Preventing Falls and Harm from Falls December 2013 2

Preventing Falls and Harm from Falls Standard 10: Preventing Falls and Harm from Falls The Victorian Department of Health is making this document freely available on the internet for health ser vices to use and adapt to meet the National Safety and Quality Health Service Standards of the Australian C ommission on Safety and Quality in Health Care. Each health service is responsible for all decisions on how to use this document at its health service and for any changes to the document. Health services need to re view this document with respect to the local regulatory framework, processes and training requirements. The author disclaims any warranties, whether expressed or implied, including any warranty as to the quality, accuracy, or suitability of this information for any particular purpose. The author and reviewers cannot be held responsible for the continued currency of the information, for any errors or omissions, and for any consequences arising there from.

Published by Sector Performance, Quality and Rural Health, Victorian Government, Department of Health

February 2014

Preventing Falls and Harm From Falls – December 2013 2 Acknowledgements The Department of Health Victoria acknowledges the contribution of medical and health specialists, Victorian health services, and members of the National Safety and Quality Health Service Standards: Educational Resources Project project team, Steering Group and Advisory Committee.

For the Preventing Falls and Harm from Falls module Professor Keith Hill, Head of School, School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University provided specialist advice. The Educational Resources Project Steering Group members comprised:  Associate Professor Leanne Boyd, Steering Group Chair; Director of Education, Cabrini Education and Research Precinct, Cabrini Health

 Ms Madeleine Cosgrave, Project Manager

 Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre

 Mr. David Brown, Consumer representative

 Dr Jason Goh, Medical Administration Registrar - Cabrini Health

 Mr Matthew Johnson, Simulation Manager, Cabrini Education and Research Precinct, Cabrini Health

 Ms Tanya Warren, Educator, Cabrini Education and Research Precinct, Cabrini Health

 Ms Marg Way, Director, Clinical Governance, Alfred Health

 Mr Ben Witham, Senior Policy Officer, Quality and Safety, Department of Health Victoria

The Educational Resources Project Advisory Committee members comprised:  Associate Professor Leanne Boyd, Advisory Committee Chair; Director of Education, Cabrini Education and Research Precinct, Cabrini Health  Ms Madeleine Cosgrave, Project Manager

 Ms Margaret Banks, Senior Program Director, Australian Commission on Safety and Quality in Health Care

 Ms Marrianne Beaty, Oral Health National Standards Advisor, Dental Health Services Victoria)

 Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre

 Mr David Brown, Consumer representative

 Dr Jason Goh, Medical Administration Registrar, Cabrini Health

Preventing Falls and Harm From Falls – December 2013 3  Ms Catherine Harmer, Manager, Consumer Partnerships and Quality Standards, Department of Health, Victoria

 Ms Cindy Hawkins, Director, Monash Innovation and Quality, Monash Health

 Ms Karen James, Quality and Safety Manager, Hepburn Health Service

 Mr Matthew Johnson, Simulation Manager, Cabrini Health

 Ms Annette Penney, Director ,Quality and Risk, Goulburn Valley Health

 Ms Gayle Stone, Project Officer, Quality Programs, Commission for Hospital Improvement, Department of Health Victoria

 Ms Deb Sudano, Senior Policy Officer, Quality and Safety, Department of Health Victoria

 Ms Tanya Warren, Educator, Cabrini Health

 Ms Marg Way, Director, Clinical Governance, Alfred Health

 Mr Ben Witham, Senior Policy Officer, Quality and Safety, Department of Health Victoria

Preventing Falls and Harm From Falls – December 2013 4 ContentsPreventing Falls and Harm from Falls

Preventing Falls and Harm from Falls 3 Introduction 3 Learning outcomes 3 National Standards 3 Aim of Standard 10 3 Policies and procedures 4 Background 4 Principles of falls prevention 4 Risk screening and assessment 4 Risk factors 5 Falls prevention strategies 6 Individualised falls prevention strategies 7 Engaging with patients and carers 7 Documentation and monitoring 8 Audit and evaluation 8 Reporting adverse events 8

Summary 9

Test Yourself 10

References 12

Appendix 1: Examples of Falls Risk Screening and Assessment Tools 13

Introduction This module relates to The National Safety and Quality Health Service (NSQHS) Standard 10: Preventing Falls and Harm from Falls.

