Clinical Guidance. Change History Date Change details, since approval Approved by

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1 Clinical Guidance Guidance n the management f adult inpatient falls Summary This guidance is fr all staff in the preventin and management f falls in adult in-patients. It invlves a risk assessment and 5 interventins t manage the risk f falls in adults wh have scred 2 r mre n the risk assessment. Dcument Detail Dcument Type Clinical Guideline Dcument name Guidance n the management f adult in-patient falls Dcument lcatin GTi Clinical Guidance Database Versin 2.0 Effective frm September 2010 Review date September 2012 Owner Clinical Lead, Elderly Care Authr(s) Mala Karasu, Safeguarding Adult Lead Apprved by, date Trust Falls Grup, May 2010 Superseded dcuments V 1.0 Related dcuments Falls Risk Assessment Flwchart fr In-patients Prcess f Identifying and Managing Patients with Multiple Falls Keywrds Falls, stratify, falls pathway, falls preventin Relevant external law, NHSLA Risk Standards, Criterin 3.5 regulatin, standards Change Histry Date Change details, since apprval Apprved by Guidance n the management f adult in-patient falls v2.0 Page 1 f 7

2 Guidance n the management f adult in-patient falls This dcument prvides guidance n the assessment f all adult in-patients fr the risk f falls and the preventin strategies t be used n each patient assessed t be at risk. This guidance is t be used in cnjunctin with the supprting dcuments listed belw: Observatin plicy Weekend walking aids guidance Falls risk assessment flwchart Bed rail plicy Delirium plicy Falls Management Care plan Multiple Falls flwchart Guidance n the Safe Use f Falls and Injury Preventin Equipment and Resurces 1.0 Intrductin Each patient must be assessed fr risk f falls and shuld receive multifaceted clinical and envirnmental interventins that culd reduce the risk (NPSA 2007). This guidance sets ut the Trust bjectives in relatin t the management f the risk f falls t patients which have huge human and financial csts Sme clinical areas will be exempt frm this guidance by nature f the fact that the patients in this area have high levels f nursing supprt i.e. ne t ne nursing. These areas wuld include intensive care and high dependency areas, maternity and theatres and recvery. Falls preventin amng children in the Evelina Children s Hspital will be managed accrding t lcal plicies and prcedures. A&E and utpatient areas will manage falls risks as part f their clinical management f cnfused patients. 2.0 Ratinale Patient falls have bth human and financial csts. Fr individual patients, the cnsequences range frm distress and lss f cnfidence, t injuries that can cause pain and suffering, lss f independence and, ccasinally, death. NRLS data suggest 530 patients may fracture their neck f femur in hspital each year, and 26 deaths have been reprted related t falls during ne year (NPSA, 2007). Althugh mst falls are reprted as causing n r lw harm, sme falls result in significant injury and death, and can lead t additinal healthcare csts. 3.0 Scpe This plicy will apply t all staff wh have clinical respnsibilities fr patients. It will als apply t all Trust staff wh individually have respnsibility fr maintaining a safe envirnment fr patients, staff and visitrs 4.0 Principles f Falls Risk Management All adult in-patients (excluding thse admitted t the areas that are exempt frm using this guidance) will have their risk f falls assessed n admissin t the clinical area and managed in the fllwing manner: Guidance n the management f adult in-patient falls v2.0 Page 2 f 7

3 Each patient admitted r transferred in will be assessed fr the risk f falls using Stratify falls risk assessment tl within 4 hrs f admissin r transfer Each patient, wh has a scre f 2 r greater, will have a multi-faceted care plan that will address the level f risk with specific actins within 6 hrs f admissin. They are as fllws: Red square abve the bed space Level f bservatin prescribed Apprpriate equipment in use Delirium assessment and care plan if apprpriate Apprpriate psitin n the ward Each patient will have their falls risk assessment repeated weekly r if their cnditin changes r if they have a fall, whichever cmes sner. Ward staff will ensure that the apprpriate equipment fr the management f falls is available n the ward. Alternatively, staff shuld be aware f hw t access the equipment via the equipment library Staff will be apprpriately trained in the management f falls. Specialist team in place t advice and supprt staff with cmplex assessments r management issues 5.0 Admissin Prcedures 5.1 Rle f Nurse On admissin r transfer in, each patient will be assessed by a nurse fr the risk f falls using Stratify within 4 hurs f reaching the ward. The Stratify dcument shuld be dated signed and timed. Patients wh scre 2 r mre Patients scring 2 r mre n Stratify shuld have a red square placed abve their bed, indicating t all that this patient is at a high risk f falls The admitting nurse with the shift leader must decide n the level f bservatin apprpriate fr this patient (Refer t bservatin plicy) within 6 hrs f admissin. If arms length nursing is required this must be reprted t the matrn fr apprval and fr resurce allcatin and management The admitting nurse must cnsider where n the ward this patient wuld be best nursed within 6 hrs f admissin. This may be dependent n the presenting patient behaviur and the level f risk f fall t this patient. Fr example, the patient may be agitated and wandering. This patient may benefit frm arms length nursing and s can be nursed in a side rm The admitting nurse must als assess the need fr use f specific falls equipment t be used t ensure patient safety, fr example, lw bed with crash mats, Wanderguard equipment etc. Within 6 hrs f admissin, the required equipment must be available fr use n the ward. The matrn/hon must be infrmed if this is nt achieved, s that alternative strategies may be used in the interim Befre the end f shift, the nurse must check that the patient has been assessed fr delirium and a medical plan f care is available if apprpriate. The admitting dctr must be cntacted if the patient has nt been assessed fr delirium. The nurse must ensure that the medical care plan instructins are incrprated int the nursing plan f care fr the patient. Guidance n the management f adult in-patient falls v2.0 Page 3 f 7

