Development of a Post Fall policy and procedure Jennifer Clarke, RN, BScN, GNC(C)
Fall Prevention Committee members:
Nursing Education Consultant
Jennifer Clarke, N co-chair
Jewish General Hospital, Integrated Health and Social Services University Network for West-Central Montreal
Julie Valiquette, PT co-chair
Louis-François Côté, Dt
Dr Elise Levinoff, MD
Ginette Aucoin, N
Estelle Kalfon, N
Jenny Liastopoulos, N
Vanessa Fedida, OT
Francesca Klapsis, OT
Allana Goodman, OT
BACKGROUND Introduction While best practices in fall prevention are well established, a gap exists regarding evidence-based management post fall to ensure patient safety and prevent recurrences.
Goals Create an evidenced based post fall policy and procedure to guide healthcare workers in the management and follow up post fall
Specific goals • To ensure that a post fall assessment, patient management and prevention of recurrence is prompt, thorough and preformed in a standardized approach using the approved tools for monitoring and analysis • To identify the cause of the fall, minimize the consequences of the fall and target patient specific risk factors in order to prevent recurrence.
Rania Ibrahim, OT
CONCLUSION Challenges
Zovig Kevorkian, N
Maya Lallouz, PT
• More training is needed for staff on the safe transfer of patients onto a backboard and the application of a neck collar (individual training vs. a Fall Team)
Quality and Safety Improvement Advisor
Chantal Bellerose, Dpt Quality and Safety Coordinator
Evaluation
Judy Bianco, N
• Quarterly audits on tool completion and application of bedside interventions by the Fall Prevention Committee.
Associate Nursing Director
PROGRAM/POLICY AND PROCEDURE 3755, Côte Ste-Catherine, Montréal, QC h3t 1e2
1. Any staff member witnessing a fall must notify a Nurse or Physician immediately.
6. Complete the Post-Fall Analysis Checklist in preparation for the Post-Fall Huddle (PFH).
2. In the case of suspected serious injury, the patient will not be moved until first assessed by a Physician. A Nurse must stay with the patient at all times until the Physician gives the directive to transfer the patient to bed.
a) Identify the circumstances of the fall and contributing factors
3. An Incident / Accident Declaration Report form will be completed by the appropriate staff member. 4. A Post Fall huddle must be held by the interdisciplinary team which may include: Physician, Nurse, Physiotherapist, Occupational Therapist, Pharmacist, Licensed Practical Nurse and Orderly, to review the incident using the Post Fall Analysis Tool. 5. All falls are to be disclosed.
Caring for a patient who has fallen 1. Assess the environment for any imminent danger which may have caused the fall before approaching the fallen patient. 2. Prior to moving the patient, perform a head to toe assessment verifying for any signs and symptoms of serious injury, including hip fracture, spinal injury, intracranial bleeding or internal bleeding. Perform initial vital signs and neurological vital signs if needed as per Post Fall Evaluation and Monitoring Checklist. 3. a) For a patient who is suspected of a serious injury, perform interventions as per chart. b) For a patient who is not injured but is unable to stand without minimal assistance: Ensure appropri ate equipment (i.e. hoist or lift) and expertise. 4. Perform ongoing monitoring and assessment using the Post-Fall Evaluation and Monitoring Checklist.
grille d’evaluation et de surveillance Post-chute Post-fall Evaluation and monitoring ChECklist
Grille d’analyse post-chute Post-fall analysis CheCklist 1.
Date de l’évaluation initiale: Date of initial evaluation:
CirConstanCes de la Chute / CirCumstanCes of fall
Date et heure de la chute: Date and time of fall:
aa / MM / JJ yy / mm / DD
Il y a-t-il des témoins de la chute ? Was the fall witnessed
oui
non
n yes n no
Description de l’événement par le patient (indiquer N/A si le patient ne peut pas décrire la chute) Patient’s description (indicate n/a if pt unable to describe what happened)
7. As soon as patient is stable, hold a huddle with members of the interdisciplinary team. a) Review the circumstances of the fall and contributing factors b) Review actions taken; highlight appropriate actions and identify areas of improvement if needed c) Review adjustments to plan of care and Fall Assessment & Preventive Interventions tool d) Ensure all interdisciplinary members are in agreement with new plan of care 8. Provide ongoing assessment of patient’s ability to mobilize and possible post-fall fear of mobilizing during activities such as bathing, dressing, getting out of bed and going to the bathroom. The majority of falls in the health care setting occur during these activities. 9. Place a “falling leaf” logo on the wall above the patient’s bed if this is a recurrent fall. 10. Monitor and document the patient’s response to the interventions as per the Fall Prevention Policy and Procedure.
