Falls Hussain Al-Zubaidi

Outline Importance of a Falls assessment Why patients fall Falls assessment Criteria for CT Head Trust Guidelines Documentation

Big Issue at the Trust Every inpatient coming into hospital now has a falls risk assessment done. The Trust also has a monthly Risk Falls forum where representatives from all divisions attend to hear about what measures are being used at other Trusts and what could be implemented at UHCW. For example one ward is about to start piloting new equipment after another Trust reported that it had reduced the amount of falls in its hospitals

Magnitude of stressor

Reasons why falling in the elderly is more dangerous Multiple system impairments  Less effective saving mechamisms Osteoporosis Secondary injury (Mainly due to post-fall immobility) Psychological impact

Falls in the Hospital Falls are common in hospital due to – Acutely unwell older people – Pts with a number of chronic co-morbidities – Unfamiliar scary environment – Hard slippery floors – Random equipment left to create obstacle course

Falls assessment History – Before, during, after – Associated neurological symptoms – Previous Hx of falls & co-morbidities – Medications (BZs, TCAs, Antipsychotics, opiates, diuretics, Antihypertensives, hypoglycaemics) – Current functional performance

Examination Examination immediately after a fall is focused on identifying any injuries and acute illness. ABCDE (Inc. BMs) EWS Neurological examination including sensory, motor and Cerebellar signs Cardiovascular examination including ECG and postural blood pressure and pulse Lower extremity joint function and muscle strength Gait, balance and mobility level Cognitive evaluation (AMTS) Visual acuity (Basic) Feet and footwear

Tests Bloods Urine dip ECG Neuro observations X-ray (Joint/CXR) CT Head – FBC – B12 & folate – U&Es – Glucose – Calcium – Phosphate – Vit D

CT Head Criteria Adults perform a CT head scan within 1 hour of the risk factor being identified: GCS less than 13 on initial assessment in A&E GCS less than 15 at 2 hours after the injury on assessment in A&E Suspected open or depressed skull fracture Any sign of basal skull fracture Post-traumatic seizure Focal neurological deficit More than 1 episode of vomiting. GCS Fracture Neuro

Causes Mechanical (NO NO NO)  Environmental Confusion (Acute or Chronic) Hypotension Sepsis Hypoglycaemia Alcohol/drug Withdrawal Urinary or bowel problems Medication Musculoskeletal (Balance/gait deficit) Cardiac events including arrhythmias

Falls in hospital Intervention – Treat infection, delirium, and dehydration – Stop incriminated drugs – Good quality footwear/walking aid – Good lighting – Bedside commode (especially for those with urinary or faecal urgency or frequency. – Ensure call bleep is to hand – Place them in the high risk areas

Intervention Reducing fall frequency Preventing adverse consequences of falls Doctor -Drug review -Treat underlying cause/stressor Physio -Strength and balance training -Walking aids OT - Environmental assessment and modification Doctor - Osteoporosis detection and treatment Physio - Teaching patients how to get up from a fall OT - Environmental assessment and modification Carers, family, voluntary agencies -Alarms -Supervision Carers, family, voluntary agencies -Reducing stressors (Like only walking indoors)

Trust Guidelines The doctors must review all patients who have fallen The doctors should carry out a focused history and clinical examination of the patient with fall The doctors should try to establish a cause or diagnosis of the fall The doctors should carry out a medication review of all patients with falls All patients with falls should be considered for a multifactorial falls risk assessment All patients with falls should be considered for an individualised multifactorial intervention All elderly patients at high risk of falls should have their osteoporosis risk assessed and treated appropriately All elderly patients at high risk of falls should have their Vitamin D level checked and treated if required

So the 8 key STEPS 1)Review every fall 2)History + examination 3)Cause 4)Med r/v 5)Multifactorial assessment 6)Individualise your plan 7)Osteoporosis Risk assessment (FRAX score app_ 8)Vit D

Multifactorial Falls Risk Assessment All patients with falls should be considered for a multifactorial falls risk assessment which include: Focused history Physical examination Functional assessment Environmental assessment Multifactorial interventions: The multifactorial fall risk assessment should be followed by direct interventions tailored to the identified risk factors, coupled with an appropriate exercise program.

Following a fall or suspected fall, the following must be implemented: The medical team must review all patients who have fallen, but injury (see below) is not suspected, within 6 hours of the fall being reported to them. Any patient who has a suspected head injury, spinal injury or fracture must be reviewed within one hour of the fall being reported to the medical team. The patient should be moved using only the specialist equipment. The junior medical team must refer to their registrar if a fracture or head/spinal injury is suspected. The registrar will then decide whether a CT scan is appropriate referring to the NICE guidance for head injuries CG56 for scanning criteria (Appendix A) if required and whether to seek advice from the neurosurgical registrar.

DOCUMENTATION Absolutely crucial For the patient and your protection Although it is a common event falls can lead to severe consequences hence why it is crucial we assess Inform seniors if you have any concerns

Example diagnosis Fall in the context of acute illness e.g. UTI, dehydration, stroke etc… Accidental fall secondary to slip, trip etc. Fall secondary to loss of balance Fall secondary to syncope/ pre-syncope Fall secondary to significant postural hypotension Fall secondary to medication/ alcohol effects Fall secondary to chronic illness e.g. Parkinson’s disease, dementia Multifactorial falls when multiple risk factors coexist Fall ?cause or unexplained fall