Post-fall Assessment Research Articles

Introduction of a ‘Post fall assessment’ proforma improves management of patients following a fall in a rehabilitation setting

Abstract Background Falls are the most frequently reported incident within HSE services. 18,023 falls were reported in acute hospitals in 2021 and resulted in harm in 19% of cases. The HSE patient safety strategy has highlighted patient falls as a priority area for service improvement. One area where improvements could be implemented is the assessment of patients following falls. Methods A retrospective audit on medical note documentation of 40 patients following an inpatient fall was carried out, with areas for improvement identified. A multidisciplinary multi-part post fall assessment proforma with embedded guidance, based on best practice guidelines was subsequently introduced. A further retrospective audit was then conducted 6 months following its introduction. Results In cycle 1 of the audit, 67.5% of assessed patients did not have the presence or absence of ‘red flags’ documented. 27.5% of reviews did not record a detailed history and 7.5% did not have a formal focused examination documented. 32.5% of patients had a medication review undertaken. 20% of patients had a focused MDT review post fall. In cycle 2 the ‘immediate medical review’ section of the proforma was completed in its entirety in 95% of cases, including documentation of history, examination and ‘red flags’. A follow up review by the primary team, which included prompts to reconsider injury and consider risk reduction for future injurious falls was documented in 50% of cases. A focused review by the wider MDT took place in 75% of cases. Conclusion The introduction of a post fall assessment proforma has resulted in improved assessment for potential injuries and a more targeted approach to reducing the risk of future injurious falls.

P27: From Development to Implementation: A Novel Clinical Post-Fall Assessment Tool in Long-Term Care

Objectives: The study aims to: (i) develop a clinical post-fall assessment tool for older adults in long-term care (LTC) settings; (ii) validate the tool’s effectiveness and usability; and (iii) assess the practical application and impact of the tool within LTC units.Methods: The three-phase study employed a sequential exploratory mixed-Methods framework. Phase I: Tool development comprised a comprehensive literature review and a qualitative study of semi-structured interviews with nine healthcare professionals. Phase II: Validation adopted an embedded design, where qualitative perceptions from 18 professionals through two focus groups informed iterative improvements and a quantitative questionnaire (a Likert scale and open-ended questions) assessed the tool’s effectiveness and user experience. Phase III: Implementation encompassed a retrospective and prospective longitudinal study, focusing on fall incidence, communication efficacy, and usability, to gauge the tool’s real-world impact.Results: From Phase I, a mnemonic checklist was developed and structured into five sections: patient characteristics, fall description, primary and secondary assessments, and post-fall management—selected for clinical practicality. In Phase II, focus group insights prompted refinements to the tool, while follow-up questionnaires indicated the tool’s substantial utility in enhancing practice (65%), communication (69%), usability (71%), and satisfaction (76%). Responses highlighted key challenges such as resistance to change and workload, contrasting with facilitators like availability and uniformity. The need for training and a period of adaptation were viewed as factors that could compromise use. In Phase III, the tool showed greater utility for identifying fall-related complications and managing falls, with a notable preference among all nurses, regardless of experience level, particularly those with less than 5 years of experience.Moreover, a comparison of falls over two three-month periods—one without the tool and one with it—revealed that the tool enhanced communication between doctors and nurses. This improvement led to quicker notification of doctors and more efficient transfers of patients to the emergency room when necessary.Conclusions: Our tool aims to improve comprehensive post-fall assessments for older adults in LTC settings, facilitating improved communication and decision-making among healthcare professionals. With its usability and practical design, this mnemonic checklist shows great potential for wide adoption in enhancing patient care practices.

Prevalence of Older Hospitalised Adults with Sustained Fractures after a Fall in Regional Australian Hospitals.