Preventing Falls and Harm From Falls – December 2013 5 Criteria to achieve Standard 10: Learning outcomes Governance and systems for preventing falls On completion of this module, clinicians will be Organisations have governance structures and systems able to: in place to reduce falls and minimise harm from falls. 1. Outline how and when to screen and Screening and assessing risk of falls and harm from assess patients for risk of falls. falling 2. Describe preventative strategies to reduce Patients on presentation, during admission, and when the risk of falls and harm from falls. clinically indicated, are screened for risk of a fall and the 3. Describe the process for engaging patients potential to be harmed from falls. and carers in falls prevention. Preventing falls and harm from falling 4. Describe how to report falls related Prevention strategies are in place for patients at risk of adverse events in your organisation. falling Communicating with patients and carers National Standards Patients, families and carers are informed of the The Australian Commission on Safety and Quality identified risks from falls and are engaged in the in Health Care (ACSQHC) developed the 10 NSQHS development of a falls prevention plan. Standards to reduce the risk of patient harm and improve the quality of health service provision in Table 1: Criteria to meet Standard 10 (ACSQHC, 2012) Australia. The Standards focus on governance, consumer involvement and clinically related areas and provide a nationally consistent statement of the level of care consumers should be able to Policies and procedures expect from health services. There are numerous policies, procedures and resources within health care services to assist you Aim of Standard 10 with the prevention of falls and harm from falls. It is important to access, read and adhere to systems, The intention of Standard 10: Preventing Falls and policies and procedures within your organisation. Harm from Falls is to reduce the incidence of patient falls and harm from falls. All health service organisations need to implement documented Background systems to address this standard. However, it is A fall can be defined as: “an event which results in recognised that some services such as day a person coming to rest inadvertently on the surgeries and paediatrics do not require the same ground or floor or other lower level. This is level of systems as those required for older excluding intentional change in position to rest in patients. furniture, or against walls or other objects.” World Health Organisation (WHO), 2007 Standard 10 also relates to Standard 1: Governance for Safety and Quality in Health Falls related injury is one of the leading causes of Service Organisations and Standard 2: Partnering morbidity and mortality in older Australians. Falls with Consumers. The principles in these Standards related incidents are the highest reported incident are fundamental to all Standards and provide a category within health services. framework for their implementation. ACSQHC, 2012

Preventing Falls and Harm From Falls – December 2013 6 Falls can be related to a number of risk factors and function and quality of life, thereby increasing the are more prevalent when observation is reduced. risk of seriously harmful falls. They often occur in and around the bedside in a hospital setting. ACSQHC, 2012 Risk screening and assessment A risk screening is a process that aims to identify people at increased risk of falls. These patients require a falls risk assessment. A falls risk assessment identifies a person’s individual risk factors. Targeted falls prevention strategies such as increased supervision can then be implemented to reduce the likelihood of a fall. Appendix 1 outlines some commonly used falls risk screening and assessment tools. Organisational policy will determine the tools used and frequency of screening in each health care service. It is important that you make yourself familiar with the specific tools you will be using. Patients should be screened for risk of falling on Principles of falls prevention admission and further assessment should occur: The Best Practice Guidelines For Falls Prevention In  following a change in the patient’s Hospitals (ACSQHC, 2009) outline the following key environment messages in falls and injury prevention:  following a change in the patient’s health  most falls can be prevented or functional status  falls and injury prevention is most effective  after a fall with a multi-disciplinary team approach  prior to discharge  best practice in fall and injury prevention ACSQHC, 2009, ACSQHC, 2012 includes: o identifying falls risk Risk factors o identifying falls risk factors which may The risk of falls and harm from falls is higher for be addressed older people and for those with: o implementing falls prevention  a past history of falls strategies  urinary frequency or incontinence o evaluating the effectiveness of these  cognitive impairment strategies  vision impairment o engaging patients in their own falls prevention program  poor balance, muscle weakness or reduced bone density Although the consequences of a fall may result in minor or no injury, the resulting fear of falling and  polypharmacy reduced activity level can profoundly affect  side effects from certain medications

