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Published by the Metropolitan Health and Aged Care Services Division Victorian Government Department of Human Services This document should not be considered prescriptive. Health Melbourne Victoria care staff should work with patient/residents and their families/carers to ensure that the most appropriate care and ' Copyright State of Victoria, Department of Human Services, 2004 treatment is provided to the individual. Some flexibility will be required to adapt these Guidelines to specific settings, local This publication is copyright. No part may be reproduced by any process except in accordance with the circumstances and to individual patient/resident needs.
provisions of the Copyright Act 1968.
Every effort has been made to ensure that the information Design by Watts Design. 3290 provided in this document is accurate and complete at the time of development. However the Victorian Quality Council, the authors, or any person that has contributed to its development do not accept liability or responsibility for any errors or omissions that may be found, or any loss or damage incurred as a result of relying on the information in this document.
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VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Contents of this Guidelines Pack A process model for minimising the risk of falls and fall-related injuries Guideline statements relating to the steps in the process model The VQC is developing a generic change and implementation best practice model due to be released before the end of 2004 Information about tools for minimising the risk of falls and fall-related injuries Examples of tools for use with the four steps of the process model EDUCATION SUPPLEMENT Training units and case studies to support the use of the process model A table recommending specific units and case studies for different healthcare services job roles RESEARCH SUPPLEMENT Details of the research findings used to support the development of these Guidelines Quick Reference Guide: descriptions of falls risk factors and actions for minimising risk Posters: key steps and information from the Guidelines The following symbols are used throughout the Guidelines Pack. These symbols indicate that further information is available in the relevant supplement. Step 3 Develop and Implement an Action List
Purpose of these Guidelines Who these Guidelines are intended for Guideline Statement for Step 3 Using these Guidelines in the different settings Patient/resident centred tasks for Step 3 Research findings and levels of evidence Organisational tasks for Step 3 Definition of a fall Rationale for Step 3 Differences in implementing Step 3 across the three settings 2. PROCESS MODEL FOR MINIMISING Actions for minimising personal risk factors THE RISK OF FALLS AND FALL-RELATED INJURIES Actions for minimising individual environmental risk factors About the process model Step 4 Respond to a falls incident appropriately
The four patient/resident-centred care steps Tools for use with the steps Guideline Statement for Step 4 Patient/resident centred tasks for Step 4 3. THE PATIENT/RESIDENT CENTRED CARE STEPS Organisational tasks for Step 4 Step 1: Conduct falls risk screen
Rationale for Step 4 Differences in implementing Step 4 across the three settings Guideline Statement for Step 1 Patient/resident centred tasks for Step 1 4. THE PROCESS MODEL AND Organisational tasks for Step 1 QUALITY IMPROVEMENT Rationale for Step 1 Differences in implementing Step 1 across the three settings Step 2: Conduct falls risk assessment
6. GLOSSARY OF TERMS Guideline Statement for Step 2 Patient/resident centred tasks for Step 2 Organisational tasks for Step 2 Rationale for Step 2 Differences in implementing Step 2 across the three settings Personal risk factors identified in the literature Individual environmental risk factors identified in the literature Minimising the Risk of Falls & Fall-related Injuries Guidelines for Acute, Sub-acute and Residential Care Settings is an initiative of the Victorian Quality Council (VQC). The development of the Guidelines Pack is one component of a strategic approach to reducing the risk of harm and improving health care quality and safety in Victoria, including: Establishing a Safety and Quality Framework, Providing Access to Better Data, Educating on Safety and Quality and Responding to Known Problems and Risks.
Falls, related injuries and loss of confidence due to fear of falling are common causes of morbidity in Australia. In hospital and residential care settings, the risk of falling is even greater than in the community setting, because of acute illness, increased levels of chronic disease, and different environments and routines. Research evidence indicates that interventions to minimise falls risk can reduce the risk of falling and fall-related injuries, even in older people with high risk of falling. Staff involved in direct care in hospital and residential care settings have a key role in successful implementation of falls risk minimisation activities.
More information about the consequences and costs of falls and fall-related injuries is given in the Research Supplement.
Purpose of these Guidelines
Using these Guidelines in emergency departments
The purpose of these Guidelines is to assist direct Forty-five percent of older people who attend a hospital emergency department after a fall are discharged care staff and others responsible for ensuring quality without admission. Emergency department staff have an important role in identifying the ongoing fall risks for of care, to put in place an effective program for these patient/residents, as well as initiating appropriate referrals or interventions that may reduce the risk of minimising the risk of falls and fall-related injuries.
future falls and hospital presentations. The information provided is based on the best These Guidelines may provide a useful framework for staff in emergency departments.
available evidence at the time of publication.
Research findings and levels of evidence
Who these Guidelines are intended for
These Guidelines are based on research evidence and, where no formal research evidence exists, on expert These Guidelines have been developed for those opinion and the findings of expert working parties.
who deliver, and are responsible for, patient/resident care. This includes clinical, management, corporate Guideline Statements have been identified for the four patient/resident-centred care steps in the process and environmental service s staff.
The research methodology is described in the Research Supplement.
Using these Guidelines in the different
Levels of evidence of effectiveness
The evidence for the guideline statements presented in these guidelines was systematically assessed and Although a broadly similar approach may be taken classified according to the National Health and Medical Research Council s (NHMRC) Guide to the to minimising the risk of falls and fall-related injuries Development, Implementation and Evaluation of Clinical Practice Guidelines [1]. in the different settings, circumstances may call for different strategies in: Levels of evidence of effectiveness describe the strength of the research evidence supporting each recommended strategy to reduce the risk of falls or fall-related injuries. From strongest to weakest, the levels acute and sub-acute hospital settings, and of evidence used for the Guideline Statements in this document are shown in the following table: hospital and residential care settings.
Table 1. Levels of evidence used for the Guideline Statements
These Guidelines have been structured as a global resource for use across all three settings, where differences exist, they are identified and described Evidence obtained from a systematic review of all relevant randomised controlled trials Evidence obtained from at least one properly designed randomised controlled trial Use of the terms "patient", "resident" and "client"
For the purpose of this document the term patient Evidence obtained from well designed pseudo-randomised controlled trials (alternate allocation refers to both patients and clients in acute and or some other method) sub-acute settings. Resident has been used to Evidence obtained from comparative studies with concurrent controls and allocation not refer to people receiving care in residential care randomised (cohort studies), case control studies, or interrupted time-series with a control group Evidence obtained from comparative studies with historical controls, two or more single-arm studies, or interrupted time series without a parallel control group Evidence obtained from case series, either post-test or pre-test and post-test.
For the purposes of this project, the term Consensus Opinion has been used to describe evidence based on consensus ofexpert opinion and the findings of expert working parties. VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Definition of a "fall"
General environmental risk factors — related to
For the purposes of these Guidelines, a fall is hazards that are outside the patient/resident s immediate area, but in places where the patient/resident goes at times (eg corridors, A sudden, unintentional change in position causing therapy areas).
an individual to land at a lower level, on an object, the floor, the ground or other surface [2]. The interaction between the individual and their environment can be considered a third type of risk factor — also called behavioural risk factors. The
nature of the activities performed (how difficult or tiring they are) and the way patient/residents perform them (safely or not) will influence their risk of falling.
falling into other people legs giving way.
If a patient/resident is found on the floor, it should be assumed that they have fallen unless they are cognitively unimpaired and indicate that they put themselves there on purpose.
It is recommended that a common definition is adopted for use across health services and within a specific setting. For further definitions of a fall see the Falls risk factors
Falls risk factors are characteristics or behaviours that make it more likely that a patient/resident will fall. Falls risk factors can broadly be considered as: Personal (intrinsic) risk factors relate to health
problems that increase the patient/resident s risk Environmental (extrinsic) risk factors relate to
hazards in the environment that increase the patient/ resident s risk of falling (eg bed brakes not locked).
These risk factors have been sub-divided into: Individual environmental risk factors — related
to hazards in the patient/resident s immediate 02 Process model for minimising the risk of falls and fall-related injuries Steps in minimising the risk of falls
Steps in minimising the risk of falls
and fall-related injuries
and and fall-related injuries
1 CONDUCT
Falls Risk Screen
daily care for patient/ 1 CONDUCT Falls Risk Screen
daily care for patient/ About the process model
resident with low falls Falls Risk Screen resident with low falls Does the level of the patient/resident's risk Falls Risk Screen Does the level of the patient/resident's risk The process model exceed the threshold? (the threshold is exceed the threshold? (the threshold is dependant upon the tool used) dependant upon the tool used) presents four steps for assessing and managing patient/residents to 2 CONDUCT Falls Risk Assessment
Review/revise plan 2 CONDUCT Falls Risk Assessment
Review/revise plan for daily care routinely, for daily care routinely, minimise their risk of falls and fall- Have the risk factors been assessed Have the risk factors been assessed related injuries, and comprehensively for this patient/resident? • patient/resident falling comprehensively for this patient/resident? • patient/resident falling • change in patient/ • change in patient/ identifies tasks and products that resident's health/ resident's health/ Collate, monitor, result from carrying out the steps.
analyse, and feedback 3 DEVELOP & IMPLEMENT
• change in patient/ 3 DEVELOP & IMPLEMENT
• change in patient/ falls incident data. minimising falls an Action List for minimising the risk
resident's environment minimising falls an Action List for minimising the risk
resident's environment Feedback to staff/ of falls and fall-related injuries and
management on data.
of falls and fall-related injuries and
INCLUDE the list in the patient/resident's
INCLUDE the list in the patient/resident's
plan for daily care
Upgrade tools and plan for daily care
process in response Do the selected actions match the Do the selected actions match the to findings.
patient/resident's risk factors and have all patient/resident's risk factors and have all the actions been implemented as part of the the actions been implemented as part of the plan for daily care? plan for daily care? IF A P TIENT/
IF A P TIENT/
RESIDENT F
RESIDENT F
4 RESPOND to a falls incident
Review circumstances 4 RESPOND to a falls incident
Review circumstances of the fall at ward/unit of the fall at ward/unit a) Care for patient/resident
a) Care for patient/resident
b) Report the incident
b) Report the incident
c) Repeat steps 1/2 and 3 of this module
c) Repeat steps 1/2 and 3 of this module
Falls Incident Data Falls Incident Data Were the appropriate actions taken? Were the appropriate actions taken? * In some settings, the Screening component may be omitted, and the Model commences with Assessment (Step 2) Organisation meets qualityimprovement requirements VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES The four patient/resident centred care steps
The four steps are integral to an effective program to minimise the risk of falls and fall-related injuries in hospitals and residential care settings. The four steps are: centred care step Identifying patient/residents who are at greatest risk of falling and in need of more Identifying the falls risk factors that contribute to the patient/resident s overall risk of falls and fall-related injuries. Developing and implementing an individualised Action List aimed at reducing the risk of falls and fall-related injuries. Appropriate response The appropriate response to a falls incident includes caring for the patient/resident and ensuring that the incident is reported and documented.
Tools for use with the steps
The Tools Supplement includes a selection of tools that can be used for these steps.
The term Tools refers to a range of support documentation and resources used in implementing programs to minimise the risk of falls and fall-related injuries. These include: falls risk screening tools Victorian Coroner s Standard for Investigation (of falls related deaths) falls risk assessment tools cognitive impairment tests, and environmental audits (both individual and falls incident data management framework (Excel file).
falls incident report patient/resident information resources list of medications associated with increased falls 03 The patient/resident centred centred care steps VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Step 1: Conduct falls risk screen Steps in minimising the risk of falls
and fall-related injuries
Definition
1 CONDUCT Falls Risk Screen
daily care for patient/ Falls risk screening refers to a brief (often less than 5 items) check to identify patient/residents who are at risk resident with low falls Falls Risk Screen Does the level of the patient/resident's risk exceed the threshold? (the threshold is of falling. These patient/residents need to have a more detailed assessment of their falls risk carried out.
dependant upon the tool used) GUIDELINE STATEMENT FOR STEP 1 2 CONDUCT Falls Risk Assessment
Review/revise plan for daily care routinely, Have the risk factors been assessed comprehensively for this patient/resident? • patient/resident falling Conduct a falls risk screen as the minimum process for identifying clients who
• change in patient/ resident's health/ are at risk of falling.
3 DEVELOP & IMPLEMENT
• change in patient/ minimising falls an Action List for minimising the risk
resident's environment Level of evidence: Consensus Opinion [3].
of falls and fall-related injuries and
INCLUDE the list in the patient/resident's
plan for daily care

