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Clinical Guidelines (Nursing)

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Falls Prevention

  • Introduction

    Falls are the most common cause of paediatric injury leading to emergency department visits. It is widely acknowledged that children are at risk of falls in the community, with many education programs supporting prevention, it is important that this education is reflected in the hospital environment. Children fall as they grow, develop coordination and new skills; often unaware of their limitations, therefore one could conclude that all children are at some risk of falling.

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    Aim

    The intention of this guideline is to raise awareness and educate nursing staff and the multidisciplinary team of the importance of maintaining a safe environment for all patients; assist with identifying patients who are high risk of fall; provide the tools to educate families and carers of the potential risk of falls and outline strategies to develop individualised management plans of care to reduce risk for high risk patients.

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    Definition of Terms

    Fall- A fall is an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.

    Anticipated falls -may occur when a patient whose score on a falls risk tool indicates she or he is at risk of falls.

    Unanticipated falls - occur when the cause of the fall is not reflected in the patient's risk factor for falls, conditions exist which cause the fall, yet these are not predictable (e.g., the patient faints suddenly).

    Accidental falls - occur when a patient falls unintentionally, usually as a result of tripping or slipping, as a result of equipment failure or other environmental factors. Patients can not be identified as being at risk for falls prior to this type of fall. 

    Risk assessment tool- a conceptual framework that organises knowledge on the aetiology of predicting falls.

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    Maintaining a safe environment for all patients

    All paediatric patients are considered at risk of falling and simple prevention strategies should be put in place to ensure the risk of injury is minimized. A safe environment should be maintained for all patients within the Royal Children's Hospital (RCH). Standard safety measures should be put place for all patients regardless of identified risk, these include:

    • Patients are nursed in an appropriate bed; children 2 years and under should be nursed in a cot
    • Orientate all patients, parents/carers to room and ward
    • Keep beds in low position with brakes on and bed ends in place
    • Side rails and cot sides are raised for appropriate age and patient groups
    • Appropriate non slip footwear for ambulating patients
    • Nurse call within reach, educate patients and families on its functionality
    • Maintain adequate lighting in child's room; low level lighting at night.
    • Keep floors clear of clutter including equipment and toys
    • Secure and supervise all children with a safety belt or harness in wheelchairs, highchairs, strollers, infant seats and any specialist seating (e.g. Tumbleforms)
    • Children on trolleys are always under the immediate and direct supervision of a staff member or a caregiver
    • Infants  in an incubator have portholes securely fastened and door closed unless directly attended 
    • Hourly rounding will support the provision of proactive care such as the need for assistance to the bathroom
    • Assist unsteady patients with ambulation; refer to physiotherapy notes where available
    • Place necessary items a patient may need within reach (drinking water, phone, etc)
    • Patients   who have received sedation or general anaesthetic may be unsteady and require supervision
    • Ensure equipment is well maintained and serviced appropriately (such as wheelchairs and commodes)

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    Educating families and carers

    Half of falls incidents within the RCH occur when a parent or carer is present. Whilst most parents are aware of maintaining a safe environment for their children in the home environment, many are unaware of the environmental risks when in hospital due to being in an unfamiliar environment accompanied with increased levels of anxiety related to hospital admission.

    The hospitalisation of children provides an opportunity to reinforce parent/carer information and education concerning normal psychological and motor development of small children, which is related to falls risks and other hazards both inside and outside hospital

    Parents/carers should be encouraged to:

    • Reinforce hospital orientation with their child
    • Provide non slip footwear for their child whilst in hospital - no mobilizing in socks
    • Maintain physical contact with infant when cot sides are down, when bathing or weighing their infant
    • Assist their child to the toilet when appropriate
    • Use bed rails or cot sides where appropriate when leaving child's bedside, even for short periods
    • Inform nursing staff when their child is unattended
    • Keep infant or child   in a suitable bed
    • Familiarise themselves the parent fact sheet to ensure they understand and are aware of   the potential risk of falls in hospitals

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    Risk Assessment

    All patients have a falls risk assessment completed using the Little Schmidy falls risk Assessment Tool completed at the following stages:

    1. On admission or as soon as practical after the admission
    2. Daily or when a patient's condition changes
    3. When the patient is transferred from one ward/department to another
    4. Following a fall incident

    The falls risk assessment score is documented in the Patient Care Record (MR856/A) in most of the inpatient areas and in the Progress Notes (MR660/A), where the Patient Care Record is not utilised. In Medical Short Stay falls risk assessment scores are captured on the Short Stay Clinical Path (MR925-81/A) or in the Progress Notes (MR660/A) when patients are using alternative clinical paths. In the Paediatric Intensive Care Unit the risk assessment score is documented in the PICU Nursing Management Plan (MR855/A).

