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PATIENT FALLS POLICY

Amendments Date Page Comments Approved by January 2012

General overview –

Compiled by: Debbie Palmer, Falls Lead Nurse

Dr Keefai Yeong, Consultant Geriatrician In consultation with : The Falls Group Ratified by: Chairman’s Action for Clinical Governance Committee Date: Date issued: January 2012 Next review date: January 2013 Target audience: All clinical staff Impact assessment carried Out by: Dr Keefai Yeong Contact name for comments: Dr Keefai Yeong

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CONTENTS

1. INTRODUCTION 2. DEFINITION OF A FALL 3. PURPOSE 4. RESPONSIBILITIES

5. GUIDANCE ON THE PATIENT WHO IS AT RISK OF FALLING

OR HAVE FALLEN 5.1 RISK ASSESSMENT

5.2 CORE CARE PLAN

5.3 IN THE EVENT OF A FALL 6. DISSEMINATION AND IMPLEMENTATION 7. REVIEW AND MONITORING 8. EQUALITY IMPACT ASSESSMENT 9. ARCHIVING 10. EDUCATION AND TRAINING 11. REFERENCES 12. APPENDICES

Appendix 1 Falling Risk Assessment

Appendix 2 Core Care Plan – Patient at Risk of Falling

Appendix 3 Core Care Plan – Post Inpatient Fall

Appendix 4 Medical Action Tool – At Risk of Falls Appendix 5 Medical Action Tool – Post Inpatient Fall Appendix 6 Bedrail Assessment Appendix 7 Confusion Assessment Method Appendix 8 Abbreviated Mental Test Score Appendix 9 Mini Mental Test Score (MMSE/Folstein) Appendix 10 Falls Clinics Appendix 11 Post Inpatient Fall Flow Chart Appendix 12 Impact Assessment

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ASHFORD & ST. PETER’S HOSPITAL NHS FOUNDATION TRUST

PATIENT FALLS POLICY

See Also : One to One (Specialling Policy) Dementia Policy Wandering Policy

Incident Reporting Policy Learning, Education and Development Policy 1. INTRODUCTION 1.1 In 2009, there were 152,000 falls reported in Acute Trusts in England and Wales,

26,000 in Mental Health Trusts and 28,000 in community hospitals (National Patient Safety Agency - NPSA)

1.2 Although the majority of falls result in no harm or minimal injury, the impact on the

patient can still be significant, leading to loss of confidence, delayed discharges and loss of independence.

1.3 A significant number of falls result in death, severe or moderate injury, at an

estimated cost of £15million per annum for immediate healthcare treatment alone (NPSA 2007)

1.4 It is accepted that falls cannot be eliminated but the risk of falling can be

minimised. It is important to recognise that falls are NOT an inevitable consequence of being an inpatient or frail and that most falls are predictable and measures can be put in place to minimise a patients’ risk of falling.

1.5 In some patients, the risk of falls remains despite all reasonable measures, such

as sensor alarms and activity boxes and in these circumstances, care should be concentrated on reducing the harm from falls e.g. the use of ultra low beds, crash mats and the treatment of osteoporosis.

1.6 Falls prevention is the responsibility of everyone involved with the patient and will

frequently feature multidisciplinary intervention. 1.7 There are many elements of falls prevention and successful management will

require the holistic approach of a Multidisciplinary Team. 2. DEFINITION OF A FALL

2.1 A fall is a sudden, unintentional change in position causing an individual to land at

a lower level on an object, the floor or the ground other than as a consequence of sudden onset of paralysis, epileptic seizure or overwhelming external force (Feder 2000)

3. PURPOSE 3.1 This policy sets out the identification, assessment and care planning of patients

who are at risk of falling or who have fallen in hospital.

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3.2 This policy is intended for use in all adult areas. For specialist areas, please refer to specific policies.

4. RESPONSIBILITIES 4.1 THE CHIEF EXECUTIVE AND THE TRUST BOARD

The Chief Executive and the Trust Board recognises that one of the major causes of injury to patients is falls. To reduce the incidence of these events, the Chief Executive has delegated the following responsibilities to key staff within the Trust. By recognising the importance of this area of care the Chief Executive and Board members support the actions outlined in this document to tackle and reduce the number of falls within the Trust.