Do the selected actions match the patient/resident's risk factors and have all the actions been implemented as part of the Patient/resident centred tasks for Step 1
plan for daily care? c) Use a recognised tool.
IF A P TIENT/
RESIDENT F
a) Conduct a falls risk screen on all 4 RESPOND to a falls incident
Review circumstances patient/residents who are not part of high falls of the fall at ward/unitlevel a) Care for patient/resident
risk populations. b) Report the incident
c) Repeat steps 1/2 and 3 of this module

d) Document the results and include in the Ward/Unit LevelFalls Incident Data Were the appropriate actions taken? Screening may not be required in settings where patient/resident s permanent file/medical * In some settings, the Screening component may be omitted, most patient/residents are considered to be at and the Model commences with record/residential care file.
Assessment (Step 2) risk of falling (eg dementia specific wards in residential care). In these settings, and for all e) Carry out a falls risk assessment (Step 2) for: High falls risk populations
patient/residents in high falls risk populations, patients/residents whose risk of falling exceeds Studies in hospital and residential care settings proceed directly to Step 2.
have identified high falls risk populations to include b) Conduct a falls risk screen at the following times: patient/residents with the following: patients/residents who are in high falls risk a history of falls, falls with injury, or fall related on admission, or as soon as practicable after populations* (eg patient/residents with neurological conditions such as stroke and when a patient/resident is transferred from one Parkinson s disease ward or department to another cognitive problems such as dementia or delirium refer the patient/resident for assessment as soon if there is a change in a patient/resident s health as practicable.
lower limb (leg) arthritis or functional status acute infections such as urinary tract infection, if a patient/resident has a fall, and haematological/oncology conditions, or as part of discharge planning.
visual impairment.

Organisational tasks for Step 1
Differences in implementing Step 1
a) Select an appropriate tool.
across the three settings
In an acute setting, the patient s health status is likely to change rapidly, and falls risk screening should be repeated on a regular basis (eg daily or weekly) or when clinical judgement indicates b) Provide staff education and training on the that there is a change in the patient s purpose and use of the tool.
c) Audit the use of the tool for compliance with In emergency departments, falls risk screening relevant policy.
could be used to determine whether falls risk assessment should be completed by hospital Rationale for Step 1
staff, and/or whether referrals should be made to The risk of falling and related injury increases community agencies.
with age [4] and increased unsteadiness [5].
Falls occur more commonly in the period Falls risk screening may be less relevant in many immediately following a transition between high care residential settings, because most settings [6].
residents are likely to exceed the falls risk Increased length of stay in a hospital setting threshold. In this situation a falls risk assessment increases falls risk [7]. should be completed on all residents (Step 2).
Falls risk is ongoing. The patient/resident should be reviewed as part of an ongoing process [8].
VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Step 2: Conduct falls risk assessment Steps in minimising the risk of falls
Definition
and fall-related injuries
1 CONDUCT Falls Risk Screen
Falls risk assessment is a systematic and comprehensive process to identify an individual patient/resident s daily care for patient/resident with low falls Falls Risk Screen Does the level of the patient/resident's risk risk factors for falling. exceed the threshold? (the threshold is dependant upon the tool used) A patient/resident s level of risk of falling and fall-related injury is a combination of: 2 CONDUCT Falls Risk Assessment
Review/revise plan for daily care routinely, Have the risk factors been assessed the severity of each risk factor (which can vary from nil to very high) comprehensively for this patient/resident? • patient/resident falling • change in patient/ resident's health/ the importance of that risk factor (some risk factors have a stronger association with the risk of falls and 3 DEVELOP & IMPLEMENT
• change in patient/ fall-related injuries than others), and minimising falls an Action List for minimising the risk
resident's environment and fall-related of falls and fall-related injuries and
INCLUDE the list in the patient/resident's
the number of risk factors. plan for daily care
Do the selected actions match the patient/resident's risk factors and have all There is a direct relationship between a patient/resident s level of falls risk and their probability for falls.
the actions been implemented as part of the plan for daily care? IF A P TIENT/
GUIDELINE STATEMENT FOR STEP 2 RESIDENT F
4 RESPOND to a falls incident
Review circumstances of the fall at ward/unit Conduct a falls risk assessment for each patient/resident who is identified as
a) Care for patient/resident
b) Report the incident

