Inpatient fall: essential care immediately after (G073)

Nearly 27,000 falls are reported annually in Scottish Hospitals³. Whilst both falls and fracture prevention strategies are an important aspect of patient safety, what happens after the fall is equally as important. Even for the less serious falls the human cost of falling includes distress, pain, injury, loss of confidence and loss of independence, as well as the anxiety caused to patients, relatives, carers and hospital staff.

The causes of falls are complex. Hospital in-patients are particularly likely to be vulnerable to falling and resulting harm due to existing medical conditions including delirium, cardiac, neurological or muscular-skeletal conditions, side effects from medication, or problems with balance, strength or mobility.

Problems like poor eyesight or poor memory can create a greater risk of falls especially when someone is out of their normal environment on a hospital ward as they are less able to spot and avoid any hazards.

Continence problems can mean patients are vulnerable to falling while making urgent journeys to the toilet.

In the hospital setting falls should be considered an ominous ‘red flag’ as the patient’s underlying medical condition may have deteriorated requiring urgent clinical assessment regardless of injury.

Detecting and treating injuries or change in medical condition as efficiently as possible will reduce the degree of harm caused to the patient. This is particularly critical for injuries such as subdural haematoma that may progress to irreversible brain damage if not detected early, similarly a fractured hip; where minimising the time elapsed between fracture and surgery is vital to reducing mortality rates and long term disability.

The relative rarity of inpatient falls that result in serious injury (less than 1% of reported falls) can make it challenging for staff to maintain their vigilance. Despite the challenges, we have a responsibility to provide optimal care. Evidenced based guidelines can help to achieve this. The purpose of this guidance is to provide information to both nursing and medical staff on essential care after an inpatient fall. Further information is available in G108 Guidance for the Prevention and Management of Falls in All Hospital Settings⁴.

The emergency response to a fall must follow the principles of basic trauma life support. This should be carried out by the first responder (usually ward nurse)
A primary survey should be conducted looking for problems with:

Airway Breathing and Circulation, Disability Exposure.

ABCDE assessment –manage each problem as you find it - in sequence.

Airway - Is patient able to talk to you? Look for stridor (high pitched inspiratory noise caused by upper airway obstruction)

Breathing - Any shortness of breath? – count respiratory rate accurately. Measure oxygen saturation using pulse oximetry.

Circulation - Signs of shock – Is patient pale/clammy? Obtain baseline observations/NEWS Score and blood glucose.

Disability - Assess AVPU (patient’s response level: Alert, Voice, Pain, Unresponsive)
If any sign of head injury or, fall is unwitnessed wake patient to most alert state and check Glasgow Coma Scale including pupil size and reaction to light. Remember GCS < 8 the airway is not protected. Activate emergency response i.e. 222/999, dependent on clinical area.

Exposure - Visual top to toe inspection

• Mechanism of injury (fall from more than 1 metre or 5 stairs)
• Patient complaining of neck or back pain, do not move, keep patient warm and request urgent medical/advanced nurse practitioner review. Consider need to immobilise C-Spine. 
• Any limb deformity or loss of sensation, do not move, keep patient warm and request urgent medical/advanced nurse practitioner review.

Commence neurological observations (if witnessed head injury or in unwitnessed falls) in patients who are cognitively impaired if any of the following are present:

• external bruising, swelling or laceration to the head
• symptoms suggesting brain injury (vomiting, headache, dizziness, altered behaviour/mental state or altered consciousness
• on any anti-coagulation (other than dalteparin 5000 U prophylaxis)
• pain or tenderness of head
• any existing coagulopathy or thrombocytopenia (platelets <50)
• recent chemotherapy (IV or oral treatment)

Patients who have been found to have a head injury, have had an unwitnessed fall or who cannot reliably report incident should have their vital signs and neurological observations recorded as recommended at least until formal assessment. Timings are shown below. Once the patient has been reviewed observations can be stipulated by the person responsible for clinical assessment and ongoing management however NICE 232 recommend, if required, the frequency of neurological observations should be:

• ½ hourly for 2 hours.
• 1 hourly for 4 hours.
• 2 hourly until no longer clinically required or advised to discontinue by medical staff/advanced practitioner.
• Revert to half-hourly observation and follow the original frequency for patients who deteriorate at any time.
• Urgent reassessment of patient if any neurological deterioration during monitoring period.

Patients who have fallen and have not sustained a head injury should have their observations / NEWS 2 score carried out as clinically indicated. Good practice suggests, as a minimum, four hourly for 24 hours.

The following high risk factors are identified in NICE clinical guideline 232⁵ :

• Age ≥ 65 years
• Coagulopathy (history of bleeding, clotting disorder), consider those on current anticoagulants/ antiplatelet, recent or current chemotherapy and patients with abnormal coagulation especially platelets less than 50. Anticoagulants include: warfarin, heparin, dabigatran, dalteparin (fragmin), enoxaparin (clexane), apixaban.
• Antiplatelet drugs include: aspirin, clopidogrel, dipyridamole, ticagrelor.
• Dangerous mechanism of injury e.g. fall from > 1 metre or 5 stairs.
• Obvious head injury (laceration, bruising, loss of consciousness, amnesia, 2 episodes of vomiting or seizure)

All patients who have fallen in hospital should be timeously assessed first by ward nurse and then by a doctor or advanced practitioner.