4.2 THE FALLS GROUP

Members will ensure that this policy is developed and disseminated throughout the Trust. They will review and contribute to the ongoing training programme to educate staff and review any resource implications needed to address this issue Trust wide.

4.3 WARD AND DEPARTMENTAL MANAGERS

It is the responsibility of the Ward/Departmental managers to ensure that their staff is appropriately trained in relation to risk assessment and falls management skills. They must also ensure that their ward/departments are conducive to the prevention of falls. This will include :

• Completion of annual risk assessment of their areas, ensuring that corrective action is taken

• Review risk assessments on an annual basis or when changes to their patients and environment occur.

They will be supported in these activities by clinical governance co-ordinators as appropriate.

4.4 NURSING

It is the responsibility of the registered nurse to ensure the following actions are taken for each patient they care for :

• To complete a Falls Risk Assessment on all adult acute admissions and identify patients at risk of falling or who have fallen (Appendix 1)

• To complete an’ At Risk of Falls’ Core Care Plan (Appendix 2) for All patient identified as ‘at risk’.

• Communicate with members of the family and healthcare team

• Document plan of care within the relevant professional notes.

• Follow correct procedure with a patient who has fallen to not casue additional harm.

• Complete a ‘Post Inpatient Fall’ Core Care Plan for any inpatients who sustain a fall. (Appendix 3)

4.5 PHYSIOTHERAPY It is the responsibility of the Physiotherapists to complete a Therapy falls assessment on patients admitted with a fall or who have fallen on the ward where

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the cause of a fall is mechanical. This will include assessment of gait and balance and identify causes of mechanical fall that will benefit from physiotherapy input.

4.6 OCCUPATIONAL THERAPY

It is the responsibility of the Occupational Therapist to complete a bio- psychosocial assessment of patient’s needs, who have been admitted following a fall. Our ultimate aim is to increase patient’s independence and maximise functional ability with everyday activities. We will make recommendations and provide the necessary equipment to enable patients to return to their home environment as safely as possible.

4.7 PHARMACY Pharmacy staff will highlight, for patients who are identified as ‘At risk of falling’ medication which should be reviewed as possibly contributing to the risk of falls. Pharmacy staff will also prompt the medical teams to consider bone protection medication.

4.8 MEDICAL PRACTITIONERS It is the responsibility of any doctor to ensure that -

• All patients who are assessed ‘At risk of sustaining a fall’ must have the Medical Action Tool for ‘At Risk’ patients completed by their doctor. (Appendix 4)

• All patients at risk of sustaining a fall or having sustained a fall must have a Bone Health Assessment completed, and where appropriate bone protection medication prescribed. (Appendix 4)

• All patients who had a fall must be seen and examined by a doctor and their findings, examination and any investigations recorded in the healthcare records using the Medical Action Tool for Post Inpatient Falls (Appendix 5) and on the incident report form. Any investigations must be clearly documented in the health care records including a management plan for review.

4.9 HEALTH AND SAFETY ADVISOR The Health and Safety advisor will jointly conduct the annual risk assessment of

the ward/department area with the manager and clinical governance co-ordinator. He will also advise should risks be identified within the environment or practice of the area.

4.10 LEGAL REQUIREMENTS 4.10.1 The Health and Safety at Work Act 1974 places a duty on employers to ensure

that the health, safety and welfare of employees and those affected by their work activity. The employee has a duty not to endanger themselves and to use any safety equipment provided by the employer.

4.10.2 Workplace Health and Safety and Welfare Regulation 1992 state that employers

so far as is reasonable and practicable, floors/traffic routes are kept free from obstructions and substances likely to cause a person to slip, trip or fall.

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4.10.3 Management of Health and Safety at Work Regulation 1999, employers must

assess the risks to include slips and trips to employees and others who may be affected by their work or businesses.