Preventing Falls and Harm From Falls – December 2013 7 ACSQHS, 2009; 2013 falls and other adverse events relating to cognitive impairment. Falls risk is also higher in the hospital environment due to unfamiliar surroundings and environmental The following table outlines some of the key hazards such as slippery floors and a cluttered features which may assist a clinician to distinguish environment. between delirium and dementia.

PAST HISTORY OF FALLS A previous fall is a significant risk factor for older patients and a predictor of high risk of future falls. It may also suggest the presence of other risk factors. Individuals with multiple risk factors have an increased risk of falls than those with a single risk factor. National Ageing Research Institute (NARI), 2004

URINARY FREQUENCY OR INCONTINENCE Key features of Delirium and Dementia Numerous falls in hospitals occur when older Dementia people go to, or return from, the toilet. Therefore, Delirium incontinence, diarrhoea, bowel or bladder Onset Rapid onset Gradual onset frequency or urgency can also contribute to falls risk. However, these risks are likely to be Course Variable & Progressive worsened by problems with mobility or cognition. fluctuating decline ACSQHS, 2009 Duration Hours to days, Months to years COGNITIVE IMPAIRMENT rarely weeks Cognitive impairment may increase risk of falling Aetiology An immediate Usually no by influencing the patient’s ability to understand cause can usually immediate and manage environmental hazards. Additionally, be identified cause patients with cognitive impairment may have a Reversal Treat underlying Cannot be tendency for confusion, increased wandering, cause reversed altered gait patterns and impaired postural stability, all of which can increase falls risk. Cognitive Global impairment, Poor short term function poor attention memory, decline Many falls for patients with cognitive impairment span, in orientation, are unwitnessed. Subsequently increasing concentration, learning, supervision of these patients can reduce the orientation, mood judgment and likelihood of falls. and perceptions comprehension Psychomotor Increased, Can be normal Older people with existing cognitive impairment activity decreased or are more likely to develop a delirium from an acute unpredictable event and distinguishing between dementia and delirium may be difficult. Establishing and treating Perception Visual Simple delusions the cause of the delirium will reduce the risk of hallucination, and delusions hallucinations

Preventing Falls and Harm From Falls – December 2013 8 Manepalli, Gebretsadik, Hook & Grossberg (2007)  ensuring easy access to visual aids or glasses VISION IMPAIRMENT  reviewing medication, particularly high risk Visual impairment is associated with increased risk medications such as sedatives and of falls. This can be exacerbated by poor lighting analgesics and other environmental factors within health care settings.  assessing and monitoring hypotension Where a previously undiagnosed visual problem is  screening urinalysis for presence of urinary identified, the patient requires referral to an tract infection optometrist or ophthalmologist for further  orientating the patient to the environment assessment. and making the environment safe, e.g. ACSQHC, 2009 keeping walkways clear and positioning bedside tables, mobility aids and call bells within reach POOR BALANCE, MUSCLE WEAKNESS OR REDUCE  showing the patient how to get help when D BONE DENSITY required Poor balance and muscle weakness increase a patient’s risk of falls. Reduced bone density  educating the patient on correct use of any increases the patient’s risk of harm from falls. gait-assisting devices  placing high risk patients close to, and in POLYPHARMACY AND EFFECT OF MEDICATIONS view of, the nurse’s station A number of factors may affect a person’s ability to  minimising the use of restraints and bed deal with, and respond to medications which can rails also lead to an increased risk of falls. These factors include the following:  considering hip protectors and alarm devices for high risk patients  ageing and disease processes  polypharmacy, or medication misuse, In some organisations, a visible flagging system is adverse interactions, overuse and non used to indicate patients at risk of falls. This compliance should be updated as required to ensure accuracy of information.  the use of medications affecting the central nervous system, e.g. psychoactive Many of these strategies are also indicators of drugs sedatives or drugs which may result quality care that should be in place for all patients, in hypotension not just those with increased risk of falls. ACSQHC, 2009 ACSQHS, 2009; 2012 Falls prevention strategies Individualised falls prevention strate Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian gies Hospitals (2009) outline evidence based falls Falls prevention strategies should be individualised prevention strategies. These should be in place for to suit the patient’s needs. patients assessed as being at risk of falling and should include: Consider:

