Falls and fall-related injuries are a common and serious problem for older people. People aged 65 and older have the highest risk of falling, with 30% of people older than 65 and 50% of people older than 80 falling at least once a year.
The UK population continues to ages, the numbers of older people above 80 is expected to double from 3 million to 6 million by 2030.
This is why in our Falls Risk Documents (FRAD) we ask if the patient is 65 years or older to capture those patients that are potentially more at risk of falls.
Establish patient baseline mobility prior to admission, including any walking/mobility aids used. IF the patients use or requires a mobility/walking aid, please ensure it is available and within arms reach for the patient. If the patient has gait or balance problems, history of falls, and off their usual functional baseline please refer to therapies.
Hospital acquired deconditioning is a syndrome of physical, psychological, cognitive and functional deterioration. older and frailer patient are more at risk of hospital acquired deconditioning from accelerated bedrest and sedentary behaviours.
Physical effects of bedrest on the body:
- Reduced muscle strength and ability to stand and walk
- Falls
- Reduced bladder function
- Increase risk of pressure sores
Psychological effects:
- Fatigued
- Low mood
- Loss of independence and dignity
Patient centred care
- FRAD to be completed within 6 hours of admission
- Falls Care plan completed to address the specific patients risk factors
- Weekly review of the FRAD and FPCP and if patients condition changes
- Referral to Falls team
- Involvement of the MDT
- Involvement of patient and families
Involvement of the MDT
Falls are multifactorial in their nature meaning many different factors contribute to patient falling. therefore to successfully managed them a range of specialities should be involved:
- Nurses
- Health care assistants
- doctors
- Pharmacist
- Occupational Therapist
- Physiotherapists
- Activities Coordinates
- Specialist teams
utilise specialist services to support tour care plan for example: dementia and delirium team, learning disabilities team, safeguarding team.
Involvement of patients and families
Patients and families should be at the centre of falls care planning. staff should be asking the patients about their normal activities of daily living, mobility, goals and aspirations will help us to create a falls care plans that focus on maintaining or even improving their previous ability prior to coming into the trust. Having meaningful discussions with the patients and families around falls preventions is proven intervention to help reduce patients risk of falling.
Please provide patients with Advice to reduce patient falls PIF 1264 found on DMS
Safeguarding
A fall can be safeguarding issues when there are concerns of abuse or neglect linked to it or that care and treatment following the fall was abusive or neglected.
- Not all falls will require a safeguarding adult referral
- A safeguarding adult referral is not the route to access further support/services in relation to falls
Please contact our local safeguarding team for support or any further questions.
Wearing correct fitting, supportive footwear can help reduce patients risk of falling.
When patients are admitted into our care it is important to check their shoes are safe and appropriate for use.
- Laces, buckle or Velcro fasting hold the foot more firmly
- Firm supportive heel cup provides support when walking
- Wide and deep toe box allows room for toe movement and comfort
- Correct length
- Thin soles with tread
- Low wide heels with round edges
If the patient's footwear is not appropriate/safe, ensure the patient is made aware and offered non-slip socks as an alternative to minimise risk whilst in hospital. Ensure non-slip socks are correctly sized as incorrect sizing can increase a patient's risk of falls.
The environment is a risk factor to falls. Identifying and managing risk in the environment can help to keep out patient safe. Many of these can be prompted by all staff:
- Environment free from clutter
- Call bell within reach
- Lighting adequate
- Bed/chair/trolley is at a safe height
- Patient has been informed of how and where to access toilet/bathroom
- Medical devices and equipment e.g. catheters, drip stands, PICC lines
- Ensure patients have their glasses and/or hearing are in working order
Yellow wrist bands
We use falls identifiers across LUFHT to make staff aware that the patient is "at risk" of falls. These should act as prompts to staff to ensure FRAD and FPCP are in place and being reviewed.
Back of bed boards
Back of bed boards are used across the trust to help assistance staff to understand the patients needs. Please ensure these are completed correctly, including mobility status and to be updated on change and ensure Falls risk icon is ticked if patient is at risk of falls.
Bed Heights and bed rails Use
Ensuring the bed is at a safe working height for the patients can only reduce the risk of mechanical falls from standing up but can reduce falls resulting in harm to patients.
If a patient is independently mobile the bed height should be at a enable a approx. 90 degree angle at the knee when the patient is sitting on the edge of the bed.
All patients must have bedrail risk assessment and care plan on admission to hospital. this should be reviewed daily and/or on conditional change and on discontinuation of use.
For further information please refer to "Safe Use of Bedrails Policy" find on DMS
Toileting
Offer regular toileting to patients, consider continence assessment, leave urine bottles within reach, monitor bowels habits to prevent constipation especially with patients who have cognitive impairment.
