person’s behaviour or condition) and extrinsic (factors that relate to a person’s environment or their interaction with the environment). Intrinsic factors include: Previous fall Postural instability, muscle weakness Cognitive impairment, delirium and disturbed behaviour Urinary frequency and incontinence Postural hypotension Medications Visual impairment Some risk factors (e.g. confusion, unsafe gait and antidepressant medications) are associated with an increased risk of multiple falls in hospital. Extrinsic factors include: Environmental risk factors (most falls in hospital occur around the bedside and in the bedroom) Time of day (falls commonly occur at times when observational capacity is low – i.e. shower time and meal times and outside visiting hours). Item Background Information and Key 10 Evidence details A snapshot of studies that have reported fall data Reference ABPG p14 Further No further on on
As part of a multifactorial program for patients with increased risk of falls in hospital, conduct a systematic and comprehensive multidisciplinary falls risk assessment to inform the development of an individualised plan of care to prevent falls. ABPG p29 Item Risk Identification and Intervention Section 10.6.1 10.7.1 1.8.2 Evidence details All implementation should be documented to ensure that health professionals involved in the patients care are aware of planned and current falls prevention interventions and the basis for them. Reference SQIG p21 Further No further Item Risk Identification and Intervention Section 10.6.1 10.7.1 1.8.2 Evidence details You should have in place effective falls prevention and harm minimisation plans that rely on comprehensive screen and assessment (where appropriate), the identification of all potential risks, and the development of tailored prevention plans for patients at risk of falling. Reference SQIG p22 Further No further Item Mobility Risks 10.6.1 Evidence details Nil Reference Nil Further No further Item Require assistance with mobility/transfer? Evidence details Postural instability and muscle weakness are risk factors for falling in hospital. Reference ABPG p15 Further No further Item Have poor coordination, balance, gait or uncorrected visual impairment? 10.6.1 Evidence details Postural instability and muscle weakness are risk factors for falling in hospital. Reference ABPG p15 Further No further Item Have poor gait or uncorrected visual impairment? 10.6.1 Evidence details Use hospitalisation as an opportunity to screen Reference ABPG p83 Further No further
Item Discuss and confirm with the patient what level of level of assistance they require (including mobility aids), and/or their need to call and wait for assistance NSQHS Evidence details Implicit in the multifactorial approach is the engagement of the patient and their carer(s) (where appropriate), as the centre of any falls prevention program. Reference ABPG p15 Further No further Item Discuss and confirm the patient what level of of assistance they (including and/or their need to call and for assistance Evidence details A high percentage of falls are unwitnessed. Reference ABPG p14 Further No further Item Refer to Physiotherapist for a comprehensive mobility assessment 10.7.1 Evidence details Organise routine physiotherapy review for patients with mobility difficulties, including transfers. Reference ABPG p23 Further No further Item Refer to for a assessment 10.7.1 Evidence details Patients considered to be at higher risk of falling should be referred to an Occupational Therapist and a Physiotherapist for needs training specific to the home environment, to maximise safety and continuity from hospital to home. Reference ABPG p21 Further No further Item Refer to Occupational Therapist (OT) for functional assessment 10.7.1 Evidence details Patients at higher risk of falling should be referred to an Occupational Therapist for needs and training specific to home environment and equipment. Reference ABPG p21 Further No further Item Medications/ Medical Conditions Risks 10.6.1 Evidence details Nil Reference Nil Further No further Item Has the patient been prescribed: Nil Evidence details Nil Reference Nil Further No further
Item Psychoactive medication e.g. benzodiazepines, antipsychotics or antidepressants? Nil Evidence details A number of studies have shown an association between medication use and falls in older people. Reference ABPG p78 Further No further Item Psychoactive e.g. benzodiazepines, antidepressants? N/A Evidence details A number of factors can affect an older person’s ability to deal with and respond to medication, which can lead to an increased risk of falls. Reference ABPG p78 Further No further Item New or old medication that may affect their blood pressure? Nil Evidence details Certain classes of medication are more likely to increase the risk of falls. Reference ABPG p78 Further No further Item Does the patient take greater than 5 medications of any sort? Nil Evidence details Taking more medications is associated with an increased risk of falls. Reference ABPG p78 Further No further Item Does the patient report dizziness or presented following a fall/collapse? Nil Evidence details Dizziness in the hospital setting remains a difficult diagnostic problem because it has many potential causes and may result from disease in multiple systems. Reference ABPG p72 Further No further Item Does the report dizziness or presented a Nil Evidence details Patients who report unexplained falls or episodes of collapse should be assessed for the underlying cause. Reference ABPG p67 Further No further Item Interventions 10.7.1 Evidence details Nil Reference Nil Further No further Item Liaise with Medical Officer (MO) or 10.7.1 Evidence details Review medication, particularly high risk medications such as sedatives, antidepressants, Reference SQIG p21. Further See note under “Other Individualised Interventions” p22.
