Published evidence recommends risk assessment followed by multidisciplinary intervention tailored to the individual. Multidisciplinary interventions include nursing, medical, physiotherapy, occupational therapy, and pharmacy. Other useful interventions include optometry, podiatry, and bone health services.
Key Points:
- A Falls Risk Assessment should be commenced as soon as possible for all adult patients who are admitted to hospital and completed within 24 hours of admission.
- This is especially important for those aged over 65, those with a history of falls or admitted due to a fall.
- It is important to identify any concern with the patient’s balance, mobility, nutritional status, continence issues or confusion through individual assessment as these factors contribute to falls risk.
- This is a simple 5 question assessment with any “YES” answer identifying the patient as more vulnerable to falls.
- The falls risk assessment should be reviewed if the patient falls, their condition deteriorates or upon transfer to another ward.
- This assessment should be reviewed in line with risk assessment guidance as set below (note: clinical judgement can be used to change the review date):
Falls Risk High – review daily
Falls Risk Low – review every 3 days
What does a Falls Risk Assessment look like?
The Falls Risk Assessment includes the following 5 questions:
- Has the patient fallen in the last 6 months – including during this admission?
- Does the patient have a 4AT greater than 0 or acute confusion (delirium)?
- Does the patient attempt to walk alone although unsteady or unsafe?
- Does the patient or their relative/s have fear or anxiety regarding falling?
- Based on your clinical judgement, is this patient at high risk of falling?
How do I complete a Falls risk assessment?
The Risk Assessment should be completed on TRAK within the Person-Centred Care plan.
An example scenario of how to complete an assessment can be found in the How to complete Falls Risk Assessment document.
Screening Patients with delirium (acute confusion) or dementia
- Patients who are confused are one of the largest patient groups at risk of falls within the hospital setting because of their reduced safety awareness.
- Confusion, whether acute (secondary to an acute illness i.e. delirium) or chronic, (secondary to dementia) should be screened for using the 4A Test screening instrument for delirium.
- It is important to ask whether the patient has a diagnosis of dementia, whether these episodes have occurred before and under what circumstances.
- When screening patients with a diagnosis of dementia, for delirium, asking a carer or family member the single question in delirium (SQID) “is this person more confused than normal?” can be helpful.
- If a fuller screening is required, a Mini-Mental State Examination (MMSE). It is essential to establish a collateral history from carers and relatives to try to determine if the problem is acute or chronic.
- Patients with dementia can become disorientated when in an unfamiliar environment increasing their risk of walking without purpose. This combined with poor safety awareness makes these individuals particularly vulnerable.
- These patients require careful management with regular orientation and nursing in a well-lit environment. Medical problems such as urinary retention, constipation, pain or sepsis should be considered, particularly in patients who are unable to communicate the source of their distress.
- To reduce the risk of injury, the bed can be lowered nearer the floor. Sedatives should be avoided if possible as they often worsen unsteadiness and can cause paradoxical agitation.
- Risk assessment and nursing/multifactorial interventions should be carried out to help reduce the risk of falling.
How do I complete a 4 A Test screening?
This should be completed on TRAK as a risk assessment within the Person-Centred Care Plan (PCCP).
How do I complete a Mini-Mental State Examination (MMSE)?
This should be completed on TRAK.
Lothian Accreditation and Care Standards (LACAS)
The NHS Lothian Accreditation and Care Assurance Standards Framework is designed to support nurses and the multi-professional team to identify and build upon what works well and to take effective action where further improvements are necessary.
Falls is part of the LACAS standard 3 “Patients who Fall”
Further information around LACAS and the standards can be found here:
