1. Preventing Patient Falls
STC Module 2
2012

2. 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

3. 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

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

6. 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.  

7. 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

8. 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.

9. 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

10. 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

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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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

20. 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

21. 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

22. 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.

23. 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

24. 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