Policy for the Prevention of Slips, Trips and Falls for Inpatients within Western Health and Social Care Trust Facilities

Transcription

1 Policy for the Prevention of Slips, Trips and Falls for Inpatients within Western Health and Social Care Trust Facilities October 2010

2 Policy Title: Policy for the Prevention of Slips, Trips and Falls for In-Patients within Western Health and Social Care Trust Facilities Policy Reference Number: Primcare10/01 Implementation Date: October 2010 Review Date: October 2012 Responsible Officer: Assistant Director for Governance, Quality and Performance Page 2 of 13 Policy for the Prevention of Slips and Trips October 2010

3 Table of Contents Introduction... 4 Aim of Policy... 4 Scope of Policy... 5 Definitions... 5 Risk Factors That Alert Increased Tendency To Fall... 6 Balancing Risk and Personal Freedom... 7 Individual Patient Assessment and Multifaceted Interventions... 7 Managing Risk... 9 Documentation... 9 Appendix: Individually Targetted Falls Risk Assessment & Interventions References Please note: Within this document the word patient is used also to denote client and refers to any person residing in an inpatient facility in the Western Health and Social Care Trust (Western Trust). Page 3 of 13 Policy for the Prevention of Slips and Trips October 2010

4 Introduction Patient falls have significant human and financial costs. For individual patients, even falls without injury may lead to distress and loss of confidence. Falls with injury can lead to pain and suffering, loss of independence and in some cases, death. Furthermore, following a fall, patients relatives and nursing staff can feel anxiety and guilt, which can adversely affect caring relationships. A patient falling is the most common patient safety incident reported to the National Patient Safety Agency (NPSA) from inpatient services. In a single year, 200,000 falls were reported to the NPSA, 26 of which resulted in the patient s death, with further deaths following hip fractures. Furthermore, there were significant associated financial costs that could have otherwise been prevented. The NPSA report on Slips, Trips and Falls in Hospital (NPSA, 2007) states that: a range of both clinical and environmental interventions need to be applied in order to have the greatest impact in reducing falls. (NPSA, 2007, p7). Aim of Policy The aim of this policy is to reduce the risk of patients falling, in primary and secondary care services that have in-patient facilities. Staff must identify the risk factors and undertake appropriate interventions that will reduce the likelihood of patients slipping, tripping or falling. The intention is to protect patients from risk of harm while maintaining their right to make decisions, increase their activity, enhance their confidence, and maximise their independence. Page 4 of 13 Policy for the Prevention of Slips and Trips October 2010

5 Scope of Policy This policy is for all staff caring for adults who are patients within the Western Trust s inpatient facilities. Policy Objectives To promote safe, high quality care and wellbeing for patients at risk of falling; To enable staff to identify the combination of clinical and environmental risk factors for each individual patient; To enable staff to identify the most effective interventions that will urgently minimise the risk of falling; To ensure staff clarify with the patients/carers the level of protection that will be required to minimise harm while maintaining the patient s personal freedom, dignity and independence; To assist in the reduction of slips, trips and falls evidence of which will be determined by reviews of the number of clinical incident reports. Definitions All slips, trips and falls even those considered as a near miss events must be reported in accordance with the Trust s clinical incident reporting mechanism. The following definitions provide clarity on what constitutes slips, trips and falls and are considered appropriate for the clinical setting: SLIP A slip is to slide accidentally causing the patient to lose their balance, this is either corrected or causes a patient to fall (adapted from COED, 2000). TRIP A trip is to stumble accidentally, often over an obstacle; causing the patient to lose their balance, this is either corrected or causes a patient to fall (adapted from COED, 2000). FALL A fall is an event which results in the patient or a part of their body coming to rest inadvertently on the ground or other surface lower than the patient, whether or not an injury is sustained (Cohen & Guin, 1991). Page 5 of 13 Policy for the Prevention of Slips and Trips October 2010

