Fall Risk Factors Fall Prevention is Everyone s Business

Transcription

1 Fall Risk Factors Fall Prevention is Everyone s Business Part 2 Prof (Col) Dr RN Basu Adviser, Quality & Academics Medica Superspecilalty Hospital & Executive Director Academy of Hospital Administration Kolkata Chapter Risk factors for falls are 3 types: 1. Intrinsic 2. Extrinsic 3. Exposure to risk Intrinsic risk factors: History of falls Age Gender: For younger, rates are same For er, women fall more 1 2 Intrinsic Fall Risk Factors Living alone Ethnicity Evidence from UK and USA Caucasian fall more than Afro-Caribbeans, Hispanics or South Asians There is no report from continental Europe Medication: certain medications increase risk Medical conditions: Circulatory disease, COPD, depression, arthritis leading to loss of peripheral sensation, Hyperthyroidism, Diabetes Intrinsic Fall Risk Factors Impaired mobility and gait Sedentary behavior Psychological status: fear of falling Reduced physical and functional activity is associated Nutritional deficiencies Impaired cognition Visual impairement Foot problems 3 4 Extrinsic Fall Risk Factors External risk factors include: Environmental hazards Poor lighting Slippery floors Uneven surfaces Footwear and clothing Inappropriate walking aids, or Assistive devices Exposure to Risk Studies suggest a U-shaped association This reveals the complex relationship between falls, activity and risk Older person s risk taking behavior interacts with intrinsic risk factors Increased activity was associated with decreased risk of fall One study showed an opposite result Some activities increase risk of falls by increasing exposure to risky environment 5 6 1

2 Screening For Falls Risk A multifactorial approach to prevent falls should be adopted for care of er people in hospitals Screening for falls risk is a brief process of estimating a person s risk of falling It classifies people in two categories High risk of falling Low risk of falling It usually involves reviewing up to five to six brief items It is not a comprehensive assessment of falls risks It may, however, provide information about intervention strategies Falls Risk Assessment The factors contributing to a patient s increased risk of falling need to be identified There are almost 200 risk factors that can precipitate falls Some important ones are: Mobility challenges Medications Mental status, and Continence needs 7 8 The falls risk screening and assessment tool to be used must Have good predictive accuracy Have been validated, and Have been evaluated across different hospital settings Screen can be done by a member of the multidisciplinary care team Screening should occur soonest after every er person is admitted Risk scores can change quickly Repeat screening should be done When a person s health or functional status changes, and Their environment changes Many screening tools are available, such as St Thomas Risk Assessment Tool in Falling Elderly in-patients (STRATIFY) Downton index Henderich II scale Morse scale The Falls Screen Should be used to guide more detailed assessment, and Targeted intervention 9 10 The outcome of screening should be documented It should be reported to other health care staff It should also be discussed with the patient and their carers When thresh score of a screening tool is Exceeded, a fall risk assessment should be done as soon as practicable Not exceeded, the patient is considered to be at low risk of falling Standard falls prevention strategy apply Falls Risk Assessment Some factors contribute to a patient s increased risk of falling These factors need to be systematically and comprehensively identified Falls risk assessment should be done for those patients who: Exceeded the thresh of falls risk screen tool Are admitted for falls, or Are from a setting in which most people are considered to have a high risk of falls

3 A falls risk assessment should be done as soon as possible: After the patient is admitted into a high-risk setting, or If a falls risk screen exceeds the thresh It should be repeated When the patient s environment is changed When the patient s health and functional status changes After a fall When the patient is to be discharged 13 Fall is of multifactorial in nature Different members of multidisciplinary health care team should assess the fall risk Responsibility of coordination should be allocated to one specific staff member of the team If multidisciplinary team assessment is not possible, nursing staff will be primarily responsible for coordination S/he should bring in medical and other health care professionals 14 Several falls risk assessment tools have been developed for use in hospital setting In any falls risk assessment both intrinsic and extrinsic risk factors need to be considered These risk factors is related to: The patient s health Functional status Environmental factors Most tools focus on intrinsic risk factors only So a separate environmental assessment is indicated to identify extrinsic falls risk factors 15 Risk Assessment Tools: In the acute care setting Care Plan Assessment items Twelve items are included into daily care plan including:» Medications» Vision» Blood pressure» Mobility etc Time needed: 5-10 mins approximately The choice of tool depend on purpose of the tool and the setting in which it is to be used 16 In the subacute or Rehabilitation Setting Peninsula Health Falls Risk Assessment Tool (FRAT) It has 3 sections Part I Falls risk status Part II Risk Factors Check List Part III Action plan Time required is minutes A score of ± 12 indicated an increased risk of fall Falls Risk for Hospitalised Older People (FRHOP) Used mostly in Australia It is a comprehensive risk assessment tool It includes a broad range of falls risk factors Grading is done from 0 to 3 risk The tool has accompanying strategies that can be used to develop an action list Additional actions to reduce overall risk is also included in the tool Time needed: 20 minutes approximately A score of 23 or more or more than 4 items rated as high risk indicates an high risk of fall

