Quality in Healthcare Project by Devin Deo

A Retrospective Audit of Documented Patient Falls in Geriatric Patients in the General Medicine Ward of a Tertiary Hospital (John Hunter Hospital, NSW) Quality in Healthcare (2019)

Members: Devin Deo Timothy Tan Javin Chee Yu Jia Ng

Department Head: Dr. Bernard Walsh

Contents Page 1. Abstract 2. Background 3. Literature Review a. Impact of inpatient of falls on the mortality and morbidity of geriatric patients b. Summary of current falls prevention strategies as currently implemented 4. Analysis of Problem (Methodology) a. Selection of patients b. Data collection and analysis c. Sample d. Limitations of study 5. Results of Analysis a. Discussion of results 6. Recommendations of improvements and their implementation and evaluation 7. References 8. Appendix a. Appendix A - Literature Search Results b. Appendix B - Ontario, FRAMP, Morse Falls Score Charts c. Appendix C - Collation of results table

Abstract Aim The aim of our study is to evaluate the effectiveness of current risk assessment and screening criteria for falls risk in use by John Hunter Hospital in preventing an inpatient fall. Our secondary aim is to identify additional high falls risk factors that could be used to supplement the existing protocols in place, using screening tools such as the Morse Fall Score. Methods A retrospective audit of patients admitted to ward G1 in John Hunter Hospital between July 2018 and July 2019 was conducted. This was done with the aid of both a Clinical Nurse Consultant for Older Person Acute Care (John Hunter Hospital) and a Patient Safety Officer in Clinical Governance. Each of these patients had one or more inpatient falls during their admission during the 1 year period of this analysis. The information recorded was taken directly from digitized patient records and documented on an Excel spreadsheet (this is illustrated as such by Table 1). This was mainly quantitative and qualitative data. For each patient, data was taken from their Ontario scores, FRAMP, discharge summaries and other relevant notes found in the patient record. Descriptive statistical analysis was then undertaken. Results Out of a total of 37 inpatient falls across 31 patients, the most significant risk factors for an inpatient fall identified were being male, having a previous history of falls, the use of walking aids, polypharmacy, delirium and/or dementia, false negative delirium screened patients and incomplete documentation. Additionally, there is a greater proportion of falls which occurred on the weekend, a greater proportion of mechanical falls versus non-mechanical falls and a significant proportion of falls which occurred in the hospital toilets as well as during mobilisation. Conclusion Inpatient falls is a significant cause of increased patient morbidity and mortality. Therefore, it warrants that efforts be conducted to minimise this where possible. In our retrospective audit, we have identified several areas where improvements to the existing system can be made and have offered suggestions to this end. However, our study focuses on primary prevention and as such, a bigger exploration of secondary and tertiary prevention would be a prudent follow up. Background Falls are a significant cause of danger and harm to older people, with injuries related to falls being associated with a substantial burden on healthcare and aged care 2

systems. In recent years, there have been significant increases in falls prevention measures undertaken in healthcare and aged care facilities to reduce these burdens. Effective measures for falls prevention require activity in a variety of healthcare settings, community-based and population-focused initiatives. Falls prevention is important because it is particularly common amongst the older people population. WHO states that approximately 28-35% of people aged 65 and over fall each year with increasing percentages of 32-42% for those over 70 years of age. (1) Thus, the frequency of falls is associated with increases in age and frailty levels. An estimated 125,021 people aged 65 and over were hospitalised due to falls in 2016â&#x20AC;&#x201C;17 in Australia, while three-quarters of all injury hospitalisations for people aged 65 and over are a result of a fall. (2) Additionally, there is a strong association of morbidity and mortality of injuries related to falls in older people. In NSW, falls lead to approximately 27,000 hospitalizations and at least 400 deaths each year in people aged 65 years and over. (3) Even falls not resulting in significant injury can negatively impact the lives of these people with a loss of confidence and restriction of activity. Falls are also the most commonly reported adverse event amongst hospital inpatients. (4) Interestingly, falls in the hospital have been shown to be associated with significantly greater rates of mortality and significantly worse outcomes as compared to falls that occur in the community. (5) In 2015â&#x20AC;&#x201C;16, about 34,000 falls resulting in patient harm in hospitals were recorded, at a rate of 3.2 falls per 1,000 separations in Australia. (6) Falls also generate substantial costs for the healthcare system and aged care system and results in long and expensive hospital stays and rehabilitation. (7) Over a million (1,218,463) patient days were required for hospital care related to injurious falls by people aged 65 and over in Australia in 2016â&#x20AC;&#x201C;17. In NSW, injuries related to falls cost the health system more than any other single injury cause with the total cost of healthcare-associated with fall injuries in older people was estimated at $558.5 million in 2006-07. (8) Projections indicate that the health system costs from injuries related to falls are likely to escalate significantly due to the expected greying population in NSW in upcoming years, should no preventive action be taken. There has also been extensive research showing the preventability of many falls among older people. In summary, the prevalence of falls is very significant worldwide and in Australia, especially in the elderly population (65 years and older), where resulting health consequences of mortality and morbidity are also more significant. Falls that occur in hospitals have also been shown to lead to worse clinical outcomes as compared to falls that occur in the community, which highlights the greater importance on increasing the effectiveness of falls prevention strategies in hospitals.

Diagram showing age-specific rates of hospitalised fall-related injuries in Australia in 2016-17 (2) Literature Review This literature review aims to determine the impact of inpatient falls of geriatric patients on their mortality and morbidity. This will provide further reasons and justify the need to improve the current practices in falls prevention already established in hospitals, to further reduce the prevalence of falls and the consequences that result from them. A systematic search in the medline and embase was performed with the following search terms: inpatient, hospital, falls, morbidity and morbidity, outcome, impact, prognosis, elderly and geriatric. Results from the search terms in both were combined with “OR” and “AND” to achieve a total number of results inclusive of the search terms. This method was performed in both databases for both topics. Results from both databases were analysed and cross-referenced for duplicates which were removed. Articles were limited to English language articles, full-text articles, “studies conducted on humans”, “population age of 65 year olds and above” and with a time limitation of the last 10 years for increased relevance. Relevance of the articles were checked and papers that did not meet the criteria were excluded. Relevance and eligibility of the articles were based on the following inclusion: 1. Within a time period of recent 10 years for increased relevance 2. In English Language 3. Population groups with major involvement of geriatric patients (>65 year old) 4. Articles discussing the impact of inpatient falls on morbidity and mortality Articles were excluded if they did not meet the following criteria: 4

1. Non-English 2. Unavailability of full text 3. Irrelevant to population or outcomes of interest Results using these search terms, inclusion and exclusion criteria achieved a total number of 84 articles. The articles were reviewed manually by the group and eventually led to the selection of 4 articles which were deemed as the most relevant to our topic. Impact of inpatient falls on the mortality and morbidity of geriatric patients Inpatient falls can have significant impacts on the clinical outcomes of patients, which can be both physical and psychological. Physical consequences include fractures and hematomas, while psychological impacts include a reduced sense of confidence, low self-efficacy and less positive attitudes which in turn may negatively impact their ability to return to their premorbid state. (9) A retrospective study by H J Hong et al (10) looked at risk factors and outcomes of falls in hospitalised patients in Korea. Data were collected from a single tertiary hospital from its electronic medical records from October 2008 to July 2011 which included 868 patients who had experienced a fall and 3472 patients who did not experience a fall in hospital as part of the control group. Even though there was no statistically significant increase in mortality between the 2 groups, there was a 2.44 times increased risk of adverse outcomes in the falls group which included death, transfer to another hospital, discharge against medical advice and hopeless prognosis. There were also a 4.83 times and 4.50 times greater risk of hospital readmission within 90 days and 180 days of discharge respectively for the falls group. In addition, there were also a 4.28 and 3.89 times increased risk of visiting the Emergency Department within 90 and 180 days of discharge respectively. According to the study, inpatient falls also led to longer hospital stays and higher medical expenses. Importantly, the falls risk of these patients was reduced after the introduction of a prevention reinforcement policy. Another retrospective study by S M Bradley (11) et al looked at predictors of serious injury amongst inpatients evaluated after a fall. The study included 513 inpatients who sustained 636 falls in 13 medical and surgical units in an urban hospital academic medical centre in New York from January 1 to December 31 2006. 73% of the analysed falls occurred on medical rather than surgical units, while 5% of patients had evidence of trauma on physical examination, which included lacerations, swelling and ecchymoses. 13% of the imaging studies conducted on these patients after the fall revealed significant findings although there was no statistically significant increase in the length of hospital stay in these patients. The study revealed that a high percentage of patients with an initial fall would have recurrent falls in the future, while inpatient falls associated with an almost 2 week increase in length of hospital stay. 5