being at risk of falling.
c) Repeat steps 1/2 and 3 of this module
Ward/Unit LevelFalls Incident Data Were the appropriate actions taken? * In some settings, the Screening Level of evidence: II [9, 10, 11].
component may be omitted, and the Model commences with Assessment (Step 2) Patient/resident centred tasks for Step 2
when the patient/resident s environment is d) Identify and describe all factors that contribute to a) Assess the following patient/residents for falls risk: changed (eg a patient/resident moves to another the patient/resident s risk of falling and fall- room, ward or setting, or new equipment is used) related injuries. patient/residents whose level of falls risk exceeded the screening threshold (Step 1) when the patient/resident s treatment is changed (eg different drug(s) prescribed) all patient/residents in high falls risk populations; the patient/resident s personal risk factors, and when the patient/resident has a fall risk factors in the patient/resident s individual all patient/residents in settings where most when a patient/resident is discharged/transferred patient/residents are expected to have a high from one setting to another, either within the e) Record the level of risk and the identified risk falls risk (eg dementia specific residential care units).
same organisation or to a different organisation factors (both personal and individual b) Assess or reassess a patient/resident s falls risk as part of a routine review, and environmental) in the patient/resident s permanent at the following times: file/medical record/residential care file.
at other times as required by your organisation s as soon as practicable after admission Proceed to Step 3 to determine actions to address the risk factors you have identified.
if there is evidence of change in the c) Use a recognised tool to carry out the patient/resident s health/functional status
Organisational tasks for Step 2
Differences in implementing Step 2
Personal risk factors identified in
a) Select an appropriate tool (falls risk assessment across the three settings
and individual environmental audit).
A number of falls risk factors relating to a In an acute setting, a patient/resident s health patient/resident s health status and b) Provide staff education on the purpose of the status and treatment may change frequently.
characteristics have been identified in the tool and training in its use.
Because of this re-assessment may need to be literature. These are known as personal risk c) Audit the use of the tool for compliance with carried out as often as staff shift changes, the factors (refer to the Research Supplement for relevant policy.
tool used should be relatively short and quick to more detail about personal risk factors).
There may be a number of possible causes for each Rationale for Step 2
Although allied health staffing levels may be more risk factor, and an important element of the falls risk Falls are usually caused by a number of risk limited in acute hospital settings than sub-acute assessment process for a patient/resident is to factors, [12] which vary between individuals, and settings, a multidisciplinary approach to falls and identify the cause/s of the risk factors identified change over time [7].
fall-related injury risk minimisation is still possible (which may often require medical and other health Falls occur more commonly in the period and desirable.
professional assessment). immediately following a transition between Sub-acute and Residential Care
Some causes may be modifiable (where the medical settings [6, 8].
A team may carry out components of condition that is the cause of the risk factor is able The risk of falling and related injury increases falls risk assessments rather than one to be improved with treatment), while others may be with age [4], and increased unsteadiness [5]. staff member. For example, the PJC- non-modifiable (often associated with chronic or FRAT is a multidisciplinary tool used in degenerative health problems). Even for non- Increased length of stay in a hospital setting the sub-acute setting, where: modifiable causes of falls risk factors, treatment can increases falls risk [7].
help to reduce the magnitude of the effect of the risk a medical officer assesses fall history, Falls risk is ongoing. The patient/resident should factor (for example, for a patient/resident with medical condition and medications be reviewed as part of an ongoing process [8].
Parkinson s disease, exercise can help to improve a nurse assesses continence status steadiness during walking even though the exercise Risk factor status changes over time, so there does not affect the underlying disease). Actions to may be a gap between needs and services. a physiotherapist assesses transfers and minimise risk of fall-related injury should also be This gap may be indicated by a change in the mobility status, and implemented for patient/residents with non- patient/resident s health or a fall [13].
an occupational therapist assesses functional modifiable causes of personal falls risk factors.
Between 10% and 50% of falls in hospitals and activities (bathing and dressing).
The personal risk factors for falls and some residential care facilities involve an environmental If a multidisciplinary team is involved in the examples of modifiable and non-modifiable causes hazard [5, 7, 14].
falls risk assessment, responsibility for are summarised in Table 2.
Over half of the falls in hospitals and residential ensuring timely completion of the assessment care facilities occur around the bedside [7, 10].
should be given to one staff member.
Direct care staff can assist by gathering information for the assessment.
VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Table 2. Personal Risk Factors
Personal risk factor Example of a modifiable cause Example of a non-modifiable cause Leg muscle weakness and deconditioning
proximal myopathy (eg osteomalacia) reduced physical activity Poor balance/unsteadiness in walking
balance and mobility problems after ankle Parkinson s disease ligament injury or joint replacement surgery Multiple medications, or use of medication
some medications may be reduced or ceased medication associated with an increased risk of associated with falling
falling for which there is no suitable substitute reduced detrusor muscle control medications that can cause postural hypotension Loss of confidence/fear of falling
Poor condition of feet and inappropriate
bunions, callouses, flattened transverse arch footwear
inappropriate or worn shoes, slippers Poor nutritional status
reduced intake from difficulty chewing due to poor fitting dentures Cognitive impairment (confusion, poor planning
and monitoring, reduced memory)
macular degeneration benign paroxysmal positional vertigo (BPPV) vestibular toxicity vitamin B12 deficiency diabetic neuropathy excessive wax, hearing aid not being used properly sensory neural deafness Factors contributing to history of previous falls
would need to investigate the causes of previous history of previous falls.
Full descriptions of these personal risk factors and actions for risk minimisation are provided in Step 3. Individual environmental risk factors
identified in the literature
The personal and individual environmental risk Individual environmental risk factors related to the factors described in this Step are only the starting patient/resident s immediate environment include the point of assessment. Their presentation may vary in individual patient/residents, or individual patient/residents may have risk factors that are not inappropriate bed or chair height included in these lists. inappropriate type of bed or chair brakes on bed/chair either not on, or broken call bell left out of reach walking aids out of reach walking aids not in good condition walking aids not used properly brakes on wheelie frame/wheelchair broken or not used properly IV drip stands, power cords etc. not positioned slippery surfaces loose floor coverings (eg rugs) hoists/lifting machines left in rooms or corridors inadequate lighting (poor lighting, lack of night lights, or excessive sun glare) inadequate rails/supports where required (eg toilets/bathrooms), and restraints/cotsides (use of restraints/cotsides can increase the risk of injury associated with falls).
Full descriptions of these individual environmental risk factors and actions for risk minimisation are provided in Step 3.
VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Step 3: Develop and Implement an Action List Steps in minimising the risk of falls
and fall-related injuries
Definition
1 CONDUCT Falls Risk Screen
daily care for patient/ An Action List for minimising the risk of falls and fall-related injuries is a list of strategies to address risk resident with low falls Falls Risk Screen Does the level of the patient/resident's risk exceed the threshold? (the threshold is factors that were identified by the falls risk assessment (Step 2). dependant upon the tool used) GUIDELINE STATEMENT FOR STEP 3 2 CONDUCT Falls Risk Assessment
Review/revise plan for daily care routinely, Have the risk factors been assessed comprehensively for this patient/resident? • patient/resident falling Develop and Implement Action List for minimising the risk of falls and fall-related
• change in patient/ resident's health/ injuries, include in patient/resident's plan for daily care.
3 DEVELOP & IMPLEMENT
• change in patient/ minimising falls an Action List for minimising the risk
resident's environment Level of evidence: II [9,10,11] and fall-related of falls and fall-related injuries and
INCLUDE the list in the patient/resident's
plan for daily care

Do the selected actions match the patient/resident's risk factors and have all the actions been implemented as part of the Patient/resident centred tasks for Step 3
permanent file/medical record/residential care plan for daily care? IF A P TIENT/
a) Determine which personal risk factors identified RESIDENT F
in Step 2 have causes that are modifiable.
4 RESPOND to a falls incident
Review circumstances discharge summary.
of the fall at ward/unitlevel a) Care for patient/resident
b) For each personal risk factor with a modifiable b) Report the incident
h) Implement Action List as indicated.
c) Repeat steps 1/2 and 3 of this module
cause, determine actions to minimise the risk of Falls Incident Data Were the appropriate actions taken? * In some settings, the Screening falls and fall-related injuries.
component may be omitted, Organisational tasks for Step 3
and the Model commences with Assessment (Step 2) c) Determine appropriate actions to manage risk a) Provide information and required resources to factors that are non-modifiable.
staff, to enable them to develop and implement c) Provide staff education and training in d) For patient/residents with high overall the Action List. Examples which may be developing and implementing an Action List.
falls risk, determine additional actions endorsed and supported from an organisational to minimise overall risk. Some tools d) Audit the implementation of Action Lists.
include a description of these actions. improved capacity for observation of high risk e) Ensure regular general environmental audits are e) Determine how often these actions should be patient/residents. This may involve restructuring of undertaken and actions implemented.
carried out, by whom and at what point in time.
work practice (eg changes to showering routines) or purchase of equipment (eg bed/chair alarms), or f) Either document all the actions in an Action List, or delegate this task to another staff member, as policies for discharge planning, which determined by your organisation s policy. include communication of falls risk information to those involved in g) Include the identified risk factors and the Action ongoing care.
List in the patient/resident s documentation including: b) Decide how the Action List should be integrated plan for daily care into the patient/resident s plan for daily care.

