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Determining Risk, Implementing Interventions and Managing Falls

Fall Prevention

Anne PanikSenior Vice President of Patient Care Services

Hello, I’m Anne Panik, Senior Vice President of Patient Care Services at Lehigh Valley Health Network. Welcome to the Fall Prevention annual training course! Did you know the Joint Commission has specifically identified Fall Prevention as a patient safety concern? Lehigh Valley Health Network has an outstanding patient safety record. But, even with a patient safety record like ours, fall events still occur. In 2009, 949 patients fell at Lehigh Valley Health Network. Did you know that 25% of the elderly who fall and fracture a hip will die within 6 months? By learning fall prevention strategies and using appropriate interventions, you can greatly reduce the number of patient falls and injuries that occur, and help improve our patients’ quality of life. This program is part of the annual Joint Commission mandatory training requirements. To ensure patient safety, it is vitally important for staff to understand the risks associated with falls and be able to implement the interventions that can prevent falls and injury. Thank you for your commitment to patient safety!

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Objectives

Identify patients most at risk for fall

List patient-related and environment-related factors that put patients at risk for falls

Describe interventions that can prevent falls

Explain the care and documentation required after a patient fall

Upon completion of this course, you will be able to: •Identify patients who are most at risk for fall •List patient-related and environment-related factors that put patients at risk for falls •Describe interventions that can prevent falls •Explain the care and documentation required after a patient fall

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Reasons for Patient Falls

Why might a patient fall?

Environmental Hazards

Patient-Related Conditions

How can we prevent patient falls? The first step is to understand the reasons why a patient may fall. Studies have identified two factors that account for most falls:

• Patient-related conditions, and • Environmental hazards

Let’s first take a look at the patient-related conditions that increase the potential risk for a fall.

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Elimination needs Confused Assistive devices

MedicationElderly History of falls

Weakness Vision Problems

Patients at risk for falls

Male

Who in our patient population is most at risk for a fall? •Patients who need assistance with toileting •Patients who are confused •Patients who use an assistive device (walker, cane, or wheel chair) •Elderly patients •Patients who take medication for pain, blood pressure, anxiety or sleep •Patients with a history of falls •Patients who are weak or have been in bed a long time •Patients with vision problems •Research shows that on average, male patients have a higher incidence of falls

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Let’s take a look at the primary patient-related risk factors that can increase the chance of a patient falling. Click the buttons on the left to review the information for each risk factor. Sensory Deficits: Difficulty hearing increases the risk for falls. Patients with hearing problems may

misinterpret sounds, or may not hear instructions properly. Poor vision also puts patients at increased

risk for falls. Elderly patients have difficulty with depth perception, visual acuity and night vision.

Walking Difficulties: Patients who have problems walking are at an increased risk for falls. For the

elderly, the center of gravity changes, posture becomes hunched, and physical strength decreases,

leading to an increased risk for falls. Certain medical conditions may also make walking difficult and

increase a patient’s risk for falls. For example, an orthopedic injury, a previous stroke, and ailments such

as Parkinson’s disease, diabetes, and cardiac disease can all impair a patient’s ability to walk safely.

Elimination Problems: Patients often need to use the bathroom. Constipation, bowel preps, IV fluids,

enemas and diuretics all increase elimination urgency. Hourly rounds are necessary to ensure that the

patient’s elimination needs are being met.

Altered Mental Status: Patients may become confused as a result of medications or a change in

environment. Poly pharmacy (several different medications prescribed for the same patient) and certain

diseases may alter the patient’s mental status and significantly increase the risk for falling. Patients may

become unaware of hazards that may cause a fall as their cognitive function is impaired.

Medications: Medications can also increase the risk for patient falls. Pain medications, blood pressure

medications, medications for sleep, anesthesia or sedation, anti-diabetic agents, and psychotropic

medications such as those used to treat anxiety, depression, or other mental health conditions, may

cause dizziness, confusion and loss of balance. Anticholenergics can decrease the patient’s ability to

focus. Laxatives and diuretics can all increase the patient’s risk for fall. Be aware that heart and blood

pressure medication can cause a sharp decrease in blood pressure within 30-60 minutes after

administration resulting in orthostatic hypotension which increases risks for falling. Hourly rounds are

necessary to monitor the patient and ensure the patient’s safety.

