Falls Prevention Direct Care

Falls Prevention A guide for direct care providers Click on arrows at bottom of page to advance or return to previous page

My 68 year old wife fell while in the hospital* for some colon surgery. The day I was to take her home she fell and hit her head.She should have been seen by a doctor immediately, but was put back in bed with a knot on her head and an ice-pack. She was on Coumadin. Falls can be tragic in their consequences Actual case—not a KMC patient. Used with permission.

By the time the neurosurgeon got notice of her it was 12 hours from the time of the fall. Her hematoma was very large and thick, pushing over the brain. She sustained an acute subdural hematoma. She was in a coma and I was told by two neurologists she would likely not ever gain consciousness.... Falls can be tragic in their consequences Actual case—not a KMC patient. Used with permission.

This was thirteen months ago. Today, thirteen months later, she is responsive and aware- but is pretty much paralyzed and speechless. She will move some with her right hand. She will smile, shrug her shoulders, wrinkle her nose, squeeze my hand, move her feet, and others. She has a trach, PEG, and ostomy. She cannot talk well, but can say her name…” She is still bedridden. We attend her everyday in the nursing home. Falls can be tragic in their consequences Actual case—not a KMC patient. Used with permission.

A 48 year patient described this incident as follows: “ I had surgery and they were giving me something to keep me from having pain; and they were also giving me something to help me sleep. And sometime during the night, I woke up and didn’t know where I was. ... I managed to get out of bed and I was - - I stood up and I was holding onto the - - I wasn’t completely awake ... I was walking. I was trying to get to the door. And I – - I was holding onto the bed and kind of bouncing up against the wall. And I say bouncing. I mean, you know, just guiding myself with the bed frame and the wall. ... And on the corridors, the hallways, they had some handrails that were - - that were about this wide and thin, you know, and padded and everything. And so I realized I was starting to go down, and I reached over to the left where this handrail was and I grabbed it with my left hand. And I eased myself down to the floor because I could feel that - - I was scared I was going to pass out.” Falls are costly, emotionally and financially… Actual case—not a KMC patient. Used with permission.

The patient reports that he twisted as he went down to the floor while holding onto the rail. Although he denied sustaining injury from this incident, he stated that sometime afterwards he began experiencing right shoulder pain that prevented him from sleeping. Over the course of the next two days the pain became worse. Eventually the patient required surgery to repair a torn rotator cuff, and has not been able to return to his former occupation. Falls are costly, emotionally and financially… The patient was awarded a large settlement. Actual case—not a KMC patient. Used with permission.

Imagine if you were caring for either of these patients Could you have prevented these falls? Could you have intervened more effectively after they fell? This module outlines the steps you can take to prevent falls and minimize their negative outcomes

Objectives: List environmental and patient factors that contribute to falls Describe interventions to reduce environment hazards Describe interventions to address patient factors Describe steps following a fall

The factors contributing to patient falls can be classified as environmental factors or patient factors Environmental factors refer to the environment of care, such as lighting, placement of equipment and furniture, floor coverings, maintenance, and other related factors

The factors contributing to patient falls can be classified as environmental factors or patient factors. Patient factors refer to patient characteristics, demographics and medical history.

Falls Prevention involves four elements Create a safe environment This involves addressing environmental factors that contribute to patient falls

Falls Prevention involves four elements Create a safe environment Assess a patient’s risk This involves evaluating a patient for the presence of risk factors

Falls Prevention involves four elements Create a safe environment Assess a patient’s risk Reduce falls risks Individualized interventions to address patient risk factors

Falls Prevention involves four elements Create a safe environment Assess a patient’s risk Reduce falls risks Evaluate Interventions How effective are falls reduction efforts and interventions following a fall?

Create a safe environment

Be aware of environmental risk factors that contribute to falls

These include:

Inadequate lighting Controls beyond reach Improper bed position/side rails Clutter Slippery floor due to spills or overly polished Unfamiliar setting

Make a habit of surveying the environment whenever you enter a patient room. Identify any possible hazards in the environment. Make sure that safety devices are in place.

Adequate lighting

Ensure the correct bed height

Ensure furniture is sturdy and wheels are locked

Take into consideration the patient’s interaction with the environment

Assign patients to beds that allow patients to exit on their stronger side

Orient patient to room

Adequate lighting

Make sure the patient has unobstructed access to needed items

Assign patients to beds that allow patients to exit on their stronger side

Orient patient to room

Adequate lighting

Ensure necessities (including bedside commode, bedpan or urinal) are within the patient’s reach

Assistive devices, such as walkers, are within reach

Ensure rooms are free of clutter or other environmental hazards such as spills

Ensuring a safe environment for patient care prevents falls. It protects patients, visitors and staff members.

