental assessment through access and home visits. RAIT to support patient on discharge home with transition of skills from hospital to home Preventing re-admission MKCHS Falls Service if require falls management, a fall is impacting on daily living Page 8 of 13

9 Age UK for practical help on discharge from hospital, Home from Hospital service Community alarm and telecare if system not available Community OT for equipment or adaptations outside the remit of Acute OT Referral for further in-patient rehabilitation WICU, Waterhall and Orchard House if patient needs further rehabilitation once medically fit for discharge Information about people who have fallen is held on database and paper notes. Box 24: Community OT Referrals accepted from health and social care professionals and the individual via ASCAT Assessment of need from which interventions include provision of equipment, signposting to other services GP to request Domiciliary Physiotherapy for assessment of walking aid MKCHS Falls Service if history of falls Age UK if practical help required e.g. rails that are outside remit of COT service Community alarm and telecare if system not available Information about people who have fallen is held in case notes on Frameworki Box 25: Extra Time Referrals are accepted from the individual, professionals and family members. Referrals can be made either by , telephone or via the Extra Time booking form. Individuals are offered an 8 week course of activities aimed at improving balance. Activities include Pilates, Tai Chi and Boccia. MKCHS Falls Service if person has fallen or at high risk and has not seen a health professional about this Safer Steps if person wants further intervention and support about health and wellbeing Reactivate to continue physical activity after attending Extra Time Information about people who have fallen is held on database Box 26: Reactivate MK The Reactivate MK programme is a portfolio of activities coordinated by the MKC Sports Development Team in partnership with Bucks & MK Sport and delivered by a range of community partners. The activities draw on the excitement of the London 2012 Olympics to inspire adults to get fit, become healthier and have fun, by connecting them to activities across MK via a variety of mediums including a booklet, website and social networking pages. For more information on the activities available visit or call Page 9 of 13

10 Box 27: Age UK Milton Keynes Referrals accepted from health and social care professionals and the individual Referrals made as appropriate for Preventative Services for Older People ie: Handyperson, Gardening, Advocacy, Home from hospital, Carers support, Relief care, Home support, Home visiting & befriending, Lunch clubs and foot care Community alarm and telecare Citizen s Advice Bucks Fire Service Thames Valley Police ASCAT COT MKCHS Falls Service Information about people who have fallen is held on database Box 28: Community Learning Disabilities Referrals accepted from health and social care professionals; individuals and their family Assessment of need from which interventions include provision of equipment, environmental assessment and improving safety, balance and strengthening exercises GP if further health screening required Orthotics if further assessment of footwear or foot posture is required Podiatry if footcare advice/intervention is required Optician if no recent eye test MKCHS Falls Service if further advice needed Information about people who have fallen is held on Frameworki Box 29: Intermediate Care Team/Reablement and Hospital Discharge Team Referrals accepted from health and social care professionals Services support people to become as independent as possible by assisting to regain former mobility; prevent deterioration in a long standing condition; provide opportunities to maintain or develop or reinstate social networks and reduce isolation. RAIT for admission avoidance Community OT for adaptations Physiotherapy for mobility assessment/longer term rehabilitation Neuro-rehab service for ongoing rehabilitation Neurological Clinical Specialist team for specialist support and advice MKCHS Falls Service if recent fall and/or recurrent falls District Nurse if medication queries Orchard House/WICU if ongoing rehabilitation required and concern about risk if remain at home Information about people who have fallen is held on Frameworki Page 10 of 13