The above 2 studies highlight the significance of the impacts of inpatient falls on the outcomes and prognosis of patients admitted to hospitals which include higher rates of adverse outcomes, hospital readmissions and longer hospital stays and higher medical expenses. Practically, falls risk assessment and prevention strategies in hospitals are also shown to be effective in reducing the risk of inpatient falls. Another study by KS Johal et al (5) compared the prevalence and characteristics of hip fractures sustained after falls in hospital and after falls in the community. This study analysed all patients over 65 years of age who suffered a hip fracture who presented to a University Hospital in Nottingham from 1st May 1999 to 30th April 2007. During the 8 year study period, a total of 5879 patients suffered hip fractures with 327 of them as a result of a fall in hospital. The analysis of the study revealed a statistically significant increase in mortality rates of the inpatient fall group of 18% as compared to 9% at 30 days post-fall and 47% as compared to 26% at 1 year post-fall. Cognitive function of the patients were also significantly lower in the inpatient falls group. Interestingly, there was however no significant difference in the length of hospital stay and postoperative complication rates between the 2 groups. The majority of the fractures after falls occurred in medical or geriatric wards, with the highest risk group occurring amongst the elderly patients on the psychiatric wards. This study reveals the severity of falls that occur in hospitals as compared to falls that happen in the community, with almost 50% mortality within a year according to the results of this study. Falls that occur in hospitals are generally associated more with a certain degree of cognitive impairment with greater amounts of medications administered to patients in hospital as compared to individuals in the community. Our literature review thus highlights the severity of the impacts of inpatient falls on the outcomes and prognosis of patients admitted to hospitals as well as the importance of falls risk reduction and falls prevention strategies in hospitals. The geriatric patient population is also shown to be of a higher risk group to inpatient falls. Hence, this leads to our decision of pursuing this retrospective audit on inpatient falls amongst geriatric patients to further evaluate and identify risk factors and ways to improve falls risk reduction in hospitals in an Australian context. Summary of current falls prevention strategies as currently implemented (12) 1) Falls prevention clinic Patients can arrange to have appointments with a falls therapist to develop an appropriate program to reduce a patientâ&#x20AC;&#x2122;s modifiable risk factors. This primarily deals with the following issues: medical issues or issues with medications, mobility equipment, falls management or floor transfers, foot care, vision and home

environment factors including Vitalcall (a pendant or necklace that an elderly patient who has just had a fall can activate to alert a medical support team and call for help.) 2) Promotion of safe footwear Appropriate footwear is a modifiable protective factor against falls. A good pair of shoes helps to provide support and traction without being too tight, which in turn may cause blisters. The current recommendations for shoes include the following: -

Firm heel collar to provide stability Laces or other secure forms of fasteners to allow for the shoe to fit snugly around the wearerâ&#x20AC;&#x2122;s foot Thin and firm midsole so patients can feel the ground beneath their feet Textured sole for traction Broad, flared, low (2.5cm) and bevelled heel to maximise contact surface with the ground and prevent slipping Encouragement to avoid wearing slippers for mobilising

3) Urge incontinence Patients often have sudden and strong urges to go to the toilet. They may also need to void their bladder more often. This leads to more falls as patients tend to be in a hurry to get to the toilet and may not pay sufficient attention to their surroundings. Waking up in the middle of the night also contributes to being a falls risks as the patient may be drowsy having just woken up and the surroundings may be poorly lit. Suggestions for tackling this issue include:

Monitoring fluid intake Avoid caffeine and alcohol particularly around bedtime Ensure the path to the toilet is clear of hazards Night lights to illuminate the path to the toilet

4) Managing confusion, delirium and dementia Delirium and dementia can increase a patientâ&#x20AC;&#x2122;s risk of falls by causing the patient to feel disoriented, dizzy, agitated and even affect the patientâ&#x20AC;&#x2122;s level of consciousness. Preventing episodes of confusion can be done by: -

Minimising background noises and distractions Encouraging an appropriate sleep-wake cycle Ensure personal needs are attended to (ie, toileting, feeding, hydration) Assistance from various allied health professionals to assist with mobility

5) Postural hypotension

Postural hypotension can cause hypoperfusion of the patient’s neurological and musculoskeletal systems. This can lead to patients experiencing dizziness, vision changes and fainting spells. In order to protect against hypotensive events, patients are advised to do the following: -

Inform their doctor to ensure their regular medications are appropriate Taking a longer time to get out of bed to give the body sufficient time to adapt to the change in posture Ensure there is adequate support for the patient should he or she feel dizzy Avoid dehydration Avoid taking hot baths or showers

6) Dizziness Dizziness is often associated with difficulty maintaining one’s balance and can lead to an unsteady gait. It could also prevent the patient from being fully cognizant of falls hazards surrounding them and may lead to some muscle weakness.There are many causes of dizziness which includes hypoglycaemia, vision problems, motion sickness and inner ear problems. Patients with these comorbidities should be wary if they experience the following; headache, blurred vision, chest pain, speech problems, limb weakness, paraesthesia, shortness of breath, changes in the level of consciousness.

7) Eyesight Changes in vision may impair a patient’s ability to identify fall hazards and may increase their risk of slipping or tripping on uneven surfaces. Visual acuity as well as changes to the patient’s field of vision should both be assessed annually. Multifocal lenses may also distort the patient’s depth perception. Analysis of Problem (Methodology) A retrospective audit was conducted on 31 patients from ward G1 of John Hunter Hospital who had at least one inpatient fall during their admission. The primary aim of this is to evaluate the effectiveness of current risk assessment and screening criteria for falls risk in use by John Hunter Hospital in preventing an inpatient fall. Specific risk factors used for screening are taken from the Ontario modified stratify (Sydney Scoring) falls risk screen, and Falls Risk Assessment and Management Plan (FRAMP). Our secondary aim is to identify additional high falls risk factors that could be used to supplement the existing protocols in place, using screening tools such as the Morse Fall Score. (13)

Selection of patients A list of patients admitted to ward G1 in John Hunter Hospital between July 2018 and July 2019 was first generated with the help of both a Clinical Nurse Consultant for Older Person Acute Care (John Hunter Hospital) and a Patient Safety Officer in Clinical Governance. A total list of 47 patients was produced, which were filtered to geriatric patients identified as patients of age 65 years and older, resulting in a final tally of 31 patients. Each of these patients either had one or more inpatient falls during their admission during the 1 year period of this analysis, with a total of 37 inpatient falls recorded across the 31 patients. Data collection and analysis The data were collected by 3 different individuals for the 31 patients that were generated, whom each reviewed patient records twice to ensure accuracy of data collected. Any discrepancies of data would be rechecked and reverified between each review of the data. The information recorded was taken directly from digitized patient records and documented on an Excel spreadsheet (this is illustrated as such by Table 1 below). This was mainly quantitative and qualitative data. For each patient, data was taken from their Ontario scores, FRAMP, discharge summaries and other relevant notes found in the patient record. Descriptive statistical analysis was then undertaken.

