POLICY FOR THE PREVENTION OF PATIENT SLIPS, TRIPS AND FALLS (PATIENTS) GENERAL POLICY NO. GP47 Applies to: Committee for Approval Date of Approval June 2012 Date Ratified: July 2012 Review Date: June 2013 Name of Lead Manager Version: V. 1 All clinical staff and staff working in clinical areas accessed by patients. Quality, Patient experience and Risk Group Patient Safety Advisor
Contents Section 1 Introduction 4 2 Statement of Intent 4 3 Definitions 5 4 Duties 6 4.1 Committees and Groups 6 4.2 Duties/Responsibilities: Individuals 7 Page 5 How the organisation assesses the risk of slips, trips and falls involving patients ( including falls from height) 10 5.1 Falls and Risk Principles of Falls Prevention 10 5.2 Risk Factors Associated with Falls 11 5.3 Clinical Assessment Processes 12 5.4 Individual Risk Assessments and Care Planning when using the Falls Risk Assessment Tool (FRAT) 14 5.5 Post Falls Assessment on Trust Property 15 5.6 Patient Home Risk Assessments 16 5.7 Available Resources to Support Falls Prevention 16 6 7 How the Organisation trains staff in line with the Trust s Training Needs Analysis How the Organisation Raises Awareness about Preventing and Reducing the Number of Slips, Trips and Falls Involving Patients 17 17 8 Incident Reporting Process for Falls on Trust Premises 18 9 How the Organisation Monitors Compliance 19 10 Equality Impact Assessment 19 11 Additional Documents 19 12 References 20 13 Appendix One - Falls Risk Assessment Tool example only 21 14 Appendix Two - Monitoring Tool 22 15 Appendix Three Risk Assessment Form 24 Page 2 of 24
Review and Amendment Log Version No Type of Change Date Description of change Page 3 of 24
POLICY FOR THE PREVENTION OF PATIENT, SLIPS, TRIPS AND FALLS 1. INTRODUCTION The Trust is committed to providing a safe and therapeutic environment for all patients having their care delivered in Trust managed premises and supporting the reduction of the risk of falls in patients own homes in the community. This policy will outline responsibilities and practical guidance for staff who care for people who may be at risk of falling in order to minimise the risk of harm and to maintain patient safety. (CQC Standard Outcome 4) Falls are a major cause of disability and the leading cause of mortality due to injury in older people aged 75 and over in the United Kingdom. The National Service Framework (NSF) for Older People (DH 2001) identifies the need for NHS organisations to take action to prevent falls and reduce the resultant fractures and other conditions associated with falls. Though, it is important to recognise that patient falls are not an inevitable consequence of becoming older. The consequences of falls for patients range from distress and loss of confidence, to injuries that can cause pain and suffering, loss of independence, increased likelihood of admission to long term care and occasionally, death. Whilst all falls in a community setting cannot be completely eliminated, the risks of falling can be minimised. Rational for improving patient safety in relation to slips, trips and falls: Falls present the most frequent and serious type of accident in those over 65 years. Every year approximately 30% older people living in the community will experience a fall. The incidence rises to approximately 50% in those aged over 85 years Physical injuries resulting from a fall account for 400,000 accident and emergency visits and costs the NHS an estimated 1.7 billion each year. The incidence of falls in patients with dementia is 40-60%, twice the rate of the cognitively normal population (RCN 2004). Serious injury is also more common, and 25% of these patients who fall sustain a fracture, three times the age adjusted figure for expected fracture incidence. 2. STATEMENT OF INTENT The purpose of this policy is to promote the welfare and safety of the service user by providing best practice guidance on the prevention and management of patient slips, trips and falls within the Trust. The policy has been developed in order to: Have systems in place for the prevention of falls by having effective assessments and early identification of individuals who are at risk of falling Page 4 of 24
Implement a standardised falls risk assessment tool into clinical practice for all clinical staff delivering care to patients at risk of falling Support patient centred care planning, interventions, rehabilitation and treatment as required to meet individual patient health needs Raise awareness of falls prevention and the appropriate management of risks 3. DEFINITIONS FALL A fall is an event which results in an individual or a body part of the individual coming to rest inadvertently on the ground or other surface lower than the individual, whether or not an injury is sustained. SLIP A slip is a slide accidentally causing the individual to lose their balance; this is either corrected or causes an individual to fall TRIP A trip is to stumble accidentally often over an obstacle causing an individual to lose their balance, this is either corrected or causes an individual to fall AT HEIGHT A place is at height if a patient could be injured falling from it, even if it is at or below ground level (except by a staircase in a permanent workplace) PATIENTS The term patients refer to all individuals