Introduction and Contents

Anywhere from 20% to 50% of acute care patients and long-term care residents experience falls; many of these individuals will have recurrent falls. The typical response to a fall, in many instances, is to rule out the occurrence of any injury or lifethreatening conditions; however, many clients who fall, especially recurrently, have multiple underlying risk factors. By concentrating only on the consequences of a fall, the causative factors responsible for a fall and risk factors for further falls often go undetected. To prevent further falls, facilities need to have a comprehensive post-fall assessment program that identifies the precipitating and predisposing factors responsible for falls and proposes interventions to reduce the risk of subsequent falls. This CD-ROM has been designed to provide staff with a best-practice approach to post-fall assessments. By increasing staff members knowledge or understanding of the post-fall assessment and its components, they will be better equipped to explore appropriate solutions aimed at reducing the risk of further falls.

TABLE OF CONTENTS
A Best-Practice Approach to Fall Prevention An overview of falls and the fall prevention process Post-Fall Assessment: In-Service Lecture A PowerPoint presentation that provides staff members with an introduction to post-fall assessments Fall Prevention Program Guidelines A chart that lists the essential components of a fall prevention program An Organized Approach to Post-Fall Assessment An overview of the post-fall assessment and its components What Is a Fall? A summary of the various definitions of falling Environmental Safety Checklist A chart that lists common environmental hazards and their suggested modifications Fall Risk Factors A chart that lists the most common fall risk factors to consider in institutional settings
Essential Falls Management Series: After the Fall. by Rein Tideiksaar. 2007 Health Professions Press, Inc., Baltimore. All rights reserved.

Post-Fall Mobility Screening Tool A screening tool to assess a clients mobility Fall Report Form A form for recording the circumstances and details of a clients fall, including a postfall action plan Post-Fall Checklist A checklist to inform staff of a clients fall and risk for further falls and strategies to reduce falls Post-Fall: Care Plan Interventions A chart describing care plan recommendations based on the post-fall assessment Root Causes of Falls: Process and Organizational Factors A chart listing care process or staff and organizational root causes of falls Post-Fall Assessment Policy A document describing the step-by-step approach to post-fall assessments Family Role in Client Safety A document describing an approach to educating family members and eliciting their help in monitoring clients Post-Fall Assessment Audit Guidelines Guidelines for conducting a post-fall assessment audit

This practical guide includes all the information needed to implement a successful post-fall assessment program. Although all of the material, including the PowerPoint presentation, can be used as is, it is recommended that each facility adapt the material to meet its individual needs.

Essential Falls Management Series: After the Fall. by Rein Tideiksaar. 2007 Health Professions Press, Inc., Baltimore. All rights reserved.

Introduction and Contents

A Best-Practice Approach to Fall Prevention

LEARNING OBJECTIVES
To understand the Problem of falls Common causes and risk factors for falls Components of fall prevention Components of post-fall assessment

SCOPE OF THE PROBLEM AND COMPLICATIONS

Within acute care hospitals and long-term care facilities (e.g., nursing facilities, assisted living centers), falls constitute the single largest category of adverse events. Anywhere from 45% to 70% of clients experience one or more falls. Falls are associated with significant physical and psychological complications, including injury, both minor (e.g., bruises, sprains) and more serious (e.g., hip and other fractures, spinal cord or brain injury); immobility resulting in muscle weakness and functional disabilities, which can increase the risk of further falls (i.e., muscle weakness results in balance instability); and psychological distress (e.g., depression, fear of falling). Client falls are equally burdensome for staff (e.g., nurses, nursing aides), often leading to increased workloads (i.e., evaluating falling episodes, caring for clients post-fall) and concerns about client safety and risk of legal liability. To reduce falls, facilities need to take a number of steps: Staff must understand the conditions under which falls occur and the most frequent or common factors associated with fall risk. Fall prevention strategies can be determined once these high-risk conditions are known. Staff must implement a formal fall prevention program (see Fall Prevention Program Guidelines).

CAUSES OF FALLS
The overwhelming majority of falls are caused by a host of underlying internal risk factors (e.g., acute and chronic diseases, adverse medication effects) and/or external risk factors (e.g., hazardous environmental conditions, faulty equipment).

Essential Falls Management Series: After the Fall. by Rein Tideiksaar. 2007 Health Professions Press, Inc., Baltimore. All rights reserved.

