F - Falls Prevention and Mx NPS 2014 v4 PDF

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ROYAL PERTH HOSPITAL

NURSING PRACTICE STANDARD FOR

FALLS PREVENTION AND MANAGEMENT FOR INPATIENTS

Version 4 Compiled: December 2004 Title: Falls Prevention and Management for Inpatients NPS Document Owner: Nursing Director Service 1 Endorsed by NPC: 24th April 2014 Authorised by: Acting Director of Nursing Robyn Kovac 23rd May 2014

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Contents Legislative Requirements.................................................................................. 6 Mandatory Requirements .................................................................................. 6 Falls Assessment .............................................................................................. 7 General Information ............................................................................... 7 Falls Risk Assessment and Management Plan (FRAMP) WA................ 7 Minimum Interventions ........................................................................... 8 Risk Assessment and Individual Interventions ....................................... 8 Documentation ....................................................................................... 9 Falls Risk Assessment and Management Plan (FRAMP) Flowchart................. 10 Bedrails ............................................................................................................. 11 General Information ...............................................................................11 Documentation ....................................................................................... 11 Post Fall ........................................................................................................... 12 Appendix I: RPH Mobility Chart......................................................................... 13 Appendix II: Patient Mobility Guidelines ............................................................ 14 Appendix III: Guidelines on Post Falls Management Summary ........................ 16

Version 4 Compiled: December 2004 Title: Falls Prevention and Management for Inpatients NPS Document Owner: Nursing Director Service 1 Endorsed by NPC: 24th April 2014 Authorised by: Acting Director of Nursing Robyn Kovac 23rd May 2014

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INTRODUCTION This Nursing Practice Standard (NPS) and e-learning on Servio Online reflect the current best available evidence in falls prevention and m anagement as applicable to Royal Perth Hospital (RPH). Relevant standard components should be applied in accordance with the needs of the individual patient. THE EVIDENCE RPH has adopted the definition for Levels of Evidence as identified by the Joanna Briggs Institute (JBI) for Evidence Based Nursing & Midwifery. In developing this NPS the feasibility, appropriateness, meaningfulness and effectiveness of evidence is considered. Level I: Evidence obtained from a s ystematic review of all relevant randomised controlled trials. Level II: Evidence obtained from at least one properly designed randomised controlled trial. Level III: Evidence obtained from well designed pseudo-randomised controlled trial Evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case-control studies or interrupted time series with a control group. Evidence obtained from comparative studies with historical control, two or more single arm studies, or interrupted time series without a parallel control group. Level IV: Evidence obtained from case series, either post-test or pre-test and post-test, expert committee reports or opinions and/or clinical experiences of respected authorities. Level IVB: Evidence obtained from local expert opinion (used only in the absence of higher levels of evidence) Available from URL: http://joannabriggs.org/jbi-approach.html#tabbed-nav=levels-of-Evidence

The logos represent the description and are used to replace the text within the NPS. Logo Description Follow the 6 Rights of Medication Administration: 4. Route 1. Patient/individual 5. Time 2. Right medication 6. Documentation 3. Dose Refer to Medication Administration NPS. Hand hygiene, which includes the use of an alcohol handrub OR a soap and water handwash, must be performed as per the 5 moments of hand hygiene: 1. Before touching a patient 5 2. Before a procedure 3. After a procedure or body fluid risk 4. After touching a patient 5. After touching a patient’s surroundings Refer to RPH Infection Control Manual. Documentation required. Refer to Documentation NPS.

Version 4 Compiled: December 2004 Title: Falls Prevention and Management for Inpatients NPS Document Owner: Nursing Director Service 1 Endorsed by NPC: 24th April 2014 Authorised by: Acting Director of Nursing Robyn Kovac 23rd May 2014

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MULTIDISCIPLINARY RESOURCES Clinical areas are to liaise with the allocated Ward Physiotherapist and/or Occupational Therapist as part of a comprehensive patient assessment. Falls E-Leaning resource available on Servio Online at: • Falls Prevention - Education (active link) Falls Team • •

Falls Clinical Nurse Consultant: Page 2365 Senior Falls Physiotherapist: Page 3012 Mental Health/Behavioural Disturbances

