Falls Prevention

Clinical Slips, Trips and Falls Protocol Please can all staff attending this Falls Prevention Theory be aware that the Clinical Slips, Trips and Falls Protocol can be found on Leeds Health Pathways. This outlines the roles and responsibilities of staff and the procedures to be followed for patients identified as at risk of a fall or who have suffered a fall.

Learning Outcomes To: Define what a fall is. Understand the risk factors for falls. Demonstrate what assessments are required for patients at risk of falling. Demonstrate the interventions required to prevent and manage falls. Understand the care required after a fall. This covers the requirement for in-patients there is a different pathway for patients attending A&E, the details can be found in the Trust Guidelines for the prevention and Management of Falls In Hospital.

What is a fall? Question: Ask what do staff consider to be a fall, definition?

Definition “An incident in which a person suddenly and involuntarily comes to rest on the ground, or other lower surface, with or without loss of consciousness”. NPSA (2011) Characteristics: Sudden Uncontrolled Unintentional Downward displacement of the body to the ground http://lthweb/sites/medicines-management-and-pharmacy/information-for-nursing-ward-staff/clinical-resources/documents/IV%20Checklist%20for%20Assessing%20Practitioners%20undertaking%20Medicines%20Management%20Competency.pdf

Falls - the size of the problem Leading cause of mortality resulting from injury in people aged > 75yr Half of the individuals who have fallen will fall again within one year. 5% of falls result in a fracture: 1% In a #NOF 152,000 falls reported to the NRLS annually 1/3 of individuals with hip fractures can no longer live independently and 25% die within 6 months Recurrent falls have a significant impact on mortality, accelerated admission to care homes and lifestyle limitations

Falls - the size of the problem Most common cause of injury in a hospital. Nearly 4 million people aged 60 and over have fallen in the last 2 years. Falls & their consequences cost the NHS & social care an estimated £6m per day. 70 falls resulting in fracture, head injury or death in 2014-2015. 2959 patients fell whilst under our care in 2014-2015 Our primary aim is to reduce inpatient harm- we have to get everyone on board that it is happening to their patients. The prevention and management of falls in older people is a key Government target in reducing morbidity and mortality. This is outlined in the National Service Framework (NSF) for England, standard six for older people, which covers falls and specifically aims to: ‘reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen’ (NSF 2001). Depending on the group you could go to the intranet and see the results for your division or insert a slide to show you divisions results and what interventions there are in any local action plans to reduce the numbers.

Inpatient falls at LTHT There were 3389 inpatient falls recorded in the Trust between April 2013 – March 2014. This graph represents the month on month trend for the whole of the Trust. Explain that individual CSU’s and wards can also be looked at.

Why focus on Falls? Discuss CQUINS and the trusts aims of reducing falls . “The very first requirement in a hospital is that it should do the sick no harm”

Environmental risk factors Wet floors Cluttered environment Tripping hazards e.g. cables, wires Changes in the level and uneven floors Doors Poor lighting Breaks not in use on equipment See LTHT Clinical Trips, Slips and Fall Protocol

Physical risk factors Previous history of falls Impaired balance/restricted mobility Reduced muscle strength Bone density Slower reaction times Mobility aids/inappropriate use Impaired vision Cognitive impairment Continence Postural hypotension Dizziness Discuss some in more detail in later slides

Functional risk factors Sleep disturbance Pain Alcohol /drug use / withdrawal Neurological conditions Parkinson's Dizziness Mobility Fear of falling Ask staff to give examples from their areas.... As there are many contributing factors it is therefore important that a MDT approach is used.

Clinical risk factors Neurological conditions Parkinson's Dizziness Previous history of falls Cardiac conditions Medications - caused by almost any drug that acts on the brain, heart or circulation. Sedation or cardiovascular medications.

Confused or Disorientated Patients Reversible causes such as medication, drugs or infection Irreversible causes such as dementia, delirium or other neurological problems Loss of awareness of the movement and posture required for mobilising which can affect balance Loss of proprioception/awarness of your movement, can be affected if diabetic or Vit b12 Deficient.

Continence Needs 15% of hospital falls are linked to incontinence & patients needing the toilet. Urge incontinence or diarrhoea are the greatest risk. Dementia patients may be agitated as they need the toilet but may not be aware. Toileting needs should be planned and tailored to patients needs. Are the toilet at the right height, easy to find, If patient has dementia ask and are looking for something ask them if they need the toilet

Assessment on Admission Areas can add local example by using findings from investigations of falls in their speciality Staff to make notes on the following, ’Think about’…… (10mins) and we will review results on the next few slides and will look at the factors to consider and then we will look at documentation available. Staff to think about what documentation is available to support them..

