Transcript Falls - mededcoventry.com

Falls
Hussain Al-Zubaidi
Outline
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Importance of a Falls assessment
Why patients fall
Falls assessment
Criteria for CT Head
Trust Guidelines
Documentation
Big Issue at the Trust
• Every inpatient coming into hospital now has a
falls risk assessment done. The Trust also has
a monthly Risk Falls forum where
representatives from all divisions attend to
hear about what measures are being used at
other Trusts and what could be implemented
at UHCW. For example one ward is about to
start piloting new equipment after another
Trust reported that it had reduced the amount
of falls in its hospitals
Magnitude of stressor
Reasons why falling in the elderly is
more dangerous
• Multiple system impairments  Less effective
saving mechamisms
• Osteoporosis
• Secondary injury (Mainly due to post-fall
immobility)
• Psychological impact
Falls in the Hospital
• Falls are common in hospital due to
– Acutely unwell older people
– Pts with a number of chronic co-morbidities
– Unfamiliar scary environment
– Hard slippery floors
– Random equipment left to create obstacle course
Falls assessment
• History
– Before, during, after
– Associated neurological symptoms
– Previous Hx of falls & co-morbidities
– Medications (BZs, TCAs, Antipsychotics, opiates,
diuretics, Antihypertensives, hypoglycaemics)
– Current functional performance
Examination
Examination immediately after a fall is focused on identifying any injuries
and acute illness.
• ABCDE (Inc. BMs)
• EWS
• Neurological examination including sensory, motor and
Cerebellar signs
• Cardiovascular examination including ECG and postural blood
pressure and pulse
• Lower extremity joint function and muscle strength
• Gait, balance and mobility level
• Cognitive evaluation (AMTS)
• Visual acuity (Basic)
• Feet and footwear
Tests
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Bloods
Urine dip
ECG
Neuro observations
X-ray (Joint/CXR)
CT Head
– FBC
– B12 & folate
– U&Es
– Glucose
– Calcium
– Phosphate
– Vit D
CT Head Criteria
Adults perform a CT head scan within 1 hour of the
risk factor being identified:
• GCS less than 13 on initial assessment in A&E
• GCS less than 15 at 2 hours after the injury on
assessment in A&E
• Suspected open or depressed skull fracture
• Any sign of basal skull fracture
• Post-traumatic seizure
• Focal neurological deficit
• More than 1 episode of vomiting.
Causes
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Mechanical (NO NO NO)  Environmental
Confusion (Acute or Chronic)
Hypotension
Sepsis
Hypoglycaemia
Alcohol/drug Withdrawal
Urinary or bowel problems
Medication
Musculoskeletal (Balance/gait deficit)
Cardiac events including arrhythmias
Falls in hospital
• Intervention
– Treat infection, delirium, and dehydration
– Stop incriminated drugs
– Good quality footwear/walking aid
– Good lighting
– Bedside commode (especially for those with
urinary or faecal urgency or frequency.
– Ensure call bleep is to hand
– Place them in the high risk areas
Intervention
Reducing fall frequency
Preventing adverse
consequences of falls
Doctor
-Drug review
-Treat underlying cause/stressor
Doctor
- Osteoporosis detection and treatment
Physio
-Strength and balance training
-Walking aids
Physio
- Teaching patients how to get up
from a fall
OT
- Environmental assessment
and modification
OT
- Environmental assessment and
modification
Carers, family, voluntary agencies
-Reducing stressors (Like only walking indoors)
Carers, family, voluntary agencies
-Alarms
-Supervision
Trust Guidelines
• The doctors must review all patients who have fallen
• The doctors should carry out a focused history and clinical
examination of the patient with fall
• The doctors should try to establish a cause or diagnosis of the fall
• The doctors should carry out a medication review of all patients
with falls
• All patients with falls should be considered for a multifactorial falls
risk assessment
• All patients with falls should be considered for an individualised
multifactorial intervention
• All elderly patients at high risk of falls should have their osteoporosis
risk assessed and treated appropriately
• All elderly patients at high risk of falls should have their Vitamin D
level checked and treated if required
So the 8 key STEPS
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Review every fall
History + examination
Cause
Med r/v
Multifactorial assessment
Individualise your plan
Osteoporosis Risk assessment (FRAX score app_
Vit D
Multifactorial Falls Risk Assessment
• All patients with falls should be considered for a
multifactorial falls risk assessment which include:
• Focused history
• Physical examination
• Functional assessment
• Environmental assessment
Multifactorial interventions:
• The multifactorial fall risk assessment should be followed
by direct interventions tailored to the identified risk
factors, coupled with an appropriate exercise program.
Following a fall or suspected fall, the following must be
implemented:
• The medical team must review all patients who have
fallen, but injury (see below) is not suspected, within 6
hours of the fall being reported to them.
• Any patient who has a suspected head injury, spinal
injury or fracture must be reviewed within one hour of
the fall being reported to the medical team. The patient
should be moved using only the specialist equipment.
• The junior medical team must refer to their registrar if a
fracture or head/spinal injury is suspected. The registrar
will then decide whether a CT scan is appropriate
referring to the NICE guidance for head injuries CG56 for
scanning criteria (Appendix A) if required and whether to
seek advice from the neurosurgical registrar.
DOCUMENTATION
• Absolutely crucial
• For the patient and your protection
• Although it is a common event falls can
lead to severe consequences hence why
it is crucial we assess
• Inform seniors if you have any concerns
Example diagnosis
• Fall in the context of acute illness e.g. UTI, dehydration,
stroke etc…
• Accidental fall secondary to slip, trip etc.
• Fall secondary to loss of balance
• Fall secondary to syncope/ pre-syncope
• Fall secondary to significant postural hypotension
• Fall secondary to medication/ alcohol effects
• Fall secondary to chronic illness e.g. Parkinson’s
disease, dementia
• Multifactorial falls when multiple risk factors coexist
• Fall ?cause or unexplained fall