4 5.1.6 By the end f the shift the shift leader must ensure that the patient has a care plan fr the management f his/her falls risk, clearly dcumented in the patient recrds. Patients with a Stratify Scre f Fr patients wh scre 1, it wuld be imprtant t fcus n the behaviur that resulted in the scre f 1. If it is agitatin, the patient wuld benefit frm an assessment by the dctr fr delirium and care planned accrdingly. If the scre was as a result f pr eyesight, then the fcus f care fr falls preventin shuld be rientating the patient t the envirnment and supprt with transfers, mbility etc. 5.2 Dctr s Rle Patients wh scre 2 r mre The admitting dctr must check that the patient has been assessed fr the risk f falls using the Stratify tl and that the patient has a red square abve the bed area, an bservatin level has been agreed and the apprpriate equipment has been requested and/r is in use The admitting dctr must ensure that the patient is assessed fr delirium and prvide a plan f care if apprpriate. Patients with a Stratify Scre f Patients wh have a stratify scre f 1 may require an assessment fr delirium. (Refer t delirium pathway) 6.0 Transfer Prcedures 6.1 When a patient is transferred t a ward, the admitting nurse shuld assess the patient using Stratify as the mve may disrientate the patient wh may becme unsettled. If the scre is 2 r greater, the nurse must fllw the instructins under t abve. 6.2 The receiving medical team must ensure that the apprpriate nursing management strategies t manage the risk f falls are in place. The dctr must als review the assessment fr delirium and take the apprpriate actins, i.e. revise the care plan, discntinue care plans f reslved etc. 6.3 The handver f the patients during transfer must include risk f falls, level f bservatin and any special equipment being used by the transferring ward 6.4 If the patient has been receiving arms length nursing, the nurse bked t prvide arms length nursing must be transferred with the patient, until the end f the shift. This is t allw the receiving ward t make the necessary arrangements fr extra resurces. If the patient is transferred later in the evening and a nurse has been bked t prvide arms length nursing by the transferring ward t cver night duty, the nurse must be sent t the receiving ward if it has nt been able t bk smene t cver night duty. 7.0 Actins fllwing a fall n the ward 7.1 All falls must be recrded n the Datix incident reprting system n the same day as the fall 7.2 Fllwing a fall, the patient must be reassessed fr the risk f falls using stratify again, taking int cnsideratin the pssible causes fr the current fall If the Stratify scre is 2 r higher, the nurse must fllw the instructins n sectins t abve. Guidance n the management f adult in-patient falls v2.0 Page 4 f 7

