Introduction
The Western Australian Multidisciplinary Post Fall Guidelines (2018) have been developed to provide a standardized, evidence-based approach to the management of patients who have fallen in a hospital setting. These guidelines are designed for use by multidisciplinary teams (MDT) within Western Australian public hospitals, ensuring that all patients receive consistent, safe, and high-quality care following a fall. The primary objectives are to minimize injury, manage immediate clinical risks, identify underlying causes, and implement strategies to prevent recurrent falls.
Falls are a significant patient safety issue in healthcare, contributing to morbidity, prolonged hospital stays, and increased healthcare costs. The guidelines emphasize a shift from merely recording incidents to actively analyzing the root causes and implementing individualized care plans.
Immediate Management Post-Fall
The immediate period following a fall is critical. The priority is to assess the patient's safety and medical status without causing further harm. Staff must remain calm and provide reassurance to the patient.
- Do not rush: Assess the environment for safety before approaching the patient.
- Do not move: Do not attempt to move the patient immediately unless there is an immediate danger (e.g., risk of further injury from equipment or environmental hazards).
- Primary Survey: Conduct a primary survey (Danger, Response, Airway, Breathing, Circulation, Disability, Exposure - DRABCDEFG).
- Check for injuries: Look for obvious signs of trauma, such as lacerations, deformities, or bleeding.
- Assess pain: Ask the patient if they are in pain and where. Observe for non-verbal signs of pain if the patient cannot communicate.
- Call for assistance: Use the call bell or shout for help if you are alone. Do not attempt to lift a heavy patient without assistance.
Getting the Patient Up
If no injury is suspected and the patient is able to assist, staff may assist the patient to rise. If there is any doubt regarding injury, or if the patient cannot assist, a mechanical hoist or ambulance trolley must be used. The "Time to Floor" and "Time to Feet" should be recorded.
Comprehensive Assessment
Once the immediate safety of the patient is established, a comprehensive multidisciplinary assessment must occur. This assessment forms the basis of the post-fall management plan.
1. Clinical Assessment
A Registered Nurse or Medical Officer should perform a thorough physical assessment. This includes:
- Vital Signs: Blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature. Compare with previous readings to detect deterioration.
- Neurological Observations: Assess consciousness level (AVPU/GCS), pupil size and reaction, and limb strength. This is crucial for ruling out head injuries.
- Skin Integrity: Check for pressure areas, bruising, or skin tears, particularly in bony prominences.
- Musculoskeletal: Check range of motion and ability to weight bear.
2. Circumstances of the Fall
Understanding the context of the fall is vital for prevention. Staff should document:
- Time and location of the fall.
- What the patient was doing at the time (e.g., walking to the bathroom, transferring from bed, standing up from a chair).
- Witness accounts (if available).
- Environmental factors (e.g., wet floor, poor lighting, obstructed pathway).
- Footwear and clothing.
- Use of assistive devices (e.g., walking frame, wheelie walker).
3. Medication Review
Medications are a major modifiable risk factor for falls. A pharmacist or medical officer should review the patient's current medication chart, specifically looking for:
- Psychoactive medications (benzodiazepines, antipsychotics, antidepressants).
- Antihypertensives and diuretics (which can cause postural hypotension).
- Sedating antihistamines.
- Polypharmacy (taking multiple medications).
Multidisciplinary Team Responsibilities
Effective post-fall care relies on the collaboration of various health professionals. The guidelines define specific roles within the team.
Medical Officer
The Medical Officer is responsible for the overall medical management. This includes examining the patient for injuries, ordering necessary investigations (such as X-rays or CT scans), and adjusting medications that may contribute to fall risk. They must certify that the patient is medically fit to mobilize.
Nursing Staff
Nurses play a pivotal role in ongoing monitoring and implementing the care plan. Responsibilities include:
- Completing the incident report in the hospital's risk management system (e.g., RiskMan).
- Updating the Falls Risk Assessment Tool (FRAT).
- Implementing falls prevention strategies (e.g., sensor mats, low beds, hip protectors).
- Providing education to the patient and family regarding falls prevention.
- Monitoring for delayed signs of injury, such as a subdural hematoma.
Physiotherapist
The Physiotherapist assesses the patients mobility, balance, gait, and muscle strength. They determine if the patient requires mobility aids and provide gait retraining. The physiotherapist also advises on the safest method for the patient to transfer and move.
Occupational Therapist (OT)
The OT assesses the patients ability to perform activities of daily living (ADLs). They evaluate the patient's cognitive status regarding safety awareness and may recommend equipment (e.g., shower chairs, raised toilet seats) to facilitate safe independence.
Pharmacist
The Pharmacist conducts a comprehensive medication review to identify drugs that increase fall risk. They work with the medical team to deprescribe unnecessary medications or switch to safer alternatives where possible.
Post-Fall Huddle
The guidelines recommend a "Post-Fall Huddle" within 24 to 48 hours of the incident. This is a brief, bedside meeting involving the patient (if appropriate), their family, and the multidisciplinary team.
The purpose of the huddle is to:
- Communicate the findings of the post-fall assessments.
- Discuss the likely cause of the fall.
- Review and update the patients care plan.
- Ensure prevention strategies are in place and understood by all.
Documentation and Reporting
Accurate documentation is a legal and clinical requirement. All falls must be documented in the patients medical record and reported via the hospital's incident reporting system.
Clinical Notes: Should include the time of the fall, position found, observations, injuries noted, treatment provided, patient response, and notifications made to Medical Officers or family.
Risk Management System: An incident report captures data for organizational analysis. This data is used to identify trends, high-risk areas, and system-wide issues that require addressing to improve patient safety.
Conclusion
The Western Australian Multidisciplinary Post Fall Guidelines 2018 promote a proactive and systematic approach to falls management. By adhering to these guidelines, healthcare teams can ensure that patients who fall receive timely and appropriate care, while simultaneously implementing robust strategies to prevent future falls. This multidisciplinary collaboration is essential for enhancing patient outcomes and maintaining a safe hospital environment.
