Standard of the monthAPRIL

National Safety and Quality Health Service (NSQHS)

Standard 10:

Preventing falls and harm from falls

Overview of Standard of the Month• The National Standards in Action program is

about providing high quality, safe patient care and improving the patient experience.

• Every month will see the launch of Standard of the Month ensuring all staff: – understand the requirements of each NSQHS

National Standards– are familiar with relevant policies and procedures– are encouraged to undertake relevant education and

quality improvements – prepare for accreditation in 2015. 5

Overview of Standard 10• Aim: Reduce the incidence of patient falls and

minimise harm from falls for patients in care. 1

• Systems for prevention of falls including screening and/or assessing patients for falls risk and having multifactorial falls prevention strategies in place.

• Ensure that a patient’s falls risk is recognised promptly and appropriate action is taken.

Importance of Standard 10

• Falls-related injury is one of the leading causes of morbidity and mortality in older Australians

• Falls and falls related injuries comprise 80% of injury-related hospital admissions in people aged 65 years and over

• Older people, in particular, are at increased risk of falls when they enter health care facilities.

• 30% of falls in hospitals results in injuries• The social impact of reduced independence through

fear, the potential for loss of independence and the increased burden on families can be significant. 1

Importance of Standard 10

Due to an ageing population, if nothing is done to prevent falls injuries in Australia:

• The estimated cost of falls related injuries will increase to $1,375 million per year in 2051 (was $498.2 million in 2001).

• The equivalent of 2,500 additional beds will permanently be allocated to treating falls-related injuries by 2051. 2

Fall

• “A fall involves a person who for some reason inadvertently drops down to a lower level”. (World Health Organisation, 2006).

• Causes may include: slip, trip, collision, pushing and shoving from another person, or a medical condition 4

• The frequency and severity of falls-related injuries increases significantly with age.

• Younger people at increased risk of falling, such as those with a history of falls, neurological conditions, cognitive problems, depression, visual impairment or other medical conditions leading to an alteration in functional ability

Criteria for achieving Standard 10

1. Governance and systems for preventing falls

2. Screening and assessing risks of falls and harm from falling

3. Preventing falls and harm from falls

4. Communicating with patients and carers 1

Documentation • FRAT – on admission, every 3 days and following

a fall/near miss/change in condition• Falls prevention strategies must be documented• Report falls, adverse events and near misses as

incidents – this provides clinical data to monitor the frequency and severity of falls. 1

• If its not documented – you did not do it! Document to prove you did everything to minimise the patient’s risk of a fall

Auditing and Investigation• Auditing and evaluation of documentation and the health care

environment:– Identifies areas of improvements and further allocation of resources and

education– Monitors compliance with, and the use of, falls minimisation policy and

procedures • Falls are reported, investigated and analysed:

– With the aim of preventing further falls and harm from falls by identifying risks.

– At a ward level, by hospital project teams and at the highest level of governance e.g. fall committees, to identify common causes and trends in fall incidents1

• These evaluation and audit results are communicated to the clinical workforce along with improvement strategies and the timing/structure of re-audits to monitor the effects of these strategies

FRAT – Falls Risk Assessment Tool• FRAT is used for screening and assessing a patient’s risk of falls

and their potential to be harmed by falls • A falls risk assessment must be completed:

– within 24 hours of admission– 3rd daily (acute care settings)– when a patients health status changes– after a fall– prior to discharge.

• Interventions & fall prevention strategies must also be recorded in the patient’s care plan and in their clinical notes

• Also ask patients about the frequency, context and characteristics of any falls over the past year 6

• There must regular auditing to ensure the above activities are occurring 4

Risk Factors • Cognitive & sensory impairment, impulsive behaviour, • Pain,• Continence problems,• Falls history, including causes and consequence (such as injury and

fear of falling),• Footwear that is unsuitable or missing (shoes need to hold the foot

firmly),• Health conditions,• Medications,• Postural instability, mobility or balance problems,• Syncope syndrome, • Visual impairment, 6

• Environment factors including equipment. 7

Preventing falls and harm from fallsMake the environment safe: • If high risk – patient nursed on a Lo-Lo bed at its lowest height• If moderate to low risk - the bed is at an appropriate height so the

patient’s knees are at 90 when sitting on the side of the bed• Their room is kept free of spills and clutter• There is adequate lighting for the patients needs, particularly at

night • The patient is aware of, and can easily reach personal possessions

especially glasses, hearing aids and gait aids• Orientate and if required re-orientate patient to surroundings

especially bathroom and nurse call bell• High risk patients in high visibility rooms• Minimise the use of restraints and bedside rails