Falls commonly occur in hospitals, particularly among older adults. Fractures in the older population can cause major morbidity, which can result in long hospital admissions and increased care costs. This study aimed to characterise the demographics of patients aged 65 years and over who fell in hospital and to determine the type of fractures they sustained. A descriptive study was undertaken to examine hospital data of older inpatients who had a fall during admission in two regional Queensland hospitals in Australia over a 2.5-year period. The prevalence of inpatient falls was 1.28%. Most falls were unwitnessed (77.34%) and they had an average of seven medical comorbidities. The mean age was 80.4 years and 63% were male. Women who fell were significantly older than men (p = 0.004). The mean length of stay of in-hospital fallers was 22.77 days and same admission mortality was 9.3%. Thirty-three fall events (3.8%) resulted in fractures, some with multiple injuries. The most common fracture was neck of femur, followed by rib, femur, and facial fractures. In conclusion, this study identifies the incidence of falls increased with age, most falls were unwitnessed, as well as provides evidence that patients with falls had multiple comorbidities and long hospital admissions. The data could be used to optimise fall prevention strategies and to refine post-fall assessment pathways.

Staff’s insights into fall prevention solutions in long-term care facilities: a cross-sectional study

BackgroundFalls are one of the most common and serious health issues in long-term care facilities (LTCFs), impacting not just residents, but staff and the healthcare system. This study aimed to explore LTCF staff’s current practices around falls prevention, and their suggested solutions for better falls prevention.MethodsIn the southwest of Ireland, a descriptive cross-sectional study was conducted in 13 LTCF sites, across a range of provider types and facility sizes. A survey, measuring staff knowledge, skills and attitudes, was distributed in physical and online formats. Staff suggestions for prioritising fall and fall-related injury prevention activities, and current staff practices regarding fall incidents were also sought. Content analysis was used to analyse responses, mapping categories and subcategories to the refined theoretical domains framework (TDF) and to an existing fall prevention guideline.ResultsThere were 155 respondents (15% response rate), from staff of the LTCFs. Environmental reviews and modifications (aligned to the TDF environmental context and resource domain) were the most common suggestions for preventing both falls and fall-related injuries. Other common suggestions for preventing falls were staff education, monitoring of residents, and using alarm/calling systems, while few staff members, across all roles, reported assessing residents, exercises, reviewing medications, and vitamin D supplements. For preventing fall-related injuries, suggestions included protective equipment, hip protectors and alarm/calling systems. Staff used a standardised approach when responding to a fall incident, with intensive and holistic post-fall control measures. HCAs focussed on transferring residents safely, while nurses of all grades focused more on post-fall assessment. Respondents believed that staff education, communication, increasing staffing levels and enhancing specialist care could support their practice.ConclusionNoting the low response rate, the results suggest an awareness gap regarding some evidence-based, resident-focussed falls prevention solutions, such as pro-active fall-risk assessment, exercise, medication review, and Vitamin D supplements. These aspects should be included in future fall prevention education programmes in LTCFs.

138 Falls management simulation

Abstract Background Simulation is a clinical education opportunity that creates an experience without having to go through a real event. Simulation facilitates a debriefing for the participants of the ‘event’. Simulations support healthcare professionals in developing knowledge and skills. Falls are common in hospital and are potentially serious events. Prompt patient post-fall assessment is important in identifying injuries, ensuring safe observations levels and taking action to prevent the next fall. Our aim was to improve post fall patient care through a Falls Management Simulation. Methods Falls management simulations, with a standardised patient event, took place on two Specialist Geriatric wards between February and April 2023 with 31 learners taking part consisting of CNM’s, staff nurses, healthcare assistants, and physiotherapists. Post simulation participants completed a Kirkpatrick’s level 1 and 2 evaluation. Results Kirkpatrick’s level 1 evaluation (feedback questionnaire) asks participants to rate eight general statements about the programme. The median outcome for each of these statements indicated participants found the simulation to be a positive learning experience. Kirkpatrick’s level 2 evaluation (self-assessment pre and post training) showed an improvement in knowledge post simulation. Participants were asked to evaluate their level of knowledge pre and post simulation from very high to very low. In the assessment of injuries post fall and, the care of the patient after an unwitnessed fall participants’ knowledge improved post simulation from a median of unsure (pre simulation) to very high (post simulation). Conclusion The feedback on the simulation reflected an increase in participant’s knowledge and confidence on the management of a patient post-fall. This education programme is in its early development. We aim to continually monitor and adapt the simulation to meet the learners’ needs, provide variation for repeat learners and ensure it is a positive educational experience for all.