Table 1: Data collection table

Sample

Diagram 1: Flowchart depicting hospital falls risk screen process Diagram 1 simplifies how patients triaged in HNE hospitals are assessed in terms of their falls risks. Patients are typically screened using tools such as the Ontario modified stratify (Sydney Scoring) falls risk screen (Appendix B). (14,15) As long as a single falls risk is identified, a FRAMP chart is filled out and a falls risk sticker should be placed (Appendix B). (14,15) Patients who have been flagged with a falls risk can easily be identified with a bright orange falls risk sticker on the front pages of their notes. After which, options can be put in to limit the patientâ&#x20AC;&#x2122;s modifiable risk factors. Measures such as ensuring patient mobilisation are safe with the use of Sara Stedy, 4 wheel walkers, adequate railings, appropriate footwear as well as I-beam machines to identify when patients get out of bed to ensure there are staff members to assist with mobilisation.

Diagram 2: Fishbone diagram depicting risk factors that increase the risk of an inpatient falls Falls can occur due to a myriad of factors as summarised above. 1. Non-modifiable risk factors are defined as patient factors that cannot be changed or improved and are intrinsic to each patient. Such factors include the patient’s age, gender, pre-existing medical conditions, and a history of previous falls. 2. Mobility issues increase a patient’s falls risk. As such, patients tend to experience difficulty maintaining a functional steady gait and may have decreased awareness of their surroundings, making them more prone to tripping over objects in their surroundings. 3. Specific medications such as antihypertensives or psychoactive drug classes can directly impact a patient’s level of cognition and their ability to maintain their balance. (16) Polypharmacy is also indicative of multimorbidity and is often a sign of the patient’s overall health and wellbeing. (17,18) 4. Hospital risk factors have also been identified as a risk factor for falls in patients admitted. A statistically significant number of falls reported occurred during weekends and public holidays. This could be a result of reduced staffing numbers leading to higher staff to patient ratios. 5. Patients aged 65 and older who are admitted often have some form of cognitive screening. This gives us a good impression of the patient’s likelihood of becoming agitated and delirious. Such events are strong risk factors for falls in

elderly patients as they can become aggressive and are often unaware of their surroundings. The above factors cumulatively result in the patientâ&#x20AC;&#x2122;s overall risk of falls, as such we can identify modifiable elements within to provide a better quality of health care and reduce morbidity in mortality as a result of falls. Limitations of the study Several limitations of this study were identified during the process of data collection. Firstly, we were limited to the documentation available and relevant information was often not recorded properly and consistently. Secondly, this study only takes into account the absolute number of falls that occurred during the patientsâ&#x20AC;&#x2122; stay in hospital and was used solely to identify strategies targeted at reducing falls in geriatric admissions. Thirdly, the results collated represent a fairly homogenous population specific to John Hunter Hospital. While we believe that the factors identified are generally representative of geriatric patients in general, we concede that it may not be an accurate reflection of all patients throughout Australia or the world. A broader study could be warranted in the future that could improve on this by conducting a multicentered study with a significantly larger population. If so, this information would be better quantified by the number of falls per 1000 bed days as suggested by the AHRQ (agency for healthcare research and Quality). Due to the nature of the study, we can only identify correlations between falls and risk factors for falls as opposed to cause and effect. This makes it difficult to draw concrete conclusions from the collected data.

Results of Analysis

Diagram 3: Column chart depicting the proportion of falls associated with NonModifiable risk factors In terms of non-modifiable risk factors, of the 31 patients aged > 65 who had a fall in ward G1 of John Hunter Hospital, the greatest risk factor for an inpatient fall is a previous falls history, with 27 of 31 patients having had a previous fall identified in the last 6 months. Males have a higher risk of an inpatient fall when compared to females. There is no significant difference in the 2 age brackets for increased falls risk.

Diagram 4: Column chart depicting the proportion of falls associated with mobility issues In terms of mobility issues, out of the 31 patients, the most significant risk factor for an inpatient fall are the use of walking aids, with 22 out of 31 patients requiring some form of walking aid such as a walking stick or 4 wheel walker. Muscle weakness & visual impairment were not significant risk factors. Surprisingly, arthritis also does not appear to be statistically significant with about 50% of patients with arthritis who also experience an inpatient fall. However, it would be harder to evaluate this depending on the severity of the arthritis which is not known based on the data. Muscle weakness was difficult to evaluate as it was not always documented. However, based on the available documentation, it was not a significant risk factor.

Diagram 5: Pie chart depicting the proportion of falls against the day of the week In terms of hospital factors, the day of the week was a significant risk factor with 36% of falls occurring on the weekends. Given the smaller proportion of weekends to weekdays in a year, there appears to be a greater correlation of risk of inpatient falls with the weekends. This could be a result of staffing issues as mentioned earlier, due to decreased staff to patient ratios. For the Transfer Score/Mobility Score/Total Score outlined in Appendix C, documentation were either poor or absent according to our data collected. This score was calculated via the adult emergency department observation chart predominantly or based on the score found in the Ontario screen. Its usefulness is thus limited.

Diagram 6: Pie chart to display the proportion of completed FRAMP charts and the presence of falls stickers after a falls risk is identified in the Ontario screen Given that the FRAMP, Ontario and Falls sticker placement are linked as per diagram 1, we decided that it was best to evaluate this together. As per our data collated in appendix C, 30 out of 31 patients had an identified falls risk in their Ontario screen. For at least 50% of the patients, this was not followed through, after the Ontario screen identifies a falls risk factor, as outlined by the directions written in each document. 33% of patients had a positive FRAMP, but no falls risk sticker. 7% of patients had no FRAMP chart filled, yet a falls risk sticker was placed. 10% of patients had neither a FRAMP chart filled nor a falls risk sticker. For the other 50%, this is done correctly. With respect to the Ontario Score alone, there are many instances where the total score is not calculated. This seems to be a common issue in the documentation that we have noted.

Diagram 7: Column chart depicting the proportion of falls risk stickers placed With respect to the falls risk sticker, following the assessment which finds the patient as a falls risk, a falls risk sticker should be placed as outlined in FRAMP. However, this was not always done.

Diagram 8: Pie chart depicting the proportion of falls due to patientâ&#x20AC;&#x2122;s mental status

In terms of mental status, out of the 31 patients, 64% have either delirium, dementia or both. Any deviation from normal cognition is a risk factor which shows that this is a significant risk factor. In fact, As per appendix C, MMSE, MOCA or Delirium screens for Older Adults did not always correlate with a patient’s mental status and were not always conducted close to the date of the fall.

Diagram 9: Column chart depicting the proportion of patients’s inpatient mental status against cognitive screening conducted i.e. Delirium Screen for Older Adults Score, MMSE & MOCA As per diagram 8, we examined the proportion of recorded patients’ mental status against any cognitive screening conducted during their admission. For patients’ with normal cognition, dementia and mixed delirium & dementia, cognitive screening was predominantly accurate. However, if a patient had delirium alone, 4 out of 11 patients had a false negative result on either their MMSE, MOCA or Delirium Screen for Older Adults alone or a combination of these cognitive screens. Hence, it appears that it is indeed difficult for delirium to be screened effectively.

Diagram 10: Pie chart depicting the proportion of falls associated with psychoactive drug usage In terms of patientsâ&#x20AC;&#x2122; medications, out of the 31 patients, 55% had one or more psychoactive drugs, whilst 45% did not. It does not seem to be a significant risk factor, but this inference is limited due to the small sample size. In terms of total number of medications, as per Appendix C, all 31 patients have polypharmacy with a prescription of 5 or more drugs being given to them on admission and throughout the interval of their admission. It is therefore a significant correlation between the risk of falls and polypharmacy.

Diagram 11: Pie chart depicting the proportion of falls against the type of fall In terms of the breakdown of the mechanism of falls, out of the 31 patients in the cohort, the majority of the falls at 76% were mechanical falls, (19) followed by nonmechanical at 19% with the remaining 5% being unwitnessed. It is difficult to determine if the unwitnessed falls are statistically significant or not.

