Standard 10: Preventing Falls and Harm from Falls

1. Standard 10: Preventing Falls and Harm from Falls Accrediting Agencies Surveyor Workshop, 13 August 2012

2. Why have a Standard about reducing falls? • Falls are one of the largest causes of harm in care for older patients (> 65 years) • Acute illness, frailty, delirium and unfamiliar surroundings are significant falls risk factors in acute care • There is good evidence that a multifactorial approach to preventing falls should be a part of routine care • There is good evidence that the rate and intensity of falls can be reduced by developing and implementing individualised falls prevention plans of care based on the findings of falls screening or assessment

3. Why have a Standard about reducing falls? • A range of standard precautionary strategies should be in place for all older people in care. • This approach is based on good practice and the assumption that all older people in hospitals are at risk of falling. • Assessment (or detailed screening) will identify factors contributing to a patient’s risk of falling, and can be addressed in individualised care plans in addition to the standard precautionary strategies. • Combining standard and individualised interventions, targeting multiple risk factors, is a multifactorial approach. There is good evidence on the effectiveness of multifactorial interventions. • However, higher acuity may require more intensive long-term interventions.

4. The Standard • Clinical leaders and senior managers of a health service organisation implement systems to prevent patient falls and minimise harm from falls. • Clinicians and other members of the workforce use the falls prevention and harm minimisation systems. The intention of the Standard is to reduce the incidence of patient falls and minimise harm from falls.

5. Four criteria to achieve the Standard • Governance and systems • Health service organisations have governance structures and systems in place to reduce falls and minimise harm from falls. • Screening and assessing risks of falls and harm from falling • Patients on presentation, during admission, and when clinically indicated, are screened for risk of a fall and the potential to be harmed from falls. • Preventing falls and harm from falling • Prevention strategies are in place for patients at risk of falling. • Communicating with patients and carers • Patients and carers are informed of the identified risks from falls and are engaged in the development of a falls prevention plan.

6. 1. Governance and systems for prevention of falls 10.1: Developing, implementing and reviewing policies, procedures and/or protocols, including the associated tools, that are based on the current national guidelines for preventing falls and harm from falls. • Why? • Systems for falls prevention and harm minimisation need to be described in all facility documents and be evidence-based • The systems need organisational support and executive and clinical leadership to be successful • What? • Policies, procedures and protocols that are consistent with the Falls Prevention Guidelines (10.1.1) • Policies and supporting documents are available to the workforce (10.1.2)

7. 1. Governance and systems for prevention of falls 10.2: Using a robust organisation-wide system of reporting, investigation and change management to respond to falls incidents • Why? • Robust clinical governance frameworks and processes for evaluation, audit and feedback are important for maintaining and improving falls prevention systems. • What? • Falls incidents reports, benchmarking, data sets, reporting (10.2.1) • Use of administrative and clinical data sets (10.2.2) • Information provided to the executive (10.2.3) • Action taken to improve falls frequency and severity (10.2.4)

8. 1. Governance and systems for prevention of falls 10.3: Undertaking quality improvement activities to address safety risks and ensure the effectiveness of the falls prevention system • Why? • Responding organisationally to falls data, incidents, risk registers and risks identified through other means will maintain and improve system effectiveness • What? • Evidence of actions taken to address risks (registers detailing outcomes, quality improvement plans, workforce and patient communications) (10.3.1)

9. 1. Governance and systems for prevention of falls 10.4: Implementing falls prevention plans and effective management of falls • Why? • Plans need to be implemented to be effective and resources are required to reduce the risk of falls and subsequent harm • What? • Individualised plans are implemented, equipment inventories are maintained and clinical use audited, procurement review systems for equipment and devices are evidenced (10.4.1)

10. 2. Screening and assessing risks of falls and harm from falling 10.5: Using a best practice-based tool to screen patients on presentation, during admission and when clinically indicated for the risk of falls • Why? • Screening patients with a screening tool or standard screening process identifies patients with a risk of falling or suffering injury from falling. • Sophisticated screening can also identify individual falls risk factors. • What? • Screening policies, procedures and protocols are accessible to staff (10.5.1) • Audits of screening compliance and recording of screening outcomes which are accessible to all staff providing care (10.5.2) • Evidence of actions taken to increase the number of patients screened for falls risk (10.5.3)

11. 2. Screening and assessing risks of falls and harm from falling 10.6: Conducting a comprehensive risk assessment for patients identified at risk of falling in initial screening processes • Why? • Assessment will identify falls risk factors specific to the patient, and which can form the basis of an individualised care plan • What? • Assessment policies, procedures and protocols are accessible to staff (10.6.1) • Audits of assessment compliance and recording of assessment outcomes which are accessible to all staff providing care (10.6.2) • Evidence of actions taken to increase the number of at risk patients assessed for falls risk (10.6.3)

