Policies,Clinical,UWHC Clinical,Department Specific,Emergency Department

Fall Prevention for Adult ED Patients (5.0)

Fall Prevention for Adult ED Patients (5.0) - Policies, Clinical, UWHC Clinical, Department Specific, Emergency Department


Effective Date:
January 15, 2016

Department (ED)
Policy Manual
Fall Prevention for
Adult ED patients
X Revision

Page 1 of 4


To identify Adult patients at risk for falls in the Emergency Department (ED), implement strategies to
reduce the risk for falls, and to prevent injuries related to falls.

II. BACKGROUND: Description of ED Environment at UWHC
Certain characteristics of the ED environment may add to a patient’s risk of falling:
ξ Increased physical distance between patient beds/room and bathrooms.
ξ Patients who are intoxicated and/or under the influence of other substances have unsteady gait, may
be impulsive in their behavior, and lack reasoning.
ξ Narrow stretchers-- more narrow than an inpatient hospital bed.
ξ The typical ED Environment is characteristic of waiting such as waiting for a bed, MD/Nurse,
treatment, and/or test results, etc. An increased wait time may trigger a higher risk for falling in the

All patients are at higher risk for falling during their stay in the ED than they would be in their home
environment. Unfamiliar surroundings, under-estimating weakness due to illness, and the effects of
medications, treatments and procedures are a few of the factors that increase this risk.

All Adult patients are assessed for risk of falling on admission, transfer (by the receiving unit) and change
in condition using the Hendrich II Fall Risk Model©. Steps are taken to minimize the risk of falling or
injury related to a fall. This includes education for the patient and family about our fall risk assessment
and our individualized fall reduction strategies.

A. Fall: Any sudden, uncontrolled, or unintentional descent to the floor.
B. "Near Miss" fall: Sudden loss of balance that does not result in a fall or other injury. This can
include a person who slips, stumbles, or trips but is able to regain control prior to falling.
C. Assisted fall: Is a witnessed fall where a staff member intervenes to prevent the actual fall
occurrence or controls the fall to reduce the risk of injury.
D. Un-witnessed fall: Occurs when patient is found on the floor and neither the patient nor anyone
else knows how he or she got there.
CONDITION CHANGES (which may be frequent during their ED stay)
A score of 5 or greater: High Risk for Falling
Risk Factors

Points Key Notes Specific Examples of
application to the patient in
the ED
1. Confusion, disorientation,
4 ξ Points are given if patient
experiences any mental
ξ Suspicious or known
presence of drugs and/or

Effective Date:
January 15, 2016

Department (ED)
Policy Manual
Fall Prevention for
Adult ED patients
X Revision

Page 2 of 4


alcohol prior to arrival
ξ Frustration and escalating
anger over increased wait
and/or other factors such as
pain, fear or anxiety
2. Symptomatic depression 2 ξ Points are given based on
clinical judgment of patient or
caregiver. Patient is not given
points for depression that is
successfully being treated

3. Altered elimination 1 Points are given for frequency,
urgency, or incontinence when these
symptoms are induced by treatment
ξ Administered bowel prep
ξ Any other laxatives
ξ Any diuretics
4. Dizziness, vertigo 1 ξ Points are given when a patient
experiences vertigo or dizziness,
including as a side effect of

ξ Side effect of many
medications administered in
the ED (opioids, anti-
emetics, or anti-
hypertensives, etc.)
5. Male Gender 1
6. Administration of
2 ξ Any antiepileptic
7. Administration of

1 ξ Any benzodiazepine

In the ED, these may be
administered for anxiety or used
with procedural sedation
8. Poor ability/performance in
rising from a seated position
(“Get-Up-and-Go” test)

This would not need to be
tested if patient walks with
steady gait (such as from
Triage to room)

Get-up-and-go Test: Rising
From Chair. Have patient sit in
chair or at side of bed and rise
to a standing position. Select

a. Able to rise in a single
movement – no loss of balance
with steps
b. Pushes up, successful in
one attempt
c. Multiple attempts, but
d. Unable to rise without

ξ If unable to assess due to
unconscious, coma, traction,
extreme debilitation/atrophy, etc,
monitor for change in activity
level and use all other risk factor
scores, but leave this one blank.