5. GUIDANCE ON THE PATIENT WHO IS AT RISK OF FALLING OR HAVE

FALLEN

a. A fall is usually multi-factorial and it is estimated that there are over 200 risk factors associated with an increase in the risk of a patient falling. It follows that falls prevention is necessarily multifaceted and has to be tailored to individual patients. The most important aspect of falls prevention is staff taking ownership of the issues and taking responsibility for addressing and improving them.

b. Falls analysis data suggests that falls solely attributable to environmental factors

are uncommon but easiest to rectify. Floors need to be free of defects such as cracks or holes. Cleaning materials used should be only those compatible for the floors so as not to create a slip/trip hazard. It is the responsibility of all staff to report any defects immediately via the Facilities Helpdesk (ext 2882), stating the urgency of the problem.

c. Lighting and signage should be clear and obvious to allow patients and staff to see any potential hazards. Broken lighting should be reported to the Facilities Helpdesk as above.

d. Obstructions and waste disposal must be removed as this may present an

unnecessary trip hazard. All waste must be stored in the appropriate storage room and will be collected as per established arrangements.

e. The falls reported in Ashford and St Peter’s NHS trust last year show that nearly

50% of these patients were reported to be “found on the floor”. This highlights the difficulty in observing vulnerable patients whilst also maintaining their privacy and dignity. It is the responsibility of the shift leader to ensure that appropriate equipment is used to help reduce these patients falling or that there are staff present at all times to supervise them.

In the event of staff shortages, the shift leader is expected to reorganise the

staffing and/or patients to ensure that the risk of falls is minimised and the issue escalated to the Matron of the relevant area.

5.1 RISK ASSESSMENT 5.1.1 Falls risk assessment must be carried out on admission on all adult patients

(Appendix 1) 5.1.2 The risk assessment once completed will identify if there is a recognised risk

present on admission. Patients identified ‘At Risk’ will have a green ‘Falls’ alert sticker placed next to their name on the ‘white board’ and a green alert sticker placed on the medical notes. The IPL will clearly indicate the patient is at risk of falls. The ‘Real Time’ screen will be updated to indicate the patient is at risk of sustaining a fall. The alerts will identify the patient as ‘at risk’ to other members of the multidisciplinary team.

5.1.3 All patients but especially those identified as at risk of falls should have the

‘Bedrail Assessment’ completed (Appenidx 6)

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5.1.4. All multidisciplinary assessments and actions, including the Core Care Plan for Patients at risk of Falls (Appendix 2), the Medical Action Tool (Appendix 4) should be completed and filed in the appropriate records.

5.1.4 Risk Assessment should be scored weekly or more frequently if the patient

condition changes. 5.2 Patients at risk of falling. 5.2.1 Implement the Core Care Plan for Patients assessed as At Risk of Falling. This

is designed to help staff minimise the risk of the patient falling. The Core Care Plan implementation will ensure that othere disciplines are aware there is a patient at risk of fall, and complete their assessments. This will include, physiotherapists, occupational therapists, pharmacy etc.

5.2.2 All patients on the Core Care Plan should have been assessed for suitability of

bed rails. Used inappropriately, bed rails can potentially cause more harm – patients are more likely to injure themselves falling from a greater height. The Bedrail Assessment tool can be found in Appendix 6.

Patients at risk, and or their relative / carer should be given the Information leaflet – Trustnet / Documents / Core Care Plans / Falls / Information leaflet.

5.2.3 If a patient is confused and wandering, it is the duty of the nurse in charge to

ensure appropriate measures are taken to minimise the risk of the patient falling and minimise the potential for harm from a fall, for instance, considering the use of equipment such as an ‘ultra low bed’, a crash mat and possibly a sensor alarm, or perhaps one to one nursing early and ensuring that windows and exits are secure. It may also be of use to try to occupy the patient with an Activity Box. The relatives / carer / other patients on the ward may find a wandering patient, or one with acute delirium distressing – they should be given the information leaflet on Delirium or Wandering Patients, (found on Trustnet / Documents / Core Care Plans / Documents / Information leaflets.)

5.2.4 The Medical Action tool for Patients ‘At Risk of Falling’– Appendix 4 should be

completed by the Doctor and filed chronologically in the medical notes. In addition to this, other factors to be considered include

1) Delirium – this should be ruled out and reversed. If the diagnosis is in doubt, consider using the Confusional Assessment Method (CAM – Appendix 7) to aid diagnosis. 2) Cognitive screen. The risk of falling increases significantly with cognitive impairment. Ensure baseline cognitive assessment is performed, for instance a 10 point Abbreviated Mental Test Score (AMTS – see appendix 8). A more detailed Mini Mental State Examination (MMSE) is recommended (appendix 9). Please refer to Dementia Strategy for further information on dementia and management of patients with dementia. 4) Assistive technology – e.g pressure pad alarm sensors. This can be considered in patients who are at risk of wandering and falls. This should only be use in extraordinary situations to maintain patient safety and promote safer wandering. Where possible, the patient’s consent should be sought and if the patient lacks capacity to decide, the views of his next of kin or an Independent Mental Capacity Advocate (IMCA) should be taken