Next steps Présomption de blessure à la tête si : head injury suspected if :
AA / MM / JJ YY / mm / dd Divulgation faite si applicable n Disclosure if applicable
Formulaire d’analyse post-chute complété n Post-fall analysis form completed
Patient ne peut confirmer l’absence de blessure à la tête
n Incident Report filled (AH-223A)
n Patient unable to confirm absence of head injury Nouveau changement de l’état mental
S’IL vouS PLAît coMPLéter Le verSo SI une BLeSSure à LA tête eSt SuSPectée. PlEasE fill in thE othEr sidE if hEad injurY is susPECtEd.
Heure / Time Intervale de temps après la chute (heures) time interval after the fall (hours) Changement de l’état mental Oui Non Change in mental status Yes } * No } N
n New change in mental status
Date
lieu : indiquer l’unité/milieu clinique location: indicate unit/clinical area ___________
Chaise Chair
Chambre du patient n Patient’s room
Chaise régulière n Regular chair
Toilette
Chaise Broda
n Bathroom
n Broda chair
Douche
Corridor
n Hallway
Chaise d’aisance Commode
n Cane
Béquilles
n
Devant le poste des infirmiers(ères)
n ou la chaise d’aisance
En pivotant dans la toilette
Se coucher/se lever du lit
n Pivoting in bathroom
Se pencher pour prendre quelque chose
En entrant dans la toilette n Entering bathroom
n Reaching for something at bedside Assis sur une chaise
n Sitting on chair
2.
Se lever d’une chaise
n Getting up from chair
Est-ce que l’aide à la marche était en bon état? Assistive device in good condition?
Marcher
n Ambulating Autre Other
D-1-96400 Nov 2012
non no
oui yes
n
non no
n
oui yes
n
non no
Légende legend
Changement au niveau des résultats de laboratoire
Quelles mesures de contention étaient utilisées : Which restraint(s) in use:
n Sudden change in blood values
Cloche d’appel à portée du patient
chaussures lors de la chute footwear at time of fall
Encombrement
Nu-pieds n Barefoot
Plancher mouillé
n Patient’s own socks
n Call bell within patient’s reach n Clutter/obstacles n Wet floor
Hauteur du lit Bed height
bas
n low
Position des ridelles : Side-rail(s) position:
Opiacés
Pantouffles d’hôpital
n Antihistamines
Antihistaminiques
n
Antiarhythmiques
Anticonvulsivants
n Anticonvulsants
Souliers
État mental et comportement avant la chute Mental status and behavior prior to fall Alerte et orienté n Alert & oriented
n
Autre Other
Antidépresseurs
Antipsychotiques
n Antipsychotics
Trouble de vision
n Visual impairment
n
Trouble d ’audition
n Hearing impairment
Confus
n Confused Si désorienté, dans quelle(s) sphère(s) : If disoriented, in which sphere(s):
Douleur Manque d’équilibre
Diurétiques n Diuretics
n Pain
n Loss of balance
n
Faiblesse
n Dizziness
Agressif
n Deconditioned
Peu coopératif
Se sentant souffrant/faible n Feeling unwell/weak
n Uncooperative n
Manque de jugement Lack of insight/judgment
n
Autre Other
Élimination elimination
n
Nouvel essoufflement New onset shortness of breath
n
Autre Other
}H
n none
Situer sur le schéma à l’aide d’un Locate on the diagram with an
}X
n none
aucun aucune
signaturE
page 1 de/of 2
grille d’evaluation et de surveillance Post-chute Post-fall Evaluation and monitoring ChECklist
Date
Heure / Time Intervale de temps après la chute time interval after the fall
Graphique des signes neurologiques complété Neurological graphic sheet completed
0
15 min
30 min
45 min
1h
2h
4h
6h
Légende / legend Information à documenter dans les Notes d’évolution / * = Information to document in the progress Notes
8h
12 h
16 h
20 h
24 h
28 h
32 h 48 h
(3)
douleur à la tête pain to the head
Oui Non Yes } * No } N
Nausées, vomissements Nausea, vomiting écoulement de sang / de liquide clair via les oreilles, le nez, la bouche blood / clear fluid from the ears, the nose, the mouth
Oui Non Yes } * No } N Oui Non Yes } * No } N
Évaluation initiale / initial evaluation
Laxatifs Laxatives
Schéma / Diagram
4. recoMMandations / reCoMMendations SVP compléter un nouvel « Outil d’évaluation du risque de chute et mesures de prévention » lors du caucus postchute et appliquer le nouveau plan d’intervention. Please complete a new “Fall Risk Assessment and Preventive Interventions Tool” in post-fall multidisciplinary huddle and apply selective interventions to practice.
