VHA NCPS Fall Prevention and Management

This Fall Prevention and Management aid is intended to prompt clinical staff (nurses, physicians, rehabilitation therapists and others) to consider a systematic assessment for determining patients' risk for falling and to recommend interventions. Post fall management guidelines are also provided that include post fall assessment, fall risk level, interventions, and documentation. If a patient is not at risk for falling based on your assessment, interventions should still be implemented to protect the patient from extrinsic fall risk factors such as the presence of clutter, spills, and electrical cords. 1. Use this aid to assess fall risk when the patient is initially admitted, there is a change in status, the patient is transferred to a new location, and prior to patient discharge. 2. Go to the Fall Risk Assessment tab to determine if there are existing intrinsic factors that may affect the patient's fall risk. 3. Go to the Morse Fall Scale and determine the fall score. Proceed to the indicated intervention based upon the derived score.

Patient Entry
This Fall Prevention and Management Aid is designed specifically for use with patients entering inpatient settings, acute care and long term care. Implied within the philosophy of the Department of Veterans Affairs, both patients and families are integrally involved in all aspects of their care planning. Thus, patients and families are involved in determining fall risk factors and designing fall prevention strategies in collaboration with the patient's health care team. Both the patient and the family should be informed and understand fall risk factors and agree on strategies to prevent the patient from falling. All fall prevention education programs for inpatients should involve their families. Patients and families should be educated about fall risk factors in the new environment and continue their active involvement in all levels of safety education throughout the continuum of their care.

Fall Risk Assessment

If any of these medical factors are present, go to Standard Fall Prevention Interventions:

Agitation/Delirium- infection, toxic/metabolic, cardiopulmonary change, CNS, dehydration/ blood loss, sleep disturbance Meds (dose/timing)-psychotropics, CV agents (digoxin especially), anticoagulants(increased risk of injury), anticholinergic, bowel prep Orthostatic hypotension, autonomic failure Frequent toileting Impaired mobility Impaired vision, inappropriate use of assistive device/footwear History of Falls (CV/light headed-dizzy, Dysequilibrium- loss of balance with no abnormal motion sensation, Vestibular/Vertigo, Weakness-Musculoskeletal/give way, combination, other) Psychotropics, digoxin, type 1a antiarrhythmic, diuretic (thiazides>loop diuretics) Antihistamines/benzodiazipines- withdrawal has shown decrease in falls risk, assess for sleep disorder, avoid routine PRN orders-try non-pharmacological approaches including quiet sleep protocols on units Antidepressants- Tricyclics higher risk than SSRI, but SSRI's have risk as well, high level of phenytoin; low dos amitriptyline affects gate; gabapentin 10-25% ADR Cardiac drugs/antihypertensives- if orthostatic (drop in sys>20 mm in 3 min) and symptomatic

Anticoagulants - subdural hematomas are rare; avoid only if very unstable gait or balance, concurrent use of alcohol, or other drugs that interact and increase bleeding, or non-compliant with regimen or lab follow up Drugs treating nocturia (consider tamsulosin due to lower risk of orthostasis) Nursing fall risk assessment, diagnoses and interventions are based on use of the Morse Fall Scale (MFS) (Morse, 1997). The MFS is used widely in acute care settings, both in hospital and long term care inpatient settings. The MFS requires systematic, reliable assessment of a patient's fall risk factors upon admission, fall, change in status, and discharge or transfer to a new setting. MFS subscales include assessment of:

MORSE FALL SCALE

1. History of falling; immediate or within 3 months 2. Secondary diagnosis

No = 0 Yes = 25 No = 0 Yes = 15 None, bed rest, wheel chair, nurse = 0 Crutches, cane, walker = 15 Furniture = 30 No = 0 Yes = 20 Normal, bed rest, immobile = 0 Weak = 10 Impaired = 20 Oriented to own ability = 0 Forgets limitations = 15

3. Ambulatory aid

4. IV/Heparin Lock

5. Gait/Transferring

6. Mental status Risk Level No Risk Low Risk High Risk

MFS Score 0 - 24 25 - 50 = 51

Action None See Standard Fall Prevention Interventions See High Risk Fall Prevention Interventions

Risk Factors:
Much work has been done to identify the risk factors associated with the likelihood of a patient falling. These risk factors are generally categorized into extrinsic (factors outside of the patient's body) and intrinsic (patient's internal, psychological factors).

Extrinsic Factors:

Hazardous activities Time of day External lighting Clutter Spoils Loose electrical cords

Intrinsic Factors:

Muscle and strength weakness Gait and balance disorders Visual disturbances Cognitive impairment/Mental status alterations Dizziness/Vertigo Postural hypotension Incontinence Polypharmacy Age Chronic disease

SAFETY EDUCATION
Safety education for patients and families requires involvement of all team members. Determine within your setting availability of individual and group fall prevention resources that include patient/family education materials, individual and group education and exercise classes, and community resources. Interventions suggested for implementation in this flip book include both standard and high risk interventions specific to the patient's fall risk score. Patients who are scored "low risk" on the Morse Fall Scale (score of 25-50) will have the following interventions implemented by the Nursing Staff. STANDARD FALL PREVENTION MANAGEMENT Nursing Staff Direct Care:

Assess patient's fall risk upon admission, change in status, transfer to another unit and discharge. Assign the patient to a bed that enables the patient to exit toward his/her stronger side whenever possible. Assess the patient's coordination and balance before assisting with transfer and mobility activities. Implement bowel and bladder programs to decrease urgency and incontinence. Use treaded socks for all patients.