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into consideration. Please contact Matron or Site Practitioner for more information on availability and training on the use of assistive technology. 5) Osteoporosis assessment – This is common in elderly patients, especially women. This is important as patients with osteoporosis are more likely to sustain significant injury i.e. fractures. For patients with a history of previous fractures, treatment can be initiated for women over the age of 75 without the need for a DEXA scan. A DEXA scan is recommended for patients under the age of 75 prior to treatment (appendix 4 and ref NICE). For patients at risk of osteoporosis without prior fractures, consider using the FRAX tool (available at Trustnet/Widgets/Frax ) to determine a patient’s 10 year absolute risk of sustaining a fragility fracture.

5.2.5 For patients presenting to Accident and Emergency (A&E) with a fall and discharged, the details of the patient should be retained for the Community Falls Coordinator to follow up. Additionally, if the patients require a medical falls assessment, please refer to the Falls Clinic (Appendix 10)

5.3 IN THE EVENT OF A FALL 5.3.1 Ensure patient safety first Follow the flow chart for Post inpatient Falls (Appenidx

11) Follow the actions in the Core Care Plan for Patients Post Inpatient Fall. (Appendix 3)

Assess the situation and condition of the patient Make the scene safe e.g. remove any objects involved in the fall or dry wet

surfaces Return the patient to the bed for a full assessment using appropriate equipment

as identified in the Post Fall Flow Chart. 5.3.2 Call for medical assistance During working hours the patient must be seen by a

doctor within 2 hours. If out of hours, the CNSP should be contacted and should assess the patient

within 1 hour, and then decide whether to call the doctor immediately or wait till the morning.

5.3.3 Reassure the patient and explain to them what you are doing and why. Maintain

the privacy and dignity of the patient at all times. 5.3.4 Record observations of vital signs 5.3.5 Medical personnel should assess the patient fully, paying particular attention to

spinal, bony and head injuries.

• Spinal or suspected fracture elsewhere – all patients should be assessed for bony injuries following a fall, paying particular attention to the spine and hips. Any new or increased pain in any part of the spinal area should be consider a potential spinal injury and appropriate care as outlined in the Post Fall Flow chart should be implemented.The combination of pain during straight leg raise, pain in groin and pain on rotation of the hips gives a very strong indication of the presence of a hip

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fracture. If in doubt, or if the patient is confused, there should be a low threshold for obtaining an x-ray of the relevant area. The doctor should complete the Medical Action Tool (Appendix 5) which should be filed in the patients medical notes in chronological order.

• Head injuries – refer to Nice Guidance CG56 for further guidance on

management of patients with head injuries. All unwitnessd falls must be treated as if they have sustained a head injury.

• Consider cause of fall – could this be a geriatric giant? Elderly patients

with concurrent illnesses often present in a non specific manner. These common modes of presentation (Immobility, Instability, Incontinence and Impairment of intellect) may be a sign of underlying acute illness which may go unnoticed if the medical staff is not vigilant. A full history and examination is essential and completion of the Medical Action Tool (Appendix 4). An opinion from a geriatrician may be of benefit if the cause is not apparent.

5.3.6 Carry out any dressing to wounds 5.3.7 Inform relatives during the shift that the incident had occurred and explain what

has happened including further investigations and plan of care. Document this discussion including who it was with.

5.3.8 Complete an incident reporting form in as much detail as possible to help

identify trends and facilitate learning from the event. A doctor will need to be informed following every fall and his/her assessment should be documented clearly on the Medical Action Tool for Post Fall, and filed chronolgically in the medical notes. The doctor will also need to complete the relevant section of the incident form.

5.3.9 Document events in the Nursing records. If the event has resulted in serious harm

or injury to the patient ensure that the Matron for the area is informed and if out of hours, the CNSP. An email should be circulated to escalate the event. This should be sent to The Director of Nursing and Acute Services, Matron, Head of Nursing, Clinical Risk Manager, Clinical Governance Coordinator, Business Unit Manager and Associate Director and #Incident Reporting..

