Bahan Pembelajaran Manajemen pasien safety
Falls Prevention
Endang Sri P Ningsih
Overview
Definition of a fall
Importance of fall prevention (incidence and
outcomes)
Fall risk factors
Overview and goals of Falls Program
What is involved in the Falls Program
Assessment of falls
Falls interventions
Program Outcomes
IMPACT
30-40% of people over age 65 will have a
fall each year
In an elderly patient who has fallen, the risk
of having a second fall within a year rises to
60%
SS. Prevention of Falls in Older Patients. AAFP 2005;72:81-88
Consequences
5-10% of community dwelling elderly
who fall will suffer a serious injury
Up to 20-30% of elderly patients overall
Falls increase risk of going to nursing
facility
3 fold increase for falls without injury
10 fold increase for falls with serious injury
8% of people > 70 come to ER for falls
each year
1/3 will be admitted
Rubenstein LZ, Josephson KR. Falls and Their Prevention in the Elderly. Med Clin N Amer 2006;90:807-824
Tinetti ME,et al. Falls, Injuries Due to Falls, and the Risk of Admission to a Nursing Home. NEJM 1997;337:1279-84
Injuries
Fractures
1% of falls in the
elderly lead to hip fx
20-30% mortality in
the year after hip fx
¼ to ¾ of patients
do not recover prior
level of ADLs
Rubenstein LZ, Josephson KR. Falls and Their Prevention in the Elderly. Med Clin N Amer 2006;90:807-824
Injuries
Other Fractures
Humerus
Rib
Subdural Hematoma
Prolonged lie- half of all elderly
patients who fall are unable to get back
up
2o rhabdo, dehydration/ARF, pressure injury
Tinetti ME et al. Predictors and Prognosis of Inability to Get Up after
Falls among Elderly Persons. JAMA 1993;169:65-70
Post Fall Anxiety Syndrome
“Fallophobia”
Self-limiting activity, worsening deconditioning, social isolation
Picture the geriatric fall as
a node on a decline spiral
Falls are a Prototypical Geriatric
Syndrome
Risk Factor
Multifactoral
Odds
Ratio
Lower extremity weakness
4.4
History of falls
3.0
Gait deficit
2.9
Balance deficit
2.9
Need for assistive device
2.6
Visual defect
2.5
Arthritis
2.4
Impaired activities of daily living
2.3
Depression
2.2
Cognitive impairment
1.8
Age > 80 years
1.7
Rubenstein LZ. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin N Am. 2006;90:807-824
Tinetti ME, Speechley M, Ginter SF. Risk Factors for Falls Among Elderly Persons Living in the Community. NEJM 1988;319:1701-8
Fall prevention
Definition of a fall:
A fall is considered “an event that results in a
person coming to rest inadvertently on the
ground or floor or other lower level.” (Registered
Nurses Association of Ontario, 2002)
According to the Institute for Healthcare
Improvements, a fall also includes “patients
assisted to the floor”.
Incidence of falls
What?
Who?
When?
Where?
Why?
Outcomes of falls
psychological effects (fear of falling)
decreased level of functioning and
independence
injuries
mortality
delayed discharges
Risk factors: Environmental
poor lighting
floor surfaces
unsteady furniture
telephone, call
bells not in easy
reach
height of seating
cluttered pathways
ill-fitting clothing,
diapers
non-working
hearing aids
dirty or improper
eyeglasses
inappropriate
footwear
Risk factors: Physical
age
history of falls
illness
neurologic disease
mobility or balance impairment
postural hypotension
sensory impairments
incontinency
poor nutrition
Risk Factors
Cognitive
Pharmacological
(benzodiazepine/sedatives,
polypharmacy >5 meds)
Goals of program
Identification of patients at risk to fall
Implementation of preventative measures to
decrease falls
Examination of circumstances surrounding a fall
Educational program for staff
Increase in patient and family participation and
awareness of falls and fall prevention
Monitoring of incidence, time and location of falls,
severity of injury and overall effectiveness of the
program
Falls Screening
SPPICES
Assessment
SPLATT (Falls History)
S - symptoms at time of fall(s)
P - previous number of falls or near falls
L - location of fall(s)
A - activity at time of fall(s)
T - time of fall(s) and time on ground
T - trauma or injury with fall(s) [physical,
emotional]
What happens after a fall
Incident Report
Interventions: Cognition
Simplify tasks
Avoid changes or make changes
gradually
Remove excessive stimulation
Use clear, concise communication
Provide consistency in staff and routine
Provide orientation cues (calendars,
clocks)
Interventions: Cognition
Increase light at twilight
Provide meaningful activity
Follow “Least Restraints Guidelines”
Encourage family members/friends/sitters to
remain with patient
Interventions:
Physical Status
Place hearing/visual aids close by
Encourage toiletting routine (q2hrs)
Provide bedside commode
Ensure urinal is within reach
Reduce fluid intake after dinner
Ensure patient maintains adequate nutrition
