Mercy Hospital Fall Prevention Education

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Mercy Hospital FallPrevention Education

• Developed by Terri Mathew RN, BSN
• Clinical Educator
• Professional Development Department

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Definition of a Patient Fall?

• Mercys 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.

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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.

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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.

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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.

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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

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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.

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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!

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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.

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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.

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Altered Elimination1 Points

• Incontinence
• Urgency
• Diarrhea
• Frequent urination
• Nocturia
• Any toileting self-care deficit

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Dizziness/Vertigo1 point

• The patient may report the room is spinning
• Patient seems to sway when standing still

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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.

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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.

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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

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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 patients care transitions to another
  caregiver.

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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

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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.

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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.

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II. Maintain a Safe Environment

• Dont block the patients 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

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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.

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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.

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IV. Meet Elimination Needs

• Implement scheduled toileting matched with the
  patients 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.

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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

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Use Interdisciplinary Team Management

• Fall prevention team must be multidisciplinary in
  nature
• Caregivers must work together to address the most
  common opportunity for falls

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What Should I Do If A Patient Falls?

• Patient Assessment
• Notification and Communication
• Patient Monitoring
• Documentation

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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

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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 patients 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

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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

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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.

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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

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In Summary

• Fall Prevention is everyones 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!