Rationale for Step 3
ACTIONS FOR MINIMISING PERSONAL RISK FACTORS A targeted falls prevention program based on the findings of a falls risk assessment has been shown to reduce falls in residential care and Table 3 outlines actions to minimise the impact of each of the personal hospital settings [9, 10, 11].
risk factors for falls, to assist in developing an Action List. The research Modification of the individual s environment can evidence clearly supports a multifaceted approach, where multiple reduce falls risk [15].
Falls are usually caused by more than one falls actions are introduced to address the full range of personal risk factors risk factor, so multi-factorial interventions targeting all identified risk factors are likely to be Many of the actions listed in Table 3 have been more effective than single interventions [16].
identified in the research literature, and further Falls risk factors may present differently in details supporting these actions are provided in the individual patient/residents. These differences can be determined through individual assessment and management of each of the risk factors [13].
In addition, a number of actions, which should be considered part of standard care for all Differences in implementing Step 3
patient/residents, can reduce the risk of falls and across the three settings
fall-related injuries. These include: identifying causes of the risk factor (medical or Because the time spent by patients in this setting allied health referral) is usually short, the approach may emphasise preventative actions such as enhanced ensuring safety (adequate supervision, supervision of patients activities and environment.
communicate mobility status to all staff, use of appropriate walking aid) Sub-acute and Residential Care
For patient/residents receiving longer-term care, ensuring safe and uncluttered environment there may be greater emphasis on behaviour keeping call bell and other personal items within modification and improving functions for daily living.
orientating patient/resident to area, and identifying and addressing individual patient/resident s needs.
VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Table 3. Actions for Minimising Personal Risk Factors
Personal Risk Factor LEG MUSCLE WEAKNESS AND DECONDITIONING Effort associated with standing up from a chair, Activities and exercise
needing to use arms to push up when standing up Encourage safe incidental activities (activities that Ask the patient/resident s family and friends to are part of daily living) to maintain muscle mass, encourage the patient/resident to carry out the What contributes to the risk?
balance, strength and mobility (eg walking, Extended bed rest and diminished activity and transferring, dressing, bathing) Explore the physical interests and recent activities Encourage the patient/resident to participate in undertaken by the patient/resident before admission Vitamin D deficiency exercise or activity groups, or an individual exercise Provide additional assistance when the patient/ Other medical problems such as renal failure and resident is tired or hurried (eg in a rush to go to the Develop a routine for physical activity and monitor toilet). Discuss this need for assistance with the the patient/resident progress patient/resident and their family and friends Incorporate physical activity goals in the Seek advice from a physiotherapist about safe patient/resident s plan for daily care exercises and activities the patient/resident can perform on their own, or with supervision For patient/residents limited to bed rest, ask a physiotherapist about appropriate bed exercises for the patient/resident Seek advice from an occupational therapist about aids/appliances to increase the patient/resident s opportunities for independent activity.
Refer patient/resident to medical review to assess Ensure effective communication of assessment possible medical factors contributing to muscle findings and action plant to all staff so that there is a consistent approach If necessary, refer to a physiotherapist, occupational therapist, or activity therapist for assessment and recommended actions Personal Risk Factor POOR BALANCE AND UNSTEADINESS IN WALKING Unsteady/veering during transfers or walking, Activities and exercise
experiencing near falls Encourage the patient/resident to participate in Seek advice from a physiotherapist about safe exercise or activity groups, or an individual exercises and activities the patient/resident can Reaching for walls or other supports while exercise program perform on their own or with supervision Encourage safe incidental activities (activities that Ask the patient/resident s family and friends to Overbalancing, especially when reaching, are part of daily living) to maintain muscle mass, encourage the patient/resident to carry out the bending, straightening or turning balance, strength and mobility (eg walking, What contributes to the risk?
transferring, dressing, bathing) Determine to what extent the patient/resident Acute health problems such as a chest infection, can manage their own balance/unsteadiness.
urinary tract infection or pain can cause If necessary, initiate safety precautions until deterioration in balance/steadiness physiotherapy response is in place Neurological problems (eg stroke, Parkinson s disease, peripheral neuropathy) Walking aids
Consider introduction of a walking aid, or change Seek a physiotherapist s advice about the most Musculoskeletal problems (eg arthritis, joint in current walking aid appropriate walking aid, and to provide instruction and practice regarding correct use Ensure walking aids are within the patient/resident s reach Consider strategies to manage falls risk (eg increased supervision) until patient/resident is seen by the physiotherapist Orientation and support
Always supervise the patient/resident when they Regularly check with patient/resident that needs are walking or making transfers are being met, to minimise the patient/resident s attempts to transfer or walk independently if it is Introduce strategies to increase not safe to do so Ask the patient/resident s family and friends to Discuss and reinforce all safety issues with also reinforce safety issues patient/residents (eg they need supervision when ambulating; they should always use walking aid) Modify the environment
Ensure furniture and other hand holds used to assist transfers are suitable (ie stable and sturdy) VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Personal Risk Factor POOR BALANCE AND UNSTEADINESS IN WALKING continued… Consider use of hip protectors Consider the different types of hip protectors available, including those which incorporate continence pads, and adhesive hip protectors Encourage ongoing wearing of the hip protectors Refer patient/resident for medical review to Ensure effective communication of assessment assess possible medical factors contributing to findings and action plan to all staff so that there is poor balance or unsteadiness a consistent approach If necessary refer the patient/resident to a physiotherapist, occupational therapist or activity therapist for assessment and recommended Personal Risk Factor USE OF MORE THAN 4 MEDICATIONS OR MEDICATIONS ASSOCIATED WITH FALLING New problems such as unsteadiness or dizziness soon after commencing new Inform doctor if side-effects of medications such as Obtain medical advice about medication needs drowsiness or unsteadiness are observed Symptoms that might be side effects of Try using non-pharmacological alternatives to Refer to the Tools Supplement for a list of the medications (eg dizziness, low blood psychotropic medications, such as relaxation, use of main falls risk medications pressure on standing up) music, and psychological support to help patient/resident manage without medication Try to minimise the number of medications a What contributes to the risk?
patient/resident needs to take, especially those that New medications added to an existing are "high falls risk" medications medication regime, or changes to dosage, to treat new health problems Orientation and Support
Medications that are associated with high risk Implement a prompted toileting program if Discuss with patient/resident and family of falls, such as antidepressants, sleeping pills, appropriate that best matches the patient/residents major and minor tranquillisers accustomed routine Modify the environment
When using medications such as sedatives that affect Seek advice from an occupational therapist about alertness and increase drowsiness, implement ways to ensure the patient/resident s individual strategies that minimise risk of falls at night: environment is as safe as possible reduce clutter in patient/resident s room supervise all transfers and mobility overnight Refer patient/resident for review by a doctor or Ensure effective communication of assessment pharmacist to assess medication and recommend findings and action plan to all staff so that there is ongoing medication needs a consistent approach If necessary, refer patient/resident to an More information is provided in the occupational therapist or a psychologist to provide Increased Surveillance section of the alternatives to high falls risk medications such as Research Supplement VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Personal Risk Factor COGNITIVE IMPAIRMENT (CONFUSION/DELIRIUM/DEMENTIA) Identify and treat
Identify and treat possible medical conditions that Poor short term memory may contribute to the cognitive impairment Poor ability to follow instructions (eg to use walking aid) or difficulty learning Monitor and review
Monitor cognitive status regularly, including Tools that may be used to monitor cognition are the: observation of the patient/resident s ability to follow Abbreviated Mental Test Score (AMTS) instructions and orientation to ward/unit Mini Mental State Examination (MMSE) Discuss patient/resident s cognitive status before or What contributes to the risk?
on admission with their family/friends Examples of these tools are in the Changes in the environment can cause or worsen a Monitor the patient/resident for features of delirium patient/resident s cognition. This may occur on (such as acute onset change in cognitive status) admission, if there is a room change or a change in Monitor the patient/resident s sleep pattern, and if Identify the patient/resident s regular sleep necessary introduce a program to support non- patterns by asking their family/friends, and ensure New medications added to an existing medication interrupted sleep. Strategies to improve sleep that this information is passed on to all staff at regime to treat new health problems patterns may include noise reduction strategies, Acute health problems such as a chest infection, such as vibrating beepers and silent pill crushers, urinary tract infection and/or pain minimisation of nocturnal disturbance by staff, not having regimented bedtimes, and review of Staff untrained in behaviour management of medication schedule patient/residents with agitation or confusion Orientation and support
Repeat orientation and safety instructions on a Develop a schedule or routine for the patient/resident (such as eating times, activity times, regular regular basis, keeping instructions simple and toileting regime) and be sure to pass this on to all staff at handover Use environmental cues to reinforce orientation Discuss patient/resident s needs, habits and and safety instructions routines, and likes and dislikes with family/friends, Maintain consistency in procedures, routines and and aim to meet/address these needs and wants schedules, staff allocation and, where possible, adhere to the patient/resident s accustomed habits and activities of daily living and use of their Personal Risk Factor COGNITIVE IMPAIRMENT (CONFUSION/DELIRIUM/DEMENTIA) continued… Orientation and support continued…
