Guidelines Published by the Metropolitan Health and Aged Care Services Division Disclaimer Victorian Government Department of Human Services This document should not be considered prescriptive. Health Melbourne Victoria care staff should work with patient/residents and their July 2004 families/carers to ensure that the most appropriate care and ' Copyright State of Victoria, Department of Human Services, 2004 treatment is provided to the individual. Some flexibility will be required to adapt these Guidelines to specific settings, local This publication is copyright. No part may be reproduced by any process except in accordance with the circumstances and to individual patient/resident needs. provisions of the Copyright Act 1968. Every effort has been made to ensure that the information Design by Watts Design. 3290 provided in this document is accurate and complete at the time of development. However the Victorian Quality Council, the authors, or any person that has contributed to its development do not accept liability or responsibility for any errors or omissions that may be found, or any loss or damage incurred as a result of relying on the information in this document. Victorian Quality Council Secretariat Phone1300 135 427 [email protected] websitehttp://qualitycouncil.health.vic.gov.au VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Contents of this Guidelines Pack THE GUIDELINES A process model for minimising the risk of falls and fall-related injuries Guideline statements relating to the steps in the process model IMPLEMENTATION SUPPLEMENT The VQC is developing a generic change and implementation best practice model due to be released before the end of 2004 TOOLS SUPPLEMENT Information about tools for minimising the risk of falls and fall-related injuries Examples of tools for use with the four steps of the process model EDUCATION SUPPLEMENT Training units and case studies to support the use of the process model A table recommending specific units and case studies for different healthcare services job roles RESEARCH SUPPLEMENT Details of the research findings used to support the development of these Guidelines WARD KIT Quick Reference Guide: descriptions of falls risk factors and actions for minimising risk Posters: key steps and information from the Guidelines The following symbols are used throughout the Guidelines Pack. These symbols indicate that further information is available in the relevant supplement. 01 1. INTRODUCTION 3 Step 3 Develop and Implement an Action List 15 Purpose of these Guidelines 4 Definition 15 Who these Guidelines are intended for 4 Guideline Statement for Step 3 15 Using these Guidelines in the different settings 4 Patient/resident centred tasks for Step 3 15 Research findings and levels of evidence 4 Organisational tasks for Step 3 15 Definition of a ÒfallÓ 5 Rationale for Step 3 16 Differences in implementing Step 3 across the three settings 16 2. PROCESS MODEL FOR MINIMISING Actions for minimising personal risk factors 16 THE RISK OF FALLS AND FALL-RELATED INJURIES 6 Actions for minimising individual environmental risk factors 32 About the process model 6 Step 4 Respond to a falls incident appropriately 37 The four patient/resident-centred care steps 7 Definition 37 Tools for use with the steps 7 Guideline Statement for Step 4 37 Patient/resident centred tasks for Step 4 37 3. THE PATIENT/RESIDENT CENTRED CARE STEPS 8 Organisational tasks for Step 4 37 Step 1: Conduct falls risk screen 9 Rationale for Step 4 38 Definition 9 Differences in implementing Step 4 across the three settings 39 Guideline Statement for Step 1 9 Patient/resident centred tasks for Step 1 9 4. THE PROCESS MODEL AND Organisational tasks for Step 1 10 QUALITY IMPROVEMENT 40 Rationale for Step 1 10 Differences in implementing Step 1 across the three settings 10 5. REFERENCES 41 Step 2: Conduct falls risk assessment 11 Definition 11 6. GLOSSARY OF TERMS 42 Guideline Statement for Step 2 11 Patient/resident centred tasks for Step 2 11 ACKNOWLEDGMENTS 45 Organisational tasks for Step 2 12 Rationale for Step 2 12 Differences in implementing Step 2 across the three settings 12 Personal risk factors identified in the literature 12 Individual environmental risk factors identified in the literature 14 02 01 Introduction n o i t c u Minimising the Risk of Falls & Fall-related Injuries Guidelines for Acute, Sub-acute and d Residential Care Settings is an initiative of the Victorian Quality Council (VQC). o The development of the Guidelines Pack is one component of a strategic approach to reducing the risk of harm and improving health care quality and safety in Victoria, including: r t Establishing a Safety and Quality Framework, Providing Access to Better Data, Educating n on Safety and Quality and Responding to Known Problems and Risks. I Falls, related injuries and loss of confidence due to fear of falling are common causes of morbidity in Australia. In hospital and residential care settings, the risk of falling is even greater than in the community setting, because of acute illness, increased levels of chronic disease, and different environments and routines. Research evidence indicates that interventions to minimise falls risk can reduce the risk of falling and fall-related injuries, even in older people with high risk of falling. Staff involved in direct care in hospital and residential care settings have a key role in successful implementation of falls risk minimisation activities. More information about the consequences and costs of falls and fall-related injuries is given in the Research Supplement. 