Preventing Falls and Harm From Falls – December 2013 9  showing the patient how to seek help Engaging with patients and carers when they need it In order to prevent falls and harm from falls,  providing more frequent observation, patients and carers should be engaged in the supervision and assistance for patients process immediately and involved in risk with delirium or dementia to facilitate safe assessment and development of a prevention plan. mobility and transfers  addressing reversible causes of acute Patients and carers should be educated about falls cognitive decline risks and prevention strategies. They should be asked whether they believe the patient is at risk of  assisting patients with ‘toileting’ every one falling, including in which situations they feel the to two hours as needed risk of falling is highest (e.g. during the night,  reviewing and monitoring medications to walking down the street). This information can ensure they are still relevant and required then be incorporated into the prevention plan.

This collaboration enables an opportunity for  modifying the environment by lowering patients, carers and clinicians to share information beds, removing clutter, ensuring adequate which may impact on the effectiveness of the falls signage and lighting and accessibility to prevention plan. belongings You should consider the following when discussing  using physical training programs to falls prevention with patients and carers: improve gait, mobility, balance and flexibility  asking the patient and carer to identify high risk situations or environments that  ensuring footwear is correctly fitted and may impact on their falls risk appropriate  maintaining the patient’s independence The use of restraints is not recommended. There wherever possible is no evidence that physical restraints reduce the  providing relevant, easy to understand incidence of falls. Indeed, the use of bed rails and information restraints can result in serious injury and death.  offering information in languages other Any reversible causes of agitation, wandering and than English and not assuming literacy confusion should be investigated and treated.  working with the patient and carer to Close supervision should be implemented to facilitate realistic goals reduce the risk of falls and injury in these patients.  engaging family members to assist in falls Patients at risk of falls should be referred to a prevention strategies physiotherapist to assist them with falls prevention  exploring and addressing barriers that strategies. An occupational therapy home visit is make it hard for patients to prevent falls also recommended for people with a history of falls in order to establish safety at home prior to  utilising falls prevention posters in ward discharge. areas ACSQHC, 2009  ensuring falls prevention strategies are included as part of patient discharge information ACSQHC, 2009