The VIP treatment: A comprehensive post-fall assessment guideline

This practice helps nurses identify frequently overlooked injuries.

1348 A QUALITY IMPROVEMENT PROJECT TO IMPROVE ASSESSMENT AND DOCUMENTATION FOLLOWING INPATIENT FALLS

Abstract Introduction Inpatient falls are a major cause of avoidable harm in patients on elderly care wards. Delays in identification of fall precipitants and recognition of sustained injuries increases morbidity, mortality and length of stay (Cameron et al, Cochrane Database Syst Rev. 2018 Sep; 2018(9)). Patients sustaining falls are often initially assessed by postgraduate year 1 and 2 doctors independently. We aimed to improve patient outcomes following inpatient falls through standardisation of the assessment and documentation following a fall in hospital. Methods Using PDSA methodology, incident reports and documentation of inpatient falls were reviewed retrospectively over three 28-bedded elderly care wards. A post-falls proforma was devised that covered various domains of the post-fall assessment and was distributed to doctors throughout the hospital. Following the intervention, a repeat PDSA cycle was performed prospectively over the same wards and the proportion of assessments fulfilling each domain was compared between the cycles. Results Medical assessment of 27 falls from November 2020 to January 2021 was compared to 31 falls occurring between February and May 2022. Use of the proforma in cycle 2 was limited to 8/31 falls following intervention. Post-intervention, the proportion of assessments fulfilling medication review (19% vs 35%, p=0.14) and anticoagulation status (41% vs 55%, p=0.28) was improved. The proportion fulfilling fall circumstances (89% vs 90%, p=0.85), medical precipitant (70% vs 61%, p=0.46) and ordering of appropriate imaging (93% vs 97%, p=0.47) remained high. Conclusion Standardisation of post-falls assessment and documentation can improve patient safety outcomes through reducing delay in recognition of medical precipitants of falls and identification and management of sustained injuries. Improved integration of a post-falls proforma into electronic systems is needed to maximise its clinical benefit and would be the target of a further PDSA cycle.

982 ARE POST FALL CT HEAD SCANS DONE ACCORDING TO TRUST GUIDELINES

Abstract Introduction Falls are a major public health concern, which poses a high risk of injury and even death. Due to fears regarding increased morbidity and mortality post fall, we have noticed that there is a tendency for junior doctors to request computerized tomography (CT) head scans beyond clinical reasoning and indications that are not found in the trusts post falls protocol. In addition, we discovered significant delays in completion of inpatient CT head scans resulting in delayed management. We therefore embarked on an audit with the aim of improving post falls assessment. We assessed compliance with trust post fall protocol regarding suspected head injury and requesting of urgent CT head scans, if urgent CT had scan are done within 1 hour and carrying out neurological observations post fall. The initial audit outcomes demonstrated poor compliance with the audited standards. As a result we introduced a new comprehensive post falls assessment proforma. Results We re-audited after the introduction of the new falls proforma, assessing inpatient falls from 20th January to 27th February 2021 at the William Harvey Hospital. 69% of falls cases have CT head scans requested as per trust policy, an improvement of 77% from the initial audit. 50% of patients who met the criteria for urgent CT head scans had it done within one hour of the request being made, an improvement of 150%. 84% of patient’s had neurological observations recorded as part of post fall assessment, an improvement of 12% from the initial audit. Conclusion The improvements seen in the audited standards are indicative that the new post falls proforma improves compliance with the trusts post falls protocol. We recommend that the new post falls proforma be a part of the trusts post fall protocol and for it to be included in the trust induction to new doctors.

Using Patient Simulation to Promote Best Practices in Fall Prevention and Postfall Assessment in Nursing Homes.