Diagram 12: Pie charts depicting the breakdown on the types of mechanical falls (20)

As seen in diagram 12, the largest number of mechanical falls occurs during toileting, giving us a value of 32%. A large proportion of mechanical falls also occurred during mobilisation, either involving a chair or bed, or while walking and subsequently tripping. Discussion of results In summary, the results that we have obtained from the audit and patients records were both incomplete and disorganised in parts. This makes our ability to conduct any valuable statistical analysis limited. The most significant risk factors identified were being male, having a previous history of falls, the use of walking aids, polypharmacy, delirium and/or dementia, false negative delirium screened patients and incomplete documentation. Additionally, there is a greater proportion of falls which occurred on the weekend, a greater proportion of mechanical falls versus non-mechanical falls and a significant proportion of falls which occurred in the hospital toilets as well as during mobilisation. A significant proportion of falls occurred in the hospital toilets, as well as in cases where patients had a fall involving getting in and out of the bed. This could be due to lapses in environmental awareness due to the urgency to void their bladder. This makes falls occurring around the period in which a patient is going to the toilet difficult to prevent as they may be less willing to wait for assistance before mobilising to go to the toilet. On the other hand, this could also be indicative of potential falls hazards that may exist between the bed and the toilet. Such hazards include but are not limited to; wires and intravenous lines attached to the patient, misjudgment of the height of the bed, personal belongings surrounding the bed, as well as bedding materials such as bedsheets and blankets that may increase the difficulty of getting out of bed. It is difficult to completely remove all of such hazards from the patientâ&#x20AC;&#x2122;s surroundings. As such, it is often recommended for frail and elderly patients to call for assistance in getting to the bathroom. Patients and visitors can also encouraged to keep their belongings neatly away from the patientâ&#x20AC;&#x2122;s bed, to prevent them from becoming tripping hazards, by providing dedicated baskets or shelves to store their belongings. Patients may experience several falls risk returning from the toilet post-voiding as well. The floor of the toilet may be slippery, making it difficult for a patient to maintain a stable footing, and patients who relieve themselves from a sitting posture may experience some postural hypotension standing back up again. This may lead to feelings of dizziness or vertigo further contributing to their falls risk. Pertaining to the Transfer Score/Mobility Score, when it was documented, several patients scores were not consistent with the total score tabulated. For some, the total score is noted but the transfer and/or mobility score is missing. Finally, for some patients, the entirety of this section is left blank despite the necessity of this being filled 21

out in the documentation to determine the falls risk score. Given that our population sample of 31 patients all experienced at least one inpatient fall, it is difficult to determine whether or not this would have reduced the risk of an inpatient fall from occurring, had the score been properly recorded, Inconsistencies found in the documentation of transfer and mobility scores could lead to failure in communicating specific movements that the patient should require assistance with. With regards to incomplete or improperly filled documentation relating to the Transfer Score/Mobility score and Ontario screen (as well as subsequent FRAMP and falls sticker placement), poor documentation (Transfer Score/Mobility score, Ontario & FRAMP) could lead to an underestimation of the patientâ&#x20AC;&#x2122;s falls risk. This could exclude the patient from receiving adequate falls prevention measures. We believe that this warrants corrective action as it can be easily remedied. Accurate documentation requires careful attention to detail when filling out the tables and charts and thorough follow through. The existing screens and charts serve a valuable and explicit purpose. The fact that the documentation was often not complete or inappropriate and has not warranted any action previously, suggests that a review of the documentation will be necessary along with a possible modification or streamlining of the existing documentation. The use of falls sticker placement was often inconsistent and itâ&#x20AC;&#x2122;s placement was often hidden in the patientsâ&#x20AC;&#x2122; notes. Given that this is not standardised, it makes it difficult for any staff involved in the care of the patient to recognize the patients falls risk. As such, patients who are a high falls risk might have been missed. Recommendations of improvements and their implementation and evaluation The following recommendations were created with the hope of augmenting the existing falls prevention system in order to more efficiently care for patients who are at a high risk of falls, as well as to improve on any shortcomings and weaknesses in the current falls protocol. We identified a mixture of external factors such as staffing numbers, patient specific factors and hospital specific factors. External factors go beyond the scope of this study as certain factors identified, especially those related to staffing may require further investigation as well as significant assistance from hospital management staff in order to be fully addressed. We acknowledge that time restraints prevented us from implementing or evaluating their effectiveness. However, the results of our retrospective audit were discussed with Dr Walsh, Head of Geriatrics Department, John Hunter Hospital. Recommendation 1: Improved Documentation

Implementation - Documentation of a patient’s falls risk could be improved by being standardised within each patient’s notes. While collecting data for this project, our group observed the documentation of falls risks and the use of a falls risk sticker was often varied. Therefore, whilst patients were identified appropriately as being a falls risk, it was difficult to discern where this was documented. This inconsistency creates a potential hazard for new health personnel who become newly involved with the patients’ care to become aware of the falls risk of the patient. This creates difficulty in terms of handing over a patient and communicating their falls risk between staff. - Our analysis is limited as patients might have had a falls risk sticker placed on their physical files in the ward or on the patients’ bedside noticeboard. However, this is something we are not able to evaluate, given that they have long since been discharged. We suggest that existing documentation should be modified to have a specific sections for a falls risk notification to be placed. - We have 3 ideas that could be implemented: ○ Firstly, a reusable falls risk tile can be placed on an external slot on the file, making it reusable and visible. ○ Secondly, a special falls risk sticker could be printed out on each patient ID sticker. Given that this sticker is placed on top of the progress notes or any other relevant documentation, any member of the healthcare team will be able to easily notice this. This can also create easy identification for any retrospective audits on falls that may be conducted in the future. ○ Lastly, as the Ontario assessment form is the initial screening tool used, the template itself should be modified to include a section where a sticker can be placed for easy identification, once a patient has been deemed a high falls risk. Evaluation - By ensuring that the falls risk sticker/tile is always visible on the file, on the top of progress notes and in the relevant falls risk documents, this makes it easier for all healthcare staff to access and take note of the falls risk. - We recognise that there are many important alerts that are all equally important for a healthcare provider to immediately recognise in each patient and that these should be the first page to be seen in the patient’s records. We strongly believe that the addition of falls alert should be added to this first page, as it not only shows that a patient is likely to fall but is also generally indicative of how frail the patient might be. Furthermore, the falls alert allows easier access for staff to the relevant falls prevention methods available. Recommendation 2: Improved falls risk documentation

Implementation - Streamlined falls risk screen documents - A modified falls screen risk could have an Ontario and FRAMP document as one document bound together (i.e. 4 pages in total). As mentioned, this documentation was incomplete on occasions. We believe that if the documents were bound together, it would more easily prompt healthcare staff to follow through the necessary documentation. Furthermore, this change would allow for the combination of the Ontario and FRAMP, now as one document to be completed at the same time. This is in contrast to the current system where as two separate documents, they are either completed at different times, or sometimes one is completed, but not the other. - Electronic based records - Falls risk documentation could be completed on the current electronic medical records known as Clinical Applications Portal (CAP). A separate falls risk tab could be created and accessed by anyone viewing a patientâ&#x20AC;&#x2122;s medical record. A system could be developed where Transfer score/Mobility scores etc. have to be filled in correctly before attempting to proceed to the next section. This documentation can thus be made compulsory for every patient of significant falls risk and can be highlighted in red on the patient notes not dissimilar to other critically important information like drug allergies. Evaluation - Streamlined falls risk screen documents - This is a relatively low cost method which only involves a few changes and simplifies the documentation process which might increase the rates of complete falls risk assessment and documentation. However, it may not necessarily guarantee that documentation is followed through completely and rates of successful completion of these documentations may still depend on hospital staff compliance to documentation guidelines. - Electronic based records - This would involve a software update which would make it compulsory for every patient of significant falls risk to have the documentation completed. This would be a relatively easy solution as it would not require any learning curve or significant changes to the existing system. In addition, prompts will be put out to alert members of the healthcare team involved in the patients care to fill out the section, similar to what is currently done for crucial details like drug allergies as previously mentioned.

