BC Children's Hospital Falls Prevention: Identifying & Mitigating Patient Risks, Study notes of Nursing

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PURPOSE

BC Children’s Hospital and Sunny Hill Health Centre for Children are committed to providing a culture that promotes patient safety. We recognize all patients seen at BCCH/SHHC are at risk for falling. Our strategy’ is to accurately identify those at greater risk for falls and to implement interventions to minimize the associated risk and harm for all patients.

POLICY STATEMENTS

All children will have strategies implemented to mitigate the risk and harm from falling.

The falls prevention strategy will be evaluated utilizing identified evaluation metrics and reported monthly to program specific Safety and Quality Committees and quarterly to the BCCH Safety and Quality Committee

An environmental scan for fall risk will be included in the monthly site safety inspections performed by the Joint Occupational Health and Safety Committee.

SITE APPLICABILITY

The Falls Prevention and Harm Reduction Strategy is applicable in all patient care areas throughout BCCH and SHHC.

PRACTICE LEVEL/COMPETENCIES

Conducting a falls risk assessment is considered a foundational competency for all nursing staff (RN, RPN, LPN). More in-depth assessments are carried out by the Occupational Therapist or Physiotherapist on an individual patient need basis.

Implementation of Primary Falls Prevention Strategies and High Risk Falls Precautions are considered a foundational level competency for all staff and physicians providing direct patient care at BCCH and SHHC.

DEFINITIONS

A patient fall is defined as a sudden unexpected descent from a standing, sitting, or horizontal position, including: slipping from a chair to the floor; an assisted fall, where an individual guides the falling individual to the floor; an accidental fall; and a developmental fall.

Types of Falls:

Anticipated Physiological: Patient’s diagnosis or characteristics may predict their likelihood of falling (i.e. medications, unsteady gait, etc.).

Unanticipated Physiological : May be attributed to physiological causes but are created by conditions that cannot be predicted before the fall occurrence.

Accidental : Falls not due to physical factors but rather environmental hazards, stress, unfamiliar environments and/or behaviour.

Developmental : Falls common in infants/toddlers as they are learning to walk, pivot or run.

INDICATIONS

At BC Children’s Hospital we utilize a 3 tiered approach to identify the level of risk for falls and

implement strategies to mitigate associated risk and harm.

1. Primary Prevention : All children admitted to BCCH and SHHC are considered at risk for falls.

Primary prevention approach to falls prevention is in place throughout the site and in all

patient care areas unless that area or clinic has been designated as a high falls risk patient

care area/clinic.

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2. Designated High Risk Patient Populations : All infants and toddlers up to 36 months of age

are considered at high risk for falls and do not require screening.

3. Designated High Risk Patient Care Programs, Services, Patient care & Outpatient

Clinics: BCCH & SHHC have designated certain programs, services, patient care areas and

clinics as High Risk.

 Pediatric Intensive Care Unit (PICU)

 Emergency Department

 Surgical Services

 Occupational and Physical Therapy Treatment areas (excluding Mental Health OT

Treatment areas)

 CAPE

 BCCH Ambulatory Clinics

 Neurology Clinic

 Neuromuscular Clinic

 Spinal Cord Clinic

 Orthopedic Clinic

 EEG/EMG

 Sunny Hill Programs

 Acute Rehabilitation Program

 Neuromotor Program

This designation was determined based upon the following criteria:

a) The majority of the children seen in the program, service or clinic would score as high risk

during their encounter on the Falls Risk Assessment Tool.

b) The service/program contains equipment and/or procedures which make the setting a high falls

risk environment for children.

4. Risk Screening: All patients admitted to BCCH for an inpatient stay will be screened at a

minimum on admission, following a significant change in status, and following a fall, unless that

patient population or patient care services area has been deemed a high risk area. Patients

aged 36 months to 18 years will be screened using the Miami Children’s Humpty Dumpty Falls

Prevention ProgramTM Risk Assessment Tool. Patients aged >18 years will be screened using

the Morse. Patients attending outpatient appointments will not be screened as the majority of

patients will have a care giver in attendance at all times. All patients are considered at risk and

will have primary prevention measures in place. Outpatient areas considered high risk will

have high risk prevention measures in place.

PROCEDURES

PROCEDURE FOR DIRECT CARE STAFF Rationale

1. Implement Primary Prevention Strategies for all patients (inpatient and outpatient).

To mitigate risk of and harm from falling.

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2. Review falls prevention information, located in the Patient Safety brochure information, with patients and families within 24 hours of admission.

To engage patients and families in the prevention of falls.

3. Conduct Falls Risk Assessment on patients requiring screening as identified in the Indications section listed above. a. Identify the appropriate numbers for each risk criteria on the Falls Risk Assessment Scoring tool (Age, Gender, Diagnosis, Cognitive Impairment, Environmental Factors, Response to surgery/sedation/anesthesia and Medication Usage). b. Total the score and record this number on the appropriate row on the patient care flowsheet.

To help identify specific populations at higher risk for falls.

