Post fall procedure

1 Aim

The vulnerability of patients who sustain serious falls-related injuries is widely acknowledged, as is the importance of high-quality and safe post-fall management. (RCP, 2022).

Effective post-fall management aims to:

minimise harm to patients from incorrect management after injurious falls
ensure prompt access or referral to ongoing treatment when injury has occurred
reduce variation(s) in post-fall management within inpatient settings.

Royal college of Physicians, supporting best and safe practice in post-fall management in inpatient settings (opens in new window).

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, or patients with pre-existing health conditions which means they are at a higher risk of falling).

3 Link to overarching policy, and or procedure

Patient falls manual (prevention and management)

4 Procedure or implementation

When a serious injury occurs as a result of a fall, safe manual handling and prompt assessment and treatment is critical to the patient’s chances of making a full recovery.

Identification and treatment of any injury, including comfort, reassurance and pain relief where necessary.
Recognition and track and trigger or signpost of any physical deterioration using NEWS national early warning score or neurological (neuro) obs.
Taking and documenting appropriate observations to identify injury, including observations to assess for medical causes of the fall (for example, increased confusion, hypotension, hypoglycaemia etc.).
Making safe any obvious environmental hazard that contributed to the fall.
Informing relatives as soon as possible and involving (where appropriate) in any actions planned to reduce the risk of further falls.
Completing an incident form even if the patient suffered no physical harm, including all the key information for learning.
If there is serious injury, for example, hip fracture, care group director to initiate investigation in-line with the incident management policy.
Reassessment of falls risk and review or development of a plan of care to reduce the likelihood of risk or harm from falls
Taking action to reduce the likelihood of further falls incidents or risk of harm from falls; this may include use of additional equipment or referral to specialist services.

4.1 Procedure or post fall pathway

Refer to appendix C post falls clinical decision-making flow chart and appendix D post fall incident reporting flow chart which provide a quick guide for actions to be taken post fall.

4.2 Immediate response

Danger.
Response.
Airway.
Breathing.
Chest compression (if needed).

COAMAC:

C, check on the floor before moving, deformity, pain etc.
O, observations.
A, if the patient won’t stay on the floor, assist from the floor, can patient get up themselves.
M, monitor neuro observations.
A, act if any concerns? Accident and emergency 999.
C, contact family.

4.3 Check for injuries

If no apparent injury, and appropriate and safe assist patient to bed or chair via appropriate means (see manual handling of the falling or fallen person procedure). If the patient can get off the floor independently, then allow them to get themselves up.
If there are contraindications to moving the patient a doctor or ambulance must be requested to attend to the patient immediately to assess prior to moving. (suspected hip fracture or spinal injury).
If head trauma and, or fracture is apparent or suspected, assess or NEWS or alert, voice, pain, unconscious (AVPU). Contact medic for advice or transfer to hospital or 999 or local pathway number.
Signs of head trauma, conduct neurological observations NEWS or AVPU.
Suspected lower limb fracture, call for ambulance, make patient comfortable on floor. Do not move patient.
Suspected upper limb fracture, immobilise limb, return patient to bed or chair, contact medic and request urgent assessment or transfer to accident and emergency (A and E) 999 or local pathway number.
For physical health wards if no doctor is available then arrange urgent transfer to A and E.
Monitor the pressure areas.

Patients must be transported by ambulance only and must attend accident and emergency not sent directly for an x-ray

Check signs of other injuries, for example, bruising, laceration, swelling, abrasion, and record.
Contact medic if cause for concern or arrange transfer to A and E if no medic available 999.
Patient must be left on the floor and made comfortable; patient must only be moved if there is a significant risk to the patient to remain in that location.
On arrival ambulance colleagues will assess and administer analgesia if required, and will transport the patient to hospital.
Clinical colleagues to provide information for transfer.

4.4 Baseline observations

Check and record any symptoms of nausea, confusion, drowsiness, delirium, agitation.
Perform appropriate measurements, for example, pulse, blood pressure, temperature, oxygen saturation and respirations as per NEWS guidance.

4.5 Make safe any environmental hazards

Remove or minimise environmental hazard(s) if any contributed to the fall.
If the hazard can’t be removed directly ensure necessary warning is implemented that no other person will be at risk.

4.6 Assist

If the patient won’t stay on the floor:

try to persuade patient to remain on floor. Offer support, blanket, pillow. If this approach fails, assist from the floor without putting yourself at risk from a manual handling perspective
if the patient can get up themselves, encourage them to do so to reduce the risk of injury to yourself
use a chair to assist for support and balance
consider using moving and handling equipment such as the Elk or Raizer to assist if available, for community patients; keep them safe and comfortable on the floor until assistance arrives
hoist as a last resort and only if necessary. Consider risks when using hoist. Avoid if possible

4.7 Monitor the patient

Observe the patient according to NEWS or head injury guidance
Some injuries may not be apparent at the time of the fall, ensure patient is checked regularly following the event for signs of injury such as pain, discomfort, decreased mobility and the appearance of bruising and swelling or for any other changes in presentation.

