Mercy Hospital Fall Prevention Education

1. Mercy Hospital FallPrevention Education Developed by: Terri Mathew RN, BSN Clinical Educator Professional Development Department

2. Definition of a Patient Fall? • Mercy’s policy defines a fall as: An unplanned descent to the floor (or extension of the floor, e.g. trashcan or other equipment) with or without injury to the patient including, those that occur as a result of physiological reasons (fainting), environmental reasons (slippery floor), assisted falls- when a staff member attempts to minimize the impact of the fall.

3. Statistics • Falls account for 1.6 million injuries in persons over age 65, and approximately 160, 000 if these occurred in healthcare institutions. • About 30% of these falls result in serious injuries and the costs of treating these injuries equals $1.08 billion annually or approximately $15, 000-$30, 000.

4. Statistics • The median age of a patient who falls in the hospital is 58. Thus, patient falls clearly is not a problem exclusive to the elderly. • Patient fall can be classified as 1) accidental falls 2) anticipated physiological falls and 3) unanticipated physiological falls. Most patient falls are predictable and preventable.

5. Extrinsic Factors • Factors that comprise conditions related to the environment, such as flooring conditions, wheel chair locks, lighting, bedrails, room design, clutter, floor surfaces, footwear, clothing, linen, and assistive devices.

6. Intrinsic Factors • Elimination Issues • History of Falls, depression, dizziness/vertigo, confusion • Visual problems, unstable gait • Medications such as, anti-arrhythmic, antidepressants, hypnotics, benzodiazepine and major tranquilizers

7. How Do We Address Fall Risk Factors? • Address both extrinsic and intrinsic fall risk factors is necessary to fully optimize patient safety. • Responsibility for assessing patients for intrinsic fall risks rests squarely with nurses who assess the patients.

8. Hendrich II Fall Risk Model • The model contains only eight risk factors and requires only a few minutes to complete. • The risk factors are confusion/disorientation, impulsivity, symptomatic depression, altered elimination, dizziness/vertigo, gender (male), administration of antiepileptic medications, benzodiazepine medications and the assessment of their ability to get up and go!

9. Confusion/Disorientation/Impulsivity 4 points • The following are observational patterns or behaviors are impulsive behavior, hallucinations, agitation, inappropriate behavior, patients who are not alert or oriented to person, place or time and patient is unable to retain or receive instructions.

10. Symptomatic Depression2 Points • Some behaviors or symptoms that will qualify a patient as depressed: Feelings of helplessness, hopelessness, tearfulness, inappropriate behavior, flat affect, lack of interest, general loss of interest in life events, melancholic mood, withdrawn and the patient states he/she depressed.

11. Altered Elimination1 Points • Incontinence • Urgency • Diarrhea • Frequent urination • Nocturia • Any toileting self-care deficit

12. Dizziness/Vertigo1 point • The patient may report the room is spinning • Patient seems to sway when standing still

13. Male Gender1 Point • Research showed this gender factor to be an independent fall risk factor. The reason may be culture-based, men may be more likely to take risks, go it alone and ignore instructions or may not want female nurse to assist them. This factor does not apply to pediatric male patients.

14. Fall Risk Medications • Patients that are on Antiepileptic or Benzodiazepines will score 2 points for the antiepileptic and 1 point for the benzodiazepines. • These medications can cause dizziness and altered elimination.

15. Get Up and Go Test: “Rising from a Chair” • Ability to rise in a single movement-No loss of balance with steps (0 points) • Pushes up to a standing position successfully in one attempt (1 point) • Multiple attempts to rise to a standing position but is successful (3 points) • Unable to rise without assistance during the test (4 points) (or if a medical order states the same and or complete bed rest is ordered) If unable to assess please document in medical record

16. Hendrich II Fall Risk Model • Assess patients upon admission • At least once a shift and sooner if the condition of the patient changes from the last assessment. • If the patient’s care transitions to another caregiver.

17. Elements of a Fall Prevention Program • Assess and Reassess Fall Risk • Maintain a Safe Environment • Monitor Gait and Mobility • Meet Elimination Needs • Deliver Patient and Family education • Interdisciplinary Team Management

18. I. Assess and Reassess Fall Risk • Continuous reassessment of patients is critical to an effective fall prevention program • The model calls for an initial assessment at admission, followed by routine reassessment each shift, or sooner, if a patient condition changes.

19. II. Maintain a Safe Environment • Identify individual patient care plan and safety needs of patients based on their eyesight, hearing, cognition, gait and balance • Remove or correct harmful hazards, such as, bedside table, commodes, unlocked bed wheels, IV tubing coiled on the floor, and linen on floor. • Patient does not have call light, bedside table, eye glasses, food, drink and phone.

20. II. Maintain a Safe Environment • Don’t block the patient’s view and path to the bathroom, commode or other equipment used for elimination • Provide adequate lighting and ensure night lights work • Implement the use of bed alarms or tabs monitors if patient in a chair

21. III. Monitor Gait and Mobility • Patient who wants to sit down into a chair or bed using a walker: Have the patient grasp the walker firmly, and then, back up toward the chair or bed until the patient feels it with the backs of his/her legs. Have the patient put one hand on the walker and the other hand on the armrest or surface of the chair or bed, slowly sit down and slide backward into a safe sitting position.

22. III. Monitor Gait and Mobility • Patients ambulating or transferring: Use a gait belt to assist in patient movement. Explain to the patient the purpose of the belt and that the belt will be removed after transfer. Put the gait belt around the waist over clothing, with the buckle in front.

23. IV. Meet Elimination Needs • Implement scheduled toileting matched with the patient’s needs and or about two hours after meals and before bed. Be aware of patients receiving diuretics • Stay with a fall-risk patient when the patient is in the bathroom or on the commode • Keep the call light within easy reach of the patient and ensure it is secured to the patient. Respond immediately to patient requests.

24. V. Deliver Patient and Family Education • Provide the patient, family members and/or significant other with practical information drawn from the principles of an effective fall prevention program • Provide information to the family about extrinsic and intrinsic risk factors • Instruct the patient/family or significant other to exercise precaution in the event of a fall at home

25. Use Interdisciplinary Team Management • Fall prevention team must be multidisciplinary in nature • Caregivers must work together to address the most common opportunity for falls

26. What Should I Do If A Patient Falls? • Patient Assessment • Notification and Communication • Patient Monitoring • Documentation

27. I. Patient Assessment • Check vital signs (Apical and Radial Pulses) • Assess cranial nerves • Check skin for pallor, trauma, circulation, abrasion, bruising and sensation • Assess for sensation and movement in lower extremities • Assess for subtle cognition changes

28. I. Patient Assessment • Assess pupils and orientation • Observe for leg rotation, hip pain, shortening of the extremity, and pelvic or spinal pain • Note any pain and points of tenderness • Determine patient’s perception of the cause of the fall. • If a server injury is suspected, stabilize the patient position and do not move him/her from the floor until a physician has arrived and completed a medical assessment, and given orders

29. II. Notification and Communication • Report to the physician • Notify family or guardian • Fill out an incident report or falls report • Communicate the fall to all staff • Follow hospital policy • If the fall results in a sentinel event follow hospital policy for reporting

30. III. Patient Monitoring and Reassessment • After the patient is rescued, perform frequent neurological checks and vital sign checks, including orthostatic vital signs. • Accompany the patient if he/she leaves the unit for radiology or other interventions. • Note all assessment findings and document in medical record.

31. IV. Documentation • Document before the fall occurs • After the Fall document all observations, if available, of the fall, patient statement and recollection of the event, medical and nursing assessments, notifications based on individual health system policies, interventions following the fall and reassessments following the fall, and classification of the fall

32. In Summary • Fall Prevention is everyone’s responsibility and is a team effort • Not one piece of a falls prevention will prevent all falls but all pieces of the program will prevent falls Information retrieved from AHI Fall Risk Program Workbook!