Inpatient post-fall assessment proforma

Clinical management of a patient with actual or suspected head injury (sustained in hospital)¹

Nearly 27,000 falls are reported annually in Scottish Hospitals³. Whilst both falls and fracture prevention strategies are an important aspect of patient safety, what happens after the fall is equally as important. Even for the less serious falls the human cost of falling includes distress, pain, injury, loss of confidence and loss of independence, as well as the anxiety caused to patients, relatives, carers and hospital staff.

The causes of falls are complex. Hospital in-patients are particularly likely to be vulnerable to falling and resulting harm due to existing medical conditions including delirium, cardiac, neurological or muscular-skeletal conditions, side effects from medication, or problems with balance, strength or mobility.

Problems like poor eyesight or poor memory can create a greater risk of falls especially when someone is out of their normal environment on a hospital ward as they are less able to spot and avoid any hazards.

Continence problems can mean patients are vulnerable to falling while making urgent journeys to the toilet.

In the hospital setting falls should be considered an ominous ‘red flag’ as the patient’s underlying medical condition may have deteriorated requiring urgent clinical assessment regardless of injury.

Detecting and treating injuries or change in medical condition as efficiently as possible will reduce the degree of harm caused to the patient. This is particularly critical for injuries such as subdural haematoma that may progress to irreversible brain damage if not detected early, similarly a fractured hip; where minimising the time elapsed between fracture and surgery is vital to reducing mortality rates and long term disability.

The relative rarity of inpatient falls that result in serious injury (less than 1% of reported falls) can make it challenging for staff to maintain their vigilance. Despite the challenges, we have a responsibility to provide optimal care. Evidenced based guidelines can help to achieve this. The purpose of this guidance is to provide information to both nursing and medical staff on essential care after an inpatient fall. Further information is available in G108 Guidance for the Prevention and Management of Falls in All Hospital Settings⁴.

The emergency response to a fall must follow the principles of basic trauma life support. This should be carried out by the first responder (usually ward nurse)
A primary survey should be conducted looking for problems with:

Airway Breathing and Circulation, Disability Exposure.

ABCDE assessment –manage each problem as you find it - in sequence.

Airway - Is patient able to talk to you? Look for stridor (high pitched inspiratory noise caused by upper airway obstruction)

Breathing - Any shortness of breath? – count respiratory rate accurately. Measure oxygen saturation using pulse oximetry.

Circulation - Signs of shock – Is patient pale/clammy? Obtain baseline observations/NEWS Score and blood glucose.

Disability - Assess AVPU (patient’s response level: Alert, Voice, Pain, Unresponsive)
If any sign of head injury or, fall is unwitnessed wake patient to most alert state and check Glasgow Coma Scale including pupil size and reaction to light. Remember GCS < 8 the airway is not protected. Call for help.

Exposure - Visual top to toe inspection

• Mechanism of injury (fall from more than 1 metre or 5 stairs)
• Patient complaining of neck or back pain. Immobilise C-Spine and call for help
• Any limb deformity or loss of sensation, do not move, keep patient warm and call for help.

Commence neurological observations if witnessed head injury or in unwitnessed falls in patients who are cognitively impaired if any of the following are present:

• external bruising, swelling or laceration to the head
• symptoms suggesting brain injury (vomiting, headache, dizziness, altered behaviour/mental state or altered consciousness
• on any anti-coagulation (other than dalteparin 5000 U prophylaxis)
• pain or tenderness of head
• any existing coagulopathy or thrombocytopenia (platelets <50)
• recent chemotherapy (IV or oral treatment)

The following high risk factors are identified in NICE clinical guideline 176 ²:

• Age ≥ 65 years
• Coagulopathy (history of bleeding, clotting disorder), consider those on current anticoagulants/ antiplatelet, recent or current chemotherapy and patients with abnormal coagulation especially platelets less than 50. Anticoagulants include: warfarin, heparin, dabigatran, dalteparin (fragmin), enoxaparin (clexane). Antiplatelet drugs include: aspirin, clopidogrel, dipyridamole, ticagrelor⁷.
• Dangerous mechanism of injury e.g. fall from > 1 metre or 5 stairs.
• Obvious head injury (laceration, bruising, loss of consciousness, amnesia, 2 episodes of vomiting or seizure)

Patients who have been found to have a head injury or were an unwitnessed fall who cannot reliably report incident should have their vital signs and neurological observations recorded as recommended at least until formal assessment. Timings are shown below. Once the patient has been reviewed observations can be stipulated by the person responsible for clinical assessment and ongoing management however NICE recommend if required the frequency of neurological observations should be:

• ½ hourly for 2 hours
• 1 hourly for 4 hours
• 2 hourly for 6 hours
• 4 hourly till agreed no longer needed

Patients who have fallen and have not sustained a head injury should have their observations / NEWS score carried out as clinically indicated, good practice suggests, as a minimum, four hourly for 24 hours.