03 Purpose of these Guidelines Using these Guidelines in emergency departments The purpose of these Guidelines is to assist direct Forty-five percent of older people who attend a hospital emergency department after a fall are discharged care staff and others responsible for ensuring quality without admission. Emergency department staff have an important role in identifying the ongoing fall risks for of care, to put in place an effective program for these patient/residents, as well as initiating appropriate referrals or interventions that may reduce the risk of minimising the risk of falls and fall-related injuries. future falls and hospital presentations. The information provided is based on the best These Guidelines may provide a useful framework for staff in emergency departments. available evidence at the time of publication. Research findings and levels of evidence Who these Guidelines are intended for These Guidelines are based on research evidence and, where no formal research evidence exists, on expert These Guidelines have been developed for those opinion and the findings of expert working parties. who deliver, and are responsible for, patient/resident Guideline Statements have been identified for the four patient/resident-centred care steps in the process care. This includes clinical, management, corporate model. and environmental serviceÕs staff. The research methodology is described in the Research Supplement. Using these Guidelines in the different Levels of evidence of effectiveness settings The evidence for the guideline statements presented in these guidelines was systematically assessed and Although a broadly similar approach may be taken classified according to the National Health and Medical Research CouncilÕs (NHMRC) Guide to the to minimising the risk of falls and fall-related injuries Development, Implementation and Evaluation of Clinical Practice Guidelines [1]. in the different settings, circumstances may call for different strategies in: Levels of evidence of effectiveness describe the strength of the research evidence supporting each recommended strategy to reduce the risk of falls or fall-related injuries. From strongest to weakest, the levels acute and sub-acute hospital settings, and of evidence used for the Guideline Statements in this document are shown in the following table: hospital and residential care settings. Table 1. Levels of evidence used for the Guideline Statements These Guidelines have been structured as a global Level of Description resource for use across all three settings, where evidence differences exist, they are identified and described I Evidence obtained from a systematic review of all relevant randomised controlled trials separately. II Evidence obtained from at least one properly designed randomised controlled trial Use of the terms “patient”, “resident” and “client” For the purpose of this document the term ÒpatientÓ III - 1 Evidence obtained from well designed pseudo-randomised controlled trials (alternate allocation refers to both patients and clients in acute and or some other method) sub-acute settings. ÒResidentÓ has been used to III - 2 Evidence obtained from comparative studies with concurrent controls and allocation not refer to people receiving care in residential care randomised (cohort studies), case control studies, or interrupted time-series with a control group settings. III - 3 Evidence obtained from comparative studies with historical controls, two or more single-arm studies, or interrupted time series without a parallel control group IV Evidence obtained from case series, either post-test or pre-test and post-test. 04 For the purposes of this project, the term Consensus Opinion has been used to describe evidence based on consensus of expert opinion and the findings of expert working parties. VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Definition of a “fall” General environmentalrisk factors — related to For the purposes of these Guidelines, a fall is hazards that are outside the patient/residentÕs defined as: immediate area, but in places where the patient/resident goes at times (eg corridors, ÒA sudden, unintentional change in position causing therapy areas). an individual to land at a lower level, on an object, the floor, the ground or other surface [2].Ó The interaction between the individual and their environment can be considered a third type of risk This includes: factor — also called behavioural risk factors. The slips being lowered nature of the activities performed (how difficult or tiring they are) and the way patient/residents perform trips loss of balance them (safely or not) will influence their risk of falling. falling into other people legs giving way. If a patient/resident is found on the floor, it should be assumed that they have fallen unless they are cognitively unimpaired and indicate that they put themselves there on purpose. It is recommended that a common definition is adopted for use across health services and within a specific setting. For further definitions of a ÒfallÓ see the Research Supplement. Falls risk factors Falls risk factors are characteristics or behaviours that make it more likely that a patient/resident will fall. Falls risk factors can broadly be considered as: Personal(intrinsic) risk factors relate to