The Get-up-and-go

a: 0
b: 1
c: 3
d: 4

ξ This may need to be
reassessed at discharged for
the ED patient.

ξ Patients may fall while
attempting to dress
themselves, preparing for

Effective Date:
January 15, 2016

Department (ED)
Policy Manual
Fall Prevention for
Adult ED patients
X Revision

Page 3 of 4

B. SCORING High Fall Risk = Score of 5 or more
Using your clinical judgment, do you agree with this score? Any staff member, physician, or
family member may request that a patient be placed on High Fall Risk Precautions

All staff members are responsible for implementing the intent and directives contained within this
policy, and for creating a safe environment of care..
If you have determined that the patient is a high risk for falls: Check “Yes” in the Healthlink
record for the question of: Does this patient require “High Fall Risk” precautions?
Key Points:
All patients will have a Standard Fall Risk plan of care. (A score of <5 on the
Hendrich fall risk scale)
ξ Only patients who warrant a higher level of fall risk awareness will be placed on
High Fall Risk precautions.
ξ The following patients may be at a greater risk for injury from an accidental fall:
o Diagnosis of osteoporosis or other bone depleting disorder
o History of initiation of anticoagulants or other bleeding disorder
o Patients with existing injuries that could be impacted by a fall
o History of syncope, falls, unsteady gait or weakness
C. INTERVENTIONS for ALL Adult patients in the ED (Standard Fall Risk Plan) Check all
that apply in the HealthLink Record
1. Call light within reach
2. Elevate one or more side rails for safety
3. ED cart in lowest position
4. Family in room
5. Use of glasses, hearing aid, walker, cane, etc., as indicated (Aids that will help them in
their movement). Walk with shoes or non-skid slippers
6. Walk with shoes or non-skid slippers
D. INTERVENTIONS for High-Risk Adult patients in the ED (Score of 5 or greater on the
Hendrich II Fall Risk Scale)

1. Interventions described above for ALL patients in the ED
2. Alert Staff of High Fall Risk:

Effective Date:
January 15, 2016

Department (ED)
Policy Manual
Fall Prevention for
Adult ED patients
X Revision

Page 4 of 4

a. Place a High Fall Risk yellow sign outside of patient’s room (located inside
pocket of nurse-server door of each patient’s room and in file folder at desk)
b. Place High Fall Risk ID band on wrist (Replacements can be ordered from CS)
3. Placing patient in wheelchair to take to bathroom OR use of bedside commode
4. Staying nearby patient during toileting
5. Instruct patient not to attempt to get up without assistance—Use call light.
6. Assess need for use of BOTH side rails. Using both side rails on a stretcher is not
considered a restraint (UWHC Policy # 13.23).
7. Assess need for gait belt during ambulation
8. Consider diversional activities (music, games, etc)
9. Patient Education: Exit Care, HFFY # 5234.

E. Document all interventions in medical record.

Reviewed by:
ED Clinical Nurse Specialist
ED Clinical Operations
ED Nurse Council

Tami Morin, RN MS
Director, Emergency Services
David Burke, RN, MS
Co-Manager, Emergency
Anne LeGare, RN, BSN
Co-Manager, Emergency

Alexander, D., Kinsley, T., & Waszinski, C. (2014). Journey to a safe environment: Fall
prevention in an emergency department at a level 1 trauma center. Journal of emergency
nursing; 39 (4) 346-352.

Hendrich, A. (2007). Predicting patient falls: Using the Hendrich II falls risk model in clinical
practice. American journal of nursing, 107, (11), 50-58.

Terrel, K.M. Weaver, C.S. Giles, B.K. & Ross, M.J. (2009). ED patients falls and
resulting injuries. Journal of emergency nursing, 25 (2), 89-92.

UWHC Policies:
Application of physical restraint: Policy # 13.23

Fall prevention for adult inpatients: Policy # 13.15