Falls Management and Prevention
This Clinical Information Sheet has been developed to assist RACF staff, medical practitioners and relevant professionals with assessing and managing a resident at the time of a fall, and reducing residents’ falls risk.
It covers:
The clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Falls
Falls occur frequently among residents of RACFs, and residents who have had previous falls are at higher risk [1]. The risk of hip fracture for nursing home residents has been estimated to be 7% per annum [1]. Falls and injury are the major reason for after hours medical care for residents, accounting for 19% of medical locum doctor visits and 40% of ambulance transfers to hospital emergency department. Nearly half (43%) residents attending ED after a fall required admission. This Clinical Information Sheet addresses the need for timely and appropriate assessment and referral of a resident at the time of a fall. It is complementary to existing falls risk assessment guidelines [7,8].
Assessment
Assessing a Resident After a Fall
For quick reference, the assessment procedure has been summarised in the Reference Card: Management after a Resident Falls.
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Procedure for Clinical Examination after a Fall [2-5]
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1. |
Determine if there is any danger to yourself in the environment, e.g. water on the floor, blood, before attending the resident. |
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Call for help using the RACF’s procedures e.g. emergency call bell or pager system. |
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Initial assessment
Conduct an immediate assessment of the resident whilst they remain on the ground, or in the position where they fell.
Quickly assess the resident’s airway, breathing and circulation to determine whether they need resuscitation. If so, follow the RACF CPR policy, resident’s advance care plan or documented NFR orders, and if appropriate contact an ambulance immediately.
Identifying the position of the resident will assist in determining parts of the body that may have sustained injury.
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Response and Level of Consciousness
Determine the resident’s response and conscious state. (see Reference Card: Neurological Observation Chart) If resident is unconscious, place the resident in the left lateral position, commence head injury observations and contact an ambulance immediately.
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Airway and Breathing
If the resident is unconscious, check the airway is clear and assess for any alterations to anatomy, chest movement and air entry and signs of cyanosis Assess the rate, rhythm, depth and effort of breathing If resident is not breathing contact an ambulance immediately. Follow the RACFs CPR policy. If resident’s breathing is unstable or irregular, apply oxygen and contact an ambulance immediately .
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Circulation
Visually inspect the resident and identify any injuries that are bleeding. Stop any bleeding by applying pressure to the wound. Assess the rate, rhythm and quality of the resident’s pulse. Take the resident’s blood pressure. Assess the severity of any wounds. If resident will require sutures, contact the resident’s GP, locum GP or an ambulance. If resident will not require sutures, assess the wound and apply an appropriate dressing to lacerations and tears.
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Assessment of Head Trauma
Visually inspect head for signs of injury. Run hands over resident’s head inspecting for signs of injury e.g. bumps. If the resident has any signs or symptoms of head injury or states that they have hit their head, commence neurological observations (use Reference Card: Neurological Observation Chart) and notify the resident’s GP or an ambulance.
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Assessment of Lower Body
Run hands over lower extremities observing for abnormalities or pain. Observe the resident for signs of a fractured neck of femur (#NOF) including shortening of leg or external rotation of leg. If these signs are present, assume the resident has a #NOF and arrange for transfer to hospital. Assess the resident for reduced range of movement of lower extremities. Consider the resident’s functional status prior to the fall. If the resident is experiencing pain, swelling, displacement, disfigurement or reduction in mobility, contact the resident’s GP or locum GP to organise an Xray.
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Assessment of Upper Body
Run hands over upper extremities observing for abnormalities or pain. Assess the resident for reduced range of movement of upper extremities. Consider the resident’s functional status prior to the fall. If the resident is experiencing pain or reduction in mobility, contact the resident’s GP to organise an Xray.
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Record a set of observations (heart rate, blood pressure, respiration rate, temperature and BSL if indicated). If the resident has any observations that are abnormal for that resident, monitor the resident’s condition closely, repeating observations half-hourly until stable. If the resident’s condition does not stabilise, contact the resident’s GP, locum GP or an ambulance. |
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Assist the resident to a comfortable position. Use a lifting machine to lift the resident – do not attempt to lift a resident off the floor. Ensure the comfort of the resident and provide counselling as required. |
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Question any witnesses to the fall to determine the likely cause of the incident. Complete an incident report according to RACF policy. An example of an appropriate incident report form is provided in the The Reference Card Incident form for reporting a resident’s fall. |
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Notify the resident’s next-of-kin or relatives. The next-of-kin should be contacted immediately if the resident has sustained an injury. If the resident has not sustained an injury contact the next-of-kin within the hours that s/he prefers to be contacted. |
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If the resident did not sustain any injuries requiring immediate contact of the resident’s GP, ensure that communication is left (according to the RACF’s policy) to inform the GP of the event the next time s/he reviews the resident. |
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Record the event in the resident’s progress notes and inform other staff members. |
Management
Management of a resident after a fall:
Provide reassurance, and immediate nursing care of injuries at the RACF; Provide analgesia and further medical treatment eg lacerations, musculoskeletal injuries; Refer for further investigations and management when required eg suspected head injuries, fractures; and Arrange follow-up to assess and reduce risk of further falls.
Consider the resident’s previous clinical condition and any Advance Care Planning requests made by the resident and/or his or her representative.
Medical Referral
The following signs and symptoms, where they are a change from the resident’s normal clinical condition, indicate prompt referral for medical treatment [3]:
Shortening of leg or external rotation of leg – referral to ambulance for hospital admission; Wounds requiring suturing – referral to GP orlocum GP; Extensive bruising, especially if the resident takes anti-coagulants – referral to GP or locum GP for assessment; Changes to resident’s vital signs – referral to GP or locum GP for assessment; and Pain and/or reduction in mobility –referral for an Xray. Determine resident’s level of immobility and pain and use clinical evidence to determine when referral to GP or locum GP is required.
If the resident has sustained a head injury, the following criteria are indications for referral to hospital:
Impaired consciousness (at any time since injury); Amnesia for the incident or subsequent events; A fall that suggests a possible penetrating brain injury; Neurological symptoms, e.g.
Severe and persistent headache; Nausea and vomiting; Irritability or altered behaviour; Seizure; Evidence of a skull fracture e.g. CSF leak; and Significant extracranial injuries; Uncertainty about the diagnosis after first assessment; and Significant medical problems, e.g. anticoagulant use [4, 6].
Collecting as much information as possible following a resident fall will help establish the cause of the fall and initiate improvements to decrease the risk of future falls. A clear description of the environment should be provided to identify any hazards that may have contributed to the resident’s fall. See Reference Card: Incident Form for Reporting a Resident’s Fall.
Prevention
Providing a safe environment
Regular auditing of the RACF’s environment can help reduce the risk of resident falls, and reviewing the environment immediately following a resident fall can assist in identification of causes of a fall and safety issues that require addressing [7].
Environmental factors may play a part in either preventing or contributing to falls and the severity of injuries caused by falls. When inspecting the environment identify and address the following:
Poor lighting; Uneven floor surfaces, e.g. slopes, steps, uplifting tiles etc; Shiny or slippery floor surfaces; Mats and rugs; Obstacles on the floor including power cords; Unstable furniture that a resident may lean on, e.g. over-bed tables; Cluttered furniture that may make it difficult to access areas of the room; Condition of equipment and furniture, e.g. broken railings, brakes that do not function; Unsafe aspects, e.g. sharp edges that may cause injury if a resident does fall or bump; Access to call bells or personal alarm e.g. is there an alert system, is it functioning, can the resident reach it, is there an adequate response time by staff members; and Condition of and access to mobility aids [7].
Reducing resident’s risk of falls
Risk assessment
Following a resident fall, comprehensive assessment of the resident should be conducted by the GP, RACF staff, physiotherapist and other appropriate health professionals in consultation with the resident and his or her relatives. This is a complex clinical area requiring a comprehensive assessment. The minimum data that is required in assessing the resident’s risk of a fall includes information on:
History of falls and pattern of injury; Confusion or altered mental state; Anxiety, mood disturbance or sleep disturbance; Sensory or visual impairment; Bowel and urinary continence; Gait and/or balance impairment; Medications; Cardiovascular status including heart rate and rhythm and postural pulse and blood pressure; Any acute conditions including infection, changes in blood glucose level [7].
It is recommended that elderly people at risk of falls and meeting the following criteria undergo a medication review:
Receiving four or more different types of medication; Taking one or more psychotropic medication (tranquillisers, antidepressants or sedative / hypnotics); Use of cardiovascular medications; With multiple medical conditions; With suspected non-adherence; With symptoms suggestive of an adverse drug reaction; Taking medications with a narrow therapeutic index; and Taking more than 12 doses of medication / day [7].
Recommendations for Reducing Falls Risk
Working to reduce the risk of resident falls is essential when caring for older adults. This is an area requiring comprehensive care planning, individual resident and environmental assessments by an experienced multidisciplinary care team. For residents in RACFs, multifaceted interventions are more likely to have an effect in reducing resident falls than implementation of a single intervention in isolation [7, 8]. In brief, the following interventions may be considered after a thorough assessment of the resident:
Reducing the number of medications where possible [8]; Reduction or cessation of psychotropic medications where possible [7]; Review of medications that have a dehydrating effect, including laxatives and diuretics [7]; Promoting the use of mobility assistive devices, e.g. frames [8]; Use of bed alarms and call bells [8]; Use of hip protectors to decrease risk of injury where a fall occurs [7, 8]; Management of any visual impairment [8]; Hard-soled, low heeled shoes [7, 8]; Individualised exercise programs with a goal of increasing muscle strength, balance and cardiovascular fitness [7]; Assessment of continence and implementation of an individualised continence management plan [7]; Restraint reduction where possible to decrease risk of serious injury if resident falls [7]; and Comprehensive nutrition assessment and development of an appropriate meal plan and supplements [7].