Background:Fall-related injuries rise with age and are of particular concern for frail populations living in nursing homes.Local Problem:The Perley and Rideau Veterans' Health Centre is a large nursing home in Ontario, Canada. In 2019, we conducted internal audits of our Falls Prevention Program and identified notable variations in staff's response to a resident fall.Interventions:We developed an in situ patient simulation program of a resident fall.Methods:This was a mixed-methods evaluation of participants' perspectives of a simulation-based interprofessional education program for fall prevention.Results:Participants indicated high-level support for simulation-based learning, with more than 80% of the participants expressing that they will apply these skills in the future when caring for a resident who falls.Conclusions:Our findings indicate that simulation-based training is well received by frontline workers in a nursing home setting and can be conducted as part of a typical shift with minimal disruption to resident care.

Using a Post Fall Assessment Simulation to Examine Nurse Thought Processes.

The prevalence of injurious falls is high in the Veterans Health Administration (VHA) and a major patient safety issue. The VHA is embracing technology such as simulation to improve patient care. Little is known regarding nurse thought processes while undergoing a post fall assessment simulation in the VHA. This article examines the benefit of using an evidence-based post fall simulation to improve nurse assessment skills while providing opportunity for practice without harm to patients.

60 Post Inpatient Fall Medical Assessment (PIFMA) Performa Quality Improvement Project

Abstract Introduction Inpatient falls are the most commonly reported patient safety incidents and in the United Kingdom, there are 250,000 reported falls per year 1. A rapid response report (RRR) issued in 2011 by the NPSA highlighted need for improvement in identifying fractures and neurological observations. These figures reflect significant implications to patients’ health and financial burden to the NHS. Aims To improve assessment and documentation of inpatient falls assessment. Methods Two PDSA cycles were completed. First PDSA cycle established a baseline of post fall assessment and documentation in which raising awareness and teaching (RAT) to junior doctors was done. Second PDSA cycle identified room for further improvement and post inpatient fall medical assessment (PIFMA) Performa was developed to aid assessment and documentation for use of junior doctors. Feedback regarding the usefulness of the PIFMA Performa was collected via survey. Results The RAT intervention involved 30 patients of the Elderly wards in November and December 2017 and the PIFMA intervention involved 29 patients in all Medical wards in January and February 2019. The PIFMA Performa improved the time taken to review patients as per doctors survey. On comparing the RAT against PIFMA Performa interventions, documentation improved in the categories of physical examination (from 80% to 97%), neurological observations (from 49% to 98%), medication review (from 53% to 83%), and measuring lying standing blood pressure (from 83% to 90%). Conclusions Feedback from junior doctors states that the PIFMA Performa was certainly a very useful guidance tool and help to speed up documentation. These improvements only translated if junior doctors utilize the PIFMA Performa and so this is now being implemented in the trust policy. Further PDSA cycle can reassess if improvements truly represent the population cross-section.

Intracranial haemorrhage detected by cerebral computed tomography after falls in hospital acute medical wards

BackgroundThere is little published data on brain imaging and intracranial haemorrhage after hospital inpatient falls. Imaging protocols for inpatient falls have been adopted from head injury guidelines developed from data in patients presenting to the Emergency Department. We sought to describe the use of brain computed tomography (CT) following inpatient falls, and determine the incidence and potential risk factors for intracranial haemorrhage.MethodsWe identified inpatient falls in acute medical wards at Monash Health, a large hospital network in the southeast region of Melbourne in Australia, from the incident reporting system during a 32 month period. We examined the post-fall medical assessment form, neurological observation chart and the diagnostic imaging system for details of the fall and brain CT findings. We used survival analysis to evaluate the timeliness of brain imaging and determined potential risk factors for intracranial haemorrhage by logistic regression.ResultsFrom 934 falls in 789 medical inpatients, 191 brain CT scans were performed. The median age of patients was 77 years. Only 55% of falls were from standing height and 24% experienced a head strike. Less than 10% of patients received an urgent scan within one hour, and timeliness of imaging was influenced by anticoagulation status rather than guideline determination of urgency. The overall incidence of intracranial haemorrhage was 0.9%. The factors associated with intracranial haemorrhage were head strike, anticoagulation, loss of consciousness or amnesia, drop in Glasgow Coma Scale and advanced chronic kidney disease.ConclusionsThe incidence of intracranial haemorrhage was low as most inpatient falls were at low risk for head injury. Research is needed to determine if guidelines specific for hospital inpatients may reduce unnecessary scans without compromising case detection, and improve timeliness of urgent scans.

