CONTROLLED DOCUMENT. Controlled Document Number: Version Number: 3 Controlled Document Sponsor: Controlled Document Lead:

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1 CONTROLLED DOCUMENT CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Version Number: 3 Controlled Document Sponsor: Controlled Document Lead: Approved By: Inpatient Falls and Injuries Prevention Procedure Procedural Clinical To provide clear guidelines to all clinical staff responsible for the care of patients who are at risk of falling. 355 Executive Director of Nursing Falls and Fracture Prevention Nurse Specialist Executive Director of Nursing On: 27 January 2012 Review Date: January 2015 Distribution: Essential Reading for: Information for: All clinical staff caring for patients who are at risk of falling or have fallen. All clinical staff. Page 1 of 35

2 Contents Page Introduction 3 National Guidance 3 Scope of Guidance 3 Assessment of Patients for risk of falls 4 Falls Assessment 4 Falls Assessment 5 Patients assessed at risk of falling 6 Emergency Department 7 Critical Care 7 Any ward/department inpatient transfer 7 Reducing the risk of falls (including at height) 8 Physiotherapy Guidance 8 Occupational Therapy Guidance 8 Pharmacy Guidance 9 Assessment for the use of bed rails 9 Footwear 9 Seating 10 What type of bed is suitable 10 New Hospital wards 10 Inpatient falls prevention leaflet 11 Falls and Fracture Prevention Team 11 On discharge from hospital 11 Falls Clinic 11 Discharge Guidance 12 Patient Post Fall Guidance Assessment of patients who have fallen in Hospital 14 Following an inpatient fall 14 Physiotherapy 15 Occupational Therapy 15 Multiple fallers 15 Staff Training 16 Associated Documents 16 References 17 Appendix 1 FIRM Document 18/19 Appendix 2 Correct Footwear Poster 20 Appendix 3 OT initial falls assessment 21 Appendix 4 OT post falls assessment (falls guidance) 22 Appendix 5 Physiotherapy Falls and Mobility Assessment 23/24 Appendix 6 Physiotherapy Post Falls Assessment 25/26 Appendix 7 Fall with Head Injury Guidance 27 Appendix 8 NPSA Essential Care after an inpatient fall 28 Appendix 9 Non Spinal Injury Algorithm 29 Appendix10 Spinal Injury Algorithm 30 Appendix11 Falls Clinic Aims and Patient Criteria 31 Appendix12 Learning through Action to reduce falls RCS Template 32/34 Page 2 of 35

3 Introduction Falls prevention is a complex issue crossing the boundaries of healthcare, social care, public heath and accident prevention. Across England and Wales, approximately 152,000 falls are reported in acute hospitals every year, with over 26,000 reported from mental health units and 28,000 from community hospitals. A significant number of falls result in death or severe or moderate injury, at an estimated cost of 15 million per annum for immediate healthcare treatment alone (NPSA, 2007). This procedure is designed to help staff understand the importance of slip, trip and fall prevention and their responsibilities. It is available on the Trust intranet and should be made available in hard copy for those staff who do not have easy access to a computer National Guidelines This procedure is based on the National Patient Safety Agency (NPSA, 2007) report on slips, trips and falls in hospital and on national and professional best practice. The NPSA report (2007) suggests that where individual risk factors are addressed for every patient, an 18% reduction in falls can be achieved. The NPSA Alert Essential Care after an inpatient fall (2011) indicates that around 200 patients with fractures or intracranial injury after a fall in hospital experience some failure of aftercare NICE - National Institute for Clinical Effectiveness Clinical Guidance 021, the assessment and prevention of Falls in older people, November NICE Guideline 21 states all older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year. Environment In order to provide a safe environment it may be necessary to co operate and co ordinate with third parties such as Balfour Beatty Workplace (BBW), Shared Services Agency and other external contractors. These agents are also obliged to conduct risk assessments for their activities and you will need to liaise with them on matters which may affect your staff and/or others in your area. For advice and guidance on minimising Slips, Trips and Falls risk in the environment refer to the Procedure for the Prevention of Slips, Trips and Falls. Scope of the guidelines These guidelines apply to all areas of the Trust and all individuals employed by the Trust including contractors, volunteers, students, locum and agency staff and staff employed on honorary contracts who are involved in Trust business both on and off the premises. Patient falls are the most common patient safety incident reported to Risk Management. The Trust recognises the need to minimise the risk of patients falling and to learn from these incidents. These guidelines are intended to provide guidance for all clinical staff to assist in the management of inpatients who are admitted with either a history of falls, following a fall or who are at risk of falling. For the ease of communication Slips/Trips and Falls Risk will be referred to as Falls risk from this point. Page 3 of 35

4 Assessment of Patients for Risk of Falls Screening and assessing the patient s falls risk on admission All patients admitted to UHB must be screened for their risk of falling using the PICS (Patient Information Communication System) falls screening Tab under the observation section of the system. The Initial falls assessment must be completed within 4 hours of admission the PICS system will alert staff with the following message on PICS. This assessment is to be completed by a Registered Nurse. The initial falls screening consists of four questions: This assessment must be completed when: The patient is admitted The patient is transferred to another clinical area The patient condition changes The patient falls As a default to a weekly update Page 4 of 35