Recommendation 3: Delirium Screening Implementation - Delirium screening in elderly patients is a good indicator of how safe a patient is to mobilise on his or her own. It is also useful in establishing a baseline for the cognition of patients who may become delirious during their stay in the hospital. More consistent use of delirium screening tools could help prevent patients from experiencing falls. This can be achieved by conducting more frequent delirium screens on patients at regular intervals. This allows staff to better monitor their progression in terms of their mental cognition and to be better able to detect any red flags that may alert to a potential fall and can be prevented with earlier intervention. Evaluation - This may be time consuming and may often be neglected in patients who appear lucid or coherent at their time of presentation. As such, this might be limited in value but may still be useful in establishing a baseline for patients who become delirious later on. However, it does enable clinicians and staff to monitor and record any changes of either improvement or deterioration in terms of the patients mental cognition.

Recommendation 4: Invisa-beam device & Three point bed exits sensor Implementation - We recommend the use of invisa-beam devices to alert medical staff when patients with high falls risk, get out of bed. The invisa beam is able to detect patient movements and allows for closer surveillance of patients without the need for more staff. Once alerted, medical staff can attend to the patient to assist them in getting out of bed. (20) This could potentially work alongside three point bed exit sensors as an early warning system to alert staff when a high-risk patient is attempting to self-mobilise. (21) This is already in use in Rankin Park but could easily be used in G1 or for any ward with a geriatic falls risk patient. Each hospital can have a stockpile of such devices and given that they are portable, they can be set up around beds in wards as needed. Evaluation: - This would help alert healthcare staff when a high risk patient is mobilising and would help notify healthcare staff who are busy or preoccupied attending to other patients. The large variety of devices available allow for placement in a variety of hospital rooms, given the variability of hospital designs. It would also be useful on days with reduced staff numbers as there will be a smaller staff to patient ratio. However, depending on the type, number and placement of invisa

beam devices, this can be cost prohibitive and has the potential to create additional falls hazard to patients. Recommendation 5: Modified vital call bracelets or additional call buttons Implementation - Vital call bracelets ○ Patients could use vital-call bracelets that can be activated while they are out of their beds to attract help from nearby staff. While not directly reducing the risk of falls, it will attract the attention of health care workers in the vicinity, especially if the patient is in a single bed room. Alternatively, it can be activated if a patient feels unsteady on their feet whilst mobilising as another method for the patient to attract help. - Additional call buttons ○ The use of the call button to ensure patients have some assistance when leaving the bed, going to the toilet or simply mobilising around the ward is often underestimated. Currently, there is a button that is attached to the patient bed as well as one in the toilet. Patients’, as well as family members, should be informed beforehand to “call, don’t fall”. (22) On that note, patients who often leave their bed or move around often could be equipped with more than one call buttons located in different locations (eg. along the wall) for ease of access. Evaluation - Vital call bracelets ○ Unlike their usefulness in the public to alert ambulance services of the location where the falls occur, such devices may only be able to show when a patient has had a fall, and may not be useful in locating the patient. This may be cost prohibitive, and requires staff to have a vague idea of where the patient is located in order to be effective. ○ Alternatively, if a modified version of the duress alarm in use in psychiatric wards could be used, this provides accurate information of the patient’s location. - Additional assistance buttons ○ This would involve installing additional wiring in the wards which would be an inconvenience in the short term but may help in the long term. The effectiveness of simply adding more alert buttons decreases beyond a certain point and should only be used larger wards or isolated rooms where it might be difficult for the patient to reach his duress alarm from certain corners of the room. ○ Alternatively, a wireless equivalent of these assistance buttons can be implemented, which will make it relatively easy to install in contrast with its wired counterpart, and while more expensive, will make it implementing it much easier to do so. However, as a wireless device, 26

regular battery checks and potential battery replacements will be necessitated. Recommendation 6: Guided railings

Diagram 13 showing an illustration of the guided railing system (23) Implementation: - A continuous and extendable grab rail system can be installed. This can be stowed away when not in use and extended when needed. (23)It can be installed along the walls, connecting the bed to the toilet. Once in the toilet, the grab rail is fully retracted and takes up minimal space. Grab rails can also be illuminated at night so that it can be better visualised by patients. (23) Evaluation: - Grab rails may potentially pose an obstruction to staff and family members who might enter the room if not folded and kept well. This might also only be feasible for single rooms and less so for rooms with multiple patient beds due to the layout of the room. If the grab rails are illuminated, this too may be more feasible in single rooms, as the extra lighting may disturb the sleep of other patients in a multiple bed unit.

Recommendation 7: Toilet Improvements Implementation: - Grab Bars

Grab Bars can be added around the entire perimeter of the toilet for patients to steady themselves with. (23) Colour Contrasts - A change in the colour scheme in toilets can aid patients with deteriorating vision. (23) This can be done by having contrasting colours for the walls and floors, as well as the various toilet fixtures. Colour contrasts can be useful to help add clarity to the environment. Toilet Sensors - Toilet sensors used in hospitals warn staff members when a patient of high falls risk has fallen off the toilet. (23) This system varies depending on the type and model, but most will activate an alarm when a change in pressure is detected, such as when a patient stands from the toilet. This alarm would be activated at the nursesâ&#x20AC;&#x2122; station, quickly alerting staff members. This can be subsequently deactivated by staff members or the patient themselves when they sit back down on the toilet seat. Alternatively, the sensors can be installed under the toilet floor as a pressurised pad. (23)

Evaluation: - Grab Bars - This is a relatively cheap modification. - In some cases,this may not be a viable option due to space constraints of the toilets. - Grab bars may also affect the overall ergonomics of the toilet and make it more inaccessible for wheelchair-bound patients. - Colour Contrasts - This would be a relatively inexpensive retrofit. - Toilet Sensor - This would be useful as per the results of our audit, a large percentage of falls occur in and around the toilet. However, this should be retrofitted with an on/off button, such that the system is only activated when there is a patient with a high falls risk that might use the toilet. Otherwise, the system may be triggered when patients with no falls risk use the toilet and might cause false positive risks. However, this would be more expensive to implement in comparison to the other suggestions.

Recommendation 8: Improving vision in the dark with the use of night lights

Diagram 14 showing an illustration of an illuminated floor lighting system (23)

Implementation - Vision is significantly impaired at night, especially in the elderly. Although, there often tends to be light from the main corridors, this might be insufficient for those whose beds are furthest away from the toilet door if in a multiple bed unit or if in a single bed unit and the lights are switched off. Night lights or floor lights to illuminate the path to the toilet can be installed to assist in reducing the limitation of night vision. (23) Hospital bed sensors can activate pathway illumination when patients start walking to the toilet. (23) Lights can also ideally be automated and “motion sensored” such that it is only switched on when necessary for patients before they mobilize out of their beds. Another alternative to reduce the cost of implementing light strips in the ward is to use glow-in-the-dark or highly reflective stickers to form arrow paths on the floor. Evaluation - This may be limited as some patients might find the lights distracting or disturbing and result in impaired sleep, which could have other negative outcomes. However, perhaps this can be limited to the beds furthest away from the toilet door and located in the main “pathway” of the multiple bed unit. Overall, this would work better in single bed units as this would not disturb other patients. This is a relatively low cost solution. - Depending on how flushed the floor lights might be to the ground, they may instead become a tripping hazard. 29

Recommendation 9: Anti-slip mats or anti-slip tiles Implementation - A statistically significant proportion of falls occur when mobilising in and around the toilet. Therefore, it is vital to ensure that the toilet itself is not a falls hazard. It could be useful to place anti-slip mats in toilets to increase traction, especially when the floors are slippery. Alternatively, anti-slip tiles could be laid down in toilets. Evaluation - Anti-slip mats - This would be a relatively low cost modification and would help to reduce the number of falls. Whilst it could be cost-prohibitive initially, it has the potential to substantially reduce the number of inpatient falls. Mats can either be installed in high slip risk areas such as the shower, the sink or the toilet bowl. - Anti-slip tiles - Bathroom floor surfaces and tiles can be changed to anti-slip tiles which have a textured finish as opposed to the current smooth surface, thereby providing slip resistance and providing the whole surface area of the toilet with slip resistance, as opposed to just an isolated area of the toilet as in the case with the anti-slip mats, which can still be incorporated into the toilets which have been fitted with anti-slip tiles. This would be more durable than anti-slip mats but would need to be cleaned regularly in order to prevent the accumulation of dirt and mould which would hinder its ability to provide traction. However, it would be best if nursing staff still assisted patients in mobilising as needed.