All Staff:

Approach patient towards unaffected side to maximize participation in care. Transfer patient towards stronger side.

Education:

Actively engage patient and family in all aspects of Fall Prevention Program. Instruct patient in all activities prior to initiating assistive devices. Teach patient use of grab bars. Instruct patient in medication time/dose, side effects, and interactions with food/medications.

Equipment:

Lock all moveable equipment before transferring patients. Individualize equipment specific to patient needs.

Environment:

Place patient care articles within reach. Provide physically safe environment (eliminate spills, clutter, electrical cords, and unnecessary equipment). Provide adequate lighting.

Medical Staff:

Evaluate and treat gait changes, postural instability, spasticity. Initiate treatment for impaired vision, hearing. Evaluate medication profile for fall risk. Evaluate and treat pain. Evaluate and treat orthostatic hypotension. Assess and treat impaired central processing (dementia, delirium, stroke, perception)

High Risk Fall Intervention Preventions

These interventions are designed to be implemented for patients with multiple fall risk factors and those who have fallen. These interventions are designed to reduce severity of injuries due to falls as well as to prevent falls from reoccurring, supplementing standard fall prevention interventions. Nursing Staff Equipment:

Consider use of: technology for fall prevention. (See Technology section), non-skid floor mat, raised edge mattress.

Environment:

Clear patient environment of all hazards

Medical Staff:

Review medications for fall risk and adjust as indicated CV agents - if orthostatic (drop in systolic > 20 mm in 3 minutes) and symptomatic o Discontinue HCTZ, liberalize sodium in diet o If ACE inhibitor appropriate, use agent with less renal metabolism (fosinopril) o If Calcium channel blocker - NOT nifedipine o If blocker - not cardioselective / not metoprolol / atenolol; use pindolol / propranolol Consider referral to services such as physical medicine and rehabilitation, audiology, ophthalmology, cardiology. Optimize treatment of underlying medical conditions. Evaluate and treat for pain. Evaluate circumstances surrounding fall for extrinsic and intrinsic contributing factors.

Education:

Exercise Nutrition Home safety Plan for emergency fall notification procedure.

Post Fall Assessment

After a patient falls: Nursing 1. Assess for injuries (e.g. abrasion, contusion, laceration, fracture, head injury) and determine Level of Injury (0, 1, 2, 3). (See Definitions) 2. Obtain and record sitting/standing vital signs. 3. Assess for change in range of motion. 4. Alert Physician. 5. Follow organizational policies for patient monitoring. 6. Document circumstances in medical record. 7. Complete incident report. 8. Assess intrinsic and extrinsic factors. 9. Notify all team members of patient fall. 10. Consider technology to prevent repeat fall (see Technology). Medical 1. 2. 3. 4. 5. Assess and treat any injury. Initiate diagnostic and treatment interventions for contributing causes. Determine probable cause of fall (history, physical factors, medications, laboratory values). Consult appropriate services. Evaluate and treat for pain.

Fall Related Outcomes

Patient Outcomes

Increased knowledge about falls Increased strength, balance, and mobility Increased ability to compensate for sensory, balance loss

Increased functional independence with use of exercises and assistive/adaptive devices Increased confidence in abilities Reduced severity of fall-related injuries Proper hydration Proper nutrition

Program Outcomes

Interdisciplinary approach to fall prevention and management Increased availability of experts in fall prevention and management Systematic program deployment and evaluation

Documentation:
Document circumstances in patient medical record. o Patient appearance at time of discovery o Patient response to event o Evidence of injury o Location o Medical provider notification o Medical/nursing actions Complete incident report Notify Nurse Manager or designee

Definitions:

Fall Loss of upright position that results in landing on the floor, ground or an object or furniture or a sudden, uncontrolled, unintentional, non-purposeful, downward displacement of the body to the floor/ground or hitting another object like a chair or stair. Fall Response Team Fall Response Teams are comprised of interdisciplinary team members that are activated following a fall to evaluate circumstances surrounding a fall with the goal of reducing risk factors and preventing a repeat fall. This team examines the environment, equipment, fall program elements, and resources including staffing, surveillance, communications, and knowledge of risk factors that may have contributed to the event. The Team makes immediate recommendations to reduce fall risks for an individual patient. Level of Injury 0 = None 1 = Minor Injury (abrasion, bruise, minor laceration) 2 = Major Injury (hip fracture, head trauma, arm fracture) 3 = Death Post Admission Fall Occurrence A fall that occurs after a patient is admitted to an inpatient setting.

Slip Loss of balance as a result of slippery surface that does not result in a fall. Stumble Loss of balance due to knees giving way or other reasons but does not result in a fall. Trip Loss of balance due to a specific obstacle that does not result in a fall.

Technology
To consider technologies for Fall Prevention, refer to the National Center for Patient Safety web site. Examples include:

Bed and/or chair alarms. Alarms at exits. Nurse call systems and communication systems. Low beds for patients at risk for falls. Video camera surveillance.

Falls and Bedrails!!!!!!

Fall prevention programs emphasize bedrail reduction. Bedrails contribute to patient fall risk by creating barriers to patient transfer in and out of beds. Use of bedrails must be assessed specific to individual patient needs. When possible, use alternative pillows and positioning devices to avoid the use of bedrails.