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Slips, trips and falls policy Slips, Trips and Falls (In-patients) Policy Policy Number LNWHT/CC/004/2016 Ratifying Committee Date ratified Name of author Clinical Quality and Risk Committee 12th April 2016 Lead Nurse / Senior Nurse Quality and Clinical Standards Name of ratifying Group Date issued Patient Safety Group May 2016 Review date May 2018 Target audience Trust wide Equality Impact Assessment Associated policies Yes Slips, Trips and Falls (non-clinical) Health and Safety Policy Incident Reporting RIDDOR reporting policy Risk Management Policy and Guidance Manual Handling Policy Bedrail Policy Safe and Supportive Observation Policy Workplace Policy Provision and Use of Work Equipment Policy Health and Safety at Work etc. ACT 1974 and its subordinate Regulations and Approved Codes of Practice Key legislation considered Circulated for consultation to North West London Hospitals NHS Trust Falls Group members Slips, trips and falls policy Contents Section Title Page 1 Introduction 3 2 Statement of Intent 3 3 Scope of Policy 3 4 Definitions 4 5 Duties and Responsibilities 4-7 6 Falls Management Process 7 – 11 7 Training and awareness raising 12 8 Monitoring 12 9 Review and Development 13 10 References and Bibliography 14 Appendices Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F Appendix G Appendix H Appendix I Appendix J Appendix K Appendix L Appendix M Appendix N Management of patients who fall in Hospital and Health Centres Falls Risk Factor Assessment Dementia and Delirium assessment Falls Risk Care Plan Bedrails Risk assessment Matrix and Plan Bed Rails Assessment Tool Mental Capacity Assessment In-patient Care Plan for bedrails Post Fall Care Bundle Medical Report Following a Fall Patient information Leaflet Falls Assessment Pathway Post Fall Protocol Equality Impact Assessment 15 - 21 22 23 24 - 25 26 27 28 29 30 31 32 34 35 36 2 Slips, trips and falls policy INTRODUCTION Patient falls are among the most commonly reported patient safety incidents to the National Patient Safety Agency (NPSA). Approximately 208,000 falls are reported each year in acute hospitals, according to NRLS data (NPSA 2010). The majority of falls result in “low” or “no” harm (96%) with the remaining 4% resulting in moderate, severe harm or death. Falls can cause distress, pain, injury, loss of confidence and mortality. (NICE CG161 2013). Falls are most likely to occur in older patients aged 65 and over ( NICE CG 161 2013) but patients of all ages may fall, due to underlying conditions, acute illness, recovery from anaesthetic or trip hazards (Patient Safety First 2009). Preventing patients from falling is a particular challenge in hospital settings because treatments and interventions that ensure a patient’s safety sometimes hinder their independence. Rehabilitation always involves risk and a patient who is not allowed to walk without staff assistance may become a patient who depends on such assistance. The main aim of this policy is to promote a proactive approach to the problem of patients slipping ,tripping or falling and this is done by undertaking comprehensive risk assessments of each patient’s personal; clinical; manual handling, needs and requirements. By doing this, a comprehensive picture is built up so that suitable actions can be undertaken and measures put in place, so as to prevent our patients slipping, tripping or falling. In the interest of providing a reasonable degree of freedom for individuals, some degree of risk will exist. All harm cannot be eliminated but staff must show that they have reduced risk as far as reasonably possible. Patient and carer views must be included in planning interventions which will seek the right balance between promoting independence and dignity and minimising risk of harm. Patients in hospital may be at risk of falling from a bed, chair, toilet seat etc. for many reasons including poor mobility, dementia and delirium, visual impairment and the effects of their treatment or medication. Although patients can be at risk of falling whilst in hospital, interventions can be put in place by health care professionals to minimise the risk of falls occurring. This policy should be read in conjunction with the Slips Trips and falls (Staff) policy and Incident Reporting policy. STATEMENT OF INTENT This policy was created to provide an overarching framework for reducing the risk of patients falling and minimising the impact on patients when falls do occur. Staff must identify risk factors and undertake appropriate interventions that will reduce the likelihood of patients falling. The aim is to protect patients from risk of harm, while maintaining their right to make decisions and maximise their activity, confidence and sense of independence. 3 Slips, trips and falls policy SCOPE OF POLICY The policy applies for all adult patients admitted as an in-patient at LNWH NHS Trust and its principles apply to all other out-patients and emergency patients who attend clinics or departments on the Trust premises; this includes the community bedded units. It also applies to all staff responsible for in-patient areas. This policy is primarily concerned with patients who slip, trip or fall at or near ground / floor level in a ward/ clinic environment. However there is the possibility that patients can fall from much higher places or levels, and therefore this policy must be read in conjunction with the Slips, Trips and Falls (including falls from a height) Trust Policy and procedure’ which provides more detail as to how to prevent ‘people’ per se, falling from higher levels or places on Trust premises. 4 DEFINITIONS Slip Slide accidently causing the person to lose their balance: this is either corrected or causes a patient to fall Trip Stumble accidentally often over an obstacle causing the person to lose their balance, this is either corrected or causes the person to fall Fall The generic term used in this policy to describe any slip, trip or fall. A fall has been defined as “an unintentional event whereby an individual comes to rest on the ground or another lower level, with or without loss of consciousness” (NICE, 2004). Bed rails Rails that can be raised to lessen risk of patient falling out of bed. Low-rise Bed A bed designed to provide floor-level nursing with a height adjustable function. The bed is suitable for patients where there is risk of falling and bed-rails are not appropriate. DUTIES AND RESPONSIBILITIES 5.1 Chief Executive Along with Trust Board, has overall responsibility for ensuring this policy is fully implemented across the Trust and associated systems assure safe and effective fall management processes. 5.2 Medical Director Responsible for ensuring Medical staff comply and adhere to the policy. 5.3 Chief Nurse Executive lead responsible for ensuring robust arrangements and resources are available to support the requirements of this policy. 5.4 Risk Management Team 4 Slips, trips and falls policy Responsible for the following falls-related tasks: 5.5 Keeping record of each fall on electronic Datix incident reporting system Reporting incidents to appropriate Trust groups and committees (i.e. Falls Group, Patient Safety Group, Health and Safety Group) and if appropriate external agencies such as the NPSA Assists divisional governance committees with analysis of incidents and the production of themes and trends reports for appropriate Trust groups Ensuring all RIDDOR reportable incidents are reported to the Health and Safety Department who will inform the HSE as per the requirements of the Trust’s RIDDOR Policy. Providing advice and support to managers about development and implementation of remedial actions Providing training on generic risk assessments, which includes assessing fall hazards Distributing, collating responses and acknowledging CAS (Central Alert System) notifications relevant to falls Director of Estates and Facilities Reduces threats posed by physical environment by ensuring: Good practice is followed when new or refurbished flooring is introduced Contractors and sub-contractors are monitored to avoid unnecessary trip hazards Suitable equipment is available with procedures in place for cleaning, servicing and maintenance of all equipment, floor coverings, grounds and pathways Roads and pathways on Trust premises are suitably maintained and treated during adverse weather conditions Effective maintenance programmes are in place to combat potholes/ poor road surfaces Good lighting in all areas to reduce risk of people misjudging surfaces Effective systems to report slipping hazards and instigate timely responsive action Risk Assessments are carried out in all common areas to identify tripping hazards and implement corrective actions All areas in the Trust have been assessed for Disability Discrimination Act (DDA) compliance and action plans are formulated to mitigate any hazards/risks 5.6 Health and Safety Team Advises on falls related environmental risks and proposes appropriate actions Review all the Datix incident reports to assess whether a patient’s slip, trip or fall, falls within the reporting requirements of the RIDDOR 2013 Regulations; and if necessary, undertake any investigations as necessary to ascertain the circumstances of the incident, report the incident to the Health and Safety Executive and make recommendations to prevent reoccurrences. 