guidelines - network of care for fall... · 2006-08-29 · 03 introduction introduction 01...

Guidelines

Published by the Metropolitan Health and Aged Care Services Division Victorian Government Department of Human ServicesMelbourne VictoriaJuly 2004' Copyright State of Victoria, Department of Human Services, 2004

This publication is copyright. No part may be reproduced by any process except in accordance with theprovisions of the Copyright Act 1968.

Design by Watts Design. 3290

Victorian Quality Council SecretariatPhone 1300 135 427Email [email protected] http://qualitycouncil.health.vic.gov.au

Disclaimer

This document should not be considered prescriptive. Health

care staff should work with patient/residents and their

families/carers to ensure that the most appropriate care and

treatment is provided to the individual. Some flexibility will be

required to adapt these Guidelines to specific settings, local

circumstances and to individual patient/resident needs.

Every effort has been made to ensure that the information

provided in this document is accurate and complete at the time

of development. However the Victorian Quality Council, the

authors, or any person that has contributed to its development

do not accept liability or responsibility for any errors or

omissions that may be found, or any loss or damage incurred

as a result of relying on the information in this document.

01

VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES

THE GUIDELINES

A process model for minimising the risk of falls and fall-related injuries Guideline statements relating to the steps in the process model

IMPLEMENTATION SUPPLEMENT

The VQC is developing a generic change and implementation best practice model due to be released before the end of 2004

TOOLS SUPPLEMENT

Information about tools for minimising the risk of falls and fall-related injuries Examples of tools for use with the four steps of the process model

EDUCATION SUPPLEMENT

Training units and case studies to support the use of the process modelA table recommending specific units and case studies for different healthcare services job roles

RESEARCH SUPPLEMENT

Details of the research findings used to support the development of these Guidelines

WARD KIT

Quick Reference Guide: descriptions of falls risk factors and actions for minimising riskPosters: key steps and information from the Guidelines

The following symbols are used throughout the Guidelines Pack.These symbols indicate that further information is available in the relevant supplement.

Contents of this Guidelines Pack

02

1. INTRODUCTION 3Purpose of these Guidelines 4

Who these Guidelines are intended for 4

Using these Guidelines in the different settings 4

Research findings and levels of evidence 4

Definition of a ÒfallÓ 5

2. PROCESS MODEL FOR MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES 6

About the process model 6

The four patient/resident-centred care steps 7

Tools for use with the steps 7

3. THE PATIENT/RESIDENT CENTRED CARE STEPS 8Step 1: Conduct falls risk screen 9

Definition 9

Guideline Statement for Step 1 9

Patient/resident centred tasks for Step 1 9

Organisational tasks for Step 1 10

Rationale for Step 1 10

Differences in implementing Step 1 across the three settings 10

Step 2: Conduct falls risk assessment 11

Definition 11






Personal risk factors identified in the literature 12

Individual environmental risk factors identified in the literature 14

Step 3 Develop and Implement an Action List 15

Definition 15






Actions for minimising personal risk factors 16

Actions for minimising individual environmental risk factors 32

Step 4 Respond to a falls incident appropriately 37

Definition 37






4. THE PROCESS MODEL AND QUALITY IMPROVEMENT 40

5. REFERENCES 41

6. GLOSSARY OF TERMS 42

ACKNOWLEDGMENTS 45

03

Introduction

Intro

duc

tion

01

Minimising the Risk of Falls & Fall-related Injuries Guidelines for Acute, Sub-acute andResidential Care Settings is an initiative of the Victorian Quality Council (VQC). The development of the Guidelines Pack is one component of a strategic approach toreducing the risk of harm and improving health care quality and safety in Victoria, including:Establishing a Safety and Quality Framework, Providing Access to Better Data, Educatingon Safety and Quality and Responding to Known Problems and Risks.

Falls, related injuries and loss of confidence due to fear of falling are common causes ofmorbidity in Australia. In hospital and residential care settings, the risk of falling is evengreater than in the community setting, because of acute illness, increased levels of chronicdisease, and different environments and routines.

Research evidence indicates that interventions to minimise falls risk can reduce the risk of falling and fall-related injuries, even in olderpeople with high risk of falling. Staff involved in direct care in hospital and residential care settings have a key role in successfulimplementation of falls risk minimisation activities.

More information about the consequences and costs of falls and fall-related injuries is given in the Research Supplement.

04

Purpose of these GuidelinesThe purpose of these Guidelines is to assist directcare staff and others responsible for ensuring qualityof care, to put in place an effective program forminimising the risk of falls and fall-related injuries.The information provided is based on the bestavailable evidence at the time of publication.

Who these Guidelines are intended forThese Guidelines have been developed for thosewho deliver, and are responsible for, patient/residentcare. This includes clinical, management, corporateand environmental serviceÕs staff.

Using these Guidelines in the differentsettingsAlthough a broadly similar approach may be takento minimising the risk of falls and fall-related injuriesin the different settings, circumstances may call fordifferent strategies in:

acute and sub-acute hospital settings, and

hospital and residential care settings.

These Guidelines have been structured as a globalresource for use across all three settings, wheredifferences exist, they are identified and describedseparately.

Use of the terms “patient”, “resident” and “client”For the purpose of this document the term ÒpatientÓrefers to both patients and clients in acute and sub-acute settings. ÒResidentÓ has been used torefer to people receiving care in residential caresettings.

Level ofevidence

I

II

III - 1

III - 2

III - 3

IV

Description

Evidence obtained from a systematic review of all relevant randomised controlled trials

Evidence obtained from at least one properly designed randomised controlled trial

Evidence obtained from well designed pseudo-randomised controlled trials (alternate allocationor some other method)

Evidence obtained from comparative studies with concurrent controls and allocation notrandomised (cohort studies), case control studies, or interrupted time-series with a control group

Evidence obtained from comparative studies with historical controls, two or more single-armstudies, or interrupted time series without a parallel control group

Evidence obtained from case series, either post-test or pre-test and post-test.

For the purposes of this project, the term Consensus Opinion has been used to describe evidence based on consensus ofexpert opinion and the findings of expert working parties.

Using these Guidelines in emergency departmentsForty-five percent of older people who attend a hospital emergency department after a fall are dischargedwithout admission. Emergency department staff have an important role in identifying the ongoing fall risks forthese patient/residents, as well as initiating appropriate referrals or interventions that may reduce the risk offuture falls and hospital presentations.

These Guidelines may provide a useful framework for staff in emergency departments.

Research findings and levels of evidenceThese Guidelines are based on research evidence and, where no formal research evidence exists, on expertopinion and the findings of expert working parties.

Guideline Statements have been identified for the four patient/resident-centred care steps in the processmodel.

The research methodology is described in the Research Supplement.

Levels of evidence of effectivenessThe evidence for the guideline statements presented in these guidelines was systematically assessed andclassified according to the National Health and Medical Research CouncilÕs (NHMRC) Guide to theDevelopment, Implementation and Evaluation of Clinical Practice Guidelines [1].

Levels of evidence of effectiveness describe the strength of the research evidence supporting eachrecommended strategy to reduce the risk of falls or fall-related injuries. From strongest to weakest, the levelsof evidence used for the Guideline Statements in this document are shown in the following table:

Table 1. Levels of evidence used for the Guideline Statements


05

Definition of a “fall”For the purposes of these Guidelines, a fall isdefined as:

ÒA sudden, unintentional change in position causingan individual to land at a lower level, on an object,the floor, the ground or other surface [2].Ó

This includes:

slips being lowered

trips loss of balance

falling into other people legs giving way.

If a patient/resident is found on the floor, it should beassumed that they have fallen unless they arecognitively unimpaired and indicate that they putthemselves there on purpose.

It is recommended that a common definition isadopted for use across health services and within aspecific setting.

For further definitions of a ÒfallÓ see the Research Supplement.

Falls risk factorsFalls risk factors are characteristics or behavioursthat make it more likely that a patient/resident willfall. Falls risk factors can broadly be considered as:

Personal (intrinsic) risk factors relate to healthproblems that increase the patient/residentÕs risk of falling.

Environmental (extrinsic) risk factors relate tohazards in the environment that increase the patient/residentÕs risk of falling (eg bed brakes not locked).These risk factors have been sub-divided into:

Individual environmental risk factors — relatedto hazards in the patient/residentÕs immediatearea

General environmental risk factors — related tohazards that are outside the patient/residentÕsimmediate area, but in places where thepatient/resident goes at times (eg corridors, therapy areas).

The interaction between the individual and theirenvironment can be considered a third type of riskfactor — also called behavioural risk factors. Thenature of the activities performed (how difficult ortiring they are) and the way patient/residents performthem (safely or not) will influence their risk of falling.

06

Process model for minimising the risk of falls and fall-related injuries

Pro

cess

mod

el

About the process modelThe process model

presents four steps for assessing and managing patient/residents tominimise their risk of falls and fall-related injuries, and

identifies tasks and products thatresult from carrying out the steps.

YESYES

Develop plan fordaily care for patient/resident with low falls risk

Falls IncidentReport

Action List for minimising falls and fall-relatedinjuries

Falls RiskAssessment

Falls Risk Screen

YESYES

YESYES

NONO

Tools Steps in minimising the risk of falls and fall-related injuries

IF A PATIENT/RESIDENT FALLSIF A PATIENT/RESIDENT FALLS

YESYESAND/OR*AND/OR*

On Admission

Have the risk factors been assessedcomprehensively for this patient/resident?