4 In the Subacute or Rehabilitation Setting Peter James Centre Fall Risk Assessment Tool (PJC- FRAT) It is a multidisciplinary falls risk assessment tool It has assessment components by staff of Medical, Nursing, Physiotherapy and Occupational therapy Four main interventions are linked to the assessment: Falls Risk Alert Card Additional Exercise Falls Prevention education Hip Protectors Time needed is approximately 15 minutes So far there is no consensus on which falls risk factors should be included in a falls risk assessment tool Several risk factors have been identified which are more prevalent in fallers than non-fallers Therefore, more specific assessments may be indicated for some risk factors Effective programme should combine assessment with interventions Therefore, interventions to address the identified risks are applied systematically No Pt newly admitted Assess Fall Risk Factors Daily Mobility Toileting Needs Mental status Medications Environmental risks Previous falls Vision Risk factor(s) Identified? Yes No Implement Universal fall precautions plus tailored response based on each risk factor identified New fall? Perform post-fall assessment and implement changes based on assessment Implement Universal fall prevention Time for Discharge? Patient discharged Fall Prevention Algorithm Fall Prevention Interventions Good Practice Points Address Interventions to risk factors identified at admission or at discharge Screen patients for fall risk and functional ability Refer patients to concerned care for follow up prevention Managing multiple risk factors (e.g., delirium or balance problem) will have wider benefits beyond fall prevention Incident report Incident report databases Fall Prevention Interventions Recommendations Interventions A multifactorial approach to preventing falls should be part of routine care for all er people in hospitals Develop and implement a targeted and individualised falls prevention plan of care After discharge: Organise an occupational therapy home visit for people with a history of falls, to safety at home Refer patients at higher risk to an occupational therapist Fall Prevention Interventions Choosing Falls Prevention Interventions Falls prevention is a multifactorial programme Use a combination of falls prevention strategies to be delivered together Using any one intervention on its own is unlikely to prevent falls in the hospital setting All staff members as below have a role to play, Support Clinical Administrative and Managerial Patients and their care givers also, where appropriate, should be involved

5 The following interventions to be included in routine practice: Screen all people using a validated tool Identify high-risk patients by using falls risk alert cards above bed Screen eyesight Their usual spectacles should be at hand Refer to ophthalmologist in undiagnosed eye problems 25 Review medications Identify high risk medications The clinician and clinical pharmacologist to review their continued requirement Organise routine screening urinalysis Identify UTI, if any and medical review Organise routine physiotherapy review for patients with mobility difficulties, including transfers Make all staff aware about patient s mobility status Keep walking aids at the side of the bed the patient prefers Assign a bed which allows patient to get up from their preferred side 26 Orthostatic Vital Sign Measurement Measure orthostatic Vital Sign Staff Nurses and Nursing Assistants can do this: This should be done (unit protocol to be followed) After a fall When a patient complains of a symptom that may be due to orthostasis (e.g. lightheadedness) As part of a routine admission assessment on units where patients frequently take medications that cause orthostasis (e.g. geriatric psychiatry) When a patient is on a medication that may cause orthostasis and has other risk factors for fall Take necessary actions in case of significant drop in BP 27 Supervise and Provide help if required Minimise prolonged bed rest and encourage activity In rehab setting, organise physiotherapist-led exercise to improve balance (e.g., tai chi) Educate and discuss falls risks and falls prevention with all staff, patients and their carers Record falls prevention education of staff, patients and their carers Establish a plan of care to maintain bowel and bladder function 28 Instruct patients who are being discharged or transferring between facilities about their medication: Time and dose, Side effects Interaction with food and other medications Ensure that unnecessary medications are not prescribed Share medication information with all relevant medical practitioners Ensure that the environment is safe by: The bed is at the appropriate height Wheels or brakes are locked when the bed is not being moved Room is free from clutter or spills Adequate lighting as per the patient s need is supplied Orient patients about the location of their personal possession so that they can access them safely Floor surfaces are clean and dry Wet Floor signs are put whenever is required

6 Recommended Light Levels by Age Group in Lumens and [footcandles] Area or activity Hallways & Walkways 2o year 40 years 60 years 80 year 21 [2] 43 [4] 86 {8] 129 [12] Conversation 27 [3] 54 [5] 108 [10] 161 [15] Bathroom / Makeup 161 [15] 323 [30] 646 [60] 968 [90] Reading 269 [25] 538 [50] 1076 [100] 1614 [150] Kitchen counter 404 [38] 807 [75] 1614 [150] 2421 [225] Hobbies (Sewing, model building) 538 [50] 1076 [100] 2152 [200] 3228 [300] Orient patient about the bed area, room, ward or unit facilities Inform them how to get help whenever required The orientation might have to be repeated several times as the patient may not be able to retain info If assistive devices are prescribed, check patient s understanding about how to use them Develop a policy for minimal use of restraints and bed rails The policy should balance the risk of injury from falls with potential problems of using restraints Consider vitamin D supplementation with calcium for er patients routinely Determine existence of osteoporosis and manage accordingly Place high risk patients within view of, and close to the nursing station Consider hip-protectors and alarm devices (e.g., bed or chair alarms) for patients at high risk of falling How should Identified Risk Factors be used for Fall Prevention It is not enough to know which patients are at risk of fall Something about it must be done Care planning guides what you need to do to prevent fall Care planning should match identified risk factors such as mobility challenges, medications, mental status and continence needs Care planning also includes planning around patient personal needs these may not have been captured by the assessment tool 35 Fall Prevention Care Planning Care planning is a process by which the patient s risk assessment information is translated into an action plan These are patient specific Each patient has a unique risk profile These are to be integrated with the care for the condition for which the patient is admitted These are in addition to universal precautions Care plan is a written document It ensures continuity of care by all care givers It is an active document It needs to incorporate patient s response to intervention 36 6

7 Management Strategies for Common Falls Risk Factors Balance and Mobility Limitations Intervention A multifactorial falls prevention program to be used in a subacute hospital setting The programme should include exercise and assessment of need for walking aids To assess balance, mobility, and strength an assessment tool to be used to: Quantify the extent of balance and mobility limitation Guide exercise prescription Measure improvements in balance, mobility and strength Assess whether patients have a high risk of falling