5.7 Moving and Handling Team Will provide advice and support to managers and staff on the following: Selection of equipment to support patients vulnerable to falling Use of appropriate equipment for raising the fallen person Training staff on patient handling risk assessment and documentation and in-house support as required 5 Slips, trips and falls policy 5.8 Procedures for evacuating patients off the floor post falls including fallen patient with fractured neck of femur or fallen person who sustains a spinal injury Full day Foundation Manual Handling for Overseas Nurses and newly recruited HCAs Prevention of manual handling related falls Access to equipment for management of falls on the inpatient sites Safe manual handling after an inpatient fall (Quality statements 1 & 2 of NICE Quality Standard 86 and NPSA RRR01 2011) Divisional Heads of Nursing (DHON) / HON and Clinical Directors Oversee the implementation and monitoring of this policy by: 5.9 Reporting results of key performance indicator relating to falls to clinical governance groups and the Falls Group Ensuring monitoring of compliance is undertaken within clinical management structure Reviewing risks related to in-patient falls and verifying that risks mitigation controls are in place as defined in this policy and Risk Management Strategy Policy and Guidance Ensuring falls incidents investigation action plans are completed within their area of responsibility Matrons Support and supervise the Senior Ward Manager/Charge Nurse in implementing this policy: Leading investigation of serious risks, developing action plans to mitigate risks and escalating any barriers to this policy’s implementation to line manager Ensuring compliance on this policy and patient falls assessments are audited within their area of responsibility at least quarterly Reporting results of key performance indicator relating to falls to the Matrons, Head of Nursing and Divisional HON meeting 5.10 Ward/ Department Managers Responsible for ensuring: Staff read and understand this policy and any related policies, and this requirement is identified as part of the appraisal process Staff attend training to enable them to implement and monitor compliance of the inpatient falls Policy Staff are trained and encouraged to use suitable moving and handling equipment Moving and handling equipment is readily available and is regularly serviced and maintained. Staff complete and document in-patient falls risk assessment tools and relevant tailored management plans within agreed time frames Falls-related incidents and injuries are promptly managed and investigated – using the Datix incident reporting system – and escalated Participation in multidisciplinary patient-specific risk assessment tools and care plans The development of future strategies for service area following investigation of falls related incidents 6 Slips, trips and falls policy 5.11 Clinical Staff All medical staff, nurses, pharmacists and allied health professionals should: Assess patients and participate in completing risk assessment tools and development of individual patient care plans. Recommend any specific patient controls (depending on individual risk assessments) and support any required escalation of care. Optimise patient care to prevent a fall Report any environmental hazards in their working area that they are unable to deal with themselves Undertake falls awareness training offered by the Trust (e-learning) 5.12 All employees Each member of staff is required to: Attend relevant training as required (section 7) Read and comply with this policy Promptly report any potential hazards or falls to person in-charge of area and ensure these are rectified Report all falls and near misses using Trust’s incident reporting system- DATIX 5.13 Trust Falls Group Meets bi-monthly and reports quarterly to the Patient Safety Group. The group acts as an advisory body identifying areas of best practice, key risks, action plans and any outstanding fall-related gaps that need addressing. It also reviews and monitors compliance with regulatory requirements and guidelines. Raises any issues that require disclosure to the Executive Team or require executive action. Researches best practice and oversee the development and monitoring of agreed action plans to ensure the Trust meets National Standards and NPSA, NICE recommendations. Reviews incident themes and trends and reviews actions from falls related incidents investigations. Reviews training needs with Education and Development Team Monitors falls key performance indicators Raises awareness and communicates with other relevant Trust groups Audits effectiveness of Falls Policy and management process Works seamlessly with other elements of fall provision within wider community. FALLS MANAGEMENT PROCESS 6.1 Measures that may be implemented to minimise the risk of inpatient falls General interventions and environmental checks All patients must be orientated to the bed, toilet and bathroom and ward area on admission. Drinks, food, walking aid and belongings must be placed within easy reach of the patient whether in bed or sitting in the chair. 7 Slips, trips and falls policy The ward environment must be clutter free and clear from obstacles. All staff has responsibilities to take reasonable care for the health and safety of themselves and others. Spillages should be isolated and cleaned immediately and hazard signs should be displayed. Identified hazards and incidents must be reported. Call Bell Every patient must be shown how to use the call bell system, and be able to demonstrate how it works. The call bell must be in sight and in reach of the patient. Patients must be reassured and encouraged to use the call bell. If a patient has cognitive impairment, communication problems and/or lacks capacity to use a call bell, there must be a documented alternative plan to ensure patients individualised needs and requirements are met. Eyesight and Hearing Patients have access to own, clean spectacles and hearing aids that work. ENT/optometry and audiology referrals made as required. Footwear Patient’s footwear must be assessed on admission as appropriately well-fitting and nonslip, Relatives/or carers should be encouraged to provide appropriate footwear. Only consider Falls Reduction Socks if patient’s gait normal, if not involve physiotherapist for assessment. Referral to podiatry, chiropody and/or orthotic assessment may also be required for medical reasons and patients, who are required to wear anti embolism stockings or boots post operatively, must be risk assessed and advice given to minimise the risk of falling. Any advice given to patients / relatives must be clearly documented in the patient notes. Positioning and observation of patients Patients who are identified as at risk of falling will be commenced automatically on hourly intentional comfort rounding. This level of observation is assigned to all patients identified at risk of falling and every hour a patient will be seen and needs met, for example toileting offered and providing drinks. An orange wrist band will be worn by the patient to alert the multidisciplinary team that patient is at risk of falls. Some patients may need to be positioned in a more observable bed. This may be in bay or a side room close to a nurse’s observation station. Any patient who needs to be moved to a side room, for infection prevention issues and the side room is unobservable; a risk assessment of the patient’s risk of falls must be carried out and interventions implemented to minimise the risk of falling. Some patients, who are identified as at high risk of falling, may require enhanced observation in the form of cohort nursing or 1:1 Specialling. Some patients who are confused, exhibiting walking behaviours and are unsteady will be at greater risk of falling and 1:1 specialling may be required. The level of supervision required and provided needs to be recorded in the risk assessment and care plan documentation (see Trust Safe and Supportive Observation Policy) Low profile beds Low profile beds can be used if a patient is assessed as “at risk of falling from a bed but bedrails are inappropriate/or unsafe”. Consideration should be given to the use of low profile beds and patients should be assessed individually to ensure that this is the safest and appropriate method of preventing a patient potentially falling from their bed. This will form part of the bed rail risk assessment. 