Improving falls in nursing homes: a post-fall huddle quality improvement project

Falls are one of the most common preventable health problems in adults 65 years and older (AHRQ, 2013). A fall in this population can have a devastating effect often leading to a significant change in morbidity or death. Adults in assisting living, nursing homes, and skilled facilities (SNF) have an increased risk of falling and having a subsequent fall due to an acute illness, weakness, or confusion. This makes individualizing a plan of care to prevent a secondary fall and identifying the root cause of falls within a facility imperative.In our agency, the fall rate is nearly triple that of the national benchmark. To address this problem, a Post-Fall Huddle project was implemented. The literature recommends and supports the practice of a post-fall assessment program in fall reduction to identify intrinsic and extrinsic fall risk etiologies. There was found to be a reduction in the absolute values of recurrent patient falls per quarterly reporting after the implementation of the post-fall huddle. The results also provided pertinent data that can be used for recommendations in future fall prevention for the SNFÂ

Children’s development of semantic verbal fluency during summer vacation versus during formal schooling

Purpose: Children’s results on school-related achievements tests, such as aspects of math, reading and writing, have been shown to decline following a lengthy summer vacation. Few studies have investigated whether this also applies to vocabulary skills. The purpose of this study is to investigate how lexical organization and retrieval, assessed by a semantic verbal fluency (SVF) task, develops during a lengthy summer vacation versus formal schooling.Method: Sixty-eight children with mean age of 7.9 (ranging from 6.5 to 9.1), were assessed pre- and post-summer vacation and post-fall semester using two SVF categories (Animals and Clothes). The number of words produced in both categories gave the total score.Results: The result of the SVF tests decreased following summer vacation. The loss was recouped at the post-fall semester assessment, but no gains compared to initial testing were shown. Neither level of parental education, general language ability, non-verbal IQ, nor bilingualism explained the variance in development during the summer vacation or the fall semester.Conclusions: Our findings indicate that a lengthy summer vacation causes a recess in the expected development of SVF ability and that this recess is recouped after a semester of formal schooling. The findings are in line with previous research indicating that summer vacation may have negative impact on the development of important scholastic abilities in children.

Interrelated Neuromuscular and Clinical Risk Factors That Contribute to Falls.

Neuromuscular and clinical factors contribute to falls among older adults, yet the interrelated nature of these factors is not well understood. We investigated the relationships between these factors and how they contribute to falls, which may help optimize fall risk assessment and prevention. A total of 365 primary care patients (age = 77 ± 7, 67% female) were included from the Boston Rehabilitative Impairment Study of the Elderly. Neuromuscular measures included leg strength and leg velocity, trunk extensor endurance, and knee range of motion. Clinical measures included memory, executive function, depressive symptoms, pain, sensory loss, vision, comorbidity, physical activity, mobility self-efficacy, and psychiatric medication. Factor analysis was used to evaluate clustering of factors. Negative binomial regression assessed the relationship of factors with three-year fall rate. Interactions were tested to examine whether clinical factors modified the relationship between neuromuscular factors and falls. Three factors emerged: (i) neuromuscular factors, pain, and self-efficacy; (ii) memory; and (iii) executive function. Having three neuromuscular impairments predicted higher fall rate (incidence rate ratio [95% confidence interval]: 3.39 [1.82-6.32]) but was attenuated by memory (1.69 [1.10-2.61]), mobility self-efficacy (0.99 [0.98-0.99]), psychiatric medication use (1.54 [1.10-2.14]), and pain (1.13 [1.04-1.23]). Pain modified the relationship between neuromuscular impairment burden (number of neuromuscular impairments) and falls. Having three neuromuscular impairments was associated with a higher fall rate in patients with high levels of pain (5.73 [2.46-13.34]) but not among those with low pain. Neuromuscular impairment burden was strongly associated with fall rate in older adults with pain. These factors should be considered together during fall risk assessment, post fall assessment, and prevention.