12. 3. Preventing falls and harm from falling 10.7: Developing and implementing a multifactorial falls prevention plan to address risks identified in the assessment Why? • Targeting individual falls risk factors reduces the rate of falls and the harm experienced from them • What? • Intervention policies, procedures and protocols are accessible to staff (10.7.1) • Care plan accessible to all care staff, audits of care plans and falls data reported(10.7.2) • Actions taken to increase the number, and effectiveness, of falls reduction interventions (10.7.3)

13. 3. Preventing falls and harm from falling 10.8: Patients at risk of falling are referred to appropriate services, where available, as part of the discharge process • Why? • Falls risk is increased for one month after discharge, so interventions to reduce the risk of falls and subsequent harm should be included in discharge planning for patients identified as having a falls risk • What? • Audits of clinical records for discharge planning, and referrals to non-acute health services (10.8.1)

14. 4. Communicating with patients and carers 10.9: Informing patients and carers about the risk of falls, and falls prevention strategies. • Why? • Relevant and usable information allows patients and carers to participate in falls prevention discussions and decisions • What? • Materials designed for patient and carer information and in a range of formats and languages (as appropriate) • Audits of information provided to patients and feedback from patients on information provided

15. 4. Communicating with patients and carers 10.10: Developing falls prevention plans in partnership with patients and carers • Why? • Effectiveness of care plans can be improved if informed by patient preferences, circumstances and interests • What? • Audits of clinical record and care plans to identify patient and carer input Links to Standard 1, Element 1.18.1, Patients and carers are partners in the planning for their treatment

16. What is the difference between screening and assessment? • Falls screening • Generally screening is a brief process of estimating a person’s risk of falling. Usually it involves reviewing only a few items (such as previous fall, mental status, vision, frequent toileting, mobility). It should occur as soon as practicable after admission (and ideally before). • Using clinical judgement is at least as good as using a screening tool. However, a tool can form part of routine clinical management which can prompt the process. A standardised format for recording screen outcomes can prompt and systematise clinical judgement screening. • It is critical that screening outcomes are routinely recorded in the medical record for use by all those involved in the patient’s care.

17. What is the difference between screening and assessment? • Falls assessment • Generally assessment is a more detailed process than screening and is used to identify underlying falls risk factors for patients that exceed the screening threshold. Assessment tools vary in the number of risk factors included and can include gait instability, lower-limb weakness, urinary incontinence or frequency, previous falls, agitation/confusion, prescription of ‘culprit’ drugs. • While no one existing falls assessment tool is recommended (or validated) for use in all hospital settings, it is preferable to adapt existing validated tools. • The critical issue is that assessment outcomes are routinely recorded in the medical record and form the basis for a care plan which is acted upon.

18. What is the difference between screening and assessment? • Screening vs. assessment • Some screening processes are sufficiently detailed to provide information about intervention strategies. This can be the case in smaller facilities where all patients are routinely screened / assessed. • If separate screening and assessment are required by the local policy, then the outcomes of both will need to be recorded in the medical record and available to other healthcare professionals providing care to the patient. • Generally re-assessment will occur again when there has been a fall, a change in health or functional status, when the environment is changed or at discharge.

19. What about patients < 65 years old? • Falls can occur at all ages • However the frequency and severity of falls, and subsequent harm, increases significantly at 65 years and older • When considering indigenous Australians, “older people” commonly refers to people aged over 50 years • Younger people can be at risk of falling, and experiencing harm, because of • a history of falls • neurological conditions • cognitive problems • depression • visual impairment • other medical conditions that alter functional ability. • Health services will need to identify younger people at risk of falling and ways of mitigating the risk

20. Summary • Purpose of the Standard is to reduce the incidence of patient falls and minimise harm from falls. • There is good evidence that identifying and responding to patients at risk of falling can reduce falls and subsequent harm. • Health services need to demonstrate that they systematically identify and respond to falls risk, and have standard falls prevention strategies in place as well as individualised care plans. • Developing patient / carer awareness of falls risk, and developing care plans in partnership with them, can improve adherence to care plans and improve health outcomes.

21. Resources • Preventing Falls and Harm from Falls in Older People: Best Practice Guidelines for Australian Hospitals 2009 • Guidebook for Preventing Falls and Harm from Falls in Older People: Australian Hospitals 2009 • Implementation Guide for Preventing Falls and Harm from Falls in Older People 2009 • Fact sheets for patients and carers, support staff, nurses, health managers, doctors, allied health professionals • www.safetyandquality.gov.au/our-work/falls-prevention/