5 The screen shot below from PICS allows for the documentation of falls risk details from the four risk screening questions. Page 5 of 35

6 Patients assessed at risk of falling If the answer is yes to any of the screening questions, then a full falls assessment must be completed using the Patient Falls and Injury Screening and Management Plan (Appendix 1). Where risk factors are identified, the associated management plan must be actioned and reviewed: if the patients condition changes if the patient has a fall weekly review The view upon the PICS system is shown as: The PICS system will add in the date and time automatically and by hovering over the date assessed the name of the nurse who completed the assessment will be shown. Weekly Assessment Prompt Page 6 of 35

7 Guidance for areas currently not completing risk assessments on the PICS system Emergency Department The Emergency Department will assess patients who are to be admitted using the falls risk assessment section on the Casualty card. It is the responsibility of the Nurse in ED handing over to the next Clinical area to inform the receiving area staff to complete the FIRM (Falls and Injury Risk Screening and Management Plan). A patient transfer checklist must be completed as per the Patient Internal Transfer Policy and Procedure. Consideration must be given at this point as to the patient s requirement for a high/low specialist bed, bed location on the ward and cognitive status. Critical Care The Critical Care Department will assess patients on the unit when: o They are considered a wardable patient o On discharge from the unit It is the responsibility of the Nurse in Critical Care Department to complete the initial falls risk assessment on the FIRM (Falls and Injury Risk Screening and Management Plan); if the patient is at risk of falls they must inform the next Clinical area that the patient requires completion of the FIRM. A patient transfer checklist must be completed as per the Patient Internal Transfer Policy and Procedure. Consideration must be given at this point as to the patient s requirement for a high/low specialist bed, bed location on the ward and cognitive status. Any ward/department Inpatient Transfer When transferring patients between clinical areas, consideration must be given at this point as to the patient s requirement for a high/low specialist bed, bed location on the ward and cognitive status. A patient transfer checklist must be completed as per the Patient Internal Transfer Policy and Procedure. Page 7 of 35

8 Reducing the risk of falls (including at height) The Falls and Injury Risk Screening and Management Plan - FIRM (Appendix 1) The Falls and Injury Risk Screening and Management Plan is an interventional evidence based guidance to enable staff to implement falls risk reduction interventions. The plan assists staff in their clinical decision making to enable falls prevention interventions for individual patients. The plan is set out in sections A to G and describes the contributory factors for falls such as; Medical, Confusion, Continence, Medication, Mobility, Discharge and Environmental hazards. Not all areas are applicable for all patients; therefore staff are advised to use the plan as a prompt to decide which contributory risk factors are appropriate for the plan of care. For risk assessment of falls from height see use of bedrails section. Physiotherapy Guidance Guidance for Physiotherapy Response and Actions for patients Admitted with a fall. Patient admitted to a ward or CDU with a fall FIRM will trigger liaison with Physiotherapy services at ward handover. CDU patients will require a PICS referral to Physiotherapy Physiotherapist will review circumstances of the fall If the patient fall is secondary to a collapse or acute medical/ surgical problem, the Physiotherapist will undertake the relevant specialist assessment. e.g. Neuro/Respiratory. All other Falls will have a Physiotherapy Falls and Mobility Assessment completed. (Appendix 5) A summary of the Physiotherapists actions will be written in the medical notes. Occupational Therapy Guidance Guidance for Occupational Therapy response and actions for patients admitted following a fall/at risk of falling Falls focus Seating/transfers, cognition, continence and circumstance of fall FIRM will trigger referral to OT via PICS/MMDT/Handover OT will review patient in terms of appropriateness of referral OT to complete OT initial assessment and OT falls assessment (Appendix 3) Page 8 of 35

9 Pharmacy Guidance If a falls assessment has been completed by the medical/nursing staff and the risk assessment score is 1 or more, the ward pharmacist must bring to the attention of the prescriber, the medications which are likely to increase the risk of falls in that patient. If it has been highlighted that a patient is at risk of falls (indicated by risk assessment on PICS) or a patient has been referred by the medical/nursing team, a review of the patient's medication must occur during the following stages: o Medication Review on admission o Professional checking of TTOs o Review of any new prescription during the patient's stay Recommendations/alternatives must be suggested where possible. Any recommendations must be followed up with the medical team looking after the patient either by phone, in person or written in the medical notes use your professional judgement as to which you think is best. Under the pharmacist message section; the words medication reviewed for falls risk must be written and any recommendations must be mentioned. Assessment for the Use of Bed Rails Patient Fall from Height A risk assessment must be completed to determine whether or not bed rails are to be used. This assessment must be clearly recorded using the bed rail risk assessment form. Patients who fall from beds with bed rails attached and in the upright position are to be considered as falling from height. Assessment for the use of bed rails must follow the Trust guidance and documents; staff are advised to refer to the Trust Procedure for the Use of Bed Rails and Trolley Sides. Bed rails usage should only occur following a risk assessment for their use. Patients who are of smaller stature are at greater risk of harm from the use of bed rails and should have additional consideration to the use of bed rails and bed rail bumpers. Footwear Whenever possible, staff should ensure that patients have safe and comfortable footwear prior to walking or transferring. Where patients have no safe footwear and where it cannot be provided by relatives, patients can be issued with a pair of QEHB Charity slippers. The correct footwear poster provides guidance to staff, including when to refer for medical footwear. (Appendix 2) Seating If a risk is identified, appropriate supervision and practical measures must be taken to reduce the risk of falling. The following must be considered: Page 9 of 35

