High risk populations for falls

Minimum standards for all at risk patients

• Ensure the bed brakes are on and the bed is the correct height for the patient
• Encourage patients to wear non-slip footwear when mobilising
• Provide instruction on how to use the call bell to obtain assistance if required
• Educate patients and carers on specific falls risks and safety issues on the ward
• Remove obstacles and clutter from the room
• Make patients aware of medication effects and any likelihood of increased falls risk

Falls risk assessments should not be considered as a one-off assessment. Inpatients should be reassessed:

• on admission
• on transfer
• directly after a fall
• on medical condition improvement or decline
• on an ongoing basis as per local health service guidelines for falls and other conditions. NB: post-operative and pain management protocols, detox protocols.

Women have an increased short-term falls risk during labour or following vaginal or caesarean birth, especially during ambulation.

Newborn falls in maternity units are associated with maternal sedation, and many falls occur when a neonate rolls from the arms of a sleeping parent.

Traditional falls risk screening tools do not address the unique characteristics experienced by women in the immediate pre and post partum period.

Interventions for maternity patients at risk of falling (in addition to the minimum standards) include:

• Reminding women to call for assistance and waiting for staff to help them to the bathroom if they wish to mobilise or they need to get their baby out of a cot.
• Placing call bells, bedside tables, water jugs and frequently used objects within easy reach (particularly women with epidurals, labouring women with intravenous lines and Cardiotocography monitoring, post caesarean section or Postpartum haemorrhage
• Providing 1:1 midwifery care to women in labour who are at risk of falling. All women and their partners should be reminded not to attempt mobilisation without staff assistance.
• Referring women experiencing any ongoing mobilisation issues to physiotherapy or occupational therapy as appropriate.

Parental education

Clinicians are reminded to educate new parents about how to keep their baby safe from falling.

• Address safety issues with baby care activities, such as changing nappies and bathing babies, as these are potential falls risk situations.
• Highlight the importance of putting the baby to sleep on their back from birth in their own cot next to the adult bed.
• Provide advice about the risk of falling asleep while holding their baby.
• Highlight the risks of walking around the maternity unit or hospital with their baby in their arms and advise them to use the wheeled cot.

• For patients experiencing delirium consider:
  • increasing surveillance as this is the most effective way to reduce risk of falls
  • positioning patient near where nurses are stationed
  • completing urine analysis/midstream specimen of urine for possible compounding diagnostics
  • regular assessment and review of physical vital signs
  • adequate hydration/nutrition status-consider referral to dietitian as needed.
• Refer to the delirium clinical standard for further guidance

The most common diagnoses within mental health populations which require hospital admission are:

• mental illness such as depression, mania, anxiety and psychosis
• behavioural disturbances associated with dementia
• deliriums associated with physical co-morbidities.
• 60 to 80 per cent of falls occur in patients who have cognitive decline (+/- a co-occurring mental illness).
• Most inpatients are ambulant. As most falls occur in areas of the ward with low staff presence such as corridors, courtyards and dayrooms.^2,4 80 to 90 per cent, falls are unwitnessed. Vigilance or surveillance is the most effective way to decrease falls risk in the mental health setting.
• Inpatients with a mental illness are at a high risk of falling both in the acute phase of their illness and when health and wellbeing improves, enabling the person to become more independent with activities of daily living.
• The primary aim of the inpatient stay is to treat the mental illness – unfortunately, this primary treatment may increase the risk of falling. Therefore, the falls risk benefit must be considered by the treating team, see Medication section below.
• Treatments may include the use of high dose anti-psychotics and/or sedatives to minimise harm to self or others (minimise aggression) and/or electroconvulsive therapy (ECT) to treat severe depression or mania which are all associated with increased falls risk.

Medication

• Commonly prescribed medication groups are:
  • antipsychotics
  • antidepressants
  • mood stabilisers
  • benzodiazepines
• Medication reduction/cessation may not be possible if therapeutic levels need to be maintained for treatment of the mental illness. However, adequate medication review should be considered to include falls prevention where-ever practicable.
• Management of side effects that impact on balance and gait and increase falls risk, should be considered alongside other falls prevention strategies (insert link to inpatient and community falls prevention webpages).