2 CONDUCT Falls Risk Assessment

Does the level of the patient/resident's risk exceed the threshold? (the threshold is dependant upon the tool used)

1 CONDUCT Falls Risk Screen

Do the selected actions match the patient/resident’s risk factors and have all the actions been implemented as part of the plan for daily care?

3 DEVELOP & IMPLEMENTan Action List for minimising the risk of falls and fall-related injuries and INCLUDE the list in the patient/resident’s plan for daily care

Review/revise planfor daily care routinely, or cued by:

• patient/resident falling

• change in patient/ resident's health/ functional status

• change in patient/ resident's environment





Falls Risk Screen

YESYES

YESYES

NONO

Tools Steps in minimising the risk of falls and and fall-related injuries



On Admission

Review circumstances of the fall at ward/unitlevel

Ward/Unit LevelFalls Incident Data







Were the appropriate actions taken?

4 RESPOND to a falls incident appropriately:a) Care for patient/residentb) Report the incidentc) Repeat steps 1/2 and 3 of this module


Ward/Unit LevelFalls Incident DataWere the appropriate actions taken?






QI CYCLECollate, monitor, analyse, and feedbackfalls incident data. Feedback to staff/management on data.

Upgrade tools and process in responseto findings.

Organisation meets qualityimprovement requirements

* In some settings, the Screening component may be omitted, and the Model commences with Assessment (Step 2)

02

07


The four patient/resident centred care steps

The four steps are integral to an effective program to minimise the risk of falls and fall-related injuries inhospitals and residential care settings.

The four steps are:

Tools for use with the stepsThe Tools Supplement includes a selection of tools that can be used for these steps.

The term ÔToolsÕ refers to a range of support documentation and resources used in implementingprograms to minimise the risk of falls and fall-related injuries. These include:

Patient/residentcentred care step

Screening

Assessment

Intervention

Appropriate responseif a fall occurs

Description

Identifying patient/residents who are at greatest risk of falling and in need of moredetailed assessment.

Identifying the falls risk factors that contribute to the patient/residentÕs overall riskof falls and fall-related injuries.

Developing and implementing an individualised Action List aimed at reducing therisk of falls and fall-related injuries.

The appropriate response to a falls incident includes caring for the patient/residentand ensuring that the incident is reported and documented.

falls risk screening tools

falls risk assessment tools

environmental audits (both individual andgeneral)

falls incident report

patient/resident information resources

list of medications associated with increased fallsrisk

Victorian CoronerÕs Standard for Investigation (of falls related deaths)

cognitive impairment tests, and

falls incident data management framework (Excel file).

08

The patient/resident centredcare steps

Pat

ient

/res

iden

tce

ntre

d c

are

step

s03

09


GUIDELINE STATEMENT FOR STEP 1

Conduct a falls risk screen as the minimum process for identifying clients whoare at risk of falling.

Level of evidence: Consensus Opinion [3].

Step 1: Conduct falls risk screen





Falls Risk Screen

YESYES

YESYES

NONO




On Admission














Patient/resident centred tasks for Step 1a) Conduct a falls risk screen on all

patient/residents who are not part of high fallsrisk populations.

Screening may not be required in settings wheremost patient/residents are considered to be atrisk of falling (eg dementia specific wards inresidential care). In these settings, and for allpatient/residents in high falls risk populations,proceed directly to Step 2.

b) Conduct a falls risk screen at the following times:

on admission, or as soon as practicable afteradmission

when a patient/resident is transferred from oneward or department to another

if there is a change in a patient/residentÕs healthor functional status

if a patient/resident has a fall, and

as part of discharge planning.

c) Use a recognised tool.

d) Document the results and include in thepatient/residentÕs permanent file/medicalrecord/residential care file.

e) Carry out a falls risk assessment (Step 2) for:

patients/residents whose risk of falling exceedsthe threshold

patients/residents who are in high falls riskpopulations* (eg patient/residents withneurological dysfunction)

OR

refer the patient/resident for assessment as soonas practicable.

High falls risk populationsStudies in hospital and residential care settingshave identified high falls risk populations to includepatient/residents with the following:

a history of falls, falls with injury, or fall relatedfracture neurological conditions such as stroke andParkinsonÕs disease cognitive problems such as dementia or deliriumdepressionlower limb (leg) arthritisacute infections such as urinary tract infection,chest infectionshaematological/oncology conditions, orvisual impairment.

Definition Falls risk screening refers to a brief (often less than 5 items) check to identify patient/residents who are at riskof falling. These patient/residents need to have a more detailed assessment of their falls risk carried out.


10

Organisational tasks for Step 1a) Select an appropriate tool.

b) Provide staff education and training on thepurpose and use of the tool.

c) Audit the use of the tool for compliance withrelevant policy.

Rationale for Step 1The risk of falling and related injury increaseswith age [4] and increased unsteadiness [5].

Falls occur more commonly in the periodimmediately following a transition betweensettings [6].

Increased length of stay in a hospital settingincreases falls risk [7].

Falls risk is ongoing. The patient/resident shouldbe reviewed as part of an ongoing process [8].

Differences in implementing Step 1across the three settingsAcute Care

In an acute setting, the patientÕs health status islikely to change rapidly, and falls risk screeningshould be repeated on a regular basis (eg dailyor weekly) or when clinical judgement indicatesthat there is a change in the patientÕshealth/functional status.

In emergency departments, falls risk screeningcould be used to determine whether falls riskassessment should be completed by hospitalstaff, and/or whether referrals should be made tocommunity agencies.

Residential CareFalls risk screening may be less relevant in manyhigh care residential settings, because mostresidents are likely to exceed the falls riskthreshold. In this situation a falls risk assessmentshould be completed on all residents (Step 2).

Step 2: Conduct falls risk assessment


Conduct a falls risk assessment for each patient/resident who is identified asbeing at risk of falling.

Level of evidence: II [9, 10, 11].

Definition Falls risk assessment is a systematic and comprehensive process to identify an individual patient/residentÕsrisk factors for falling.

A patient/residentÕs level of risk of falling and fall-related injury is a combination of:

the severity of each risk factor (which can vary from nil to very high)

the importance of that risk factor (some risk factors have a stronger association with the risk of falls andfall-related injuries than others), and

the number of risk factors.

There is a direct relationship between a patient/residentÕs level of falls risk and their probability for falls.


Patient/resident centred tasks for Step 2a) Assess the following patient/residents for falls risk:

patient/residents whose level of falls riskexceeded the screening threshold (Step 1)

all patient/residents in high falls risk populations;and

all patient/residents in settings where mostpatient/residents are expected to have a highfalls risk (eg dementia specific residential care units).

b) Assess or reassess a patient/residentÕs falls riskat the following times:

as soon as practicable after admission

if there is evidence of change in thepatient/residentÕs health/functional status

when the patient/residentÕs environment ischanged (eg a patient/resident moves to anotherroom, ward or setting, or new equipment is used)

when the patient/residentÕs treatment is changed(eg different drug(s) prescribed)

when the patient/resident has a fall

when a patient/resident is discharged/transferredfrom one setting to another, either within thesame organisation or to a different organisation

as part of a routine review, and

at other times as required by your organisationÕspolicy.

c) Use a recognised tool to carry out theassessment.

d) Identify and describe all factors that contribute tothe patient/residentÕs risk of falling and fall-related injuries.

These include:

the patient/residentÕs personal risk factors, and

risk factors in the patient/residentÕs individualenvironment.

e) Record the level of risk and the identified riskfactors (both personal and individualenvironmental) in the patient/residentÕs permanentfile/medical record/residential care file.

f) Proceed to Step 3 to determine actions toaddress the risk factors you have identified. 11



Action List for minimising falls and fall-related injuries


Falls Risk Screen

YESYES

YESYES

NONO




On Admission















12

Organisational tasks for Step 2a) Select an appropriate tool (falls risk assessment

and individual environmental audit).

b) Provide staff education on the purpose of thetool and training in its use.

c) Audit the use of the tool for compliance withrelevant policy.

Rationale for Step 2Falls are usually caused by a number of riskfactors, [12] which vary between individuals, andchange over time [7].

Falls occur more commonly in the periodimmediately following a transition betweensettings [6, 8].

The risk of falling and related injury increaseswith age [4], and increased unsteadiness [5].

Increased length of stay in a hospital settingincreases falls risk [7].

Falls risk is ongoing. The patient/resident shouldbe reviewed as part of an ongoing process [8].

Risk factor status changes over time, so theremay be a gap between needs and services. This gap may be indicated by a change in thepatient/residentÕs health or a fall [13].

Between 10% and 50% of falls in hospitals andresidential care facilities involve an environmentalhazard [5, 7, 14].

Over half of the falls in hospitals and residentialcare facilities occur around the bedside [7, 10].


In an acute setting, a patient/residentÕs healthstatus and treatment may change frequently.Because of this re-assessment may need to becarried out as often as staff shift changes, thetool used should be relatively short and quick tocomplete.

Although allied health staffing levels may be morelimited in acute hospital settings than sub-acutesettings, a multidisciplinary approach to falls andfall-related injury risk minimisation is still possibleand desirable.

Sub-acute and Residential Care A team may carry out components offalls risk assessments rather than onestaff member. For example, the PJC-FRAT is a multidisciplinary tool used inthe sub-acute setting, where:

a medical officer assesses fall history,medical condition and medications

a nurse assesses continence status

a physiotherapist assesses transfers andmobility status, and

an occupational therapist assesses functionalactivities (bathing and dressing).