8 Slips, trips and falls policy Cognitive impairment and Delirium Clinical staff are able to assess patients for any acute changes in cognitive function by carrying out cognitive tests such as the Abbreviated Mental Test Score (AMTS). Patients who are confused and wandering in ward areas can be at risk of falls, so it is important that sources of delirium (such as infection) are identified and treatment commenced. A urinalysis must be performed in patients who are either confused or have urinary symptoms during admission, to rule out the possibility of urinary infection causing falls and delirium. The Trust Dementia and Delirium Assessment should be completed for all patients identified at risk of falling, admitted with a fall or has had a fall as an inpatient (Appendix C) Medications and lying & standing blood pressure Patients can be at risk of falling if they are on certain medications which may be sedating, induce confusion or continence problems, cause symptomatic hypotension or systolic drop on standing. As part of a multi factorial assessment, medical staff with pharmacist involvement will be able to complete a risk/benefit review of patient’s medications. The Royal College of Physicians (RCP) through a project called FallSafe, advise that there should be no prescribing of new night sedation (unless there are documented medical reasons to do so). There is a comprehensive list of “medicine and falls in hospital” available (Implementing FallSafe, Royal College of Physicians 2012). Osteoporosis/bone health review must be considered, and if necessary interventions for falls and bone health treatment commenced (NICE guidance CG 146 Osteoporosis: assessing the risk of fragility fracture Aug 2012) Patients who are admitted with a fall/or collapse or syncope (faint) will require completion of a lying and standing blood pressure. The need to complete this measurement will be based on an initial medical assessment on admission to hospital, in addition to investigating underlying causes of unexplained falls or collapse. Patients recovering from post-operative procedures may be at risk of falling and as the anaesthetic medication wears off patients may be more susceptible to postural hypotension. Continence and Toileting Patients can be more at risk of falls if they have urgency or incontinence. A full assessment including urinalysis needs to be undertaken and referral to continence service as appropriate. A patient who is assisted to use the commode or taken to the toilet, must be risk assessed if left alone for any length of time. The risk assessment must include reviewing a patient’s ability to use the call bell to request assistance and balancing this with privacy, dignity and autonomy of the patient. Balance and Mobility On admission, all patients receive a moving and handling assessment which is periodically reviewed during the patient journey. As part of the assessment, each patient will be assessed for their physical capability and what activities they would be expected to undertake in a toilet or bathroom to ensure the risk of falls is minimised. 9 Slips, trips and falls policy Physiotherapy staff will review patients who require balance, mobility and strength assessment. Mobility aids will be provided as appropriate and advice given to both patients and staff of plans to reduce the risk of falls. Occupational Therapists will complete a functional assessment and also a home hazard assessment in the community. Patients, relatives and carers If a patient is identified at risk of falling, discuss plan of care with both the patient and relatives/or carers explaining the risk and prevention measures being taken and provide the information leaflet for patient and relatives about risk of falling (Appendix K). Relatives/carers must be informed of an inpatient fall at the earliest opportunity (with the patient’s consent) and be given time to discuss the incident and an explanation of interventions that have been implemented to mitigate further falls occurring 6.2 Falls Risk Factor Assessment All in-patients must be assessed for the risk of slips, trips and falls on admission to each clinical area/ward using the Falls Risk Factor Assessment Form (Appendix B). For patients assessed to be at risk of falling, slipping or sliding out of bed, an assessment must be undertaken using the Bed Rails Risk Assessment Matrix (Appendix E). The Bed Rails Assessment Tool (Appendix F) must be used on admission and reviewed weekly to determine if bed rails should be used or continued to be used. If the mental status of a patient is in question or a patient has impaired judgement such as confusion, significant memory loss then a Mental Capacity Assessment must be completed (Appendix G) All inpatients must have a Falls Risk Factor Assessment Form and Bed Rails Risk Assessment Form within 6 hours of admission. Following assessment, the Falls Care Plan and Interventions (Appendix D) must be completed. Table 1: Time frames for completion of falls risk factor assessment and bedrails/trolley rails assessment/care plan and review in all inpatient facilities Accident and Emergency (A&E) On arrival (adults only) Complete the Risk Assessments / action plan in ED Inpatient Within 6 hours of admission including transfers from ED and assessment wards Within 6 hours of transfer Transfer to another area Following a fall or change of condition (see below) Within 6 hours If patients length of stay > 7 days Repeat falls and bedrails assessment every 7 days If the risk to the patient has changed significantly i.e. “condition change”, due to mental or physical condition which increases the risk of a fall, this warrants immediate risk review but within 6 hours. 10 Slips, trips and falls policy Examples of “condition change” that would require a repeat assessment include: • Patient has a slip, trip or fall • Patient has undergone a procedure under general anaesthetic/sedation • Patient’s medical/surgical condition has declined e.g. may have developed confusion/delirium due to an infection • Patient’s mental status or capacity has declined, increasing risk of falling • A decline in the patients mobility or balance • A patient who was initially assessed as immobile or “unlikely to move unless assisted”, is now mobilising, but is “unsafe” and requires supervision These examples are not exhaustive and staff must use clinical judgement. Some patients may require continuous risk factor review on a daily basis. 6.3 Falls Care Plan Completion and implementing interventions All patients identified at risk of falling, following the completion of a falls risk assessment, must have a falls care plan completed (Appendix D). The falls care plan details good practice guidance on necessary interventions to reduce the risk of falls. The following interventions in this section provide a comprehensive list of multi-factorial interventions that should be considered, based on individualised falls risk factors. It is important to review the interventions implemented, within the timeframe indicated in section 6.2 (Table 1). 6.4 Care Plan for the Use of Bed Rails Once a patient has been identified as at risk of a fall – and an assessment has been undertaken outlining the need for the use of bedrails – the In-Patient Care Plan for Bed Rails (Appendix H) must be commenced. 6.5 Falls Risk Symbol Patients who are identified as at risk from falling will have a symbol placed on the boards behind their bed. This pictorial symbol is used in addition to the verbal and written handover identifying those patients assessed as at risk of falling. 6.6 Handover for Transfer of Patients All in-patients being transferred from one clinical area/ward to another must be included in a specific handover of all the assessments and care plans to ensure that the management of this risk is emphasised to the new clinical area. 6.7 Reporting a Slip, Trip or Fall. Irrespective of where they occurred, all instances of falls must be reported on the Trust incident reporting system DATIX. The slip, trip or fall (including near- misses) must be documented within the patient’s records and both medical staff and the patient’s next of kin should be informed 6.8 Post Fall Assessment and Management When a patient is found after a fall the Post Fall Care Bundle must be completed (Appendix I) and Management of Patients Who Fall in Hospital and Health Centres (Appendix A) followed. 11 Slips, trips and falls policy A LAMINATED POST FALL PROTOCOL (Appendix L) SHOULD BE AVAILABLE FOR STAFF TO FOLLOW AND A SAFETY HUDDLE INSTIGATED AFTER EACH FALL TO REVIEW THE INCIDENT AND LEARNING SHARED TO PREVENT FURTHER FALLS (as per NICE Guidelines). 6.9 Post Fall Medical Assessment Following a slip, trip or fall within in-patient settings, a medical review needs to be undertaken using the Medical Report Following a Fall (Appendix J). Regarding timing of investigations post fall the NICE Guidelines recommend:For adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified: GCS less than 13 on initial assessment in the emergency department. GCS less than 15 at 2 hours after the injury on assessment in the emergency department. Suspected open or depressed skull fracture. Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). Post-traumatic seizure. Focal neurological deficit. More than 1 episode of vomiting Patient’s GP must be informed of inpatient fall and /or identified falls risk. Training and awareness-raising All Trust staff will be made aware of the requirements of this policy and their associated responsibilities. They are also required to attend mandatory clinical Risk Assessment Training and the mandatory Moving and Handling training every 2 years. All clinical staff are expected to undertake the Falls awareness training offered by the Trust. Staff line managers will monitor compliance of training at staff appraisals. Further information on training requirements is available via Education and Development Department. Monitoring The Trust monitors the implementation of the Slip, Trips and Falls policy by a number of mechanisms listed in the table below: Aspect of compliance or effectiveness being monitored Monitoring method Individual or department responsible for the monitoring Requirement to undertake risk assessments described within this Audit Heads of Nursing (HON) Frequency of monitoring activity Group / committee forum which will receive the findings/ monitoring report Six monthly Falls Group Committee/ individual responsible for ensuring that the actions are completed Divisional HON/HON and Matrons forum Matrons 12 Slips, trips and falls policy policy Completion of Falls Risk Factor Assessment and post fall action record Training Falls Group Audit Heads of Nursing Matrons Six monthly Divisional HON/HON and Matrons forum Data Education Annual Interrogation and from ELMS Development Team Falls Group Falls Group Falls Group HR , Training and Education committee This policy will be reviewed by the Falls Group and monitored by each Directorate in their Clinical Governance meetings. The responsibility to monitor and to raise awareness of how to prevent and to manage slips, trips and falls in each area will rest with each Directorate with advice from the Falls group when necessary. The Risk Management Team will keep records of all incident forms and provide reports to the falls group and relevant committees/groups. Reports provided to the falls group and Patient Safety will include the incidence of patient’s falls, common themes and trends. All falls incidents investigation ((Internal Critical Investigation and Serious Investigation) report will be presented by the Divisional Governance Coordinators or representative to the falls group for information and discussion that will influence the Trust falls strategy and policy review Matrons/Departmental Managers must review each incident with support from divisional governance coordinators and when appropriate involve other personnel (e.g. physiotherapists, occupational therapists, the moving and handling facilitator and estates staff if appropriate). The review aims to ensure effective actions have been implemented to avoid similar incidents in the future either to staff, a patient, contractor or visitor. All incident Forms will be used to monitor and review falls statistics to establish any trends. 8.1 Compliance Compliance with this policy will be monitored via the Clinical Incident Reports and conduct of audit (see monitoring above). Benchmarking will be undertaken via participation on National Falls Audits and NHS Safety Thermometer survey results. Recommendations from the national reports and audits will be reviewed by the STF Group and supported by the Trust Clinical Audit Team. Review and development This policy will be reviewed every two years or as required by changes in operational practices and to reflect national requirements when required. 13 Slips, trips and falls policy References, Sources and Bibliography NICE CG161 Falls: Assessment and Prevention in Older People (June 2013) NICE Quality Standard 86 Falls in Older People: Assessment after a fall and preventing further falls (March 2015) Brown, H. (2010). Graded Response Observation Chart (Leeds Teaching Hospitals Trust Revision date: November 2012) Department of Health (2001): National Service Framework for Older People Standard Six: HMSO, p16 Department of Health High (2009): Quality Care for All the journey so far HMSO Mowbray C, Betts M, Douglas S, Taylor R, 2006 (unpublished presentation for Disabled Living Foundation, Islington): To hold or not to hold? Managing the falling and fallen client – An everyday occurrence NICE (2004): Guidelines for assessment and prevention of falls in older people NICE: Head Injury. Issue Date: September 2007 NMC (2009): Record Keeping: Guidance for Nurses and Midwives NPSA (2007 & 2010 reports): Slips, Trips and Falls in Hospitals www.npsa.nhs.uk Patient Safety First campaign: ‘How to’ guide for reducing harm from falls National Back Pain Association (NBPA/RCN), (1997): Guide to the handling of patients Middlesex ProFaNE, Prevention of falls http://www.profane.eu.org Resuscitation Council (UK), (2001): Guidance for Safer Handling During Resuscitation in Hospitals, London Subbe CP, Kruger M, Rutherford P, Gemmel L (2001) Validation of a modified Early Warning Score in medical admissions Tappen et al (2000) Effects of combined walking and conversation intervention on functional mobility of nursing home residents with Alzheimer Disease 14 Slips, trips and falls policy Appendix A MANAGEMENT OF PATIENTS WHO FALL IN HOSPITAL AND HEALTH CENTRES A risk assessment is the key to the successful management of falls; it is not possible to exclude the risk completely. There are two situations that staff may find themselves in: When a person starts to fall or is falling When a person has already fallen and is on the floor Although it is a reactive response to try to catch a falling person, the current advice is that this should not be done. Understandably, the healthcare staff within the Trust may not feel comfortable with that approach, but they must at all times consider their own health and wellbeing above that of the patient/other person. Figure ..: examples of high-risk practices The Guide to handling of patients, (NBPA/RCN, 2011), stated that “poor manual handling practices including assisting people who were falling or had fallen resulted in 5000 injuries per year. Manual handling risk increases when people fall because a handler may attempt to catch, support or intervene with a falling person or because they attempt to retrieve the fallen person manually. Where it is impractical to demonstrate manoeuvres to manage a fallen person, it has been acknowledged that theoretical and pictorial discussions regarding systems to manage the fallen person are sufficient. BackCare in 2005 advocates that lowering a falling person to the ground is only appropriate if we assume that staff are standing by the side of the person slightly behind; the person is falling is backwards or directly downwards; the person does not resist; the person is not significantly taller or heavier than the staff; and that there is sufficient space with no obstructions. Therefore, staff MUST NOT hold a patient or other person up if they are falling or fainting. General rules for management of a falling person The management of falling person may be achieved in a number of ways, but the general rules do not change. Do not support the person when they are falling, but allow them to slide to the floor/ground Do not catch or control the descent of a falling person Consider your own health and safety above that of the falling person Unsafe practice when a person is falling: Rushing up to ‘catch’ a falling person Trying to hold a collapsed/falling person upright. A Person on the Floor – (A Fallen Person/Patient) Approach the management of any fallen person in a calm and systematic manor, before carrying out the following assessment; 15 Slips, trips and falls policy Assessment Check for danger – make area safe for yourself and the person Check the person – ‘ABCDE’ (first aid measures), medical and physical assessment Stay with the person - Do not attempt to move the person until he/she has calmed down; exception would be if there is a danger of a person injuring themselves. If appropriate place a pillow under the person’s head and keep the person warm. Do not give a pillow if a spinal or head injury is suspected. If you suspect serious Injury seek Medical Attention. Call 999 in the community locations or call the Doctor (on call) in the hospital settings Any person who has fallen and has a suspected head, back, pelvic or lower limb fracture must not be manhandled or hoisted off the floor. To prevent further injury, a scoop stretcher must be used by suitably trained nurses, clinicians or paramedics to lift the patient off the floor / ground. Consideration must also be given to the use of a spinal board with neck / spine and fracture immobilisation Scoop stretchers can be obtained from the accident and emergency departments. Strategies to Manage a Falling Person The Guide to handling of patients, (NBPA/RCN, 2011) states that Organisations should refrain from blanket of no intervention systems and should focus on risk management strategies to reduce the risk of falls. 1. Controlled lowering of the falling person The extent of risk of catching the falling person is significant. This technique should only be used if the patient can weight bear fully or partially. The assumption is that: The handler is standing by the side of the person and slightly behind before the person starts to fall The person is falling backwards or slightly directly downwards There is sufficient space with no obstructions e.g. beds commodes The person is not resisting No significant height and size difference between the patient and the staff member Release hold of patient and get behind patient once behind patient place one foot in front of the other to form a stable base Bend the knee of the leading leg With both hands open grasp the patient by holding on to the trunk near the hips Allow patient to slide down leading leg until they are lowered safely to the floor. Handler should avoid flexing the back, and should kneel behind person Staff to ensure they have performed a dynamic risk assessment and consider factors mentioned above Figure 2: Represents the stages of lowering of a falling person in a controlled manner 1.1. Redirecting a fall on the stairs Patient with weight bearing activity undertaking stair mobility 16 Slips, trips and falls policy 1.2.1 Ascending the stairs Staff to position themselves behind the patient with arm outstretched behind providing a support figure If the patient starts to fall on the stairs, staff to use body weight to redirect patient to higher step 1.2.2 Descending the stairs Staff to stand in front and to the side of the patient figure If a patient starts to fall, staff to use outstretched arm and body weight to redirect patient to on to the step behind. 