Preventing Patient Falls STC Module 2 2012

Outline Why a fall prevention program Defining falls Extent of the problem Defining falls General TMC Guidelines Prevention of falls and reducing injuries among adult patients Using the Morse Fall Scale Prevention of falls and reducing injuries among pediatric patients Using the Humpty Dumpty Fall Scale After a fall

Why a fall prevention program In Australia, 38% of hospital incidents are related to falls (Joanna Briggs Institute. Falls in hospitals. Best Practice 1998; 2 (2).) 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. Falls are a common occurrence among elderly inpatients in subacute hospitals and are generally reported to affect between 13% and 32% of admitted patients (Mion L, Gregor S, Buettner M, Chwirchak D, Lee O, Paras W. Falls in the rehabilitation setting: incidence and characteristics. Rehabil Nurs 1989; 14: 17–22) Cost due to injuries may run up to $500million in Australia and £15 million per annum in UK

Preventing falls & reducing International Patient Safety their harm is an International Patient Safety Goal!

Defining Falls A fall happens when a patient unintentionally lands on the floor or any other surface or object lower than him/her as a result of a sudden and unplanned accident A near fall happens when a patient loses balance but recovers and does not fall.   An unwitnessed fall happens when a patient is found on the floor, and neither the patient nor anyone else knows how he or she ended up there.  

Types of Falls Accidental – when a patient slips or loses his/her balance as a result of slippery surface or when a patient trips or loses his/her balance because of an obstacle, such as an object on the ground Psychological - if caused by a biological condition and not an external factor; those conditions may be anticipated or unanticipated

General TMC Guidelines Scope: Newborns (automatically assessed as high risk) All inpatients Patients of the Emergency Department (EMR) Patients undergoing outpatient diagnostic or treatment procedures that are expected to last for at least one hour. When to assess risk upon admission after a fall upon change in status transfer to a new setting.

3. Use official TMC Forms in initial assessment, re-assessment and monitoring Evaluation of effectiveness of intervention 1. Adult inpatient Adult Patient Assessment Form Adult Inpatient Fall Risk Assessment Tool Risk Fall Monitoring Tool (RFMT) 2. Pediatric inpatient Pediatric Patient Assessment Form Pediatric Inpatient Fall Risk Assessment Tool 3. Outpatient Adult Outpatient Fall Risk Assessment Tool Pediatric Outpatient Fall Risk Assessment Tool

General Guidelines In case of fall, report incident to Safety Management Department using the Fall Incident Report Form, or to Patient Safety Office using the Sentinel & Adverse Event Report Form. The goal, in both adult and pediatrics patients, is to reduce the fall score during subsequent re-assessments

Using the morse fall scale (MFS) Preventing falls among adult patients Using the morse fall scale (MFS)

The Morse Fall Scale (MFS) is a tool that determines the likelihood of an adult patient falling based on six parameters: History of falling Secondary diagnosis Ambulatory aid IV/Heparin lock Gait/transferring Mental status

MORSE FALL SCALE History of falling; immediate or within 3 months NO = 0 YES = 25 Secondary diagnosis YES = 15 Ambulatory aid None, bed rest, wheel chair, nurse = 0 Crutches, cane, walker = 15 Furniture = 30 IV/ Heparin lock YES = 20 Gait( ability to walk/change position) Normal, bed rest, immobile = 0 Weak = 10 Impaired = 20 Mental status (Awareness of own abilities) Oriented to own ability = 0 Forgets limitations = 15

The total MFS score determines the patient’s risk for falling the appropriate interventions addressing the risks Total MFS Score Risk Level Action 0-24 No risk None 25-50 Low risk Standard Fall Prevention Interventions 51 and above High risk High Risk Fall Prevent Interventions

Nurse’s roles STANDARD PREVENTION HIGH RISK FALL PREVENTION Standard protocol plus: Assurance of 24-hour supervision and assistance with toileting, transfer and ambulation activities. Placing patient in a room close to nurses station if possible Visual alert signage on the patient’s door. communicating to Attending Physician or designee that patient is high risk for falls by: Documenting in the patient’s Nursing Assessment and/or Progress Note .Discussing and initiating a plan of care which addresses: Medications, cognitive function, gait and balance, and other conditions that may contribute to falls. Recommend /suggest initiation of referrals or consults to address individually assessed problems (ie. PT, OT, KT, Dietary, SWS, Pharmacy). Orient patient to surroundings as condition warrants Tell patient to wear non-skid slippers or treaded socks Keep bed in low position and raise bedrails with extreme caution. When possible, use alternative pillows and positioning devices to avoid the use of bedrails. Check that wheels on all wheelchairs, beds and stretchers are locked Implement toileting programs to decrease urgency and incontinence Keep nurse call system, phone, personal items and personal assistive devices accessible Review medications that increase fall risk or fall injury Educate patient and family ; tailor fit educational needs with patient conditions and risks