receiving a current package of care or clinical intervention by Trust staff and can be used interchangeably with the term service user PEOPLE MOVING AND HANDLING TRAINING This training is for all staff who move patients and help support patients to move, it includes slips, trips and falls training. NON PEOPLE MOVING AND HANDLING TRAINING This training is delivered to staff as part of the Clinical and Non-Clinical Essential Learning Programme, as per the Trust s Mandatory Training Matrix. FALLS RISK ASSESSMENT TOOL (FRAT) A tool designed to support clinical decision making for patients who score against known risk factors that can be a contributory factor when patients fall. GENERAL PRACTITIONER ASSESSMENT OF COGNITION (GP COG) A validated assessment tool for the early detection of short term memory loss. Page 5 of 24
4. DUTIES 4.1 COMMITTEES AND GROUPS The Trust Board The Trust Board will: Review risks and associated action plans that have been escalated by the Quality and Governance Committee. Review risks and associated action plans relating to slips, trips and falls for mitigation or reduction in the level of risk which score 15 or above using the Trust s risk scoring matrix as per the Policy for Risk Identification and Management (GP45). Quality and Governance Committee The primary function of the Quality and Governance Committee is to provide assurance to the Board of overall compliance with all statutory and regulatory obligations and will ensure the effective management of Incidents, Complaints, Claims and Inquests and subsequent dissemination of lessons learnt, this includes compliance with the Trust s standards for this policy and that risk is effectively managed Quality, Patient Experience and Risk Group The purpose of this group includes monitoring effective risk management of patients under the care of Wirral Community NHS Trust. In addition the group provides information and assurance to the Quality and Governance Committee regarding how risks are being managed within the organisation. The group reviews and monitors service level risks and escalate risks which score15 or above and escalates them when appropriate to the Quality and Governance Committee and lessons learnt shared as appropriate Divisional Governance Groups The role of the groups is to review incidents, complaints and claims which occur in the service. The group monitors action plans for risks belonging to the division and ensures significant risks are recorded using the risk register, escalating risk issues which score 12 or above using the Trust risk matrix to the Quality, Patient Experience and Risk Group. Page 6 of 24
4.2 DUTIES / RESPONSIBILITIES: INDIVIDUALS Chief Executive The Chief Executive is responsible for the statutory duty of quality and clinical governance and takes overall responsibility for this policy. This responsibility is delegated to the Quality and Governance Committee Divisional Managers To ensure the implementation of the Trust s Slips, Trips and Falls Policy by the Clinical Lead within their area of control and escalate any concerns to the Quality, Patient Experience and Risk Group. Monitor compliance with relevant risk assessments in the service and safe systems of work designed to reduce the risk of slips, trips and falls and escalate any concerns to the Quality, Patient Experience and Risk Group. To ensure all staff comply with the Trust s Incident Reporting Policy and escalate any concerns to the Quality, Patient Experience and Risk Group. To ensure all staff comply with the Trust s Risk Management Policies and escalate any concerns to the Quality, patient Experience and Risk Group To monitor attendance at mandatory training as per Trust wide and service level Training Matrix. Service Leads Ensure staff are completing holistic patient assessments include risk assessments of slips, trips or falls occurring are completed and any concerns are escalated to the Divisional Manager Ensuring employees attend mandatory training as identified in the Trust s Training Matrix and escalate any concerns via the Divisional Manager to the Quality, Patient Experience and Risk Group. Monitor compliance with relevant risk assessments within the team/s and safe systems of work are designed to reduce the risk of slips, trips and falls and escalate any concerns to the Divisional Manager Monitor the effectiveness of existing controls and implement any further controls agreed as a result of assessment and escalate any concerns to the Divisional Manager Investigate accidents and incidents involving patient slips, trips and falls that do not cause harm to patients and use any reports of near misses to determine and address potential risks and escalate any concerns to the Divisional Manager Ensure leaks and other defects, which may result in a person, slipping, tripping or falling are promptly reported and the area is made safe and escalate any concerns to the Divisional Manager Page 7 of 24