If a multidisciplinary team is involved in thefalls risk assessment, responsibility forensuring timely completion of the assessmentshould be given to one staff member.

Direct care staff can assist by gatheringinformation for the assessment.

Personal risk factors identified in the literatureA number of falls risk factors relating to apatient/residentÕs health status andcharacteristics have been identified in theliterature. These are known as personal riskfactors (refer to the Research Supplement formore detail about personal risk factors).

There may be a number of possible causes for eachrisk factor, and an important element of the falls riskassessment process for a patient/resident is toidentify the cause/s of the risk factors identified(which may often require medical and other healthprofessional assessment).

Some causes may be modifiable (where the medicalcondition that is the cause of the risk factor is ableto be improved with treatment), while others may benon-modifiable (often associated with chronic ordegenerative health problems). Even for non-modifiable causes of falls risk factors, treatment canhelp to reduce the magnitude of the effect of the riskfactor (for example, for a patient/resident withParkinsonÕs disease, exercise can help to improvesteadiness during walking even though the exercisedoes not affect the underlying disease). Actions tominimise risk of fall-related injury should also beimplemented for patient/residents with non-modifiable causes of personal falls risk factors.

The personal risk factors for falls and someexamples of modifiable and non-modifiable causesare summarised in Table 2.

Table 2. Personal Risk Factors

Personal risk factor

Leg muscle weakness and deconditioning

Poor balance/unsteadiness in walking

Multiple medications, or use of medicationassociated with falling

Incontinence

Postural hypotension

Loss of confidence/fear of falling

Poor condition of feet and inappropriatefootwear

Poor nutritional status

Cognitive impairment (confusion, poor planningand monitoring, reduced memory)

Sensory loss:VisionVestibularSomatosensory Hearing

Factors contributing to history of previous falls

Example of a modifiable cause

proximal myopathy (eg osteomalacia) reduced physical activity

balance and mobility problems after ankleligament injury or joint replacement surgery

some medications may be reduced or ceasedwithout harm

reduced detrusor muscle control

medications that can cause postural hypotensiondehydration

bunions, callouses, flattened transverse archinappropriate or worn shoes, slippers

reduced intake from difficulty chewing due topoor fitting dentures

delirium

cataractsbenign paroxysmal positional vertigo (BPPV)vitamin B12 deficiencyexcessive wax, hearing aid not being used properly

would need to investigate the causes of previousfalls

Example of a non-modifiable cause

polio

ParkinsonÕs disease

medication associated with an increased risk offalling for which there is no suitable substitute

toe amputation

dementia

macular degenerationvestibular toxicitydiabetic neuropathysensory neural deafness

history of previous falls.

Full descriptions of these personal risk factors and actions for risk minimisation are provided in Step 3.

13


14

Individual environmental risk factorsidentified in the literatureIndividual environmental risk factors related to thepatient/residentÕs immediate environment include thefollowing:

inappropriate bed or chair height

inappropriate type of bed or chair

brakes on bed/chair either not on, or broken

call bell left out of reach

walking aids out of reach

walking aids not in good condition

walking aids not used properly

brakes on wheelie frame/wheelchair broken ornot used properly

IV drip stands, power cords etc. not positionedproperly

slippery surfaces

loose floor coverings (eg rugs)

clutter

hoists/lifting machines left in rooms or corridors

inadequate lighting (poor lighting, lack of nightlights, or excessive sun glare)

inadequate rails/supports where required (eg toilets/bathrooms), and

restraints/cotsides (use of restraints/cotsides canincrease the risk of injury associated with falls).

Full descriptions of these individual environmentalrisk factors and actions for risk minimisation areprovided in Step 3.

Note: The personal and individual environmental riskfactors described in this Step are only the startingpoint of assessment. Their presentation may vary inindividual patient/residents, or individualpatient/residents may have risk factors that are notincluded in these lists.

15


Step 3: Develop and Implement an Action List


Develop and Implement Action List for minimising the risk of falls and fall-relatedinjuries, include in patient/resident’s plan for daily care.

Level of evidence: II [9,10,11]



Action List for minimising falls and fall-related injuries


Falls Risk Screen

YESYES

YESYES

NONO




On Admission














Definition An Action List for minimising the risk of falls and fall-related injuries is a list of strategies to address riskfactors that were identified by the falls risk assessment (Step 2).

Patient/resident centred tasks for Step 3a) Determine which personal risk factors identified

in Step 2 have causes that are modifiable.

b) For each personal risk factor with a modifiablecause, determine actions to minimise the risk offalls and fall-related injuries.

c) Determine appropriate actions to manage riskfactors that are non-modifiable.

d) For patient/residents with high overallfalls risk, determine additional actionsto minimise overall risk. Some toolsinclude a description of these actions.

e) Determine how often these actions should becarried out, by whom and at what point in time.

f) Either document all the actions in an Action List,or delegate this task to another staff member, asdetermined by your organisationÕs policy.

g) Include the identified risk factors and the ActionList in the patient/residentÕs documentation including:

plan for daily care

permanent file/medical record/residential carefile, and

discharge summary.

h) Implement Action List as indicated.

Organisational tasks for Step 3a) Provide information and required resources to

staff, to enable them to develop and implementthe Action List. Examples which may beendorsed and supported from an organisationallevel include:

improved capacity for observation of high riskpatient/residents. This may involve restructuring ofwork practice (eg changes to showering routines)or purchase of equipment (eg bed/chair alarms), or

policies for discharge planning, whichinclude communication of falls riskinformation to those involved inongoing care.

b) Decide how the Action List should be integratedinto the patient/residentÕs plan for daily care.

c) Provide staff education and training indeveloping and implementing an Action List.

d) Audit the implementation of Action Lists.

e) Ensure regular general environmental audits areundertaken and actions implemented.


16

Rationale for Step 3A targeted falls prevention program based on thefindings of a falls risk assessment has beenshown to reduce falls in residential care andhospital settings [9, 10, 11].

Modification of the individualÕs environment canreduce falls risk [15].

Falls are usually caused by more than one fallsrisk factor, so multi-factorial interventionstargeting all identified risk factors are likely to bemore effective than single interventions [16].

Falls risk factors may present differently inindividual patient/residents. These differencescan be determined through individual assessmentand management of each of the risk factors [13].


Because the time spent by patients in this settingis usually short, the approach may emphasisepreventative actions such as enhancedsupervision of patientsÕ activities and environment.

Sub-acute and Residential Care For patient/residents receiving longer-term care,there may be greater emphasis on behaviourmodification and improving functions for daily living.

Table 3 outlines actions to minimise the impact of each of the personalrisk factors for falls, to assist in developing an Action List. The researchevidence clearly supports a multifaceted approach, where multipleactions are introduced to address the full range of personal risk factorsidentified.

Many of the actions listed in Table 3 have beenidentified in the research literature, and furtherdetails supporting these actions are provided in theResearch Supplement.

In addition, a number of actions, which should beconsidered part of standard care for allpatient/residents, can reduce the risk of falls andfall-related injuries. These include:

identifying causes of the risk factor (medical orallied health referral)

ensuring safety (adequate supervision,communicate mobility status to all staff, use ofappropriate walking aid)

ensuring safe and uncluttered environment

keeping call bell and other personal items withinreach

orientating patient/resident to area, and

identifying and addressing individualpatient/residentÕs needs.

ACTIONS FOR MINIMISING PERSONAL RISK FACTORS

17


Indicator/s

Effort associated with standing up from a chair,needing to use arms to push up when standing up

What contributes to the risk? Extended bed rest and diminished activity andexercise

Vitamin D deficiency

Other medical problems such as renal failure andthyroid disease

ActionsActivities and exercise

Encourage safe incidental activities (activities thatare part of daily living) to maintain muscle mass,balance, strength and mobility (eg walking,transferring, dressing, bathing)

Encourage the patient/resident to participate inexercise or activity groups, or an individual exerciseprogram

Develop a routine for physical activity and monitorthe patient/resident progress

Incorporate physical activity goals in thepatient/residentÕs plan for daily care

ReferralRefer patient/resident to medical review to assesspossible medical factors contributing to muscleweakness

If necessary, refer to a physiotherapist,occupational therapist, or activity therapist forassessment and recommended actions

Ensure effective communication of assessmentfindings and action plant to all staff so that there isa consistent approach

Hints & Tips

Ask the patient/residentÕs family and friends toencourage the patient/resident to carry out theactivities

Explore the physical interests and recent activitiesundertaken by the patient/resident before admission

Provide additional assistance when the patient/resident is tired or hurried (eg in a rush to go to thetoilet). Discuss this need for assistance with thepatient/resident and their family and friends

Seek advice from a physiotherapist about safeexercises and activities the patient/resident canperform on their own, or with supervision

For patient/residents limited to bed rest, ask aphysiotherapist about appropriate bed exercises forthe patient/resident

Seek advice from an occupational therapist aboutaids/appliances to increase the patient/residentÕsopportunities for independent activity.