2.0 FALLEN PATIENT Prior to assisting the fallen person staff should always check the following: No environmental hazards are in situ and there is safe and clear access Airway Breathing Circulation (ABC) Check for injuries, bruising, possible fractures, pain and behavior. This assessment should be performed by trained members of the team. Adequate staff to assist Staff are trained to support the process 2.1 Supervised approach (minimal assistance to the fallen person) Independent transfer from the floor (using 1 or 2 chairs or stools) Position the chair at the head of the fallen person Verbally instruct patient to bring one arm across chest until arm is flat on the floor Instruct patient to move other arm away unto their side into side lying Instruct patient to push up in to sitting and go on all fours facing the chair Instruct patient to face the chair an position for arm on chair seat Ask patient to bend one knee and place foot flat on floor Instruct patient to push up with their hands and forearms Instruct patient to push up, straighten legs and turn to sit on chair If required another chair or stool can be placed behind the patient for them to sit backwards Person completes the process with minimal supervision from healthcare staff. 2.2 Backward chaining – 1 chair Position the chair at the head of the fallen person Verbally instruct patient to bend knees up and to bring one arm across chest Instruct patient to move other arm away from the body and roll unto their side into side lying Once on the side, instruct patient to bring the arm on the chest across the body and place palm flat on the floor Instruct patient to push up in to sitting and go on all fours facing the chair Instruct patient to push up, straighten legs and turn to sit on chair Person completes process with minimal supervision from healthcare staff. 2.3 Sideway transfer – 1or 2 chairs Ensure there is a stable platform [1 or 2 stable stool(s)/chair(s) – preferably no arms] at the person’s side. Encourage the person to get into half kneeling position by: Placing their near hand onto chair seat Bringing their near leg through, foot flat on the floor 17 Slips, trips and falls policy The person’s other hand is on their bended knee or they use it on the floor/another chair by their side. Ask the person to push down with near hand on the chair and at the same time on their raised knee / floor/ chair with their other hand. When the person pushes down on the seat, encourage them to bring through their foot while swinging their hips round to sit onto the seat. 2.4 Supervised movement from the floor – 2/3 chairs. (Most people will find it easier to use 2 chairs - one on each side to push down) Ask the person to get on all fours and then into a half kneeling position With one hand on each chair ask the person to push down on the chairs while swinging their hips sideways lift himself onto one of these chairs. Or Pushing down onto the chairs to come up into a standing position, then a third chair is placed behind the person to sit down. 2.5 If the person is unable to kneel, but co-operates then try the following: Assist the patient to sit forward on the floor Place a foot stool or chair cushion behind them Ask the patient to place their hands behind themselves on the side of the stool / cushion and digs their heels in (knees bent) and push themselves onto the stool/cushion. This is repeated gradually onto higher surfaces until the person is able to stand. If the fall occurs near stairs ,the patient can utilise the stairs by pushing themselves up onto the stairs and using the banister to pull up into standing Note: If a person is on the floor and cannot roll onto ‘all fours’ or sit up on the floor, equipment must be used, unless the situation is life-threatening. 3.0 HOISTING A PERSON FROM THE FLOOR WITH A SLING HOIST Before deciding how to assist the person, the person must be assessed. DO NOT hoist someone with suspected spinal injury or fracture. You must: (a) Be aware of the person’s ability: Are they fully dependant, unable to weight bear or unable to turn in order to move onto hands and knees? The persons weight must be less than the Safe Working Load (SWL) of either the hoist or the sling, Consider their medical condition, pain, skin condition Can they co-operation, Are there any attachments (catheters, drips etc.). (b) Check that the hoist is suitable for the task: The sling goes with the hoist, the sling is a correct size for the person, and that you are competent to use this hoist. Check the hoist and the sling as required by the Lifting Operations and Lifting Equipment Regulations (L.O.L.E.R.) Hoist inspection: Service label: Last maintenance/service date of the hoist - within last 6 months. Hoist in working order – Check that the hoist goes up & down; brakes work; hoist legs open & close; power supply is OK: hoist battery charged or alternative battery on charge SWL of the hoist and the sling – the smallest one of these must be more than the patient’s weight. 18 Slips, trips and falls policy Sling inspection: Is the sling safe to use – Check that the material, seams and stitching is intact and not torn, straps and/or clips are not broken, washing instructions, sling number and Safe Working Load (SWL) is visible and that the sling is clean. Patient Specific Slings, check as above and ensure the person’s name and the date of issue is recorded on the sling and that it is used for one person only. The sling must be discarded if soiled, or following a person’s discharge or if the ’do not wash’ sign has disappeared or changed to a round circle with a line across. Staff: All staff must ensure that they are: Fit for the task Familiar with the use of the hoist and the sling and able to use it safely. Familiar with the emergency stop and lowering mechanism of the hoist. (c) Assessment of the area Consider the space for hoisting and ensure it is safe to proceed. If more space is needed for hoisting, slide the person using a transfer slide sheet (pillow under the person’s head) to an area that has sufficient space. Should a person fall in an area where there is no hoist, one can be obtained from the nearest ward, as all wards in the Trust have a hoist. PROCEDURE FOR HOISTING A PERSON FROM THE FLOOR There must be at least 2 or 3 staff present. 2 staff kneel on the floor and roll the person onto a sling or Insert 2 slide sheets under the person and slide the sling between the slide sheets by rocking back on their heels. The top slide sheet is removed once the hoist sling is in position. or 2 staff sit the person forward using the elbow to elbow grip and position the sling behind the persons back. This move should only be attempted providing that the person is lightweight, Has strength in both arms and s able to flex their knees slightly. To aid with connection of the sling to the hoist spreader bar one staff could kneel on the floor with the person’s head and shoulders resting on their knees. This can provide reassurance for the fallen person. or The person may be able to sit forward against an upturned chair with a pillow against the backrest rather than resting their head on the staff’s knees. In preference, if the person is able to bend their knees, the hoist can approach from slightly sideways to the person. The hoist legs open fully. Move the hoist to fit one hoist leg fit under the person’s bended knees and the other just past the person’s head that is resting on a pillow. or When the hoist is in position, brakes are applied while the spreader bar is lowered and the sling is attached to prevent the person pushing or kicking the hoist away. For ARJO hoists the brakes are released before starting to lift the person off from the floor. For LIKO hoist the brakes are kept on until the patient is just starting to lift from the floor. Do not apply brakes when lowering the person onto the bed. Management of a person who has fallen in a confined space after completion of the assessment 19 Slips, trips and falls policy 4.0 Unsafe Techniques These manual techniques should NOT be used when assisting a person off from the floor: ‘Arm and leg lug’ ‘Underarm drag lift’ Shoulder lift Canvas and pole Use of a Pat slide 5.0 Manual lift from the floor A full risk assessment must be carried out taking into account: The environment Individuals carrying out the lift Positioning of the trolley or the bed The person on the floor Remember: This is a high-risk technique and should only be used if there is no other option. All members of staff should be made aware of the risks to themselves and be given an option to refuse to assist in the transfer. A minimum of six – seven staff are required and therefore help should be requested from other departments/wards if necessary. All staff taking part must be able to bend their knees and should have no current musculoskeletal disorders. Listed below are the situations that can be defined as exceptional and