Employees All employees have a general duty to take reasonable care of their own safety and that of others who may be affected by their actions, which includes the prevention of the risk of slips, trips and falls to patients. All employees must: Comply with this policy Be vigilant and ensure any slips and trips hazards that they are aware of are reported to their Line Manager as a minimum requirement Ensure leaks and other defects, which may result in a person, slipping, tripping or falling are promptly reported and the area is made safe Appropriately risk access any spillages and take remedial action to protect themselves and others from injury Use the Trust s incident reporting system where an incident or near miss occurs, as detailed in the Incident Reporting Policy Undertake all necessary risk assessments and keep them up to date Attend training, as identified in the Mandatory Trust s Training Matrix Complete the Falls Risk Assessment Tool (FRAT) when appropriate Health and Safety Advisor Assisting relevant managers of services with the risk assessment process and development of safe systems of work to ensure the risk of slips, trips and falls is eliminated or reduced, including giving advice for any flooring modification or new build complies with regulations Ensuring all major injuries resulting from slip, trip, fall type accidents are promptly investigated within 25 working days (only if it relates to our premises), appropriate action is taken and any action taken is recorded and the Health & Safety Executive are notified as per the requirements of the Reporting of Injuries, Diseases or Dangerous Occurrences Regulations (RIDDOR) Monitoring accident and incident statistics relating to patient slips, trips and falls and advise management of ways of reducing slips, trips and falls. The advisor will monitor statistics relating to staff falls and falls of others that occur on our premises and the work that is conducted within these premises, however no statistics are monitored in relation to clinical aspects of falls, e.g. if a member of staff arrived at a patient s home to find them lying on the floor. Ensuring sufficient arrangements are in place to regularly inspect common areas of the Trust, identifying hazards which may cause a patient to slip, trip or fall and records of inspection and actions taken are recorded Page 8 of 24
Head of Estates / Office Services / Business Support Manager Community Clinics Ensuring floor surfaces replaced or newly fitted as part of a modification, extension or new build comply with standards of slip resistance/surface roughness Ensuring adequate control of contractors to ensure potential hazards associated with their work that may cause persons to slip, trip or fall (including falls from height) are eliminated where possible or are adequately controlled Ensuring sufficient arrangements are in place to deal promptly with leaks and other defects which may cause a person to slip, trip or fall (including falls from height) Ensuring slip, trip fall accident and incidents in common areas are promptly reported and, where appropriate, properly investigated; also ensuring appropriate action is taken and recorded Ensuring sufficient arrangements are in place to regularly inspect both internal and external common areas of the Trust, identifying hazards, which may cause a person to slip, trip or fall (including falls from height). Records of inspections and any action taken to be recorded Ensuring cleaning regimes are adequately risk assessed Assisting the Trust Health & Safety Advisor with flooring risk assessments in common areas and the development and review of a slip, trip and falls action plan Monitoring compliance with relevant risk assessments Ensuring that arrangements are in place for gritting of external areas in the event of adverse weather conditions Community Therapy and Falls Prevention Service The Community Therapy and Falls Prevention Service is an integrated service which offers tailored assessments, treatment and advice to patients with a key focus on the prevention and management of falls. The service conducts falls prevention assessments with referrals being made to postural stability groups when appropriate. The service receives referrals from health care professionals using the Single Referral Point Form. Quality and Governance Service The Quality and Governance Service has the responsibility of monitoring the number of incident forms completed by Trust staff and identifying factors which could prove harmful to individuals, teams within the Trust and the organisation as a whole. All incidents are reported in the Monthly Quality Report which identifies the total number of incidents for that month and also the theme of the clinical incidents. Page 9 of 24
Patient Safety Advisor The Patient Safety Advisor has the delegated responsibility to promote safety improvements within the Trust, thereby aiming to continually improve the overall quality of clinical care relating to patient safety within the Trust. The role includes monitoring accident and incident statistics relating to patient slips, trips and falls and advice on the management of ways of reducing patient slips, trips and falls. Risk Advisor The Risk Advisor has the delegated responsibility to implement and monitor standards of risk management, including the ongoing review and development of the Trust s Risk Management Strategy and provides advice to staff as required. Also actively promotes good risk management practices and the achievement of national risk management standards and performance indicators. 