Pharmacist for review of medication associated with falls antipsychotics and centrally acting pain relief. Item Liaise with Officer (MO) or Pharmacist for of with falls 10.7.1 Evidence details Older people admitted to hospital should have their medications (prescribed and non-prescribed) reviewed and modified appropriately (and particularly in cases of multiple drug use). Reference ABPG p77 Further information Also: see note under “Other Individualised Interventions” p22. Item Liaise with Officer (MO) or Pharmacist for of with falls 10.7.1 Evidence details Patients psychoactive medication should have their medication reviewed and, where possible, discontinued gradually to minimise side effects and reduce their risk of falling. Reference ABPG p77 Further information Also: see note under “Other Individualised Interventions” p22. Item If reporting dizziness, check lying/standing blood pressure. If a drop >20mmHg systolic or 10mmHg diastolic is present, discuss plan of care with MO 10.7.1 Evidence details Monitor and record postural blood pressure. Reference ABPG p69 Further No further Item If reporting dizziness, check If a drop systolic or 10mmHg is present, discuss of care with MO N/A Evidence details Assessment and management of postural hypotension and review of medications, including medications associated with pre-syncope and syncope should form part of a multifactorial assessment and management plan. Reference ABPG p67 Further No further Item Educate patient to stand 10.7.1 Evidence details Encourage patient to sit up slowly from lying, stand Reference ABPG p69 Further No further
despite the use of different measures of depressive symptoms and falls and varying length of follow-up and statistical methods. difference between community samples and those with identified healthcare needs with respect to depressive symptoms being a risk factor for falls. Item Interventions 10.7.1 Evidence details Nil Reference Nil Further No further Item Establish a baseline cognitive screen. For example the abbreviated Mental Test (AMT) or as per local guidelines. 10.7.1 Evidence details Identifying the presence of cognitive impairment should form part of the falls risk assessment process. Reference ABPG p37 Further No further Item Establish a baseline screen e.g. Abbreviated Test (AMT) or as per local 10.7.1 Evidence details Think of cognition as another vital sign that needs to be monitored. Reference ABWTC (clinicians) p5 Further No further Item If result abnormal (e.g. AMT <8) refer to OT or MO for prompt review. 10.7.1 Evidence details The screening tool is not expected to diagnose, but to detect cognitive impairment and to trigger further investigation and action. Reference ABWTC(9) (Managers) p40 Further The score for an abnormal result will depend the tool/s in use at each site. For instance for the AMT 4 any score <4 will be abnormal and a trigger for further review. Item If result (e.g. AMT <8) to OT or MO for 10.7.1 Evidence details Treat medical conditions that may contribute to an alteration in cognitive status. Reference ABPG p51 Further The score for an abnormal result will depend the tool/s use at each site. For for the AMT 4 any score <4 will be abnormal and a trigger for further Item If result (e.g. AMT <8) to OT or MO for 10.7.1 Evidence details Older patients with a progressive decline in cognition should undergo a detailed assessment Reference ABPG p51 Further The score for an abnormal result will depend the tool/s use at each site. For for the AMT 4 any score <4 will be abnormal and a trigger for further
so treatment can be provided to the reversible causes. Item Remain in attendance at all times when the patient is toileting or showering as this is a high risk activity for the patient. 10.7.1 Evidence details A staff member should remain with patients with cognitive impairment and a high risk of falls while the patient is in the bathroom. Reference ABPG p97 Further No further Item If agitated commence behaviour observation chart to assist behaviour management plan. 10.7.1 Evidence details Identify causes of agitation, wandering and impulsive behaviour, and reduce or eliminate them. Reference ABPG p53 Further No further Item Avoid use of bedrails due to climbing/ entrapment risk and consider low-low bed. 10.7.1 Evidence details Minimise the use of restraint and bedside rails. Reference SQIG p21 Further No further Item use of bedrails due to risk and consider bed. 10.7.1 Evidence details Avoid the use of physical restraints as they make delirium worse and increase the risk of falls. Reference ABWTC (clinicians) p28 Further No further Item Set an alarm system in place to alert when patient is trying to get up unaided. 10.7.1 Evidence details Use fall alarm devices to alert staff that patients are attempting to mobilise. Reference ABPG p52 Further No further Item Re-orientate patient and 10.7.1 Evidence details Establish orientation programmes using Reference ABPG p53 Further No further
