A Case Example
The elderly patient, in this case, was admitted to hospital for investigations following a fall in their own home. Whilst an in-patient they were left unattended and fell, sustaining a head injury.
The main learning points from this review stem from the following events:
- The patient was left unattended and subsequently suffered a fall
Recommendations to Prevent Incident Recurrence and Improve Patient Safety
TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:
• Ensure the patients’ blood pressure is monitored to ensure they do not have postural hypotension. A common risk factor of postural hypotension is Syncope [temporary loss of consciousness caused by a fall in blood pressure]. It is also in line with the best practice of a minimum of one lying blood pressure and two standing blood pressures when documenting lying and standing blood pressures.
• All patients over the age of 65 should be considered as at risk of falls and should therefore be screened and have appropriate plans of care in place to mitigate against falls. NICE Guidelines regard all patients over the aged 65 or older are at risk of falling in hospital and their care should be managed.
• All patients who have a diagnosis of postural hypotension should be advised about the risks of falling when standing from a sitting or lying position. Patients should be advised that they should not mobilise unassisted due to the risk of falls. For patients who have a degree of cognitive impairment and are unlikely to remember to call for assistance then alternative measures should be considered such as increased visual observations, bay nursing and or a falls alarm.
• NICE Guidelines suggest all patients who are 65 and over should be considered at risk of delirium and be screened for it on admission to hospital and during their admission if there is a change in their cognition. Older people are more a risk of delirium and outcomes can be poor if not identified and treated early.
• NICE Guidelines suggest multifactorial risk assessment should be completed of older people who present for medical attention because of a fall or report recurrent falls in the past year. In this case the patient was admitted due to a fall and a physiotherapist evidenced the patient had a history of falls over the previous 12 months. It should be suggested that this information if effectively shared with practitioners in charge of the patients care so an appropriate plan of care can be put in place. With NICE Guidelines practitioners should ensure that any multifactorial assessment identifies the patient’s individual risk factors for falling in hospital that can be treated, improved or managed during their expected stay. These may include:
- cognitive impairment
- continence problems
- falls history, including causes and consequences (such as injury and fear of falling)
- footwear that is unsuitable or missing
- health problems that may increase their risk of falling
- medication
- postural instability, mobility problems and/or balance problems
- syncope syndrome
- visual impairment.
Conclusions
In summary, any patient over the age of 65, who is admitted to hospital should receive a multifactorial falls risk assessment. Patients who are identified as being at risk of falls should have plans of care in place to mitigate against any identified risks and this should include an assessment of their ability to understand their risk factors and the plan to manage them. Not all falls can be prevented however, thorough assessment and appropriate plans of care can minimise the risk of falls. Clinicians should be mindful of the heightened risk of falls in patients who have postural hypotension due to the syncope risk factor.
TMLEP would like to highlight the importance of identifying patients at risk of falls and then managing their time in hospital accordingly.