{"id":392,"date":"2024-01-30T12:22:53","date_gmt":"2024-01-30T12:22:53","guid":{"rendered":"https:\/\/staff.nhslothian.scot\/falls\/falls-risk-assessment-and-screening\/"},"modified":"2024-02-21T13:30:27","modified_gmt":"2024-02-21T13:30:27","slug":"falls-risk-assessment-and-screening","status":"publish","type":"page","link":"https:\/\/staff.nhslothian.scot\/falls\/falls-risk-assessment-and-screening\/","title":{"rendered":"Falls Risk Assessment and Screening"},"content":{"rendered":"\n<p>Published evidence recommends risk assessment followed by multidisciplinary intervention tailored to the individual. &nbsp;Multidisciplinary interventions include nursing, medical, physiotherapy, occupational therapy, and pharmacy. Other useful interventions include optometry, podiatry, and bone health services.<\/p>\n\n\n\n<p>Key Points:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>A Falls Risk Assessment should be commenced as soon as possible for all adult patients who are admitted to hospital and completed&nbsp;within 24 hours of admission.<\/li>\n\n\n\n<li>This is especially important for those aged over 65, those with a history of falls or admitted due to a fall.<\/li>\n\n\n\n<li>It is important to identify any concern with the patient\u2019s balance, mobility, nutritional status, continence issues or confusion through individual assessment as these factors contribute to falls risk.<\/li>\n\n\n\n<li>This is a simple 5 question assessment with any \u201cYES\u201d answer identifying the patient as more vulnerable to falls.<\/li>\n\n\n\n<li>The falls risk assessment should be reviewed if the patient falls, their condition deteriorates or upon transfer to another ward.<\/li>\n\n\n\n<li>This assessment should be reviewed in line with risk assessment guidance as set below (note: clinical&nbsp;judgement can be used to change the review date):<br>Falls Risk High \u2013 review daily<br>Falls Risk Low \u2013 review every 3 days<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\">What does a Falls Risk Assessment look like?<\/h2>\n\n\n\n<p>The Falls Risk Assessment includes the following 5 questions:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Has the patient fallen in the last 6 months \u2013 including during this admission?<\/li>\n\n\n\n<li>Does the patient have a 4AT greater than 0 or acute confusion (delirium)?<\/li>\n\n\n\n<li>Does the patient attempt to walk alone although unsteady or unsafe?<\/li>\n\n\n\n<li>Does the patient or their relative\/s have fear or anxiety regarding falling?<\/li>\n\n\n\n<li>Based on your clinical judgement, is this patient at high risk of falling?<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\">How do I complete a Falls risk assessment?&nbsp;<\/h2>\n\n\n\n<p>The Risk Assessment should be completed on TRAK within the Person-Centred Care plan.<\/p>\n\n\n\n<p>An example scenario of how to complete an assessment can be found in the <a href=\"https:\/\/staff.nhslothian.scot\/falls\/wp-content\/uploads\/sites\/27\/2024\/02\/How-to-complete-Falls-Risk-Assessment.docx\">How to complete Falls Risk Assessment<\/a> document.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Screening Patients with delirium (acute confusion) or dementia<\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>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.<\/li>\n\n\n\n<li>Confusion, whether acute (secondary to an acute illness i.e. delirium) or chronic, (secondary to dementia) should be screened for using the&nbsp;<strong>4A Test screening instrument for delirium.<\/strong><\/li>\n\n\n\n<li>It is important to ask whether the patient has a diagnosis of dementia, whether these episodes have occurred before and under what circumstances.<\/li>\n\n\n\n<li>When screening patients with a diagnosis of dementia, for delirium, asking a carer or family member the single question in delirium (SQID) \u201cis this person more confused than normal?\u201d can be helpful.&nbsp;<\/li>\n\n\n\n<li>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.<\/li>\n\n\n\n<li>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.<\/li>\n\n\n\n<li>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.<\/li>\n\n\n\n<li>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.<\/li>\n\n\n\n<li>Risk assessment and nursing\/multifactorial interventions should be carried out to help reduce the risk of falling.<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\">How do I complete a 4 A Test screening?&nbsp;<\/h2>\n\n\n\n<p>This should be completed on TRAK as a risk assessment within the Person-Centred Care Plan (PCCP).<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">How do I complete a Mini-Mental State Examination (MMSE)?<\/h2>\n\n\n\n<p>This should be completed on TRAK.<\/p>\n\n\n\n<p>Lothian Accreditation and Care Standards (LACAS)<\/p>\n\n\n\n<p>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.<\/p>\n\n\n\n<p>Falls is part of the LACAS standard 3 \u201cPatients who Fall\u201d<\/p>\n\n\n\n<p>Further information around&nbsp;LACAS and the standards can be found here:<\/p>\n\n\n\n<p><a href=\"https:\/\/staff.nhslothian.scot\/falls\/framework\/\">Lothian Accreditation &amp; Care Assurance Standards Framework<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Published evidence recommends risk assessment followed by multidisciplinary intervention tailored to the individual. &nbsp;Multidisciplinary interventions include nursing, medical, physiotherapy, occupational therapy, and pharmacy. Other useful interventions include optometry, podiatry, and<\/p>\n","protected":false},"author":5,"featured_media":0,"parent":0,"menu_order":26,"comment_status":"closed","ping_status":"closed","template":"page-templates\/widewidth.php","meta":{"_searchwp_excluded":"","footnotes":""},"categories":[],"class_list":["post-392","page","type-page","status-publish","hentry"],"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"davidmcbain","author_link":"https:\/\/staff.nhslothian.scot\/falls\/author\/davidmcbain\/"},"rttpg_comment":0,"rttpg_category":false,"rttpg_excerpt":"Published evidence recommends risk assessment followed by multidisciplinary intervention tailored to the individual. &nbsp;Multidisciplinary interventions include nursing, medical, physiotherapy, occupational therapy, and pharmacy. Other useful interventions include optometry, podiatry, and","_links":{"self":[{"href":"https:\/\/staff.nhslothian.scot\/falls\/wp-json\/wp\/v2\/pages\/392","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/staff.nhslothian.scot\/falls\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/staff.nhslothian.scot\/falls\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/staff.nhslothian.scot\/falls\/wp-json\/wp\/v2\/users\/5"}],"replies":[{"embeddable":true,"href":"https:\/\/staff.nhslothian.scot\/falls\/wp-json\/wp\/v2\/comments?post=392"}],"version-history":[{"count":1,"href":"https:\/\/staff.nhslothian.scot\/falls\/wp-json\/wp\/v2\/pages\/392\/revisions"}],"predecessor-version":[{"id":558,"href":"https:\/\/staff.nhslothian.scot\/falls\/wp-json\/wp\/v2\/pages\/392\/revisions\/558"}],"wp:attachment":[{"href":"https:\/\/staff.nhslothian.scot\/falls\/wp-json\/wp\/v2\/media?parent=392"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/staff.nhslothian.scot\/falls\/wp-json\/wp\/v2\/categories?post=392"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}