Previous Falls: Previous Fall victims are at a greater risk to fall again. Statistics show that 2/3 of those

who have fallen will fall again within 6 months. The likely hood of falling increases with age. A very

sobering statistic is that 25% of the elderly who fracture a hip will die within 6 months.

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Altered Mental Status

Perform hourly roundsOrient the patient:

Provide visual cues Keep the whiteboard up to date

Observe the patient

Here are some safety tips that you should keep in mind when caring for a patient with an altered mental status: •Perform hourly rounds. 2. Help orient the patient: •Provide visual cues, like a clock or family pictures by the bedside. •Keep the white board up to date with information such as the current date and the nurse taking care of the patient. 3. Frequently observe the patient – for example, use bed and chair checks as reminders and to notify staff if the patient is attempting to get out of bed without asking for assistance.

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Delirium

Delirium is an abrupt change of mental status and an acute medical condition.

To help the delirious patient:

Perform hourly rounds

Notify physician

Review patient’s history

Notify and involve the family

Delirium is a medical emergency associated with an acute medical condition. The first signs of delirium may be confusion and falls. It is a transitory condition that requires emergent care and treatment. If you suspect delirium: •Perform hourly rounds •Notify the patient’s physician •Review the patient’s history •Notify and involve the patient’s family

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Now, it’s time to see how much you’ve learned so far. Read each review question carefully, then select

the best answer.

1. Which of the following patients are at a risk for falling? Select all that apply:

a. 27 year old patient who has just returned from surgery who gets up to use the

bathroom

b. 54 year old patient who has just started on blood pressure medication

c. 42 year old outpatient getting x-rays for suspected pneumonia

d. 73 year old outpatient who uses a walker

2. From the list below, select all the patient-related conditions that are known to increase the risk

for a fall:

a. Old age

b. Hyperactivity

c. Impaired hearing

d. Poor eyesight

e. Disorientation

3. How many patient falls occurred at LVHN in 2009?

a. 1-250

b. 251-500

c. 501-750

d. 751-1,000

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Environmental Hazards

Environmental hazards are

primarily found in the

patient’s room

There are also hazards within the hospital that can place a patient at risk for a fall. Some environment-related hazards are in the patient’s room. Let’s enter this patient’s room to see just how hazardous the patient’s environment can be.

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A hospital room may contain hazards which could cause a patient to fall. Perform hourly rounds to ensure the environment is free of fall hazards. Several of the hazards are shown here in this patient room. Click on each marker to learn information about the potential hazards. Excessive Reach

Keep items that patients use within easy reach.

Footwear

Patients should wear non-skid slippers or their own shoes.

Obstructed pathway

Keep all pathways clear. Keep the room clear of clutter or any items that could cause a fall.

Spills

Spills can originate from many sources: food trays, visitor’s refreshments, water pitchers, bed pans, etc. Spills need to be cleaned up immediately to eliminate potential slips and/or falls.

Tubing

Keep all tubes and devices off the floor.

Equipment/telephone cords

Keep power cords out of the patient’s path and off the floor whenever possible. Use carabineer hooks to keep these items off the floor whenever possible.

Inadequate lighting

Adequate lighting can help patients avoid potential hazards. Use floor night lights.

Re-arranged furniture

Simply moving a chair to a different location can “un-familiarize” the patient with the room. This could result in the patient tripping over an unexpected obstacle.

