Preventing Patient Falls Is Key to Keeping Kidney Patients Safe

Facts About Falls An estimated 15,240 End Stage Renal Disease patients fall in dialysis facilities nationwide every three months. 40% of patients who fell cited dizziness as the main reason for their fall. Tripping, slipping, loss of balance and weakness are also contributing factors. Once patients fall, they may become more cautious and less physically active thereby becoming weaker and increasing the likelihood of future falls. Renal Physicians Association: Health and safety survey to improve patient safety in end stage renal disease: Report of findings from the ESRD patient survey, 2007. Desmet C et al. Falls in hemodialysis patients: prospective study of incidence, risk factors, and complications. Am J of Kidney Dis 45(1): 148-153. Brouwer B, Musselman K, Culham E. Physical function and health status among seniors with and without a fear of falling,” Gerontology 50(3): 135-41.

Contributing Factors Impaired Cognition Degenerative Arthritis Peripheral Neuropathy Peripheral Vascular Disease Lower Extremity Amputation Living Alone

Contributing Factors Vision Impaired Environmental Factors Medications Assistive Devices Poor Physical Functioning Prior Fall ID Fluid Removal

Fall Prevention Best Practices Patient Fall Risk Assessment Educational Programs Physical strengthening/therapy Pre-Dialysis Assessment Prior to Each Treatment Fall Reporting and Physician Notification Dialysis Heparinization for Patients with Prior Falls

Patient Fall Risk Assessment Physical Conditioning Assessment Medication Review Home Environment Questionnaire Dialogue with Patient and Caregivers Physical Conditioning/Therapy Needs Assessment

Focused Education Program for Patients, Caregivers and Staff Train new staff in all fall risk assessment procedures and fall prevention policies 1 Provide additional training to staff during in-service training and as need arises 2 Reinforce fall prevention policies through newsletter articles, brochures and bulletin board postings 3 Offer patients and caregivers information and education opportunities 4

Physical Strengthening/Therapy Address physical functioning/strength issues May include referral to a physical therapist May include recommendation for an assistive device Individually tailored strength training to increase patient’s coordination and muscle function

Pre-dialysis Risk Assessment Ask patient about falls occurring since previous dialysis-most falls occur at home during the first half of the interdialytic interval Post dialysis and orthostatic hypotension do not safely predict falling risk Determine need for physician notification and/or adjustment in dialysis heparinization Enter information into patient’s medical record The Pre-Dialysis Assessment represents a key line of defense against patient falls when conducted before every dialysis treatment. Each patient should be asked if any falls have occurred since their last visit. All pertinent information from the assessment is entered into the patient’s medical record for future reference. If the patient has experienced a prior fall, adjustment of dialysis heparinization by the physician may be needed.

Physician Notification When serious injury results from a fall When falls occur in the dialysis facility When there is any acute change in patient condition subsequent to a fall When there is a head injury with active bleeding

Dialysis Heparinization For patients who have fallen prior to dialysis treatment, anticoagulation may be adjusted Heightened alert for patients receiving Warfarin Prothrombin time/International Normalized Ratio before dialysis subsequent to fall or injury Consider decreasing/withholding heparin The importance of reporting every patient fall is critical to the adjustment of anticoagulants, as this can contribute subsequent falls. Staff should be particularly attentive to the possible need for adjustment after a fall for patient’s receiving Warfarin. Subsequent to a fall or injury, a Prothrombin time/International Normalized Ratio should be conducted before dialysis. Finally, decreasing or withholding heparin may be necessary for patients who have fallen.

Which of the following is NOT a contributing factor to patient falls? Poor physical functioning No record of prior falls Living Alone Impaired Cognition ID Fluid Removal Which of the following is NOT a contributing factor to patient falls? Poor physical functioning. No record of prior falls. Living Alone. Impaired Cognition. ID Fluid Removal.

Which of the following is NOT a contributing factor to patient falls? Poor physical functioning No record of prior falls Living Alone Impaired Cognition ID Fluid Removal

Which of the following IS part of an effective patient falls risk assessment? A. Knowledge of patient’s likes and dislikes B. Review of patient punctuality C. Number and age of close family members D. Home environment questionnaire E. Level of interaction with other patients

Which of the following IS part of an effective patient falls risk assessment? A. Knowledge of patient’s likes and dislikes B. Review of patient punctuality C. Number and age of close family members D. Home environment questionnaire E. Level of interaction with other patients

TRUE OR FALSE? Recommending the use of assistive devices to patients is inappropriate in dialysis centers.

TRUE OR FALSE? Recommending the use of assistive devices to patients is inappropriate in dialysis centers.

TRUE OR FALSE? Recommending the use of assistive devices to patients is inappropriate in dialysis centers. FALSE Recommending assistive devices may be part of effectively addressing patient physical functioning and strength issues affecting the risk of patient falls.

Prior to dialysis, patients should be asked about? Any falls that have occurred since their last dialysis treatment Falls occurring ONLY in the dialysis facility Any fall that resulted from dizziness ONLY falls that resulted in injury

Prior to dialysis, patients should be asked about? Any falls that have occurred since their last dialysis treatment Falls occurring ONLY in the dialysis facility Any fall that resulted from dizziness ONLY falls that resulted in injury

The physician must be notified: When a patient requests physician notification ONLY when the fall results in serious injury ONLY when a fall occurs in the dialysis facility D. When there is any acute change in patient condition subsequent to a fall E. ONLY if the fall was witnessed by two or more people

The physician must be notified: When a patient requests physician notification ONLY when the fall results in serious injury ONLY when a fall occurs in the dialysis facility D. When there is any acute change in patient condition subsequent to a fall E. ONLY if the fall was witnessed by two or more people

Adjustment in dialysis heparinization should be considered: ONLY if a patient requests it When a Prothrombin time/International Normalized Ratio has been performed When a patient receives Warfarin When a patient has fallen prior to dialysis treatment.

Adjustment in dialysis heparinization should be considered: ONLY if a patient requests it When a Prothrombin time/International Normalized Ratio has been performed When a patient receives Warfarin When a patient has fallen prior to dialysis treatment.

Additional Resources Tool for Preventing Falls - Joint Commission – https://www.centerfortransforminghealthcare.org/tst_pfi.aspx National Institute for Health and Clinical Excellence – https://www.nice.org.uk/guidance/cg161 Falls among hemodialysis patients: potential opportunities for prevention? Clinical Kidney Journal– https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4377754/