Conclusion Inpatient falls is a significant cause of increased patient morbidity and mortality. Therefore, it warrants that efforts be conducted to minimise this where possible. In our retrospective audit, we have identified several areas where improvements to the existing system can be made and have offered suggestions for said improvement. It is important to note that while our study focused on inpatients identified as a high risk of falls, a more holistic management of these patients outside of hospital is essential in reducing falls related morbidity and mortality. Additionally, our study focuses on primary prevention of falls in the elderly. However, secondary and tertiary prevention of falls are also vital in reducing patient morbidity and mortality. Examples of such include issuing high risk patients (elderly patients living alone) with vital-call devices so that they may be found, identified, and managed as soon as possible. However, this goes outside the scope of our study and should be explored in a bigger study to reduce falls overall. 30

References 1. WHO. [Internet]. WHO Global Report on Falls Prevention in Older Age; 2007.

[Cited 2019 Sept 28]. Available from: https://www.who.int/ageing/publications/Falls_prevention7March.pdf 2. Australian Institute of Health and Welfare. [Internet]. Canberra. Trends in hospitalised injury due to falls in older people 2007–08 to 2016–17; 2019. [Cited 2019 Sept 28]. Available from: https://www.aihw.gov.au/reports/injury/trends-in-hospitalised-injury-due-tofalls/contents/table-of-contents 3. Population Health Division. Sydney: NSW Department of Health. The Health of the people of New South Wales – Report of the Chief Health Officer, Data Book – Injury & Poisoning; 2008. [Cited 2019 Sept 25]. 4. Clinical Excellence Commission (CEC) and NSW Department of Health [Internet]. Sydney. Clinical Incident Management in the NSW Public Health System 2009: January to June; 2010. [Cited 2019 Sept 25]. Available from: http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0007/259207/patientsafety-report-clinical-incident-management-in-the-nsw-phs.pdf 5. Johal KS, Boulton C, Moran CG. Hip fractures after falls in hospital: a retrospective observational cohort study. Injury. 2009;40(2):201-4. 6. Australian Institute of Health and Welfare. [Internet]. Canberra. Admitted patient care 2015–16 Australian hospital statistics; 2017. [Cited 2019 Sept 28]. Available from: https://www.aihw.gov.au/getmedia/3e1d7d7e-26d9-44fb8549-aa30ccff100a/20742.pdf.aspx?inline=true 7. National Ageing Research Institute. [Internet] Canberra: Commonwealth of Australia. An analysis of research on preventing falls and falls injuries in older people: Community, residential care and hospital settings; 2004. [Cited 2019 Sept 25]. Available from: https://www1.health.gov.au/internet/main/publishing.nsf/Content/14D0B87F9C 15C1E8CA257BF0001DC537/$File/falls_community.pdf 8. NSW Department of Health. Sydney: NSW Health Department. Management Policy to Reduce Fall Injury Among Older People – Detailed strategies and performance requirements 2003-2007; 2003. [Cited 2019 Sept 25]. 9. Turner N, Jones D, Dawson P, Tait B. The Perceptions and Rehabilitation Experience of Older People After Falling in the Hospital. Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses. 2019;44(3):141-50. 10. Hong HJ, Kim NC, Jin Y, Piao J, Lee SM. Trigger factors and outcomes of falls among korean hospitalized patients: analysis of electronic medical records. Clinical nursing research. 2015;24(1):51-72. 11. Bradley SM, Karani R, McGinn T, Wisnivesky J. Predictors of serious injury among hospitalized patients evaluated for falls. Journal of hospital medicine. 2010;5(2):63-8.

12. Clinical Excellence Commission [Internet]. New South Wales. Hospital Fall

Prevention Strategies; 2017. [Cited 2019 Oct 8]. Available from: http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0006/258468/Hospit al-Fall-Prevention-Strategies-2017.pdf 13. Network of Care. [Internet]. United States. Morse Fall Scale; [Cited 2019 Sept 26]. Available from: http://www.networkofcare.org/library/Morse%20Fall%20Scale.pdf 14. Clinical Excellence Commission NSW Health. [Internet]. New South Wales. Ontario Modified Stratify (Sydney Scoring) Falls Risk Screen; 2011 [cited 2019 Sept 24]. Available from: http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0010/258472/NH606 658-ontario-modi-stratify-sydney-scoring-falls-risk-screen.pdf 15. Clinical Excellence Commission [Internet]. New South Wales. Standard 10: Preventing Falls and Harm from Falls; 2013. [Cited 2019 Oct 8]. Available from: http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0008/258479/standar d-10-requir-july-2013.pdf 16. Lumen Learning. [Internet] Psychoactive drugs and addiction; [Cited 2019 Sept 25]. Available from: https://courses.lumenlearning.com/waymakerpsychology/chapter/reading-psychoactive-drugs/ 17. NPS Medicine Wise [Internet] Australia. The dilemma of polypharmacy; 2008 [Cited 2019 Sept 25]. Available from: https://www.nps.org.au/australianprescriber/articles/the-dilemma-of-polypharmacy 18. Page AT, Falster MO, Litchfield M, Pearson S-A, Etherton-Beer C. Polypharmacy among older Australians, 2006â&#x20AC;&#x201C;2017: a population-based study. Medical Journal of Australia. 2019;211(2):71-5. Available from: https://www.mja.com.au/journal/2019/211/2/polypharmacy-among-olderaustralians-2006-2017-population-based-study 19. Fairview Health Services [Internet]. Minnesota. Patient Education Mechanical Fall; 2019/ [Cited 2019 Oct 8]. Available from: https://www.fairview.org/sitecore/content/Fairview/Home/PatientEducation/Articles/English/f/a/l/l/o/Mechanical_Fall_116046en 20. Reference 1: . Invisa-Beam [Internet]. ACT Australia. Invisa-beam Monitors Monitoring Systems for Falls Prevention; [Cited 2019 Oct 2] Available from: http://invisabeam.com/ 21. Cuttler SJ, Barr-Walker J, Cuttler L. Reducing medical-surgical inpatient falls and injuries with videos, icons and alarms. BMJ Open Quality. 2017;6(2):e000119. 22. Queensland Health [Internet]. Queensland, Australia. The most important button in your hospital room and why you need to press it; April 2018. [Cited 2019 Oct 2]. Available from: https://www.health.qld.gov.au/newsevents/news/falls-hospital-call-button-nurse-toilet 23. Minnesota Hospital Association [Internet]. Minnesota USA. Creating a Safe Environment to Prevent Toileting-related Falls; 2014. [Cited 2019 Oct 8]. 32

Available from: https://www.mnhospitals.org/Portals/0/Documents/ptsafety/falls/CreatingASaf eEnvironmenttoPreventToiletingRelatedFallsReport.pdf Appendix A Medline Search

Embase Search

Our literature search was conducted on the 24th August 2019 using the specified key words on databases MEDLINE and Embase. Initial search through MEDLINE yielded 773 results. Duplicates were removed and further limitations were added, such as English language, full text, humans, all aged 65 and older, elderly and from the years 2009 to current. This reduced the number of results to 83. Our Initial search through Embase yielded 167 results, which had duplicates removed and limited to English language, full text, humans and the last 10 years. The number of results was reduced

to 1. After reviewing the articles for eligibility to be included in the literature review, 4 results were identified.

