1. Falls Prevention

2. Learning Outcomes To: Define what a fall is
State awareness of the predisposing factors that can contribute to a patient falling
Understand the falls risks
Demonstrate what assessments are required for patients at risk of falling
Demonstrate the interventions required to prevent and manage falls
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.

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

4. 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 of a fall
Sudden
Uncontrolled
Unintentional
Downward displacement of
the body to the ground

5. Falls - the size of the problem
The leading cause of mortality resulting from injury in people aged 75yr and over in the UK
Research has shown that half of the individuals who have fallen will fall again within one year.
Recurrent falls have a significant impact on mortality, accelerated admission to care homes and lifestyle limitations
5% of falls result in a fracture, of which 1% are to the hip
One third of individuals with hip fractures can no longer live independently and 25% die within 6 months
14,000 people die every year from hip # in UK
Add references
1,150 people are dying every month in the UK as a result of hip fractures.
NICE: 86, 000 hip fractures occur annually in the UK
Close et al, 1999
(Torgerson 2001) and 95 per cent of hip fractures are the
result of a fall (Youm 1999).Although only 5 per cent of falls result in fracture (Tinetti 1988), the total annual cost
of these fractures to the NHS has been calculated as £1.7billion (Torgerson 2001) with many individuals losing independence and quality of life (Cooper 1993)

6. 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
Estimated cost from falls and their consequences to NHS & social care is £6m per day/£2.3 billiion per year
In one year there are more fractures caused by falling than heart attacks or strokes; 310,000 fractures compared to 275,000 heart attacks and 110,000 strokes/TIAs
3389 patients fell whilst under our care in
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.

7. Inpatient falls at LTHT
There were 3389 inpatient falls recorded in the Trust between April 2013 – March 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.

8. Why focus on Falls?
“Patient falls result in a vast amount of avoidable harm. Many falls can be avoided by implementing good practice consistently.
We need to dispel the myth that nothing can be done. That is what people used to say about hospital acquired infections, but now big advances are being made.”
Peter Walsh, CEO, Action against Medical Accidents
Discuss CQUINS and the trusts aims of reducing falls .

9. 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
Inappropriate walking aids
See LTHT Clinical Trips, Slips and Fall Protocol

10. Physical risk factors Previous history of falls
Impaired balance/restricted mobility
Reduced muscle strength
Bone density
Reaction times slower
More likely to use aids to assist mobility
Impaired vision
Cognitive impairment
Continence
Postural hypotension
Discuss some in more detail in later slides

11. Physical risk factors Sleep disturbance Pain
Post – operative, level of recovery
Alcohol /drug use / withdrawal
Neurological conditions
Parkinson's
Dizziness
Medication
Ask staff to give examples from their areas....
As there are many contributing factors it is therefore important that a MDT approach is used.

12. Medication Risks
Falls can be caused by almost any drug that acts on the brain, heart or circulation. Usually the mechanism leading to a fall is caused by one or more of:
Sedation, with slowing of reaction times and impaired balance
Hypotension, reduction of blood pressure
All patients who are at risk of falling need their medication reviewing, especially if they are on more that 4 different medicines.
The following medicines may be a contributory factor in causing patients to fall and
should be reviewed as a means to reducing the risk of a patient falling , and should be reviewed by the pharmacist
(in no particular order) Anti-hypertensives, Diuretics, ß-blockers (including ophthalmic preparations), Sedatives ( Hypnotics & Benzodiazepines)
Neuroleptics/antipsychotics, Woolcott JC et al. Arch Intern Med 2009;169:
Also consider anti-anginals, anti-histamines, drugs to treat Parkinson’s disease and opioids

13. Confused or Disorientated Patients
May be due to medication, drugs, dementia delirium or other neurological problem
Do they know where they are and are they able to request help if needed?
May have loss of awareness of the movement and posture required for mobilising which can affect balance
May have continence problems that they are unaware of.
Loss of proprioception/awarness of your movement, can be affected if diabetic or Vit b12 Deficient.

14. Fear of falling
30% of older people fear falling. Fear level is greater than the fear of being robbed in the street (Arfken 1994)
Associated with older people, poor balance and reduced mobility
Psychological barrier to exercise
How do you feel looking at this picture?
People who have a fear of falling don’t need to be a great height to get the same feeling you or I might have looking over a cliff edge.
Reference; 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):

15. Poor Vision A B C D Which of the above is the following? 1. Glaucoma
2. Diabetic retinopathy
3. Hemianopia
4. Cataract
5. Dirty or wrong glasses
How do we check for patients level of vision?
Patients with poor vision have a slower more cautious gait pattern, which makes a person unsteady
If a patient wears glasses please ensure they have them whilst they are in hospital.
As we get older our sight is affected by changes in Acuity, contrast, depth perception
Patients may have:
A. Cataract
B. Glaucoma – loss of peripheral vision,
C. Diabetic retinopathy-spots/floaters
D. Hemianopia,
Dirty or wrong glasses may look like any of above depending on where the dirt is, need to check the right glasses not reading, bifocals
Check patients can see a pen from the end of the bed if not report to medical staff

16. Continence Needs
15% of hospital falls are linked to patients needing the toilet and often linked to incontinence
Urge incontinence or diarrhoea are the greatest risk as patients tend to rush to the to the toilet
Dementia patients may be agitated as they need the toilet but may not be aware, so walking about looking for something…
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

17. Assessment on Admission
Ronald Dreighton is 78 years old. He is admitted to A&E with a history of not eating or drinking and feeling generally unwell. He is known to suffer from incontinence and has dementia with increasing levels of confusion. He has no nightwear or slippers with him
Think about:
What factors you might consider?
How do you assess the risk?
What guidance, documentation is available to you?
What action and nursing care would you plan?
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..