health problems that increase the patient/residentÕs risk of falling. Environmental (extrinsic)risk factors relate to hazards in the environment that increase the patient/ residentÕs risk of falling (eg bed brakes not locked). These risk factors have been sub-divided into: Individual environmentalrisk factors — related 05 to hazards in the patient/residentÕs immediate area 02 Process model for minimising l e d the risk of falls and fall-related injuries o m Tools Steps in minimising the risk of falls Tools Steps in minimising the risk of falls and fall-related injuries and and fall-related injuries On Admission 1 CONDUCT Falls Risk Screen Ddaeivlye lcoapr ep lfaonr pfoartient/ On Admission 1 CONDUCT Falls Risk Screen Ddaeivlye lcoapr ep lfaonr pfoartient/ About the process model Falls Risk Screen Does the level of the patient/resident's risk rreisskident with low falls Falls Risk Screen Does the level of the patient/resident's risk rreisskident with low falls The process model exceed the threshold? (the threshold is NNOO exceed the threshold? (the threshold is NNOO s dependant upon the tool used) dependant upon the tool used) presents four steps for assessing YYEESS YYEESS AANNDD//OORR** AANNDD//OORR** s and managing patient/residents to 2 CONDUCT Falls Risk Assessment Review/revise plan 2 CONDUCT Falls Risk Assessment Review/revise plan minimise their risk of falls and fall- Falls Risk for daily care routinely, Falls Risk for daily care routinely, Assessment Have the risk factors been assessed or cued by: Assessment Have the risk factors been assessed or cued by: e related injuries, and comprehensively for this patient/resident? • patient/resident falling comprehensively for this patient/resident? • patient/resident falling • change in patient/ • change in patient/ identifies tasks and products that resident's health/ resident's health/ QI CYCLE c result from carrying out the steps. Action List for 3 DEVELOP & IMPLYYEEEMSS ENT • fcuhnacntgioen ianl pstaattieunst/ Action List for 3 DEVELOP & IMPLYYEEEMSS ENT • cfuhnacntgioen ianl pstaattieunst/ Canoalllaytsee,, manodn itfeoer,d back falls incident data. minimising falls an Action List for minimising the risk resident's environment minimising falls an Action List for minimising the risk resident's environment Feedback to staff/ o ainnjudr ifeasll-related of falls and fall-related injuries and ainnjudr ifeasll-related of falls and fall-related injuries and management on data. INCLUDE the list in the patient/resident’s INCLUDE the list in the patient/resident’s plan for daily care plan for daily care Upgrade tools and process in response r Do the selected actions match the Do the selected actions match the to findings. P pthaet ieanctt/iorenssi dbeenetn’s i mrispkl efmacetnotresd a ansd phaarvte o af ltl he YYEESS pthaet ieanctt/iorenssi dbeenetn’s i mrispkl efmacetnotresd a ansd phaarvte o af ltl he YYEESS plan for daily care? plan for daily care? IIFF AA PPAATTIIEENNTT// IIFF AA PPAATTIIEENNTT// RREESSIIDDEENNTT FFAALLLLSS RREESSIIDDEENNTT FFAALLLLSS Falls Incident 4 RESPOND to a falls incident Review circumstances Falls Incident 4 RESPOND to a falls incident Review circumstances Report appropriately: of the fall at ward/unit Report appropriately: of the fall at ward/unit a) Care for patient/resident level a) Care for patient/resident level b) Report the incident b) Report the incident c) Repeat steps 1/2 and 3 of this module c) Repeat steps 1/2 and 3 of this module Ward/Unit Level Ward/Unit Level 06 Were the appropriate actions taken? Falls Incident Data Were the appropriate actions taken? Falls Incident Data * In some settings, the Screening component may be omitted, and the Model commences with Assessment (Step 2) YYEESS Organisation meets quality improvement requirements VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES The four patient/resident centred care steps The four steps are integral to an effective program to minimise the risk of falls and fall-related injuries in hospitals and residential care settings. The four steps are: Patient/resident Description centred care step Screening Identifying patient/residents who are at greatest risk of falling and in need of more detailed assessment. Assessment Identifying the falls risk factors that contribute to the patient/residentÕs overall risk of falls and fall-related injuries. Intervention Developing and implementing an individualised Action List aimed at reducing the risk of falls and fall-related injuries. Appropriate response The appropriate response to a falls incident includes caring for the patient/resident if a fall occurs and ensuring that the incident is reported and documented. Tools for use with the steps The Tools Supplement includes a selection of tools that can be used for these steps. The term ÔToolsÕ refers to a range of support documentation and resources used in implementing programs to minimise the risk of falls and fall-related injuries. These include: falls risk screening tools Victorian CoronerÕs Standard for Investigation (of falls related deaths) falls risk assessment tools cognitive impairment tests, and environmental audits (both individual and general) falls incident data management framework (Excel file). falls incident report patient/resident information resources list of medications associated with increased falls risk 07 03 The patient/resident centred ts n p care steps e e d t is s e e r r / a t nc e d i t e a r P t n e c 08