It’s not just nursing-- Nearly every staff member has a role in reducing falls

Our policy requires environmental rounds at a minimum of every four hours to ensure patient safety

Test yourself How many environmental risk factors for falls can you name: 1. 2. 3. 4. 5. 6. … Answers on next page (test yourself before advancing)

Create a safe environment Environmental factor that contribute to falls: Inadequate lighting Controls beyond reach Improper Bed position/side rails Clutter: Furniture or equipment in pathways Slippery floor due to spills or overly polished Unfamiliar setting

Assess a patient’s risk In order to effectively intervene to reduce falls one must be aware of the various patient factors that contribute to falls…

Factors for Falls Patient risk factors for falls can be considered in four broad categories

Factors for Falls Demographic factors Older age (especially >=75 years) Female White race Living alone Common Causes of Patient Falls Accident, environmental hazards, fall from bed (Environmental factors) Gait disturbance, balance disorders or weakness, pain related to arthritis Vertigo Medications or alcohol Acute illness Chronic illness (especially two or more) Confusion and cognitive impairment Postural hypotension Visual disorder Central nervous system disorder, syncope, drop attacks, epilepsy *--Listed in approximate order of occurrence.

Factors for Falls Demographic factors Older age (especially >=75 years) White race Living alone Historical factors Use of cane or walker Previous falls Acute illness Chronic conditions, especially neuromuscular disorders Medications, especially the use of four or more prescription drugs

Drugs That May Increase the Risk of Falling

Sedative-hypnotic and anxiolytic drugs (especially long-acting benzodiazepines)

Antidepressants

Major tranquilizers (phenothiazines and butyrophenones)

Antihypertensive drugs

Cardiac medications

Corticosteroids

Nonsteroidal anti-inflammatory drugs

Anticholinergic drugs

Hypoglycemic agents

Diuretics (A large proportion of falls are elimination related; the most common activity related to falls is ambulation to the bathroom)

Any medication that is

likely to effect balance

In addition to specific

medications being a falls

risk, as the total number

of medications increases

so does the risk of falling.

Factors for Falls Demographic factors Older age (especially >=75 years) White race Living alone Historical factors Use of cane or walker Previous falls Acute illness Chronic conditions, especially neuromuscular disorders Medications, especially the use of four or more prescription drugs Physical deficits Cognitive impairment (However, in one large study, the majority of falls involved patients who were alert and oriented) Reduced vision, including age-related changes Difficulty rising from a chair Foot problems Neurologic changes, including age-related Decreased hearing, including age-related changes

Factors for Falls Demographic factors Older age (especially >=75 years) White race Living alone Historical factors Use of cane or walker Previous falls Acute illness Chronic conditions, especially neuromuscular disorders Medications, especially the use of four or more prescription drugs Physical deficits Cognitive impairment Reduced vision, including age-related changes Difficulty rising from a chair Foot problems Neurologic changes, including age-related Decreased hearing, including age-related changes Others Environmental hazards Risky behaviors

Use a standardized scale to assess a patient’s risk of falls . An evidence based multi-factor tool is built into the computer documentation system.

Assess risk on admission , transfer , change in status , and after a fall

Assess a patient’s risk

Beware of how of environmental and patient factors interact; for example:

Largest proportion of falls occur at night, in the patient’s room, are elimination related, and occur in patients receiving medications with central nervous system or vaso-active action.

The majority of patients who fell did not use the call light prior to falling.

Test Yourself What are the four broad categories of patient risk factors? Answers on next page (test yourself before advancing)

Demographic Other (Example: risky Behavior) Physical Deficits Historical Test Yourself What are the four broad categories of patient risk factors?

Test Yourself

Assess risk on: __________________ __________________ __________________ __________________ Assess a patient’s risk When do you assess a patient for falls risks? Answers on next page (test yourself before advancing)

Test Yourself

Assess risk on:

Admission

Transfer

Change in status , and

After a fall

Assess a patient’s risk When do you assess a patient for falls risks?

Reduce falls risks All patients identified as high risk will have a comprehensive risk reduction plan developed with the patient and family. High risk patients will be identified in a manner that respects personal privacy and dignity. “Catch a Falling Star” signs are to be used to identify high risk patients.

Signage and other indicators (Ruby Slippers) to make high risk patients easily identifiable

Reduce falls risks Individualize interventions to address patient and environmental risk factors

Ruby Slippers Red (Ruby) non-slips sock are available from Central Supply for patients who are at risk for falling. Ruby slippers are easily recognizable by staff members as indicating a patient who has been identified as an increased falls risk, even when the patient is away from his or her room. The red slipper socks are to be used in addition to any sign in and near the patient’s room.

Move high risk patients to rooms near the nursing station

Provide assistive devices, and transfer assistance for weak patients

Implement toileting schedules for incontinent patients

Toileting and falls A highest percentage of falls are elimination related. In other words, the single most common activity associated with falls is a patient going to the bathroom. In addition to instructing and reminding patients to use the call light, regular rounding to ensure patient comfort, and keeping commode at bedside (when appropriate) can reduce falls.