Falls Prevention Care Plan This is the pathway to identify which documentation and interventions are required. Note to review screening on change of condition/weekly. Screening for falls is now included in the nursing specialist assessment (Key used►) The old documentation looked at a risk score to predict the likelihood of a patient falling, but still some patients fell though not deemed at risk. There is now more emphasis on the ‘actions’ required to prevent falls rather than the likely risk.

Bed rails care plan

Falls prevention Identification & communication of risk especially on transfer Intentional rounding Alarm sensors Bed on the lowest setting/low care bed Spillages cleaned up Glasses if needed MDT assessment/review Patient involvement Correct mobility equipment in reach Staying Safe Preventing Falls leaflet Correct fitting appropriate footwear Lighting Cohorting Location on the ward Bed area free from clutter/wires Brakes on equipment Nurse call bell to hand

Post Falls Falls Prevention Care Plan; Print Unit number: WUN1019 TO BE UPDATED WHEN NEW CAREPLAN IN CIRCULATION Show examples… Risk assessment and falls prevention plan highlight that intervention is the key. No harm is prevented by purely assessing risk. You must do something about it, includes initial and DAILY intervention. In two parts first part covers first 24hrs, completed by nursing staff. Though many questions will link to other members of the MDT… Discuss the following with the group and ask how each can affect a patients falls risk Confused, blood glucose, urinalysis, lying & standing B/P (staff poor at completing this why?) eyesight, (meds review later) knows how to use call bell. Footwear later.

Incident Reporting The description should outline as much factual detail as possible about the fall, including what the patient was doing Action taken immediately following the fall and to further reduce risk e.g equipment Previously IR1s have not been completed correctly, the post-falls proforma should help you identify the important information required when a patient has fallen. There are plans for this to be electronic and go directly on to datix. PLEASE check that you have correctly completed the level of risk/score, if a patient is being sent for an x-ray then they may have a fracture and would be considered serious harm which would require a RCA. Serious harm is defined as a fall that results in a fracture, serious head injury or death.

Post falls management Ensure patient safety Medical & MDT review IR1 Post falls proforma Re-assessment of risk Nursing Kardex Inform relatives RCA if moderate harm sustained Investigations

Post falls investigations Not all interventions apply to every fall Full set of observations including lying & standing BP Neuro observations CT X-Ray Blood capillary glucose Urinalysis ECG Blood tests Medication review – for patients who are on 4 or more medications

Areas for the MDT team to review History of falling History of relevant neurological disease Number and type of medications Mobility & Musculo-skeletal gait/balance Balance /Hearing Postural Hypotension Vision Alcohol Nutritional deficits Environmental Hazards ability to function in home setting Psychological, cognitive function Some of the areas of investigation/actions are shared among the MDT team. Note this is a multi-professional problem requiring multi-professional intervention- docs/nurses/physios/pharmacists all have to do their bit to make a difference. but working together and doing simple interventions well reduces harm.

Planning for Discharge Referral to the Community Falls Team (CFT) or LTHT Specialist Falls Assessment Clinic. Give out patient leaflet ‘Stand Tall Avoid a Fall’ available to order from Public Health Resource Centre Leeds http://www.phrc.leeds.nhs.uk/Resources/Leaflets-and-Posters.htm With reference to the CFT & Specialist Falls Clinic,, the referral forms for both teams can be accessed via the Leeds Health Pathways. The OT would be able to advise the MDT regarding this. Falls clinic based at Beckett Wing SJH is mainly for falls assessments for patients in the community as we should be resolving patients falls risk in hospital, but the GP can contact the falls clinic if required once the patient is back in the community. Falls clinic Beckett Wing 0113 20 – 67012. New leaflet due out soon for inpatient from the falls group.

References LTHT Guidelines Falls in Hospital Areas – Guidelines for the Prevention and Management of Falls in Hospital (2011) NICE Falls: the assessment and prevention of falls in older people (2011) The FallSafe care bundle – Royal College of Physicians 2011. Arfken CL, Lach HW, Birge SJ,Miller JP (1994) The prevalence and correlates of fear of falling in elderly persons living in the community, American Journal of Public Health, 84(4):565-570.