WSC & SPC have 24 hour cover for Psychiatric Registrar and Consultant available via switchboard (dial 91) • Older Persons Psychiatry Assessment Liaison (OPAL) Team: Page 3149 (or via e-Consult) • 65 years and older • 45 years and older for Indigenous clients Psychiatric referrals and consults can be faxed to 9224 1786 or phone 9224 3776 (contactable via switch on 91) WSC: • Emergency Department Mental Health Liaison Team (EDMHLT): contact Page 3000 • 24hrs/day 7days /week • Adult Psychiatry Consultation Liaison Team: contact on mobile: 0404 894 097 (CNS) • Mon-Fri 0800hrs-1630hrs SPC: (The following times are subject to change – please check with Clinical Nurse Manager at SPC for clarification) • Psychiatric Consultation Liaison Nurse: Contact on 0424 155 505 • Every Thursday & Friday 0800-1630 • Alternate Tuesdays 0800-1630 • Psychiatric Registrar: Contact Page 2158 • Monday – Wednesday AM & All day Thursday Drug and Alcohol Withdrawal WSC: General Hospital Referrals: Drug and Alcohol Advisory Service on mobile 0404894005 or fax consultation request to Ext 41786 Critical Care Division Referrals: Drug and Alcohol Nurse: Page 2722

Version 4 Compiled: December 2004 Title: Falls Prevention and Management for Inpatients NPS Document Owner: Nursing Director Service 1 Endorsed by NPC: 24th April 2014 Authorised by: Acting Director of Nursing Robyn Kovac 23rd May 2014

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Original Authors: Trish Baldwin CNS Surgical Division Katherine Birkett CNM Medical Specialties Division Annie Buchanan CNS Critical Care Division Margaret Charlett CNS Surgical Division Gail King CNM Medical Specialties Division Graeme Pascoe NM Medical Specialties Division Deborah Sinclair CNS Surgical Division Teresa Williams Research Nurse Review Authors: Tina Williamson – A/CNC Falls Prevention Program Safety and Quality Investment for Reform RPH Khye Davey – Senior Falls Physiotherapist Feedback Received from: Carol Watson – Acting head of Department Physiotherapy Facilitator: Sally Simpson – SDE Evidence Based Practice, The Education Centre The following 2 authors or those holding the position at that time will coordinate a f ull review of the literature relating to the prevention and management of falls in October 2016. All new evidence will then be fully evaluated and this NPS amended as appropriate for implementation in May 2017. Tina Williamson – A/CNC Falls Prevention Program Royal Perth Hospital Wellington Street Campus Tel: 9224 8529 Page 2365 Email: [email protected]

Khye Davey Senior Falls Physiotherapist Royal Perth Hospital Wellington Street Campus Tel: 9224 2250 Page 3012 Email: [email protected]

Version 4 Compiled: December 2004 Title: Falls Prevention and Management for Inpatients NPS Document Owner: Nursing Director Service 1 Endorsed by NPC: 24th April 2014 Authorised by: Acting Director of Nursing Robyn Kovac 23rd May 2014

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LEGISLATIVE REQUIREMENTS Health Practitioner Regulation National Law (WA) Act 2010 Australian Health Practitioner Regulation Agency (AHPRA) Code of Ethics for Nurses August 2008 • AHPRA Code of Professional Conduct for Nurses August 2008 • Poisons Act 1964 (Amended 2012), Poisons Regulations 1965 (Amended 2012) • The Occupational Health, Safety and Welfare Act 1984 • Carers Recognition Act 2004 • Government of Western Australia Department of Health Clinical Handover Policy 2013 THE STANDARD The Registered Nurse and Enrolled Nurse (under the supervision of a R egistered Nurse) will provide nursing interventions appropriate to the needs of the individual patient while reassessing the clinical status of the patient in response to all interventions and disease processes and in accordance with medical instructions. Additionally practice should: • Apply the Australian Nursing & Midwifery Council (ANMC) Decision Making Framework (DMF) N.B: Nurse Practitioners to comply with legislation and their scope of nursing practice • Consider cultural, ethical and c ommunication requirements for the patient. Utilise interpreter as required • Ensure information about the specific treatment or procedure is provided prior to intervention and patient consent is obtained. Refer to SMHS Consent Policy • Maintain standard precautions at all times including the use of personal protective equipment (PPE). In particular, change PPE between different care activities for the same patient to prevent cross contamination. Hand hygiene must be performed according to the RPH Hand Hygiene policy • Ensure risk to self and others is assessed and appropriate strategies to minimise risk are implemented • Ensure all findings are documented according to RPH Documentation Nursing Practice Standard and communicate to relevant staff • Comply with Single Use / Single Patient Use Medical Devices Policy • Comply with RPH Aseptic Technique Policy • Comply with SMHS Chaperone Policy MANDATORY REQUIREMENTS • Initial falls risk screen and implementation of strategies is to be performed within 10 hours on all patients who are confirmed for admission • All staff are to ensure the minimum interventions for falls prevention are adhered to at all times • All patients identified as at risk of falls to be handed over during iSoBAR handover • Staff should partner with the patient/carer to identify their individual falls risks and frequently discuss falls prevention strategies, especially when there is a change in their condition/environment • The patient’s risk and associated intervention strategies should be reassessed if a fall occurs or their medical condition changes and on transfer from another ward • All other interventions/strategies are to be documented on the Falls Risk Assessment and Management Plan (FRAMP) • •

