Prevention and management of falls in all hospital settings (G108)

This guidance document provides the recommended action and interventions for the prevention and management of falls in adult in-patients. The aim of the guidance is to help staff improve safe, person centred care in a ward area. When implemented, this guidance must support staff to achieve a reduction in falls using evidence based interventions, whilst promoting recovery, independence and rehabilitation (Scottish Patient Safety Programme, 2012).

The Scottish Patient Safety Programme (SPSP) recommends utilising four bundles of care for falls:

• Falls bundle for all patients (undertaken within the first 24 hours of admission)
• Safety bundle for more vulnerable patients (and all patients in care of older peoples’ wards)
• Multi-disciplinary assessment and intervention bundle for more vulnerable patients (and all patients in care of older peoples’ wards)
• Post fall bundle.

It is important that all adults are screened for their risk of falls as early as possible and actions identified as part of the bundles are implemented quickly.

Further information on falls bundles can be found at:
Acute Adult | Scottish Patient Safety Programme (SPSP) | ihub - SPSP Acute Adult

Falls prevention is a multi-disciplinary challenge as falls are complex and multi-factorial in nature. A fall may be a consequence of an underlying condition that could be treated. This may include intrinsic patient risk factors (gait, balance, cognition, acute illness etc) and extrinsic risk factors (obstacles, wet floors, poor lighting, unsuitable footwear etc).

The human cost of falling includes distress, pain, injury, loss of confidence, loss of independence and mortality. Falling also affects the family members and carers of people who fall (NICE, 2013).

Patient safety is a priority and multi-professional involvement is essential. However, it must be balanced with the patient’s right to choose, rehabilitation, independence, privacy and dignity.

It is important that any measures or interventions put in place to reduce falls are person centred and tailored to the individual. The evidence base indicates that the multidisciplinary intervention of nursing, medical, physiotherapy, occupational therapy and pharmacy staff working together is effective at reducing falls. Other useful interventions may also include the involvement of the hospital falls coordinator, podiatry, optometry and bone health services. This resource outlines key themes and components of good practice noted from evidence.

1.1 Definition of a fall

“A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.”
(World Health Organisation October, 2012)

The definition includes unobserved falls and controlled falls.

1.2 Definition of a fall with harm

“Any instance where a fall with harm is identified. Harm will be where another secondary care intervention is necessary (steri-strip, suture, and/or management of dislocation, fracture, head injury, death), and/or a patient has fallen and received harm or injury requiring radiological investigation (x-ray, ultrasound, MRI or CT) with a confirmed harm.”

N.B: Occurrence of a radiological investigation must not lead to an automatic categorisation of ‘harm’ (harm must be confirmed by the investigation). Minor harms (e.g. grazes, light bruising, small cuts) would be excluded.
(Scottish Patient Safety Programme, 2012)

Falls remain a common cause of harm to patients in hospital settings and
many factors contribute to the risk of falls in wards. A combination of processes which include risk assessment falls bundles, review of local environment and the use data to help to understand and communicate data which contributes to a measurable reduction in harm (Scottish Patient Safety Programme, 2012)

All adult patients admitted to any ward throughout NHS Ayrshire and Arran must have the Falls for All assessment bundle completed on admission. If “Yes” to any question the patient is a vulnerable person and must be commenced on the Safety bundle for more vulnerable patients which are part of care and comfort rounding.

In mental health inpatients the mental health specific Slips Trips and Falls Assessment is completed on admission and any patient scoring low or above has a person centred care plan in place for falls prevention. Both are completed on Care Partner – electronic patient records system.

An individualised falls care plan must be completed and regularly updated, according to the patient`s own needs and involvement with the patient and relative/carer to discuss the care bundles and treatment process to reduce risk of falling.

Provide to the patient and relative/carer the information leaflet ‘A Guide for patients, carers and visitors. Working together to keep you safe. Reducing the risk of falling’ (Healthcare Improvement Scotland).

Having a fall is a reliable predictor of risk. Every year 30% of the population aged 65-79 years and 50% of people 80 years and over have a fall. From evidence 60% of people who have a fall will fall again within the year. A falls history with causes and consequences such as injury and fear of falling must be taken and must include the following elements:

• health problems that may increase risk of falling (including mental health, delirium, movement disorder)
• mobility and/or balance problems
• syncope syndrome (collapse or fainting)
• visual impairment
• frailty.

The Falls bundles:

• will be recorded in the Acute Hospital Admission booklet
• will be undertaken within the first 24 hours of admission
• will be reviewed post fall
• will be reviewed with any change of patient’s condition or circumstance (delirium, change of medication, change in mobility, risk taking) and
• will be reviewed following a transfer to another care setting
• in mental health in-patients settings the Slips Trips and Falls (STF) assessment will be undertaken within 12 hours of admission.