Personal Risk Factor LEG MUSCLE WEAKNESS AND DECONDITIONING

Table 3. Actions for Minimising Personal Risk Factors

Indicator/s

Unsteady/veering during transfers or walking,experiencing near falls

Reaching for walls or other supports whilewalking

Overbalancing, especially when reaching,bending, straightening or turning

What contributes to the risk?Acute health problems such as a chest infection,urinary tract infection or pain can causedeterioration in balance/steadiness

Neurological problems (eg stroke, ParkinsonÕsdisease, peripheral neuropathy)

Musculoskeletal problems (eg arthritis, jointinstability)

Personal Risk Factor POOR BALANCE AND UNSTEADINESS IN WALKING

18

ActionsActivities and exercise

Encourage the patient/resident to participate inexercise or activity groups, or an individualexercise program


Walking aidsConsider introduction of a walking aid, or changein current walking aid

Ensure walking aids are within thepatient/residentÕs reach

Hints & Tips

Seek advice from a physiotherapist about safeexercises and activities the patient/resident canperform on their own or with supervision

Ask the patient/residentÕs family and friends toencourage the patient/resident to carry out theactivities

Determine to what extent the patient/resident can manage their own balance/unsteadiness.If necessary, initiate safety precautions untilphysiotherapy response is in place

Seek a physiotherapistÕs advice about the mostappropriate walking aid, and to provide instructionand practice regarding correct use

Consider strategies to manage falls risk (egincreased supervision) until patient/resident is seenby the physiotherapist

Orientation and supportAlways supervise the patient/resident when theyare walking or making transfers

Introduce strategies to increaseobservation/surveillance

Discuss and reinforce all safety issues withpatient/residents (eg they need supervision whenambulating; they should always use walking aid)

Regularly check with patient/resident that needsare being met, to minimise the patient/residentÕsattempts to transfer or walk independently if it isnot safe to do so

Ask the patient/residentÕs family and friends toalso reinforce safety issues

Modify the environmentEnsure furniture and other hand holds used toassist transfers are suitable (ie stable and sturdy)

19


Indicator/s ActionsInjury minimisation

Consider use of hip protectors

ReferralRefer patient/resident for medical review toassess possible medical factors contributing topoor balance or unsteadiness

If necessary refer the patient/resident to aphysiotherapist, occupational therapist or activitytherapist for assessment and recommendedactions

Hints & Tips

Consider the different types of hip protectorsavailable, including those which incorporatecontinence pads, and adhesive hip protectors

Encourage ongoing wearing of the hip protectorswhen supplied

Ensure effective communication of assessmentfindings and action plan to all staff so that there isa consistent approach

Personal Risk Factor POOR BALANCE AND UNSTEADINESS IN WALKING continued…

20

Indicator/s

New problems such as unsteadiness ordizziness soon after commencing newmedications

Symptoms that might be side effects ofmedications (eg dizziness, low bloodpressure on standing up)

Falls at night

What contributes to the risk?New medications added to an existingmedication regime, or changes to dosage, totreat new health problems

Medications that are associated with high riskof falls, such as antidepressants, sleeping pills,major and minor tranquillisers

ActionsMedication review

Inform doctor if side-effects of medications such asdrowsiness or unsteadiness are observed

Try using non-pharmacological alternatives topsychotropic medications, such as relaxation, use ofmusic, and psychological support to helppatient/resident manage without medication

Try to minimise the number of medications apatient/resident needs to take, especially those thatare "high falls risk" medications

Modify the environmentWhen using medications such as sedatives that affectalertness and increase drowsiness, implementstrategies that minimise risk of falls at night:

reduce clutter in patient/residentÕs room

use night lights

supervise all transfers and mobility overnight

ReferralRefer patient/resident for review by a doctor orpharmacist to assess medication and recommendongoing medication needs

If necessary, refer patient/resident to anoccupational therapist or a psychologist to providealternatives to high falls risk medications such assedatives

Hints & Tips

Obtain medical advice about medication needsand alternatives

Refer to the Tools Supplement for a list of themain falls risk medications

Seek advice from an occupational therapist aboutways to ensure the patient/residentÕs individualenvironment is as safe as possible


More information is provided in the Increased Surveillance section of the Research Supplement

Personal Risk Factor USE OF MORE THAN 4 MEDICATIONS OR MEDICATIONS ASSOCIATED WITH FALLING

Orientation and SupportImplement a prompted toileting program ifappropriate that best matches the patient/residentsaccustomed routine

Discuss with patient/resident and family

Indicator/s

Poor planning/judgement/self-monitoring/safety

Poor short term memory

Poor ability to follow instructions (eg to usewalking aid) or difficulty learning

Agitation

Wandering

Impulsiveness

What contributes to the risk?Changes in the environment can cause or worsen apatient/residentÕs cognition. This may occur onadmission, if there is a room change or a change inroutines

New medications added to an existing medicationregime to treat new health problems

Acute health problems such as a chest infection,urinary tract infection and/or pain

Staff untrained in behaviour management ofpatient/residents with agitation or confusion

Actions Hints & Tips

Personal Risk Factor COGNITIVE IMPAIRMENT (CONFUSION/DELIRIUM/DEMENTIA)

Identify and treatIdentify and treat possible medical conditions thatmay contribute to the cognitive impairment

Monitor and reviewMonitor cognitive status regularly, includingobservation of the patient/residentÕs ability to followinstructions and orientation to ward/unit

Discuss patient/residentÕs cognitive status before oron admission with their family/friends

Monitor the patient/resident for features of delirium(such as acute onset change in cognitive status)

Monitor the patient/residentÕs sleep pattern, and ifnecessary introduce a program to support non-interrupted sleep. Strategies to improve sleeppatterns may include noise reduction strategies,such as vibrating beepers and silent pill crushers,minimisation of nocturnal disturbance by staff, nothaving regimented bedtimes, and review ofmedication schedule

Tools that may be used to monitor cognition are the:

Abbreviated Mental Test Score (AMTS)

Mini Mental State Examination (MMSE)

Examples of these tools are in the Tools Supplement

Identify the patient/residentÕs regular sleeppatterns by asking their family/friends, and ensurethat this information is passed on to all staff athandover

Develop a schedule or routine for the patient/resident (such as eating times, activity times, regulartoileting regime) and be sure to pass this on to allstaff at handover

Discuss patient/residentÕs needs, habits androutines, and likes and dislikes with family/friends,and aim to meet/address these needs and wants

Orientation and supportRepeat orientation and safety instructions on aregular basis, keeping instructions simple andconsistent

Use environmental cues to reinforce orientationand safety instructions

Maintain consistency in procedures, routines andschedules, staff allocation and, where possible,adhere to the patient/residentÕs accustomedhabits and activities of daily living and use of theirown possessions

21


22

Indicator/s Actions Hints & Tips

Consider the different types of hip protectors,including those which incorporate continence pads,and adhesive hip protectors

Encourage ongoing wearing of the hip protectorswhen supplied

Personal Risk Factor COGNITIVE IMPAIRMENT (CONFUSION/DELIRIUM/DEMENTIA) continued…

Orientation and support continued…

Identify some triggers for the agitated, impulsivebehaviour, such as particular medication, time ofday, infection, and loud noise, and try to reducethem

Ensure that patient/resident uses appropriate aids(hearing aids, glasses, walking aids) and that theyare in correct working order

Consider options for increasingobservation/surveillance

Increase surveillance through more frequentobservation, moving the patient/resident to anarea of higher visibility, using a bed alarm, andfamily/friends providing additional assistance withobservation. Use sitters for high surveillance ward

More information is provided in the Increased Surveillance section of the Research Supplement

Injury minimisationConsider use of hip protectors


ReferralRefer patient/resident for a medical review toexclude acute delirium or other reversible causesof cognitive impairment

If necessary, refer patient/resident to aphysiotherapist to determine whether gait aids willbe able to be used appropriately and correctly

If necessary, refer patient/resident to anoccupational therapist to assist with behaviourmanagement and to develop a plan to maximiseorientation, awareness and function.

Indicator/s

Light-headedness or unsteadiness when movingfrom lying to sitting, or sitting to standing

What contributes to the risk?Bed rest or prolonged periods of inactivity

Inadequate time to adjust to changes in position (egmoving too quickly from lying to standing)

Some medications (eg major tranquillisers,antidepressants, diuretics)

Some acute and chronic illnesses (eg ParkinsonÕsdisease, diabetes, heart failure)

Dehydration

ActionsIdentify and treat

Identify and treat acute reversible contributoryfactors

Monitor and reviewMonitor and record blood pressure, both lying andstanding (at 1 minute and 2 minutes)

Supervise changes of position

Encourage patient/resident to sit up from lying,and to stand up from sitting, slowly, and to wait ashort time before walking

Determine indications and appropriateness ofelastic compression stockings

Orientation and SupportEncourage increased fluid intake by providingdrinks at regular intervals

ReferralRefer patient/resident for medical review toassess and recommend ongoing management forthe postural hypotension

Hints & Tips

If there is a drop in systolic blood pressure>20mmHg or diastolic blood pressure >10mmHgseek medical review

Discuss strategies with the patient/residentÕsfamily/friends and ask them to reinforce these with patient/residents

Ensure that elastic compression stockings fitproperly, and do not have any creases.Physiotherapists or nursing staff are oftenresponsible for supply and fitting of elasticcompression stockings


Personal Risk Factor POSTURAL (ORTHOSTATIC) HYPOTENSION

23


Indicator/s

Frequency of need for toileting

Poor fluid intake

Strong odour of urine

Urinary or bowel accidents

History of nocturia

What contributes to the risk?The patient/resident may be physically unable toget to the toilet in time, or to unfasten garmentsquickly enough (due to, for example, a newhealth problem such as a stroke or hip fracture)

