The Prevention and Management of Falls in the Community: A Framework for Action for Scotland 2014/15

Stage Three: Responding to an individual who has just fallen and requires immediate assistance

Description (adapted from Up and About)

At this stage:

• A person has fallen and has requested or requires immediate assistance.
• The person may have sustained an injury and/or be unwell or is asymptomatic, appears uninjured but is unable to get up from the floor/ground independently.
• Appropriate onward referral and intervention at this stage may prevent further falls and unwanted consequences of falls.

Definitions

Responding services

In the context of the pathway, 'responding services' refers to all services that have designated responsibilities for responding to an older person who has fallen and requires immediate assistance. Responding services include, amongst others, the Scottish Ambulance Service, community alarm/telecare and mobile emergency care services and other dedicated falls response services (including those provided by the third sector).

Standard operating procedure

Standard operating procedures are detailed written instructions to achieve uniformity of the performance of a specific function.

Rationale

This is a critical point in the journey of care. A rapid and appropriate response, which provides both effective management of the immediate situation and consideration of further health and care needs, is key to preventing unnecessary admission to hospital, functional decline and further falls.

A consultation conducted by NHS Quality Improvement Scotland in 2009^[2] identified that there is lack of clarity in some localities around which service should respond to a person who has fallen, is uninjured, but requires assistance to get up from the floor. It was reported that in a number of cases this had resulted in an older person lying on the floor, waiting for assistance for an unacceptable period of time.

The Scottish Ambulance Service will usually be the first point of contact if someone has fallen, is injured or unwell, and requires immediate assistance. It is often less clear which service should respond if a person has fallen, is uninjured but requires assistance to get up from the floor.

A 'long lie' following a fall, defined as remaining on the ground or floor for one hour or more, is associated with serious complications for an older person, including pressure ulcers, kidney damage caused by muscle breakdown, pneumonia, hypothermia, dehydration, psychological harm and even death. This is regardless of whether or not they have sustained an injury in the fall^[10].

Responding services must assess the individual to ascertain (a) the presence of injury and/or illness, and (b) whether or not the individual needs to attend the Emergency Department. If there is not an immediate clinical need, attendance at the Emergency Department may not be in the interests of an older person. In some cases rapid response intermediate care services in the community can provide an appropriate alternative to Emergency Department attendance or emergency admission to hospital. This approach is described in Making the Right Call for A Fall^[11].

Suitable decision support for responding services will ensure individuals who have fallen then receive the right care in the right place. Decision support takes a variety of forms including algorithms or triage tools, professional to professional support and a range of ehealth solutions, such as the Key Information Summary^[12].

Actions to achieve the minimum standard for 2014/16

Action 3.1

Responding services have a standard operating procedure for responding to an older person who has fallen and has or has not sustained injuries.

Principles

• There is absolute clarity and agreement amongst all local responding services on arrangements for responding to:
  • injured and/or unwell individuals following a fall.
  • uninjured individuals following a fall.
• NHS 24 is informed of local arrangements for responding to an uninjured individual following a fall so it can respond to emergency calls appropriately and in a timely manner.

Implementation note

Local variation in 'responding services' provision often results in the Scottish Ambulance Service becoming the default responder to people who have fallen and only need help to get up again.

This is inappropriate use of a service for emergency health care. Local service provision requires to be mapped and understood before a standard operating procedure can be agreed.

Action 3.2

A responding service attends an older person who has fallen within one hour of being alerted to the fall, or as close to this timescale as possible given geographical and other constraints.

Principles

• The timing of the hour starts when the responding service receives the call and stops when the responding service is in attendance.

Action 3.3

Responding services have a standard operating procedure (SOP) for identifying and meeting the immediate needs of an older person who has fallen.

Principles

• The SOP covers:
  • assessment for the presence of injury and/or illness and management options,
  • mechanisms for assisting the person safely from the floor
  • arrangements for large or obese people
  • Suitable decision support (see above) is available to responding services to ensure individuals who have fallen receive the right care in the right place. This includes information on referral options locally, for example, intermediate care services.

Action 3.4

Health and social care services working with older people in their own homes (including care homes) and day care facilities have a standard operating procedure to identify and meet the immediate needs of a person who falls in their presence or is found on the floor.