18. ADULT FALLS PREVENTION PATHWAY
Perform initial screening questions
(Document on nursing specialist assessment or pathway)
Two or more falls in the last 12 months?
Admitted with acute fall?
Difficulty with walking or balance?
Patient has a fear of falling
Patient is confused or disorientated
or Staff have concerns that the patient may fall
Answers positive to any of the screening questions?
Yes No
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.
Complete daily falls prevention intervention bundle
No further intervention needed at this stage. Review screening weekly or on change of condition
Patient falls on ward
Patient falls on ward
Complete post fall document & IR1 form
Update/amend care plan and review level of risk

19. Falls Interventions
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.

20. 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.

21. Medication Review For patients on four or more medications.
See the list on the ‘Guidance and Considerations on Medicines and Falls’ which can be found within ‘The Medication Review for Patients who Fall’, document, developed for a pharmacist to use when reviewing a patient.
The following medicines may be a contributory factor in causing patients to fall and
should be reviewed as a means to reducing the risk of a patient falling , and should be reviewed by the pharmacist
(in no particular order) Anti-hypertensives, Diuretics, ß-blockers (including ophthalmic preparations), Sedatives ( Hypnotics & Benzodiazepines)
Neuroleptics/antipsychotics, Woolcott JC et al. Arch Intern Med 2009;169:
Also consider anti-anginals, anti-histamines, drugs to treat Parkinson’s disease and opioids

22. What has caused ‘your’ patient to Fall?
It is important that you, along with the MDT try to find the mostly likely cause of the fall, this is to help you adapt the care to that patients individual needs. It may be a very specific or a combination of reasons but it should help you to prevent further falls. E.g.
Physical ability to mobilise ?
Circulation and medication ?
Cognition ?
Environmental ?

23. Fall prevention care
Patient information leaflet and/or discuss what they can do to reduce the risk
Nurse call bell is at hand and the patient knows how to use it
Toileting
Lighting on the ward
Mobility equipment within reach
Moving patient near to the nurses station
Good fitting footwear or slipper socks
Rounding
Explain that tables have wheels and can move unexpectedly.
GOOD FITTING slippers or even shoes and socks, slipper socks should only be for emergency use, get relatives to buy new slippers or bring in own shoes. This is as important as hearing aids/glasses.
Some hospital have made reductions in falls by insisting that patients have the right footwear.

24. Fall prevention care Ensure the bed area is free from clutter
Level of orientation can they call for help
Equipment , low care beds, tabs, movement sensors, seat pads
Use of bed rails – risk assessment to be completed
Ensure when patients are transferred to another clinical area, i.e. moving ward, attending x-ray etc, that their risk of falls is communicated.
Tabs are sensors that can be used on beds/chairs to indicated that a patient is on the move.
If a patient has cognition problems and cant or doesn't know to call a nurse for help then, they need to be checked frequently in case they need a drink, toileting or are in pain otherwise they will try to walk alone?
It is important that the care provided is tailored according to the individual patients needs, there is space on the daily section of the care plan to add any individualised care required. Even if ‘intentional rounding’ is not in use in your area, you need to consider that if you increase the frequency of checks to see if they need a drink, the toilet, or are in pain then this can reduce the falls risk in patients who are unsteady but are trying to attend to these needs themselves. You can also prescribe this frequency in the care plan by asking for the patient to be checked, 2/4/6 hourly or even one to one/one, or a nurse always in the bay for high risk patients when all other interventions have failed. Discuss with your Matron, this is currently being piloted on some wards across the Trust.

25. Post Fall Management Ensure the patient is safe Inform the doctor
Post Falls Proforma
Datix
Full set of observations including neuro obs.
Review and update fall prevention care plan and modify care as required to include new interventions
Communicate with all staff that patient has fallen and increased risk
Inform relatives and the actions taken to reduce risk further
Show example of the Post Falls Performa Print Unit Number: WQN1387 INFORM Matron/ward manager of any falls with serious harm #
Complete Post Falls Performa document proforma & IR-1 form
Covers the initial assessment and expected response when a patient who has fallen is found
Immediate safety actions for the nurse, doctors examination and type/frequency of post fall observations
Supports information required for completion of the IR1 form and to help identify if the patients care plan actions needs amending.;

26. 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.

27. 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
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 –
New leaflet due out soon for inpatient from the falls group.

28. 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 (2004)
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):

29. Exercises
Look at the following slides and describe what assessments you would need to complete and the actions required to help prevent the patients falling

30. Mr Hall 72 years old
Tripped at home and was admitted to hospital following a fall
He is diabetic and has arthritis in his right knee and he usually walks with a stick. He has had cataract surgery in his left eye and is awaiting to have right eye done.

31. Lucy 21 years old
Had been out drinking all night, presented to the Emergency department with a fall and injury to her left ankle. She is very unsteady on her feet and keeps falling in the department.

32. Mrs Laycock 76 years old
Has had a fall at home and has a black eye, medicines brought in from home are, painkillers, beta blockers and some over the counter meds. She is vague about how she fell.