Care staff are not always sure about what to do when a person has fallen. Additionally, Care at Home (Domiciliary Care) policies often state that when a person falls, the staff member should always call 999, which, when this is not needed, is clearly a burden on resources.
The Hertfordshire ‘Management of a Person who has Fallen in a Care Home Pathway’ (click here for link) and the ‘Management of a Person who has Fallen in Domiciliary Care Pathway’ (click here for link) clarify when it would be appropriate to call 999 and when it would not.
The flowchart here (click here for link), describes how to assess for Red Flags:
- Primary Survey – which is your D.R.A.B. assessment, is the area clear of any danger, such as electrical danger, broken glass, slippery surfaces etc
- Is there any response from the person, is their airway open, and are they breathing?….. If either you cannot clear the danger without causing injury to yourself or more injury to the person, or if there is no danger and there is no response or they are not breathing, you call for help and call 999.
If the person responds and they are breathing next you check for:
- Other RED FLAGS using the acronym ISTUMBLE
- ISTUMBLE is a nationally recognised tool developed by Winncare in collaboration with the Welsh Ambulance Services NHS Trust… which has an algorithm and app and is used to support decision making to help minimise any adverse effects of a fall and to determine the appropriate course of action in the occurrence of a fall.
If there is a YES to any of these – The flowchart again directs you to call 999.
- The third RED FLAGS box – is the FAST Test normal?
- Facial weakness – Can the person smile? Is there Arm weakness – Can the person raise both arms? Are there Speech Problems – Can the person speak freely and understand what you say? If any of these are NOT NORMAL, this indicates the person has had a Stroke, and the flowchart again directs you to 999
- Then the last RED FLAGS box – Is the person taking blood thinning medication (anticoagulants) AND have they had a suspected head trauma? Or they are taking blood thinning medication and the fall was unwitnessed?
- A yes to either of these questions directs you to call the Avoidance of Admission Services so that they can ascertain whether the person is for further investigation or not
N.B. An Advanced Care Plan, Treatment Escalation Plan/ ReSPECT form/PEACE documentation that says that the person is NOT for hospital conveyance, means you would NOT call 999 (you should have these documents, or, if you haven’t already, you need to ensure that they are put into place for each person as soon as possible, as it is abuse to go against the person’s wishes/advanced decisions). The same goes for each of the scenarios, when you come up with any of the red flags, you need to make sure that calling 999 is in line with the person’s RESPECT form/TEP (and their wishes at the time, providing they have the capacity to make the decision at the time). Remember they are allowed to change their mind at the time too, and they DO NOT need to write it down if they change their mind and choose to have treatment or go to hospital, even if this means they are overriding a previous Advanced Decision to refuse treatment.
- When you have established that it is the appropriate thing to do to call 999 – You follow the instructions on the flowchart, and you keep the person calm, still and comfortable, monitoring them as directed by the 999 call handler.
- If there are no red flags, then you move on to the Secondary Survey, which is checking for AMBER FLAGS – cuts, bruises, controllable bleeding etc, and if you need advice for managing any of these, you call the Avoidance of Admission services – instead of 999.
- Providing there are no amber flags, or the ones that are identified have been managed, the pathway then takes you through verbally assisting a person off the floor, or using a lifting device/hoist as necessary, or calling the Avoidance of admission services if you are not able to get the person up.
The online flowchart document also has a checklist attached to record the red/amber flags, as well as the paperwork to carry out your post falls assessment documentation so that you do not miss anything out. All relevant documents are attached to the pathway as linked documents, to make everything crystal clear.