Common Internal Risk Factors

New admission or relocation History of falls (fallen at least one time in the past 30 days or other facilityspecified time frame) Visual impairments (e.g., cataracts, macular degeneration, glaucoma) Dizziness Lower extremity dysfunction (e.g., arthritis, muscle weakness, impaired sensory function) Gait or balance impairments (e.g., due to stroke or Parkinson disease) Use of a cane or walker (ambulation aids are a marker for underlying gait and balance impairments) Elimination disorders (e.g., nocturia, incontinence) Altered mental status (e.g., dementia, depression) Polypharmacy (client takes four or more prescription drugs) Certain medications, especially drugs that affect the central nervous system, such as sedatives and tranquilizers Mobility impairments (i.e., client requires assistance with bed, toilet, chair, or wheelchair transfers)

Common External Risk Factors

Toilets without support equipment (e.g., grab bars) Inappropriate furnishings, such as beds or chairs that are not the appropriate height Slippery or uneven floors, including loose or thick-pile carpeting, sliding rugs, and highly polished or wet ground surfaces Inadequate lighting that is too dim or badly placed Improper footwear (e.g., ill-fitting shoes, slippery soles) Faulty assistive devices, such as an improper or broken cane, walker, or wheelchair Side rails on beds (i.e., rather then preventing falls, side rails increase the risk for injurious falls)

WHERE AND WHEN FALLS OCCUR

As many as half of all falls occur from or near the clients bed. Another common fall location is the bathroom, particularly during toileting. Most falls occur during the

Essential Falls Management Series: After the Fall. by Rein Tideiksaar. 2007 Health Professions Press, Inc., Baltimore. All rights reserved.

A Best-Practice Approach to Fall Prevention

early period of institutionalization or the first 72 hours of stay at a facility, during nighttime hours, and after meal times. The most frequently cited activity at the time of falling is transferring from a bed or chair. Other activities commonly associated with falls include getting up from bedside commodes and wheelchairs.

FALL PREVENTION PROCESS

The success of fall prevention, to a large extent, depends on adherence to an organized process or approach that includes the following steps.

Step 1: Assessing Fall Risk

Because many falls are a result of predictable risk factors or causes, assessing fall risk is an important starting point in attempting to reduce falls. Once clients who are most likely to fall are identified, appropriate interventions can be instituted to minimize their risk. Baseline fall risk assessments should be completed within 2 hours of an individuals admission to the facility. These individuals are subject to a change of condition at any time, including increased acuity of illness, new medications, and other comorbidity changes that can affect mobility and cognition so that fall risk factors are subject to change as well. As a result, assessment of fall risk needs to be ongoingcompleted whenever clients experience a change of condition or medication, daily or during every shift in certain high-risk individuals (e.g., recent confusion, taking sedatives, recent fall, temporary acute illness), and immediately post-fall.

Step 2: Multidisciplinary Evaluation

Following risk assessment, an attempt should be made to identify the underlying cause or causes of all of the identified risk factors. Because most clients will have multiple risk factors, multidisciplinary referral and evaluation is necessary. Identified risk factors and the results of subsequent multidisciplinary evaluations serve as the basis for selecting interventions or strategies aimed at reducing fall risk.

Step 3: Care Planning

A fall prevention program is only useful if there is also an effective treatment or intervention available. Interventions should be targeted toward identified risk factors and multidisciplinary evaluations. As risk factors change, interventions may have to change as well. The following are possible fall preventive interventions.

Medical Strategies
Disease management Medication review

Essential Falls Management Series: After the Fall. by Rein Tideiksaar. 2007 Health Professions Press, Inc., Baltimore. All rights reserved.

A Best-Practice Approach to Fall Prevention

Nursing Strategies
Anticipation of client needs Continuous supervision (observation) Toileting schedules

Rehabilitation Strategies
Gait and balance exercises Strengthening exercises Ambulation devices (e.g., canes, walkers) Wheelchairs Appropriate footwear

Environmental Strategies
Elimination of hazardous conditions Using furnishings that support mobility

Equipment Strategies
Bed/chair exit alarms Side rails (enablers) or transfer bars Hip protectors Bedside commodes Nurse call systems Low beds or floor mats (to prevent injurious falls)

Educational Strategies
Safety awareness (for client and family members)

Step 4: Monitoring
Monitoring or follow-up of the clients care plan should occur on a regular basis. The purpose of monitoring is twofold: first, to evaluate the effectiveness of interventions in reducing falls and fall risk; and second, to decide what to do next if interventions are not effective in reducing risk.

Step 5: Post-Fall Assessment

All clients who fall should receive a post-fall assessment. The purpose of this assessment is to discover what caused the fall and to prevent another fall from occurring (see An Organized Approach to Post-Fall Assessment).

Essential Falls Management Series: After the Fall. by Rein Tideiksaar. 2007 Health Professions Press, Inc., Baltimore. All rights reserved.

A Best-Practice Approach to Fall Prevention