equipement utilisé lors de la chute equipment in use at time of fall
Incontinence
D-1-61405 Oct 2012
Patient déconditionné
Situer sur le schéma à l’aide d’un Locate on the diagram with an
Douleur Pain init.
Étourdissements
Agité
n Aggressive
signaturE
Hématome hematoma
Ajustement du PTI (Plan thérapeutique infirmier) (3) Adjustment of theTNp (Therapeutic Nursing plan) initiales initials
Antiparkinsoniens Antiparkinsonians Médicaments pour la maladie d’Alzheimer
n Alzheimer drugs
n Weakness n Agitated, restless
Hypnotiques Hypnotics
n Antidepressants
condition du patient lors de la chute Patient condition at time of fall
Pour une plaie ou une lacération, svp se référer au formulaire de suivi de soin des plaies. For a wound or laceration please refer to the wound care flow sheet. localisation sur le schema / loCation on diagram Plaie, lacération Situer sur le schéma à l’aide d’un aucune L n none Wound, laceration Locate on the diagram with an }
évaluation et documentation du site et de l’intensité de la douleur (3) Intensity & location of pain evaluated and documented Céphalée Oui Non headache Yes } * No } N Alignement des extrémités Anormal Normal Alignment of extremities Abnormal } * Normal } N déformation des extrémités Oui Non Deformity of extremities Yes } * No } N Mobilité et amplitude du mouvement des extrémités Anormal Normal Mobility and range of Abnormal } * Normal } N motion of extremities évolution de la plaie post-chute Oui Non Changes to the wound post-fall Yes } * No } N
Antihypertenseurs Antihypertensives
n Antiarrhythmics
Bas anti-emboliques n Anti-embolic stockings
Information à documenter dans les Notes d’Évolution /
• The development of pilot projects to improve communication of fall prevention strategies amongst all health care workers (poster)
Changement de l’état mental Oui Non Change in mental status Yes } * No } N évaluation et documentation des signes vitaux (3) Vital signs evaluated and documented
Sédatifs
n Sedatives
n Slippers from home
n
Autre Other
Benzodiazépines Benzodiazepines
Chaussettes du patient
n Shoes
Cordons ou fils encombrants
n Cords or wires in the way
traitement treatment
Analgésie contrôlée par le patient
n
Pantouffles du patient
haut
n high
prophylaxie prophylaxis
n Opiates
n Hospital slippers
Éclairage insuffisant
n Poor lighting/lights off
n n
n Patient-Controlled Analgesia
Nouveau symptôme en investigation
n New symptoms being investigated
environnement lors de la chute environment at time of fall
Patient anticoagulé : Patient on anticoagulation:
Nouvelles prescriptions dans les 24 h : New prescriptions in the last 24 hrs:
Nouveau diagnostic
n New diagnosis
• Further development of strategies to identify recurrent fallers (ID bracelet)
comPlétez cette Page seulement en cas de blessure à la tête ComPlEtE this PagE for hEad injury only
Médicaments Medications
Apport nutritif insuffisant
n Poor po intake/appetite
Schéma / Diagram
REFERENCES page 1 de/of 2
changement récent de la condition du patient (dans les 24 h) recent change in patient condition (within 24 hrs)
• Post Fall awareness campaign to accompany the Fall Prevention campaign; “Fall in the Fall”
évaluation initiale initial evaluation
48
* = Information to document in the Progress Notes
init.
