Introduction
In contrast, many emergency department trauma triage systems identify older trauma patients as requiring assessment by more experienced staff, often ST3 and above. There is increasing recognition that until recently, existing trauma triage pathways have focused on high-energy mechanisms to identify patients most likely to sustain major trauma. However, a fall from a height of <2m is now the most common mechanism of injury in patients meeting the criteria for major trauma and in those >69 years old, the most common cause of trauma-related death (3).
Delays in identifying and managing injuries in the older age groups may represent preventable harm in the patient group who are most likely to decompensate as a result. The challenge is that most inpatient falls do not result in major trauma and in many settings, the resource is not available to trigger an inpatient trauma call for all falls. This document aims to provide a framework to support a systematic assessment of the patient to promote early identification of possible injuries and to prompt relevant and timely investigations to confirm diagnosis and enable appropriate management.
1. Initial referral
1.1 Information: SBAR handover
When called about a patient who has had an inpatient fall, try to elicit the information that will allow you to prioritize the review appropriately and to communicate relevant instructions to the staff whilst awaiting your review.
An example of SBAR handover giving the relevant information:
Situation: “I am the nurse in charge on X ward, and one of our patients, Mrs Smith has had an unwitnessed fall and was found on the floor by her bedside 15 minutes ago”
Background: “She is an 80yr old woman, admitted with a community acquired pneumonia and has been delirious on the ward. She is on prophylactic dalteparin and clopidogrel.”
Assessment: “We have done a set of obs - EWS, BM and GCS (what are they) - and assessed from head to toe. She appears to be in pain around her right hip. I am concerned she may have broken her right hip. We have moved her to the bed using flat lifting equipment. I have given her the PRN paracetamol that is already on her drug chart.”
Recommendation: “Please can you assess her urgently within 30 minutes? Is there anything else you want me to do in the meantime?”
1.2. Response times
NEWS2 response times (4):
Scoring 7 or more - immediate review and continuous monitoring
Scoring 5 or more – urgent response
Scoring 3 in one parameter – nurse to inform medical team who will review and decide frequency of monitoring, consider sepsis
Scoring 1-4 – registered nurse to review
Scoring 0 – routine observations
Falls response times as per NICE quality standards 86(1):
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Within 30 minutes if injury suspected
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Within 12 hours if no injury suspected (local policies may stipulate more urgent response)
1.3 Instructions to give to the nurse:
Depending on NEWS2 score, ask for appropriate frequency of observations and escalate following your local escalation policy if required e.g to outreach team, medical emergency team (MET) call
Remember in an unwitnessed fall, consideration of possible head injury is required –ask for neurological observations and check for anticoagulant therapy status (described in section 4.1.v)
Consider what analgesia is required and could be given whilst waiting for your review. The expectation is that this is given within 30 minutes of injury. If nurses are reporting significant pain, the patient needs an urgent review.
2. On arrival to the ward
Assess where the patient is.
- If the patient is still on the floor, conduct an initial assessment (post-fall check - refer to best and safe practice resource)
- Before moving the patient from the floor, discuss and agree with staff present the safest moving and handling method to use (refer to best and safe practice resource).
Do you have enough help for the current situation?
3. The primary survey
Many patients who fall are not critically unwell and the temptation will be to skip aspects of the assessment to maximise efficiency. The primary survey is intended to identify life threatening conditions and ensure these are treated in a prioritized sequence. It is possible to conduct this at speed and several steps may be able to be performed simultaneously. Even if the patient is clinically stable, it is advisable to retain a structured approach to the assessment to ensure significant findings are not missed and to accurately reflect and document the clinical state of the patient to allow comparison if the patient were to deteriorate at a later stage.
Is the patient responsive? If confirmed cardio-respiratory arrest, commence CPR (taking into account DNACPR status)
A – Airway (with C-spine immobilisation)
- Talk to the patient, can they talk back? Can they give an account of what happened?
- Are you concerned about the C-spine (obvious head injury, neck pain, mechanism of injury)? If so, call for more help, immobilise C-spine by holding head until help arrives (see section 4.3 Thoracic/lumbar spine - iii. Guidance on immobilisation) then continue assessment
- Chin lift and jaw thrust can be performed without hyperextending the neck
B- Breathing
- Respiratory rate, oxygen saturation (sats)
- Apply O2 if target sats not reached
- Assess for obvious injuries, increased work of breathing, expansion, asymmetrical or abnormal breathing, auscultate for air entry / added sounds
C- Cardiovascular
- Pulse – rate, rhythm, skin perfusion
- Blood pressure (BP)
- Do you need intravenous (IV) access/bloods?
- In the context of trauma with major haemorrhage, control of bleeding is key and should take priority. Local protocols for major haemorrhage should be followed
- Consider fluid challenge if signs of shock, sepsis, hypovolaemia (follow sepsis guidance relevant to clinical setting) (5)
If significant abnormalities in examination so far, call for help.