10 o Select a bedside chair of an appropriate height and depth to ensure the patient s feet are flat on the floor, with their hips and ankles at an angle of 90. The ward area will have a selection of different height and depth chairs for you to select from. o If an appropriate chair cannot be found due to specialist requirements for the patient refer to the Occupational Therapy Team for assessment. o If the patient does not have an appropriate chair, DO NOT sit them out. o Consider how long a patient is sat out for, they may require to rest o Consider the use of a one way glide sheet o Tissue viability risk assessment S.K.I.N tool o Consider the risk of falling off the chair when using the pressure relieving cushion o Ensure the appropriate use of pillows for support. o Provide appropriate supervision. o Monitor the patient during Care Rounds What type of bed is suitable? The appropriate selection of a bed for a patient is a significant falls prevention intervention. The reported incident data demonstrates that falls from bed are our second highest risk of falling within the Trust. Therefore there has been a significant investment in the purchase of high/low Spirit beds. Currently there are 2 systems of high/low bed in use at the Trust, the Pegasus (white) bed and the Carroll Spirit bed. The clinical areas have each been supplied with a DVD, supplied by the manufacturer. The Trust no longer uses the Arrow bed system. To support staff with their clinical decision making there is a risk assessment for the use of high/low bed, available from the falls documentation page on the internet. Whilst the patient is on the high/low bed, staff must assess the requirement for the use of the bed daily. Patients should be assessed on an individual basis in regards to the height of the bed, it is advised that the bed be left at it s lowest level at all times, unless assessed and documented that this is a variation to standard advice. New Hospital wards In the new hospital it is advisable that the position patient chairs in side rooms, when clinically possible, should be opposite the bathroom door. In the four bedded bay the chairs should be in the centre part of the bay. The rationale for this is to allow for a clutter free walking space and the most direct route to bathrooms. Patient falls Prevention Leaflet All patients, and where appropriate relatives/ carers of all patients who have fallen or who are at risk of falling in hospital should have access to the Trust falls leaflet which is available from the print room. Patients should receive advice regarding falls and bone health as appropriate. The Staying Steady leaflet is available free of charge from the Age UK website, there is also a large selection of Bone Health (Osteoporosis) leaflets on the National Osteoporosis Society Website. Page 10 of 35

11 Falls and Fracture Prevention Team o The Falls and Fracture Prevention Team will provide expert advice on the prevention of inpatient falls. Review all reported falls clinical incidents and subsequent investigations prior to final draft. o Ensure that staff are supported in the clinical area for post falls interventional care. o Ensure processes are in place to monitor all in patients who fall more than once in an episode of care. o Ensure the clinical teams are supported with specialist advice during reported falls incidents and when serious harm is caused following the Procedure for the Management of Serious Incidents Requiring Investigation (SIRI). o Plan, facilitate and support falls related audits. o Lead annual falls benchmarking and review all action plans. o Work collaboratively with other disciplines within the Trust and support falls prevention strategies. o Work collaboratively with local/regional/national agencies to support falls prevention strategies o Actively engage and support compliance with Care Quality Indicator requirements, e.g. CQC, HIA s and CQUIN Indicators. o Promote awareness through training, materials and awareness campaigns. o Provide relevant materials to raise awareness for inclusion on the Trust intranet site. On discharge from hospital A multidisciplinary decision is to be made as part of the discharge from hospital plan about the most appropriate treatment and place to follow up patients in the primary care or acute setting. The Trust discharge letter must be provided for the patients and their GP, a patient who has been assessed at risk of falling will have an automated Tendency to fall co morbidity. The patient discharge letter must include requests for bisphosphonate, calcium, vitamin D or DEXA scans in accordance with NICE (2004) guidelines. For patients who require additional community rehabilitation, multidisciplinary teams should consider referral to the Rapid Response Team, IMT (community physiotherapy), UHB physiotherapy, or the falls clinic in accordance with local criteria (This is not an exhaustive list and may change due to service development in the community). The falls and Fracture Prevention Team will update the wards at regular time periods to ensure staff have the appropriate referral pathways on discharge. Information on obtaining care alarms is available via occupational therapy usually following a functional assessment or via the Community Care Team on request by patients and relatives. Falls clinic Page 11 of 35