5. HOW THE ORGANISATION ASSESSES THE RISK OF SLIPS, TRIPS AND FALLS INVOLVING PATIENTS (INCLUDING FALLS FROM HEIGHT) 5.1 FALLS AND RISK PRINCIPLES OF FALLS PREVENTION All patients 65 years of age or over, or when otherwise clinically indicated are to be assessed on the first face-to-face contact for their individual level of risk relating to falls using the Falls Risk Assessment Tool (FRAT). This assessment can be found on the Trust website. A single fall is not necessarily the sign of a major problem or an increased risk of subsequent falls; it may be an isolated event. However recurrent falls, determined as more than two falls in a six month period, should be evaluated for treatable causes. Older people who survive a fall may experience significant morbidity, hospital stays are almost twice as long as older patients admitted for other reasons (RCN 2004). The reasons why patients fall are complex. Falls can be influenced by physical illness, mental health problems, medication and age-related issues, as well as the environment. Consequently, efforts to reduce falls and injury will need to involve a, multi disciplinary approach, to include those working in nursing, medical, therapy, pharmacy, management and facilities services. It follows that falls prevention is multifaceted and has to be tailored to meet individual patients needs Falls analysis data suggests that falls solely attributable to environmental factors are uncommon but easiest to rectify. Floors need to be free of defects such as cracks or holes. Cleaning materials used should be only those compatible for the floors so as not to create a slip/trip hazard. Page 10 of 24
During an environmental risk assessment consideration must be given to the potential for falls from height within the patient s home environment. Any identified concerns regarding the potential for a fall from height in the patient s home environment, including Care Homes, must be discussed with the patient and/or individual responsible for their care, for example Care Home Manager or next of kin. The risk of falls from height occurring on premises where Wirral Community NHS Trust Services are delivered, is included within the Slips, Trips and Falls Policy (Staff) HS25, Section 5, Workplace Risk Assessments. Where a risk of a patient falling from bed is identified, staff must follow the Procedure for the Safe use of Bed Rails and Bed Grab Handles (CP40). The most important aspect of falls prevention is for staff to taking responsibility for addressing issues of concern and improving them as required There needs to be close collaboration between patients and their carers to strike the right balance between preventing falls, providing independence, privacy, dignity and rehabilitation 5.2 RISK FACTORS ASSOCIATED WITH FALLS Intrinsic factors; Ageing process (risk increases over 65yrs) Poor mobility Cognitive impairment / confusion/ agitation Continence problems History of falls Medical conditions Sensory deficits (vision, hearing, sensation) Poor nutritional status Emotional distress / depression Extrinsic factors; Lack of exercise Environmental hazards (steps, stairs, worn carpets, rugs etc) Unfamiliar environment Inability to provide appropriate nutrition due to physical factors (lack of transport to shops, inability to use equipment for preparing / cooking etc) Page 11 of 24
5.2 CLINICAL ASSESSMENT PROCESSES All patients 65 years of age or over, or when otherwise clinically indicated are to be assessed by a registered healthcare professional on the first face-to-face contact for their individual level of risk relating to falls using the Falls Risk Assessment Tool (FRAT). The National Service for Older People (DH 2001) Standard 6 focuses on falls, highlighting the need for NHS organisations to identify the cause of falls, and raise awareness of prevention and intervention strategies through the integration of best practice standards. Identifying those at risk is the first stage in falls prevention. The National Safety Patient Agency (2007) recommends that each patient at high risk of falling should receive multifaceted clinical and environmental interventions that could reduce risk. Older people in contact with health professionals should be routinely asked if they have fallen in the past twelve months and asked about the frequency, context and characteristics of the falls (NICE 2004) Staff who assess patients in relation to prevention or management of slips, trips and falls should document clinical assessments in the patient health record and show how each risk factor that has been identified leads to a clear plan of action (CQC 2010). Standards of clinical assessment:- All patients 65 years of age or over, or when otherwise clinically indicated are to be assessed by a registered healthcare professional on the first face-to-face contact for their individual level of risk relating to falls using the Falls Risk Assessment Tool (FRAT). This assessment can be found on the Trust website. Depending on the outcome of the FRAT assessment any interventions to reduce the risk of falls will be identified and implemented as appropriate with all actions recorded in the patients health records Review patient s medication as there may be a clinical need to refer the patient to the Trust Community Pharmacist for a Medication Review if on 4 medications. Trust staff need to complete a Medication Intervention Referral Form which can be located on the Trust website under the Quality and Governance section. Staff should investigate physiological causes leading to high risk of falls, e.g. cardiovascular factors, delirium and other physiological factors. Nursing observations would include testing of urine samples, lying and standing blood pressures, and monitoring of a patient s temperature. Depending on findings, Page 12 of 24