Communication of falls risk and the controls and interventions must be recorded in the individualised falls care plan. These interventions and controls must be shared with the team caring for the person and involvement with the patient and relative/carer to discuss the care bundles and treatment process to reduce risk of falling.

Any patients identified at risk of falls (or identified on the STF Assessment in mental health settings) must be discussed at Safety Brief, SBAR handover, huddles and falls risk stated on the bed board.

All healthcare professionals have a key role to play in the prevention of falls as part of their ongoing care, especially for patients at risk. It is important to communicate both verbally and within the patient care documentation between the whole multi disciplinary team and at times of handover so that all involved in the patient’s care are aware of what risk reduction strategies are in place. Communication of risk reduction strategies is the responsibility of all staff to contribute and identify outcomes of assessment.

Common risk factors for falls must be identified in all patients and interventions targeted:

• reduced mobility
• delirium
• postural instability
• visual impairment
• poly-pharmacy
• postural hypotension and syncope
• urinary incontinence and frequency
• cognitive impairment and behavioural disturbance
• other acute mental health problems (e.g. depression with motor retardation/acute psychosis)
• nutrition and hydration.

Analysis and understanding falls on a patient, ward and site level is important to prevent and manage future falls. Defined process and outcomes data must be collected for falls. All falls and falls with harm data must be submitted to the Quality Improvement portal on a monthly basis. This data can be used to identify areas for improvement and to communicate process & compliance measures to clinical staff and management teams.

A weekly and monthly review of falls data is recommended to ensure that staff are aware of falls on their ward. This should be displayed and discussed with the multidisciplinary team.

Linking falls data with Excellence in Care enables staff to understand other factors that may impact on falls such as safe staffing, times of day.

All patients must also have an individual moving and handling risk assessment undertaken and documented in their admission records. This will highlight to all healthcare staff involved in the care of the patient the risk involved in assisting this patient and provide a framework for that care.

If the patient is not independent, staff must document how many patient handlers are required and the specific equipment required when moving.

Patient assessments must be documented within the care plan and regularly reviewed in line with the assessment outcome and accessible to staff. Guidance on risk identification, assessment and reduction is provided at NHS Ayrshire and Arran mandatory training courses for Moving & Handling. Further Information is available on Athena.

Falls - factors to consider

All healthcare professionals dealing with patients known to be at risk of falling must develop and maintain basic professional competence in falls assessment and prevention (NICE, 2013).

For more information on tools and materials for education visit the ihub which has been designed to help to ensure that health and care services continue to improve.

Wards/departments should identify falls champions to ensure that there is a focus on the prevention and management of falls.

Staff should complete appropriate falls training and refresh this learning annually.

Fundamentals of care training will help to support staff to understand how to prevent falls from happening.

If someone has fallen on the ward then the GO73 guideline on ‘Essential care immediately after an in-patient fall’ must be followed. 

Appendix 3 provides guidance on moving and handling a person immediately post fall in hospital.

MDT Learning from a fall

It is important to complete an MDT debrief following a fall. Learning from falls will help to improve the outcomes for patients, prevent future falls and improve collaborative team working.

Medical staff must complete a post fall medical review.

Resources available

Health Information Resources: Afton House, Ailsa Hospital – 01292 885927

• ‘A Guide for patients, carers and visitors. Working together to keep you safe. Reducing the risk of falling’ (Healthcare Improvement Scotland)
• NHS Inform Preventing Falls
• The local Positive Steps resource is available, for use on a one to one discussion with patients, carers and relatives. It can be used to improve communication about falls prevention and linking in the wider range of community falls prevention options in the transition from hospital to home.
• NHS Scotland ‘Up and About’ Taking positive steps to avoid trips and falls (Posters also available for display with Tips to prevent trips and falls– NHS Scotland ‘Up and About’)
• Take the balance challenge ‘The Super Six’ (AILIP Falls Programme)
• Royal Osteoporosis Society 

Patient information leaflets are available with advice for patients and relatives/carers on how they can help to reduce the risk of falls whilst in hospital. Patients, relatives/carers must be provided with falls prevention information on admission and during stay on ward and must be encouraged to actively participate in minimising the risk of falls i.e. the provision of appropriate clothing, footwear, glasses etc.