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Fall Prevention Interventions

1. Perform hourly rounds

2. Make sure bed alarm is functioning properly

3. Make sure call bell is within reach

4. Keep all personal items nearby

5. Check for Orthostasis

6. Patients who are at risk for falls should not be left alone in the bathroom or on the commode

Follow these fall prevention musts:

We have learned that falls can be the result of patient-related and environment-related conditions. Now we will identify the interventions that can help reduce patient falls. To protect the safety of your patients, follow these fall prevention musts: •Perform hourly rounding on all patients; assessing patients for “the three P’s” - pain, personal needs, and positioning. •If the patient requires the use of a bed alarm make sure the alarm is functioning properly and if required reset the alarm after patient movement. •Make sure the call bell is within reach and the patient can use it. •Keep all personal items nearby to prevent the patient from having to reach for them. •Check for orthostasis. Orthostasis is a sudden drop in blood pressure upon standing, which results in dizziness. Encourage the patient to rise slowly and sit on the end of the bed for a few minutes. There are many medications that may cause a patient to experience orthostasis. •Don’t leave patients who are at high risk for falls or injuries alone in the bathroom or on the commode.

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Always Remember to:

To prevent patient falls:

Identify at risk patientsRemind patients to call for assistance to get out of bedFollow Physical Therapy recommendationsUse assistive and adaptive devicesUse the call bellAnswer call bells promptlyApply non-skid slippers or the patient’s own shoesAssist patientsProperly reset bed alarms as needed

To prevent patient falls, always remember to: •Identify at risk patients •Remind patients to call for assistance to get out of bed (often patients are over confident in their ability to ambulate safely) •Follow Physical Therapy recommendations for safe transfer and ambulation •Use assistive devices, such as canes and walkers, and adaptive devices, such as glasses and hearing aides •Make sure patients know how to use the call bell and are physically able to use it •Answer call bells promptly and perform hourly rounds •Apply non-skid slippers or the patient’s own shoes for walking •Assist patients out of bed and with ambulation. Use ceiling or stand alone lifts to safely transfer and move patients, and •Remember to follow the proper procedure for resetting bed alarms, specifically after movement of patients in the Tower (K), Care Assist beds

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Falls can be a result of hazards in the patient environment:

Check wheel locksClean up spills Eliminate clutterCheck for cords

Place call bell within reach

Toilet patientsafter meals

Perform hourly roundsAsk for help

Remember, falls can occur as a result of hazards in the patient’s environment. You can help to prevent patient falls by: •Performing hourly rounds – assess the patient for pain, personal needs and positioning •Checking locks on beds and wheel chairs •Cleaning up spills promptly •Eliminating clutter from patient walkways and hallways •Checking for any loose equipment cords and securing them to the bed frame •Placing the call bell and patient items within reach of the patient •Toileting patients •Asking for assistance. Get help if you feel a patient is in any danger of falling. Use ceiling lifts and stand alone lifts to reposition, transfer or move the patient.

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Fall Prevention Education

Educate the patient and their family on fall prevention. Assure that the patient and family receive the Patient Guide. Instruct the patient and family to watch the patient safety issues on channel 52 during their hospital stay. The Division of Education’s Patient Education Intranet site has more information on what materials are available for your patients. Provide any additional teaching materials to the patient and family. Educate the patient and family on hourly rounds, especially in regard to the patient’s toileting schedule. Document all patient education in Krames.

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Review Safety Tips

Use the call bellRise slowly and sit on the edge of the bed for a few minutesWear your own shoes from home or non skid socksEngage and partner with the family

Reinforce safety tips with the patient and family. Safety tips include: •Use the call bell before getting out of bed or off of the toilet •Rise slowly and sit on the end of the bed for a few minutes •Wear footwear from home or non-skid socks when out of bed •You should also engage and partner with the family to keep the patient safe

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Fall Risk for Outpatients

Ask patient in outpatient areas:1. Do you use anything to help you walk?2. Do you feel unsteady on your feet?3. Have you fallen in the past year?

Did you know that patients are screened for fall risk in the outpatient areas as well? Patients in the outpatient areas are also at risk for falls. In fact, in 2009 423 outpatients fell at LVHN. A simple procedure is used in outpatient areas to screen patients for fall risk. Outpatients are asked 3 fall risk screening questions: •Do you use anything to help you walk? (Cane, walker, etc.) •Do you feel unsteady on your feet? •Have you fallen in the past year? One positively answered question indicates potential risk for falls.