11 Box 30: Podiatry Referrals made to MKCHS Falls service Box 31: Fracture clinic MKFHT Box 32: Willen Hospice Community Team Person found on floor or falls whilst staff in attendance. Full assessment made to check for injuries. Assist person from the ground if no injuries using moving & handling equipment if available. NB: Patient may also alert staff at a later date that they have fallen Call to SCAS when unable to move patient from floor or evidence of possible bony injury apparent MKCHS Falls Service referral if known to have fallen previously normally actioned by District Nurse GP informed by telephone as soon as possible after incident District Nurse informed by telephone as soon as possible after incident Documented in nursing evaluation notes and in District Nursing notes. Box 33: Social Workers Referrals for assessment accepted by ASCAT from any group or individual as long as has the consent and agreement of the person being referred. If situation urgent, care can be put in straight away via ASCAT; otherwise passed to Community Social Work Team who will complete Assessments of need resulting in support Plans and services incorporating support such as shopping, assistance with personal care social opportunities etc. Referrals could also be made to: Community OT and Physiotherapy Assessments which will result in support and advice and possibly equipment to facilitate independence Community Alarm Service and/or Telecare Intermediate Care Services MKCHS Falls Service Age UK for Safety at Home check Box 34: Domiciliary Care Agencies Assist person from the ground if no injuries and the person wishes or insists on getting up; complete basic observations and inform Team Leader, who will inform DN, family and social worker. Call 999 when person unable to get up from ground or are injured People identified as high risk have falls sensor in situ GP review Adult social care review of service if changes need to care. Incident form completed and falls risk assessment completed and if needed care plan revised Notification to CQC under regulation 18 (serious injury to person using the service)by registered manager if appropriate Page 11 of 13

12 Information about people who have fallen is held in file as an incident or near miss and sent to MK Council health and safety team Box 35: Mental health Services Box 36: Community Dementia Team Individual Practitioner are informed of clients falls from various sources e.g. Client, family, carers, friends, neighbour, day care staff, ambulance staff, GP, district nurse (this can be immediately or days or weeks after the fall) Depending on the situation referrals are made as appropriate to: Falls clinic GP to review medication RAIT District Nurse - UTI test Telecare/Community Alarm Age UK home safety check Liaise with family, advice on environment/clutter on the floor and fluid intake Box 37: Neurological Clinical Specialist Team Parkinson s Service: Patient or other report fall Assess Parkinson s disease and general condition including blood pressure Provide falls and Parkinson s disease information factsheet Manage Parkinson s disease symptoms/blood pressure if possible (ie med changes to improve mobility) Refer to falls team if there are co-morbidities of recurrent unexplained falls Patients under 65 may be referred to RAIT Epilepsy service: Patient reports a fall Check a seizure did not occur either at the time or just prior to fall and titrate medicines/advise as necessary Refer to falls service if confirmed patient fell and is age appropriate to falls service Brain injury: Patient or other report fall Assess general condition, current symptoms and try to establish possible reason for fall Offer advice, possibly strategies to help manage symptoms Liaise with GP/specialist consultant and liaise with relevant MDT member in relation to specific symptoms as appropriate Patients under 65 may be referred to RAIT with client consent Patients over 65 refer to Falls service with client consent Box 38: Practice Nurses Page 12 of 13

13 References Nandy S et al. (2004) Development and preliminary examination of the predictive validity of the Falls Risk Assessment Tool (FRAT) for use in primary care. Journal of public health and medicine 26 (2). pp National Institute Clinical Excellence (2004) Clinical practice guideline for the assessment and prevention of falls in older people Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Eng J Med 1988; 319: Appendix Appendix 1 Abbreviations ADL A&E ASCAT CQUIN CSD DOH ECP FRAT GP MK MKC MKCHS MKHFT MKUCS OH OOH OT RAIT RIDDOR RiO SCAS TOPAS WICU Activities of Daily Living Accident and Emergency Adult Social Care Access Team Commissioning for Quality and Innovation Clinical Support Desk Department of Health Emergency Care Practitioner Falls Risk Assessment Tool General Practitioner Milton Keynes Milton Keynes Council Milton Keynes Community Health Services Milton Keynes Hospital Foundation Trust Milton Keynes Urgent Care Service Orchard House Out of Hours Occupational Therapy Rapid Assessment and Intervention Team Reporting of Injuries, Diseases and Dangerous Occurrences Regulations NHS Electronic patient record system South Central Ambulance Service The Older Peoples Assessment Service Windsor Intermediate Care Unit Page 13 of 13