How To Use This Aid
Following the assessment a team approach to initiate fall prevention interventions is recommended. If the patient is at risk for falls, this guide suggests interdisciplinary interventions that include medical, nursing, and rehabilitations management.
This Fall Prevention and Management aid is intended to prompt clinical staff (nurses, physicians, rehabilitation therapists and others) to consider a systematic assessment for determining patients' risk for falling and to recommend interventions.
Post fall management guidelines are also provided that include post fall assessment, fall risk level, interventions, and documentation. If a patient is not at risk for falling based on your assessment, interventions should still be implemented to protect the patient from extrinsic fall risk factors such as the presence of clutter, spills, and electrical cords.
- Use this aid to assess fall risk when the patient is initially admitted, there is a change in status, the patient is transferred to a new location, and prior to patient discharge.
- Go to the Fall Risk Assessment tab to determine if there are existing intrinsic factors that may affect the patient's fall risk.
- Go to the Morse Fall Scale and determine the fall score. Proceed to the indicated intervention based upon the derived score.
Fall Prevention and Management Aid is designed specifically for use with patients entering inpatient settings, acute care and long term care. Implied within the philosophy of the Department of Veterans Affairs, both patients and families are integrally involved in all aspects of their care planning. Thus, patients and families are involved in determining fall risk factors and designing fall prevention strategies in collaboration with the patient's health care team. Both the patient and the family should be informed and understand fall risk factors and agree on strategies to prevent the patient from falling. All fall prevention education programs for inpatients should involve their families. Patients and families should be educated about fall risk factors in the new environment and continue their active involvement in all levels of safety education throughout the continuum of their care.
Fall Risk Assessment
If any of these medical factors are present, go to Standard Fall Prevention Interventions:
- Agitation/Delirium- infection, toxic/metabolic, cardiopulmonary change, CNS, dehydration/ blood loss, sleep disturbance
- Meds (dose/timing)-psychotropics, CV agents (digoxin especially), anticoagulants(increased risk of injury), anticholinergic, bowel prep
- Orthostatic hypotension, autonomic failure
- Frequent toileting
- Impaired mobility
- Impaired vision, inappropriate use of assistive device/footwear
- History of Falls (CV/light headed-dizzy, Dysequilibrium- loss of balance with no abnormal motion sensation, Vestibular/Vertigo, Weakness-Musculoskeletal/give way, combination, other)
- Psychotropics, digoxin, type 1a antiarrhythmic, diuretic (thiazides>loop diuretics)
- Antihistamines/benzodiazipines- withdrawal has shown decrease in falls risk, assess for sleep disorder, avoid routine PRN orders-try non-pharmacological approaches including quiet sleep protocols on units
- Antidepressants- Tricyclics higher risk than SSRI, but SSRI's have risk as well, high level of phenytoin; low dos amitriptyline affects gate; gabapentin 10-25% ADR
- Cardiac drugs/antihypertensives- if orthostatic (drop in sys>20 mm in 3 min) and symptomatic
- Anticoagulants - subdural hematomas are rare; avoid only if very unstable gait or balance, concurrent use of alcohol, or other drugs that interact and increase bleeding, or non-compliant with regimen or lab follow up
- Drugs treating nocturia (consider tamsulosin due to lower risk of orthostasis)
Morse Fall Scale
Nursing fall risk assessment, diagnoses and interventions are based on use of the Morse Fall Scale (MFS) (Morse, 1997). The MFS is used widely in acute care settings, both in hospital and long term care inpatient settings. The MFS requires systematic, reliable assessment of a patient's fall risk factors upon admission, fall, change in status, and discharge or transfer to a new setting. MFS subscales include assessment of:
|1. History of falling; immediate or within 3 months
||No = 0
Yes = 25
|2. Secondary diagnosis
||No = 0
Yes = 15
|3. Ambulatory aid
||None, bed rest, wheel chair, nurse = 0
Crutches, cane, walker = 15
Furniture = 30
|4. IV/Heparin Lock
||No = 0
Yes = 20
||Normal, bed rest, immobile = 0
Weak = 10
Impaired = 20
|6. Mental status
||Oriented to own ability = 0
Forgets limitations = 15
Much work has been done to identify the risk factors associated with the likelihood of a patient falling. These risk factors are generally categorized into extrinsic (factors outside of the patient's body) and intrinsic (patient's internal, psychological factors).
- Hazardous activities
- Time of day
- External lighting
- Loose electrical cords
- Muscle and strength weakness
- Gait and balance disorders
- Visual disturbances
- Cognitive impairment/Mental status alterations
- Postural hypotension
- Chronic disease
Safety education for patients and families requires involvement of all team members. Determine within your setting availability of individual and group fall prevention resources that include patient/family education materials, individual and group education and exercise classes, and community resources.
