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Tool 3N: Postfall Assessment, Clinical Review

Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care

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Background: This protocol explains how to assess and follow injury risk in a patient who has fallen.

Reference: Adapted from the South Australia Health Fall Prevention Toolkit. Available at: www.sahealth.sa.gov.au/wps/wcm/connect/5a7adb80464f6640a604fe2e504170d4/Post+fall+management+protocol-SaQ-20110330.pdf?MOD=AJPERES&CACHEID=5a7adb80464f6640a604fe2e504170d4. 

How to use this tool: Staff nurses and physicians should follow this protocol, in combination with clinical judgment, with patients who have just fallen. Training on the Glasgow Coma Scale is available at: www.nursingtimes.net/Binaries/0-4-1/4-1735373.pdf. (Full citation: Jevon P. Neurological assessment part 4—Glasgow Coma Scale 2. Nurs Times 2008;104(30):24-5.) This training includes graphics demonstrating various aspects of the scale.

Postfall Assessment, Clinical Review

Note: There is increased risk of intracranial hemorrhage in patients with advanced age; on anticoagulant and/or antiplatelet therapy; and known coagulopathy, including those with alcoholism.

In addition, there may be late manifestations of head injury after 24 hours.

Does not hit headHits head or has unwitnessed fall
  1. Assess immediate danger to all involved. Assess circulation, airway, and breathing according to your hospital's protocol.
  2. Call for assistance. Activate appropriate emergency response team if required.
  3. Do not move the patient until he/she has been assessed for safety to be moved. Examine cervical spine and if there is any indication of injury do not move the patient; instead, immobilize cervical spine, and call treating medical provider.
  4. Identify all visible injuries and initiate first aid; for example, cover wounds.
  5. Assist patient to move using safe handling practices.

Proceed to:

  1. Check vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation, and hydration).
  2. Clean and dress any wounds.
  3. Inform treating medical provider.
  4. Provide analgesia if required and not contraindicated.
  5. Arrange further tests as indicated, such as blood sugar levels and x rays.
  6. Review current care plan and implement additional fall prevention strategies.
  7. Provide fall prevention information (Tool 3J).

Observations:

  • Continue observations at least every 4 hours for 24 hours or as required.
  1. Assess immediate danger to all involved. Assess circulation, airway, and breathing according to your hospital's protocol.
  2. Call for assistance. Activate appropriate emergency response team if required.
  3. Do not move the patient until he/she has been assessed for safety to be moved. Examine cervical spine and if there is any indication of injury do not move the patient; instead, immobilize cervical spine, and call treating medical provider.
  4. Assess Glasgow Coma Scale.
  5. Identify all visible injuries and initiate first aid; for example, cover wounds.
  6. Assist patient to move using safe handling practices.

Proceed to:

  1. Record neurologic observations, including Glasgow Coma Scale. Observe for signs indicating stroke, change in consciousness, headache, amnesia, or vomiting.
  2. Get baseline vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and hydration).
  3. Clean and dress any wounds.
  4. Arrange medical review.
  5. Provide analgesia if required and not contraindicated.
  6. Arrange further tests as indicated, such as blood sugar levels, x rays, ECG, and CT scan.
  7. Review current care plan and implement additional fall prevention strategies.
  8. Provide fall prevention information (Tool 3J).

Observations:

  • Record vital signs and neurologic observations at least hourly for 4 hours and then review.
  • Continue observations at least every 4 hours for 24 hours, then as required.
  • Notify treating medical provider immediately if any change in observations.

Important Communications

  • In the medical record, document the incident, outcome, and initial and ongoing observations, and update fall risk assessment and care plan.
  • Notify the treating medical provider at the time of the incident, and schedule an interdisciplinary review of the patient's care.
  • At handover, inform all clinical team members about the incident, any changes to the care plan, and possible investigation process.
  • Notify family in accordance with your hospital's policy.

Glasgow Coma Scale

The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 3-8 are usually said to be in a coma. The total score is the sum of the scores in three categories. For adults, the scores follow:

Activity Score
ActivityScore
Eye opening
None1 = Even to supraorbital pressure
To pain2 = Pain from sternum/limb/supraorbital pressure
To speech3 = Nonspecific response, not necessarily to command
Spontaneous4 = Eyes open, not necessarily aware
Motor response
None1 = To any pain; limbs remain flaccid
Extension2 = Shoulder adducted and shoulder and forearm rotated internally
Flexor response3 = Withdrawal response or assumption of hemiplegic posture
Withdrawal4 = Arm withdraws to pain, shoulder abducts
Localizes pain5 = Arm attempts to remove supraorbital/chest pressure
Obeys commands6 = Follows simple commands
Verbal response
None1 = No verbalization of any type
Incomprehensible2 = Moans/groans, no speech
Inappropriate3 = Intelligible, no sustained sentences
Confused4 = Converses but confused, disoriented
Oriented5 = Converses and oriented

TOTAL (3–15): _______

Reference

Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2(7872):81-4.

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Current as of January 2013
Internet Citation: Tool 3N: Postfall Assessment, Clinical Review: Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/fallpxtk-tool3n.html