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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: 7 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: 8 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 9 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) 10 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 11 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 15