Appendix B

Appendix C Previous

Date of Age Age Fall Mental Status - Normal No. Incident date Admission Gender 65-80 >80 History Cognition / Delirium / Dementia 1 2

14-Jul-19

13-Jul-19

Yes

Delirium

4-Jul-19 27-May-19

Yes

Dementia

14-Jun-19

11-Jun-19

30-May-19

Yes

Delirium and Dementia

30-Apr-19

7-Apr-19

Yes

Delirium and Dementia

20-Apr-19

12-Apr-19

Yes

Normal Cognition

17-Apr-19 13-Apr-19

13-Apr-19

6-Apr-19

Yes

Dementia

2-Apr-19

26-Mar-19

Normal Cognition

18-Mar-19

14-Mar-19

Delirium

16-Mar-19

13-Mar-19

Normal Cognition

6-Mar-19

12-Jan-19

Yes

Normal Cognition

25-Feb-19

23-Jan-19

Yes

Normal Cognition

21-Feb-19

5-Feb-19

Yes

Delirium

12-Feb-19

10-Feb-19

Yes

Delirium

7-Feb-19

1-Feb-19

Yes

Delirium

11-Jan-19

7-Jan-19

Yes

Normal Cognition

31-Dec-18

17-Dec-18

Dementia

17-Dec-18

11-Dec-18

Yes

Normal Cognition

23-Nov-18

19-Nov-18

Yes

Delirium

17-Nov-18

15-Nov-18

Yes

Dementia

4-Nov-18

2-Nov-18

29-Oct-18

Yes

Normal Cognition

25-Oct-18

23-Oct-18

Yes

Delirium and Dementia

21-Oct-18

18-Oct-19

Yes

Normal Cognition

13-Oct-18

10-Oct-18

Yes

Normal Cognition

21-Sep-18

15-Sep-18

Yes

Delirium

22-Sep-18

12-Sep-18

24-Aug-18

Yes

Dementia

28-Aug-18

30-Jul-18

Yes

Delirium and Dementia

17-Aug-18

4-Aug-18

Yes

Delirium

6-Aug-18

1-Aug-18

27-Jul-18

Yes

Delirium

17-Jul-18

28/6/18

Yes

Dementia

8-Jul-18

5-Jul-18

Yes

Normal Cognition

7-Jul-18

4-Jul-18

Yes

Delirium and Dementia

Total

13 Weekends 23 Weekdays

20 Male 11 Female

27 Yes 4 - No

11 - Normal Cognition 5 - Delirium and Dementia 9 - Delirium Only 6 - Dementia Only

Delirium Screen for Older Adults No. Score 9/10

1 (14/7/19) 5/10

2 (3/7/19)

4/10 3 (9/6/19)

MMSE / MOCA Score MMSE 29/30 MMSE 22/30

MOCA 14/30

Not completed due to None due visual and to visual hearing and hearing impairment impairments

10/10 5 (12/4/19)

3/10

6 (20/4/19)

Vision Toileting Impairment **

Yes

Transfer Score / Mobility Score / Total Score 1/1/7

None

0/0/0

1/1/2

Number of Medicat Muscle ions Weakness

Walking Aids

Postural Hypotension

Yes

Yes Walking Stick

Yes Walking Stick / 4WW

Yes Walking Stick

Yes

MMSE 29/30

Yes

2 / 1/ / 7

Yes

Yes 4WW / Scooter

MOCA 14/30

Yes

0/0/0

None

0/0/0

No No No

9/10

7 (4/4/19) 2/10 8 (15/3/19)

None

1/1/2

Yes 4WW

9/10 9 (13/3/19)

None

0/0/0

Yes

10 (13/3/19)

9/10

None

0/0/0

Yes 4WW

Nil - Not done in the same month as 11 fall

None

0/0/7

Yes

5/10 (6/2/19) 3/10 (7/2/19) 2/10 (8/2/19) 5/10 12 (16/2/19)

MOCA 18/30

2/2/4

Yes Walking Stick (2010) / 4 WW (2017)

13 Nil

MMSE 26/30 MOCA 18/30

Yes

None

14 Nil

None

1/1/2

Yes

15 Nil

None

2/1/3

16 Nil

MOCA 19/30

Yes Walking Frame

Nil Docume nted

Yes 4WW

Yes 4WW / Walking Stick

8/10 17 (11/12/18) (20/11/18) Patient answered yes to all questions A - was given in the total score 6/10 18 (21/11/18)

None

Yes

3/0/7

None

2/2/7

10/10

19 (16/11/18)

MOCA 25/30

2/1/7

Yes Motor Neuron Disease

Nil Docume nted

Yes 4WW

Yes

9/10

20 (1/11/18)

None

0/0/0

21 (24/10/18)

None

Yes

0/0/0

Nil Docume nted

22 Nil

None

Yes

2/2/7

7/10

8/10 23 (13/10/18)

None

0/0/1

Nil Nil Docume Docum nted ented

Yes 4WW

24 Nil

None

1/1/0

Nil Docume nted

5/10 (26/8/18) 0/10 (30/8/18) 3.5/10 25 (31/8/18)

MMSE 7/30 MOCA 18/30

1/1/0

Yes 4WW

Nil Docum ented

1/1/0 (26/8/18) 2/2/7 (31/7/18) 2/2/7 (3/8/18)

Yes Bilateral lower limb weakness

Yes 4WW

Nil Docume nted

Yes 4WW

Yes

Nil Yes Docume Walking nted Stick

6/10 26 (7/8/18)

MMSE 22/30

9/10 (12/8/18) 8/10 27 (17/8/18)

None

28 8/10

MOCA 14/30

Yes

1/1/0

?/?/7

6/10 (3/7/18) 6/10 29 (21/7/18)

7/10 30 (6/7/18)

None

Yes

2 /3 / 7

1/1/0

Yes

Yes - 4WW requires assistance with ADLs

Yes 4WW

Yes Forearm Support Frame

4/10

31 (6/7/18)

Total

No.

None

Yes 27 - No Vision Impairment 4 - Vision Impairment

Ontario Score

No 14 - Yes 16 - No 1 - Nil Docume nted

2/1/7

20 - No 4 - Yes 7 - Nil Docume nted

22 - Yes 8 - No 1 - Nil Docume 7 - Yes nted 24 - No

Falls Risk Assessment and Management Falls Risk Plan (FRAMP) Sticker

Date of Admission - 13/7/19 Ontario (13/7/19) - 7 1 (14/7/19) - 31

No Corresponding FRAMP (13/7/19) FRAMP (14/07/19)

Yes

Date of Admission - 27/5/19 Ontario (28/5/19) - 6 (5/6/19) - 20 (14/6/19) - 20 (5/7/19) - 6 (12/7/19) - 23 2 (22/7/19) - 20

FRAMP (29/5/19) (5/6/19) No Corresponding FRAMP (14/6/19) (5/7/19) No Corresponding FRAMP (12/7/19) (22/7/19)

Yes

Date of Admission - 30/5/19 Ontario (31/5/19) - 1 (High Risk + Clinical Judgement) (1/6/19) - 10 (11/6/19) - 21 (14/6/19) - 23 (19/6/19) - 14 3 (7/7/19) - 21

FRAMP (31/5/19) No Corresponding FRAMP (1/6/19) No Corresponding FRAMP (11/6/19) (14/6/19) (19/6/19) No Corresponding FRAMP (7/7/19)

Yes

Date of Admission -7/4/19 Ontario (1/5/19) - 28 (8/4/19) - 30 (14/4/19) - 27 (1/5/19) - 27 4 No Ontario Done (11/5/19)

No Corresponding FRAMP (1/5/19) FRAMP (8/4/19) (14/4/19) (1/5/19) (11/5/19)

Yes

Date of Admission - 12/4/19 Ontario (13/4/19) - 13 5 (20/4/19) - 13

FRAMP (13/4/19) (20/4/19)

Yes

Date of Admission - 6/4/19 Ontario (6/4/19) - 22 (13/4/19) - 24 6 (17/4/19) - 29

No Corresponding FRAMP (6/4/19) No Corresponding FRAMP (13/4/19) (17/4/19)

Yes

Date of Admission - 26/3/19 Ontario (26/3/19) - 2 7 (2/4/19) - 15

No Corresponding FRAMP (26/3/19) (2/4/19)

Yes

Date of Admission - 14/3/19 Ontario (15/3/19) - 17 8 (18/3/19) - 20

No Corresponding FRAMP (15/3/19) (18/3/19)