Increase surveillance through more frequent Identify some triggers for the agitated, impulsive observation, moving the patient/resident to an behaviour, such as particular medication, time of area of higher visibility, using a bed alarm, and day, infection, and loud noise, and try to reduce family/friends providing additional assistance with observation. Use sitters for high surveillance ward Ensure that patient/resident uses appropriate aids More information is provided in the (hearing aids, glasses, walking aids) and that they Increased Surveillance section of the are in correct working order Research Supplement Consider options for increasing Consider use of hip protectors Consider the different types of hip protectors, including those which incorporate continence pads, and adhesive hip protectors Encourage ongoing wearing of the hip protectors Refer patient/resident for a medical review to Ensure effective communication of assessment exclude acute delirium or other reversible causes findings and action plan to all staff so that there is of cognitive impairment a consistent approach If necessary, refer patient/resident to a physiotherapist to determine whether gait aids will be able to be used appropriately and correctly If necessary, refer patient/resident to an occupational therapist to assist with behaviour management and to develop a plan to maximise orientation, awareness and function.
VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Personal Risk Factor POSTURAL (ORTHOSTATIC) HYPOTENSION Light-headedness or unsteadiness when moving Identify and treat
from lying to sitting, or sitting to standing Identify and treat acute reversible contributory What contributes to the risk?
Bed rest or prolonged periods of inactivity
Monitor and review
Inadequate time to adjust to changes in position (eg Monitor and record blood pressure, both lying and If there is a drop in systolic blood pressure moving too quickly from lying to standing) standing (at 1 minute and 2 minutes) >20mmHg or diastolic blood pressure >10mmHg seek medical review Some medications (eg major tranquillisers, Supervise changes of position Discuss strategies with the patient/resident s Encourage patient/resident to sit up from lying, family/friends and ask them to reinforce these Some acute and chronic illnesses (eg Parkinson s and to stand up from sitting, slowly, and to wait a with patient/residents disease, diabetes, heart failure) short time before walking Ensure that elastic compression stockings fit Determine indications and appropriateness of properly, and do not have any creases.
elastic compression stockings Physiotherapists or nursing staff are often responsible for supply and fitting of elastic compression stockings Orientation and Support
Encourage increased fluid intake by providing drinks at regular intervals Refer patient/resident for medical review to Ensure effective communication of assessment assess and recommend ongoing management for findings and action plan to all staff so that there is the postural hypotension a consistent approach Personal Risk Factor INCONTINENCE Frequency of need for toileting Identify and treat
Identify and treat acute reversible contributory Poor fluid intake Strong odour of urine Urinary or bowel accidents History of nocturia Monitor and review
What contributes to the risk?
Identify possible causes of incontinence using the Use a continence chart The patient/resident may be physically unable to following techniques: Discuss with the medical staff or pharmacist get to the toilet in time, or to unfasten garments monitor fluid intake and bladder and bowel activity quickly enough (due to, for example, a new Discuss with patient/resident and family health problem such as a stroke or hip fracture) identify medications such as anti-cholinergic medications, sedatives, narcotics, and diuretics, Lack of orientation or confusion about location which may contribute to the continence problem (including review of timing and dosage) Some medications can increase the risk of look for signs of urinary tract infection and treat if incontinence (eg diuretics) Acute health problems such as a chest infection, Review timing and amount of caffeine intake urinary tract infection and/or pain Ensure adequate hydration by providing drinks at regular intervals Implement a prompted voiding (regular toileting) Discuss with patient/resident and family program that best matches the patient/resident s Ensure other staff are aware of patient/resident s accustomed routine needs if you are going to be away or are involved in Respond to requests for toileting promptly other work for a period of time If possible, locate the patient/resident close to the VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Personal Risk Factor INCONTINENCE continued… Ensure patient/resident is wearing suitable clothes Discuss with patient/resident and family without fasteners, or with fasteners that are easy Seek advice from a physiotherapist about safe to undo (eg pants with an elastic waist) exercises and activities the patient/resident can Encourage patient/resident to participate in perform on their own, or with supervision exercise or activity groups, or individual exercise Provision of appropriate continence aids (eg commode by bed, non-spill urinals, pads etc) Refer patient/resident for a medical review to Ensure effective communication of assessment assess and recommend ongoing management for findings and action plan to all staff so that there is a consistent approach If necessary, refer to a continence specialist for comprehensive assessment and management Personal Risk Factor SENSORY LOSS Identify and treat
Inability to see detail in objects Identify and treat acute reversible contributory Not wanting to, or inability to, read or watch Monitor and review
Identify change in sensory status over the Discuss with patient/resident and family preceding months, and how long since sensory Bumping into objects Seek advice and treatment from a podiatrist to status has been investigated reduce problems associated with sensory loss Monitor skin and nail condition for people with Poor skin condition somatosensory loss (eg diabetic neuropathy) Cuts or bruises on feet Investigate the cause if the patient/resident Lack of feeling in feet reports dizziness, as some common causes of dizziness are easily treatable by medical or allied Pressure areas/ulcers health staff (eg benign paroxysmal positional vertigo) Vestibular (inner ear)
Reports of dizziness Modify the environment
Maintain a safe environment free of physical Seek advice from an occupational therapist about Leaning forward when listening ways to ensure the patient/resident s individual environment is as safe as possible Needing to have things repeated Ensure appropriate signage, particularly leading to Appropriate night lighting Having radio or TV volume loud What contributes to the risk?
Adjusting to a new environment is more difficult
Orientation and support
if there is reduced sensory input Ensure that patient/residents who need them are Seek advice from an occupational therapist to Sensory loss can be due to medical problems wearing their glasses, that they are in optimal working assist in checking sensory aids, and providing affecting the sensory function, or by inadequate order (eg clean) and that they are the correct aids/supports to minimise functional impact of condition or use of aids to improve sensory prescription (eg strength may need to be upgraded) Ensure that patient/residents who need them are wearing hearing aids, that they are in optimal working order (eg batteries working) and suit the level of VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Personal Risk Factor SENSORY LOSS continued… Ensure effective communication of assessment Refer patient/resident for medical review to findings and action plan to all staff so that there is assess and recommend ongoing management for a consistent approach Refer patient/resident to specialist for detailed assessment of sensory system/s (eg optometrist or ophthalmologist for vision problems; podiatrist for somatosensory problems) Personal Risk Factor POOR CONDITION OF FEET/INAPPROPRIATE FOOTWEAR Limping due to pain or poor condition of feet Identify and treat
Identify and treat acute reversible contributory Reddened areas on the feet (eg over a Poor condition of skin around toes Poor condition of toe nails Monitor and review
Inappropriate footwear: Review footwear and condition of feet on Explain the importance of good footwear to the patient/resident and their family/friends Provide an information brochure on appropriate footwear to patient/resident and their poor or no fastenings Action purchase and repairs as indicated What contributes to the risk?
Refer patient/resident for medical review or to Ensure effective communication of assessment podiatrist to assess and recommend ongoing findings and action plan to all staff so that there is Wearing inappropriate footwear, such as management of foot problems and appropriate a consistent approach VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Personal Risk Factor LOSS OF CONFIDENCE/FEAR OF FALLING Acknowledges being afraid of falling when asked Monitor and review
Monitor all aspects of ambulation, transferring and Seek advice from a physiotherapist, who will Reluctance to walk related activity, and provide encouragement and identify whether the loss of confidence is Reaches for additional support when walking or support as required appropriate to the patient/resident s level of balance Discuss with family/friends and ask them to Anxious about walking or transferring reinforce with patient/residents the importance of safe walking and activity Near falls or previous falls What contributes to the risk?
Activity and exercise
Medical condition affecting balance and mobility, such as stroke or hip fracture Encourage patient/resident to participate in Seek advice from a physiotherapist about safe exercise or activity groups, or individual exercise exercises and activities the patient/resident can Adjusting to a new environment perform on their own, or with supervision Inadequate sensory input (eg poor lighting) Encourage safe incidental activities (activities that Ask the patient/resident s family and friends to Environmental hazards are part of daily living) to maintain muscle mass, encourage the patient/resident to do the safe balance, strength and mobility (eg walking, incidental activities transferring, dressing, bathing) Walking aids
Consider use of walking aid or change in current Seek advice of a physiotherapist about the most appropriate walking aid, and to provide instruction and practice regarding correct use Ensure walking aids are within the patient/resident s reach Refer patient/resident for medical review to Ensure effective communication of assessment assess and recommend ongoing management for findings and action plan to all staff so that there is the loss of confidence a consistent approach Refer patient/resident for physiotherapy, occupational therapy, and/or psychologist support to assess and recommend ongoing management Personal Risk Factor POOR NUTRITIONAL STATUS Recent weight loss Identify and treat
Identify and treat acute reversible contributory Low Body Mass Index What contributes to the risk?
Monitor and review
Different meals to those the patient/resident is Monitor patient/resident s food intake Talk to the patient/resident and their family/friends about the patient/resident s usual and preferred diet Insufficient time or assistance provided to Review patient/resident s diet for adequate ensure the patient/resident is able to nutritional content Some factors contributing to reduced oral intake complete meal prior to dishes being collected include depression, food not liked, culturally If food intake (amount) is poor, despite adequate inappropriate food, reduced sense of smell, or ill Acute and chronic medical problems can food being provided, determine factors reduce the effectiveness of swallowing contributing to this Seek advice from a doctor and speech pathologist if Inadequate dietary calcium, and lack of If eating is associated with coughing or choking swallowing difficulties are apparent exposure to sunlight over a prolonged period check that the patient/resident s swallowing of time can result in increased risk of bone mechanism is intact Discuss with the doctor about the need for tests for low levels of vitamin D or osteoporosis Identify presence of osteoporosis and osteomalacia (inadequate mineral deposit in bone, If osteoporosis or osteomalacia is identified consider: related to vitamin D deficiency) vitamin D and calcium supplementation options for sunlight exposure (especially in residential care) Orientation and Support