12 There has not been any randomised controlled research on the efficacy of falls clinics. However NICE (2004) recommend that older people who present for medical attention because of a fall, report recurrent falls in the previous year, or demonstrate abnormalities of gait and/or balance, should be offered a multifactorial falls risk assessment. This assessment should be part of an individualised, multifactorial intervention and should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. UHB has a weekly falls clinic to deliver this service. For the aims and referral criteria for this clinic see (Appendix 11). Considerations prior to referral to QEHB Falls clinic o The clinic is not suitable for patients with a one off identifiable accidental fall. o If the admitting team are investigating the patient s fall, they should follow up the patient in their own outpatient clinic. o Falling patients who live in nursing homes and residential homes should be considered for referral to the Rapid Response Team rather than to the UHB Falls Clinic. o If the patient has not had their fall(s) investigated during their hospital stay; if a referral is appropriate the admitting team, should indicate on the discharge form that the G.P can make a referral to the falls clinic. o Patients should not be discriminated against because of mental health or cognitive status (NSF for Older people 2002). Patients with poor memory or cognitive impairment will need to be accompanied to clinic by a carer. Discharge guidance: a) If there is a solely extrinsic cause for the fall and the patient is mobile (with usual walking aids), it is safe to discharge the patient and follow-up is probably unnecessary. b) Referrals back to the patient s GP should be explicit with respect to the cause(s) for concern and suggested actions. c) If the gait is abnormal, the patient is unsteady and this is their normal walking pattern or there are no identifiable and treatable risk factors, refer the patient to the UHB Falls Clinic, physiotherapy or to the Rapid Response Team. d) If the gait is abnormal and the patient is unsteady and this is a new feature/symptom, consider referral to RMO for admission or to the Falls Clinic for investigation? e) If a patient is 65 or over and cannot walk safely with their usual walking aid(s), consider admission to a community bed for assessment and rehabilitation. f) If the patient is medically fit to return home, is mobile, but would benefit from short-term support (e.g. assistance with personal care, rehabilitation and/or a home safety check) consider referral to the Rapid Response Team. The Rapid Emergency and Care Team (REACT) is available Monday to Friday 8am until 6pm to assist with Falls Assessment: Call on Page 12 of 35

13 Assessment of Patients who have fallen in hospital What to do in the event of a patient falling in hospital Assessment of Environment to make sure it is safe for you ( as staff) to assist the patient Identify the mechanism of fall this will influence your clinical assessment Is the patient in pain? Is there any evidence of injury? Follow the ABCDE rule for assessment Ensure that there is a medical assessment of the patient post fall If there is a potential injury follow the: Post head injury observation guidance (Appendix 7) Decision flow chart potential limb fracture (Appendix 9) Decision flow chart potential Spinal injury (Appendix10) The NPSA Alert Essential Care after an inpatient fall (2011) indicates that around 200 patients with fractures or intracranial injury after a fall in hospital experience some failure of aftercare. The alert states that NHS organisations with inpatient beds should ensure that: (Appendix 8) Compliance with the above requirements are met by: Post falls and Manual Handling training Post fall care plan available on the Trust intranet Required Documentation following an inpatient fall Following an inpatient fall staffs are required to complete/review: Post falls care plan PICS initial falls assessment FIRM document Neurological Observations must be completed as per Fall with head injury / suspected head injury (inpatient) guidance. ½ hourly for 4hours 1hourly for 4 hours 2 hourly for 6 hours Consider: Bed rails assessment Use of high/low bed How visible the patient is and patient bed positioning on ward Does the patient require an increased level of interaction(observation/1:1) nursing Confusion and Agitation Guidance and Care plans Staff must also: Complete an incident falls form on Datix If an injury is suspected contact risk department on (leave message if out of hours) Communicate circumstances of the fall with the next of kin(if patient gives permission) Page 13 of 35

14 offer a copy of the incident form to patient/next of kin; if there is a potential for serious harm Refer to Physiotherapy who will complete a post falls assessment Refer Occupational Therapist who will assess and consider a post falls assessment where appropriate Refer to Ward Pharmacist who will review patient medication Physiotherapy Guidance Guidance for Physiotherapy Response and Actions for Patients who have fallen after admission. Ward Physiotherapist is informed of patient fall at handover and /or MDT. Ward Physiotherapists to enquire about in-patient falls overnight. CDU patients will require a PICS referral to Physiotherapy services Physiotherapist will review the circumstances of the fall If appropriate, a falls assessment will be completed using the Physiotherapy assessment for an In-patient who has fallen since admission (Appendix 6) A summary of the findings and actions will be written in the medical notes. If a decision is made by the Physiotherapist that assessment, or intervention from a Physiotherapist would be inappropriate, ineffective or unnecessary, the reasons for this should be clearly documented in the medical notes. If the occupational therapist is not in attendance at the ward handover or MDT the Physiotherapist can refer the patient to Occupational therapy via Pics in accordance with the agreed criteria for referral to Occupational therapy. If the patient does not have any clinical need for Occupational Therapy Falls assessment (based on the criteria for referral), this will be documented in the Physiotherapy falls assessment. Occupational Therapy Guidance Guidance for Occupational Therapy Response and Actions for Patients who have fallen after admission: Occupational therapy falls lead will continue to review falls Datix form and send it to the ward Occupational therapists to alert them of in-patient fallers. PICS referral from Physiotherapists to occupational therapy according to agreed criteria PICS referral triggered by nursing staff via the FIRM MDT/Handover If the Occupational Therapist is in attendance at ward Handover/ MDT: Discuss circumstances of fall with ward staff and Physiotherapist, or review the medical notes. A clinical decision will be made about the appropriateness of assessing /not assessing the patient based on the agreed criteria for occupational therapy review. Where these criteria are met, Occupational Therapy falls assessment will be completed and the findings documented in the medical notes. If the occupational therapist is not in attendance at the ward handover or MDT the Physiotherapist can refer the patient to Occupational therapy via PICs, in accordance with agreed criteria for referral to Occupational therapy.. Page 14 of 35