Encourage patient to dangle before
standing/walking
Encourage patient to perform ankle pumping in
sitting position before walking
Encourage patient to sit down immediately if
feeling dizzy
Interventions: Mobility/Gait
Make sure patient uses proper
gait aid
Place gait aids at side of bed
(canes at bottom of bed)
Ensure gait aids are at
appropriate height
Provide visual cues/signs to
remind patient of safety
techniques for transfers,
ambulation
Interventions: Mobility/Gait
Ensure patients wear
shoes/non-skid socks at all
times
Provide patient and/or
family with Falls Prevention
Pamphlet
ROM exercises, prevention
of deconditioning
Review fall prevention
techniques with patient
and/or family
Interventions:
Environmental
Ensure height of bed/chair is at level
where the patient’s feet touch the
floor
Keep bottom bedrails down
Ensure easy access to call bell,
radio/tv controls
Ensure improved lighting, minimize
glare
Maintain straight paths to bathroom
Interventions:
Environmental
Use bedside commodes for patients who
can transfer independently but are unsafe
to ambulate independently to bathroom
Ensure clean, dry floors
Place higher risk patients in room near nurse's
station
Place higher risk patients in bed by
bathroom
Ensure brakes on equipment are
operational
Interventions:
Environmental
Encourage use of appropriate footwear and
properly fitting clothing
Place garbage under sink and no basins on
bathroom floor
Remove equipment not in use
Place IV equipment at top of bed
Ensure nightlights are operational and in use
Push bed against wall; place mattress on floor,
beside bed, if patient climbing out of bed
Interventions: Meds
Review medication list for drugs which may
predispose patient to falls
Decrease use of benzodiazepines
Diuretics given in the morning
Community Resources
Day Hospital
Falls Programs
CCAC
Day Programs
Emergency Response Systems
MOW
Assistive Devices Program
Wheel Trans
Outcomes of Program
Staff, patients, families educated
on fall prevention
Increased awareness of need for
teamwork to keep patients safe
Decrease number of falls and
injuries secondary to falls
Endang Sri P Ningsih
Overview
Definition of a fall
Importance of fall prevention (incidence and
outcomes)
Fall risk factors
Overview and goals of Falls Program
What is involved in the Falls Program
Assessment of falls
Falls interventions
Program Outcomes
IMPACT
30-40% of people over age 65 will have a
fall each year
In an elderly patient who has fallen, the risk
of having a second fall within a year rises to
60%
SS. Prevention of Falls in Older Patients. AAFP 2005;72:81-88
Consequences
5-10% of community dwelling elderly
who fall will suffer a serious injury
Up to 20-30% of elderly patients overall
Falls increase risk of going to nursing
facility
3 fold increase for falls without injury
10 fold increase for falls with serious injury
8% of people > 70 come to ER for falls
each year
1/3 will be admitted
Rubenstein LZ, Josephson KR. Falls and Their Prevention in the Elderly. Med Clin N Amer 2006;90:807-824
Tinetti ME,et al. Falls, Injuries Due to Falls, and the Risk of Admission to a Nursing Home. NEJM 1997;337:1279-84
Injuries
Fractures
1% of falls in the
elderly lead to hip fx
20-30% mortality in
the year after hip fx
¼ to ¾ of patients
do not recover prior
level of ADLs
Rubenstein LZ, Josephson KR. Falls and Their Prevention in the Elderly. Med Clin N Amer 2006;90:807-824
Injuries
Other Fractures
Humerus
Rib
Subdural Hematoma
Prolonged lie- half of all elderly
patients who fall are unable to get back
up
2o rhabdo, dehydration/ARF, pressure injury
Tinetti ME et al. Predictors and Prognosis of Inability to Get Up after
Falls among Elderly Persons. JAMA 1993;169:65-70
Post Fall Anxiety Syndrome
“Fallophobia”
Self-limiting activity, worsening deconditioning, social isolation
Picture the geriatric fall as
a node on a decline spiral
Falls are a Prototypical Geriatric
Syndrome
Risk Factor
Multifactoral
Odds
Ratio
Lower extremity weakness
4.4
History of falls
3.0
Gait deficit
2.9
Balance deficit
2.9
Need for assistive device
2.6
Visual defect
2.5
Arthritis
2.4
Impaired activities of daily living
2.3
Depression
2.2
Cognitive impairment
1.8
Age > 80 years
1.7
Rubenstein LZ. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin N Am. 2006;90:807-824
Tinetti ME, Speechley M, Ginter SF. Risk Factors for Falls Among Elderly Persons Living in the Community. NEJM 1988;319:1701-8
Fall prevention
Definition of a fall:
A fall is considered “an event that results in a
person coming to rest inadvertently on the
ground or floor or other lower level.” (Registered
Nurses Association of Ontario, 2002)
According to the Institute for Healthcare
Improvements, a fall also includes “patients
assisted to the floor”.