may, as a last resort require manual lifting: In the event of evacuation e.g. fire. Where the use of a hoist may be contra-indicated e.g. suspected spinal injury In this case a spinal board should be used. (Spinal board is kept in A&E Department at Ealing Hospital). Medical or life threatening situations e.g. where there is imminent danger of harm if the patient is not moved or where a patient is brought to the Accident and Emergency Department in a private vehicle or of their own volition and may require immediate assistance. Cardiac or respiratory arrest - a person on the floor; the person should only be lifted once stabilised or when a clinical decision has been made and ‘a sufficient’ number of ‘fit’ staff has arrived to assist as it is deemed more appropriate to continue resuscitation on a better height surface. In the first instance’ if necessary, use a slide sheet/transfer sheet to move a patient to an area where resuscitation can start. The Liko Viking XL hoist with a stretcher attachment and sling for lifting horizontal patients from A&E should always be the first choice rather than a manual lift. A trolley or a bed must be ready on its lowest level with a slide sheet on it. The person should be rolled and a lifting sheet placed underneath. Additional staff may be required to support the person’s head and one at their feet. A ski sheet or a ski pad should be used. Appropriate equipment should be kept ready in the areas where it is likely to be needed. Regular auditing will indicate the equipment that is needed, for example the question ‘should a scoop stretcher be purchased’ should be based on incidents when it would have been more appropriate than the lifting sheet or the spinal board that are currently available in the Trust. Incidents of heavier patients collapsing on the floor would indicate the need for a MANGA Lifting cushion – CAMEL or ELK – not currently available in the Trust. 20 Slips, trips and falls policy A lifting sheet is specifically designed for transferring or lifting a person and will have an appropriate Safe Working Load (SWL) and handholds. All wards and departments should have at least one lifting/transfer sheet. The number of lifting/transfer sheets should be based on the department’s annual generic risk assessment for managing of falls. [If the resuscitation on the floor was unsuccessful then a sling hoist must always be used to lift the body onto a trolley/bed, ensuring that the privacy and dignity of the patient are maintained]. Pat Slides must not be used for the task of lifting a person from the floor 6.0 Procedure for Managing Fallen/Collapsed Person in Non-Clinical Areas or Hospital Grounds Action to be taken If a person falls/collapses inside the Hospital Buildings If an incident is reported to you that a person has collapsed/fallen in the common areas of the Trust i.e. inside the building: Dial 2222 immediately, report as a medical emergency. Switchboard to fast bleep the medical team and the Clinical Site Practitioner The Site Practitioner and the medical team to attend the area to provide medical assistance. Action to be taken if a person falls/collapses in the Hospital Grounds If a person falls/collapses in the Hospital Grounds Dial 2222 immediately and report as a medical emergency If outside the Hospital building switchboard will call an ambulance for medical assistance. Incident Report A Datix incident form must be completed at the time with details of any witnesses/persons involved and notified a member of the Risk Management Team within 3 days. RIDDOR Reportable Serious injury Deaths must be reported to Health and Safety Executive (HSE) immediately. In Working Hours: This must be escalated to a Senior Manager in the service (i.e. General Manager, Assistant Director or Community Service Director and Risk Management Team. Out of Hours: This must be reported to the: Acute: Community: Clinical Site Practitioner Senior Manager on call via Ealing Hospital switchboard. 21 Slips, trips and falls policy Appendix B Falls Risk Factor Assessment To be completed for all Adult inpatients as per Trust Policy PATIENT NAME: Hospital / NHS No: Date of admission: Repeat the assessments within 6 hours Of transfer If the patient’s condition changes or post fall Post-operatively / post procedure (if sedation used) Every 7 days Complete assessment for every patient within 6 hours of admission FALLS RISK FACTOR ASSESSMENT If Yes (Y) to any of the following 8 questions – the interventions identified in the Falls Risk Care Plan overleaf must be completed Falls Risk Factors Questions 1. Is the patient 65 years or above? 2. History of falls before admission? 3. Admitted with a fall/collapse? 4. Fall since admission 5. Patient or relative/carer anxious about falls 6. Tries to walk alone but unsteady and/or unsafe? 7. Is patient Delirium / Dementia (assessment) 8. In your professional judgment, is the patient at risk of falling? Ward: Ward: Ward: Ward: Admission Assessment: Date: Review Assessment: Date: Review Assessment: Date: Review Assessment: Date: Time: Time: Time: Time: Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Reason Y/N Reason Y/N Reason Y/N Reason PRINT NAME: SIGNATURE: 22 Slips, trips and falls policy NHS number Hospital Number Name DOB Male/Female Appendix C DEMENTIA AND DELIRIUM ASSESSMENT MANDATORY FOR ALL EMERGENCY ADMISSIONS AGED ≥ 75 YEARS Exclusions: Unconscious/severely unwell Assessment declined by patient with capacity Communication / sensory difficulties Doesn’t understand English / no translator STEP ONE: FIND PATIENTS WITH DEMENTIA OR DELIRIUM (complete within 72 hrs) 1 Does the patient already have a formal diagnosis of dementia? YES NO 2 Was the patient admitted with delirium - CAM positive? YES NO YES NO YES: STOP form and continue with best practice NO: go to Question 2 YES: go to STEP TWO and follow NICE Guidelines to treat delirium NO: go to Question 3 3 Ask the patient / family / carer: ‘Has the patient been more forgetful in the last 12 months to the extent that it has significantly affected their daily life?’ YES: go to STEP TWO NO: STOP form and continue with usual care Signature Name in capitals Contact number STEP TWO: ASSESS AND INVESTIGATE A: AMT (from clerking booklet) B: Clinical history (ask patient / family / carer) 1. How old are you? 2. What is your date of birth 3. Repeat “42 West Street” 1/0 1/0 - When did the memory problems begin? I am going to tell you an address. Remember it as I’ll ask you about it later. 4. 5. 6. 7. What year is it? What time is it? Name of this hospital Recognise two people 1/0 1/0 1/0 1/0 How did the memory problems begin – gradually/suddenly? Do you remember my name or job? Do you remember this person’s job? 8. What was the date of WW1 9. Who is the current monarch 10.Count backwards from 20 11.Recall “42 West Street” 1/0 1/0 1/0 1/0 Do you remember the address I told you the start of the assessment? Total AMT score: at Date C: Physical examination/ investigations/medication review Reversible causes of cognitive impairment identified: a. Physical examination b. Investigations: FBC, U&E, Ca, LFTs, TFT, CRP, B12, folate, CXR, ECG, urine dip, MSU, HIV, treponemal serology, consider CT head c. Medication review: especially antipsychotics Answer: Have memory problems stabilised or been getting worse? /10 (AMT ≤7:consider dementia) Signature Name in capitals Contact number Date STEP THREE: REFER ON FOR FURTHER DIAGNOSTIC ADVICE OR FOLLOW-UP Delirium / inconclusive diagnosis – ask GP to re-assess at 4 weeks post discharge and consider referral to memory clinic as necessary. Suspected dementia – inform GP of suspicion and tests performed so far, ask GP to re-assess at 4 weeks post discharge and consider referral to memory clinic. Delirium /suspected or known dementia If concerns about mood, behavioural disturbance, antipsychotic treatment or diagnostic complexity consider referral to the Dementia Matron +/or Liaison Psychiatry (via ICE at NPH or white card at CMH). Signature Name in capitals Contact number Date 23 Slips, trips and falls policy Appendix D Falls Risk Care Plan and Interventions To be completed by Nursing Staff ALL ACTIONS MUST BE CLEARLY DOCUMENTED IN PATIENT NOTES PATIENT NAME: Hospital / NHS No: Interventions Ward: Ward: Ward: Ward: “Yes” – Interventions required and in place “N/A” – Not needed or required “U” – unable to provide/achieve State reason in additional comments section Initial Assessment: Review Assessment: Review Assessment: Review Assessment: Date: Date: Date: Date: Time: Time: Time: Time: Display Falling Leaf symbol above patients bed Patient has an orange name band on Call bell within reach and patient understands how to use it Footwear is well fitting and nonslip. Provide alternative if required Implement minimum hourly “Intentional rounding” Patient needs positioning in an observable area of ward? State where positioned Enhanced level of observation required? State which Cohort nursing Specialling (1:1 constant supervision) If bed rails not recommended and patient at risk of falling from bed is a Low profile bed required? (refer to guidance) Toileting and Continence issues Assess if frequency &/or urgency/mobility issues Urinalysis required/completed? Complete continence assessment/refer for further advice? Refer to Moving & handling care plan for toileting requirements Patient able to access