6. DISSEMINATION AND IMPLEMENTATION 6.1 The policy will be disseminated through the Aspire global email and will be

circulated to Chairs and Secretaries of ratifying committees. Support will be given to ensure implementation.

6.2 Policy training days will be set up at intervals to support staff 7. REVIEW AND MONITORING 7.1 This policy will be reviewed and monitored by the Falls Group who will determine

key indicators that will be used to monitor the effectiveness of the policy.

These will include: 1. Quarterly review of Falls statistics to establish trends 2. Regular falls audits to ensure quality

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3. Monitor and review “near miss” incidents in relation to falls 4. Monitor for and review any changes in regulation, legislation and national guidance 5. The success of most falls prevention programmes are dependent on education and improving awareness. The Falls Group and the Practice Development Team are committed to providing a continuous educational programme for Falls Prevention to all staff and engaging in activities that will improve awareness on falls e.g. Falls Awareness Days

7.2 Any changes to this policy will be ratified through the Trust Consultation process.

7.3 The group will report annually to the Trusts’ Clinical Governance Committee. 8. EQUALITY IMPACT ASSESSMENT 8.1 This can be found in Appendix 12. 9. ARCHIVING ARRANGEMENTS 9.1 Archiving arrangements are managed by the Quality Department and can be

contacted to request master/archived copies. 15. EDUCATION AND TRAINING 15.1 Training on Falls will be cascaded through the Practice Development Team and

the Lead Nurse – Falls Prevention. 15.2 Further training on falls prevention include: 1) For all staff on induction 2) Mandatory Non Clinical Staff 3) Mandatory B Clinical Staff

Appendix 1

Appendix 2

CARE PLAN for Patient at Risk of

Falling

ADDRESSOGRAPH

(basic information sticker to be used only,

not full addressograph)

PROBLEM: Patient assessed as at risk of falls GOALS

• To minimise risk of a fall PLAN OF CARE

1. Patient

• Encourage and reassure patient and explain care.

• Orientate to ward environment – particularly the toilet and the need to always ask for help..

• Place alert sticker on whiteboard and drug chart and alert staff at all handovers.

• Ensure call bell always in reach.

• Keep bed area de-cluttered.

• Place bed in high visibility area if possible.

• Ensure night light working and patient understands how to use it.

• Give patient a copy of the information leaflet – You have been assessed at risk of sustaining a Fall

• (Can be printed off the Intranet)

• Supervise walking at all times possible if necessary Signature of RN………………………..print……………………...

2. Assess

• Complete Cotside assessment • Cotsides appropriate YES / NO

• Consider use of Cotside protectors.

• If Cotsides appropriate – give relatives leaflet YES / NO

• (Can be printed off the Intranet) • Complete mobility assessment. YES / NO

• Assess patient’s elimination needs and continence status.

• Implement Falls Care Rounding sheet.

• Record Lying and standing Blood Pressure Lying…………………..Standing……………………..

• Record urinalysis

• Record ECG Signature of RN………………………print………………………

3. Family / Carer / Friend

• Contact family / carer / friend if possible and request they bring the following items in: - distance glasses - dentures - hearing aid and spare battery - pts usual mobility aid - pts own night wear – well fitting - well fitting appropriate footwear – slippers or shoes – non slip soles.

• Give family / carer / friend a copy of the information Falls leaflet

• Name of family member / carer / friend given info: ………………………………………………………….

Signature of RN…………………..…..print………………………

PLAN OF CARE (cont.)

4. Refer

• Refer to patient’s Dr as a risk of falls.

• Name of Consultant team………….…………………..

5. Refer

• Refer to physiotherapist for mobility and gait and balance assessment / treatment.

• Date referred……………………………………………

6. Refer

• Refer to Occupational Therapist for assessment and advice.

• Date referred……………………………………….…..

7. Refer

• Refer to ward pharmacist for assessment of medication.

• Date referred.…………………………………………..

8. Real Time

• Highlight patient at risk of falls on Real Time.

9. Equipment

• Call bell working and in reach.

• Cotsides well fitting and in use if appropriate.