Bibliography

1. Scottish Patient Safety Programme Acute Adult | Scottish Patient Safety Programme (SPSP) | ihub - SPSP Acute Adult
2. National Institute for Health and Care Excellence (2013) Falls: assessment and prevention of falls in older people. [NICE clinical guideline 161] Falls in older people: assessing risk and prevention (nice.org.uk) Available from: https://www.nice.org.uk/guidance/cg161/resources/falls-in-older-people-assessing-risk-and-prevention-pdf-35109686728645g.uk
3. Royal Marsden Online Manual (2015) The Royal Marsden of Clinical Nursing Procedures (9th Ed.) Available from: http://www.rmmonline.co.uk/ (via Athena)
4. NHS Forth Valley (2014) In-patient Falls Resource Pack 4 Introd. Available from: https://www.yumpu.com/en/document/read/32197243/in-patient-falls-resource-nhs-forth-valley/7
5. National Patient Safety Agency – Slips,trips and falls in hospital. London (2007)
6. The ‘How to’ guide for reducing harm from falls. Patient Safety First (2009)
7. Oliver. D, Healey.F and T.P.Haines (2010) Preventing falls and fall related injuries in hospitals. Clinical Geriatric Medicine 26 (2010) 645-692
8. Miake-Lye et al. (2013) Inpatient fall prevention programs as a patient safety strategy: a systematic review. Annals of Internal Medicine Volume 158 Number 5 (part 2) 158:390-396
9. Royal College of Physicians Report of the 2011 Inpatient Falls Pilot Audit (February 2012)
10.  Determinants of disparities between perceived and physiological risk of falling among elderly people: cohort study. British Medical Journal 2010 341:c4165
11. Occupational therapy in the prevention and management of falls in adults practice guideline (2015).
12. REFINE. Age and Ageing 2014; 43: 247–253).
13. The National Delivery Plan for the Allied Health Professions in Scotland, 2012–2015 AHPs as agents of change in health and social care (2012).
14. American Geriatric Society and British Geriatric Society Clinical Practice Guideline, 2010.
15. Acute Adult Programme: reduce harm and mortality in hospitals (2012).
16. World Health Organisation global report on falls prevention in older age (2007).

Staff are reminded that they may have patients who require communication in a form other than English e.g. other languages or signing. Additionally, some patients may have difficulties with written material. At all times, communication and material must be in the patients preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on this guideline e.g. choice of gender of healthcare professional. Consideration must be given to these issues when treating/examining patients. Some patients may have a physical disability that makes it difficult for them to be treated/examined as set out in the guideline requiring adaptations to be made. Patient’s sexuality may or may not be relevant to the implementation of this guideline, however, non-sexuality specific language must be used when asking patients about their sexual history. Where sexuality may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality and Diversity Impact Assessment Tool Kit. No additional Equality & Diversity issues were identified. Emergency Services have systems in place to ensure that patients attending who are not registered with a GP receive information on where to seek ongoing health care needs.

This classification has been based upon a review of the clinical evidence of medicines most commonly implicated in falls.  The list is not meant to be fully comprehensive but intended to raise awareness. Advice is provided on how medicines should be stopped (deprescribed).

Reproduced from: Scottish Government Polypharmacy Model of Care Group. Polypharmacy Guidance, Realistic Prescribing. 3rd Edition, 2018. Scottish Government. Available from: https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/09/Polypharmacy-Guidance-2018.pdf

Reproduced with permission from Juliet Harvey. Source: Harvey J (2018) Sedentary Blethering. Available from: https://sedentaryblethering.wordpress.com/2018/06/19/what-happened-to-my-legs-when-i-broke-my-arm/

The green area highlighted in the left pie chart above outlines the amount of activity an individual completed 4 weeks prior to a fall that led to a hospital admission (pre accident). The middle pie chart highlights the limited activity during hospital admission and then finally on discharge home (right pie chart). This individual sustained a fracture to their arm. There was no physical impact on their mobility. This does however highlight the importance of building confidence and early mobilisation in hospital to improve the overall outcomes for individuals.

In hospital post falls moving & handling

Once patient is stable, follow the guidance below:

Risk assess:

• load
• individual
• task
• environment.

If no injuries and patient is physically able:

• Talk patient up from the floor to chair or bed with no physical handling from staff member.

If no injuries but physical assistance is required:

Equipment will be necessary

• hoist patient in sling
• scoop stretcher attached to hoist
• HoverJack with HoverMatt (only available at UHC)

Spinal hip/injury suspected:

• straight lift using scoop stretcher with straps attached to hoist
• scoop stretcher with HoverJack and HoverMatt.

Never bodily lift scoop stretcher directly from floor

Ferno scoop stretchers are located:

• UHC - Ward 2B
• UHA - Station 10 (relocating to Station 16)
• ACH - Douglas Grant Rehab Ward
• Biggart Hospital - Lindsay Ward
• Arran War Memorial – Equipment available from local Ambulance Staff
• Moving & Handling training rooms - CSU/ACH.