Doctor’s roles STANDARD PREVENTION HIGH RISK FALL PREVENTION Resolve secondary diagnoses, if possible Shift from IV to oral meds as soon as possible Evaluate and treat gait changes, postural instability, orthostatic hypotension and spasticity Initiate treatment for impaired vision, hearing Evaluate medication profile for fall risk Evaluate and treat pain Educate the patient about exercise, nutrition, and home safety Assess and treat impaired central processing, such as dementia, delirium, stroke, and perception Standard protocol plus: Review medications for fall risk and adjust as indicated Consider referral to services such as physical medicine and rehabilitation, audiology, ophthalmology, and cardiology Optimize treatment of underlying medical conditions Formulate plans for emergency fall notification

The humpty dumpty fall scale (HDFS) Preventing falls in pediatric patients The humpty dumpty fall scale (HDFS)

The Humpty Dumpty Fall Scale™ (HDFS) is a tool that determines the likelihood of a pediatric patient falling based on seven parameters: Age Gender Diagnosis Cognitive impairments Environmental factors Response to surgery/anesthesia/sedation (for in-patients) Medication usage

HUMPTY DUMPTY FALL SCALE RISK FACTORS ASSIGNED SCORE Age Less than 3 years old – 4 3 to less than 7 years old – 3 7 to less than 13 years old – 2 13 years and above – 1 gender Male – 2 Female – 1 diagnosis Neurological diagnosis – 4 Alterations in oxygenation (respiratory diagnosis, dehydration, anemia, anorexia, syncope/ dizziness, etc.) – 3 Psychiatric/ behavioral disorders – 2 Other diagnosis – 1 cognitive impairments Not aware of limitations – 3 Forgets limitations – 2 Oriented to own ability – 1 environmental factors History of falls or infant-toddler placed in bed – 4 Patient uses assistive devices or infant-toddler in crib or furniture/lighting – 3 Patient placed in bed – 2 Outpatient area – 1 Response to Surgery/ Sedation/ Anesthesia Within 24 hours – 3 Within 48 hours – 2 More than 48 hours/ None – 1 Medication Usage Multiple usage of: Sedatives (excluding ICU patients sedated and paralyzed) Hypnotics, Barbiturates, Phenothiazines, Antidepressants, Laxatives/ Diuretics, Narcotics – 3 One of the meds listed above – 2 Other medications/ none - 1

The total HDFS score determines the child’s risk for falling the appropriate interventions addressing the risks Total HDFS Score Risk Level Activate 6-11 Low risk Low risk prevention protocol 12 and above High risk High Risk Fall Prevention protocol

Pediatric fall prevention LOW RISK HIGH RISK Orient patient/family to room Put bed in low position, brakes on, side rails up; assess large gaps, such that a patient could get extremity or other body part entrapped, use additional safety procedures Use of non-skid footwear for ambulatory patients, use of appropriate size of clothing to prevent risk of tripping Assess elimination/voiding needs, assist as needed Ensure that call light is with in reach, educate patient/ family on its functionality Environment clear of unused equipment, furniture’s in place, clear of hazards Assess for adequate lighting, leave nightlight on Patient and family education available to parents and patient Document fall prevention teaching and include in plan of care CARRY OUT ALL LOW RISK PREVENTION PROTOCOL PLUS: Identify patient with “Humpty Dumpty Sticker” in patient chart/door tag Educate patient/ parents on falls prevention Check patient minimum of every 2 hours Accompany ambulatory patients Place patient in an appropriately modified bed based on child development Evaluate medication administration times Remove all unused equipment out of the room Keep door open at all times unless specified isolation precaution are in use

After a fall Nursing staff needs to Medical staff needs to Assess for level of injury, such as abrasions, bruises and head traumas. Get and record sitting/standing vital signs Assess for change in range of motion Notify the Head Nurse, the Attending Physician and the Safety Officer Document post-fall assessment and treatment on Nurses’ Notes Assess level of injury and treat any resulting problem Initiate diagnostic and treatment interventions for contributing intrinsic and extrinsic causes Document post-fall assessment and treatment in SOAP format Find out probable cause of fall, such as history, physical factors, medications, and laboratory values Refer patient to appropriate services.

Summary Patient falls is a real problem that need to be addressed JCI recognizes this and aims to reduce fall incidents and harm resulting from falls The TMC has adapted tools for assessing falls risk and identifying appropriate interventions TMC has policy guidelines for assessing and re-assessing risk and evaluating the effectiveness of interventions

Summary The Morse Fall Scale was adapted for assessing risks among adult patients The Humpty Dumpty Fall Scale was adapted for assessing risks among pediatric patients Factors with high risk scores should help the health care team tailor-fit the interventions for individual patients The goal of the interventions is to reduce the fall scale scores