• Sensor alarm if appropriate YES / NO

• Low bed YES / NO

• Wanderguard YES / NO

Signature of RN………………….…print……………………

Appendix 3

CARE PLAN for

Patient has sustained an inpatient Fall

ADDRESSOGRAPH

(basic information sticker to be used only,

not full addressograph) PROBLEM: Patient has sustained a fall

GOALS:

• To assess for and minimise injury from fall. PLAN OF CARE: (date, individualise & tick boxes as appropriate) Immediate Action: Assess ABCDE immediately

No signs of life � Priority Call if appropriate (2222)

Signs of life � Proceed

A. Signs of Life

• Assess MEWS / GCS / Pain / Limb deformity / Loss of Sensation

B. Possible spinal injury [ YES / NO ]

Signature of RN……………………..print……………………..

• If NO – proceed to ‘C’, assess patient for moving to a safe environment.

• If YES – DO NOT USE SLING HOIST or HOVERJACK. Do not move patient until assessed by appropriate Doctor and appropriate equipment and staff trained to operate it are available.

� Priority Trauma call – 2222 � SPH - USE SCOOP HOIST kept in rear of A/E � Ashford - Call 999

C. Limb deformity [ YES / NO ]

Signature of RN…………………………..print……………………….

• If NO – proceed to ‘D’

• If YES – consider analgesia and immobilisation prior to moving patient. Do not move patient until assessed by appropriate Doctor and appropriate equipment and staff trained to operate it are available.

• Call Dr – to be seen immediately.

D. Signs of Head injury, all unwitnessed falls or GCS ≤13 (less than 13) [ YES / NO ] please circle

Signature of RN…………………………print……………………………

• If NO – Repeat observations – if NAD return to previous frequency. DR to review within 2hours 9am –

5pm, Out of hours – CSNP to review within 1 hour.

• If YES – Dr to review immediately - � ½ hrly neuro obs till GCS = 15 (or 14 in previously � confused patients) � Then 1 hrly for 4 hrs � Then 2 hrly until further senior review

E. MEWS ≥ 3/4 - follow contact details for Outreach

Dr to review immediately.

PLAN OF CARE (cont.)

F. Loss of sensation and / or altered GCS [ YES / NO ]

• If NO – proceed to all other sections. Singanture RN……………………..print…………………….

• If YES – Dr to review immediately. Consider putting out Stroke Call.

G. Document in nursing records method of moving patient – i.e. assisted to stand, sling hoist, hoverjack, scoop hoist.

H. Ensure reassurance and explanation given to patient at all times and ensuring that

dignity and privacy are maintained.

I. Record ECG - when possible obtain urinalysis

J. Complete Incident Report

• note any other injury; bruising, laceration etc

K. Statements collected from all staff if injury caused

L. PAS referral made to Lead Nurse Falls Prevention

M. Within 24 Hours

• Refer to patients own Dr to complete a Risk of Falls Assessment if appropriate.

• Refer to ward Pharmacist to review medication.

• Refer to ward physiotherapist for reassessment.

• Refer to ward Occupational Therapist.

• Give relatives a copy of ‘At risk of Falls’ leaflet if they have not already been given one.

N. Pre-discharge

• Consider referral to Community Falls Team on discharge

Signature RN…………………..………..print…………………………

Appendix 4

DATE : _____________________

MEDICAL ACTION TOOL – Patients Assessed at Risk of Falling

Risk

Action Date

Dr Sign

Print Name

Lying and standing blood pressure

1 min 3 mins Lying Sitting/ Standing Pulse

If significant (>20/10mmHg) 1) Advise to be cautious lying to standing 2) Check pt hydrated/haemodynamically stable 3) Check medications 4) Raise head of bed 5) Full length TEDS if appropriate 6) Consider medications eg fludrocortisone

ECG Review ECG

Medication

Check medication associated with falls: All unnecessary medications stopped? (eg anti-depressants, Parkinson’s Disease medications, anticholinergics, analgesia, sedatives, anti-psychotics and diuretics?)