Incidence of falls
What?
Who?
When?
Where?
Why?
Outcomes of falls
psychological effects (fear of falling)
decreased level of functioning and
independence
injuries
mortality
delayed discharges
Risk factors: Environmental
poor lighting
floor surfaces
unsteady furniture
telephone, call
bells not in easy
reach
height of seating
cluttered pathways
ill-fitting clothing,
diapers
non-working
hearing aids
dirty or improper
eyeglasses
inappropriate
footwear
Risk factors: Physical
age
history of falls
illness
neurologic disease
mobility or balance impairment
postural hypotension
sensory impairments
incontinency
poor nutrition
Risk Factors
Cognitive
Pharmacological
(benzodiazepine/sedatives,
polypharmacy >5 meds)
Goals of program
Identification of patients at risk to fall
Implementation of preventative measures to
decrease falls
Examination of circumstances surrounding a fall
Educational program for staff
Increase in patient and family participation and
awareness of falls and fall prevention
Monitoring of incidence, time and location of falls,
severity of injury and overall effectiveness of the
program
Falls Screening
SPPICES
Assessment
SPLATT (Falls History)
S - symptoms at time of fall(s)
P - previous number of falls or near falls
L - location of fall(s)
A - activity at time of fall(s)
T - time of fall(s) and time on ground
T - trauma or injury with fall(s) [physical,
emotional]
What happens after a fall
Incident Report
Interventions: Cognition
Simplify tasks
Avoid changes or make changes
gradually
Remove excessive stimulation
Use clear, concise communication
Provide consistency in staff and routine
Provide orientation cues (calendars,
clocks)
Interventions: Cognition
Increase light at twilight
Provide meaningful activity
Follow “Least Restraints Guidelines”
Encourage family members/friends/sitters to
remain with patient
Interventions:
Physical Status
Place hearing/visual aids close by
Encourage toiletting routine (q2hrs)
Provide bedside commode
Ensure urinal is within reach
Reduce fluid intake after dinner
Ensure patient maintains adequate nutrition
Encourage patient to dangle before
standing/walking
Encourage patient to perform ankle pumping in
sitting position before walking
Encourage patient to sit down immediately if
feeling dizzy
Interventions: Mobility/Gait
Make sure patient uses proper
gait aid
Place gait aids at side of bed
(canes at bottom of bed)
Ensure gait aids are at
appropriate height
Provide visual cues/signs to
remind patient of safety
techniques for transfers,
ambulation
Interventions: Mobility/Gait
Ensure patients wear
shoes/non-skid socks at all
times
Provide patient and/or
family with Falls Prevention
Pamphlet
ROM exercises, prevention
of deconditioning
Review fall prevention
techniques with patient
and/or family
Interventions:
Environmental
Ensure height of bed/chair is at level
where the patient’s feet touch the
floor
Keep bottom bedrails down
Ensure easy access to call bell,
radio/tv controls
Ensure improved lighting, minimize
glare
Maintain straight paths to bathroom
Interventions:
Environmental
Use bedside commodes for patients who
can transfer independently but are unsafe
to ambulate independently to bathroom
Ensure clean, dry floors
Place higher risk patients in room near nurse's
station
Place higher risk patients in bed by
bathroom
Ensure brakes on equipment are
operational
Interventions:
Environmental
Encourage use of appropriate footwear and
properly fitting clothing
Place garbage under sink and no basins on
bathroom floor
Remove equipment not in use
Place IV equipment at top of bed
Ensure nightlights are operational and in use
Push bed against wall; place mattress on floor,
beside bed, if patient climbing out of bed
Interventions: Meds
Review medication list for drugs which may
predispose patient to falls
Decrease use of benzodiazepines
Diuretics given in the morning
Community Resources
Day Hospital
Falls Programs
CCAC
Day Programs
Emergency Response Systems
MOW
Assistive Devices Program
Wheel Trans
Outcomes of Program
Staff, patients, families educated
on fall prevention
Increased awareness of need for
teamwork to keep patients safe
Decrease number of falls and
injuries secondary to falls