Provide assistance with eating Refer patient/resident for medical or dietician Ensure effective communication of assessment review to assess and recommend ongoing findings and action plan to all staff, so that there management of oral intake problems or is a consistent approach VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Personal Risk Factor HISTORY OF PREVIOUS FALLS History of falls, either documented or verbal Monitor and review
Review factors that contributed to previous fall/s Record relevant falls history in the medical record, and on a falls incident report if the fall Address the risk factors contributing to previous occurred during the current admission May need to obtain additional information from Use the information from previous incidents to implement appropriate falls minimisation strategies Follow the Guidelines to assist the development of the falls minimisation action plan ACTIONS FOR MINIMISING INDIVIDUAL ENVIRONMENTAL RISK FACTORS Table 4 outlines actions to Many of the actions have been identified in the research literature, and further details supporting these actions are provided in the Research Supplement.
minimise the impact of individual This Table allows easy identification of actions to address individual environmental risk factors for environmental risk factors for A multifaceted approach, where actions are introduced to address each of the identified individual falls that can form part of a environmental falls risk factors, is likely to be most effective. patient/resident s Action List.
An Individual Environmental Audit should be carried out to identify prevailing risk factors for individual patient/residents. Examples of Audit Tools are provided in the Tools Supplement.
Table 4. Individual Environmental Risk Factors and Action for Minimising Risk
Individual Environmental Risk Factor INAPPROPRIATE BED HEIGHT If the height of a bed is adjusted during an The bed should be at a height which allows What contributes to the risk?
activity, return it to the correct height afterwards ease of standing for the patient/resident. The Bed heights are often adjusted for assessments, patient/resident s feet should be in contact with nursing or domestic activities. If they are left at an the ground before standing incorrect height, this may increase the risk of Seek advice from an occupational therapist or physiotherapist about optimal bed height for an BED BRAKES NOT ON OR BROKEN Ensure bed brakes are on/locked after the bed is What contributes to the risk?
Bed brakes are often unlocked, and the bed moved, Ensure that regular monitoring and maintenance is during domestic activities undertaken on all beds CHAIR HEIGHT/TYPE Ensure that the patient/resident has a chair that is As a general rule, appropriate seating should What contributes to the risk?
the appropriate height and type for them result in a 90¡ hip and knee angle, and the Different height chairs can affect the safety and ease patient/resident s feet should be in contact with of standing up and transfers Seek advice from an occupational therapist or physiotherapist about optimal chair height for an VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Individual Environmental Risk Factor CALL BELL OUT OF REACH Ensure that the call bell or an alternative means of Discuss with family/friends and ask them to be What contributes to the risk?
seeking attention is within the patient/resident s aware that the call bell should be in reach at all Call bells are often moved for assessments, nursing reach at all times or domestic activities WALKING AIDS OUT OF REACH In consultation with the patient/resident, decide Communicate this information to all staff What contributes to the risk?
where the walking aid will be located within their Patient/residents who need a walking aid may try to stand and walk without the walking aid if it is not Position the aid so that the handle can be grasped easily (eg upright) WHEELIE FRAME/WHEELCHAIR Ensure that wheelie frames, wheelchair brakes Ensure your organisation has processes for BRAKES BROKEN OR NOT USED and other similar equipment are regularly checked checking of equipment safety to occur regularly Seek advice from physiotherapists or What contributes to the risk?
occupational therapists, as they often have the Moving parts on equipment, such as brakes on role of supplying walking frames and wheelie frames or wheelchairs, can become worn or wheelchairs, and organising broken, making them unsafe repairs/replacements if required WALKING AIDS NOT IN GOOD Ensure that regular checking and maintenance is Ensure your organisation has processes for undertaken on all walking aids checking safety of walking aids regularly What contributes to the risk?
Seek advice from physiotherapists or With prolonged use, components of walking aids occupational therapists, as they often have the can become worn (eg stoppers) or broken role of supplying walking aids and repairs/replacements if required Individual Environmental Risk Factor WALKING AIDS NOT USED Monitor patient/resident s use of the walking aid, Seek advice from physiotherapists or compared to mobility instructions occupational therapists about correct use of What contributes to the risk?
Provide regular feedback to improve appropriate If a walking aid is used incorrectly (eg a stick in the use of the walking aids Communicate this information to all staff wrong hand or wrong height or incorrect sequence Position IV drip stands that are in use so that they of stepping and moving the walking aid) it can result are out of general walkway areas in increased risk of falling IV DRIP STANDS, POWER CORDS, Store IV drip stands that are not in use away from Identify areas on the ward/unit for storage of ETC NOT POSITIONED PROPERLY areas accessed by patient/residents equipment and communicate this to all staff What contributes to the risk?
Avoid running power cords across general Use an extension lead to provide extra length to Objects like IV drip stands and power cords are walkway areas and secure other cords flush to allow running a power cord along a wall rather potential tripping hazards than across walkways SLIPPERY SURFACES Identify areas with slippery surfaces, both when Seek advice from occupational therapists or the What contributes to the risk?
wet and dry, explore options for minimising Occupational Health and Safety representative Regular cleaning/polishing of floors in wards/units slipperiness, and work towards implementation about floor surface modifications to increase may result in slippery surfaces Clearly mark wet areas due to cleaning, and ensure alternative paths are available for patient/residents Remind all staff that any spills must be cleaned up Report the need for an upgrade of floor surfaces LOOSE FLOOR COVERINGS eg RUGS Avoid use of loose floor covering such as rugs Seek advice from occupational therapists or the What contributes to the risk?
Occupational Health and Safety representative If loose floor coverings are used ensure that they Loose floor coverings can turn up at the edges and about safety associated with floor coverings are non slip, and that all edges are stuck down be a tripping risk VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Individual Environmental Risk Factor Review need for all items contributing to clutter Communicate this information to all staff What contributes to the risk?
Discuss with patient/resident/family about the There is often a need for personal items, mobility best location for items to minimise clutter and and other aids, and medical equipment to be maximise availability located within the patient/residents individual Modify the environment to provide for improved placement and storage of personal possessions and equipment (eg shelving) INADEQUATE LIGHTING (POOR Review lighting available at different times of day Night lights with movement sensor can be LIGHTING, LACK OF NIGHT LIGHTS, and night, and the vision needs of useful for patient/residents needing to get up EXCESSIVE SUN GLARE) What contributes to the risk?
Ensure appropriate opening/closing of curtains to Seek advice from occupational therapists about Many patient/residents have visual problems that are minimise effect of sun glare made worse if lighting conditions are not optimal Replace existing light globes with higher wattage Replace incandescent lights with fluorescent lights which provide greater illumination Ensure available lights are in working order and switched on when required Enhance available light through use of non- reflective light colours on walls INADEQUATE RAILS/SUPPORTS IN Review patient/resident needs within Temporary aids such as an over toilet seat can BATHROOM AND TOILET provide additional support in some instances What contributes to the risk?
Consider long term needs for permanent Seek advice from occupational therapists about Bathrooms and toilets are common locations for falls changes, such as fitting of rails to bathroom and rails and supports/aids in the bathroom/toilet Individual Environmental Risk Factor RESTRAINTS/COTSIDES IN USE Adhere to professional standards and organisation Discuss the patient/resident s routines prior to Restraint use is the intentional restriction of a admission (timing of meals, rest, sleep, toileting) person s voluntary movement or behaviour by the and where possible accommodate these Seek a team review of the issue use of any manual, physical, or mechanical device [or medications] that restrict freedom of movement Investigate causes of agitation, wandering, or or where part of the intended pharmacologic effect other behaviour warranting consideration of of a drug is to sedate a person for convenience or restraints. Treat reversible causes (eg delirium) disciplinary purposes Investigate alternatives to restraint use such as: Restraint can include any of the following: Strategies to increase surveillance of the patient/resident (eg move to higher observation area, use of bed alarm) Use of very low (adjustable) beds Encouraging increased mobility (with wrist/ankle restraints supervision/assistance as required) other mechanical restraints, such as tables locked Reducing environment noise and activity Providing repeated reality orientation if required medications, which are used with a primary purpose of limiting a person s movement and Investigate and treat falls and fall-related injury risk What contributes to the risk
Incorporate other injury minimisation approaches Restraints can increase a patient/residents agitation (eg hip protectors) and increase likelihood of getting up unassisted Patient/residents climbing over cotsides will fall from a greater height, increasing risk of serious injuries VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Step 4: Respond to a falls incident appropriately Steps in minimising the risk of falls
and fall-related injuries
Definition
1 CONDUCT Falls Risk Screen
daily care for patient/ The appropriate response to a falls incident includes caring for the patient/resident and ensuring that the resident with low falls Falls Risk Screen Does the level of the patient/resident's risk exceed the threshold? (the threshold is incident is reported and documented. dependant upon the tool used) Use the standard definition of a fall developed by your organisation to determine whether an incident is to be 2 CONDUCT Falls Risk Assessment
Review/revise plan for daily care routinely, regarded as a fall. An example definition is included in the Introduction section of this document.
Have the risk factors been assessed comprehensively for this patient/resident? • patient/resident falling • change in patient/ resident's health/ Other definitions are provided in the Research Supplement.
3 DEVELOP & IMPLEMENT
• change in patient/ minimising falls an Action List for minimising the risk
resident's environment and falls-related of falls and fall-related injuries and
INCLUDE the list in the patient/resident's
plan for daily care