Version 4 Compiled: December 2004 Title: Falls Prevention and Management for Inpatients NPS Document Owner: Nursing Director Service 1 Endorsed by NPC: 24th April 2014 Authorised by: Acting Director of Nursing Robyn Kovac 23rd May 2014

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Nursing Practice Falls Assessment General Information A fall is an event which results in a person coming to rest inadvertently on the ground or on a lower level 1 [Level I]. Falls are a major cause of death, injury, functional decline, hospital admission, psychological trauma and institutionalisation in older people 1,2 [Level I]. Patients in hospital who have fallen should be considered as high risk for future falls 3 [Level I]. Up to 30% of falls can lead to moderate to severe injuries, such as fractures, resulting in reduced quality of life, increased risk of early death and avoidance of activities leading to social isolation 4 [Level I]. Methods that have been proven to minimise falls rates include recognising and treating delirium, medication review and/or a multifaceted, targeted falls prevention intervention strategy 5 [Level I]. Falling has an impact on quality of life, health and health care costs 1 [Level I]. The use of a standardised assessment tool and intervention strategies within organisations can assist in the prevention of falls 6 [Level I] Falls Risk Assessment and Management Plan (FRAMP) Initial falls risk screen and implementation of strategies is to be performed within 10 hours on all patients who are confirmed for admission Each shift determine if patient: • Is a new admission or transferred from another ward/area • Is post fall (within last shift) • Has a change in their medical condition (deterioration or improvement) If No to ALL of the above - confirm appropriate interventions are in place as per Minimum Interventions and/or Individual Interventions on FRAMP If Yes to any of these, perform a falls risk screen utilising the appropriate screening criteria: Screening Criteria • Has had a fall in the past 12 months? • Unsteady when walking /transferring or uses a walking aid? • Confused, known cognitive impairment, or incorrectly answers any of the following: age, date of birth, current year and place • Has urinary or faecal frequency/urgency or nocturia? • • •

Complete the name of the assessor, designation, signature, ward, date and time of assessment If YES to ANY of screening criteria, the patient is at risk of falls. Complete Risk Assessment and Individual Interventions (see section) If No to ALL, check Minimum Interventions are in place at the bedside Initial Falls Care Plan on the FRAMP (each shift)

Version 4 Compiled: December 2004 Title: Falls Prevention and Management for Inpatients NPS Document Owner: Nursing Director Service 1 Endorsed by NPC: 24th April 2014 Authorised by: Acting Director of Nursing Robyn Kovac 23rd May 2014

