ESSENTIAL CARE AFTER AN IN-PATIENT FALL

Transcription

1 ESSENTIAL CARE AFTER AN IN-PATIENT FALL In line with the National Patient Safety Agency Rapid Response Report (NPSA/2011/RRR001): Essential care after an inpatient fall, in caring for a patient who has fallen, we have a responsibility not only to detect and treat the consequences of a fall, but its causes. In hospital patients, falls can be an indication of serious underlying illness. Nursing staff will normally be first to respond to a fall. Involvement of the appropriate medical staff must be on the basis of need, as outlined below. If medical staff or emergency services are contacted, the nurse must be clear on the area of concern and use SBAR to ensure effective communication. Immediate Safety 1. Assess patient, utilising an ABCDE approach, if acute life threatening medical emergency activate the emergency response system Ensure a full patient assessment and observations are carried out (in line with your training). Check blood glucose level using near patient testing and document all appropriate information on a FEWS chart. 3. Address any urgent problems (e.g. compromised airway, breathing difficulty, circulation/bleeding). 4. Patient must be clinically assessed for any signs of injury, including symptoms of fracture, head injury or potential spinal injury before being moved. 5. If a head injury is suspected or cannot be excluded, neurological observations must be undertaken in line with SIGN Guideline-110; Early Management Of Patients With A Head Injury and urgent medical advice sought (Appendix 1) 6. If any injuries noted, then appropriate referral must take place (e.g. medical staff or emergency services) N.B. special equipment e.g. hard collars, flat-lifting equipment, scoops may be required before moving the patient. 7. If the patient presents with signs and symptoms of a suspected fracture (e.g. severe pain; loss of sensation; absent distal pulse; limb in unnatural position) do not move the patientmake the patient comfortable on the floor and contact medical staff for advice and guidance. 8. If there is no sign of injury, including symptoms of fracture, head injury or potential spinal injury, assist the patient back to bed or chair as appropriate, following safe manual handling methods. For all but the most agile patients, hoists are likely to be required following a fall to the floor. Where patients are unable to get themselves off the floor independently, they will require to be hoisted. Where patients have sustained a fracture, in particular to the neck of femur, they will be required to be flat lifted. Staff must familiarise themselves with the location of the nearest available flat lifter so it can be utilised when required. Author: Essential Care After an Inpatient Fall SLWG Page 1 of 5 Review date: n/a

2 Treating minor injuries Nursing staff must use their clinical judgement, in the treatment of minor injures. These may include bruising; grazes and skin tears but should not hesitate to inform medical staff if they require further advice and guidance. Informing Relatives 1. The patient s next of kin / carers should be informed of the fall. a) When a patient falls and suffers significant injury (e.g. fracture) their next of kin would be contacted as soon as possible. b) For a fall with minor injury, their next of kin should be informed during normal working hours. If the patient falls during the night, they should be contacted the next morning. c) For a fall with no apparent injury, their next of kin must be informed when they next visit or telephone the ward. d) Where there is no close relative, staff should use their judgement, considering the closeness of the relationship between the patient and their most significant relative/friend. (e.g. if next of kin. is a neighbour who frequently visits patient, inform them of fall, but if next of kin is a second cousin in USA, it may not be appropriate). e) If the patient is a frequent faller, relative s preferences about phone calls subsequent to a fall (e.g. no night calls) should be discussed in advance and recorded next to their telephone number in the nursing notes. Aftercare 1. Document the circumstance surrounding the fall and action taken to reduce further falls and inform the appropriate line manager if any severe injury has been sustained. 2. Ensure that the clients handling risk assessment form is updated to reflect any changes in manual handling requirements 3. Reassess the patient using NHS Fife Falls Risk Assessment. If no extrinsic factor can be associated with a fall, medical advice and review including current medication (Appendix 2) must be sought to rule out any pathophysiological or any other contributing factors. 4. A NHS Fife Incident Report Form (IR1) must be completed following a fall or near miss as soon as possible after the incident. 5. Following a fall that results in major or extreme harm to a patient, senior management must be informed. An investigation will be undertaken by the senior management using the rapid event investigation tool (incorporated in falls and bone health toolkit) 6. Educate patient /carer in falls prevention. Author: Essential Care After an Inpatient Fall SLWG Page 2 of 5 Review date: n/a

3 Action Plan Patient must be clinically assessed for any signs of injury, including symptoms of fracture, head injury or potential spinal injury before being moved. If any injuries noted then appropriate referral must take place. This must be documented in the patients notes Safe manual handling methods must be used for patients with signs and symptoms of fracture, head injury or potential spinal injury, including the use of special equipment The frequency of neurological observations for all patients where a head injury has occurred, or cannot be excluded, are carried out in line with SIGN guideline 110 Early Management of Patients with a Head Injury Document the circumstance surrounding the fall and action taken to reduce further falls and inform the appropriate line manager Medical Staff N.B. Medical staff must review the patient s medication (Appendix2) Patient reassessed using NHS Fife Falls Risk Assessment The Patients next of kin/carer should be informed Advice and guidance can be sought from medical staff and where appropriate or emergency services Complete NHS Fife Incident Report Form Following a fall that results in major or extreme harm to a patient, the senior management must be informed. An investigation will be undertaken by senior management using the rapid event investigation tool. Author: Essential Care After an Inpatient Fall SLWG Page 3 of 5 Review date: n/a