Preventing Falls and Harm From Falls – December 2013 10 Summary

Documentation and monitoring ACSQHC, 2012 The results of risk screening and assessment and Preventing falls and harm from falls is the focus of the individual falls prevention strategies should be Standard 10 in the National Safety and Quality documented and communicated during clinical Health Service Standards. handover and on transfer or discharge. This ensures that all clinicians, the patient and their The key messages are: families can manage falls risk. All clinicians should 1. Most falls can be prevented. monitor and evaluate the effectiveness of falls prevention strategies and document in the clinical 2. The risk of falls and harm from falls is record. higher for older people and for those with: ACSQHC, 2012  cognitive impairment  urinary frequency or incontinence,  vision impairment Audit and evaluation  poor balance, muscle weakness or, reduced bone density You may be required to participate in audit  side effects from certain activities which could include examination of: medications  patient clinical records 3. Falls are also more prevalent when  risk screening and assessment tools observation is reduced and often occur in and around the bedside in a hospital  falls prevention plans setting. The purpose of audit is to measure compliance 4. Best practice in fall and injury prevention with policies and protocols and to monitor the includes: frequency and severity of fall. This information can  identifying falls risk be used to improve practice.  implementing falls prevention Reporting adverse events strategies  evaluating effectiveness of falls All falls should be reported to the nurse/midwife in prevention strategies charge and the attending medical officer and be documented in the clinical record. Any fall should  engaging patients in their own falls be managed according to your organisation’s falls prevention program management protocol and entered into your risk 5. Patients should be screened on admission or incident management system. for risk of falling and further assessment should occur: Patients and carers should be fully informed of any falls and the organisation’s open disclosure  following a change in the patient’s processes implemented. environment  following a change in the patient’s Risk and incident information can be used to health or functional status improve the falls prevention guidelines in your organisation. It may also inform changes to  after a fall equipment, education and training activities.

Preventing Falls and Harm From Falls – December 2013 11 6. Evidence based falls prevention strategies should be in place for patients at risk of falling. 7. Falls prevention strategies should be individualised to suit the patient’s needs. 8. The use of restraints and bed rails is not recommended. 9. Patients at risk of falls should be referred to a physiotherapist and/or occupational therapist. 10. Patients and carers should be educated about falls risks and prevention strategies and engaged in the development of a falls prevention plan. 11. Patients and carers should be asked to identify high risk situations or environments that may impact on their falls risk. 12. The results of risk screening and assessment and the individual falls prevention strategies should be documented and communicated during clinical handover and on transfer or discharge. 13. All falls should be entered into your organisation’s risk or incident management system.

Preventing Falls and Harm From Falls – December 2013 12 TestAnswers Yourself

Fill in the blanks. 1. Patients should be screened for risk of falling on admission and further assessment should occur following a change in the patient’s ______, following a change in the patient’s health or ______status, after a fall and prior to ______.

2. The risk of falls and harm from falls is higher for older people and for those with a past history of falls, urinary frequency or ______, cognitive impairment, ______impairment, poor balance, muscle weakness or reduced ______density, polypharmacy and side effects from certain medications.

3. A risk ______is a process that aims to identify people at increased ______of falls. These patients require a falls risk assessment.

4. A falls risk assessment identifies a person’s individual risk ______. Targeted falls ______strategies such as increased supervision can then be implemented to ______the likelihood of a fall.

5. In order to prevent falls and harm from falls, patients and carers should be ______in the process immediately and ______in risk assessment and development of a prevention _____.

1. condition, functional, discharge 2. incontinence, vision, bone 3. screen, risk 4. factors, prevention, reduce 5. engaged, involved, plan

Preventing Falls and Harm From Falls – December 2013 13 ReferencesAppendix 1: Examples of Falls Risk Screening an d Assessment Tools Australian Commission on Safety and Quality in Health Care. (2012). Safety and Quality Improvement Guide Standard 10: Preventing Falls and Harm from Falls. Sydney: Commonwealth of Australia

Australian Commission on Safety and Quality in Health Care. (2013). Preventing Falls and Harm from Falls, Standard 10: Fact Sheet. ACSQHC, Sydney

Australian Council for Safety and Quality in Health Care (ACSQHC). (2009). Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Hospitals. Accessed at http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Guidelines-HOSP1.pdf

National Ageing Research Institute (NARI) (2004). An Analysis of Research on Preventing Falls and Falls Injury in Older People: Community, Residential Care and Hospital Settings, Australia Government Department of Health and Ageing, Department of Health and Ageing, Injury Prevention Section,Canberra

Manepalli, J. N., Gebretsadik, M., Hook, J., & Grossberg, G. T. (2007). Differential Diagnosis of the Older Patient With Psychotic Symptoms. Primary Psychiatry, 14(8), 55-62.