15 Multiple Fallers Occupational Therapy and Physiotherapy Falls leads to be forwarded alerts for patients who have fallen more than once. These patients will be reviewed by both disciplines and any actions documented in the medical notes. Pharmacy Guidance Refer to at risk of falls section The Trust s Mandatory training for falls is identified in the Trust s Training Catalogue (Training Needs Analysis). The following shows all the different types of training that is available; where an M is shown this indicates that the Training is mandatory. Department managers have a responsibility to consider staff training needs in relation to: o Falls reporting. o Falls assessment. o Falls benchmarking. o Implementation of the Patient Falls and Injury Screening and Management Plan. o Ability to undertake accurate patient handling assessments. o PICS training All Clinical Staff o As part of rolling program for frontline staff every 2 years M o All new staff receive training on induction via the HPIP program M o Trust falls annual training session is available for all disciplines of staff. o Training and Education can be requested as required o Training and Education programs in clinical areas as identified by the falls team/ investigations Medical Staff o Junior doctors have teaching on falls assessment and fracture prevention as part of their rolling educational programme. Non Medical Staff o Physiotherapists have quarterly education sessions for new staff in rotation posts. o Physiotherapy/ OT and Pharmacy receive annual updates from the Falls Team Associated Documents Patient Internal Transfer Procedure. Policy for the Prevention, Reduction and Management of Slips, Trips and Falls, Including work at height Training Catalogue (Training Needs Analysis) Guidelines for the Use of Bed Rails and Trolley Sides Discharge and Transfer of Care Procedure Page 15 of 35

16 References and Bibliography Audit Commission (2000). United they stand: Coordinating care for elderly patients with hip fracture. Audit Commission, London. Department of Health (2002) National Service Framework for Older People. Department of Health, London. Department of Health Policy (2007) Guidance: Urgent care pathways for older people with complex needs. Department of Health, London Healey, F et al (2004) Using risk factor reduction to prevent falls in older in-patients: a randomised controlled trial. Age & Ageing. 33, p National Patient Safety Agency. (2007). Third report from the Patient Safety Observatory. Healey F, Scobie S et al. Slips, trips and falls in hospital. National Patient Safety Agency, London. National Patient Safety Agency. (2011). NPSA/2011/RRR001 Essential care after an inpatient fall. National Patient Safety Agency, London. National Institute for Clinical Excellence (2004) Guidelines Falls: the assessment and prevention of falls in older people (No 21). National Institute for Clinical Excellence, London. National Institute for Clinical Excellence (2007) Head injury, triage, assessment, investigation and early management of head injury in infants, children and adults. Methods, Evidence and Guidance. National Collaborating Centre for Acute Care, London. Accessed University Hospital Birmingham NHS Foundation Trust. (2008) Guidelines For The Use Of Bed Rails And Trolley Sides. University Hospital Birmingham NHS Foundation Trust, Birmingham. University Hospital Birmingham NHS Foundation Trust. (2008) Guidelines for the Management of Confused and Agitated Patients. University Hospital Birmingham NHS Foundation Trust, Birmingham. Page 16 of 35

17 Patient Label Falls and Injury Risk Screening and Management Plan Falls Care Bundle The Falls Screening Tool Section must be completed on PICS for admission or transfer for all patients. FALLS RISK SCREENING TOOL History of falls before or on admission? Yes/No Patient unsteady/unsafe with/without walking aid/s and/or tries to walk alone Yes/No Falls since admission? Yes/No Patient or relatives anxious about patient at risk of falling? Yes/No If YES to any of the questions above, complete the Falls Management Plan below Name Signature Designation Date..Time. Action suggested A plan of care will be required for all actions identified and implemented below A. Was the patient admitted after a fall/ have they fallen since admission? Prevention Interventions Document relevant actions in this section Date / time/ sign Print Name Designation Review /date/ time/ sign Print Name Designation Monitor and record lying and standing BP. If systolic BP drops by more than 20 mmhg inform doctor. Refer to doctor to consider examination of the patient s cardiovascular, and neurological systems to look for causes of falls. Perform an ECG and ensure ECG has been reviewed by a doctor. All patients over 65yrs of age with risk of falls must have ECG. Liaise with doctors to consider osteoporosis risk. Consider prescribing a bisphosphonate in line with NICE. Offer the patient, and their family or carers, a copy of the University Hospital Birmingham NHS Foundation Trust (UHB) Falls Advice leaflet. Consider Physiotherapy and OT (PICS) referral Complete Care Rounds B. Does the patient seem to be confused or agitated at any time? Refer to the UHB Agitation and Confusion Guidelines Ensure an abbreviated mental test is completed and record result in the medical notes. For potential delirium complete 4AT assessment. Seek advice from psychiatric services (RAID) if appropriate. Consider causes of confusion/delirium undertake infection screening if appropriate Establish the appropriate level of interaction (observation) required. Is the patient in the right bed, in the right bay? Consider cohorting patients if enhanced interaction (observation) required. Assess the need for bed rails, if not suitable, document on this form (Refer to the Bed Rail Guidelines). Use a low-profile bed, if available. If not, consider Enterprise bed and keep the bed at its lowest level. Refer to occupational therapy if further cognitive assessment required. C. Does the patient have poor eyesight? If the patient wears spectacles, ensure they are clean and worn, or within reach, at all times. If eyesight is poor despite spectacles, advise patient to arrange to see an optician after discharge. Ensure lighting is adequate where possible Utilise underbed lighting on Enterprise beds Page 17 of 35