Urinalysis

Perform urinalysis Blood □ Nitrates □ Leucocytes □ If any positive send MSU

Continence

Consider removing cath or change to leg bag If patient incontinent: 1) Commence Fluid balance chart for 72 hours 2) Check for and treat bladder instability 3) Treat UTI if dipstick positive 4) Advise regular toileting If faecally incontinent: 6) Rectal examination and treat constipation

Visual

Is the patient able to identify pen or key from end of bed? Y/N

Ward

Patient Addressograph

Assessment If no, 1) Check visual acuity using Snellen chart 2) Full visual assessment 3) Consider referral to opthalmology

Feet

Check toe nails Assess for sensory impairment

AMTS Score

PLEASE FILE IN MEDICAL NOTES

Bone Health

History of previous “fragility fracture” (Fracture resulting from a fall from

standing height) ≥ 75

Initiate bone protection providing no contraindications - 1st line is alendronate 70mg once weekly + Adcal D3 1 tablet bd - Consider strontium 2g o.n if unable to tolerate/failure of therapy

< 75 Order DEXA scan Yes / No BMD (if known) = ___________________ If BMD shows osteopenia – perform FRAX risk assessment If patient osteoporotic, initiate treatment as above

Patient has recurrent falls but NO fractures – perform FRAX calculation FRAX tool available – Trustnet / Widgets / FRAX Treatment guidance available – click on NOGG on completion of FRAX.

Treatment required - Yes / No Signed………………………………………

Appendix 5

Patient

Name: Ward: Date:

MEDICAL ACTION TOOL – Post Inpatient Fall Protocol Doctor’s Name: ______________________________________ Signature: ___________________________________________ Time of assessment: ___________________________________

1) Spinal Injuries

Does patient complain of new or worsening pain in neck or spine?

Yes � No � If yes, put out Trauma call SPH 2222 ASHFORD 999

Time bleeped : ___________________________

Do not attempt to move patient until they have been assessed by an appropriate practitioner and appropriate manual handling equipment and staff trained to operate it are available. 2) Examine to exclude fracture

In particular, the following should be checked:

Pain/tenderness in the groin area Yes: � No: � Unable to straight leg raise Yes: � No: �

Limited range of hip movements Yes: � No: �

Shortened and rotated hip Yes: � No: �

Any other fracture suspected Yes: � No: � If yes to any of the above:

Time xray requested _________________________ *ENSURE CORRECT CONSULTANT LISTED FOR CODE 5 REPORTS

File in medical notes

REQUEST URGENT XRAY IMMEDIATELY �

Review of Xray

Name of Dr: ______________________ Time Reviewed: ________________ No fracture Fracture Unsure

Result .................................................................................................................................. .................................................................................................................................. .................................................................................................................................. .................................................................................................................................. .................................................................................................................................. ..................................................................................................................................


Inform Ortho SHO Immediately (bleep 5941)

Time ____________________

Document in notes

1) 9-5 – Hot seat reporting

2) Out of Hours – refer to Orthopaedics

Xray Result

Fracture

3) Examine to exclude head injury

Feature Scale Score

Eyes Opening

Spontaneous To speech To pain None

4 3 2 1

Verbal response

Orientated Confused conversation Words (inappropriate) Sounds (incomprehensible) None

5 4 3 2 1

Best Motor Response

Obey commands Localise pain Flexion – normal abnormal Extend None

6 5 4 3 2 1

Total:

GCS < 13 Yes �� No �� If GCS <13, record neurological observations every 30 minutes till GCS 15 achieved (or 14 in previously confused patients), then follow the regime below

Evidence of Head injury (GCS 15) Yes � No �

Unwitnessed fall (GCS 15) Yes � No � If YES to the above, record neurological observations at these frequencies:

Every 30mins for 2hr

Every 1 hour for 4hrs

Every 2 hours thereafter until instructions to stop If lateralising signs, seizures or drop in GCS, CONSIDER STROKE CALL 2222 (SPH) ASHFORD 999

Time CT booked: __________

*ENSURE CORRECT CONSULTANT LISTED FOR CODE 5 REPORTS File in medical notes

Results to be reviewed as soon as available Results Review

Assess Glasgow Coma Scale (GCS) �

Book urgent CT brain immediately �

Name of Dr __________________________ Time Reviewed ____________ If no apparent Head Injury, and not an unwitnessed fall: Repeat full observations If observations within normal parameters: Return to frequency prior to fall Result ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………………………


CT Brain Result

Subarachnoid Haemorrhage

Subdural Haematoma Extradural Bleed

Intracerebral bleed

Refer to Neurosurgeons

Other abnormality or unsure

Normal

Document in notes

Discuss with consultant

4) Check for bruises and lacerations Location of bruises or lacerations

Sutures required Yes � No �

No of sutures: ________________________________________

Date of removal: ________________________________________ Any additional comments / instructions