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Outpatient Interventions As appropriate, interventions will be implemented for outpatients identified at risk for falls and may include:

Assist patient with ambulation to test/treatment areaMonitor patient frequently during test/treatmentAssist/accompany patient to examination areaConsider use of assistive devices as needed (ie. Wheelchair, walker, other transfer deviceRemain with patient during study/treatmentAssure environment is hazard free

If a patient is identified as at risk, the staff in the outpatient department provides for the patient’s safety. As appropriate, interventions for outpatients identified at risk for falls include: •Assist patient with ambulation to test or treatment area •Monitor patient frequently during test or treatment •Assist or accompany patient to examination area •Consider use of assistive devices as needed (ie. Wheelchair, walker, other transfer device) •Remain with patient during study/treatment •Assure environment is hazard free

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Let’s take another break for some review questions. Read each question carefully and select the best

answer.

1. What three questions should always be asked in the outpatient areas to determine if a patient is

considered at-risk for a fall?

a. Do you feel unsteady on your feet?

b. Have you fallen in the past year?

c. Do you use anything to help you walk? (cane, walker, etc.)

d. Are you currently taking any medication?

2. Your patient receives a sleeping pill at bedtime. This will increase their risk for a fall.

Please indicate is the statement is true or false.

a. True

b. False

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When a patient fall occurs, the following steps are to be taken in this order. Click each number to learn about each step.

1. Assess for injury – Before moving the patient, the RN should immediately assess the patient for

signs of injury.

2. Return to bed/chair – Return the patient to their bed or chair, taking into consideration possible

injury. Use mechanical lift devices to ensure the patient’s and staff’s safety.

3. Review medications – Review the patient’s current medications and history of anticoagulant

use. If the patient is on an anticoagulant, obtain the most recent PT/INR/PTT. If a head injury is

suspected, request a stat PT/INR/PTT.

4. Neurological assessment – Perform a neurological assessment for any unwitnessed fall or if the

patient’s head contacted a hard surface. A brief neurological check would include level of

consciousness, pupils, grasp, mental status exam, speech, and vital signs.

5. Contact Physician and report – Contact the patient’s physician and report the event.

6. Contact next of kin – Contact the patient’s next of kin or primary caregiver and inform them of

the fall as soon as possible.

7. Assess and Re-assess – Continue to assess and re-assess the patient. Symptoms may not

immediately be visible, particularly in the case of internal injuries. Assess the patient every 15

minutes, until you have assessed the patient a total of 4 times. Then, re-assess the patient every

4 hours for the next 48 hours. When re-assessing the patient, you should also perform

neurological assessments. Refer to the Clinical Practice Guideline for Fall Precautions for

additional information.

8. Consult Pharmacist – Consult the pharmacist for medication review to determine if any of the

medications could have resulted in triggering the fall. See the list of high risk medications

attached to the end of this module.

9. Post Fall Huddle – Complete a post fall huddle prior to shift end. Include all team members.

Submit scantron to the unit director. Remember to notify and include the Rapid Response Team

nurse (RRT).

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You Make the Difference

Assess all patients for fall risk at least dailyImplement interventionsProvide post-fall attentionCommunicate fall risks to all caregivers

Patient falls can be prevented. You are responsible for protecting the safety of your patients! Remember to: •Assess patients for fall risk at least daily and after any change in condition (for example: post op, post procedure, etc.). •Implement fall prevention interventions to keep our patients safe at all times. •Provide close attention to the patient who has fallen by following the post-fall interventions. •Communicate fall risks to all caregivers. Hand off communication of fall risk and fall prevention interventions are a 24 hour responsibility of all caregivers. Our patients’ conditions change frequently and it is up to us to ensure their safety. Interventions in place to prevent a fall may change during a shift. Hand off communication is also important because the physician may write a new medication order and because transporters need this information to do their job safely.