18 Patient Label Action suggested A plan of care will be required for all actions identified and implemented below D. Does the patient need to go to the toilet frequently? Prevention Interventions Document relevant actions in this section Date / time/ sign Print Name Designation Review /date/ time/ sign Print Name Designation Assess continence. Complete and document urinalysis Consider proximity to the toilet on ward. Encourage good fluid intake Ensure call bell is within reach. Offer a routine of frequent toilet visits as part of the Care Round E. Is the patient on 4 or more medications? Communicate to pharmacist that patient is at risk of falls Pharmacist will identify patient on PICS system The Ward Pharmacist will complete Medication Use Review and liaise with medical team Ensure any change of medication explained to patient and communicated to G.P on discharge (TTO form) refer to medical team F.Does the patient have any mobility/ transfer problems with or without walking aids? Perform and implement UHB Patient Handling Assessment. Refer to physiotherapist via ward handover Ensure walking aids (specify...) are within easy reach. Ensure patient wears own shoes or sturdy slippers that fit. Patients, who do not have slippers, supply a pair of UHB Charity slippers. (wards 410/518/302) Cut, or file, the patient s toenails in line with UHB Nail care guidelines. Discuss at MDT which services are required on discharge Page 18 of 35

19 G. Are there any environmental hazards that contribute to a fall? Minimise bedside clutter and trip/slip hazards such as wet floors, trailing flexes, leads, drips and catheters. Ensure patient can reach his/her possessions (e.g. water and tissues) safely. Ensure use of call bell is explained and it is within reach. Ensure the bed and chairs are of a height and size that allow safe transfers. Liaise with occupational therapy if seating assessment required. Consider length of time that is appropriate for patient to be sitting in chair. Consider use of a one-way glide sheet to prevent patient from slipping from chair. Page 19 of 35

20 ppendix 2: Correct Footwear Who needs medical footwear Definition of medical need: Any patient who has a medical problem which prevents a normal diameter slipper from being worn. For example: i) Leg ulcers/sores/leaking wounds requiring dressings. ii) Oedematous legs and feet secondary heart failure and other conditions which compromise venous or lymphatic circulation. iii) Any condition requiring dressings which make it impossible to put slippers on. These patients need appropriate footwear from the appliance department. Who needs Charity Slippers Any patient who have been assessed at risk of falling. And that Those patients that have no family or friends to provide appropriate footwear. Slippers are available from CDU, 518, 410 and ELB Who needs Tread Socks Any patient who does not have any footwear and are NOT at risk of falling. These may also be used for patients wearing TED stockings. No longer recommended for any patient Page 20 of 35

21 Patient s Name: Consent gained for assessment: ID: Id Checked: OCCUPATIONAL THERAPY ASSESSMENT Falls Assessment History of this fall: Date: Previous falls:. How many falls have you had in the past:- 3 months / 6 months / 12 months / Do you remember your last fall? Do you recall hitting the ground? Do you remember why you fell? Have your falls happened in the same place/whilst doing the same task? Do you have a fear of falling? Environment: Suggested actions Appropriate footwear Yes/No Liaise with family / NOK Visual problems Yes/No Focus referral / eye test Difficulty getting to the toilet Yes/No Commode / toileting aids Appropriate seating Yes/No Seating assessment Is the patient confused or agitated? Yes/No Cognitive Assessment Action Plan / Implications for discharge: Careline at home Community referral for Home Hazard Assessment Other Community services Patient agrees Yes / No Yes / No Yes / No OT Name: Signature: Date: Time: Page 21 of 35

22 Patient s Name: Consent gained for assessment: ID: Id Checked: Falls Guidance OCCUPATIONAL THERAPY ASSESSMENT Problem Action Further input Seating Issues Assessment of current chair : At home In hospital Referral for supportive seating if needed Liaise with nursing staff or Tissue Viability if additional equipment needed Suggest alternate seat height Assessment with supportive seating Referral onto community for seating on discharge Environmental issues Suggest any changes to the ward / room layout Check appropriate footwear is available Assessment for falls risk hazards in home Appropriate equipment / adaptations Care-line Transfer heights New Agitation or confusional state If changes from normal then complete cognitive screen / assessment Corroborate history with family Initiate referral to Social Worker or Discharge liaison Nurse if increased support is needed on discharge Establish impact any changes may have on function Toileting issues Suggest positioning patient closer to toilet Suggest equipment for use on ward e.g. urinal bottles Consider equipment for home Consider behaviour of patient Check no underlying medical issue / infection OT Name: Signature: Date: Time: Page 22 of 35