Do the selected actions match the patient/resident's risk factors and have all the actions been implemented as part of the plan for daily care? IF A P TIENT/
RESIDENT F
GUIDELINE STATEMENT FOR STEP 4 4 RESPOND to a falls incident
Review circumstances of the fall at ward/unitlevel a) Care for patient/resident
Respond to a falls incident appropriately.
b) Report the incident
c) Repeat steps 1/2 and 3 of this module

Level of evidence: Consensus Opinion [18].
Falls Incident Data Were the appropriate actions taken? * In some settings, the Screening component may be omitted, and the Model commences with Assessment (Step 2) Patient/resident centred tasks for Step 4
using a consistent and standard definition of a Organisational tasks for Step 4
a) At a minimum, an appropriate post falls response fall as adopted by your organisation a) Develop a protocol for care of patients/residents after a fall has occurred. Ensure staff are aware reporting the falls incident, using the process of and understand the protocol.
responding to the patient/resident s immediate and documents defined by your organisation.
b) Develop a stand-alone Falls Incident b) Document the fall in the patient/resident s Report template or add a falls section examining the patient/resident for injuries, permanent file/medical record/residential care file, to your organisation s existing incident especially head or joint trauma and fracture either include a copy of the incident report or report. See Tools Supplement for and minimise any adverse effects from the add information from the incident report to the c) Provide staff education on the purpose of if head injury is suspected, instituting c) Review the patient/resident s risk assessment incident reporting and training in the use of the neurological observations and Action List in the plan for daily care, and incident report.
make changes to reduce the risk of another fall.
moving the patient/resident only after fully Steps 1, 2 and 3 of the process model may d) Audit the use of the incident report for assessing the individual s situation.
need to be repeated.
compliance with relevant policy.
Addressing later care needs when the incident situation has been stabilised.
e) Assign the analysis of falls incident data to a Circumstances of the fall: An organisation s falls rate may increase in the short clinical staff member on a ward or to a term when its management: designated person in a facility, such as a Clinical activity being performed by the patient/resident at introduces falls and fall-related injury risk Risk Manager. An example Excel file template for the time of the incident, eg transfer details minimisation activities or programs entering data from falls incident forms, calculating rates of falls/1000 bed relevant information about clothing, footwear, introduces a new definition of a fall, or increases days, and examples of graphs for glasses and gait aids used at the time of the fall awareness of the definition, or of reporting reporting falls data is included in the requirements, or environmental conditions, eg floor, lighting, Tools Supplement.
implements these Guidelines and process model.
Ensure incident data is analysed regularly to Type of fall, eg slip, bumping into/falling on an object define the scope, common causes and Rationale for Step 4
complications arising from falls. Whether the patient/resident was injured and, if so, Some falls can cause injuries that may not be the nature and severity of the fall-related injury g) Provide clinically meaningful feedback on falls apparent at the time of the fall. All falls should be and fall-related injury data to wards or units, on a The patient/resident s perception of the incident, reported, even if injuries are not apparent, and regular and scheduled basis.
including description of any preceding sensations or patient/residents should be observed after the fall. This is particularly important in cases where h) Ensure data is analysed at ward-level. Findings there is a possible head injury [19].
from periodic reviews can help inform strategies Action taken following the fall and or fall-related to minimise risk and reduce the rate of falls. A Information about factors that contribute to falls high level of falls may indicate the need for root on a ward or unit can be used to inform targeted Signature of the person who observed and/or cause analysis.
activities to reduce future falls [20].
reported the fall Using a standard definition of a fall [1, 21] enables: Designated process for: An incident report should include sufficient detail submitting the report shared understanding of the focus and about the fall, circumstances surrounding the fall and dimensions of what is described (what is entering the report into the patient/resident s consequences of the fall to provide a clear included and what is not), and understanding of factors contributing to the fall the grouping of falls incident data for and/or injury if sustained. As a minimum, the If a death results from a fall in a Victorian comparison and trend analysis.
following information should be recorded in a Falls hospital an investigation by the State Incident Report or other standard documentation: Coroner will be performed. An Investigation Good quality falls data and meaningful analysis Standard published by the Victorian State can provide evidence to guide responses within Patient/resident identification — minimum data set Coroner s Office outlines the details required for this the organisation and elsewhere [20]. Data has investigation (see Tools Supplement). implications for: Whether the fall was witnessed These details outline the main features required by developing management strategies that the Coroner s Investigation Standard. In addition, benefit the patient/resident and the the Coroner s Investigations Standard will review the organisation, and organisations policies on falls risk screening, falls meeting legal, regulatory and insurance prevention and falls management.
requirements about recording adverse
VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES Differences in implementing Step 4
across the three settings