6 Risk factors that alert increased tendency to fall Preventing patients from falling is a particular challenge in hospital settings because the treatments and interventions that ensure a patient s safety sometimes hinder their independence. Rehabilitation always involves risks, and a patient who is not permitted to walk without staff may become a patient who is unable to walk without staff. Older people are more vulnerable to falls and those who have fallen once are at a higher risk of falling again. Surgery and anaesthetic can cause imbalance while sedation, pain relief and other medications can affect balance and memory. Delirium, brain injury and dementia can cause confusion. Patients with dementia are at a higher risk of falling as they find it difficult to recognize environmental hazards, find it hard to save themselves when they become offbalance, and may be unaware of any limitations to their own mobility. Dementia is also associated with changes in walking patterns and low blood pressure on standing, making people with dementia at least twice as vulnerable to falls compared to those without memory or cognitive problems. Most falls are due to a combination of several factors and the interaction between these factors is crucial. The following intrinsic and extrinsic factors will increase the likelihood of a patient falling: Types of intrinsic and extrinsic risk factors Examples Intrinsic Factors Extrinsic Factors Personality and lifestyle Age related Illness or injury Medication Environment Activities, attitudes to risk, independence and receptiveness to advice. Changes in mobility, strength, flexibility and eyesight that occur even in healthy old age. Stroke, arthritis, dementia, cardiac disease, acquired brain injury, delirium, Parkinson s disease, dehydration, disordered blood chemistry and hypoglycemic episodes in diabetes. Sleeping tablets, sedation, painkillers, medication that causes low blood pressure, medication with Parkinsonian side effects, alcohol and street drugs. Lighting, wet floors, loose carpets, cables, steps, footwear, distances and spaces. Page 6 of 13 Policy for the Prevention of Slips and Trips October 2010

7 Balancing risk and personal freedom Healthcare staff have a duty of care to prevent or reduce risk of harm to a person or others. They are also expected not to interfere unduly with an individual s personal freedom and autonomy. In the interest of providing a reasonable degree of freedom for individuals, some degree of risk will exist. All harm cannot be eliminated but staff must demonstrate that they have minimised risk as far as reasonably possible. Patients and their carers views MUST be included in planning interventions, which will give clarity about providing a balance between maintaining and promoting independence and dignity and minimising risk of harm. Individual patient assessment and multifaceted interventions The NPSA report (2007) states that NHS organisations place too much emphasis on completing falls risk scores rather than preventing falls. Instead research shows that applying multi-faceted interventions has the greatest effect in reducing patients falling. On admission, all adult patients must be screened for the risk of falls and then individually assessed regarding any physical, psychological and environmental factors to determine their level of dependence in light of their need for support, treatment and care. Assessment of risk must be undertaken when patients enter an in-patient setting, when transferred from one area to another, when changes in the patient s condition increase their risk of falling or at review of initial assessment. For those who are vulnerable, discussions must include the patient s main carer, to ensure that the most effective interventions are selected and agreed. Main Risk Factors: Immediately following a fall Has a problem with balance, walking unsteadily Appears agitated, restless, confused, prone to fits History of falls, slips, trips or stumbling On daily medications that impact on balance (see above table) Patients whose size places them at risk of falling from hospital beds / trolleys Patients over 65 years are at a higher risk of falls All the above intrinsic and extrinsic factors need to be considered, however the main risk factors if evident MUST have interventions to reduce the likelihood of the patient slipping, tripping or falling. Page 7 of 13 Policy for the Prevention of Slips and Trips October 2010

8 Interventions A combination of environmental and clinical interventions is required to minimise the risk factors and significantly reduce the likelihood of patients falling. These interventions are dependent upon a thorough risk assessment in close consultation with patients and/or their carers. Often this will involve specific multidisciplinary assessments and action plans that will address the following as appropriate: Detecting and treating causes of delirium/ cognitive impairment Detecting and treating cardiovascular illness Detecting and treating neurological conditions that increase risk of fits/falling Detecting and treating osteoporosis Detecting and treating foot conditions that hinder balance Detecting and treating or managing incontinence or urgency Reviewing medication associated with a risk of falls Detecting and treating eyesight problems and having the right glasses Providing safer footwear Physiotherapy, balance-gait assessment appropriate exercise plan and access to appropriate walking aids Communication with family. Environmental Assessment An assessment must be made of the environment including the following: Flooring Lighting Door/ hand rails Toilet/ bathroom facilities Distances and spaces between amenities Position in ward environment e.g. single room, open bay Trip hazards Furniture and medical equipment. Environmental Interventions Environmental interventions must include: The line of sight for staff observing identified at risk patients Page 8 of 13 Policy for the Prevention of Slips and Trips October 2010