Preventing falls and harm from fallsIdentify less obvious risk factors:• Review medication, particularly high-risk medications

such as sedatives, antidepressants, antipsychotics and centrally acting pain relief

• Measure postural blood pressure• Organise routine screening urinalysis to identify urinary

tract infections• Full patient assessment e.g. dehydration, pain, blood

tests for hyponatraemia, remove unnecessary attachments asap e.g. IDC, IVT, etc

• Encourage physical activity as inactivity increases the risks of loss of conditioning and reduced functional capacity

Preventing falls and harm from fallsEnsure falls prevention is maximised:• Do ‘roundings’ hourly (establish a care plan for bowel

and bladder function), especially for high risk patients7

• Allow patients time to adjust to changes in positions, promote leg exercises (pointing their toes down) to encourage venous blood supply.

• Encourage patients when ambulating – hold head high and focus eyes ahead, tuck pelvis under torso, position feet a shoulder width apart, gently tighten stomach muscles.

• Utilise all appropriate equipment e.g. low-low beds, concave mattresses, chair sensors, bed sensors, floor mats, hip protectors, non-slip mats, etc.

Preventing falls and harm from falls• Instruct the patient how to use aids e.g. 4WF, etc and

check their understanding after instruction • Minimise the use of restraints and bedside rails• Consider vitamin D supplementation as a routine

management strategy for mobile older patients• If patient is moderate to high risk – orange falls risk

sign must be placed above their bed• Appropriate referrals to PT, OT (with home

assessments), dietician, continence nurse, pharmacist, etc.

Preventing falls and harm from fallsModerate to high risk patient:• A high falls risk must be documented on the Patient Alert

Form 00• Remember to regularly reassess FRAT score• If a patient falls from a low-low bed in its lowest position

onto a floor mat and no injury occurs, document in the clinical progress notes but a Riskman is not required

• Fall mats only to be used at night time.• Remain with patient in the bathroom. • Best practice is to use more than one technique to prevent

falls (constantly assess the effectiveness and appropriateness of each strategy)

Preventing falls and harm from falls• Fall prevention strategies that have been identified but

have not been implemented must have the reason for non-implementation documented in the patient’s progress notes & reported to the nurse in charge

• All falls prevention and harm minimisation interventions, planned and current, should be included in verbal handover

• Handover should include any inpatient falls or near misses

• Falls risk, actual falls and risk minimisation strategies must all be documented in PFMS

Restraints • Category 1 restraints

– Are when limb(s)are secured to a bed or trolley– Prescribed by an authorised medical officer/psychiatrist, sectioned under the

mental health act– Contact Dr Peter Lange before initiating category 1 restraints

• Category 2 restraints– bed rails (unless transporting the patient), tilting/tub chairs, lap belts, concave

mattress, mittens (found in APU storeroom)– Nurse in charge can initiate category 2 restraints but must report without

delay to authorised medical officer/psychiatrist. • Release restraints every 2 hours • Document the release of the restraints and limb observations on

the mechanical restraint order and observation forms• Mechanical restraints must be used as a last resort and in the least

restrictive manner. • The reasons for the use of the restraints and the ongoing plan must

be documented in the medical notes. 9

Communicating with patients and carers

• The brochure ‘Tips to prevent falls and keep you safe in hospital’ and further education regarding falls minimisation strategies must be given to patient/family/carer on admission during completion of FRAT. Educate using the brochure.

• Brochures are available also in Italian, Arabic, Chinese, Turkish, Vietnamese, Greek and Polish

• Nursing staff are required to document in the clinical progress notes that this education has taken place and that the brochure has been given to the patient or carer

• Patients, families and carers are informed of the identified risk of falls. They are encouraged to engage in developing individualised prevention strategies/plans.

Communicating with patients and carers• Discuss the need for hip protectors (and the fact that the

family will need to purchase these - 3 pants for $166)• Family members can help reinforce advice from staff and

institute the strategies suggested e.g. new shoes, OT home assessments, use gait aids for all transfers and mobilisation, etc.

• Family members can help by staying with the patient if they are confused, and advise staff when they are leaving

• Families are especially important if the patient is not able to communicate in english - also utilise interpreter services

• Promote patient independence and improve their physical and psychological functioning

Communicating with patients and carers

Overall, individuals at risk of falls and their carers should be offered written and verbal information about:

• Measures to prevent further falls,• How to keep motivated to undertake exercises

and balancing strategies• Where to obtain further advice and assistance• How to cope if they had a fall, how to summon

help and prevent a long lie. 6

Falls Management• When a patient falls, call for assistance, inform nurse in charge,

do not move them until assessment has been carried out by a RN. Treat unwitnessed falls as if the patient has hit their head.