Victorian Quality Council. (2004). Minimising the risk of falls and fall related injuries: Guidelines for Acute, Subacute and Residential Care Settings Tool Supplement

Victorian Department of Health. (2012). Accreditation Resource – Standard 10: Preventing Falls and Harm from Falls. Accessed at http://www.health.vic.gov.au/accreditation/resources/victorian-department-of- health

World Health Organisation. (WHO). (2007). WHO Global report on falls prevention in older age. WHO, Geneva

World Health Organisation (WHO). (2012). Fact sheet no. 344: Falls. Accessed at http://www.who.int/mediacentre/factsheets/fs344/en/

Setting Tool Description Time Required

Preventing Falls and Harm From Falls – December 2013 14 Hospital The Northern The tool contains nine clinical factors 1 -2 minutes Health STRATIFY associated with falling, and a simple scoring system. Risk factors include age, falls history, mental state, toileting needs, balance, vision impairment, drug or alcohol abuse, and mobility. Criterion: A score of 0 = low risk. High risk = ≥3

Hospital Ontario Modified The tool contains six clinical factors associated 1 -2 minutes STRATIFY with falling (falls history, mental status, vision, toileting, transfers between chair and bed, and mobility score). Management strategies are provided, according to the participant’s overall score. Criterion: A score of 0–5 = low risk, 6–16 = medium risk, 17–30 = high risk

Emergency FROP-Com A three-item screening tool developed based on 1 -2 minutes Department screening tool research using the FROP-Com assessment tool in a sample of older people presenting to an emergency department after a fall. The three items are:  steadiness during walking and turning  history of falls in the past 12 months  the need for assistance with activities of daily living before the presenting fall Criterion: A score of 4 or more indicates high risk.

Acute hospital Care plan Twelve items are incorporated into the daily care 5 - 10 minutes assessment items plan, including intrinsic risk factors (medications, vision, blood pressure, mobility, etc), as well as environmental risk factors (safe environment, appropriate bed height, nurse call bell accessible, etc). No criterion for high falls risk. Individual risk factors identified are addressed according to guidelines

Setting Tool Description Time Required

Preventing Falls and Harm From Falls – December 2013 15 Acute and Falls risk assessment The tool assesses 8 clinical factors associated 5-10 minutes subacute scoring system with risk of falls (Age, mental status, emotional (FRASS) status, toileting, history of falling, sensory impairment, activity and medications) Criterion: Score of 8 - 14 high risk for falls; Score of 15 + SUPER HIGH risk for falls

Subacute or Peninsula Health The FRAT has three sections: Part 1—falls risk Approximately 15 – rehabilitation Falls Risk Assessment status, Part 2—risk factor checklist, and Part 3— 20 minutes setting Tool (FRAT) action plan. The complete tool (including the instructions for use) is a full falls risk assessment tool. However, Part 1 can be used as a falls risk screen. Criterion: A score of ≥12 indicates an increased risk of falls.

Subacute or Falls Risk for The FRHOP is a comprehensive risk assessment Approximately 20 rehabilitation Hospitalised Older tool that includes a broad range of falls risk minutes setting People (FRHOP) factors, most of which are graded from nil (0) to high (3) risk. The tool has accompanying strategies that can be used to develop an action list. It also has additional actions for minimising overall risk. Criterion: An overall score of 23 or more indicates high risk

Subacute or Peter James Centre The PJC-FRAT is a multidisciplinary falls risk Approximately 15 rehabilitation Fall Risk Assessment assessment tool used as the basis for developing minutes setting Tool (PJC-FRAT) intervention programs in the subacute hospital setting that successfully reduced patient or resident falls. Four main interventions are linked to the assessment: falls risk alert card, additional exercise, falls prevention education, and hip protectors. Criterion: No criterion for high falls risk. Individual risk factors identified are addressed according to guidelines. There is no consensus on which falls risk factors should be included.

ACSQHC, 2009 VQC, 2004

Preventing Falls and Harm From Falls – December 2013 16 Preventing Falls and Harm From Falls – December 2013 17