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Nursing Practice Falls Assessment cont’d Minimum Interventions – to be implemented for all patients • Provide ongoing orientation for patient to bed area, toilet facilities and ward • Demonstrate the use of call bell, ensure it is in reach and that they can use it effectively • Ensure frequently used items including mobility aids are within easy reach of patient • Encourage patient to use their aids such as glasses or hearing aids • Adjust bed and chair to appropriate height for patient • Minimise prolonged bed-rest as it contributes to negative cardiovascular and muscle effects that may lead to falls • Place IV pole and all other devices/attachments on exit side of bed • Remove clutter and obstacles from room • Provide adequate lighting according to patient activities/needs • Encourage patient to take adequate fluids and nutrition • Optimise footwear where possible - discourage walking in socks/compression stockings or ill fitting footwear. Bare feet (if there is no infection risk) and non-slip socks are acceptable • Educate that all inpatients are at increased risk of falling due to injury/illness/ medications Risk Assessment and Individual Interventions A systematic approach to assessment and interventions using a collaborative approach can reduce risks of falls 7 [Level IV]. Complete a risk assessment and select individual interventions as per FRAMP: Mobility/Functional Ability • Mobility (including deficits with muscle strength, gait, balance and coordination): Muscle strength is pivotal in maintaining balance and dependability in movement. It has been suggested that lower body strength is a particularly significant and a modifiable risk factor 8 [Level I] Medications/Medical Conditions • Certain medications are identified as a precursor to falls, particularly centrally acting medications (e.g. sedatives1 [Level I], antipsychotics and antidepressants) or antihypertensive medications 1 [Level IV] • Observe for side effects especially when these medications are newly prescribed, the dose is altered or when combined with polypharmacy Cognitive State: Impaired cognition is strongly associated with increased falls risk in hospital; this includes delirium, dementia, depression, and acquired brain injury. • Establish a baseline cognitive function to determine the patient’s ability to follow instructions and engage in their care. • Reassess cognitive function when there is a change in behaviour • Alter interventions appropriately to respond to the patient’s level of dependence and cognitive function, to reduce falls risk • Consider if increased surveillance and/or equipment is required in cognitively impaired patients to closely monitor behaviour and reduce falls risk • Refer to Falls Prevention (active link) on Servio Online for Protean bed and falls alarm mat information Version 4 Compiled: December 2004 Title: Falls Prevention and Management for Inpatients NPS Document Owner: Nursing Director Service 1 Endorsed by NPC: 24th April 2014 Authorised by: Acting Director of Nursing Robyn Kovac 23rd May 2014

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Nursing Practice Falls Assessment cont’d Risk Assessment and Individual Interventions cont’d Continence/Elimination Needs Many falls in hospital occur in relation to incontinent episodes or the patient’s ability to access toileting facilities. Continence assessment and management may reduce the need for risk taking behaviour associated with avoiding an incontinent episode 1 [Level I]. • Assess the patients ability to access toilet facilities and determined if assistance with continence care is required • Discuss and implement a toileting plan with patients who require assistance with toileting or continence care Falls prevention is best managed utilising a collaborative care approach involving the patient and the multidisciplinary team. Staff should partner with the patient/carer to identify their individual falls risks and frequently discuss falls prevention strategies, especially when there is a change in their condition/environment. Refer to other allied health as necessary for further assessment and interventions. Ensure each patient’s individual risks for falling and the strategies that have been put in place as per FRAMP are included in iSoBAR handover. Documentation Complete FRAMP as appropriate Ensure FRAMP ‘shift by shift check’ is signed each shift to indicate interventions in place Document evaluation of strategies and reason for change as appropriate in the patient integrated notes Highlight “patient of concern” as a falls risk on iSOFT handover sheet

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Reference Details Safety and Quality Council. Preventing Falls and Harm from Falls in Older People. Best Practice Guidelines for Australian hospitals. Commonwealth of Australia; Canberra: 2009. Chang JT, Morton SC, Rubenstein LZ et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised controlled trials. BMJ 2004; 328(7441): 680-690. Jayasekara R. Joanna Briggs Institute (JBI). Fall assessment and intervention: Acute care setting. 16/10/2011. Department of Health, Western Australia. Falls Prevention Model of Care. Perth: Health Strategy and Networks, Department of Health, Western Australian; 2014. Healey F, Oliver D. Milne A. Connelly J. The effect of bedrails on falls and injury: a systematic review of clinical studies. Age and Ageing 2008; 37: 368-378. Delelau J, Belz M, Bungum L, Flavin PL, Harper C. Leys K, Lundquist L, Webb B. Institute for Clinical Systems Improvement (ICSI). Prevention of Falls (Acute Care). Third edition April 2012.available at: www.icsi.org Williams T, King G, Kane AM, Rajagopal M, Barnes T, Basu A, Pascoe G, Birkett K, Kidd H. Evaluation of a falls prevention programme in an acute tertiary care hospital. Journal of Clinical Nursing 2007; 16:316-324. Kunde L. Joanna Briggs Institute (JBI). Evidence summary: Falls: risk factors in the elderly. 2011 Version 4 Compiled: December 2004 Title: Falls Prevention and Management for Inpatients NPS Document Owner: Nursing Director Service 1 Endorsed by NPC: 24th April 2014 Authorised by: Acting Director of Nursing Robyn Kovac 23rd May 2014

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Nursing Practice Falls Risk Assessment and Management Plan (FRAMP) Flowchart On admission AND each shift ASSESS • • •

Has the patient been admitted or transferred from anot...