    The falls risk assessment tool does not replace clinical judgment, if a patient does not present with a high risk score but is thought to be high risk by medical or nursing staff, allied health, parents or carers extra precautions to protect such patients should be documented and auctioned. 

    Factors influencing risk include

    • Environmental Issues: Are a common cause of falls, some examples of previous incidents at the RCH have included inappropriate use of cot side or side rails, equipment clutter, wet floors, nurse call buttons out of patient reach or the use of faulty equipment. By implementing the standard safety measures listed above these risks can be greatly reduced
    • Age: RCH incident data identified the adolescent group (10-17 years) have the highest risk of falls in hospital closely followed by the toddler group (1 -2 years). The developmental stage and ambulation capabilities are key potential fall risk factors
    • Medical Diagnosis: Various medical conditions may increase a child's risk of falling. Some high risk diagnosis includes drop seizures, severe ataxia, epilepsy surgery or patients who have had a craniectomy, for these patients soft helmets may be considered
    • Mental State: Altered mental state is the most commonly identified risk factor for falling and is perhaps the most difficult to manage in terms of minimizing the risk of falling. Use of a High/Lo bed should be considered for those with significant neurological impairment, such as, Post Traumatic Amnesia (PTA)
    • Mobility: Impaired mobility    and orthopeadic restrictions are key potential fall risk factors, interventions such as non slip footwear, supervising or assisting with transfers can reduce risk
    • Elimination: Special toileting needs are a factor for increased risk of falling. Simple strategies such as regularly checking patients and toileting patients regularly will help minimize risk
    • Bedrest: The majority of falls occur at the patient's bedside, interventions such as ensuring the bed is in a low position, the brakes are locked, appropriate use of bed rails and ensuring patients can reach necessary items will reduce the risk of falling
    • Medications: Use of medications such as Barbiturates, Phenothiazines, Sedatives, Hypnotics, Antidepressants, Laxatives and Diuretics may increase the risk of falls. Care should be taken to check the patient regularly following administration and inform the parents/carers of possible associated side effects
    • Length of Stay: RCH incident data shows that most of our patients who fall do so in the first 5 days of admission and have had previous admissions to hospital
    • History of Falls: Patients who have a history of falls in hospital or at home have an increased risk of falling again, appropriate precautions should be implemented

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    Management

    Standard safety measures should be put in place for all patients regardless of the risk identified

    Falls score equal to or greater than 3 necessitates the implementation of a Falls High Risk Management Plan. Please note this form is currently being evaluated in  Kelpie and Cockatoo Wards. Please use this form in all wards until the evaluation is complete and a formal MR is available.

    For all patients identified as high risk, i.e., those with a falls risk score of 3 or greater; a Falls High Risk Management Plan must be commenced. The plan will be developed in collaboration with the child's parent or carer and will be specific to the patient's individual needs.

    The plan will remain in use and visible in the bedside charts until the patients falls risk score changes. If the falls risk score alters a new plan will be implemented as the patients needs may have changed. Patient risk should continue to be assessed daily, once the patient's risk score is less than 3 and the patient's risk of falling is reduced, a management plan is no longer required; however it is important that a safe environment is always maintained.

    A physiotherapist can advise as to how to safely support the patient during positioning, transfers, standing, walking and use of mobility aids.

    An occupational therapist can ensure safe setup of the ward bedroom, bathroom and toilet to minimize falls risks and recommend management techniques/assistive equipment for self care tasks.