All patients who have fallen in hospital should be timeously assessed first by ward nurse and then by a doctor or advanced nurse practitioner (ANP).

A proforma has been developed for the use of junior medical staff and ANPs to assist with documentation, assessment and management. Copies are available on the ward and should not be printed from this guidance. The form should be made available to the reviewing practitioner and filed in the patients case notes in chronological order.

Referral

Following initial assessment referral should then be made for formal assessment to medical staff or advanced nurse practitioner using Situation Background Assessment Recommendation (SBAR) communication structure⁵.

SBAR example

Situation

My name is...................
Calling from................... state ward area.....................
Briefly state the problem........I have patient who has fallen...

Background

Patient's name....................................
Age..................
Diagnosis (if available).......................
Any relevant medicines? (See above, high risk factors).

Assessment

What is your assessment of the situation.......... the patient has sustained a head injury...or.....I suspect the patient may have sustained an injury to..... NEWS/GCS is......
Remember A to E (REsCUE)

Recommendation

What is it you want?
What are you requesting?
Think - is everyone clear about what I needs to be done?

It is not within the scope of this guideline to stipulate moving and handling procedures as these are already taught to all staff annually. However, it should be highlighted that:

• If hoists and fabric sling are used to move patients with spinal fracture, the spinal cord can be damaged.
• For a fractured hip this method could displace the fracture causing internal bleeding and severe pain and ultimately making surgical intervention more complex.
• Staff should continue to use the skills and equipment as already taught. In the rare event that a patient has to be raised from the floor with spinal cord injury or fracture hip then specific equipment is available. NHS Ayrshire and Arran has scoop stretchers that can be used with the 6 point spreader bar of the Oxford range of hoists (e.g. Major, Presence) or the Liko Golvo hoist. Ferno Lifting Scoop 65EXL.
• Liko Straps for Stretcher.

Falls can have a wide range of consequences ranging from loss of confidence to injuries which cause pain and suffering, loss of independence and occasionally death⁶. It is important to identify patients who are at risk of falling. Guidance is available for the prevention and management of falls in all hospital settings⁴. The guidance describes NHS Ayrshire & Arrans falls risk assessment tool and appropriate prevention strategies which should be implemented for all patients considered to be at risk of falls which should be implemented or updated after a fall.

For those patients who do fall despite our best efforts, care must be person centred, safe and effective. Following assessment and management of the fallen patient, staff must ensure:

• falls assessment tool is updated.
• the fall is reported via DATIX system.
• the patient’s family/next of kin are informed by the nurse on duty when the fall occurred (before contacting relatives (especially out of hours) consider firstly, the severity of injury and secondly, the time incident occurred)
• all falls should be added to the safety brief for the next shift, nurse in charge should be made aware of any patients that have fallen, with special consideration for those who suffer major injuries, to ensure timeous escalation for investigation of the incident. All falls should also be highlighted at daily safety huddle including a report of any harm sustained.
• the patient’s own medical team should be made aware of the injury as soon as is practicable.

Staff are reminded that they may have patients who require communication in a form other than English e.g. other languages or signing. Additionally, some patients may have difficulties with written material. At all times, communication and material should be in the patients preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on this guideline e.g. choice of gender of healthcare professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability that makes it difficult for them to be treated/examined as set out in the guideline requiring adaptations to be made.

Patient’s sexuality may or may not be relevant to the implementation of this guideline, however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexuality may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality and Diversity Impact Assessment Tool Kit. No additional equality & diversity issues were identified. Emergency Services have systems in place to ensure that patients attending who are not registered with a GP receive information on where to seek ongoing health care needs.

1. Hurley N et al. Oxford handbook for the foundation programme. 2nd ed. Oxford: Oxford University Press; 2008.

2. NICE. Head injury: assessment and early management. CG176. Published 22 January 2014 [Updated 13 September 2019]. Available from: https://www.nice.org.uk/guidance/cg176

3. Scottish Government. National falls and fracture prevention strategy 2019-2024 draft: consultation. 2019. Available from: https://www.gov.scot/publications/national-falls-fracture-prevention-strategy-scotland-2019-2024/

4. NHS Ayrshire & Arran. Guidance for the prevention and management of falls in all hospital settings. G108. 2021. Available from: http://athena/cgrmrd/ClinGov/DraftGuidance/G108%20Guidance%20for%20the%20Prevention%20and%20Management%20of%20Falls%20in%20All%20Hospital%20Settings.pdf

5. SBAR: Situation Background Assessment Recommendation
Available at: http://www.nodelaysscotland.scot.nhs.uk/ServiceImprovement/Tools/Pages/IT138_SBAR%20-%20SituationBackgroundAssessmentRecommendation.aspx