Move high risk patients to rooms near the nursing station

Provide assistive devices, and transfer assistance for weak patients

Implement toileting schedules for incontinent patients

Use bed alarms to alert staff when patients attempt to get out of bed unassisted

Frequent monitoring/sitter. Consider hourly rounding to assess safety and comfort needs

Patient education on risk of falls

Patient education and falls reduction A high percentage of falls occur in patients who are alert and oriented. Patients and their families are often unaware of how their condition, medications, or procedures may effect their strength or balance. Consequently they may over estimate their ability to transfer or ambulate independently. It is up to care providers to educate patients on the various factors that might increase the risks of a fall, emphasize the use of the call light, and be available to attend to patient care and comfort needs. As with all patient education, document your interventions

Reduce falls risks Individualize interventions to address patient and environmental risk factors What about restraints? It is the philosophy of Kootenai Health to prevent, reduce and eliminate the use of restraints as much as possible. Interventions to reduce falls risk often have the effect of reducing the need for restraints as well. While it is preferable, it is not always possible to avoid the use of restraints,and when used properly they are a life-saving and injury sparring interventions. If restraints are needed, be aware of patient factors (such as, age, culture , past history) that place patient at higher risk of adverse response to restraints. In all cases the least restrictive alternative is the preferred means of restraints.

Reduce falls risks Use the resources of all members of the health care team Pharmacy - Does your patient’s medicine increase falls risk? What about the interaction of different medications? Physical Therapy- Does this patient require gait training, or other rehabilitation assistance? Nursing- Are assessments complete and up to date? Does patient history accurately reflect all risk factors? Physicians- Are all diagnostic information, treatments and interventions communicated between care providers? Others- Who else has or needs relevant information?

Evaluate interventions Complete Post Fall Assessments & Incident reports to allow the Falls Team to evaluate the effectiveness of interventions After a fall Individualize interventions based on complete patient picture. Ask, “What high risk factors does this patient have for complications from a fall?” (Previous injuries, medications, etc.) Periodically Evaluate the effectiveness of falls prevention measures. Have the rate of falls decreased? Keep up to date on evidence based practices to prevent falls.

This could have been prevented…

This could have been prevented… Create a safe environment Were there any environmental hazards that if addressed could have prevented this fall?

This could have been prevented… A ssess a patient’s risk Before the fall: What was patient’s mobility status? After the fall: What factors indicated high risk for complications?

This could have been prevented… Reduce the patient’s risk Before the fall: environmental and patient factors could have been addressed. After the fall: high risk factors need to be addressed

This could have been prevented… Evaluate interventions Ineffective interventions had a tragic result

And so could this… High risks: Post surgery Pain medications and sleep aids Bed alarm or closer monitoring could have prevented this fall Ineffective assessment and intervention immediately post fall

Falls Prevention involves four elements Create a safe environment Assess a patient’s risk Reduce the patient’s risk with Individualized interventions Evaluate interventions

Falls Prevention involves four elements Create a safe environment Assess a patient’s risk Reduce the patient’s risk with Individualized interventions Evaluate interventions Remember the fifth element

You Your actions to: C reate a safe environment A ssess a patient’s risk R educe risks, and E valuate the effectiveness of interventions Make all the difference…

The consequences of falls can be tragic Preventing falls depends on you

Falls Prevention Congratulations, you’ve completed the Module… Now what? Take the Falls Prevention knowledge assessment (last page of this presentation)

The End Advance to see references and post test at end

References American Geriatric Society, British Geriatric Society, and American Academy of Orthopaedic Panel on Falls Prevention (2001). Guideline for the Prevention of Falls in Older Persons. Journal of American Geriatric Society (49) 664-672 Evans, D., Hodgkinson, B., Lambert, L. and Wood, J. (2001) Falls Risks in the Hospital Setting: A systematic Review. International Journal of Nursing Practice (1) 38-45 Tinnetti, M. (2003) Preventing Falls in Elderly Persons. New England Journal of Medicine . 348 (1), 42-49 For any questions regarding this module or its contents contact Education Department X2720

Falls Prevention Knowledge Assessment- print, complete, and submit to Education Department via interoffice mail or drop in 1. Factors contributing to patients falls can be classified as : _____________________ and ___________________________ 2. The four elements of Falls Prevents are: ________________________________ ________________________________ ________________________________ ________________________________ 3. Give an examples of an environmental risk factors and appropriate interventions: Factor ___________________________________________________________ Intervention_______________________________________________________ 4. Restraints are the preferred intervention to reduce falls True False 5. Alert and oriented patients can be assumed to be low risk for falls True False 6. The activity most frequently associated with falls is going to the bathroom True False 7. Both the number of medications and types of medications are risk factors for falls True False 8. Risk of falls increases with age True False 9. The only time it’s necessary to assess for falls risk is on admission True False Printed name ____________________________________________ Title ___________________ Dept. ____________________________________________ Date _____________ Signature ___________________________ (signature certifies that I have read and understand the material in this presentation and in the Falls Prevention Guide) To print , find and click on this symbol above on left Important: When a box like this opens, under Print Range select Current page Then click OK