ask family to assist in orientating and settling patient. environmental cues. Repeat orientation and safety instructions regularly. Item Re-orientate patient and ask family to assist in and settling patient 10.7.1 Evidence details Encourage family members or carers to spend time sitting with the patient. Reference ABPG p97 Further No further Item Increase frequency of patient checks to proactively attend to patient needs. 10.7.1 Evidence details Place high-risk patients within view of, and close to, the nursing station. Reference SQIG p21 Further No further Item frequency of checks to proactively attend to patient needs 10.7.1 Evidence details Falls commonly occur at times when observational capacity is low. Reference ABPG p15 Further No further Item frequency of checks to proactively attend to patient needs 10.7.1 Evidence details Provide more frequent observation, supervision and assistance to ensure that older patients with delirium or dementia who are not capable of standing and walking safely receive help with all transfers. Reference ABPG p52 Further No further Item Continence/ Elimination Risks 10.6.1 Evidence details Nil Reference Nil Further No further Item Require assistance with toileting? 10.6.1 Evidence details Assess and address functional considerations, such as reduced dexterity or mobility, which can affect toileting. Reference ABPG p58 Further N/A Item Require assistance with 10.6.1 Evidence details Numerous falls in hospital occur when people go to or return from the toilet. Reference ABPG p57 Further No further Item Have constipation, 10.6.1 Evidence details Reference Further No further
including frequency, patient’s requirement for continence/ toileting aids and assistance required to access toilet facilities. Item Review needs with daily patient’s for continence/ toileting aids and assistance to access toilet facilities 10.7.1 Evidence details Assess functional considerations such as mobility and accessibility of the toilet. Reference ABPG p58 Further No further Item Review needs with daily patient’s for continence/ toileting aids and assistance to access toilet facilities 10.7.1 Evidence details As part of multifactorial intervention, toileting protocols and practices should be in place for patients at risk of falling. Reference ABPG p55 Further No further Item Review needs with daily patient’s for continence/ toileting aids and assistance to access toilet facilities 10.7.1 Evidence details Managing problems with urinary tract function is effective as part of a multifactorial approach to care. Reference ABPG p55 Further No further Item Complete urinalysis. If abnormal, discuss with MO if MSU indicated. 10.7.1 Evidence details Organise routine screening urinalysis to identify urinary tract infections. Reference SQIG p21 Further No further Item urinalysis. If abnormal, discuss with MO if indicated 10.7.1 Evidence details Ward urinalysis should form part of routine assessment for older people with a risk of falling. Reference ABPG p55 Further No further Item Minimum Interventions 10.4 Evidence details Environmental modifications should be included as part of a multifactorial intervention. Reference ABPG p91 Further No further Item Provide ongoing orientation for patient to bed area, toilet facilities 10.4 Evidence details Orient the patient to the bed area, room, ward or unit facilities. Some patients might need repeated orientation because of cognitive impairment. Reference ABPG p24 Further No further
and ward. Item Demonstrate the use of call bell; ensure it is in reach and that they can use it effectively. 10.4 Evidence details Tell patients how they can obtain help when they need it. Reference ABPG p24 Further No further Item Ensure frequently used items including mobility aids are within easy reach of patient. 10.4 Evidence details Make sure that the patient’s personal belongings and equipment are easy and safe for them to access. Reference ABPG p91 Further No further Item Encourage patient to use their aids such as glasses or hearing aids. 10.4 Evidence details Ensure that patients have their usual spectacles and visual aid to hand. Reference SQIG p21 Further No further Item Encourage to use their such as glasses or 10.4 Evidence details Make sure that the patient’s personal belongings and equipment are easy and safe for them to access. Reference ABPG p91 Further No further Item Adjust bed and chair to appropriate height for patient. 