23 Queen Elizabeth Hospital Birmingham Pt. name: Physiotherapy Falls and Mobility Assessment Date: Reg. no: Consent to assessment: Y N Pt. ID confirmed: Y N History of most recent fall (please specify any surgical intervention) Does the patient remember hitting the floor? If No consider review by a doctor. Yes No Did the patient feel giddy/dizzy prior to this fall? Yes No If Yes consider review by a doctor and/or assessment of lying and standing BP If Yes, how does the patient describe this dizziness? vertigo / faintness / off-balance / other Was the patient able to get up? Yes No Does the patient have a call alarm? Yes No History and number of previous falls Investigations, PMH, (consider relevant other renal state, acute infection?) SH (social support, care packages, W&D, stairs, steps into house, stair lift, handrails) DH: Is the pt on 5 or more medicines? Yes No (If yes, consider discussing with medical team) Does the patient present with risk factors for osteoporosis? (Low trauma fracture, family history of osteoporosis or hip # age < 70, early menopause (untreated), steroid therapy >3 months, low weight BMI<19) If Yes discuss with Drs Current footwear Continence Vision Alcohol history Bi-focals: Y N Lying and standing BP (A significant change is a drop in systolic bp of 20 mg hg with symptoms) Fear of falling 0 = I m not afraid of falling 1 = I occasionally think I may fall. 2 = I often think I may fall 3 = I am constantly afraid of falling Signature / print name: Page 23 of 35

24 Physiotherapy Falls and mobility assessment Pt. name: Reg. no: Memory Place Year Time Age Total /4 Cognitive state Pain / analgesia Exercise tolerance Changes in function and mobility due to fall (ie how do they compare now from their pre-admission state) Restricted ROM relevant to falls Muscle strength relevant to falls Significant neurology relevant to fall (consider presence of neurological history, tremor, tone, sensory changes ) Current bed mobility Current sitting/sit to stand/balance, transfers Current standing ability/ balance Current gait analysis (heel strike, toe off, pattern, symmetry) (consider elements of Berg Scale: sit to stand, standing, standing feet together) Patient perception of needs Consider Timed up and go test, TUSS Patient expectation / goals Clinical impression / summary Actions following assessment (immediate / future) Walking aid issued (specify aid and supervision required) Exercise programme offered (document / add to treatment plan) Yes No NA Declined Written and verbal falls advice given to patient Yes No Signature / print name: RG, KF, NF April 2011 Page 24 of 35

25 Queen Elizabeth Hospital Birmingham Physiotherapy Assessment for an In-patient who has fallen since admission Patient name: Date: Patient Reg. no: I.D confirmed: Y N Consent to assessment: Y N Date of fall: How did you know this patient had fallen? Actions already identified and taken by Nursing or Medical staff post fall i.e. read the Nursing Post Fall Management Care plan Subjective details of fall and summary of event after discussing with ward staff and patient (Any dizziness prior to the fall?) Considerations post fall Does the patient have any signs of injury? Actions including who you have spoken to. (nurses, Doctors, OTs) Sitting posture and balance (consider: support required, chair height, footwear, sitting tolerance). Recommended time for sitting in chair? Gait post fall (consider appropriateness of walking aids and level of supervision required) If the patient is already known to you, has their mobility changed post fall? Signature: Print name: Page 25 of 35

26 Physiotherapy assessment for an In-patient who has fallen since admission Patient name: Considerations post fall Ability to transfer bed/chair: (level of supervision required) Patient Reg. no: Actions including who you have spoken to (nurses, Doctors, OTs) Strength and balance impairments that may have contributed to the fall Does the patient have suitable footwear? Is the patient agitated or confused? (ability to engage with treatment or instructions) Any other risk factors? (bed rails, environment, ability to observe the patient, ability to use call bell, fear of falling) Clinical impression and summary: (Consider any changes you may need to make to their goals, treatment or patient therapeutic handling plan) Does the patient need an OT assessment?(check against OT criteria) No - Patient does not fit OT criteria. Yes - OT already aware of patient Yes - PICS referral to OT required Rate the likelihood of this happening again. Unlikely1-5% Possible 6-20% Likely 21-50% Almost certain>50% Signature: Print name: Date: Page 26 of 35

27 Appendix 7: Guidelines following a fall with head injury or suspected head injury Fall with head injury / suspected head injury (inpatient) Head injury: any trauma to the head, other than superficial injuries to the face Doctors responsibilities Assess patient with suspected head injury & perform neurological examination Nurses responsibilities Monitor level of consciousness for potential deterioration. Complete Neurological Observations Neurological observations MUST be commenced on any patient following a fall if any of the following signs/symptoms or indications apply Head injury reported by patient, witnessed, or cannot be excluded External bruising, swelling or laceration to the head New onset of symptoms suggestive of brain injury Vomiting, headache, altered consciousness, dizziness On anticoagulation therapy (full anticoagulant, not DVT prophylaxis) Pain or tenderness on head Patient must be commenced on a neuro observation chart & have neurological observations recorded half-hourly (overnight the patient must be woken up) until GCS (Glasgow Coma Scale) returns to what is normal for the patient. ½ hourly neuro obs for 4 hours If GCS is NOT normal for patient, there must be a Medical Review within 30 minutes If GCS drops by 1 or more points Review by doctor Within 30 minutes Recommence ½ hourly neuro obs 1 hourly neuro obs for 4 hours 2 hourly neuro obs for 6 hours Review and back to normal regime for observations Note Patients with cognitive decline or dementia may not present in the same way As well as the above, distinct changes in usual behaviour / level of agitation, restlessness or listlessness will require immediate medical review All other post fall care should continue in line with falls policy/procedure. Reference: NICE Clinical Guideline 56. Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults (NICE, 2007) Page 27 of 35