4.8 Interventions post fall if no injury sustained

Post fall monitoring in accordance with policy:

multi-disciplinary team (MDT) review to consider cause of fall and action required
if the wards use the purposeful in patient admission (PIPA) model, any falls must be discussed in the PIPA meeting the next day
medication review must be completed
investigate medical causes leading to the high-risk status, for example, cardiovascular factors, other physiological factors. Groundwork for medical interventions are nursing observations including consideration of urine tests, lying and standing blood pressure, and temperature. Consider electrocardiogram (ECG)
MFRA and care plan review
refer to physiotherapy for assessment or review of the patient’s balance and mobility and provide appropriate advice and, or mobility aids. Evidence based exercise programmes for fall prevention may be indicated
refer to occupational therapy for assessment of the safest ways for individuals to carry out activities of daily living if indicated, this may include an environmental assessment, see separate procedure
communicate the advice from physiotherapy and occupational therapy to all colleagues and ensure mobility aids remain within reach
assess the patient’s continence. Are there remedial causes of
incontinence or urgency, such as dehydration, urinary tract infections or constipation? Would he or she benefit from a tailored routine of offers to assist to the toilet? needs medical review or continence assessment or referral
undertake an osteoporotic risk factor review and if necessary treat
or request GP intervention (as per NICE Osteoporosis, prevention of fragility fractures guidance, CG 146 2017 (opens in new window) this may include FRAX)
high risk of falling needs to be considered as part of the discharge planning and aftercare, therefore those involved in this planning need to be aware
consider need for follow up or referral to specialist services
consider use of bed rails (refer to bed rails procedure). The decision-making regarding the use of bed rails is a complex issue especially in mental health units
although many of the patients who fall may be too confused to access help before mobilising, any patient who is able to safely use a call bell or colleagues alert system should have it within sight and within reach

4.8.1 Community, outpatient or day centre patients

For those patients who fall in the community or fall within an outpatient or day care setting and don’t require conveyance to hospital, then the following post fall actions should be taken:

ask the patient if you can contact their next of kin, carer or someone who can be nominated to look out for them following their fall. The following information can then be relayed to them as-well as to the patient
advise the patient of the latent signs and symptoms to look out for following a fall including any new pains, feeling dizzy or unbalanced; blurred vision, headache or vomiting if they hit their head
advise the patient to contact their GP should any of the above new symptoms develop or dial 111 if out of hours. For a serious or sudden deterioration then dial 999 for an ambulance
share any advice for reducing the risk of further falls
complete an incident form IR1
inform patient’s GP via letter or task to inform them of the fall

Further consideration:

the clinician may wish to do a follow-up phone call or visit to the patient within 24 hours of their fall if they have specific concerns
a referral to physiotherapy for a mobility assessment may be required if the fall was mobility related
a routine GP review may also be required if there are any medical concerns

4.9 Post fall incident reporting on safeguard incident reporting system (IR1)

The incident will be reported as soon as possible via the trust safeguard incident reporting (IR1) system. If a fracture or other serious injury is confirmed the colleagues must contact the manager who will escalate as required. If the manager is not around, colleagues are to inform the on-call manager.

Information reported via the safeguard system (IR1) will include:

time of incident
place of incident
any relevant environmental factors
circumstances of the fall
a patient who has fractured a hip from an inpatient fall is unlikely to regain the levels of mobility and independence they had prior to the fall, in which case the degree of harm is severe. However in a few cases the patient could recover (moderate) or die (death). National Patient Safety Agency (2004). Each incident will be judged individually at the falls panel
confirmation that national early warning score (NEWS) and or neurological observations have been completed and recorded
the patients fall risk category prior to the fall and any relevant details captured in the fall’s prevention care plan
immediate actions taken or strategies to be put in place following the fall to reduce the risk of harm and any further falls
document how the patient was transferred from the floor following a fall
a RIDDOR (The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013), report will be completed by the modern matron or service manager if there was a serious injury as a result of an environmental factor

4.10 Inform relevant contacts

Inform the patient’s relatives, and inform and involve them in any actions planned to reduce the risk of further falls.

4.11 Review

Review MFRA and care plan.
MDT review including medication.

5 Learning lessons

5.1 Falls reviews and serious incidents (SI’s)

All falls which result in harm and are graded as moderate harm or above (3 or above) will be reviewed in-line with the trust incident management policy.

Such falls will be investigated locally by the relevant clinician and the falls leads (if available) and presented at the falls review panel.

If the outcome from the falls review panel concludes that there has been a significant and avoidable lapse in the expected level of care provision which has contributed to the fall, then the incident will be escalated as an SI (serious incident) and be investigated accordingly.

The head of patient safety, trust strategic falls lead and care group falls leads will be made aware of any significant falls and may assist any investigation if required.

5.2 Themes and trends analysis

Falls data is routinely recorded and reviewed monthly using the FallSafe audit tool (appendix F FallSafe audit).

Falls reports are produced monthly by the Falls Leads on the frailty wards. Data is shared with respective care groups as part of their quality dashboards to allow local review and action planning.

Following a fall, in-depth analysis of the fall and of related clinical information is carried out immediately within the service area by ward managers and falls leads (as part of clinical post fall procedures). Any themes or trends are noted, and specific actions developed to address the apparent issues.

Any learning from falls incidents will be shared at team meetings with the full MDT if available.

6 References

Royal College of Physicians (2022) ‘Supporting best and safe practice in post-fall management in inpatient settings’ (opens in new window).
National Patient Safety Agency. (2004) Seven Steps to patient safety.

7 Appendices

Please see patient falls manual (prevention and management) webpage for appendices attached to this procedure.

Appendix C Post falls clinical decision-making flow chart
Appendix D Post fall incident reporting flow chart
Appendix F FallSafe audit

Document control

Version: 1.3.
Unique reference number: 1051.
Approved by: Clinical policy review and approval group.
Date approved: 6 February 2024.
Name of originator or author: Clinical team leader.
Name of responsible individual: Executive director of nursing and AHP’s.
Date issued: 19 February 2024 (amendment).
Review date: 31 August 2026.
Target audience: Clinical staff.
Description of change: Section 4.8.1 has been added which specifically relates to patients who fall at home or in the community.

Page last reviewed: December 12, 2024
Next review due: December 12, 2025

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