Bundle for all patients |
1. A history of previous falls and of fear of falling is taken at the time of admission.
2. Urinalysis is conducted on admission. 3. New prescriptions of night sedation are avoided. 4. A call bell is in reach.
5. Appropriate footwear is available and in use.
6. There is immediate assessment for and provision of walking aids.
Physiotherapists must train nursing staff to provide appropriate walking aids at the time of admission to the ward, or as soon as they might be required. Walking aids need to be made available for each ward area, and need a suitable storage area.
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Bundle for older and more vulnerable patients |
7. A cognitive assessment (mini-mental state examination (MMSE) or abbreviated mental test score (AMTS)) is conducted in all admissions aged >70 years. 8. Those at risk are tested for delirium (confusion assessment method).
9. An assessment of risk versus benefit for use of a bedrail is conducted. 10. Visual assessment is conducted.
11. Lying and standing blood pressure are taken with a manual sphygmomanometer. 12. Medication is reviewed with respect to cardiovascular and central nervous system acting medications.
Nurses should request a review of medication to try and reduce the burden of drugs, particularly those associated with falls, and in patients who are unsteady, hypotensive or have orthostatic hypotension.
13. Based on observation, toileting arrangements are assessed and planned (tailored to needs rather than the standard two-hourly arrangement).
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Bundle for after a fall |
14. After a fall, appropriate assessments and procedures are followed, including neurological observations in those who have hit their head or had an unwitnessed fall.
15. A post-fall review (how can further falls be prevented for this patient) is conducted. 16. A complete incident report (all falls) is created. 17. A root cause analysis (lessons to prevent falls for future patients) is carried out for severe harm falls.
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*Long stay units may wish to amend to ‘at least monthly’ rather than ‘on admission’; For rehabilitation units, community hospitals, stroke units, orthogeriatrics units, care of the elderly units and dementia units this should equate to all patients. In wards and units with a more mixed population, patients with a high vulnerability to falls are likely to be determined by local policy eg positive response to any of the NPSA ‘four questions’, total of Morse score or STRATIFY score, or all patients not fully independent and mobile. Reproduced with permission.8 |