Download here - Southern Health and Social Care Trust

Falls Toolkit
January 2014
January 2014
1
Contents:
Introduction
Page: 3-4
Falls Risk Assessment Pro-Forma Page: 5-6
Post-falls Pathway
Page: 7-8
References / Bibliography
Page: 9
Appendices
2
Falls Toolkit for use in Independent Sector Care Homes throughout
SHSCT
January 2014
Introduction:
Nursing Homes were identified as a priority for improvement work by the Northern Ireland
Health and Safety Forum in 2011. Within the Southern Trust’s geographical area, 3 Home
Managers have engaged with Trust personnel to explore the needs of older people in
relation to falls reduction and post-falls care with the aim of developing a toolkit addressing
falls issues. Reducing the number of falls and the likelihood of sustained injury should be a
priority within all Care Home settings where older persons reside. The risk of falls is a
complex issue and consequently a multi-factorial risk assessment process and the coordination of services specific to need is required to achieve person-centred care.
Definition of a fall:
“an event which results in a person coming to rest unintentionally on the ground or lower
level, not as a result of a major intrinsic event (such as stroke) or overwhelming hazard”
Tinetti et al (1988)
Purpose:
The aim of the toolkit is to enhance person-centred care in the assessment and reduction of
risk using Evidence Based Practice (EBP). Underpinning the strategy for reducing the risk of
falls and promotion of consistent management in the Nursing Home environment is based
on the premise that all residents are at risk. Using a process whereby risks are identified,
addressed and monitored will further reduce the risk of falls. The assessment, management
and recording of falls will support the use of robust clinical audit and serve as a driver to
bring about changes in practice.
Best Practice / Legislation:
The National Service Framework for older people (DOH, 2001), National Patient Safety
Agency (NPSA, 2004), Nursing Home Minimum Standards (DHSSPS, 2008) Royal College of
Physicians (RCP, 2012) and the National Institute for Clinical Excellence (NICE, 2013) clinical
guideline 161, collectively support person-centred assessment and care. Staff are required
to work in partnership with residents and their families with assessment being an on-going
process whereby prescribed nursing care is reflective of multi-disciplinary working where
risks are modifiable.
3
Factors influencing falls:
A table of contributing factors is included and incorporates intrinsic and extrinsic risks. Good
communication is essential in promoting falls awareness and reducing the number of falls in
the Nursing Home environment. Staff should be alerted to those residents at risk and
informed at report of those who have sustained a fall, whether resulting in injury or not.
Liaison with or onward referral to other disciplines should be integral to practice with
recording reflective of actions taken, evident in accident / incident recording documentation
and nursing evaluation. A post-falls review and reassessment should be carried out as part
of the resident’s care. Any new presenting factors should be recorded along with actions
taken in respect of them, including changes to the care plan. All falls should be logged to
assist with monthly auditing of outcomes and to achieve a policy of openness and
transparency.
**Falls risk scores can be misleading and are not a necessary part of a falls prevention
policy**
The National Institute for Clinical Excellence (NICE) Clinical Guideline 161 (June, 2013)
defines older people as those aged 65 years or above. However as part of the Royal College
of Physicians (RCP, 2012) FallSafe project, the age threshold used for the cognitive
assessment was over 70 years and all patients in hospitals for older people were counted as
high-risk and received this bundle. The RCP recommended that all in-patients with a history
of falls or fear of falling, or who tried to walk alone although unsteady or unsafe, received it.
The greater the number of risk factors, the greater likelihood of falling (Social Care and
Social Work Improvement Scotland, SCSWIS, 2011).
This toolkit contains a falls assessment pro-forma based on the evidence and resources for
Nursing and Care Home staff to facilitate implementation of best practice.
4
FALLS RISK ASSESSMENT PRO-FORMA
To be completed on ADMISSION, MONTHLY and FOLLOWING A FALL with the
falls care plan amended accordingly
(Derived from the RCP FallSafe care bundle (2012) and NICE clinical guideline 161, 2013)
Date/Time
Detail
Has resident had one
or more falls in past
year?
5
Refer to
Appendix 2
Section:
a)
Is resident taking 4
or more medications
or any drugs in
appendix 2?
Has there been a
change to
medications in the
last month?
b)
Is the resident
confused,
disorientated,
restless, irritable or
agitated?
c)
Does the resident
have any long term
condition which
would increase falls?
d)
Does the resident
experience dizziness
or fainting?
Record Blood
Pressure (sitting and
standing)
e)
Has the resident lost
weight?
Is the resident
adequately
hydrated?
Do continence issues
contribute to the
resident’s falls?
Is the resident
unsteady / unsafe
walking?
Any difficulty with
transfers?
f)
(See Appendix
3 also)
g)
h)
Yes/No
Action
Signature
Date/Time
Detail
Refer to Appendix
No 2 Section:
Does the resident difficulty
with vision / poor hearing?
i)
Does the resident have any
foot problems? Is footwear
appropriate?
j) And also
resource pack
Is the resident able to get
out of bed safely?
Does the resident get out of
bed during the night?
k)
Yes/No
Action
Signature
*If the answer is YES to any of the questions above a detailed falls care plan
must be in place*
6
INITIAL ACTION WHEN A RESIDENT IS ON THE FLOOR
POST FALL PATHWAY:
Action to be taken when a resident falls:








consider if the fall was witnessed or unwitnessed
raise alarm; inform nurse in charge
keep calm and provide reassurance
ensure safety of resident & self/others
check airway, breathing and circulation (ABC)
do not move until safe to do so
collect as much information as possible for records
keep resident comfortable
Consider possibility of the following types of injury:



suspect head injury (treat unwitnessed fall as potential head injury)
suspect lower/upper limb fracture(s)
suspect spinal fracture
DO A FULL HEAD TO TOE EXAMINATION,CHECKING FOR BRUISING, CUTS AND SWELLING;
COMPLETE BODY MAP & DOCUMENT ACCURATELY THE EXTENT OF SAME
IF YOU SUSPECT ANY OF THE ABOVE:

seek medical advice – GP / OOH / 999
IF NO APPARENT INJURY:



assist to a comfortable position, such as chair/bed
use appropriate equipment & moving & handling techniques
check clinical observations & GCS (may highlight TIA)
If the resident refuses help or services, consider their ability to make decisions and liaise with family
as necessary, ensuring accurate documentation and notify the Care Manager / CHST.
COMPLETE FOLLOWING A FALL:





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Accident book/form
Post fall investigation report
Gather information from any witnesses
Ensure resident can use call system or summon help
Update falls risk assessment





Update falls care plan
Ensure appropriate supervision is recorded in the care plan and provided accordingly
following re-assessment
Check footwear/continence/medications
Carry out relevant investigations i.e. MSSU/CSU
Refer to falls team if deemed appropriate
Inform relevant people:





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Next of kin
Line manager
Care manager
RQIA
Inform SHSCT via [email protected]
References:
Health and Social Care Safety Forum (2013) Northern Ireland Nursing Home Regional
Collaborative Falls prevention. Belfast: HSC.
National Institute for Clinical Excellence (2013) Falls: assessment and prevention of falls in
older people. NICE guideline 161. June 2013. Available from: www.nice.org.uk/guidance
Royal College of Physicians (2012) FallSafe care bundles. Available from:
www.rcplondon.ac.uk/projects/fallsafe
Social Care and Social Work Improvement Scotland (2011) Managing falls and fractures in
care homes for older people. Scotland: SCSWIS.
Southern Health and Social Care Trust (2012) Community post-falls pathway. Craigavon:
SHSCT.
Tinetti, M.E. Speechley, M. and Ginter, S.F. (1988) Risk factors for falls among elderly
persons living in the community. New England Journal of Medicine. Vol 319 (26), 1701 –
1707.
Bibliography:
Help the Aged (2004) Preventing Falls. Managing the risk and effect of falls among older
people in care homes. Available from: www.helptheaged.org.uk/slipstrips/practitioners
National Patient Safety Agency (2009) Patient Safety First. The ‘How to’ guide for reducing
harm from falls. Available from: www.nrls.npsa.nhs.uk/resources
Southern Health and Social Services Trust (2013) Falls Directory. Available from:
www.southerntrust.hscni.net/falls.htm
Woods, S. Bellis, M.A. Lyons, R. and Macdonald, D. (2010) Falls in older people. A review of
evidence for prevention. Available from: www.preventviolence.info
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APPENDIX 1
Working group:
Jane Greene (Nurse Consultant for Older People)
Jacqueline Toner (Older People’s Specialist Nurse)
Janet Dickson (Older People’s Specialist Nurse)
John Rafferty (HOS, Residential Care)
Nina Daly (Accident Prevention Officer)
Brian McGuire (OPPC Nursing Governance)
Rachel Crozier (Falls Co-ordinator)
Sandra Crawford (Physiotherapist, Falls Clinic, Armagh)
Mary McConnell (Nurse, Falls Clinic, Newry)
Gemma McVeigh (CPN, Memory Service)
Ann Keppler (Nursing Home Manager)
Mary McKee (Nursing Home Manager)
Connie Mitchell (Nursing Home Manager)
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APPENDIX 2
A GUIDE
(TO BE USED IN CONJUNCTION WITH THE FALLS RISK ASSESSMENT PRO-FORMA)
ALL CONSIDERED ACTIONS TO BE INCLUDED IN FALLS CARE PLAN
Risk Factors
a) Falls History
-
Has the resident had
one or more falls in the
past year?
-
Has the resident ever
had a fracture after a
minor bump or fall over
the age of 50?
b) Medications
-
Is the resident taking 4
or more medications
including any of the
following?
Sedatives
Anti-depressants
Anti-Parkinson’s
Diuretics
Antipsychotics
Anti-coagulants
Anti-hypertensives
Anti-arrhythmics
Corticosteroids
Benzodiazepines
Anti-histamines
Anticonvulsants
Hypoglycaemics
OTC drugs
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Identify the following: Actions to be considered
1. Number of falls in the past
year
2. When did the last fall occur
3. Can the resident easily
explain what happened?
4. Was the resident ill or had a
temperature when they fell?
5. Does the resident have a fear
of falling?
1. Contact G.P.
2. Discuss with resident/family
3. Check for causes e.g. orthostatic
hypotension
4. Check for infection.
5. Refer to G.P. for
physiotherapy/falls clinic
1. Have medications been
reviewed in past year?
2. Are all medications are taken
as prescribed?
3. Observe for and report side
effects / symptoms e.g.
unsteady gait / balance,
sleepiness, blurred vision,
weakness and postural
hypotension in residents
taking anti-psychotics / night
sedation to G.P.
4. Easy access to toilet facilities
for residents taking diuretics.
5. Fluid intake especially if
taking diuretics.
6. Steroids for more than 3
months?
1. Alerting staff to any issues in
relation to medication side
effects.
2. Reporting and discussing any of
the following with the G.P.  Compliance, drug toxicity
and therapeutic state.
 Blood monitoring to
exclude toxicity and / or
electrolyte imbalance.
 Any change in the
resident’s alertness or
mobility following
changes to medication.
 Reducing or withdrawing
certain drugs
 Prescribing cascade
c) Cognitive Impairment
-
-
1. Is there a change in cognitive
status (monitor for pain,
Is the resident confused,
signs of infection or
disorientated, restless,
constipation).
irritable, agitated or
2. If a risk assessment and
exhibiting low mood?
monitoring of behavioural
issues needs to be carried
Does the resident have
out and discuss with G.P.
reduced insight or are
3. Is optimal environmental
they uncooperative with
safety (including the use of
staff?
assistive technology) being
promoted?
4. Are visual clues e.g. signage
in use?
5. If an individual routine in
daily activities has been
established e.g. bath times,
bedtime and are these
reflected in the care plan?
6. Has the need for falls
prevention equipment been
considered?
d) Medical Conditions
-
Has the resident any
long term medical
conditions that would
increase falls e.g.
1. Refer to (b) above
2. Has the resident ever had a
fracture after a minor bump
or fall over the age of 50?
3. Has the resident lost height
or have a curvature of the
spine.
Parkinson’s Disease
M.S.
Arthritis
Epilepsy
Diabetes
Osteoporosis
Dementia
Heart conditions
Depression
Alcohol dependency
e) Dizziness and fainting
-
12
Does the resident
experience dizziness or
fainting on standing?
Does the resident
1. Record blood pressure after
lying for at least 15 minutes,
repeat when standing and
then record again after 3
minutes.
2. Refer to G.P. for review
3. If postural hypotension