A proforma has been developed for the use of junior medical staff and advanced practitioners to assist with documentation, assessment and management. A copy is included in this guideline. These are available on the ward and should not be printed from this guidance. The form should be made available to the reviewing practitioner and filed in the patients case notes in chronological order.

Referral

Following initial assessment, referral should be made for formal assessment to medical staff or advanced practitioner using Situation Background Assessment Recommendation (SBAR) communication structure.

SBAR example

Situation

My name is...................
Calling from................... state ward area.....................
Briefly state the problem........I have patient who has fallen...

Background

Patient's name....................................
Age..................
Diagnosis (if available).......................
Any relevant medicines? (See above, high risk factors).

Assessment

What is your assessment of the situation.......... the patient has sustained a head injury...or.....I suspect the patient may have sustained an injury to..... NEWS/GCS is......
On A to E assessment, I have found...

Recommendation

What is it you want?
What are you requesting?
Think - is everyone clear about what I needs to be done?

It is not within the scope of this guideline to stipulate moving and handling procedures as staff should have attended moving and handling training. However, it should be highlighted that:

• Flat lift kits also known as Hoverjacks are available to assist with moving patients after a fall.
• A straight lift must be used for potential hip/spinal/neck injuries; NHS Ayrshire & Arran have ferno scoop stretchers that can be used with the Flat Lift Kits.
• Hoists and fabric slings should not be used to move a patient with potential hip/spinal/neck injuries as this may exacerbate any underlying injury.
• Nursing staff within acute and community hospitals should record the method of moving and handling used after a fall on the immediate post fall checklist sticker.
• Locations of Flat Lift Kits are:

UHC
Emergency Department (ED)
Ward 2B
Ward 3E
Mortuary

UHA
Combined Assessment Unit (CAU) –Yellow Zone
Station 16
Acute Cardiac Care Unit (ACCU)
Medical Day Care Unit

Community Locations
East Ayrshire Community Hospital (EACH) –Photocopier Room
Biggart Hospital –Lindsay Ward
Woodland View –Ward 4
Ailsa Hospital –Clonbeith Ward
Mortuary.

Falls can have a wide range of consequences ranging from loss of confidence to injuries which cause pain and suffering, loss of independence and occasionally death. It is important to identify patients who are at risk of falling. Guidance is available for the prevention and management of falls in all hospital settings⁴. The guidance describes NHS Ayrshire & Arrans falls risk assessment tool and appropriate prevention strategies which should be implemented for all patients considered to be at risk of falls which should be implemented or updated after a fall.

For those patients who do fall despite our best efforts, care must be person centred, safe and effective. Following assessment and management of the fallen patient, staff must ensure:

• Falls risk assessment tool is updated.
• The Registered Nurse should fully complete an immediate post fall checklist sticker and place in nursing records (acute and community hospitals)
• A DATIX must be completed.
• After a patient fall, the family/next of kin should be informed by the nurse on duty. NB. Before contacting relatives (especially out of hours) consider firstly, the severity of injury and secondly, the time incident occurred.
• All falls should be added to the safety brief for the next shift. Nurse in charge should be made aware of any patients that have fallen, with special consideration for those who suffer major injuries, to ensure timeous escalation for investigation of the incident. 
• The patient’s own medical team should be made aware of the injury as soon as is practicable.

Staff are reminded that they may have patients who require communication in a form other than English e.g. other languages or signing. Additionally, some patients may have difficulties with written material. At all times, communication and material should be in the patients preferred format. This may also apply to patients with learning difficulties.

In some circumstances there may be religious and/or cultural issues which may impact on this guideline e.g. choice of gender of healthcare professional. Consideration should be given to these issues when treating/examining patients.

Some patients may have a physical disability that makes it difficult for them to be treated/examined as set out in the guideline requiring adaptations to be made.

Patient’s sexuality may or may not be relevant to the implementation of this guideline, however, non-sexuality specific language should be used when asking patients about their sexual history. Where sexuality may be relevant, tailored advice and information may be given.

This guideline has been impact assessed using the NHS Ayrshire and Arran Equality and Diversity Impact Assessment Tool Kit. No additional equality & diversity issues were identified. Emergency Services have systems in place to ensure that patients attending who are not registered with a GP receive information on where to seek ongoing health care needs.

1. Hurley N et al. Oxford handbook for the foundation programme. 6th ed. Oxford: Oxford University Press; 2025.

2. Glasgow Coma Scale.

3. Scottish Government. National falls and fracture prevention strategy 2019-2024 draft: consultation. 2019. Available from: https://www.gov.scot/publications/national-falls-fracture-prevention-strategy-scotland-2019-2024/

4. NHS Ayrshire & Arran. Prevention and management of falls in all hospital settings. G108. 

5. NICE. Head injury: assessment and early management. NG232. Published 18 May 2023.

Inpatient post-fall assessment proforma

Clinical management of a patient with actual or suspected head injury (sustained in hospital)¹