Consultant Nurse, Nursing Documentation Group

Falls Prevention Toolkit- Section 7 - APPENDICES 3 rd edition September 2015 Review: September 2017 Principal Authors: Rob Morris Karen King Ellen McMahon Beverley Brady Pathway Lead Clinician for Older people Matron Additional contributors: Fiona Branch Emma Grace Faye O Callaghan Kathryn Draper Keith Knox James Saxton Dave Allen Nicola Fountain Nicky Lindley Abbie Betts Consultant Nurse, Nursing Documentation Group Senior Pharmacist Datix manager Information Support Officer Patient Safety Administrator Matron, Patient Safety Medstrom Clinical Nurse Specialist Section Content Page Section 7 Appendices Children s In Patient Falls Management Policy 2 Critical Care Falls Assessment Flow Chart 5 Critical Care Falls Standard Operating Procedure 6 Critical Care Falls Assessment Record 8 Falls Prevention Toolkit 3 rd Edition September 2015- Section 7- APPENDICES Page 1

Appendix 1 NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST CHILDREN S IN-PATIENT FALLS MANAGEMENT 1. Policy Statement The Children s Hospital aims to keep the number and harm from preventable falls to a minimum in children and young people. 2. Assessment of falls risk All patients will receive a nursing assessment on admission. This assesses the patient s mobility and whether the child uses bed sides or is in a cot at home. By discussing the patient s usual routine at home you can also find out if there are any particular issues such as high risk behaviour and the level of independence or supervision a child has in their usual home environment. All carers and children of an appropriate age/ability to understand will be given verbal advice about safe use of cot sides and bed rails on admission. As well as standard beds and cots the following equipment is also available for vulnerable children: Pit bed this is stored in a roll cage on the Children s Neurosciences ward. It consists of a mattress on the floor surrounded by padded walls which Velcro in place. o This offers a protective area to nurse patients but there is poor visibility of the patient. o There are risks to staff working at a low level in regard to back care. o Particular care needs to be taken if using infusion devices as they need to be at the level of the child to prevent risk of siphoning and therefore syringe drivers should be used in preference to infusion pumps. Inflatable cot sides for a bed these are stored on the Children s Neurosciences ward. They consist of inflatable sides to fit on a standard bed and offer a height of about 11/2 times the standard bed rails height. o The sides are clear so offer good visibility and the advantage of nursing a child on a height adjustable bed o Consideration needs to be given to a child who may be a risk of falling a greater height if they can climb over the sides. Ultra low bed available from the equipment store. o It has all the benefits of an electric adjustable height and profiling bed but lowers to about 9 inches from the floor. o Use of the ultra-low bed needs to be documented in the child s care plan and reviewed daily. In all circumstances, if there is a risk that the child will climb over the sides and injure themselves falling, then increased observation needs to be put in place. Falls Prevention Toolkit 3 rd Edition September 2015- Section 7- APPENDICES Page 2

3. Reporting and Monitoring All falls of in-patients must be recorded using the DATIX Incident Reporting System. Incidents will be monitored through monthly incident summaries by the Practice Development Lead for Governance and reported to the Quality, Risk and Safety group for the Children s Hospital. Guidance on the use of cot sides and bedrails in the Children s Hospital 2015 Appendix 1. Falls Prevention Toolkit 3 rd Edition September 2015- Section 7- APPENDICES Page 3

Children and Young People s Hospital Use of Cots Cots and Bed Rails Guidance Generally children under 2 yrs should be nursed in a cot however this decision should be made in conjunction with the parents and should reflect where the child usually sleeps at home. Occasionally children over 2 may need to be nursed in a cot for their safety, however if there is a risk of them climbing over the sides use a bed. Beware of toys in the cot, which may allow a child to stand and climb more easily over the sides. Cot sides Cot sides should be fully raised at all times unless an adult is providing care or directly supervising. Unoccupied cots should have the sides raised to prevent children climbing in and potentially falling. When the cot sides cannot be raised, for example a ventilated child a risk assessment must be completed and a sign attached to the child s cot. Appropriate supervision must be put in place at all times. Bed rails Beds must be kept at the lowest height when not delivering care to minimise risk of falls and even when empty to minimise risk of a child climbing onto bed and falling. Use during the day - consider use of bed rails for: Children who are sedated/ post op or receiving opiates Children who are confused or disorientated e.g. alcohol ingestion, head injuries Children who are known to have epilepsy or children who may fit Children with special needs (physical disabilities and or learning disabilities) Children nursed on special mattresses (as they raise the height of the bed) NB: Give careful consideration to children who are confused who may climb over the cot side and fall even further. You may need to consider using the pit bed (stored on E40) or inflatable cot sides. Use at night - consider use for: Children under 5 yrs Sedated/post op/ IV analgesia Children with special needs On advice of parents Falls Prevention Toolkit 3 rd Edition September 2015- Section 7- APPENDICES Page 4

Appendix 2 Critical Care Falls Assessment Flow Chart Falls Prevention Toolkit 3 rd Edition September 2015- Section 7- APPENDICES Page 5