Lack of orientation or confusion about locationof the toilet

Some medications can increase the risk ofincontinence (eg diuretics)

Acute health problems such as a chest infection,urinary tract infection and/or pain

Constipation

Personal Risk Factor INCONTINENCE

24



Monitor and reviewIdentify possible causes of incontinence using thefollowing techniques:

monitor fluid intake and bladder and bowel activity

identify medications such as anti-cholinergicmedications, sedatives, narcotics, and diuretics,which may contribute to the continence problem(including review of timing and dosage)

look for signs of urinary tract infection and treat ifidentified

Review timing and amount of caffeine intake

Ensure adequate hydration by providing drinks atregular intervals

Toileting programImplement a prompted voiding (regular toileting)program that best matches the patient/residentÕsaccustomed routine

Respond to requests for toileting promptly

If possible, locate the patient/resident close to thetoilet

Hints & Tips

Use a continence chart

Discuss with the medical staff or pharmacist



Ensure other staff are aware of patient/residentÕsneeds if you are going to be away or are involved inother work for a period of time

Indicator/s

Personal Risk Factor INCONTINENCE continued…

25


ActionsOptimise function

Ensure patient/resident is wearing suitable clotheswithout fasteners, or with fasteners that are easyto undo (eg pants with an elastic waist)

Encourage patient/resident to participate inexercise or activity groups, or individual exerciseprogram

Provision of appropriate continence aids (eg commode by bed, non-spill urinals, pads etc)




ReferralRefer patient/resident for a medical review toassess and recommend ongoing management forincontinence

If necessary, refer to a continence specialist forcomprehensive assessment and management

Hints & Tips

26

Indicator/sVision

Inability to see detail in objects

Not wanting to, or inability to, read or watchtelevision

Spilling drinks

Bumping into objects

SomatosensoryPoor skin condition

Cuts or bruises on feet

Lack of feeling in feet

Pressure areas/ulcers

Vestibular (inner ear)Reports of dizziness

HearingLeaning forward when listening

Needing to have things repeated

Speaking loudly

Having radio or TV volume loud

What contributes to the risk?Adjusting to a new environment is more difficultif there is reduced sensory input

Sensory loss can be due to medical problemsaffecting the sensory function, or by inadequatecondition or use of aids to improve sensoryinput



Monitor and reviewIdentify change in sensory status over thepreceding months, and how long since sensorystatus has been investigated

Monitor skin and nail condition for people withsomatosensory loss (eg diabetic neuropathy)

Investigate the cause if the patient/residentreports dizziness, as some common causes ofdizziness are easily treatable by medical or alliedhealth staff (eg benign paroxysmal positional vertigo)

Modify the environmentMaintain a safe environment free of physicalhazards

Ensure appropriate signage, particularly leading tothe toilet area

Appropriate night lighting

Minimise glare

Orientation and supportEnsure that patient/residents who need them arewearing their glasses, that they are in optimal workingorder (eg clean) and that they are the correctprescription (eg strength may need to be upgraded)

Ensure that patient/residents who need them arewearing hearing aids, that they are in optimal workingorder (eg batteries working) and suit the level ofimpairment

Hints & Tips

Personal Risk Factor SENSORY LOSS


Seek advice and treatment from a podiatrist toreduce problems associated with sensory loss

Seek advice from an occupational therapist aboutways to ensure the patient/residentÕs individualenvironment is as safe as possible

Seek advice from an occupational therapist toassist in checking sensory aids, and providingaids/supports to minimise functional impact ofsensory loss

27


Indicator/s Actions Hints & Tips

Personal Risk Factor SENSORY LOSS continued…

Referral

Refer patient/resident for medical review toassess and recommend ongoing management forthe sensory loss

Refer patient/resident to specialist for detailedassessment of sensory system/s (eg optometristor ophthalmologist for vision problems; podiatristfor somatosensory problems)


Indicator/s

Limping due to pain or poor condition of feet

Reddened areas on the feet (eg over abunion)

Poor condition of skin around toes

Poor condition of toe nails

Inappropriate footwear:

loose fitting

open backed

worn sole/heel

poor or no fastenings

high heel

slippers

What contributes to the risk?Wearing inappropriate footwear, such asslippers

Personal Risk Factor POOR CONDITION OF FEET/INAPPROPRIATE FOOTWEAR

28



Monitor and reviewReview footwear and condition of feet onadmission

Provide an information brochure on appropriatefootwear to patient/resident and theirfamily/friends

Action purchase and repairs as indicated

ReferralRefer patient/resident for medical review or topodiatrist to assess and recommend ongoingmanagement of foot problems and appropriatefootwear

Hints & Tips

Explain the importance of good footwear to thepatient/resident and their family/friends


29


Indicator/s

Acknowledges being afraid of falling when asked

Reluctance to walk

Reaches for additional support when walking ortransferring

Anxious about walking or transferring

Near falls or previous falls

What contributes to the risk?Medical condition affecting balance and mobility,such as stroke or hip fracture

Adjusting to a new environment

Inadequate sensory input (eg poor lighting)

Environmental hazards


Personal Risk Factor LOSS OF CONFIDENCE/FEAR OF FALLING

Monitor and reviewMonitor all aspects of ambulation, transferring andrelated activity, and provide encouragement andsupport as required

Activity and exerciseEncourage patient/resident to participate inexercise or activity groups, or individual exerciseprogram


Walking aidsConsider use of walking aid or change in currentwalking aid

Ensure walking aids are within thepatient/residentÕs reach

ReferralRefer patient/resident for medical review toassess and recommend ongoing management forthe loss of confidence

Refer patient/resident for physiotherapy,occupational therapy, and/or psychologist supportto assess and recommend ongoing management

Seek advice from a physiotherapist, who willidentify whether the loss of confidence isappropriate to the patient/residentÕs level of balance

Discuss with family/friends and ask them toreinforce with patient/residents the importance ofsafe walking and activity


Ask the patient/residentÕs family and friends toencourage the patient/resident to do the safeincidental activities

Seek advice of a physiotherapist about the mostappropriate walking aid, and to provide instructionand practice regarding correct use


30

Indicator/s

Recent weight loss

Low Body Mass Index

Poor oral intake

What contributes to the risk?Different meals to those the patient/resident isused to

Insufficient time or assistance provided toensure the patient/resident is able tocomplete meal prior to dishes being collected

Acute and chronic medical problems canreduce the effectiveness of swallowing

Inadequate dietary calcium, and lack ofexposure to sunlight over a prolonged periodof time can result in increased risk of bonefracture


Personal Risk Factor POOR NUTRITIONAL STATUS

Identify and treatIdentify and treat acute reversible contributoryfactors

Monitor and reviewMonitor patient/residentÕs food intake

Review patient/residentÕs diet for adequatenutritional content

If food intake (amount) is poor, despite adequatefood being provided, determine factorscontributing to this

If eating is associated with coughing or chokingcheck that the patient/residentÕs swallowingmechanism is intact

Identify presence of osteoporosis andosteomalacia (inadequate mineral deposit in bone,related to vitamin D deficiency)

Talk to the patient/resident and their family/friendsabout the patient/residentÕs usual and preferred diet

Some factors contributing to reduced oral intakeinclude depression, food not liked, culturallyinappropriate food, reduced sense of smell, or illfitting dentures

Seek advice from a doctor and speech pathologist ifswallowing difficulties are apparent

Discuss with the doctor about the need for tests forlow levels of vitamin D or osteoporosis

If osteoporosis or osteomalacia is identified consider:

vitamin D and calcium supplementation

hip protectors

options for sunlight exposure (especially inresidential care)

ReferralRefer patient/resident for medical or dieticianreview to assess and recommend ongoingmanagement of oral intake problems orosteoporosis/osteomalacia

Ensure effective communication of assessmentfindings and action plan to all staff, so that thereis a consistent approach

Orientation and SupportProvide assistance with eating

Indicator/s

History of falls, either documented or verbal

Personal Risk Factor HISTORY OF PREVIOUS FALLS

31


Actions Hints & TipsMonitor and review

Review factors that contributed to previous fall/s

Address the risk factors contributing to previousfall/s

Use the information from previous incidents toimplement appropriate falls minimisation strategies

Record relevant falls history in the medicalrecord, and on a falls incident report if the falloccurred during the current admission

May need to obtain additional information fromfamily

Follow the Guidelines to assist the developmentof the falls minimisation action plan

Table 4. Individual Environmental Risk Factors and Action for Minimising Risk

Individual Environmental Risk Factor INAPPROPRIATE BED HEIGHTWhat contributes to the risk?Bed heights are often adjusted for assessments,nursing or domestic activities. If they are left at anincorrect height, this may increase the risk ofpatient/residents falling


If the height of a bed is adjusted during anactivity, return it to the correct height afterwards

The bed should be at a height which allowsease of standing for the patient/resident. Thepatient/residentÕs feet should be in contact withthe ground before standing

Seek advice from an occupational therapist orphysiotherapist about optimal bed height for anindividual patient/resident

BED BRAKES NOT ON OR BROKENWhat contributes to the risk?Bed brakes are often unlocked, and the bed moved,during domestic activities

Ensure bed brakes are on/locked after the bed ismoved

Ensure that regular monitoring and maintenance isundertaken on all beds

CHAIR HEIGHT/TYPEWhat contributes to the risk?Different height chairs can affect the safety and easeof standing up and transfers

Ensure that the patient/resident has a chair that isthe appropriate height and type for them

As a general rule, appropriate seating shouldresult in a 90¡ hip and knee angle, and thepatient/residentÕs feet should be in contact withthe ground

Seek advice from an occupational therapist orphysiotherapist about optimal chair height for anindividual patient/resident32

ACTIONS FOR MINIMISING INDIVIDUAL ENVIRONMENTAL RISK FACTORS

Table 4 outlines actions to minimise the impact of individualenvironmental risk factors for falls that can form part of apatient/residentÕs Action List.