Date of Admission - 13/3/19 Ontario (13/3/19) - 7 9 (16/3/19) - 14

FRAMP (13/3/19) (16/3/19)

Date of Admission - 12/1/19 Ontario (16/2/19) - 21 (20/2/19) - 8 (6/3/19) - 20 (11/3/19) - 6 (17/3/19) - 6 (18/3/19) - 6 10 (19/3/19) - 6

FRAMP (16/2/19) (20/2/19) No Corresponding FRAMP (6/3/19) No Corresponding FRAMP (11/3/19) No Corresponding FRAMP (17/3/19) No Corresponding FRAMP (18/3/19) (19/3/19)

Date of Admission - 23/1/19 Ontario (24/1/19) - 8 (28/1/19) - 29 (30/1/19) - 13 (25/2/19) - No Corresponding ONTARIO 11 (16/3/19) - 14

No Corresponding FRAMP (24/1/19) No Corresponding FRAMP (28/1/19) (30/1/19) (25/2/19) No Corresponding FRAMP (16/3/19)

Yes

Date of Admission - 5/2/19 Ontario (5/2/19) - 28 (16/2/19) - 29 12 (21/2/19) - 29

FRAMP (5/2/19) (16/2/19) (21/2/19)

Date of Admission - 10/2/19 No Before Fall Ontario 13 (12/2/19) - 30

No Before Fall Framp (12/2/19)

Date of Admission - 1/2/19 Ontario (2/2/19) - 24 14 (7/2/19) - 30

FRAMP (2/2/19) (7/2/19)

Yes

Date of Admission - 7/1/19 Ontario (7/1/19) - 10 15 (11/1/19) - 30

FRAMP (8/1/19) (11/1/19)

Yes

Date of Admission - 17/12/18 Ontario (18/12/18) - 22 (20/12/18) - 8 16 (31/12/18) - 28

No Corresponding FRAMP (18/12/18) (20/12/18) (31/12/18)

Date of Admission - 11/12/18 Ontario (11/12/18) - 13 + Clinical Judgement 17 (17/12/18) - 9

FRAMP (11/12/18) (17/12/18)

Yes

Date of Admission - 19/11/18 Ontario (19/11/18) - 29 (20/11/18) - 27 18 (23/11/18) - 6

FRAMP (19/11/18) (20/11/18) (23/11/18)

Yes

Date of Admission - 15/11/18 Ontario (15/11/18) - 13 19 (17/11/18) - 13

FRAMP (15/11/18) No corresponding FRAMP (17/11/18)

Date of Admission - 29/10/18 Ontario (29/10/18) - 14 (2/11/18) - 21 20 (4/11/18) - 23

FRAMP (29/10/18) (2/11/18) (4/11/18)

Date of Admission - 23/10/18 Ontario (23/10/18) - 27 (24/10/18) - 21 21 (25/10/18) - 21

No Corresponding FRAMP - 23/10/18 (24/10/18) (25/10/18)

Date of Admission - 18/10/18 Ontario (18/10/18) - 16 22 (21/10/18) - 16

No Corresponding FRAMP (18/10/18) (21/10/18)

Date of Admission - 10/10/18 Ontario (10/10/18) - 1 23 (13/10/18) - 8

FRAMP (11/10/18) (13/10/18)

Yes

Date of Admission - 15/9/18

24 Ontario (16/9/18) - 21

FRAMP (16/9/18)

Yes

Date of Admission - 24/8/18 Ontario (26/8/18) - 24 (9/9/18) - 17 (12/9/18) - 2 (13/9/18) - 20 25 (22/9/18) - 22

FRAMP (26/8/18) No Corresponding FRAMP (9/9/18) No Corresponding FRAMP (12/9/18) No Corresponding FRAMP (13/9/18) (22/9/2018)

Date of Admission - 30/7/18 Ontario (31/7/18) - 29 (3/8/18) - 29 (26/8/18) - 20 (28/8/18) - 22 (18/9/18) - 13 26 (19/9/18) - 29

FRAMP (31/7/18) (3/8/18) No Corresponding FRAMP (26/6/18) (28/8/18) (18/9/18) (19/9/18)

Yes

Date of Admission - 4/8/18 Ontario (6/8/18) - 22 (11/8/18) - 22 (17/8/18) - 20 27 (18/8/18) - 20

FRAMP (6/8/18) No Corresponding FRAMP (11/8/18) (17/8/18) No Corresponding FRAMP (18/8/18)

Yes

Date of Admission - 27/7/18 Ontario (28/7/18) - 23 (29/7/18) - 30 (6/8/18) - 30 28 (1/8/18) - 30

FRAMP (28/7/18) No Corresponding FRAMP (29/7/18) (6/8/18) (1/8/18)

Yes

Date of Admission - 28/6/18 Ontario (29/6/18) - 30 29 (17/7/18) - 30

No Corresponding FRAMP (28/6/18) (17/7/18)

Date of Admission - 5/7/18 Ontario (15/7/18) - 15 30 (8/7/18) - 22

FRAMP (5/7/18) (8/7/18)

Date of Admission - 4/7/18 Ontario (4/7/18) - 20 31 (7/7/18) - 20

FRAMP (4/7/18) (7/7/18)

Total

17 - Yes 14 - No

Psychoactive Drugs*

Arthritis

1 - Fully conscious

Yes

Mechanical Fall - TOILET (Fall from 2 slipping in toilet)

Yes

Non-Mechanical Fall 3 - Neuropathy

Yes

Mechanical Fall 4 - Fall from tripping

Yes

Non-Mechanical Fall 5 - Neuropathy

Yes

8 - Dizziness

Yes

Mechanical Fall - TOILET (Fall 9 from or off toilet)

Yes

Mechanical Fall - TOILET (Fall from 10 slipping in toilet)

Yes

No.

Mechanism of Fall Unwitnessed Fall

Unwitnessed Fall - Fully conscious

Mechanical Fall - TOILET (Fall from or off toilet) Mechanical Fall - Fall from bed

6 Mechanical Fall - Fall from bed Mechanical Fall

7 - Fall from tripping Non-Mechanical Fall

Mechanical Fall

11 - Fall from bed

Mechanical Fall 12 - Fall from bed

13 - Fall from bed

Yes

Mechanical Fall - Fall from 14 tripping

Mechanical Fall 15 - Unspecified Fall

Yes

16 - Fall from chair

Yes

Mechanical Fall - TOILET (Fall 17 from or off toilet)

Non-Mechanical Fall 18 - Dizziness

Yes

19 Non-Mechanical Fall

Yes

20 Mechanical Fall - Fall from bed

Mechanical Fall - TOILET (Fall from slipping 21 in toilet)

22 - TOILET (Fall from slipping in toilet)

Yes

Mechanical Fall 23 - Fall from bed

Yes

25 Mechanical Fall - Fall from tripping

Yes

26 Non-Mechanical Fall

Yes

Mechanical Fall

Mechanical Fall - Fall from chair

Mechanical Fall

24 - Fall from chair Non-Mechanical Fall

Mechanical Fall - TOILET (Fall from 27 slipping in toilet)

Yes

29 - Fall from bed

Yes

Mechanical Fall - TOILET (Fall from 30 slipping in toilet)

Yes

Mechanical Fall - Unspecified Fall

28 Mechanical Fall - Unspecified Fall Mechanical Fall

Mechanical Fall

31 - Fall from chair

Total

28 – Mechanical Falls • Fall Involving Bed – 8 • Fall involving chair – 4 • Fall from tripping – 4 • Unspecified Fall – 3 • Fall from slipping on toilet surface – 6 • Fall from on or off the toilet – 3 7 - Non-Mechanical Falls 2 - Non-Witnessed Falls

17 - Yes 14 - No

16 - Yes 15 - No

*Psychoactive drugs included in this study were identified as medication that fell broadly into the following category; depressant, stimulant, opioids, and hallucinogens **Toileting refers to either urinary incontinence or increased urinary frequency Legend: Male Female Yes No Nil Documented Weekend Mechanical Fall Non-Mechanical Fall Unwitnessed Falls