Considerations in major trauma (6):
- Early signs of shock are tachycardia and peripheral vasoconstriction. A low BP is a later sign of shock, and relying on this can delay recognition.
- Neurogenic shock presents classically with hypotension without tachycardia, cutaneous vasoconstriction or narrowed pulse pressure.
- Older patients may not demonstrate an appropriate tachycardia because of their limited cardiac response to catecholamine stimulation or medication such as beta blockers / calcium channel blockers or with certain pacemakers.
- Older people may also be more likely to have hypertension. Relative hypotension should be identified by reviewing their normal BP.
- Initial fluid resuscitation should be with a 250–500 mL crystalloid solution bolus (7) and assess response – identify evidence of adequate end-organ perfusion and tissue oxygenation. Early blood products are beneficial in the context of significant bleeding, and a balance is needed between maintaining BP and increasing rate of active bleeding – control of haemorrhage is key.
D- Disability
- BM, temperature
- Glasgow coma scale (GCS) – separate out into component parts; if GCS 8 or less, consider securing airway
- Pupil size and reaction
- Any lateralising signs or sensory loss/change (can they move their arms and legs, any obvious facial asymmetry, can they feel you touching them? Observe for spontaneous movements if unable to follow instructions)
E- Exposure
- Look for rashes, evidence of bleeding, joint or long bone deformity, bruising to indicate site of impact, lines, catheter
Consider adjuncts to primary survey: bloods, arterial/venous blood gases, electrocardiogram, urinary catheter, chest X-ray
Do you need more help? Consider the need for escalation (to Medical Escalation Team or other escalation team / service call)
In community or mental health settings, does the patient need to be transferred elsewhere? Dial 999.
4. The secondary survey
A secondary survey does not begin until the primary survey is completed (go back and reassess if there are abnormalities on the primary survey), appropriate resuscitation has been initiated and the patient’s observations are responding appropriately. It consists of a head-to-toe evaluation of the patient including a complete history and examination, including reassessment of all vital signs.
At this stage, if not already done, it is advisable to review a brief history of the admission and the patient’s past medical history, including previous falls, risk of fracture, any known spinal pathology, and what medications are they on – in particular, antiplatelets or anticoagulants. Together with the history from the ward staff and your initial assessment, consider what could have precipitated the fall.
4.1 Head
4.2 C-spine
4.3 Thoracic/lumbar spine
4.4 Chest including clavicles, ribs and sternum
4.5 Abdomen
4.5.i History:
Abdominal injuries are less likely to be a feature of inpatient falls however, from the findings so far, think about:
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- solid organ laceration in the context of lower rib fractures
- bladder and bowel injury from pelvic fractures
- bladder or bowel dysfunction from spinal injury.
4.5.ii Examination:
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- Bruising including flanks and genital areas may indicate spinal or pelvic fractures or injury to urinary tract, including kidney.
- Check for tenderness, guarding, bowel sounds.
- Look for evidence of acute urinary retention.
4.6 Hip/pelvis
4.7 Extremities – bones and joints in all four limbs
Have you reviewed:
If injury is suspected or diagnosed, appropriate and prompt analgesia is an essential component of the patient’s management and should be given within 30 minutes of the fall. Pain scoring to assess severity and response to analgesia should be recorded. Follow local guidelines for pain scoring - using appropriate tools for those with cognitive impairment, e.g Abbey pain scale or PAINAD - and for prescribing guidance.
Take into account those patients who are unlikely to ask for analgesia on a PRN basis and consider prescribing regular medication. If opiate-based drugs are used, include laxatives and PRN anti-emetics.
Rapidly reverse anticoagulation in patients who have major trauma with haemorrhage or head injury with suspected intracranial haemorrhage, following local haematological policies/ advice. Do not reverse anticoagulation in patients who do not have active or suspected bleeding (21, 27, 28, 29)
A senior decision maker should be involved in risk-benefit decision to stop and restart essential anticoagulation or antiplatelets (11).
If an inpatient fall results in major bleeding or suspected significant intracranial bleed (GCS 12 or less), tranexamic acid may be indicated and trauma/ haematological advice should be urgently sought (10,21).
- Assessment for injuries in the context of delirium or dementia is more challenging and requires a meticulous history, examination and period of observation.
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Understand the patient’s baseline cognition and function (involving carer/relative for collateral history) and screen for delirium, treating possible causes promptly
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Use appropriate pain scoring tool, observing for non-verbal signs of pain in accordance with your local policies
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Have a low threshold for imaging
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How can the patient be managed safely e.g is enhanced supervision required?