4 The Glasgow Coma Scale (GCS) and Score Appendix 1 Management Plans: ½ hours clinical observations including GCS for first 2 hours or if GCS less than 15.* 1 hourly clinical observations including GCS for next 4 hours. 2 hourly clinical observations including GCS for next 6 hours. 4 hourly clinical observations including GCS until medical advice dictates otherwise. Nursing staff to call for a medical review if: o Development of agitation or altered behaviour. o Any decrease in GSC of one point o Development of severe or increasing headache or persistent vomiting. o New or evolving neurological symptoms and signs. For further information please refer to NHS Fife JBI Nursing Procedure Manual (on the NHS Fife intranet) and SIGN 110 Feature Scale Responses Score Notation Eye opening Spontaneous 4 To speech 3 To pain 2 Verbal response Orientated 5 Confused conversation 4 Words (inappropriate) 3 Sounds (incomprehensible) 2 Best motor response TOTAL COMA SCORE Obey commands 6 Localise pain 5 Flexion Normal 4 Abnormal 3 Extend 2 3/15 15/15 * NB: It is essential when interpreting clinical observations, including the GCS, to take into account any underlying health condition prior to the suspected head injury (e.g. Dementia) Author: Essential Care After an Inpatient Fall SLWG Page 4 of 5 Review date: n/a

5 Appendix 2 Commonly Prescribed Drugs that May Contribute to Falls This list has been based upon a review of the clinical evidence of medicines implicated in falls, including the most commonly used drugs with side effect associated with an increase in falls risk. The list is not meant to be fully comprehensive but intended to raise awareness of the types of drugs that can contribute to falls. Drugs have been graded as either a high, moderate or low risk in terms of their potential to cause falls. HIGH RISK DRUGS Antidepressants Antipsychotics including atypicals Avoid Tricyclic antidepressants esp TCAs with high anti-muscarinic activity eg Amitriptyline. SSRIs are associated with a reduced incidence of side effects in the elderly. Trial of gradual withdrawal should beattempted for all anti-depressants after 6 12 months of initial treatment. Risk of hypotension is a dose related effect reduced by the start low go slow approach. ttemptedwithdrawal MUST always be gradual to avoid precipitation of withdrawal symptoms e.g. rebound agitationetc. All antipyschotics are capable of inducing extra-pyramidal disorders although incidence is less withatypicals. The phenothiazine Prochlorperazine (Stemetil) is frequently inappropriately prescribed fordizziness due to postural instability and the most frequently implicated drug causing drug induced Parkinson s disease. Anti-muscarinic drugs (Anticholinergics) Benzodiazepines & Hypnotics Dopaminergic drugs used in Parkinsons disease Anti-muscarinic drugs are used in treatment of urinary incontinence and in Parkinson s disease. Oxybutyninmay cause acute confusional states in the elderly especially those with pre-existing cognitive impairment. Whilst complete withdrawal may not be an achievable goal there is still benefit to be gained in reducing useto the minimum effective dose. (Ref BNF). Avoid long acting benzodiazepines e.g, Nitrazepam. Newerhypnotics e.g. Zopiclone are associated with reduced hangover effects but all licensed for short-term use only. Sudden excessive daytime sleepiness can occur with Levodopa and other dopamine receptor agonists. Careful dose titration is particularly important in initiation of treatment because of additional risk of inducing confusion. As the patient ages, maintenance doses may need to be reduced. MODERATE RISK DRUGS ACE inhibitors / Angiotensin II antagonists Alpha blockers Anti-arrhythmics Anti-histamines Beta-blockers Diuretics Opiate analgesics LOW RISK DRUGS Calcium Channel Blockers Nitrates Oral anti-diabetic drugs Proton Pump Inhibitors (PPIs) & H2 Antagonists Risk of hypotension is potentiated by concomitant diuretic use. Incidence of dizziness varies from 4-12% of patients but affects twice as many patients with heart failure than hypertension. Doses used for treatment of BPH less likely to cause hypotension than those required to treat hypertension. Dizziness and drowsiness are possible signs of Digoxin toxicity risks of toxicity greater in renal impairmentor in the presence of hypokalaemia. Flecainide has a high risk for drug interactions and can also cause dizziness. Somnolence may affect up-to 40% of patients with older antihistamines e.g. Chlorpheniramine. The neweranti-histamines e.g. Desloratidine cause less sedation and psychomotor impairment. Risk of hypotension with Cinnarizine is a dose related side effect. Reports of dizziness may be due to postural hypotension and can affect up to 10% of patients. Water-solublebeta-blockers can accumulate in renal impairment and therefore dose reduction is often necessary. Postural hypotension, dizziness and nocturia are the most frequent problems seen in the elderly. Diuretics should not be prescribed for long-term use in the treatment of gravitational oedema. Drowsiness and sedation common with initiation of treatment but tolerance to these side effects is usually seen within 2 weeks of continuous treatment. Drowsiness and sedation is rare with Codeine unlessconcurrently used in combination with other drugs with CNS effects. Confusion also reported with Tramadol. Incidence dizziness low especially for once daily dihydropyridone calcium channel blockers e.g. Felodipine Dizziness may be due to postural hypotension. Advise patient to sit when using GTN spray or tablets. Dizziness due to hypoglycaemia but usually avoidable. Avoid long acting sulphonylureas e.g.chlorpropamide. Avoid Cimetidine in polypharmacy patients high risk of potential drug interactions. Cimetidine alsoassociated with causing confusion in the elderly. Reports of dizziness, somnolence are uncommon andmental confusion or blurred vision rare with the other PPIs and H2 antagonists. Adapted from: (Accessed 11th August 2011) Author: Essential Care After an Inpatient Fall SLWG Page 5 of 5 Review date: n/a