Many of the actions have been identified in the research literature, and further details supportingthese actions are provided in the Research Supplement.

This Table allows easy identification of actions to address individual environmental risk factors forfalls. A multifaceted approach, where actions are introduced to address each of the identified individualenvironmental falls risk factors, is likely to be most effective.

An Individual Environmental Audit should be carried out to identify prevailing risk factors for individualpatient/residents. Examples of Audit Tools are provided in the Tools Supplement.

33


Individual Environmental Risk Factor CALL BELL OUT OF REACHWhat contributes to the risk?Call bells are often moved for assessments, nursingor domestic activities


Ensure that the call bell or an alternative means ofseeking attention is within the patient/residentÕsreach at all times

Discuss with family/friends and ask them to beaware that the call bell should be in reach at alltimes

WALKING AIDS OUT OF REACHWhat contributes to the risk?Patient/residents who need a walking aid may try tostand and walk without the walking aid if it is notwithin reach

In consultation with the patient/resident, decidewhere the walking aid will be located within theirroom

Position the aid so that the handle can begrasped easily (eg upright)

Communicate this information to all staff

WHEELIE FRAME/WHEELCHAIRBRAKES BROKEN OR NOT USEDPROPERLY What contributes to the risk?Moving parts on equipment, such as brakes onwheelie frames or wheelchairs, can become worn orbroken, making them unsafe

Ensure that wheelie frames, wheelchair brakesand other similar equipment are regularly checkedand maintained

Ensure your organisation has processes forchecking of equipment safety to occur regularly

Seek advice from physiotherapists oroccupational therapists, as they often have therole of supplying walking frames andwheelchairs, and organisingrepairs/replacements if required

WALKING AIDS NOT IN GOODCONDITIONWhat contributes to the risk?With prolonged use, components of walking aidscan become worn (eg stoppers) or broken

Ensure that regular checking and maintenance isundertaken on all walking aids

Ensure your organisation has processes forchecking safety of walking aids regularly

Seek advice from physiotherapists oroccupational therapists, as they often have therole of supplying walking aids andrepairs/replacements if required

34

Individual Environmental Risk Factor WALKING AIDS NOT USEDPROPERLYWhat contributes to the risk?If a walking aid is used incorrectly (eg a stick in thewrong hand or wrong height or incorrect sequenceof stepping and moving the walking aid) it can resultin increased risk of falling


Monitor patient/residentÕs use of the walking aid,compared to mobility instructions

Provide regular feedback to improve appropriateuse of the walking aids

Position IV drip stands that are in use so that theyare out of general walkway areas

Seek advice from physiotherapists oroccupational therapists about correct use ofwalking aids


IV DRIP STANDS, POWER CORDS,ETC NOT POSITIONED PROPERLYWhat contributes to the risk?Objects like IV drip stands and power cords arepotential tripping hazards

Store IV drip stands that are not in use away fromareas accessed by patient/residents

Avoid running power cords across generalwalkway areas and secure other cords flush tothe floor

Identify areas on the ward/unit for storage ofequipment and communicate this to all staff

Use an extension lead to provide extra length toallow running a power cord along a wall ratherthan across walkways

SLIPPERY SURFACESWhat contributes to the risk?Regular cleaning/polishing of floors in wards/unitsmay result in slippery surfaces

Identify areas with slippery surfaces, both whenwet and dry, explore options for minimisingslipperiness, and work towards implementation

Clearly mark wet areas due to cleaning, and ensurealternative paths are available for patient/residents

Remind all staff that any spills must be cleaned uppromptly

Report the need for an upgrade of floor surfaces

Seek advice from occupational therapists or theOccupational Health and Safety representativeabout floor surface modifications to increasesafety

LOOSE FLOOR COVERINGS eg RUGS What contributes to the risk?Loose floor coverings can turn up at the edges andbe a tripping risk

Avoid use of loose floor covering such as rugs

If loose floor coverings are used ensure that theyare non slip, and that all edges are stuck downproperly

Seek advice from occupational therapists or theOccupational Health and Safety representativeabout safety associated with floor coverings

35


Individual Environmental Risk Factor CLUTTERWhat contributes to the risk?There is often a need for personal items, mobilityand other aids, and medical equipment to belocated within the patient/residents individualbedroom area


Review need for all items contributing to clutter

Discuss with patient/resident/family about thebest location for items to minimise clutter andmaximise availability

Modify the environment to provide for improvedplacement and storage of personal possessionsand equipment (eg shelving)


INADEQUATE LIGHTING (POORLIGHTING, LACK OF NIGHT LIGHTS,EXCESSIVE SUN GLARE)What contributes to the risk?Many patient/residents have visual problems that aremade worse if lighting conditions are not optimal

Review lighting available at different times of dayand night, and the vision needs ofpatient/residents

Ensure appropriate opening/closing of curtains tominimise effect of sun glare

Replace existing light globes with higher wattageglobes

Replace incandescent lights with fluorescent lightswhich provide greater illumination

Ensure available lights are in working order andswitched on when required

Enhance available light through use of non-reflective light colours on walls

Night lights with movement sensor can beuseful for patient/residents needing to get upduring the night

Seek advice from occupational therapists aboutlighting options

INADEQUATE RAILS/SUPPORTS INBATHROOM AND TOILETWhat contributes to the risk?Bathrooms and toilets are common locations for falls

Review patient/resident needs withinbathroom/toilet

Consider long term needs for permanentchanges, such as fitting of rails to bathroom andtoilet

Temporary aids such as an over toilet seat canprovide additional support in some instances

Seek advice from occupational therapists aboutrails and supports/aids in the bathroom/toilet

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Individual Environmental Risk Factor RESTRAINTS/COTSIDES IN USERestraint use is Òthe intentional restriction of apersonÕs voluntary movement or behaviour by theuse of any manual, physical, or mechanical device[or medications] that restrict freedom of movementÉor where part of the intended pharmacologic effectof a drug is to sedate a person for convenience ordisciplinary purposesÓ

Restraint can include any of the following:

cot-sides

vests

waist restraints

wrist/ankle restraints

other mechanical restraints, such as tables lockedonto chairs

medications, which are used with a primarypurpose of limiting a personÕs movement andactivity

What contributes to the riskRestraints can increase a patient/residents agitationand increase likelihood of getting up unassisted

Patient/residents climbing over cotsides will fall froma greater height, increasing risk of serious injuries


Adhere to professional standards and organisationprotocols

Seek a team review of the issue

Investigate causes of agitation, wandering, orother behaviour warranting consideration ofrestraints. Treat reversible causes (eg delirium)

Investigate alternatives to restraint use such as:

Strategies to increase surveillance of thepatient/resident (eg move to higher observationarea, use of bed alarm)

Use of very low (adjustable) beds

Encouraging increased mobility (withsupervision/assistance as required)

Reducing environment noise and activity

Providing repeated reality orientation if required

Investigate and treat falls and fall-related injury riskfactors

Incorporate other injury minimisation approaches(eg hip protectors)

Discuss the patient/residentÕs routines prior toadmission (timing of meals, rest, sleep, toileting)and where possible accommodate these

37


Step 4: Respond to a falls incident appropriately



Action List for minimising falls and falls-related injuries


Falls Risk Screen

YESYES

YESYES

NONO




On Admission














Definition The appropriate response to a falls incident includes caring for the patient/resident and ensuring that theincident is reported and documented.

Use the standard definition of a fall developed by your organisation to determine whether an incident is to beregarded as a fall. An example definition is included in the Introduction section of this document.

Other definitions are provided in the Research Supplement.

Patient/resident centred tasks for Step 4a) At a minimum, an appropriate post falls response

should include:

responding to the patient/residentÕs immediateneeds for care:

examining the patient/resident for injuries,especially head or joint trauma and fractureand minimise any adverse effects from thefall

if head injury is suspected, institutingneurological observations

moving the patient/resident only after fullyassessing the individualÕs situation.Addressing later care needs when theincident situation has been stabilised.

using a consistent and standard definition of aÔfallÕ as adopted by your organisation

reporting the falls incident, using the processand documents defined by your organisation.

b) Document the fall in the patient/residentÕspermanent file/medical record/residential care file,either include a copy of the incident report oradd information from the incident report to thefile/record.

c) Review the patient/residentÕs risk assessmentand Action List in the plan for daily care, andmake changes to reduce the risk of another fall.Steps 1, 2 and 3 of the process model mayneed to be repeated.

Organisational tasks for Step 4a) Develop a protocol for care of patients/residents

after a fall has occurred. Ensure staff are awareof and understand the protocol.

b) Develop a stand-alone Falls IncidentReport template or add a falls sectionto your organisationÕs existing incidentreport. See Tools Supplement forsamples.

c) Provide staff education on the purpose ofincident reporting and training in the use of theincident report.

d) Audit the use of the incident report forcompliance with relevant policy.



Respond to a falls incident appropriately.

Level of evidence: Consensus Opinion [18].