Call bell
Call bells provide a way for patients to communicate with staff. They are a way for staff to be alerted to a patient's needs. All inpatient must have a call bell available to them, staff must explain to the patient how to use it and ensure it is always within reach. if the patient is unable to use call bell an alternative must be put in place.
Patient should be encouraged to use call bell if:
- They need help to move
- They need help going to the toilet
- They need help getting in or out of bed
- If they feel unwell
- If something is out of their reach
Falls can be caused by almost any drug that acts on the brain or on the circulation. For a pharmacist medication review, please refer via WellSky Web Portal (BLUE DOT) if the patient meets one or more of the criteria below:
- Patient is admitted with a fall or related injury.
- On 4 or more medications.
- On any sedating medications
- Any patient where it is felt medications may be contributing to falls.
There is also a nurses guide to using the medicines galls risk assessment tool.
'This is Me'
This national scheme helps to provide the best care possible for dementia patients by recording their needs, likes, dislikes and preferences on admission to the Trust and helping staff to know their patient - these packs are provided to patients on admission.
Cognitive Impairment
"Is problem with a person's ability to think, learn, remember, use judgement and make decision"
patients with cognitive impairment makes up to 73-96% of patients who sustained inpatient falls.
Inattention is one of the main contributing factors to why patients with cognitive impairment fall due to lack of awareness around safety cues.
Early identification of patients with cognitive impairment is imperative for early management to reduce risk. All inpatients 65 and over at LUHFT should have a 4AT delirium screening completed within 72 hours of admission.
4AT
Rapid clinical test for the detection of delirium
- Alertness
- AMT4: Abbreviated Mental test-4
- Attention: months of the year backwards
- Acute change or fluctuating course
The 4AT is scored from 0-12
A score of 4 or more suggest delirium but is not diagnostic
A score of 1-3 suggests cognitive impairment and more detailed cognitive testing.
Enhanced Observations
Risk assess and determine Levels.
This decision to be made about the appropriate level of observation should be made with MDT involvement. For some patients their behaviours may increase their risk of falling, particularly those with cognitive impairment there an enhanced observation risk assessment should be utilised along with behavioural charts.
- Level 1 (Green): Routine Care- this is not a raised level of observation. The nursing team will ensure the general whereabouts of the patients and will encompass intentional rounding processes.
- Level 2 (Yellow): Intermittent Observations- This level of enhanced observation could be used when patients are first admitted to the ward, when the MDT feel that the patient needs further assessment of risk
- Level 3 (Amber): Continuous within eyesight- This level of observation is used when patient has been accessed as being unwell such that they require specific care and observation. At all times the patient will be within eyesight of a member of staff. Tagged bay observations sits under this level of observations
- Level 4 (Red): Continuous within eyesight- This level of observation is used when the patient has been accessed as being at risk of harming themselves or others or their condition is likely to deteriorate. These patients require constant care to maintain safety.
Communication: Is vital to ensure ward teams are aware of levels of observation patient are under and ensure where appropriate patients and families are engaged with throughout the process. For more details please consult to the LUHFT policy Enhanced observation risk assessment on DMS
Tag Bay
Tagged Bay with the overall aim to minimise the risk of patients falling during their admission as part of Fall Prevention Methods.
Patients who are confused, agitated, wandering unsafely or walking unaided or need one to one enhanced observation may not always be feasible and within the capability of the ward staffing numbers. Implementing a Tagged Bay for a cohort of patients deemed at risk of falls due to the risk factors will aid the reduction of risk to these patients. A Tagged Bay is a way of providing enhanced observation to patients who have been identified as being at higher risk of potential falling episodes.
Falls alarms
Available throughout the trust
Can be used as an early warning tool to help reduce falls
they should not be used as a restraint to patients
Falls alarm checklist must be completed on Day and Night shift to ensure equipment is in working order.
Systems
- Broadgreen: Gleen wireless system
- Aintree: Gleen wired system
- Royal: reference guide available here.
Useful documents
Postural hypotension (also called orthostatic hypotension) is a drop in blood pressure when a patient stand up after lying or sitting down. This can make the patient feel dizzy and can even cause the patient to faint.
Symptoms patients can also report include:
- Light headiness
- Vagueness
- Pallor
- Dizziness
- Vision and hearing disturbances
- Feeling of weakness and palpitations
- Unexplained falls
Lying and standing blood pressure should be completed for all patients within the trust who are at risk of falls. The Lying and standing blood pressure is located on ADT and will automatically be generated by the staff completing a FRAD.
Report a positive test to the registered nurse or medical team and provide postural hypotension leaflet.
There are also seven minute briefings to help manage this risk.