Trust staff members should contact the patient s GP accordingly to make them aware of the findings. Assessment of cognitive problems should be conducted using the General Practitioner Assessment of Cognition (GPCOG). This assessment tool can be found on the Trust website under the Quality and Governance section. Recent changes or fluctuating cognitive problems can indicate delirium, requiring medical attention, and previously unnoticed cognitive impairment should prompt a medical review. When appropriate Trust staff should complete a Medical Intervention Referral Form which will prompt a review of the patient s medication by the Trust Community Pharmacist. This document can be found on the Trust website under Quality and Governance. The GP should also be informed of the patient s fluctuating cognitive state following assessment using the GPCOG, who then may decide to refer to other services. Patients should be advised during the assessment process to have their vision tested if deemed appropriate by the assessing member of staff. Patients may need to be referred to ophthalmology services for condition such as cataracts. Trust staff should advise patients to have their eyes tested and liaise with the GP when appropriate so the patient can be referred to secondary care to be assessed by Ophthalmology services. When patients are experiencing remedial causes of incontinence or urgency, such as dehydration, urinary tract infections or constipation assess the patient s continence needs and if appropriate Trust staff should refer to the Trust s Integrated Continence Service as the patient may benefit from a tailored routine to reduce their level of risk of falling (PSF 2009). The Trust s Integrated Continence Service Referral Form can be accessed via the Trust website under Community Nursing. If relevant staff should refer to physiotherapy service for a review of the patient s balance and mobility and provide appropriate advice and/or mobility aids. Trust staff should complete a Wirral Wide Physiotherapy and Rehabilitation Services Referral Form when clinical judgement deems it necessary to do so. This form can be located on the Trust website. If relevant staff should refer to occupational therapy service who will be able to assess the safest ways for patients to carry out activities of daily living. Trust staff should complete a Wirral Wide Physiotherapy and Rehabilitation Services Referral Form when clinical judgement deems it necessary to do so. This form can be located on the Trust internet under Community Nursing. If relevant, staff should advise the patient to make an appointment with their GP as they may need to undergo an osteoporotic risk factors review. Once this has Page 13 of 24
been investigated and reviewed, treatment may need to be provided via the GP, as per NICE guidance (NICE 2008). Staff should assess patient s consumption of alcohol as part of a holistic assessment. When staff feel the patient s alcohol consumption levels are putting them at risk of falling, this should be documented within the patient s health care records and remedial action taken only when consent is given by the patient. This involves liaising with the patient s GP and when appropriate referring to Wirral Drug and Alcohol Action Team for further assessment and support using the Cheshire Wirral Partnership Alcohol Service Referral Form and faxing it to the appropriate fax number as stated on the form. This form can be found on the Trust website under Community Nursing. Staff should provide the Trust s Falls Leaflet to patients and their families/carers to promote self care by having up to date information on the benefits and risks associated with falls prevention and management. Available from the Community Therapy and Falls Prevention Service Staff should always ensure they are providing care in the most appropriate place in order to reduce their risk of falling e.g. clinic setting or in the patient s own home. Communication and updating patient health records and care plans: Advice from physiotherapy and occupational services should be communicated to and within the multidisciplinary team to ensure staff are aware of the level of risk associated with a specific patient including the frequency, nature and seriousness of falls 5.4 INDIVIDUAL RISK ASSESSMENTS AND CARE PLANNING WHEN USING THE FALLS RISK ASSESSMENT TOOL (FRAT) The risk of falls will be discussed with the patient and, if consent has been given, with their carer/family (RCN 2004). A care plan should be completed identifying the patient as being low, medium or high risk and placed in the patient s health care records in addition to the FRAT. Frequency of reassessment will be dependent on the patient s level of risk, a minimum of 6 monthly. Low Risk if all answers to questions on the FRAT are no, or where there is only one positive yes response, this indicates that the patient has a low risk of falling, Trust staff should provide the Trust s Falls Leaflet discussing the contents and documenting this within the health care records. Medium Risk a yes response to two questions on the FRAT indicates that the patient is at medium risk of falling. Staff should address any issues within their scope of practice, Page 14 of 24