5 7.2.2 If the patient has a scre f 1 r less, please seek guidance frm the multidisciplinary team r the Falls Grup fr advice n the management f this patient. 8.0 Multiple Falls (als refer t Flw Chart) 8.1 When the patient has fallen fr the secnd time, the patient must be referred the multidisciplinary team (MDT) fr advise n the assessment and management f this patient at an immediate available pprtunity and at the latest within the next wrking day. The MDT must cnsist f the ward nurse, a physitherapist and a dctr as a minimum. 8.2 If the patient has a third fall, the incident must be investigated using the RCA mdel, t ascertain why this patient cntinues t fall. The patient must als be reviewed by a Falls cnsultant and a Falls Grup member, and tgether with the MDT, the management f the risk f further falls r injury t this patient must be agreed and recrded in the health recrds. The review must take place within the next wrking day fllwing the fall and extra steps t minimise the risk f further falls must be used until the review is undertaken 9.0 Falls Grup 9.1 The Falls Grup will review plicies, prcedures and prtcls yearly r as necessary and disseminate the infrmatin Trust-wide. This grup will als act as an advisry grup fr staff wh require advice and supprt in managing falls in patients 9.2 The Falls Grup Chair will rganise and supprt s that mnitr cmpliance with the guidance, incidence f falls acrss the trust and equipment bi-mnthly. 9.3 The Falls Grup will review the falls data mnthly and analyse trends, incidences and recmmend remedial actins where apprpriate 9.4 The Falls Grup will review cmplex cases r all incidents f multiple falls by a patient r areas cnsidered t have higher incidence f falls and use the infrmatin t infrm plicy and disseminate the learning, widely acrss the Trust 10.0 Training and Educatin 10.1 All staff wh prvide care and treatment t adult patients will be ffered training n hw t assess and manage falls in in-patients. Staff must cntact their practice develpment nurses fr falls management training Equipment fr the Management f Falls 11.1 Each clinical area shuld ensure that it has access t lw beds and crash mats. (Refer t flw chart re access t lw beds) 11.2 Each clinical area shuld have access t Wanderguard chair and bed sensrs t help mnitr patient mvement in the management f falls either n the ward r via the equipment library 11.3 In additin t the abve all wards where lder patients are nursed shuld have access t the fllwing equipment as part f its standard ward equipment: Frames surrunding tilets as transfer supprt fr lder patients Raised tilet seats Chairs f varying heights t suit patients with different heights Access t walking aids ut f hurs t ensure safety with mbility and transfers Guidance n the management f adult in-patient falls v2.0 Page 5 f 7

6 Access t chair raisers t suit the needs f patients with varying heights Supply f apprved slippers fr patients wh d nt have ftwear with them and are unable t get any during their admissin Bars alng walls t supprt thse patients wh are frail in walking independently and safely Access t apprpriate bed rails t supprt patients wh may be at risk f rlling r slipping ut f bed (Refer t Safe and Effective use f Bed Rails Guidance) 12.0 Mnitring Cmpliance f this Guidance 12.1 Use f and cmpliance with this Clinical Guidance n the Management f Adult In-Patient Falls will be mnitred by the Falls Grup. Measurable Plicy Objective All apprpriate in-patient adults have been risk assessed using Stratify Existence f Care Plans fr each f the patients scre 2 r mre n Stratify that include: Red square abve bed Observatin level Equipment Delirium assessment and actins Psitin n ward All wards have the apprpriate equipment fr safe management f patients with a risk f falls Evidence that all patients are assessed weekly r if their cnditin changes, i.e. a fall, transfer t anther area etc Mnitring/ Audit methd Case ntes Case ntes Case ntes Incident reprting Case nte Frequency f mnitring Respnsibility fr perfrming the mnitring 6 mnthly Matrns/ward managers 6 mnthly Matrns/Ward Managers 6 mnthly Matrns/Ward Managers 6 mnthly Matrns/Ward Managers Mnitring reprted t which grups/ cmmittees, inc respnsibility fr reviewing actin plans Falls grup Clinical Indicatr Falls grup Clinical Indicatr Falls grup Clinical Indicatr Falls grup Clinical Indicatr Guidance n the management f adult in-patient falls v2.0 Page 6 f 7

7 PATIENTS NAME: WARD: HOSPITAL NO: S. T. R. A. T. I. F. Y. Admissin Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Date Did the patient present t hspital with a fall r 1 have they fallen n the ward since admissin? (Yes = 1, N = 0) D yu think the patient is: (Questins 2-5) Agitated? 2 (Yes = 1, N = 0) Visually impaired t the extent that their 3 everyday functin is affected? (Yes = 1, N = 0) In need f especially frequent tileting? 4 (Yes = 1, N = 0) Gait Pattern 5 Unable t walk/stand withut majr prmpting and help (Yes = 0) Independently and safely mbile with r withut a walking aid (Yes = 0) Mbile/independent with minimum assistance but unsteady (Yes = 1) TOTAL SCORE Signature f nurse assessing If ttal scre is 2 r mre r if the patient falls n the ward prceed t, falls interventin strategy including nursing care plan (see belw) INSTRUCTIONS FOR COMPLETION: When cmpleting this tl cnsider all patient falls risks, including falls frm height (e.g. frm beds, stairs etc.). T be cmpleted n day f admissin t ward fr all patients by the nurse and t be kept at the end f bed ntes until discharge If the STRATFY scre is 2 r mre, (e.g. scre fr agitatin and pr gait fr thse withdrawing frm alchl), the patient is at high risk f a fall and needs t (a) be placed n the falls pathway, and (b) have an amber r red risk square placed abve the bed accrding t the falls risk assessment flwchart If the STRATIFY scre is belw 2, repeat STRATIFY if the patients cnditin changes in a way that may increase their falls risk (e.g. new nset cnfusin r incntinence) Guidance n the management f adult in-patient falls v2.0 Page 7 f 7