Appendix 3 Adult Critical Care Falls Prevention - Standard Operating Procedure Applicable to all patients in Adult Critical Care. Falls assessment must be completed within 4 hours of admission to critical care. The Richmond Agitation Sedation Scale (RASS) is assessed as per observation frequency and documented on the 24 hour chart. The falls assessment and actions taken must be completed at least once per shift, more frequently as the patient s condition changes and at sundown alongside the delirium assessment. Mandatory requirement for all nursing staff to attend a Falls Prevention and Awareness training session annually. All Patients And/or a relative should receive information about falls prevention strategies. Visitors will be asked to inform the nursing staff when leaving their relative to ensure patients at risk of falling are not left unattended. Will have their privacy and dignity maintained at all times. Will have their medications reviewed by the medical team during each ward round. Patients with capacity can refuse interventions relating to falls prevention. The risks of falling must be explained to the patient and this discussion must be documented. Capacity can be assessed using MCA / two stage test. Will receive care as per the Critical Care falls Flow Chart and falls prevention strategies as listed below: Falls Prevention strategies 1. Ensure nurse call bell is within reach / offer an alternative where necessary. 2. Ensure use of appropriate footwear (slippers, shoes, tote socks). 3. If patient requires use of a walking aid, ensure walking aid is available. 4. Offer regular assistance with toilet visits / regular opportunities to use the bed pan / commode. Patients require continuous observation when toileting. 5. Ensure that bed area and surrounding area are free from clutter / obstacles. 6. Patient should have glasses available, clean and within easy reach at all times. 7. Patient should have hearing aid available to use at all times. 8. Patient will have their communication needs assessed and appropriate communication tools implemented. 9. Nurse patient in COHORT bay 10. Implement 1:1 supervision (when assessment is RED). 11. Use of low bed (when assessment is RED). 12. Bed rails use as per bed rails assessment (when assessment is RED). Falls Prevention Toolkit 3 rd Edition September 2015- Section 7- APPENDICES Page 6

Post Fall All Patients who fall should be reviewed by the Nurse in Charge to ensure that the correct Post Falls care is implemented. Use the Post Fall Checklist and sticker for notes. The Nurse in Charge needs to review the incident form before it is submitted onto Datix to ensure the incident has been correctly reported, (description of the event and the correct category of harm). Completion of duty of candour if moderate harm or above. All patients who fall should be reviewed by a Medic, the Nurse in Charge on review of the Patient will decide if the Patient needs to be reviewed immediately and escalate this directly appropriately. On transfer out of Critical Care: When the Patient is identified as being ready for transfer to the ward the Bedside Nurse must identify what level of supervision and what falls prevention strategies are required for the patient and communicate this clearly with the nurse taking handover from the receiving ward. This communication must take place at the earliest opportunity to allow the ward to make adjustments or request additional staff where require. If the patient s condition changes which will impact on the patients risk of falls these must be communicated with the ward in a timely manner. o A patient will require 1:1 supervision or cohorting on transfer if they are receiving 1:1 care or being nursed in a cohort bay on Critical Care. o If the patient has any of the following then a detailed discussion needs to held with the receiving nurse and cohorting the patient on the receiving area needs to be considered these are: o If the patient has been assessed as being delirium positive o If the patient has incontinence issues, an alteration to their normal toileting habits and/or requires a toileting regime. o Does not have the capacity and/or cognition to use the call bell o If any of the indications highlighted on the red aspect of the Critical Care Falls Prevention Flow Chart; have been admitted with a fall from standing height, have sustained a brain injury, have a diagnosis of Dementia / Alzheimer s, have a fluctuating GCS, if they are intoxicated or withdrawing from alcohol o In addition to these if the patient also has any limb weakness, has had a stroke, a spinal or an epidural these need to be communicated with the receiving nurse for them to make an informed decision about falls prevention strategies to be put in place. Please ensure a CAM-ICU is also undertaken when the Patient is identified as being ready for transfer and is repeated prior to transfer (within 1 hour of transfer) and the ward updated if there are any changes. Please ensure all the above points are document in the Critical Care Risk Booklet and transfer document and any changes in condition are documented. Nursing staff should complete transfer paperwork. The medical team should document a discharge summary and review and update the prescription charts Please also refer to the following Policies and Guidelines: The Adult In-Patient Falls Management Policy CLCGP024 The Adult In-Patient Bed Rails Policy CLCGP045 Guideline for the Detection and Management of Delirium in Adult Critical Care. Falls Prevention Toolkit 3 rd Edition September 2015- Section 7- APPENDICES Page 7

Appendix 4 Please assess patient at the start of each shift or as patients RASS / clinical condition changes Date RASS + Assessment (Red / amber / green) Action taken (From Falls Prevention Strategies) Signature Falls Prevention strategies 1. Ensure nurse call bell is within reach / offer an alternative where necessary. 2. Ensure use of appropriate footwear (slippers, shoes, tote socks). 3. If patient requires use of a walking aid, ensure walking aid is available. 4. Offer regular assistance with toilet visits / regular opportunities to use the bed pan / commode. Patients require continuous observation when toileting. 5. Ensure that bed area and surrounding area are free from clutter / obstacles. 6. Patient should have glasses available, clean and within easy reach at all times. 7. Patient should have hearing aid available to use at all times. 8. Patient will have their communication needs assessed and appropriate communication tools implemented. 9. Nurse patient in COHORT bay (when assessment is RED). 10. Implement 1 :1 supervision (when assessment is RED). 11. Use of low bed (when assessment is RED). 12. Bed rails use as per bed rails assessment. Falls Prevention Toolkit 3 rd Edition September 2015- Section 7- APPENDICES Page 8