Inpatient falls in older adults: a cohort study of antihypertensive prescribing pre- and post-fall

BackgroundFalls are common during hospital admissions and may occur more frequently in patients who are taking antihypertensive medications, particularly in the context of normal to low blood pressure. The review and adjustment of these medications is an essential aspect of the post-fall assessment and should take place as soon as possible after the fall.Our aim was to investigate whether appropriate post-fall adjustments of antihypertensive medications are routinely made in a large National Health Service (NHS) Trust.MethodsInpatient records over an eight-month period were captured from an electronic prescribing system to identify older adults (≥80 years old) with normal/low blood pressures (< 140 mmHg systolic) who had a documented inpatient fall as these patients were considered to be at high risk of further falls. Prescribed antihypertensive medication on admission was then compared with the post-fall (within 24 h after the fall) and discharge prescriptions.ResultsA total of 146 patients were included in the analysis. Of those, 120 patients (82%) were taking the same number of antihypertensive medications in the 24 h after the fall as they were before; only 19 patients (13%) had a reduction in the number of medications and seven patients (5%) had an increase in medications during that period. Only 9% of the antihypertensive classes assessed were either stopped or reduced in dose immediately post-fall. In addition, 11 new antihypertensives were prescribed at this time.At discharge, half of the patients (n = 73) remained on the same number of antihypertensive medication as on admission, 51 patients (35%) were on fewer antihypertensives and 22 (15%) were on more. Additionally, no changes were made to individual antihypertensives in 49% of prescriptions; 34% were stopped or reduced in dose but 38 new agents were started by the time of discharge. Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers (ACEi/ARB) were the class of medications most commonly stopped or reduced (51%).ConclusionsAntihypertensive prescriptions are frequently unchanged after an inpatient fall. Routine medication review needs to be part of post-fall assessments in hospital to reduce the risk of further falls.

Advanced Practice Nurse-Led Statewide Collaborative to Reduce Falls in Hospitals.

Thirty-eight hospitals participated in falls prevention team training, followed by coaching and mentoring over 3 months to develop unit-based initiatives to reduce falls. Initiatives centered on fall risk assessment, rounding, or postfall assessment. Paired t test of the pre-/postintervention fall rates of 23 of the hospitals revealed reduced fall rates (P < .01). The estimated mean decrease was 1.7 falls per 1000 patient days (95% confidence limits of 0.7-2.7).

Use of a Postfall Assessment Tool to Prevent Falls

Nursing research in fall prevention should not only identify etiologic risk factors to fall but seek to identify underlying causes, whenever possible. Few studies have investigated the use of a comprehensive postfall assessment tool (PFAT) by nurses as an intervention for the prevention of recurrent falls, especially one that prompts nurses to consider all potential causes through a categorization scheme. This study tested use of a comprehensive PFAT as an intervention, prospectively, facility-wide for 1 year by registered nurses using a pretest-posttest design. A 29.4% reduction in the fall rate (z = 3.89, p < .001), 27.6% decline in total falls experienced by all fallers (p < .001), and a 34.0% decline for recurrent fallers (p = .025) from preintervention to intervention year was observed when trained nurses categorized falls according to perceived causes. These declines are likely due to consistent and rigorous use by trained nursing staff, prompting their critical examination of each fall.

Interventions to improve post-fall assessment in nursing home patients: A quality improvement study

Introduction/Objective: Fractures in the elderly result in significant morbidity and mortality. Nursing home residents often undergo post fall imaging to rule out fractures without adequate joint examination. A prior study conducted in a local long-term care facility with 58 nursing home beds and 34 adult care beds showed high rates of post fall imaging without appreciable detection of fractures with an overall lack of specific documentation of joint examination after falls. Objective: To study the effectiveness of an in-service for the nursing staff in improving documentation of joint examination after fall.

Introducing a post-fall assessment algorithm into a community rehabilitation hospital for older adults

The aim of this paper is to describe a study designed to standardise and improve practice by introducing a new assessment tool to guide nurses in the evaluation of patients following a fall in a community hospital for older people. The idea behind the assessment tool is that it would support nurses in prioritising medical attendance to review particular patients by requesting immediate, same day or the next working day care. An action research approach was used.