walking aids Patient needs a full mobility and functional assessment Refer to OT / Physio for assessment Spectacles are well fitting and clean Check patient wearing as needed hearing aids are working – Check battery Patient, relative/carer information leaflet “Risk of Falling” must be given Additional Comments (Please use this section to state reasons why unable to provide or achieve interventions) MSSU Dipstick Physio OT PRINT NAME: SIGNATURE: PRINT DOUBLE SIDED 24 Slips, trips and falls policy Appendix D Falls Risk Care Plan and Interventions To be completed by Medical Staff ALL ACTIONS MUST BE CLEARLY DOCUMENTED IN PATIENT NOTES PATIENT NAME: Hospital / NHS No: Interventions Ward: Ward: Ward: Ward: “Yes” – Interventions required and in place “N/A” – Not needed or required “U” – unable to provide/achieve State reason in additional comments section Initial Assessment: Review Assessment: Review Assessment: Review Assessment: Date: Date: Date: Time: Time: Time: Date: Time: Consider Trust Dementia and Delirium assessment Postural Hypotension if applicable (Supine / Erect) Lying and standing blood pressure to be commenced and recorded on NEWS chart History of blackouts or syncope Medication Review with help from Pharmacist 1. Drugs that increase the chance of a fall 2. Bone Health 3. Use of anticoagulation LMWH / NOAC Unable to see/recognise pen/watch from 2m Hearing (cannot hear conversational speech) Additional Comments (Please use this section to state reasons why unable to provide or achieve interventions) PRINT NAME: SIGNATURE: PRINT DOUBLE SIDED 25 Slips, trips and falls policy Appendix E Bedrails Risk Assessment and Plan Risk matrix tool MENTAL STATE Risk matrices provide a familiar format that is easy to understand but may over-simplify some decisions. For example, in the matrix below there are more relevant elements that the matrix suggests including vulnerability to injury and visual and spatial awareness. Patient is confused and disorientated Use bedrails with care Bedrails NOT recommended Bedrails NOT recommended Patient is drowsy Bedrails recommended Use bedrails with care Bedrails NOT recommended Patient is orientated and alert Bedrails recommended Bedrails recommended Bedrails NOT recommended Patient is unconscious Bedrails recommended N/A N/A Patient is very immobile (bedfast or hoist dependant) Patient is neither independent nor immobile Patient can mobilise without help from staff MOBILITY Using the matrix and professional judgement, to support decision making, also consider the following questions and decide if bedrails are recommended Is this patient at risk of falling, slipping or sliding out of bed? Yes No Does this patient have capacity to consent to use of bedrails? Yes No If yes, has verbal consent been obtained for the use of bedrails? Yes No If no, has a decision been made in the patients best interest? Yes No Are bedrails, mattress and bed in safe condition? Yes No Are bedrails recommended? Yes No Date: Review Date Sign and Print Name: Continue bedrails use Discontinue bedrails use Name/signature 26 Slips, trips and falls policy Appendix F Attach Patient Label Ward: ……..………………… Bed Rails Assessment Tool Complete this form for every patient on admission and review weekly to determine if the bed rails (side rails / cot sides) on the bed should be used. Admission 1 2 3 4 5 6 Week 1 Week 2 Week 3 Week 4 Date Does the patient use bed rails at home? YES NO History of falling out of bed at home / on the ward YES NO Altered level of consciousness YES NO Mental status - impaired judgement such as confusion, significant /severe Memory loss YES NO (**if the answer to question 4 is YES, complete the Mental Capacity assessment over leaf) Poor sitting balance YES NO Poor spacial awareness (e.g. Visual neglect of one side of environment due to CVA) YES NO Signature: If the answer is YES to any of the questions above – USE BEDRAILS If all the answers are NO – DO NOT USE BEDRAILS unless the patient request to have bed rails. Bed rails to be used Bedrails not needed / NOT to be used If patient’s head / body is smaller than average adult consider use of bumpers with side rails / paediatric bedrails if bedrails are needed Use of bedrails discussed with ………………………………patient / relative. Date: …………………….. Signature: …………………………. 27 Slips, trips and falls policy Appendix G Name x Date of birth addressograph label here Hospital/NHS No. Ward MENTAL CAPACITY: (If the answer to question 4 in the Bed Rails Assessment Tool was YES) If the patients assessment indicates the use of bedrails the following questions about the patient’s ability to retain information and make decisions about the use of bed rails must be asked; – – – – Does the patient understand why bedrails are used? Can they repeat the question? Do they understand why they need or do not need bedrails? Can they tell you in their own words why they do not want bed rails to be used? Yes Yes Yes Yes No No No No Outcome: 1. If the answers are YES = Patient is able to understand and able to make decisions: USE BEDRAILS as indicated by the assessment over leaf – discuss with the patient; BUT if the patient refuses to have bedrails regardless of the assessment indicating the use of bedrails – DO NOT USE BEDRAILS. 2. If the answers are NO = Patient is unable to understand or retain information about the use of bedrails: If the assessment indicates the use of bedrails, but the patient is unable to understand or retain the information about why bed rails should be used - discuss with members of MTD (available at the time), meanwhile USE BEDRAILS for the patient’s safety and document the decision in the patient’s notes as for the best interest of the patient. WHEN NOT TO USE BED RAILS ON A PATIENT’S BED NOTE: Consider other options rather than use of bed rails When a patient has chronic confusion and is able / is attempting to climb over the bed rails When a mobile patient is acutely confused and disoriented Independently mobile patient unless they request the use of bed rails - Leave the bed on its lowest height position when no care is provided and use the ‘lock out facility’ of the bed Nurse nearer the nurses station for better observation, call bell near, adequate lighting One to one supervision Use low-rise bed: keep the bed on the floor level when no care is provided always consider the need for crash mats on the floor by the bed. – DO NOT USE both bed rails on a low-rise bed frame 28 Slips, trips and falls policy Appendix H Name Date of Birth Hospital / NHS No IN-PATIENT CARE PLAN FOR BED RAILS Ward To be reassessed each shift and amended as circumstances change. WARD : Care plan start date: Named nurse / nursing team: Problem: ______________________ is at risk of rolling/slipping/falling out of bed Desired outcome: For _________________________ to remain safe at all times using bedrails as appropriate NURSING ACTIONS: 1. Ensure patient safety at all times. This could mean using bedrails in the first instance until a more indepth risk assessment takes place. The results of the risk assessment could indicate that bedrails may be required permanently. 2. Patient assessment must include mental capacity assessment to ascertain whether the patient has the ability to make decisions regarding the use of bedrails. 3. If the patient does not hold the necessary capacity an immediate discussion with the members of the MDT (available at that time) must be held and a decision made regarding the use of bedrails. 4. Obtain consent from the patient to use bedrails where appropriate. 5. Inform patient/family/carer about the decision to use or not to use bedrails. 6. Any decisions regarding the use or not of bedrails must be documented in the nursing notes. The names of all the people involved in the decision making must also be documented. 7. Ensure bedrails are in good working order. If bedrails found to be faulty, beds should not be used and must be reported to the Huntleigh technician on ext. 6009. Out of hours the bed with the faulty bedrails must be removed from service and replaced with a fully operational bed (can be obtained via the porters). Ensure reported to ext. 6009 as soon as possible after the event. 8. Ensure bed is maintained at its lowest position when the patient is not being attended to. Staff must also ensure that the lock-up facility (up and down function) on the bed is used. 9. Consider moving the patient to an area where he/she can be more easily observed. 10. If unsuccessful implementing the above or patient is still experiencing falls consider the use of a low rise bed. Signature : ANY CHANGES TO CARE PLAN 1. Print name: SIGNATURE & NAME DATE 2. 