Acute and Sub-acute Care
In these settings there are often pre-determined processes in place to collect and analyse falls incident data and to provide feedback to staff and management. Ensure that falls data is included and talk to Risk Management/Quality personnel to determine appropriate methods and Residential Care
Given the nature of staffing in residential care settings, it is more likely that a non-professional caregiver may witness a falls incident.
Appropriate support from professional staff is Capacity for analysing falls incident data may be 01 The Process Model & Quality Improvement Given the magnitude of the problem of falls and fall- s elated injuries in residential care and hospital
Steps in minimising the risk of falls
Steps in minimising the risk of falls
and fall-related injuries
and and fall-related injuries
settings, and the increasing evidence that many falls 1 CONDUCT
Falls Risk Screen
daily care for patient/ 1 CONDUCT Falls Risk Screen
daily care for patient/ evented, there is a need for a systematic, resident with low falls resident with low falls Does the level of the patient/resident's risk Falls Risk Screen Does the level of the patient/resident's risk organisation-wide appr exceed the threshold? exceed the threshold? (the threshold is dependant upon the tool oach to falls and fall-r (the threshold is dependant upon the tool used) injury risk minimisation in these settings. 2 CONDUCT Falls Risk Assessment
Review/revise plan 2 CONDUCT Falls Risk Assessment
Review/revise plan A comprehensive approach would: for daily care routinely, for daily care routinely, Have the risk factors been assessed Have the risk factors been assessed comprehensively for this patient/resident? • patient/resident falling comprehensively for this patient/resident? • patient/resident falling Encourage a culture of safety and quality at all • change in patient/ • change in patient/ resident's health/ resident's health/ levels of the organisation Collate, monitor, analyse, and feedback 3 DEVELOP & IMPLEMENT
• change in patient/ 3 DEVELOP & IMPLEMENT
• change in patient/ falls incident data. minimising falls an Action List for minimising the risk
resident's environment minimising falls an Action List for minimising the risk
resident's environment Feedback to staff/ of falls and fall-related injuries and
management on data.
Support staff to work with patient/residents to of falls and fall-related injuries and
INCLUDE the list in the patient/resident's
INCLUDE the list in the patient/resident's
Upgrade tools and plan for daily c fective and appr
plan for daily care
process in response Do the selected actions match the Do the selected actions match the to findings.
patient/resident's risk factors and have all patient/resident's risk factors and have all Provide targeted continuing education for staf the actions been implemented as part of the the actions been implemented as part of the plan for daily care? plan for daily care? update and improve patient/r IF A P TIENT/
IF A P TIENT/
RESIDENT F
RESIDENT F
4 RESPOND to a falls incident
Review circumstances 4 RESPOND to a falls incident
Review circumstances Identify and develop strategies to minimise of the fall at ward/unit of the fall at ward/unit a) Care for patient/resident
a) Care for patient/resident
individual and envir b) Report the incident onmental falls risk
b) Report the incident
c) Repeat steps 1/2 and 3 of this module
c) Repeat steps 1/2 and 3 of this module
Falls Incident Data Falls Incident Data Collect data on falls and fall-r Were the appropriate actions taken? elated injuries that Were the appropriate actions taken? occur within the organisation to contribute to improvements in the care delivered to * In some settings, the Screening component may be omitted, Organisation meets quality and the Model commences with improvement requirements Assessment (Step 2) The diagram illustrates the process model within a Implementing all the components of the model should:
quality improvement framework that includes reduce falls and fall-related injuries over time ongoing monitoring of performance. This may address the needs of individual patient/clients encompass collecting a range of indicators, and reviewing falls risk reduction activities to improve ensure a consistent approach to minimising the risk of falls and fall-related injuries, and Quality Improvement patient/resident care. embed these tasks within the organisation s systems for monitoring and evaluating quality NHMRC. A guide to the development, Halfon P, Eggli Y, Van Melle G, Vagnair A.
14. Lipsitz L, Jonsson P, Kelley M, Koestner J.
implementation and evaluation of clinical Risk of falls for hospitalized patients: a Causes and correlates of recurrent falls in guidelines. Canberra: National Health and predictive model based on routinely available ambulatory frail elderly. Journal of Medical Research Council (NHMRC); 1998.
data. J Clin Epidemiol 2001;54(12):1258-66.
Tinetti M, Baker D, Dutcher J, Vincent J, Vassallo M, Sharma JC, Briggs RS, Allen SC.
15. Cumming R, Thomas M, Szonyi G, Salkeld Rozett R. Reducing the risk of falls among Characteristics of early fallers on elderly G, O'Neill E, Westbury C, et al. Home visits older adults in the community. Berkeley, CA.: patient rehabilitation wards. Age Ageing by an occupational therapist for assessment Peacable Kingdom Press.; 1997.
and modification of environmental hazards: Arandomised controlled trial. Journal of the Perell KL, Nelson A, Goldman RL, Luther SL, Haines TP, Bennell KL, Osborne RH, Hill KD.
American Geriatrics Society 1999;47:1397- Prieto-Lewis N, Rubenstein LZ. Fall risk Effectiveness of targeted falls prevention assessment measures: an analytic review. J programme in subacute hospital setting: Gerontol A Biol Sci Med Sci randomised controlled trial. British Medical 16. Gillespie L, Gillespie W, Robertson M, Lamb S, Cumming R, Rowe B. Interventions forpreventing falls in elderly people. Cochrane Hoidrup S, Sorensen TI, Gronbaek M, Schroll 10. Jensen J, Lundin-Olsson L, Nyberg L, Database Syst Rev 2003;4:CD000340.
M. Incidence and characteristics of falls Gustafson Y. Fall and injury prevention in leading to hospital treatment: a one-year older people living in residential care facilities.
17. Queensland Health. Restraint and protective population surveillance study of the Danish A cluster randomized trial. Ann Intern Med assistance guidelines. Brisbane; 2003.
population aged 45 years and over. Scand J 18. Lord S, Sherrington C, Menz H. Falls in older Public Health 2003;31(1):24-30. 11. Ray WA, Taylor JA, Meador KG, Thapa PB, people: Risk factors and strategies for Bueno-Cavanillas A, Padilla-Ruiz F, Jimenez- Brown AK, Kalihara HK, et al. A randomised prevention. Cambridge, UK: Cambridge Moleon JJ, Peinado-Alonso CA, Galvez- trial of a consultation service to reduce falls University Press; 2001.
Vargas R. Risk factors in falls among the in nursing homes. Journal of American 19. Nagurney JT, Borczuk P, Thomas SH. Elderly elderly according to extrinsic and intrinsic Medical Association 1997;278(7):557-62.
patients with closed head trauma after a fall: precipitating causes. Eur J Epidemiol 12. Salgado R, Lord S, Packer J, Erlich F.
mechanisms and outcomes. J Emerg Med Factors associated with falling in elderly Friedman SM, Denman MD, Williamson J.
hospital patients. Gerontology 1994;40:325- 20. Gowdy M, Godfrey S. Using tools to assess Increased fall rates in nursing home residents and prevent inpatient falls. Jt Comm J Qual following relocation to a new facility. Journal 13. Kallin K, Lundin-Olsson L, Jensen J, Nyberg of American Geriatrics Society L, Gustafson Y. Predisposing and 21. Cumming R, Kelsey J, Nevitt M.
precipitating factors for falls among older Methodologic issues in the study of frequent people in residential care. Public Health and recurrent health problems: falls in the elderly. Annals of epidemiology 1990;1:49-56.
Activities of Daily Living
Benign Paroxysmal Positional Vertigo
Activities necessary for everyday function, such as A medical condition affecting the inner ear, which dressing, bathing, and self care causes dizziness, unsteadiness, and can increase Body Mass Index (BMI)
A measurement of body fat calculated from height Referring to a hospital for management of acute illness (does not include rehabilitation and Geriatric Evaluation and Management [GEM] units or Abnormal growth of bone at the base of the first toe, which can result in deformity in the alignment of the Adverse effects (from a fall)
Negative consequences (from a fall) such as injury or loss of confidence Dietary addition of a mineral essential for bone development, maintenance and repair Unplanned events which have potential to cause harm, such as falls or medication errors Hardened, thickened layer of skin caused by excessive pressure or friction (such as poor fitting Restless, on edge Changes in the lens of the eye which can impair A state of increased restlessness and limited Referring to a circulatory incident in which damage occurs within the cerebellum, a part of the brain attached to the brainstem. The cerebellum is Medications which block the passage of impulses important for balance and coordination through the parasympathetic nerves (eg tricyclic Chronic (disease / illness)
antidepressant treatment for incontinence) Persisting over the long term Medications given to treat depression Interference of the ability of the brain to perform functions requiring conscious thought, such as A state of increased stress, nervousness or worry problem solving and planning Bed alarm
A device that signals that the occupant of the bed is Ability to think, plan and remember departing/has departed from the bed VQC: MINIMISING THE RISK OF FALLS AND FALL-RELATED INJURIES GUIDELINES FOR ACUTE, SUB-ACUTE AND RESIDENTIAL CARE SETTINGS: GUIDELINES State of being disoriented to the time, place (or Usually used in reference to the metabolic disease of Deterioration in the health of a specific tissue in the location), and the people around them Diabetes Mellitus, which is characterised by high eye that interferes with clarity in the central field of sugar levels, excessive urine production, and excessive thirst. Can be controlled with diet, oral A record that shows the pattern of an individual s Muscle mass
medications or may require use of insulin level of control over the passage of urine/micturition The size and density of the body of a muscle Loss of sensation caused by deterioration in nerve Aids (pads) worn in the underwear which help to Medications that diminish conscious awareness, function associated with the disease Diabetes avoid incontinence accidents often used for pain control Continuous Quality Improvement
A cyclical, ongoing, organisation-wide process of Problems associated with disorders of the nervous Medications that increase the production of urine monitoring and evaluating all aspects of the system, such as stroke and Parkinson s disease (eg institution's activities in order to continuously Fear of falling
difficulty with movement, speech, or swallowing) Being afraid that a fall could occur during routine Voiding urine at night Generalised muscle weakness and limited Flattened transverse arch
endurance associated with lack of use (eg bed rest) Stretching of ligaments under the foot that result in Referring to things or actions that are not loss of the side to side curve under the foot and drug/medication related results in pain under the foot on walking Acute deterioration in brain function with associated behavioural changes due to factors including drug The health of the body measured by nourishment toxicity, infection and metabolic problems. Delirium is Ability of an individual on one or more activities (eg factors or dietary intake reversible if the cause is identified and treated walking, dressing) A condition related to cancer/a tumour A classification given to a group of diseases that Related to disorders of the blood involve chronic degeneration of the brain and associated functions which is due to various causes Softening of the bones associated with low levels of A protective device that may be worn to minimise damage to the hip should a fall occur A state of undue sadness, and lack of interest in relevant personal events Weakening of the bone substance and structure to a Spontaneous response to stimuli that aren t modified level where the risk of fracture is high by insight or rational thought A degenerative condition of the nervous system Detrusor muscle control
Loss of control over when urine is passed characterised by difficulty initiating movement, Referring to conscious movement of the detrusor Key Performance Indicators (KPIs)
slowness of movements, tremor, and stiffness in the urinae muscles that coat the urinary bladder and A set of standards that are essential to the control passing of urine successful performance of an activity Plan of daily care
Care activities or services to be provided for a Medications that have the effect of enhancing rest or Passage of urine from the urinary bladder through patient/residents over a 24 hour span sleep. These medications are also associated with the urinary tract to the exterior of the body; or increased risk of falling faeces through the bowel to the exterior of the body.
May be voluntary or involuntary.
A viral infection affecting cells in the spinal cord, Sensory loss
affecting muscle control. Although the disease is Reduced function in any of the sensory systems Walking aid
almost eradicated in terms of new cases in western (eye-sight, hearing, sensation in the limbs, and inner A tool that can improve stability for people with countries, many people live with the long term reduced balance or risk of falling (eg a four prong effects from the polio epidemic of the 1950 s stick or walking frame) Sensory neural deafness
Inability of the individual to accurately interpret A drop of 20mmHg or more in systolic blood sounds due to malfunction of nerve endings in the pressure, or 10mmHg or more in diastolic blood ear or the brain that are responsible for transmitting pressure, when moving from lying to standing and interpreting sound messages Prompted voiding program
Regular reminding/asking a patient/resident about Referring to loss of feeling from the skin and joints in the need for toileting the limbs (often affecting the feet) Medications that exert an effect on the mind A heart and/or circulatory incident resulting in damage to the brain and/or spinal cord and affecting the tissues they control Upgrade in overall standard measured by key Less severe and often of longer duration than acute Quality Improvement Cycle
The repeated, ongoing cycle of Continuous Quality Improvement within an organisation Rehabilitation or Geriatric Evaluation and Management (GEM) unit or hospital Any method where a person s voluntary movement or behaviour is restricted physically (eg posey vests; Relating to one of the important senses with a key cotsides) or by the use of medications where part role in balance. Located in the inner ear of the intended effect is to sedate a person for convenience or disciplinary purposes [17] A condition related to loss of vestibular function Root cause analysis
bilaterally due to an adverse reaction to specific Detailed analysis of the circumstances and factors contributing to an adverse event such as a fall, and Vitamin D supplementation
taking actions to prevent the event occurring again Addition to normal diet of a fat soluble vitamin that assists in the building, maintenance and repair of The Victorian Quality Council thanks all those who contributed to the Development of these Guidelines Project team
Expert Advisory Group for support and
Input and feedback
Dr Keith Hill (Project Manager) - National Ms Diana Clayton - Peninsula Health Ageing Research Institute Dr Caroline Brand - Clinical Epidemiology & Ms Caroline Freeman - Peninsula Health Ms Marcia Fearn (Project Officer) - National Health Service Evaluation Unit, Melbourne (and Literature Review) Ageing Research Institute Mr Terry Haines - Eastern Health Ms Joan Nankervis - National Ageing Ms Karen Bull - Falls Prevention Service, Ms Jeannette Kamar - Northern Health Research Institute Peninsula Health (and Literature Review) Ms Anne McGann - Melbourne Health Ms Erin Cassell - Monash University Accident Research Centre, Monash University Dr Jane Sims - Department of General Ms Mary Lancaster - Word Design Interactive Practice, The University of Melbourne Dr Michael Dorevitch - Centre for Applied Gerontology, Northern Health Ms Janet Taylor - Bayside Health Dr Joanne Wilkinson - Word Design Ms Willeke Walsh - Western Health Interactive Pty Ltd Victorian Quality Council Falls Working
Ms Bernadette Hally - Word Design Health Services that trialled
Interactive Pty Ltd Ms Stella Axarlis (Chair to 16 June 2003) Ms Wendy Hubbard (Chair) Melbourne Health Professor Peter Chong Ballarat Health Service Ms Marie Cuddihy Associate Professor Christine Kilpatrick Ms Lesley Thornton - Project Manager Peninsula Health West Gippsland Health Group Review of Guidelines and Education
Supplement

Acknowledgments 45 Dr Jenny Schwarz, Melbourne Extended Care and Rehabilitation Service, Melbourne Health

Source: http://fallshaw-test.prontoavenue.biz/attachments/Page/98/VQC.pdf?ts=1429860438

jwa.org.hk

A Discussion for the JWA Amy Mines Tadelis October 29, 2014 •  Cancer prevention is action taken to lower the chance of getting cancer; the number of new cases of cancer in a group or population is lowered. •  To prevent new cancers from staring scientists look at risk factors and protective factors. Anything that increases your risk of developing cancer is cal ed a risk factor and anything that decreases your chance of developing cancer is cal ed a protective factor.

Microsoft word - womens_reproductive_system.doc

Hormone-Regulating Herbs and Phytoestrogens Adapted from Women's Herbs, Women's Health Christopher Hobbs L.Ac. and Kathi Kevil e German BGA, (the German equivalent of the FDA), says black cohosh has no Dr. Lois Johnson, MD from Northern contraindications, and only a few side California has a busy practice and works a effects like occasional gastric discomfort