…………………………………………………………………………………………

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Appendix 6

Appendix 7

Appendix 8 Abbreviated Mental Test Score Instructions The following standardised questions are put to the patient. Each correct response scores one point. 1) Do you know where you are at the moment? 1 point 2) What is your date of birth? 1 point 3) What is the year? 1 point 4) How old are you? 1 point 5) What is the time? (to the nearest hour) 1 point 6) Give the patient an address and ask him/her to repeat 1 point it at the end of the test eg 42 West Street 7) Count backwards from 20 to 1 1 point 8) What is the name of the Queen? (not Prime minister 1 point or anyone else) 9) When was the First World War? 1 point 10) 2 person recognition 1 point Total /10 Interpretation A score of less than 8 is considered an abnormal score and may suggest cognitive impairment or delirium

Appendix 9

Appendix 10 Falls Clinics Woking and Chobham residents – Woking Community Hospital – Dr Raad Nari Walton, Chertsey, Staines and Ashford residents – Walton Community Hospital – Dr Radcliffe Liske Referrals should be sent with a copy of the discharge summary to the relevant consultant’s secretary, requesting an appointment. Visit from the Community Falls Team

• Fax discharge summary to Falls Team (01932 872337)

• If any questions, contact Falls Team (01932 722285)

Appendix 11

Appendix 12

Equality Impact Assessment Summary

Name : Keefai Yeong, Consultant Geriatrician Policy/Service : Patient Falls Policy Background

• Description and aims of the policy

• Context in which the policy operates

• Who was involved in the Equality Impact Assessment

This policy details the identification, assessment and care planning of patients who are at risk of falls or have fallen. This policy applies to all adults areas and is intended to be used by all clinical staff. This equality assessment has been completed by Dr Keefai Yeong, Consultant Geriatrician and Chair of the Falls Group. Methodology

• A brief account of how the likely effects of the policy was assessed (to include race and ethnic origin, disability, gender, culture, religion or belief, sexual orientation, age)

• The data sources and any other information used

• The consultation that was carried out (who, why and how?) The elderly are more prone to falls. This policy has a strong focus on the management of falls in the elderly. It addresses all the relevant issues including communication, assessment of hearing, vision and cognition. The recommendation for treatment of osteoporosis is guided by age and is in line with current guidance from NICE. Older females aged over 75 are more at risk of osteoporosis and in this context, a DEXA scan is not deemed to be essential in initiating treatment following a fragility fracture. The policy does not impact on race and ethnic origin, disability, gender, culture, religion or belief and sexual orientation. The consultation was carried out in conjunction with the Falls Group and the Clinical Risk Manager. Key Findings

• Describe the results of the assessment

• Identify if there is adverse or a potentially adverse impacts for any equality groups

1) The policy focuses on mainly on the management of falls in the elderly but as this is by far the commonest group in which falls occur, it is not seen as a negative impact.

2) The age criteria for secondary prevention of osteoporosis is in line with current national guidance

Conclusion

• Provide a summary of the overall conclusions The impact assessment did not reveal any adverse impacts apart from the above.

Recommendations

• State recommended changes to the proposed policy as a result of the impact assessment

• Where it has not been possible to amend the policy, provide the detail of any actions that have been identified

• Describe the plans for reviewing the assessment

1) No recommended changes were proposed as a result of the assessment 2) This will be reviewed again next year at the time the policy is reviewed again.

References

1) Slips, Trips and Falls in Hospitals – The Third Report from the Patient Safety Observatory. Ref Number 0483. Available online at http://www.nrls.npsa.nhs.uk/resources

2) Reducing Harm from Falls – “How to” Guide. Patient Safety First Campaign.

Available online at http://www.patientsafetyfirst.nhs.uk 3) The assessment and prevention of falls in older people – NICE Clinical

Guidance CG021 Available online at http://www.nice.org.uk/CG021

4) Osteoporosis – Secondary Prevention, including strontium ranelate – NICE Clinical Guidance TA161 Available online at http://www.nice.org.uk/TA161

5) Head Injury – Triage, Assessment, Investigation and early management of head injuries in infants, children and adults – NICE Clinical Guidance CG056 Available online at http://www.nice.org.uk/CG056