9 Increasing observation or supervision Ensure appropriate use of alarm devices Ensure close proximity of call bells Ensure floors are clean, free from spillages and trip hazards (cables, clutter, equipment) Ensure close proximity of handholds, beds, chairs and toilets Have a range of beds and chairs to suit different patients needs Assessing the need for bedrails if the benefit outweighs the risks. It is important to note that the use of alarm devices does not replace the need for increased supervision or observation. Managing risk When a patient falls, staff must ensure least harm, ensure urgent medical assessment and make the patient comfortable in accordance with moving and handling legislation. Following a fall the patient s next of kin or an identified individual must be informed. A review of the risk assessment and intervention plan must also be undertaken and implemented. All falls may result in some degree of harm, the impact of which has repercussions for patients, staff and the organisation. In order to reduce and prevent falls, managers must maintain close surveillance of the impact of this policy. Staff responsible and accountable for patient care must regularly review and investigate the causes of slips, trips and falls. Detailed information must be recorded in the patient s records and also forwarded to the Risk Management Department in line with the Trust s clinical incident reporting mechanism. Documentation Patient records must be based upon a rigorous assessment that clearly demonstrates all the identified risk factors with the corresponding interventions associated with the patient s overall condition. Planned care must be accompanied by the times and frequency required for undertaking actions. This should include review dates for evaluation of interventions, which are then modified accordingly. Records must also demonstrate the patients and/or carers involvement in decisions that might impinge upon their personal freedom or dignity while reducing risk of harm. The current NMC (2009) Record Keeping: Guidance for Nurses and Midwives must be adhered too. Page 9 of 13 Policy for the Prevention of Slips and Trips October 2010

10 Individually targeted intervention tool NPSA report (2007) states that NHS organisations place too much emphasis on completing falls risk scores rather than preventing falls. Instead research shows that applying multi faceted interventions has the greatest effect in reducing patients falling. The following tool provides the risk factors that alert staff to a patient s increased tendency to fall with a combination of interventions that must be selected to target individual need. Instruction for Use All adult patients should be screened at the earliest appropriate opportunity but within 24 hours of admission to hospital. All patients deemed to be at high risk of falling in hospital must have intervention plan completed. Individuals will be reassessed following a change in condition, in the event of a fall in hospital or after a period of 28 days in hospital setting. Assessment of Risk Factors Identify if any of the risk factors are present and document Yes or No against those that apply appropriate interventions Record and describe the appropriate interventions for the patient Planned care must be accompanied by the times and frequency required for undertaking actions. All interventions must be followed by a review date for evaluation and modified accordingly Complete section for recording Assessment number, Date completed and Review Date Print name and designation and sign form Continue to record reviews and changes to interventions on reverse of form. Page 10 of 13 Policy for the Prevention of Slips and Trips October 2010