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See section 4.3.iii on immobilising agitated patients
8. Investigations
8.1 To exclude fracture/ significant injury:
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CT in head injury meeting criteria in flowchart figure 1
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CT C-spine meeting criteria in flowchart figure 2
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Spinal injury (12):
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In suspected isolated spinal injury (T1–L3) without abnormal neurological signs or symptoms in the thoracic or lumbosacral regions, perform an X-ray as the first-line investigation
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Perform CT if the X-ray is abnormal or there are clinical signs or symptoms of a spinal column injury
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If a new spinal column fracture is confirmed, image the rest of the spinal column
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If there is a neurological abnormality which could be attributable to spinal cord injury, perform MRI after CT, regardless of whether or not the abnormality is evident on CT (10)
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CT chest for suspected rib fractures
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Use whole-body CT with blunt major trauma and suspected multiple injuries (12). The initial scanogram should help identify injuries to extremities but usually scan from head to mid-thigh. Note that this usually uses IV contrast.
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Order plan X-rays for suspected fractures to extremities
Be aware that it is easy to miss injuries if there is an obvious painful and distracting injury. Maintaining a systematic method of assessing for injury and careful consideration of the imaging requested, will reduce this risk.
Be mindful of expected timescales and communicate these appropriately. Ensuring appropriate review of results and prompt action is an expected responsibility of the reviewer.
8.2 To exclude medical deterioration and investigate cause for fall,
perform:
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Delirium screening (4AT)
Investigations as clinically indicated:
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Bloods
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ECG
- ABG (lactate, respiratory function, Hb)
- Blood cultures
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Bladder scan
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urine culture
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CXR – for medical reasons, not for rib fractures
9. Community/mental health settings
This resource should be used in conjunction with the NAIF post-fall management resource for first responders. Pathways can be adapted locally depending on the resource available, training and experience of the healthcare practitioners involved.
For specific guidance in community settings on head injuries, spinal injuries and pelvic/ hip injuries, please refer to individual sections:
- 4.1 Head injury
iii. For patients in community settings - 4.3 Thoracic/lumbar spine
vi. In a community setting - 4.6 Hip/pelvis
iv. In a community setting without access to flat lifting equipment
10. Handover checklist
- Document frequency of observations and ensure that nursing staff are aware of particular signs and symptoms to look for (increased drowsiness, agitation, changes in pupil size or reaction, slurred speech, vomiting, seizures, difficulty swallowing, abnormalities in limb function, pain, bladder or bowel difficulties).
- Be aware that, in older patients, delayed presentation of subdural haemorrhage does not always result in focal neurological signs; cognitive impairment and headache are most common (11) . Have a low threshold for rescanning patients at high risk.
- Document examination findings and any narrative of the fall, thoughts about possible causes or risk factors.
- Complete the appropriate incident reporting forms / post-fall proforma / post-fall debrief.
- Update family/carer and consider duty of candour.
- Ensure prompt review of imaging and involvement of relevant specialties, including trauma nurses or trauma geriatrician if this resource is available.
11. For parent team/MDT
MDT Swarm huddle may be appropriate (29). Be guided by local Patient Safety Incident Response Framework (PSIRF) policy. Consider duty of candour.
- Ensure full assessment of mobility (if the falls review has not already included the assessment) and, if injuries have been sustained, ensure early specialist therapy input.
- Repeat the multifactorial assessment to optimise safe activity (MASA) including medication review, lying/standing blood pressure, continence assessment, vision assessment, mobility assessment, delirium assessment.
- Bone health assessment (eg FRAX score), pressure area assessment, VTE assessment (consider mechanical prophylaxis if heparin contraindicated).
- Be mindful of potential for delayed presentation of injuries. If there is a deterioration in injuries or diagnosis of new injuries, ensure that appropriate teams are involved to confirm whether transfer to an alternative hospital (eg major trauma centre) is required.
- Patients who have sustained a traumatic brain injury should have appropriate occupational therapy and vestibular assessments, avoiding opiates to treat isolated headaches. Written head injury advice should be given on discharge (10,15).
- Patients with conservatively managed C-spine injuries may not tolerate prolonged use of cervical collars and associated complications. Seek specialist MDT input to assist in making patient-centred decisions regarding continued immobilisation (15).
- Communicate clearly with orthopaedic teams to obtain prompt weight-bearing decisions, with emphasis on the fewest restrictions possible for older, frailer patients to allow maximum function.
- Consideration may also need to be given to any significant change in the patient’s condition that requires review of escalation or resuscitation decisions, adoption of end-of-life care approach or change to longer-term care planning (eg previous discharge decisions, or home support in place).
12. Local policies
This summary of existing guidance will require review at a local level to determine how it aligns with local policies, pathways and resource. Areas of practice around immobilisation and access to prompt imaging, for example, need careful thought.
It is expected that only a small percentage of patients who fall as inpatients will require immobilisation. However, it is advised that local stakeholders discuss how this can be done safely in the event that it is necessary, and that agreed escalation pathways are communicated to the relevant staff performing these assessments.
Potential barriers to prompt imaging include:
- ordering imaging – who can do this and do they need to personally review the patient?
- radiology – what staffing is available for manual handling out of hours, especially if the patient is immobilised, in pain or delirious?
- ability (workload, skillset) to chase investigations and review results out of hours.
Local monitoring and quality improvement may be required to address some of these barriers if there is evidence of delays in imaging and diagnosis of injuries.