38

e) Assign the analysis of falls incident data to aclinical staff member on a ward or to adesignated person in a facility, such as a ClinicalRisk Manager. An example Excel file template forentering data from falls incident forms,calculating rates of falls/1000 beddays, and examples of graphs forreporting falls data is included in theTools Supplement.

f) Ensure incident data is analysed regularly todefine the scope, common causes andcomplications arising from falls.

g) Provide clinically meaningful feedback on fallsand fall-related injury data to wards or units, on aregular and scheduled basis.

h) Ensure data is analysed at ward-level. Findingsfrom periodic reviews can help inform strategiesto minimise risk and reduce the rate of falls. Ahigh level of falls may indicate the need for rootcause analysis.

Note:

An incident report should include sufficient detailabout the fall, circumstances surrounding the fall andconsequences of the fall to provide a clearunderstanding of factors contributing to the falland/or injury if sustained. As a minimum, thefollowing information should be recorded in a FallsIncident Report or other standard documentation:

Patient/resident identification — minimum data set

Time of fall

Whether the fall was witnessed

Circumstances of the fall:location

activity being performed by the patient/resident atthe time of the incident, eg transfer details

relevant information about clothing, footwear,glasses and gait aids used at the time of the fall

environmental conditions, eg floor, lighting,clutter

Type of fall, eg slip, bumping into/falling on an object

Whether the patient/resident was injured and, if so,the nature and severity of the fall-related injury

The patient/residentÕs perception of the incident,including description of any preceding sensations orsymptoms

Action taken following the fall and or fall-relatedinjury

Signature of the person who observed and/orreported the fall

Designated process for:submitting the report

entering the report into the patient/residentÕsdocumentation.

If a death results from a fall in a Victorianhospital an investigation by the StateCoroner will be performed. An InvestigationStandard published by the Victorian StateCoronerÕs Office outlines the details required for thisinvestigation (see Tools Supplement).

These details outline the main features required bythe CoronerÕs Investigation Standard. In addition, the CoronerÕs Investigations Standard will review theorganisations policies on falls risk screening, fallsprevention and falls management.

An organisationÕs falls rate may increase in the shortterm when its management:

introduces falls and fall-related injury riskminimisation activities or programs

introduces a new definition of a fall, or increasesawareness of the definition, or of reportingrequirements, or

implements these Guidelines and process model.

Rationale for Step 4Some falls can cause injuries that may not beapparent at the time of the fall. All falls should bereported, even if injuries are not apparent, andpatient/residents should be observed after thefall. This is particularly important in cases wherethere is a possible head injury [19].

Information about factors that contribute to fallson a ward or unit can be used to inform targetedactivities to reduce future falls [20].

Using a standard definition of a ÔfallÕ [1, 21] enables:

shared understanding of the focus anddimensions of what is described (what isincluded and what is not), and

the grouping of falls incident data forcomparison and trend analysis.

Good quality falls data and meaningful analysiscan provide evidence to guide responses withinthe organisation and elsewhere [20]. Data hasimplications for:

developing management strategies thatbenefit the patient/resident and theorganisation, and

meeting legal, regulatory and insurancerequirements about recording adverseevents.

39


Differences in implementing Step 4across the three settingsAcute and Sub-acute Care

In these settings there are often pre-determinedprocesses in place to collect and analyse fallsincident data and to provide feedback to staffand management. Ensure that falls data isincluded and talk to Risk Management/Qualitypersonnel to determine appropriate methods andformats.

Residential Care Given the nature of staffing in residential caresettings, it is more likely that a non-professionalcaregiver may witness a falls incident.Appropriate support from professional staff isimportant.

Capacity for analysing falls incident data may belimited.

40

The Process Model & Quality Improvement

Pro

cess

Mod

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Q

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vem

ent01

Given the magnitude of the problem of falls and fall-related injuries in residential care and hospitalsettings, and the increasing evidence that many fallscan be prevented, there is a need for a systematic,organisation-wide approach to falls and fall-relatedinjury risk minimisation in these settings. A comprehensive approach would:

Encourage a culture of safety and quality at alllevels of the organisation

Support staff to work with patient/residents toprovide safe, effective and appropriate care

Provide targeted continuing education for staff toupdate and improve patient/resident care

Identify and develop strategies to minimiseindividual and environmental falls risk

Collect data on falls and fall-related injuries thatoccur within the organisation to contribute toimprovements in the care delivered topatients/residents

YESYES





Falls Risk Screen

YESYES

YESYES

NONO




On Admission















Falls Risk Screen

YESYES

YESYES

NONO

Tools Steps in minimising the risk of falls and and fall-related injuries



On Admission


Ward/Unit LevelFalls Incident Data







Were the appropriate actions taken?









QI CYCLECollate, monitor, analyse, and feedbackfalls incident data. Feedback to staff/management on data.

Upgrade tools and process in responseto findings.

Organisation meets qualityimprovement requirements


The diagram illustrates the process model within aquality improvement framework that includesongoing monitoring of performance. This mayencompass collecting a range of indicators, andreviewing falls risk reduction activities to improvepatient/resident care.

Implementing all the components of the model should:reduce falls and fall-related injuries over time

address the needs of individual patient/clients

ensure a consistent approach to minimising the risk of falls and fall-related injuries, and

embed these tasks within the organisationÕs systems for monitoring and evaluating quality of care.

41

Reference list

Ref

eren

ce li

st

041. NHMRC. A guide to the development,

implementation and evaluation of clinicalguidelines. Canberra: National Health andMedical Research Council (NHMRC); 1998.

2. Tinetti M, Baker D, Dutcher J, Vincent J,Rozett R. Reducing the risk of falls amongolder adults in the community. Berkeley, CA.:Peacable Kingdom Press.; 1997.

3. Perell KL, Nelson A, Goldman RL, Luther SL,Prieto-Lewis N, Rubenstein LZ. Fall riskassessment measures: an analytic review. JGerontol A Biol Sci Med Sci2001;56(12):M761-6.

4. Hoidrup S, Sorensen TI, Gronbaek M, SchrollM. Incidence and characteristics of fallsleading to hospital treatment: a one-yearpopulation surveillance study of the Danishpopulation aged 45 years and over. Scand JPublic Health 2003;31(1):24-30.

5. Bueno-Cavanillas A, Padilla-Ruiz F, Jimenez-Moleon JJ, Peinado-Alonso CA, Galvez-Vargas R. Risk factors in falls among theelderly according to extrinsic and intrinsicprecipitating causes. Eur J Epidemiol2000;16(9):849-59.

6. Friedman SM, Denman MD, Williamson J.Increased fall rates in nursing home residentsfollowing relocation to a new facility. Journalof American Geriatrics Society1995;43(11):1237-42.

7. Halfon P, Eggli Y, Van Melle G, Vagnair A.Risk of falls for hospitalized patients: apredictive model based on routinely availabledata. J Clin Epidemiol 2001;54(12):1258-66.

8. Vassallo M, Sharma JC, Briggs RS, Allen SC.Characteristics of early fallers on elderlypatient rehabilitation wards. Age Ageing2003;32(3):338-42.

9. Haines TP, Bennell KL, Osborne RH, Hill KD.Effectiveness of targeted falls preventionprogramme in subacute hospital setting:randomised controlled trial. British MedicalJournal 2004;328(7441):676.

10. Jensen J, Lundin-Olsson L, Nyberg L,Gustafson Y. Fall and injury prevention inolder people living in residential care facilities.A cluster randomized trial. Ann Intern Med2002;136(10):733-41.

11. Ray WA, Taylor JA, Meador KG, Thapa PB,Brown AK, Kalihara HK, et al. A randomisedtrial of a consultation service to reduce fallsin nursing homes. Journal of AmericanMedical Association 1997;278(7):557-62.

12. Salgado R, Lord S, Packer J, Erlich F.Factors associated with falling in elderlyhospital patients. Gerontology 1994;40:325-31.

13. Kallin K, Lundin-Olsson L, Jensen J, NybergL, Gustafson Y. Predisposing andprecipitating factors for falls among olderpeople in residential care. Public Health2002;116(5):263-71.

14. Lipsitz L, Jonsson P, Kelley M, Koestner J.Causes and correlates of recurrent falls inambulatory frail elderly. Journal ofGerontology 1991;46:114-22.

15. Cumming R, Thomas M, Szonyi G, SalkeldG, O’Neill E, Westbury C, et al. Home visitsby an occupational therapist for assessmentand modification of environmental hazards: Arandomised controlled trial. Journal of theAmerican Geriatrics Society 1999;47:1397-1402.

16. Gillespie L, Gillespie W, Robertson M, LambS, Cumming R, Rowe B. Interventions forpreventing falls in elderly people. CochraneDatabase Syst Rev 2003;4:CD000340.

17. Queensland Health. Restraint and protectiveassistance guidelines. Brisbane; 2003.

18. Lord S, Sherrington C, Menz H. Falls in olderpeople: Risk factors and strategies forprevention. Cambridge, UK: CambridgeUniversity Press; 2001.

19. Nagurney JT, Borczuk P, Thomas SH. Elderlypatients with closed head trauma after a fall:mechanisms and outcomes. J Emerg Med1998;16(5):709-13.

20. Gowdy M, Godfrey S. Using tools to assessand prevent inpatient falls. Jt Comm J QualSaf 2003;29(7):363-8.

21. Cumming R, Kelsey J, Nevitt M.Methodologic issues in the study of frequentand recurrent health problems: falls in theelderly. Annals of epidemiology 1990;1:49-56.