4. For designated high risk patient populations or patients in designated high risk patient care services/units or in patients whose total score on the falls risk screening tool indicates High Risk: a. Implement High Risk Safety Precautions in addition to Primary Prevention Strategies. b. Place a yellow sticker on patient’s chart and a Falls Risk poster above bed. Exception: In designated high risk inpatient/outpatient areas, Risk of Falls information will be displayed throughout patient care areas and other identified areas. In Mental Health Inpatient areas a yellow sticker will be placed on the inpatient whiteboard in lieu of the Falls Risk poster above the bed. c. Write note in Kardex/Standard Care Plan: “patient at high risk for falls” and document patient specific interventions in the health record. d. Communicate high falls risk assessment at each shift change or transfer of care to other healthcare providers.

To implement patient specific strategies for children identified as higher risk for falls.

To facilitate communication among health care team members regarding who is identified as high risk for falls.

5. Communication and Education about Falls Risks: a. Communicate the results of the falls risk assessment to all members of the healthcare team, patient and the family; b. Educate staff, patients and their caregivers on the prevention of falls and falls injuries; c. Educate patients and families of those who are assessed as a high risk of falling

To mitigate risk and/or harm from falling.

CC.07.10 BCCH Child & Youth Health Policy and Procedure Manual Effective Date: Dec-07-

regarding their status. d. Instruct patient/family on falls risk factors and appropriate primary and high risk interventions to promote safety and protect the child from injury as per BCCH Falls Prevention Strategy – Primary and High Risk Prevention Strategies e. Consider consultation to a Physiotherapist and/or Occupational Therapist.

5. Should a Fall occur, provide immediate response and evaluate for injury: a. Remove patient from imminent danger as necessary. b. Monitor responsiveness, assess vital signs. c. Provide and maintain comfort. d. Assess the situation – what caused the fall? e. Notify Physician. f. Document in the medical record:  Time, location and what happened  If the fall was witnessed or unwitnessed  Safety measures in effect at the time of the fall  Vital signs, any observable injuries and skin assessment  Who was notified and if an examination was completed  New orders or additional precautions implemented g. Conduct a Post Fall Safety Huddle and update patient care plan. h. Complete a PSLS report.

To ensure the patient receives immediate care for a fall.

To assist in the identification of risk mitigation strategies.

To add to organizational learning regarding fall risk prevention and mitigation of harm.

PROCEDURE FOR LEADERSHIP Rationale

1. Investigate each fall or near fall (near miss) to identify contributing factors and to prevent reoccurrence by Quality & Safety Team and unit managers. Ensure that information is entered and follow up recorded into the Patient Safety and Learning System (PSLS).

To assist in the identification of risk mitigation strategies.

2. Ensure unit specific safety huddles and/or leadership walk arounds include environmental audits for falls risks with modifications/interventions implemented as required.

To foster a culture of safety.

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DOCUMENTATION

Documentation of falls risk, fall risk mitigation strategies and the occurrence of a fall, will occur in the health record, both on the nursing clinical assessment flow sheet and interprofessional and discipline specific notes.

REFERENCES

DeChamp, N., Wrong, T. (2011). Falls Prevention Strategies: Do Paediatric facilities really need them? Canadian Association of Pediatric Health Centres Patient Safety Collaborative (online). http://ken.caphc.org/xwiki/bin/view/PatientSafety/Falls+Prevention+Strategies+- +Do+paediatric+facilities+really+need+them%3F.

Dove, K, McAnallen, D. (2016) Pediatric falls risk assessment & prevention strategy: Education Module Children’s Hospital, London Health Sciences Centre. (online) http://www.lhsc.on.ca/Research_Training/Student_Affairs/orientation/falls/presentation_content/external_files/Paediatr ic%20Falls%20Power%20Point.pdf

Gill, A.C., Kelly, N.R. (2016). Prevention of falls in children.(online) https://www.uptodate.com/contents/prevention-of- falls-in-children (accessed Sept 22, 2016).

Hill-Rodriguez, D etal (2008). The Humpty Dumpty Falls Scale: A case control study. Journal for specialists in pediatric nursing, 14 (1), 22-32.

Pauley, B.J., Houston, L.S., Cheng, D., Johnston, D.M. (2014). Clinical relevance of the humpty dumpty falls scale in a pediatric specialty hospital. Pediatric Nursing , May-Jun; 40(3): 137-42. (online).

Safer Healthcare Now! (2013). Reducing falls and injury from fall: Safer Health care Now! Getting started Kit. www.saferhealthcarenow.ca/EN/Interventions/Falls/Pages/resources.aspx.

Shewchuk, K., Lahti, D. (2016). Humpty Dumpty sat on a wall…Humpty dumpty never did fall: Enhancing patient safety through the implementation of the humpty dumpty pediatric falls prevention program (online webinar). http://ken.caphc.org/xwiki/bin/view/PatientSafety/Humpty+Dumpty+sat+on+a+wall+Humpty+Dumpty+never+did+fall

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