Falls risk assessment tools and care plans in New Zealand DHBs - A review and discussion document

The Health Quality & Safety Commission’s national programme, Reducing Harm from Falls, has an initial emphasis on preventing falls and reducing fall-related injuries in public hospitals. While the ideal of set of programme components at hospital level is not yet clear, risk assessments are common elements in programmes demonstrated to be effective. This project therefore provides a critical foundation for the programme’s first focus on inpatient falls.

Because patients who fall have several risk factors, programmes which provide multifactorial interventions (ie, those which address the several or more risk factors particular to individual patients) are being shown to reduce the rate of inpatient falls by 20–30 percent. This finding also requires that we give attention to risk assessment and care planning as processes which support multifactorial interventions.

The overall intent of this project was to recommend effective approaches to risk assessment and care planning based on evidence and best practice, and thus promote a degree of consistency in these processes nationally. The project also provides support to district health boards (DHBs) as they monitor their implementation of processes for risk assessment and individualised care planning for older inpatients at risk of falling against the Commission’s quality and safety markers for falls prevention.

Documents currently in use for inpatients related to managing falls risk were sought from directors of nursing in DHBs for review. Findings were that there was considerable variation between DHBs (even within regions) and very little evidence of the patient’s involvement (or that of their family/whānau). Further, document formats did not appear to facilitate the critical thinking and clinical judgement required for individualisation of care and it appeared that completion of the tool was most important.

This project recommends that measures to ensure that all patients find themselves in a safe environment and receiving safe care are considered necessary but separate from individualised care. Risk assessment and care planning are the processes of care fundamental to ensuring that individual patients receive the interventions and support which address their particular risks.

Common risk factors found in the older inpatient population are:

• a history of falling
• problems in mobilising and use of assistive devices
• taking medications with side-effects that increase the risk of falling
• impaired cognitive state
•  problems with continence
• problems related to underlying conditions and risks associated with hospitalisation.

Rather than a tick-box approach, a checklist of common risk factors can be used to direct a thoughtful assessment of risk with each patient and their family/whānau, and their participation in the implementation of a plan to address these risks. These factors are recommended as essential elements in any risk assessment tool and process. Critical thinking, clinical judgement and the involvement of the patient and their family/whānau are suggested as essential approaches to effective risk assessment and care planning.

Although in total, the multifactorial interventions and support the patient receives are the coordinated effort of the multidisciplinary team, this discussion document is primarily directed to the 24/7 responsibility of nursing staff with patients in hospital.

The recommended practices, essential elements and approaches offer a framework for DHBs to adopt and incorporate in the tools and processes they are using, or against which to audit their current tools and processes.

Recommendations

It is recommended that the Health Quality & Safety Commission’s national Reducing Harm from Falls programme considers the following as part of its activities over the next two years:

1. Continue to promote system development to assist with the automation/integration of risk assessment and care planning to improve delivery of care.
2. Support the learnings and findings from this document in the national programme’s learning activities and other resources for health professionals and older people admitted to hospitals and their families/whānau.
3. Promote the integration of the programme’s learning activities into staff education, training and induction processes.
4. Facilitate regional training and education workshops with DHBs, and other providers, to build on the concepts outlined in this document.
5. Adapt the ‘universal precautions’ terminology to promote a better understanding of the essential elements in the concept, which are increasing patient safety through improvements in the care environment and delivery of nursing care.
6. Evaluate the extent to which the recommended practices, elements and approaches given in this document have been taken up by repeating a review of the risk assessment and care planning tools in use in DHB hospitals in 2015.