11 INDIVIDUALLY TARGETED FALLS RISK ASSESSMENT & INTERVENTIONS Western Health and Social Care Trust October 2010 If the patient presents with any of the following main risk indicators then the following risk assessment and interventions must be initiated RISK FACTORS Y N Appendix: since admission Individually Targetted Falls Hospital Risk number. Assessment & Tries to walk alone but unsteady / unsafe? D.O.B: Age: Interventions A B C History of falls before admission? When reviewing Patient or relatives anxious about falls? D Medication associated with falls e.g. anti-depressants, sleeping tablets, sedation, anti-psychotics E Are you aware of substance withdrawal e.g. drugs or alcohol F History of confusion or is patient confused at present? ` Location: Ward : Room: If Yes to any of the questions above or you, patient, carer still remain concerned, please complete the care plan below. Assessment of Risk Factors Mental state Environmental Issues Restricted Mobility Interventions Decide level of supervision Nurse in sight of staff Medical assessment re: delirium/cognitive impairment/disorientation Orientate patient to time and place Call bell (inappropriate for confused, disorientated patients) and personal possessions in easy reach Nurse in direct line of view Lower bed height/use low bed OT assessment & access to appropriate adaptive intervention Use suitable chair Consider alarm sensors Bed rail assessment Ensure equipment in least obstructive place Remove possible causes of distress e.g. background noise, light, temperature Bedside light left on overnight Identify assistance with 1, 2, With walking aid Moving and handling assessment to be completed Please affix addressograph here if available. Patient's Name : Address: Assessment 1 Describe interventions initiated Appendix Footwear Ensure well fitting footwear, no trailing laces, non-slip sole Bladder & Bowel Management Medications Patient's Vision / Hearing Medical Conditions Communication Referrals Assessor s Printed Name: Designation: Signature: Treat cause of frequency Treat possible constipation Offer regular assistance to the toilet Urinalysis MSU sent Ask Doctor to review medications / times associated with a risk of falls Do not stop abruptly Ensure patients glasses are worn Last eye check up Initiate medical/orthoptic referral if glasses absent or inadequate or concerns re: vision Explain positioning of potential obstacles Leave personal objects within easy reach Hearing aid with patient if used Refer to Doctor to detect and treat cardiovascular disease, postural hypotension or osteoporosis Lying / standing BP recorded Discuss with patient/ carer and gain agreement on the use of interventions which may infringe on their personal freedom and autonomy Referrals to Physiotherapy Occupational therapy / Falls prevention service Rehabilitation Team, Brain Injury team Other Expected date of Discharge / / Date Completed Page 11 of 13 Policy for the Prevention of Slips and Trips October 2010 Further assessments and interventions to be recorded overleaf. Review Date

12 Assessment of Risk Factors If Yes to any of the questions above or you still remain concerned, please complete the care plan below. Please write Y or N to risk factors. Mental state Environmental Issues Restricted Mobility Footwear Bladder & Bowel Management Medications Patient's Vision / Hearing Medical Conditions Communication Referrals Interventions Assessment 2 Assessment 3 Assessment 4 Western Health and Social Care Trust October 2010 Decide level of supervision Nurse in sight of staff Medical assessment re: delirium/cognitive impairment/disorientation Orientate patient to time and place Call bell (inappropriate for confused, disorientated patients) and personal possessions in easy reach Nurse in direct line of view Lower bed height/use low bed OT assessment & access to appropriate adaptive intervention Use suitable chair Consider alarm sensors Bed rail assessment Ensure equipment in least obstructive place Remove possible causes of distress e.g. background noise, light, temperature Bedside light left on overnight Identify assistance with 1, 2, With walking aid Moving and handling assessment to be completed Ensure well fitting footwear, no trailing laces, none-slip sole Treat cause of frequency Treat possible constipation Offer regular ass is tance to the toilet Urinalysis MSU sent Ask Doctor to review medications / times associated with a risk of falls Do not stop abruptly Ensure patients glasses are worn Last eye check up Initiate medical/orthoptic referral if concerns re: vision or glasses inadequate / absent Explain positioning of potential obstacles Leave personal objects within easy reach Hearing aid with patient if used Refer to Doctor to detect and treat cardiovascular disease, postural hypotension or osteoporosis Lying / standing BP recorded Discuss with patient/ carer and gain agreement on the use of interventions which may infringe on their personal freedom and autonomy Referrals to Physiotherapy Occupational therapy / Falls prevention service Rehabilitation Team, Brain Injury team Other Expected date of Disc harge / / Date Review Date A B C D E F A B C D E F A B C D E F Page 12 of 13 Policy for the Prevention of Slips and Trips October 2010 Assessor s Printed Name Assessor s Signature

13 References Cohen l, Guin P (1991) Implementation of a patient fall prevention program. Journal of Neuroscience Nursing. 23(5): National Patient Safety Agency (2007) Slips, trips and falls in Hospital. The third report from the patient Safety Observatory. National Patient Safety Agency. London. NMC (2009) Record Keeping: Guidance for Nurses & Midwives. Nursing and Midwifery Council. London Page 13 of 13 Policy for the Prevention of Slips and Trips October 2010