offer a Trust Falls advice leaflet and discuss its contents. Advise the patient to discuss their risk of falls with their own GP when they are next reviewed. In addition staff should be informing the GP of the findings FRAT, when the patient has been assessed as being classified as medium risk or high risk. This should either through the means of a fax and a follow up phone call to ensure the fax has been received, alternatively a telephone call to the Practice will suffice. High Risk a yes response to three or more questions on the FRAT indicates a patient is at high risk of falling and should be referred to the Trust s Falls Prevention Team using their current referral form. Once the Community Therapy and Falls Prevention Service receive the referral patients will be triaged and responded to accordingly. When appropriate the patient may need to be referred to other services following an holistic assessment. NICE guidelines relating to falls (NICE 2004) suggest that a multifactoral assessment may include the following: Assessment of gait, balance and mobility, and muscle weakness Assessment of osteoporosis risk Assessment of the patient s perceived functional ability and fear relating to falling Assessment of visual impairment Assessment of cognitive impairment and neurological examination Assessment of urinary incontinence Cardiovascular and medication review. Staff should provide all patients, if consent given, and their cares about the measures they can take to prevent falls, this must be recorded in the patients health records Staff should provide the Trust s Falls Leaflet to patients and their families/carers to promote self care by having up to date information on the benefits and risks associated with falls prevention and management to promote self care 5.5 POST FALLS ASSESSMENT ON TRUST PROPERTY In the event of a fall by a patient on Trust premises, a visual risk assessment of the immediate area must be undertaken by Trust staff and the following considered and documentation made within the patient s health care records: Address any urgent problems Reassure the patient Assess for pain and sign of injury. Trust staff who witness or are involved in the event of a patient falling should always complete an incident form using the Trust s incident reporting system. Page 15 of 24
5.6 PATIENT HOME RISK ASSESSMENTS Many aspects of the environment may have an impact on the risk of falls or injury (NPSA 2007). Environmental risk assessments must be undertaken as required, and updated at least six monthly. This involves completing a:- 1. Blank risk assessment template (when necessary) See Appendix 3 The assessment may include the following: The condition of flooring related to the condition of the patient s soles and heels on footwear The bed and chair used by the patient, as to whether it meets their needs in terms of stability, support and height Assessment of the bathroom area. Bathrooms and toilets are common locations for falls and may be adapted to meet the needs of older adults who may be at risk of falling. Staff should consider the most effective source of lighting in relation to patient care and in order for their safety to be maintained at all times. Staff should consider advising on bedside lamps, or alternatively a night light in the toilet when providing care within the patient s own home. Assess the risk of potential falls from a bed, assessing the need for bedrails when the clinical need arises. Refer to the Trust s Procedure for the Safe Use of Bed Rails and Bed Grab Handles. The Trust s Bed Rails Risk Assessment form and Bed Rails Equipment Fitting form must be completed when assessing patients for the use of bed rails in conjunction with the Trust s Bedrail Risk Matrix Tool. Check the patient s bed is at the lowest possible height unless this would reduce mobility or independence. There should always be consideration made for the use of a special low bed. Patients should be informed that they are able to self refer to the Community Therapy and Falls Prevention Service. 5.7 AVAILABLE RESOURCES TO SUPPORT FALLS PREVENTION The Trust s Community Equipment Store provides a service for the provision, collection and repair or maintenance of a wide range of equipment and independent living aids. The Community Equipment Service aims to improve the quality of life and independence of patients by supporting them in the community. Referral to the Community Equipment Service is via the patient s GP or health care professional. Assistive Technology Assistive technology is a service that uses simple technology to help people live safely and independently in their own home. The equipment can help keep people safer by reducing the risk of falls, accidents and hospital admissions. It may also provide reassurance for families and carers who are at risk of falling. Page 16 of 24