Facteurs contribuants / Contributing faCtors
chutes antérieures
utilisation de mesures de contention use of restraints
24
PtI (absence de blessure à la tête) / tnP (absence of head injury) 3 Risque de détérioration post-chute / Surveillance selon la Grille d’évaluation et de surveillance post-chute. Risk of deterioration post-fall / Monitoring as per Post-fall Evaluation and Monitoring Checklist. 3 Cesser problème prioritaire si approprié (min. 48 hres) / Cesser l’évaluation. Discontinue priority problem if appropriate (min. 48 hrs) / Discontinue evaluation. 3 Patient à risque de chutes relié à une chute en milieu hospitalier (indiquez la date de la chute) / Se référer à l’Outil d’évaluation du risque de chute et mesures de prévention. Patient at risk for falls secondary to fall in hospital (indicate date of fall) / refer to Fall Assessment & Preventive Interventions Tool.
stratégies de prévention des Chutes déJà Mises en plaCe / fall Prevention strategies alreaDy in PlaCe
Grille d’analyse post-chute Post-fall analysis CheCklist
n history of falls
n
n
n
SVP vous référez à « l’Outil d’évaluation du risque de chute et mesures de prévention ». Est-ce que le plan d’intervention a été respecté ? Please refer to the most recent “Fall Risk Assessment and Preventive Interventions Tool”: Was the intervention plan respected? oui non n yes n no
Aller à la toilette n Going to the bathroom
3.
Le patient utilisait-il l’aide à la marche de façon adéquate ? Was pt using it appropriately?
Getting up/sitting down on toilet or commode
n Getting in/out of bed
Autre Other
Le patient utilisait-il une aide à la marche recommandée ? oui n yes Was pt using the recommended assistive device?
En se levant/en s’asseyant sur la toilette
Autre Other
activité lors de la chute activity at time of fall
16
Déformation des extrémités Oui Non Deformity of extremities Yes } * No } N Mobilité et amplitude du mouvement des extrémités Anormal Normal Mobility and range of Abnormal } * Normal } N motion of extremities Évolution de la plaie post-chute Oui Non Changes to the wound post-fall Yes } * No } N Ajustement du PTI (Plan thérapeutique infirmier) (3) Adjustment of theTNP (Therapeutic Nursing Plan) initiales initials
Canne
n Crutches
toilette / élimination Bathroom / elimination
n In front of nursing station
n
n
Les freins étaient appliqués oui non n yes n no Brakes were on (si chaise roulante, Broda ou chaise d’aisance) (if wheelchair, Broda or commode)
n Shower
n
n
Marchette n Walker
8
Évaluation et documentation des signes vitaux (3) Vital signs evaluated and documented Évaluation et documentation du site et de l’intensité de la douleur (3) Intensity & location of pain evaluated and documented Céphalée Oui Non Headache Yes } * No } N Alignement des extrémités Anormal Normal Alignment of extremities Abnormal } * Normal } N
utilisation d’aides à la marche lors de la chute use of assistive devices at time of fall Chaise roulante Wheelchair
0
• Implementation of the Post Fall Policy and Procedure hospital wide
Absence de témoins lors de la chute
n No witnesses during the fall
Rapport d’incident complété (AH-223A)
Médecin avisé
n Physician notified
b) List actions taken c) Identify necessary adjustments to individualized plan of care and create/update Fall Assessment & Preventive Interventions tool
• Weekly audits on tool completion and application of bedside interventions by unit managers
3755, Côte Ste-Catherine, Montréal, QC h3t 1e2
PTI (blessure à la tête) / tnP (head injury) 3 Risque de détérioration post-chute avec blessure à la tête / Surveillance selon la Grille d’évaluation et de surveillance post-chute avec blessure de la tête Risk of deterioration post-fall with head injury / Monitor as per post-fall Evaluation and Monitoring Checklist, head injury. 3 Cesser problème prioritaire si approprié (min. 48 hres) / Cesser l’évaluation. Discontinue priority problem if appropriate (min. 48 hrs) / Discontinue evaluation. 3 Patient à risque de chutes relié à une chute en milieu hospitalier (indiquez la date de la chute) / Se référer à l’Outil d’évaluation du risque de chute et mesures de prévention. patient at risk for falls secondary to fall in hospital (indicate date of fall) / refer to Fall Assessment & preventive Interventions Tool. localisation sur le schema / loCation on diagram Plaie, lacération Situer sur le schéma à l’aide d’un Wound, laceration Locate on the diagram with an } L
n
aucune none
Hématome hematoma
Situer sur le schéma à l’aide d’un Locate on the diagram with an
}h
n
aucun none
Douleur Pain
Situer sur le schéma à l’aide d’un Locate on the diagram with an
}X
n
aucune none
init.