3. ALL ENTRIES MUST BE IN BLACK INK, MUST BE SIGNED AND NAME PRINTED 29 Slips, trips and falls policy Appendix I Ward /Department Patient Addressograph Date ----/---/------ Time ---:--FALLS CARE BUNDLE Falls Care Bundle Actions : Tick the appropriate box in each element and date and sign Section 1 If the patient has been assessed as being at risk of falling or has had a fall whilst on the ward. Actions Section 1 Yes No N/A Date Time Signature Time Signature Falls Risk Factor Assessment initiated within 6 hours of admission Complete Cot side /Bedrail assessment. Ensure patient/ carer is aware or the outcome of the assessment. Does the patient need a low rise bed? Is the bed at its lowest point? Review Staffing ratio; is there a need for the patient to have 1:1 care (Refer to Safe and Supportive Observation Policy) Position the patient in an easily observed area of the ward, ensure the patient is given the nurse call bell and all personal equipment is placed within easy reach of the patient. Ensure night light is on POST FALL ACTIONS Section 2 To be completed if the patient has sustained a fall All actions to be completed If the patient has sustained a fall as an inpatient complete the following below Yes No N/A Date Injury assessment for fracture and spinal injury Injuries assessed equipment and staff used to manage patient safely as per manual handling policy ¼ hourly observations using Glasgow Coma Scale and NEWS score for the first hour1 hourly for 4 hours After 4 hours as clinically appropriate Medical Team Informed Medical Report following a Fall (Appendix J) completed and filed in patients notes All Clinical Interventions such as CT / X-ray completed within 4 hours Any injury sustained to be documented in the patients notes Incident report completed Any patient injury to be escalated to ward manager for root-cause analysis Patients relatives informed Ensure that GP / community services are aware of the patient falling and are referred to the appropriate services [ ] Peel off this sticker and place in notes when completed. Patient Detail information to be placed in audit folder Please complete the following for audit. 1. Initial Assessment completed 2. Patient Environment Reviewed 3. Cot – Side Assessment completed 4. Staffing Reviewed 5. 1 :1 special Required 6. Observations Completed hourly following fall 7. Medical Report completed by Doctor 8. Incident Report (Datix) Completed 9. Relatives / Carers informed Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No 30 Appendix J Medical Report Following a Fall (attach to medical notes) Medical Report following a Fall Site(s) of injury (mark with an X) Patient Name: Hospital/NHS No Date of Birth: Reviewed By: Sign: Date and time: Datix Incident Number: Assessment: History: Cause of fall (Exclude new problem e.g. MI, PE, stroke, delirium): Examination: Lying and standing BP(if possible), CVS, RS, Abdomen, Neurology P BP lying standing GCS: E= /4 V= /5 M= /6 = /15 Injuries Cognitive Assessment: Is patient known Dementia or New Delirium Yes / No None Gait Assessment: Involve physiotherapy and OT Bruising Investigations ordered: Must have ECG if Chest Pain, LOC,SOB or no recent ECG Laceration Medication review: Stop unnecessary drugs. Consider bone protection / Discuss with Ward Pharmacist Fracture Consider footwear and visual problems: Which may need onward referral Other Specify 31 Appendix K Preventing falls in hospital This leaflet is to tell you how we try to prevent patient falls, and what you and your visitors can do to help. Sometimes patients experience a fall while in hospital. This may be because of a sudden change in health, disorientation due to unfamiliar surroundings, the effect of new medication, or mobility and balance problems. Unfortunately accidents can happen at any time, but we will do our very best to minimise this risk, respecting your freedom to move around and your wishes at all times. We hope the information below will assist you, your relatives and carers to reduce the chance of a fall while you are in hospital. However, if you have any questions, don’t be afraid to ask us for help. Our advice to patients If you have fallen at home in the past 12 months please let us know. If you have a fear of falling please let the nursing staff know. Listen to the advice from the therapists and nursing staff. Use the nurse call bell for assistance if you feel weak, unsteady or dizzy. Do not get up in the dark alone; use the call bell for help. Keep everything you need within easy reach. Ensure you have your glasses, hearing aids and dentures. Bring any walking aids from home. Use any walking aids given to you by the physiotherapists. Wear non-slip well-fitting slippers or shoes. To help prevent you tripping, wear clothes that are not too long or too loose. Report any problems such as spills, trailing wires or cables to staff. Ask your relatives or carers to take items home to reduce bedside clutter. Be careful when standing up or getting out of bed, take your time. Don’t use hospital furniture for support as it may not be stable enough 32 Our advice to visitors Please replace anything that you have moved during your visit. Inform nursing staff before you leave and ensure that the patient realises you are leaving. Ensure the patient has well-fitting non slip footwear and clothing that is not too loose or long. Discuss any falls prevention and walking aids that the patient uses at home with nursing staff and bring them in if needed. Ensure the patient has their glasses, hearing aids and dentures with them. Tell us if the patient has had any previous falls. Minimise clutter by taking unnecessary items home. Looking after patients who may be at risk of falling Although falls cannot always be prevented, we assess all adult patients on admission to reduce the chance of them having a fall. If you or your relative is assessed as being at risk of a fall, these are some of the steps we may take to minimise this risk; Moving the patient’s bed to a more suitable position on the ward Using bedrails to stop a patient from rolling or sliding out of bed. Using an ultra-low bed [which is lower to floor level] when bedrails are not suitable. Sometimes a padded mat or mattress will be placed on the floor next to the ultra-low bed. Carefully monitoring the patient, which may be continuous or at set periods of time. Using other falls prevention aids as directed by the nursing staff. Please remember The measures detailed in this leaflet are designed to minimise the risk of patients falling whilst in hospital. However we cannot restrain patients or deprive them of their liberty and we will always adhere to patients’ wishes, or act in their best interests if they are unable to express their wishes. Some patients will still fall even if we have done all the things mentioned in this leaflet, being in hospital does not mean we can prevent falls. However, by working in partnership with patients, their relatives and carers we aim to minimise the risk of falls. Further information If you have any further concerns regarding falls please do not hesitate to ask a member of staff. 33 Appendix L FALLS ASSESSMENT PATHWAY Adult Patient Admitted Complete Falls Risk Factor Assessment Form Within 6 hours of Admission Answer YES to any of the Questions NO to all Questions Complete Falls Risk Care Plan and Interventions Nursing and Medical Team Assessments Repeat the Assessment If the patient’s Complete Bedrails Risk Assessment and Tool Condition Changes Post Fall Complete Mental Capacity Assessment if indicated Post Operatively / Post Procedure Every 7 days Commence Bedrails care plan if bedrails required PATIENT FALLS Follow Post Fall Protocol Complete Falls Care Bundle Ensure Post Fall Medical Report Completed Incident Form Completed Repeat the Assessment 34 Appendix M POST FALL PROTOCOL Has the Patient Sustained an injury NO Observe the patient for any signs of deterioration Report Incident on Datix Complete Falls Bundle and Post Fall Medical Report YES Check Patient for signs or symptoms of Fracture and Potential for Spinal Injury before Patient is moved NO Observations to be carried out every ¼ hour for first hour and hourly for 4 hours then review Use the NEWS & Glasgow Coma scale Escalate deterioration as appropriate. YES Ensure that you have enough staff and the right Equipment to move the patient Spinal scoop, flat lifting hoist and Neck Collars can be found in A&E Community Hospitals – Call Emergency Services Call Medical team to review the patient Medical Team to Complete Post Fall Report Patient must be seen within 1 hour If patient needs CT Head this must be performed within 1 hours of referral After each fall a Safety Huddle (MDT Discussion) must take place to review the incident and lessons learnt shared 35 Appendix N EQUALITY IMPACT ASSESSMENT SCREENING TOOL Directorate / Department LONDON NORTHWEST HEALTHCARE NHS TRUST Policy or Operating Procedure or Guidelines Title / Service Name and role of Assessor Date of Assessment SLIPS, TRIPS AND FALLS POLICY (In-patients) SENIOR NURSE – QUALITY AND CLINICAL STANDARDS JANUARY 2016 Yes/No 1 2 Race, Ethnic Origins (including gypsies and travellers) and Nationality NO Gender (including gender reassignment) NO Age Religion, Belief or Culture Disability – mental, physical and learning disability Sexual orientation including lesbian, gay and bisexual people Married/or in civil partnership Pregnant Is there any evidence that some groups are affected differently? NO NO NO NO NO NO NO 3 Is there a need for external or user consultation? NO 4 If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? NA 5 Is the impact of the policy/Guideline likely to be negative? NO 6 If so, can the impact be justifiable? NA 7 What alternatives might enable achievement of the policy/ guidelines without the impact? NA Can we reduce the impact by taking different actions? NA 8 Comments Does the policy/Guideline affect one group less or more favourably than another on the basis of: Recommendation Full Equality Impact Assessment required: Assessor’s Name: U.Hicks NO Date: 25.01.16 36