10.4 Evidence details Ensure the bed is a the appropriate height for the patient (in most cases it should be at a height that allows the patient’s feet to be flat the floor, with their hips, knees and ankles at 90-degree angles when sitting the bed or chair). Reference ABPG p24 Further No further Item Minimise prolonged bed-rest as it contributes to negative cardiovascular and muscle effects that may 10.4 Evidence details In addition to structured training programs, hospital staff should provide the patient with opportunities to be as active as possible throughout the day. The patient’s bed rest should be minimised during the day and the patient should be encouraged to be Reference ABPG p46 Further No further
Item Optimise footwear where possible- discourage walking in socks/compression stockings or ill-fitting footwear. Bare feet (if there is no infection risk) and non-slip socks are acceptable. 10.4 Evidence details In addition to using standard falls risk assessments, screen patients for ill-fitting or inappropriate footwear admission to hospital. Reference ABPG p61 Further The evidence indicates that a shoe with safe characteristics is the most appropriate footwear, however not all patients own such shoes and/or bring them to hospital, and often do not put shoes if they need to get up overnight. Some individuals/cultural groups might prefer not to wear footwear. Item Optimise stockings or footwear. feet (if is no infection risk) and socks acceptable. 10.4 Evidence details Include an assessment of footwear and foot problems as part of an individualised, multifactorial intervention. Reference ABPG p61 Further information No further information Item Optimise stockings or footwear. feet (if is no infection risk) and socks acceptable. 10.4 Evidence details Hospital staff should educate patients and provide information about footwear features that may reduce the risk of falls. Reference ABPG p61 Further No further Item Optimise stockings or footwear. feet (if is no infection risk) and socks acceptable. 10.4 Evidence details Safe footwear characteristics include: shoes with thinner, firmer soles appear to improve foot position sense; a tread sole may further prevent slips slippery surfaces; a low square heel further improves stability; shoes with a supporting collar improve stability. Reference ABPG p61 Further The evidence for nonslip socks versus bare feet is inconclusive, but the studies listed in the reference column indicate that, in the absence of well-fitting safe shoes (and infection risk) these options are safer than regular socks and compression stockings.
Item Optimise stockings or footwear. feet (if is no infection risk) and socks acceptable. 10.4 Evidence details Walking barefoot or in socks is associated with a 10-13 fold increased risk of falling and athletic shoes are associated with the lowest risk. Reference ABPG p62 Further No further Item Optimise stockings or footwear. feet (if is no infection risk) and socks acceptable. 10.4 Evidence details Discourage people from walking in socks, because this is associated with a 10 fold increased risk of falling. Patients should not walk in anti-embolism stockings without appropriate footwear their feet. Reference ABPG p64 Further No further Item Optimise stockings or footwear. feet (if is no infection risk) and socks acceptable. 10.4 Evidence details Bare feet provide better slip resistance than socks and therefore might represent a safer foot condition. Reference Chari et al. 2009 (11) Further No further Item Optimise stockings or footwear. feet (if is no infection risk) and socks acceptable. 10.4 Evidence details Walking with socks, compared with walking barefoot, might present a greater balance threat for older adults. Clinically, safety precautions about walking in socks should be considered to be given to older adults, especially those with balance deficits. Reference Yi-Ju Tsai, Sang-I Lin. 2013 (12) Further No further Item Optimise stockings or footwear. feet (if is no infection risk) and socks acceptable. 10.4 Evidence details Barefoot or nonslip socks may be a safer footwear option than standard cotton socks for older people walking indoors potentially slippery surfaces. Compared with wearing standard socks, wearing nonslip socks improves gait performance and may be beneficial in reducing the risk of slipping in older people. Reference Hatton et al. 2013 (13) Further No further