42

Activities of Daily LivingActivities necessary for everyday function, such asdressing, bathing, and self care

Acute (illness)Short and severe

Acute (setting)Referring to a hospital for management of acuteillness (does not include rehabilitation and GeriatricEvaluation and Management [GEM] units orhospitals)

Adverse effects (from a fall)Negative consequences (from a fall) such as injury orloss of confidence

Adverse eventsUnplanned events which have potential to causeharm, such as falls or medication errors

AgitatedRestless, on edge

AgitationA state of increased restlessness and limitedcooperation

AmbulationWalking

Anti-cholinergic medicationsMedications which block the passage of impulsesthrough the parasympathetic nerves (eg tricyclicantidepressant treatment for incontinence)

AntidepressantsMedications given to treat depression

AnxietyA state of increased stress, nervousness or worry

Bed alarmA device that signals that the occupant of the bed isdeparting/has departed from the bed

Benign Paroxysmal Positional VertigoA medical condition affecting the inner ear, whichcauses dizziness, unsteadiness, and can increaserisk of falling

Body Mass Index (BMI)A measurement of body fat calculated from heightand weight

BunionsAbnormal growth of bone at the base of the first toe,which can result in deformity in the alignment of thefirst toe

Calcium supplementationDietary addition of a mineral essential for bonedevelopment, maintenance and repair

CallusesHardened, thickened layer of skin caused byexcessive pressure or friction (such as poor fittingshoes)

CataractsChanges in the lens of the eye which can impaireye-sight

Cerebellar strokeReferring to a circulatory incident in which damageoccurs within the cerebellum, a part of the brainattached to the brainstem. The cerebellum isimportant for balance and coordination

Chronic (disease / illness)Persisting over the long term

Cognitive impairmentInterference of the ability of the brain to performfunctions requiring conscious thought, such asproblem solving and planning

Cognitive statusAbility to think, plan and remember

Glossary of terms

43


ConfusionState of being disoriented to the time, place (orlocation), and the people around them

Continence chartA record that shows the pattern of an individualÕslevel of control over the passage of urine/micturition

Continence padsAids (pads) worn in the underwear which help toavoid incontinence accidents

Continuous Quality ImprovementA cyclical, ongoing, organisation-wide process ofmonitoring and evaluating all aspects of theinstitution’s activities in order to continuouslyimprove them

Deconditioning Generalised muscle weakness and limitedendurance associated with lack of use (eg bed rest)

DeliriumAcute deterioration in brain function with associatedbehavioural changes due to factors including drugtoxicity, infection and metabolic problems. Delirium isreversible if the cause is identified and treated

DementiaA classification given to a group of diseases thatinvolve chronic degeneration of the brain andassociated functions which is due to various causes

DepressionA state of undue sadness, and lack of interest inrelevant personal events

DeteriorationWorsening status

Detrusor muscle control Referring to conscious movement of the detrusorurinae muscles that coat the urinary bladder andcontrol passing of urine

DiabetesUsually used in reference to the metabolic disease ofDiabetes Mellitus, which is characterised by highsugar levels, excessive urine production, andexcessive thirst. Can be controlled with diet, oralmedications or may require use of insulin

Diabetic neuropathyLoss of sensation caused by deterioration in nervefunction associated with the disease DiabetesMellitus

DiureticsMedications that increase the production of urine

Fear of fallingBeing afraid that a fall could occur during routineactivities

Flattened transverse archStretching of ligaments under the foot that result inloss of the side to side curve under the foot andresults in pain under the foot on walking

Functional statusAbility of an individual on one or more activities (egwalking, dressing)

Haematalogical conditionRelated to disorders of the blood

Hip protectorA protective device that may be worn to minimisedamage to the hip should a fall occur

Impulsive behaviourSpontaneous response to stimuli that arenÕt modifiedby insight or rational thought

IncontinenceLoss of control over when urine is passed

Key Performance Indicators (KPIs)A set of standards that are essential to thesuccessful performance of an activity

Macular degenerationDeterioration in the health of a specific tissue in theeye that interferes with clarity in the central field ofvision

Muscle massThe size and density of the body of a muscle

NarcoticsMedications that diminish conscious awareness,often used for pain control

Neurological dysfunctionProblems associated with disorders of the nervoussystem, such as stroke and ParkinsonÕs disease (egdifficulty with movement, speech, or swallowing)

NocturiaVoiding urine at night

Non-pharmacologicalReferring to things or actions that are notdrug/medication related

Nutritional statusThe health of the body measured by nourishmentfactors or dietary intake

Oncology conditionA condition related to cancer/a tumour

OsteomalaciaSoftening of the bones associated with low levels ofVitamin D

OsteoporosisWeakening of the bone substance and structure to alevel where the risk of fracture is high

Parkinson’s diseaseA degenerative condition of the nervous systemcharacterised by difficulty initiating movement,slowness of movements, tremor, and stiffness in themuscles and body

44

Plan of daily careCare activities or services to be provided for apatient/residents over a 24 hour span

PolioA viral infection affecting cells in the spinal cord,affecting muscle control. Although the disease isalmost eradicated in terms of new cases in westerncountries, many people live with the long termeffects from the polio epidemic of the 1950Õs

Postural hypotensionA drop of 20mmHg or more in systolic bloodpressure, or 10mmHg or more in diastolic bloodpressure, when moving from lying to standing

Prompted voiding programRegular reminding/asking a patient/resident aboutthe need for toileting

Psychotropic medicationMedications that exert an effect on the mind

Quality improvementUpgrade in overall standard measured by keyindicators

Quality Improvement CycleThe repeated, ongoing cycle of Continuous QualityImprovement within an organisation

RestraintAny method where a personÕs voluntary movementor behaviour is restricted physically (eg posey vests;cotsides) or by the use of medications Òwhere partof the intended effect is to sedate a person forconvenience or disciplinary purposesÓ [17]

Root cause analysisDetailed analysis of the circumstances and factorscontributing to an adverse event such as a fall, andtaking actions to prevent the event occurring again

SedativesMedications that have the effect of enhancing rest orsleep. These medications are also associated withincreased risk of falling

Sensory lossReduced function in any of the sensory systems(eye-sight, hearing, sensation in the limbs, and innerear function)

Sensory neural deafnessInability of the individual to accurately interpretsounds due to malfunction of nerve endings in theear or the brain that are responsible for transmittingand interpreting sound messages

Somatosensory (loss)Referring to loss of feeling from the skin and joints inthe limbs (often affecting the feet)

StrokeA heart and/or circulatory incident resulting indamage to the brain and/or spinal cord and affectingthe tissues they control

Sub-acute (illness)Less severe and often of longer duration than acute

Sub-acute (hospital/setting)Rehabilitation or Geriatric Evaluation andManagement (GEM) unit or hospital

VestibularRelating to one of the important senses with a keyrole in balance. Located in the inner ear

Vestibular toxicityA condition related to loss of vestibular functionbilaterally due to an adverse reaction to specificmedication

Vitamin D supplementationAddition to normal diet of a fat soluble vitamin thatassists in the building, maintenance and repair ofbone

VoidingPassage of urine from the urinary bladder throughthe urinary tract to the exterior of the body; orfaeces through the bowel to the exterior of the body.May be voluntary or involuntary.

Walking aidA tool that can improve stability for people withreduced balance or risk of falling (eg a four prongstick or walking frame)

45

Acknowledgments

Ack

now

led

gmen

ts

The Victorian Quality Council thanks all those who contributed tothe Development of these GuidelinesProject team

Dr Keith Hill (Project Manager) - NationalAgeing Research Institute

Ms Marcia Fearn (Project Officer) - NationalAgeing Research Institute

Ms Joan Nankervis - National AgeingResearch Institute

Ms Mary Lancaster - Word Design InteractivePty Ltd

Dr Joanne Wilkinson - Word DesignInteractive Pty Ltd

Ms Bernadette Hally - Word DesignInteractive Pty Ltd

Expert Advisory Group for support andexpertise

Dr Caroline Brand - Clinical Epidemiology &Health Service Evaluation Unit, MelbourneHealth

Ms Karen Bull - Falls Prevention Service,Peninsula Health (and Literature Review)

Ms Erin Cassell - Monash University AccidentResearch Centre, Monash University

Dr Michael Dorevitch - Centre for AppliedGerontology, Northern Health

Victorian Quality Council Falls WorkingGroup

Ms Stella Axarlis (Chair to 16 June 2003)

Ms Wendy Hubbard (Chair)

Professor Peter Chong

Ms Marie Cuddihy

Associate Professor Christine Kilpatrick

Ms Lesley Thornton - Project Manager

Input and feedback Ms Diana Clayton - Peninsula Health

Ms Caroline Freeman - Peninsula Health(and Literature Review)

Mr Terry Haines - Eastern Health

Ms Jeannette Kamar - Northern Health

Ms Anne McGann - Melbourne Health

Dr Jane Sims - Department of GeneralPractice, The University of Melbourne

Ms Janet Taylor - Bayside Health

Ms Willeke Walsh - Western Health

Health Services that trialled the Guidelines

Melbourne Health

Ballarat Health Service

Austin Health

Barwon Health

Peninsula Health

West Gippsland Health Group

Review of Guidelines and EducationSupplementDr Jenny Schwarz, Melbourne Extended Careand Rehabilitation Service, Melbourne Health

guidelines - network of care for fall... · 2006-08-29 · 03 introduction introduction 01...

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