Mercy Hospital FallPrevention EducationDeveloped by: Terri Mathew RN, BSN

Clinical EducatorProfessional Development Department

Definition of a Patient Fall?• Mercy’s policy defines a fall as: An unplanned descent to the floor (or

extension of the floor, e.g. trashcan or other equipment) with or without injury to the patient including, those that occur as a result of physiological reasons (fainting), environmental reasons (slippery floor), assisted falls- when a staff member attempts to minimize the impact of the fall.

Statistics Falls account for 1.6 million injuries in

persons over age 65, and approximately 160, 000 if these occurred in healthcare institutions.

About 30% of these falls result in serious injuries and the costs of treating these injuries equals $1.08 billion annually or approximately $15, 000-$30, 000.

Statistics The median age of a patient who falls in the

hospital is 58. Thus, patient falls clearly is not a problem exclusive to the elderly.

Patient fall can be classified as 1) accidental falls 2) anticipated physiological falls and 3) unanticipated physiological falls. Most patient falls are predictable and preventable.

Extrinsic Factors Factors that comprise conditions related to the

environment, such as flooring conditions, wheel chair locks, lighting, bedrails, room design, clutter, floor surfaces, footwear, clothing, linen, and assistive devices.

Intrinsic Factors Elimination Issues History of Falls, depression, dizziness/vertigo,

confusion Visual problems, unstable gait Medications such as, anti-arrhythmic,

antidepressants, hypnotics, benzodiazepine and major tranquilizers

How Do We Address Fall Risk Factors? Address both extrinsic and intrinsic fall risk

factors is necessary to fully optimize patient safety.

Responsibility for assessing patients for intrinsic fall risks rests squarely with nurses who assess the patients.

Hendrich II Fall Risk Model The model contains only eight risk factors and

requires only a few minutes to complete. The risk factors are confusion/disorientation,

impulsivity, symptomatic depression, altered elimination, dizziness/vertigo, gender (male), administration of antiepileptic medications, benzodiazepine medications and the assessment of their ability to get up and go!

Confusion/Disorientation/Impulsivity 4 points

The following are observational patterns or behaviors are impulsive behavior, hallucinations, agitation, inappropriate behavior, patients who are not alert or oriented to person, place or time and patient is unable to retain or receive instructions.

Symptomatic Depression2 Points

Some behaviors or symptoms that will qualify a patient as depressed: Feelings of helplessness, hopelessness, tearfulness, inappropriate behavior, flat affect, lack of interest, general loss of interest in life events, melancholic mood, withdrawn and the patient states he/she depressed.

Altered Elimination1 Points

Incontinence Urgency Diarrhea Frequent urination Nocturia Any toileting self-care deficit

Dizziness/Vertigo1 point

The patient may report the room is spinning Patient seems to sway when standing still

Male Gender1 Point

Research showed this gender factor to be an independent fall risk factor. The reason may be culture-based, men may be more likely to take risks, go it alone and ignore instructions or may not want female nurse to assist them. This factor does not apply to pediatric male patients.

Fall Risk Medications Patients that are on Antiepileptic or

Benzodiazepines will score 2 points for the antiepileptic and 1 point for the benzodiazepines.

These medications can cause dizziness and altered elimination.

Get Up and Go Test: “Rising from a Chair” Ability to rise in a single movement-No loss of

balance with steps (0 points) Pushes up to a standing position successfully in one

attempt (1 point) Multiple attempts to rise to a standing position but is

successful (3 points) Unable to rise without assistance during the test (4

points) (or if a medical order states the same and or complete bed rest is ordered) If unable to assess please document in medical record

Hendrich II Fall Risk Model

Assess patients upon admission At least once a shift and sooner if the

condition of the patient changes from the last assessment.

If the patient’s care transitions to another caregiver.

Elements of a Fall Prevention Program

Assess and Reassess Fall Risk Maintain a Safe Environment Monitor Gait and Mobility Meet Elimination Needs Deliver Patient and Family education Interdisciplinary Team Management

I. Assess and Reassess Fall Risk Continuous reassessment of patients is critical

to an effective fall prevention program The model calls for an initial assessment at

admission, followed by routine reassessment each shift, or sooner, if a patient condition changes.

II. Maintain a Safe Environment Identify individual patient care plan and safety

needs of patients based on their eyesight, hearing, cognition, gait and balance

Remove or correct harmful hazards, such as, bedside table, commodes, unlocked bed wheels, IV tubing coiled on the floor, and linen on floor.

Patient does not have call light, bedside table, eye glasses, food, drink and phone.

II. Maintain a Safe Environment Don’t block the patient’s view and path to the

bathroom, commode or other equipment used for elimination

Provide adequate lighting and ensure night lights work

Implement the use of bed alarms or tabs monitors if patient in a chair

III. Monitor Gait and Mobility Patient who wants to sit down into a chair or

bed using a walker: Have the patient grasp the walker firmly, and then, back up toward the chair or bed until the patient feels it with the backs of his/her legs. Have the patient put one hand on the walker and the other hand on the armrest or surface of the chair or bed, slowly sit down and slide backward into a safe sitting position.

III. Monitor Gait and Mobility Patients ambulating or transferring: Use a gait

belt to assist in patient movement. Explain to the patient the purpose of the belt and that the belt will be removed after transfer. Put the gait belt around the waist over clothing, with the buckle in front.

IV. Meet Elimination Needs Implement scheduled toileting matched with

the patient’s needs and or about two hours after meals and before bed. Be aware of patients receiving diuretics

Stay with a fall-risk patient when the patient is in the bathroom or on the commode

Keep the call light within easy reach of the patient and ensure it is secured to the patient. Respond immediately to patient requests.

V. Deliver Patient and Family Education

Provide the patient, family members and/or significant other with practical information drawn from the principles of an effective fall prevention program

Provide information to the family about extrinsic and intrinsic risk factors

Instruct the patient/family or significant other to exercise precaution in the event of a fall at home

Use Interdisciplinary Team Management

Fall prevention team must be multidisciplinary in nature

Caregivers must work together to address the most common opportunity for falls

What Should I Do If A Patient Falls?

Patient Assessment Notification and Communication Patient Monitoring Documentation

I. Patient Assessment Check vital signs (Apical and Radial Pulses) Assess cranial nerves Check skin for pallor, trauma, circulation,

abrasion, bruising and sensation Assess for sensation and movement in lower

extremities Assess for subtle cognition changes

I. Patient Assessment Assess pupils and orientation Observe for leg rotation, hip pain, shortening of the

extremity, and pelvic or spinal pain Note any pain and points of tenderness Determine patient’s perception of the cause of the

fall. If a server injury is suspected, stabilize the patient

position and do not move him/her from the floor until a physician has arrived and completed a medical assessment, and given orders

II. Notification and Communication Report to the physician Notify family or guardian Fill out an incident report or falls report Communicate the fall to all staff Follow hospital policy If the fall results in a sentinel event follow

hospital policy for reporting

III. Patient Monitoring and Reassessment

After the patient is rescued, perform frequent neurological checks and vital sign checks, including orthostatic vital signs.

Accompany the patient if he/she leaves the unit for radiology or other interventions.

Note all assessment findings and document in medical record.

IV. Documentation Document before the fall occurs After the Fall document all observations, if

available, of the fall, patient statement and recollection of the event, medical and nursing assessments, notifications based on individual health system policies, interventions following the fall and reassessments following the fall, and classification of the fall

In Summary Fall Prevention is everyone’s responsibility

and is a team effort Not one piece of a falls prevention will

prevent all falls but all pieces of the program will prevent fallsInformation retrieved from AHI Fall Risk Program Workbook!