Principles

• The SOP covers:
  • immediate actions to be taken, including how to gain access to the person's home in an emergency
  • arrangements for large or obese people.
• The service will determine appropriate actions for staff to take. This will be based on a number of factors including the nature of the service, the knowledge and skills of staff and the availability of moving and handling equipment.

Action 3.5

Responding services have a level 1 conversation with an older person presenting following a fall who is not conveyed to hospital.

Action 3.6

Services have a level 1 conversation with an older person they assist in the event of a fall who is not conveyed to hospital.

Principles

• A level 1 conversation aims to identify people who are at high risk of falling again and may benefit from intervention to prevent further falls and restore/retain function following a fall.
• A level 1 conversation is a simple process, which can be facilitated by the use of a tool or an algorithm. To meet the minimum standard, a level 1 conversation identifies people who have experienced:
  • two or more falls in the previous 12 months.
  • loss of consciousness/blackouts/dizziness at the time of the fall/s or an unexplained fall (found themselves of the floor for no apparent reason).
  • difficulties with walking or balance.
  • a change in their ability or confidence to carry out their usual day to day activities following the fall/s.
• A level 1 tool or algorithm includes clear guidance for the 'screener' on what steps to take next, based on the outcome of the conversation.
• As part of the conversation, the 'screener' explains to the individual the reason why the intervention is indicated, what this will involve, such as a home visit or clinic attendance, and ensures consent has been given to share information and refer for further assessment.
• There are local referral pathways to services providing level 2 screen and agreed referral protocols. For responding services, referral processes require to be as simple as possible, ideally a single point of access to a range of services.
• For people referred for further intervention, written information is provided to explain what will happen next.
• For people not referred for further intervention, and those who decline further intervention, up-to-date information is offered on the prevention of falls and the prevention of harm from falls (as described in Action 1.1). People declining further intervention are offered details of the appropriate service to contact should they decide at a later date they would like to receive further intervention.

The Framework in Action

Edinburgh Health and Social Care have developed linked pathways to respond to people who have fallen at home and require assistance, but who are not injured. The Scottish Ambulance Service, NHS 24 and Edinburgh Health and Social Care have worked closely together to ensure the individual gets the right response in the most timely fashion. When an ambulance response is not required, the 'Fallen Uninjured Person' pathway ensures that individuals living without a care alarm are responded to by social care workers and will have appropriate follow-up intervention.

In addition, an 'Emergency Treat and Refer Falls Pathway' has been developed with the Scottish Ambulance Service to provide safe alternatives when a conveyance to Emergency Departments is considered unnecessary. The pathway ensures the individual has appropriate follow-up care.

Falkirk Council's Mobile Emergency Care Service has a standardised operating procedure for responding to someone who has fallen. It includes guidance on (1) action to take whether or not an obvious injury is present, (2) moving and handling, and (3) reporting and documentation.

The British Red Cross (BRC) has a Care Call Responders service in Stewartry & Wigtown which is delivered in partnership with NHS Dumfries and Galloway and Dumfries and Galloway Council. The commissioning partners worked with the BRC to develop an alternative telecare model which utilises trained volunteers as responders for people unable to identify local friends or family responders. The volunteers are all registered members with Disclosure Scotland and trained in: first aid, safer handling, safeguarding adults, providing emotional support and health and safety. They also have an awareness training of Care Call equipment and procedures.

More information and contact details for the examples provided can be found on the Falls and Bone Health Community at: http://www.knowledge.scot.nhs.uk/fallsandbonehealth/the-national-falls-programme.aspx

Further information

Making the Right Call for a Fall. Produced by the Scottish Ambulance Service, the Joint Improvement Team and the National Falls Programme in 2013. Access at: http://www.knowledge.scot.nhs.uk/media/CLT/ResourceUploads/4035271/SAS_Making_The%20Right_Call_for_a_Fall_singles.pdf

TSA Good Practice Guide. Telecare Service Providers in Scotland and the Scottish Ambulance Service - working together to improve service delivery. Produced by SCTT, JIT, Scottish Ambulance Service and the Telecare Services Association in 2013. Access at: http://www.telecare.org.uk/publications/telecare-service-providers-in-scotland-and-the-scottish-ambulance-service

Managing Falls and Fractures in Care Homes for Older People. Produced by the Care Inspectorate and NHSScotland in 2011. Access at: http://www.scswis.com/index.php?option=com_content&view=article&id=7906:falls-and-fractures&catid=328&Itemid=725