The Prevention and Management of Falls in the Community: A Framework for Action for Scotland 2014/2015

Stage 3: Responding to an individual who has just fallen and requires immediate assistance

Description (taken 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.

^†In the context of the pathway, 'responding services' refers to all health or social care services that have designated responsibilities for responding to an older person who has fallen. Responding services include, amongst others, the Scottish Ambulance Service, community alarm/telecare and mobile emergency care services and dedicated falls response services.

Actions to achieve the minimum standard for 2014/15

Action 3.1

Responding services have a standard operating procedure^† for responding to people who have fallen and have or have 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.

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 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 a 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.

• Suitable decision support (see below) is available to responding services to ensure individuals who have fallen receive the right care in the right place.

Action 3.4

Health and social care services working with older people in their own homes (including care homes) have a standard operating procedure to identify and meet the immediate need of an older 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.
• 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

Older people presenting to responding services following a fall and who are not conveyed to hospital, are offered Level 1 assessment^†.

Action 3.6

Older people assisted by other health and social care services in the event of a fall, and who are not conveyed to hospital, are offered Level 1 assessment^†.

Principles

• A Level 1 assessment aims to identify individuals who are at high risk of falling again and may benefit from intervention to prevent further falls and restore/retain function following a fall.
• Level 1 Assessment is a simple process, quick to administer and may take the form of a tool or an algorithm. It includes questions about:
  • Frequency and circumstances of the fall/s.
  • Loss of consciousness/blackouts/dizziness at the time of the fall/s.
  • Difficulties with walking or balance.
  • Impact of the fall/s on day to day activities.
• A Level 1 assessment tool or algorithm includes clear guidance for the assessor on what steps to take next, based on the assessment findings.
• There are local referral pathways to services providing further Level 2 assessment^†, and agreed referral protocols.
• For people referred for further intervention, written information is provided to explain what will happen next.
• For people who decline further intervention or are not referred for further intervention, up-to-date information is offered on the prevention of falls and the prevention of harm from falls.

^†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 avoidable admission to hospital, functional decline and further falls.

A consultation conducted by NHS Quality Improvement Scotland in 2009⁴ 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, and even death. This is regardless of whether or not they have sustained an injury in the fall⁵ .

Responding services, whether health or social care 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 alternative to Emergency Department attendance or emergency admission to hospital.

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 electronic Emergency Care Summaries and Anticipatory Care Plans.

For evidence base for standards, see references 1, 2 and 6.

Further information

Making the Right Call for A Fall, produced by the Scottish Ambulance Service, the Joint Improvement Team and the National Falls Programme, 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. 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 & NHSScotland, 2011. Access at: http://www.scswis.com/index.php?option=com_content&view=article&id=7861:managingfalls-and-fractures-in-care-homes-for-older-people-&catid=246:Consultations&Itemid=570