    In the event of the occurrence of a fall:

    • Ensure patient safety
    • Provide immediate supportive action for the child
    • Conduct a physical examination, measure and document vital signs
    • Commence neurological observation if the child's head was the first point of impact
    • Do not move the patient until injuries are identified
    • Notify appropriate medical staff
    • Ensure safe transfer back to bed, consider using a hoist if necessary

    Documentation of Falls event

    • Record the incident in the medical record, including: description of event (location, activity occurring, time, who was present), assessment findings, interventions and patient outcomes, notification of the incident to the parent.
    • Report the incident through the hospital incident reporting system, VHIMs. All falls, including near misses should be reported. The information from reported falls is used to gain insight of the causes of falls for patients at the RCH and continuously improve the local falls prevention program   
    • The Medical staff/AUM or NUM to inform the parents if they are not present that:
      • A fall has occurred
      • What factors contributed to the fall
      • Outcome of post-fall assessment
      • What additional protective measures have been put in place

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    Considerations for discharge

    Some patients may have a high risk score at the time of discharge. For this patient group the following should be considered:

    • Parent/carer education, tips and advice on how to manage their child in the home environment
    • An Occupational Therapy referral - to assist parents and carer in the safe setup of the home environment and recommend management techniques/assistive equipment for self care tasks.
    • A Physiotherapy referral - to educate parents and carers how to safely support their child during positioning, transfers, standing, walking and use of mobility aids.
    • High risk patients may be eligible for Post Acute Care (PAC). To make a referral complete the RCH HIP Services Referral Form and contact the intake liaison officer on extension 5674

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    Companion Documents

    • Little Schmidy Risk AssessmentTools
    • Falls- High Risk Management Plan
    • Parent Information (Kids Health Info)- Fall Safety in hospital

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    Links

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    References

    • Cooper, C L.,& Nolt, J. D. (2007) Development of an evidence-based fall prevention program. Journal of nursing care Quality, 22(2), 107-112
    • Hill-Rodriguez, D., Messmer, P R., Williams, P D., Zeller, R A., Williams, A R., Wood, M., Henry, M.The Humpty Dumpty Falls Scale: A Case-Control Study. Journal for Specialist in Paediatric Nursing. January 2009. 14(1) 22 -32
    • Harvey, K., Kramlich. D.,Chapman. J., Parker. J., Blades. E. Exploring and evaluating 5 paediatric falls assessment instruments and injury risk indicators: an ambispective study in a tertiary care setting. Journal of Nursing Management. July 2010. 18(5). 531-541.
    • Jamerson, J., Adlard, K., Akre, M., Barton, S J., Bennett, C., Brewer, M A., Bufe, G., Cooper, C L., Fields, H W., Graf,  E., Kerby, R., Hill-Rodriguez, D.Paediatric falls: State of Science.Paediatric nursing July-August 2009. 35(4),227-231
    • Keefe, S. Reducing Falls in Paediatrics - Ongoing assessment and family educationare essential to ensuring safety in the inpatient setting. 2011. 7(6), 7
    • Mc Williams, J R.Paediatric Fall Risk Assesment Tool for home health practice. Home Health Nurse February 2011. 29(2), 98-105
    • Morse, J.M. (2002) Enhancing the safety of hospitalisation by reducing patient falls. American Journal of infection Control. 30(6), 376-380.
    • Owens, P.L., Zodet, M.W.,Berdahl, T., Dougherty, D.,McCormick, M.C., & Simpson, L.A. (2008). Annual report on health ccare for children and youth in the united States: Focus on injury related-related emergency department utilizationand expenditures. Ambulatory Paediatrics, 8(4), 219-240.
    • Razmus, I., Wilson, D., Smith, R, Newman, E. (2006)Falls in Hospitalised Children.Paediatric Nursing. 32(6), 568-572
    • UCSF Medical Center-Falls Prevention Program (2005) University of California, San Francisco Children's Hospital
    • Yifan Xu.,Paediatric Patient Falls: Prevention.Evidence Summaries - Joanna Briggs Institute. Adelaide: Jan 15, 2009

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    Evidence Table

    Falls Prevention Evidence Table

    Please remember to read the disclaimer.

    The development of this clinical guideline was coordinated by Kylie Moon, Nursing Services. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published February 2012 (replacing Falls Prevention Procedure published July 2009), Reviewed February 2013.

     

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