Consider using the Cornell
Depression / 6 CIT screening tool
(Appendix 3)
Consider use of an ABC tool.
Liaise with Memory Service
Liaise with G.P.

Liaise with G.P.
-
experience a sensation
that the room is
spinning when moving
their head or body?
Does the resident
experience fainting
attacks or palpitations?
f) Nutrition and
Hydration
-
-
Has resident lost weight
unintentionally or do
they have a poor
appetite?
Does the resident spend
little time in sunlight?
g) Continence
-
Is the resident
incontinent of urine + / faeces?
h) Balance and Mobility
-
-
13
Is the resident unsteady
/ unsafe when walking?
Does the resident have
difficulty with transfers?
diagnosed advise resident to
always get up slowly and wait
before walking, encourage
them not to rush after
getting up.
1. MUST
2. Ensure adequate hydration.
3. Commence Fluid balance
chart.
4. Commence food chart.
5. Document alcohol intake
1. Carry out a continence
assessment.
2. Agree a toileting
programme.
3. Ensure adequate
hydration.
4. Optimise safety by
removing clutter /
hazards and consider
night lighting.
5. Provide urinal /
commode / containment
products as appropriate
1. Moving and handling Risk
assessment.
2. Ensure use of mobility
aids as appropriate



Fortify foods initially and refer to
GP for onward referral to
Dietician for assessment
Refer to GP for assessment of
Vitamin D levels.
Refer to continence team as
appropriate.

Consider referral to falls
team
i) Sensory Impairment
-
-
Does the resident have
poor vision?
Does the resident have
poor hearing?
j) Footwear
-
-
Is the resident’s foot
wear well-fitting and
safe?
Does the resident have
corns, bunions, ingrown
toe nails, fungal
infections, pain or loss
of sensation in their
feet?
k) Night Patterns
-
-
14
Does the resident often
get out of bed during
the night?
Is the resident able to
get out of bed safely?
1. Ensure annual vision
testing (follow GAIN
guidelines).
2. Ensure room is clutter free
3. Ensure adequate lighting
including night lighting
4. Ensure glasses are clean
and in good condition and
worn as directed
5. Ensure hearing aid is worn.
6. Minimise excess noise
7. Speak clearly

Refer to Optician or
Audiology as appropriate
1. Refer to GP any for any
infections.
2. Refer to Podiatrist if
required.
3. Liaise with family re foot
wear.
1. Check bed height is suitable
for the resident’s needs.
2. Optimise environmental
safety.
3. Provide night lighting
appropriate to visual needs.
4. Ensure glasses and nurse
call bell are within easy
reach.
APPENDIX 3
6 CIT ASSESSMENT TOOL
SCORE:
1.
What year is it?
Correct
Incorrect
0
4
2.
What month is it?
Correct
Incorrect
0
3
Remember the following address:
John Brown, 42 West Street,
Bedford.
3.
What time is it?
(within 60 minutes)
Correct
Incorrect
0
3
4.
Count backwards 20 - 1
Correct
1 Error
More than 1 error
0
2
4
5.
Months of year backwards
Correct
1 Error
More than 1 error
0
2
4
6.
Repeat the memory phrase
Correct
1 Error
2 Errors
3 Errors
4 Errors
All incorrect
0
2
4
6
8
10
TOTAL SCORE:
0-7
8-9
10 - 28
Not significant
Probably significant – referral is advised
Significant - refer
CIT = Cognitive Impairment Test
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