Medical assessment and management of falls procedure (including hip fracture, spinal injury and head injury)

1 Aim

To define the appropriate medical intervention following a fall, to reduce the likelihood of further harm and to identify the required post fall management plan.

2 Scope

This is a trust wide procedure which is applicable to all patients under our care. It focuses in particularly on the needs of those patients who are in the higher falls risk groups or who already have a history of falls (over 65’s and patients with pre-existing health conditions which means they are at a higher risk of falling).

3 Link to overarching policy

Patient falls manual (prevention and management)

4 Procedure

People who sustain a femoral fracture as an inpatient are twice as likely to die within 30 days, then those who fracture in a non-inpatient setting (NAIF 2021 interim report (opens in new window)), highlighting the vulnerability of inpatients who sustain serious fall related injuries, and the importance of high-quality and safe post-fall management (RCP, 2022).

Therefore following a patient fall, the possibility of such serious injuries must not be overlooked. Medical assessment and management after a fall is one aspect of the post-fall management and is linked to the following quality standard 86 (opens in new window) (NICE, 2015):

quality statement 4, checks for injury after an inpatient fall
quality statement 6, medical examination after an inpatient fall

In the absence of a prompt medical assessment and management, then at best an increase in pain and distress associated with the fall may occur but at worst could lead to delays in management and associated poorer outcomes (RCP, 2022).

(National Institute of Clinical Excellence (NICE) quality standard 86, statements 4, 5 and 6).

Following a fall, the nurse or other non-medical professional will triage the patient and make an assessment regarding the severity of the situation. Routine observations can be initiated whilst the patient is on the floor to inform next steps. The medic on duty or on call will be contacted for advice and assessment as required.
If there is a suspected hip fracture, spinal injury or an acute medical emergency then an ambulance will be called. See appendix C post falls flow chart and manual handling the falling and fallen person procedure.

See appendix H medical considerations for further information.

4.1 Hip fracture

All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation.

All patients with hip fracture who are medically fit should have surgery on a planned trauma list on the day of, or the day after, admission (2012, updated 2023 NICE Quality standard 16 fractures).

Patients in whom a hip fracture is strongly suspected, but the initial radiograph is normal should undergo further imaging (magnetic resonance imaging (MRI), computerized tomography (CT) or bone isotope scan). This should not be undertaken by RDaSH services and the patient should be referred to trauma and orthopaedics or accident and emergency for further assessment.

If a hoist and a fabric sling are used for a patient with a fractured hip this method could displace the fracture causing internal bleeding and severe pain and make surgical intervention more complex.

4.1.1 Risks

Unnecessary delay can present risks to the patient of possible blood loss due to fracture, increased risk of pressure sores if the patient is immobilised for long period, confusion and pain.

4.1.2 Signs and symptoms

The key common presenting symptoms of a suspected hip fracture are:

pain
not being able to lift, move or rotate (turn) the leg
not being able to stand or put weight on the leg
bruising and swelling around the hip
injured leg appearing shorter than the other leg
injured leg turning outwards

However approximately 15% of fractures are un displaced, and therefore may produce no shortening or external rotation of the limb. Hip movements, although painful, may be possible and the patient may even be able to walk. In the event of a suspected fracture the patient must not be moved.

4.2 Spinal injury

Following a fall there is potential for spinal injury or vertebral fracture. An initial brief examination can identify if there is any pain, loss of sensation, visible injury or limb deformity that could indicate such injuries. It is therefore essential that the patient is appropriately immobilised to reduce the risk of further harm if a spinal injury is suspected (see appendix C post falls clinical decision-making flowchart).

A hoist and a fabric sling should not be used for a patient with a patient with a suspected spinal injury as the spinal cord can be damaged. Spinal Injury may be a fracture, dislocation, or spinal shock. Whichever, the initial emergency treatment is the same. (See appendix C post falls clinical decision-making flow chart).

4.2.1 Signs and symptoms

History of traumatic event, blow to head or neck, fall, accident involving speed, crushed.
Unnatural posture or position.
Pain in neck or back.
Step or twist in curve of spine.
Pale, cool, clammy skin.
Often a slow pulse.
Absence of feeling and, or movement in part of the body.
Loss of bladder or bowel control.
Difficulty breathing.

4.2.2 Treatment

Danger.
Response.
Airway.
Breathing.
Compressions (if needed).

4.2.3 If the person is conscious

Reassure the person whilst telling them not to move, ensure you are in their eye line, if not they will move to see where the voice is coming from.
Ensure ambulance is on the way.
Keep the person in the position you found them in.
Hold their head still with your hands, keep the head and neck in line with the upper body.
Treat any other injuries, bleeding etc.
Physical observations, NEWS. Continue to monitor response, airway and breathing.
Have handover ready for ambulance service.

4.2.4 If person is unconscious

See resuscitation manual.

4.3 Head injuries, observation after head injury