Download The humpty dumpty fall scale

Preventing Patient Falls
STC Module 2
2012
Outline
 Why a fall prevention program
» 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
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
12
1.2
10
1
8
0.8
6
0.6
4
0.4
2
0.2
0
0
Number
Rate/1,000 bed-days
Rate/1,000 bed-days
Number o falls
Falls in TMC, all ages
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.
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
General TMC Guidelines
1. Scope:
a.
b.
c.
d.
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.
2. When to assess risk
a.
b.
c.
d.
upon admission
after a fall
upon change in status
transfer to a new setting.
3. Use official TMC Forms in initial
assessment, re-assessment and monitoring
Initial
assessment
Re-assessment
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
General Guidelines
4. 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.
5. The goal, in both adult and pediatrics
patients, is to reduce the fall score
during subsequent re-assessments
Preventing falls among adult patients
USING THE MORSE FALL
SCALE (MFS)
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
MORSE FALL SCALE
1. History of falling; immediate
or within 3 months
NO = 0
YES = 25
5. Gait( ability to walk/change
position)
NO = 0
YES = 15
None, bed rest, wheel chair,
nurse = 0
Crutches, cane, walker = 15
Furniture = 30
NO = 0
YES = 20
Normal, bed rest, immobile = 0
Weak = 10
Impaired = 20
6. Mental status (Awareness of
own abilities)
Oriented to own ability = 0
Forgets limitations = 15
2. Secondary diagnosis
3. Ambulatory aid
4. IV/ Heparin lock
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
Nurse’s roles
STANDARD PREVENTION HIGH RISK FALL PREVENTION
 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
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).
Doctor’s roles
STANDARD 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
HIGH RISK FALL
PREVENTION
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
Preventing falls in pediatric patients
THE HUMPTY DUMPTY FALL
SCALE (HDFS)
 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 inpatients)
» Medication usage
HUMPTY DUMPTY FALL SCALE
RISK FACTORS
1. Age
2. Gender
3. Diagnosis
4. Cognitive Impairments
5. Environmental Factors
6. Response to Surgery/
Sedation/ Anesthesia
7. Medication Usage
ASSIGNED SCORE
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
Male – 2
Female – 1
Neurological diagnosis – 4
Alterations in oxygenation (respiratory diagnosis, dehydration, anemia,
anorexia, syncope/ dizziness, etc.) – 3
Psychiatric/ behavioral disorders – 2
Other diagnosis – 1
Not aware of limitations – 3
Forgets limitations – 2
Oriented to own ability – 1
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
Within 24 hours – 3
Within 48 hours – 2
More than 48 hours/ None – 1
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
Total HDFS
Score
Risk Level
Activate
6-11
Low risk
Low risk prevention
protocol
12 and above
High risk
High Risk Fall Prevention
protocol
Pediatric fall prevention
LOW 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
HIGH RISK
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
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.
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
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