Falls Prevention Programs
It is recommended that each RACF implement a falls prevention program that aims to reduce the incidence of falls and injuries among its resident population. Review of resident’s falls risk after a fall could be incorporated into the facility’s falls prevention program.
Residents, relatives and RACF staff should have access to education on managing and preventing falls. Education should include information on:
The risk of falling, safety issues and activity limitations; Techniques for making position changes slowly and techniques for getting up following a fall; Balance and strength exercises/flexibility and joint stretching techniques/cardiovascular programs; Environmental modification; Use of hip protectors; and The importance of supervision and call bell/personal alarm systems [7].
Sources of Information
Where to go for more information
Individual residents can be referred for assistance with falls risk reduction to local Aged Care Assessment Services (ACAS) or hospital Falls and Balance Clinics. Some ACAS will assess a high level care resident at the RACF.
Assistance with commencing a Falls Prevention Program at the RACF can be obtained through Falls Prevention Programs located at some local municipalities or hospitals.
National Aging Research Institute
NARI is a centre for medical research (biological, clinical and service delivery) into the causes and consequences of ageing and its social accompaniments. It has conducted several studies into falls prevention, and can provide training and advice on falls prevention.
Contact: 8387 2000
Website: http://www.nari.unimelb.edu.au/
Hornsby Hip Protectors
Hornsby Ku-ring-gai Health Service Hip Protector Studies Unit has conducted significant research into the use of hip protectors as part of falls prevention programs for those residents at high risk of falling. The Unit provides free information about hip protectors. For further information, and to purchase supplies:
Website: http://www.nsh.nsw.gov.au/hornsby/hkhs/hpsumain.htm
References
S Scherer, C Jennings, M Smeaton, P Thompson, M Stein, A multidisciplinary practice guideline for hip fracture prevention in residential aged care. Australiasian Journal on Ageing, 2002. 21(4). Holloway Hostel, Fall Checklist. 2002 Roxborough Park, Falls Policy. 2004 Scottish Intercollegiate Guidelines Network, Early Management of Patients with a Head Injury. 1st ed. 2000, Edinburgh: SIGN. Joanna Briggs Institute, Aged Care Practice Manual. 2nd ed. 2003, Adelaide: JBI. National Collaborating Centre for Acute Care, Clinical Guidelines 4: Head injury Triage, assessment, investigation and early management of head injury in infants, children and adults. 1st ed. 2003, London: National Institute for Clinical Excellence. Queensland Health, Falls Prevention Best Practice Guidelines for Public Hospitals and State Government Residential Aged Care Facilities. 3rd ed. 2003, Brisbane: The State of Queensland, Queensland Health. American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention, Guideline for the prevention of falls in older persons. JAGS, 2001. 49(5): p. 664-672. National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
This CIS was based on Level I evidence produced by the National Institute for Clinical Excellence (London), and American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention as well as clinical guidelines and procedures developed by Joanna Briggs Institute and Queensland Health.
The information for assessing a resident following a fall was developed from Level I evidence on management of head injuries produced by Scottish Intercollegiate Guidelines Network, as well as Level V evidence provided by RACFs detailing the procedures currently used for immediate assessment and management of a resident who falls. Limited published information could be located on recommendations for management of a resident who falls in an RACF. Information on falls assessments and prevention was developed from a variety of Level 1 and Level IV evidence sources.
The level of evidence of all references used to compile this Clinical Information Sheet is provided in the table below.
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Reference |
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Level of Evidence |
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1 |
S Scherer, C Jennings, M Smeaton, P Thompson, M Stein |
2002 |
Level IV evidence |
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2 |
Holloway Hostel |
2002 |
Level V evidence |
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3 |
Roxborough Park |
2004 |
Level V evidence |
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4 |
Scottish Intercollegiate Guidelines Network |
2000 |
Level I evidence |
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5 |
Joanna Briggs Institute |
2003 |
Level IV evidence |
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6 |
National Collaborating Centre for Acute Care |
2003 |
Level I evidence |
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7 |
Queensland Health |
2003 |
Level IV evidence |
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8 |
American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention |
2001 |
Level I evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) [9] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (level V) for non-referenced material, e.g. developed in local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Falls Management and Prevention
The following reference cards are designed to be used in conjunction with the Falls Management and Prevention Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
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Reference Cards:
Management after a resident falls
Neurological observation chart
Incident form for reporting a resident’s fall
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