Standard Fall Prevention Interventions
Interventions suggested for implementation in this flip book include both standard and high risk interventions specific to the patient's fall risk score.
Patients who are scored "low risk" on the Morse Fall Scale (score of 25-50) will have the following interventions implemented by the Nursing Staff.
- Assess patient's fall risk upon admission, change in status, transfer to another unit and discharge.
- Assign the patient to a bed that enables the patient to exit toward his/her stronger side whenever possible.
- Assess the patient's coordination and balance before assisting with transfer and mobility activities.
- Implement bowel and bladder programs to decrease urgency and incontinence.
- Use treaded socks for all patients.
- Approach patient towards unaffected side to maximize participation in care.
- Transfer patient towards stronger side.
- Actively engage patient and family in all aspects of Fall Prevention Program.
- Instruct patient in all activities prior to initiating assistive devices.
- Teach patient use of grab bars.
- Instruct patient in medication time/dose, side effects, and interactions with food/medications.
- Lock all moveable equipment before transferring patients.
- Individualize equipment specific to patient needs.
- Place patient care articles within reach.
- Provide physically safe environment (eliminate spills, clutter, electrical cords, and unnecessary equipment).
- Provide adequate lighting.
- Evaluate and treat gait changes, postural instability, spasticity.
- Initiate treatment for impaired vision, hearing.
- Evaluate medication profile for fall risk.
- Evaluate and treat pain.
- Evaluate and treat orthostatic hypotension.
- Assess and treat impaired central processing (dementia, delirium, stroke, perception)
High Risk Fall Prevention Interventions
These interventions are designed to be implemented for patients with multiple fall risk factors and those who have fallen. These interventions are designed to reduce severity of injuries due to falls as well as to prevent falls from reoccurring, supplementing standard fall prevention interventions.
- Consider use of: technology for fall prevention. (See Technology section), non-skid floor mat, raised edge mattress.
- Clear patient environment of all hazards
- Review medications for fall risk and adjust as indicated
- CV agents - if orthostatic (drop in systolic > 20 mm in 3 minutes) and symptomatic
- Discontinue HCTZ, liberalize sodium in diet
- If ACE inhibitor appropriate, use agent with less renal metabolism (fosinopril)
- If Calcium channel blocker - NOT nifedipine
- If ß blocker - not cardioselective / not metoprolol / atenolol; use pindolol / propranolol
- Consider referral to services such as physical medicine and rehabilitation, audiology, ophthalmology, cardiology.
- Optimize treatment of underlying medical conditions.
- Evaluate and treat for pain.
- Evaluate circumstances surrounding fall for extrinsic and intrinsic contributing factors.
- Home safety
- Plan for emergency fall notification procedure.
To consider technologies for Fall Prevention, refer to the National Center for Patient Safety
- Bed and/or chair alarms.
- Alarms at exits.
- Nurse call systems and communication systems.
- Low beds for patients at risk for falls.
- Video camera surveillance.
Falls and Bedrails
Fall prevention programs emphasize bedrail reduction. Bedrails contribute to patient fall risk by creating barriers to patient transfer in and out of beds. Use of bedrails must be assessed specific to individual patient needs. When possible, use alternative pillows and positioning devices to avoid the use of bedrails.
Department of Veterans Affairs. (1996, June). Clinical practice guidelines: The prevention and management of patient falls. Tampa, Fl: Author.
Hendrich, A, Nyhuis, A, Kippenbrock, T, et al, (1995). Hospital falls: Development of a predictive model of clinical practice. Applied Nursing Research , 8. 129-139.
Hoskin A.F. (1998). Fatal Falls: Trends and Characteristics. Statistical Bulletin, Apr-Jun, 10-15.
Maki, B.E. (1997). Gait changes in older adults: Predictors of falls or indicators of fear? Journal of American Geriatrics Society, 45 , 313_20.
Morse J. (1997). Preventing patient falls . Thousand Oaks, CA: Sage.
National Safety Council. 1999. Report on Injuries in America . Itasca, IL.
Rawsky, E. (1998). Review of the literature on falls among the elderly. Image , 30(1), 47-2.
Steven, J, & Olson, S (1999, October). Check for safety. A home fall prevention checklist for older adults. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
Tideiksaar, R (1997). Falling in old age. Its prevention and management . (2nd ed). New York: Spinger Publishing.
VA National Center for Patient Safety (NCPS). (2000).
VISN 8 Patient Safety Center. (January 2001). Proceedings: Promoting Patient Freedom and Safety: Preventing Falls. VISN 8 Patient Safety Center of Inquiry: St. Pete Beach, FL.
VISN 8 Patient Safety center of Inquiry.(1998).
For suggestions to improve or broaden this algorithm, please contact Dr. Pat Quigley, Associate Director, Clinical Division, VISN 8 Patient Safety Center of Inquiry, Tampa, Florida. E-mail: Patricia Quigley