28 Appendix 8: NHS organisations with inpatient beds should ensure that: 1. They have a post-fall protocol that includes: a) checks by nursing staff for signs or symptoms of fracture or potential for spinal injury before the patient is moved; b) safe manual handling methods for patients with signs or symptoms of fracture or potential for spinal injury*; c) frequency and duration of neurological observations for all patients where head injury has occurred or cannot be excluded (e.g. unwitnessed falls) based on National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 56: Head Injury; d) timescales for medical examination following a fall (including fast track assessment for patients with signs of serious injury, or high vulnerability to injury, or who have been immobilised). 2. Their post-fall protocol is easily accessible (e.g. laminated versions at nursing stations). 3. Their staff have access to clear guidance and formats for recording neurological observations using a 15 point version of the Glasgow Coma Scale (GCS) and that changes in the GCS that should trigger urgent medical review are highlighted. 4. Their staff have access at all times to special equipment (e.g. hard collars, flat-lifting equipment, scoops)* and colleagues with the expertise to use it, for patients with suspected fracture or potential for spinal injury. 5. Systems are in place allowing inpatients injured in a fall access to investigation and specialist treatment* that is equal in speed and quality to that provided in emergency departments and conforms to NICE Clinical Guideline 56: Head Injury. Page 28 of 35

29 Appendix 9: Non Spinal Following patient assessment and completion of post falls care plan Potential suspected limb fracture - Non Spinal Fracture following assessment Injury unclear following assessment Patient to X-ray within 1 hour Complete PICS radiology request. To obtain urgent imaging discuss with: Radiology Inpatient Reception (in hours) 12298/99 A&E Radiology Reception (out of hours) Is fracture confirmed? NO Physiotherapy referral YES Refer to Senior Trauma (Registrar) opinion within 2 hours and inform Trauma Nurse Practitioner on Fracture confirmed? NO Follow Falls Guidance Have clinical signs improved? NO Commence suspected hip fracture protocol YES No further intervention Hip fracture? NO Fracture management plan YES If hip fracture confirmed commence hip fracture protocol Page 29 of 35

30 Appendix 10: Spinal Following patient assessment and completion of post falls care plan Potential suspected spinal fracture Do not move patient Obtain spinal injury pack located on Ward 412 Page on call Trauma Registrar with post fall spinal alert message Has injury been identified by Medical Trauma Team? NO Follow Falls Guidance YES Following assessment, Trauma Team to immobilise patient in hard collar and spinal scoop Patient requires imaging Complete PICS radiology request. To obtain urgent imaging discuss with: Radiology Inpatient Reception (in hours) 12298/99 A&E Radiology Reception (out of hours) Has injury been identified by Radiology? NO Follow Falls Guidance YES Senior review by Trauma Team and Management Plan documented in patient s notes Follow Spinal Care Bundle Page 30 of 35

31 Appendix 11: Falls Clinic Aims and Patient Criteria. Aims: - To comply with the good practice guidelines for the management of older people who fall. To ensure that the cause of a person s fall is identified. To ensure that patients have access to information and strategies which could reduce the harm and distress caused by further falls. To ensure that patients have access to treatment which may reduce their risk of further falls. (For example: medical review, balance training, podiatry opinion.) Criteria for referral to the falls clinic: The presence of some or all of the following features may trigger a referral to the falls clinic: Patients with unexplained falls. Patients who have previously sustained a fracture. Patients who have attended A+E and demonstrate risk factors for falling are identified. Patients who have fallen in their own home. Patients who have >1 risk factor and have fallen. Patients who are very afraid of falling. Carers/ relatives who are concerned about the patient risk of falling. Patients whose fall may be due to a medical problem, which has not already been identified. Page 31 of 35

32 Appendix12: Learning through action to reduce Falls Patient location: Injury following fall: Patient date of birth: Date of fall: Patient name: Patient Hospital number: Incident form No Date Falls Risk Assessment completed Yes No Date of beginning this process Falls Management Plan completed Yes No Date.. Name of the person coordinating the review: Their job title: Funded staff establishment Staff establishment at time of fall: Early Late Night Early Late Night Qualified Qualified Unqualified Unqualified A - What happened? Date Time Events/interventions Outcome/Actions Page 32 of 35

33 Date Time Events/interventions Outcome/Actions B - Critical problems/issues Example: No review of causes of hypotension Patient not offered high low bed Main contributory factors/root causes Example: Poor documentation of falls risk factors Page 33 of 35 Staff knowledge regarding national guidance

34 B - Critical problems/issues Example: No review of causes of hypotension Patient not offered high low bed Main contributory factors/root causes Example: Poor documentation of falls risk factors Staff knowledge regarding national guidance C Reflect on what the information you have gathered is telling you For each of the most significant critical problems/issues consider: what has contributed to, influenced or caused that problem/issue? You may have a long list of contributory factors. Review it and identify the main contributory factors (root causes) which have had the greatest impact on the incident/infection and would help reduce the chances of it happening again. Action Plan Recommendations/ solutions What changes need to be made? Actions and steps How will you make the changes? Person responsible for the change Who will be the lead person responsible for ensuring that each step happens? Timescale/ Milestones What is the due date for completion of each step or action? Date completed/ achieved When you have completed this process: Check that each stage has been completed and recorded. Record the details of other key staff who have participated and ensure that the outcome is fed back to all of them. Name Designation Date informed Page 34 of 35