• Assessment: neurological observations and BGL, assess for obvious injuries. Consider potential injuries to head, neck, bruising, soft tissue, fractures, non-observable injury.

• If patient has not hit their head and has no obvious injury or pain, assist patient back to appropriate position i.e. Bed or chair. Monitor vital signs half hourly for 2 hours.

• If the patient has an obvious injury, localised pain, or suspected or confirmed that patient has hit their head - consider potential injuries when moving patient and utilise appropriate equipment e.g. scoop board.

Falls Management• For any confirmed or suspected (in an unwitnessed fall)

that the patient has hit head - monitor neuro obs half hourly for 4 hours.

• inform and have patient reviewed by medical officer. Liaise with medical officer for appropriate tests i.e. X-ray, CT 4

• Report to medical officer if patients condition deteriorates post fall at any stage (eg. Decreased conscious state, behavioural changes and/or headache). Special consideration of heightened risk in patients on; warfarin, aspirin, asasantin, clopidogrel, clexane, heparin.

• Medical officer or nurse in charge to notify next of kin/family and registrar/consultant (open disclosure)

Falls Management• Document details of the incident, actions taken and

notification of Doctor and carer in the clinical progress notes.

• Falls logo sticker in the progress notes, and patients level of falls risk (re-evaluation).

• All falls must be reported on riskman – asap or before the end of the day. Incident report includes the answers to – who, what, when, where, how and why.

• Any falls incident must be handed over to oncoming staff, and a referral made to the appropriate Allied Health professional if required. 4

Falls Management• If a patient falls 3 times within 24hrs or 3 times during an

admission episode;– In hours, the nurse in charge should contact the Divisional Director,

Nursing and Operations or Facility Manager – After hours the nurse-in-charge should contact the bed manager/after

hours coordinator. • If a patient dies as a result of a fall, the following people must be

notified:• the treating team senior Medical Officer• NUM• the patient’s nominated next of kin (or representative)• the Coroner• Director of Nursing• Divisional Director• Risk and Patient Safety Manager

Staff Responsibilities

• Falls prevention education package (available via the training space icon on the MH intranet homepage) annual learning competency.

• Where possible attend monthly falls minimisation forums held on high falls risk wards/areas i.e. APU

• Be familiar and comply with the hospitals manual handling policy and cervical spine guideline (from Trauma services). Manual handling should be eliminated in all but life threatening situations.

• Know where and how to obtain policies and procedures on ipolicy 8

Staff Resources • Policies, procedures and or protocols (based on

best practice guidelines including from the National Preventing Falls and Harm from Falls Best Practice Guidelines 2009) are available.

• Education and orientation resources for staff 1

• APU FRAT interventions cue cards • APU CNE’s in-service regarding FRAT scoring• MH intranet > accreditation > standard 10:

preventing falls and harm from falls – fact sheets are available regarding falls i.e. Appropriate shoes for patients.

Falls resources will be saved in one location on the Intranet.

MH Intranet

http://trainingspace.mh.org.au

Staff to complete Mandatory Training review almost completed

Mandatory Education

Any questions, comments, feedback?

By Emily Nielsen (CNE, CNS) 2013, revised 2014

Reference list 1. Australian Commission on Safety and Quality in Health

Care. Safety and Quality Improvement Guide Standard 10: Preventing Falls and Harm from Falls (October 2012). Sydney. ACSQHC, 2012.

2. Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 10: Preventing Falls and Harm from Falls – Fact Sheet. NSW.

3. Melbourne Health. Tips to prevent falls and keep you safe in hospital. Flyer. Falls Committee. Executive Director, Nursing Services and Allied Health. Reviewed June 2011. From ipolicy.

4. Melbourne Health Policies, Procedures and Guidelines. Falls minimisation. Jul 2013. From ipolicy.

Reference list

5. Dr Gareth Goodier – Chief Executive – email to all staff 2014

6. National Institute for Health and Care Excellence. Falls: assessment and prevention of falls in older people. Issued June 2013. guidance.nice.org.uk/cg161

7. Australian commission on safety and quality in healthcare. Preventing falls and harm from falls. Best Practice Guidelines for Australian hospitals. 2009.

8. Melbourne Health Policies, Procedures and Guidelines. Patient manual handling procedure. 2 may 2013. MH 15.11.

Next month - May:

Standard 3:

Preventing and Controlling Healthcare Associated Infections