signaturE
Une tige de pompe intraveineuse
n Incontinence
n IV pole
Urgence
Signature
Tubulure d’oxygène
n Urgency
n Oxygen tubing
Fréquence
n Frequency
Sonde urinaire
Titre Title
Autre Other
Date Date
n Urinary catheter
Utilisation de culotte d’incontinence (ex. couches)
n Use of adult briefs (eg. diapers) D-1-96400 PILOT Nov 2012
n
Heure Time
signature
title
Pour une plaie ou une lacération, svp se référer au formulaire de suivi de soin des plaies. For a wound or laceration please refer to the wound care flow sheet. page 2 de/of 2
Grille d’analyse post-chute Post-fall analysis CheCklist
date
tiMe
D-1-61405 Oct 2012
grille d’evaluation et de surveillance Post-chute Post-fall Evaluation and monitoring ChECklist
page 2 de/of 2
Anderson K., Morley, W. (2008). Policy and Protocol for the Assessment and Management of Adult Hospital Patients with Falls. National Health Service (NHS) Lothian, UK. Retrieved January 25, 2013 from: http://www.nhslothian.scot.nhs.uk CDC - Falls among the older adults: An overview. The Center for Disease Control (2012). Retrieved February 5, 2013 from: http://www.cdc.gov/HomeandRecreationalSafety/ Falls/adultfalls.html Courtney, K., (2011). Implementing Post-Fall Huddles. University of Massachusetts. Retrieved January 25, 2013 from: http://scholarworks.umass.edu/nursing_dnp_capstone/8 Currie L., (2008). Fall and Injury Prevention: Chapter 10. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US). Retrieved February 25, 2013: http://www.ncbi. nlm.nih.gov/books/NBK2653/ Fenton W., (2008). Introducing a post-fall Assessment Algorithm into a Community Rehabilitation Hospital for Older Adults. Nursing Older People. Vol 20:1 Hook, M.L., Winchel, S., (2006). Fall related Injuries in Acute Care: Reducing the Risk of Harm, MEDSURG Nursing. Vol 15:6. Fitzpatrick , M., Jorgensen, J., Forte, J., … Esper-Kanze, C., (2011). Best Practices for Falls Reduction: A Practical Guide Special Supplement to American Nurse Today Vol. 6 (2) National Institute for Clinical Excellence (2004). Clinical practice guideline for the assessment and prevention of falls in older people. Clinical Guideline No. 21. London: Royal College of Nursing (UK). Retrieved on February 15, 2013 from: http://www.ncbi.nlm. nih.gov/books/NBK55851/ National Health Service (2011). Essential care after an inpatient fall: Supporting Information. Rapid Response Report NPSA/2011/RRR001. Retrieved on February 21, 2013 from: http://www.nrls.npsa.nhs.uk Management (2011). The Initial Management of Closed Head Injury in Adults, 2nd Edition. RNOA Best Practice guideline (2011). Prevention of Falls and Fall Injuries in the Older Adult. International Affairs & Best Practice Guidelines United States Department of Veterans Affairs. Safe patient handling and movement (2010). Retrieved February 5, 2013 from: http://www.visn8.va.gov/PatientSafetyCenter/safePtHandling ASSTSAS (2015). PDBS. Retrieved August 10, 2015 www.asstsas.qc.ca/fiches-pdsb.html
