Falls in hospitals / Falls in the community Lisa Stewart, Falls Co-ordinator, Edinburgh CHP Tel: 0131 537 7441 Email: lisa.stewart@nhslothian.scot.nhs.uk

Falls Falls in older people Falls in hospital Edinburgh CHP Role of Falls Co-ordinator Performance measures

Definition of a fall ‘Have you had any fall including a slip or trip in which you lost your balance and landed on the floor or ground or lower level?’ (Lamb et al, 2005)

Incidence of Falls Age over 65 years: 28 - 35% per year (Population set to rise to 1 in 4 by 2031) Age over 80 years: >40% per year Nursing home residents: ~60% per year Dementia sufferers 40 - 60% per year

Consequences 95% of people with a hip fracture have sustained a fall 5% of falls result in a fracture 1% of falls result in a hip fracture Approx cost of hip fracture: £12,000 Around 1/3 of those with a hip fracture die within a year Around half of all hip fracture patients will not return to their previous state of health and independence Fear of further falls

Scottish Hip Fracture Audit (2007) A Borders General Hospital 165 B Dumfries and Galloway Royal Infirmary 166 C Queen Margaret Hospital, Dunfermline 375 D Forth Valley 354 E Ninewells Hospital, Dundee 464 F Aberdeen Royal Infirmary 491 H Hairmyres Hospital 196 I Glasgow Royal Infirmary 374 J Wishaw General Hospital 290 K Dr Gray’s Hospital, Elgin 140 L Western Infirmary, Glasgow 322 M Crosshouse Hospital 206 N Raigmore Hospital, Inverness 325 O Royal Alexandra Hospital, Paisley 421 P Inverclyde Hospital, Greenock 216 Q Monklands Hospital 232 R Perth Royal Infirmary 185 S Victoria Infirmary, Glasgow 212 T Ayr Hospital 175 U Southern General Hospital, Glasgow 139 V Royal Infirmary of Edinburgh 921 Total 6369

Emergency Hospital Admissions: City of Edinburgh (aged 65 and over with a fall) 1998 2001 2006 2007 1270 1280 1488 1558

National / local guidelines: BOA & BGS (2008):The care of patients with a fragility fracture NICE Clinical Guideline 21 (2004) SIGN Guideline 111 (2009): Management of hip fracture in older people Rehabilitation Framework (2007): Co-ordinated, integrated and fit for purpose National Patient Safety Agency (2007): Slips, trips and falls in hospitals NHS Lothian: Policy & Protocol for the assessment and management of adult hospital patients with falls

Falls in hospitals Patients most vulnerable to falls: Older patients, particularly those over 80 Relative to the proportion of men and women in hospital, there are more reported falls of men than women* *National Patient Safety Agency, 2007

Falls in LUHD 2009

Damned if you do damned if you don’t?

Types of risk factors Intrinsic factors: Extrinsic factors: Examples Intrinsic factors: Personality & lifestyle Activities, attitudes to risk, independence and receptiveness to advice Age-related changes Changes in mobility, strength, flexibility and eyesight that occur even in healthy old age Illness & Injury Stroke, arthritis, dementia, cardiac disease, acquired brain injury, delirium, Parkinson’s disease, dehydration, disordered blood chemistry Extrinsic factors: Medication Sleeping tablets, sedation, painkillers, medication that causes low blood pressure, medication with Parkinsonian side effects, alcohol Environment Lighting, wet floors, loose carpets, cables, steps, foot wear, distances and spaces

Why patients fall Most falls are the result of a combination of factors Poor mobility and confusion are often contributing factors Environmental hazards such as wet floors or steps are identified in only a small proportion of patient falls

When patients are most likely to fall Weekdays, when there are more patients in hospital Mid-morning, when patients are more likely to be active Fewer falls occur at mealtimes and in the early hours of the morning

Staff witnessing patient falls Only a minority of falls are witnessed by staff Even when a member of staff witnesses a fall, they are unlikely to be able to stop the patient from falling

What patients were doing when they fell Most falls occur whilst patients are walking Patients are particularly likely to fall whilst using the toilet or commode Falls from trolleys may be more likely to lead to serious injury and litigation

Components of multifaceted interventions (Oliver et al BMJ 2007) – Medical/Nursing care plans for common reversible risk factors e.g. Medication Syncope/presyncope Delirium/Agitation Urinary frequency/incontinence Gait/Balance Visual impairment Staff/Patient/Carer education/training High risk alert bands/stickers Post fall assessment and plan (medical or nursing) Environmental Safety/Equipment: increasing range of beds and chairs to suit different needs Continuous learning from incidents Policies/Guidelines (inc restraint/bedrail minimisation)

STRATIFY (Oliver BMJ 1997 and subsequent e.g. Vassallo 2004 JAGS) Did the patient fall as a cause for admission or during this admission? Are they agitated? Do they have urinary frequency/frequent assisted toileting? Visual impairment? Gait instability (able to stand and transfer with difficulty/assistance?) Total Score 0-5

Risk Assessment Tools Are any of them good enough? False reassurance that something is being done? Better to concentrate on reviewing each person post fall and modifying reversible risk for everyone Some of the better trials didn’t bother with them Why we are so addicted to “off the shelf” tools Assessment ≠ intervention! (Oliver, 1997)

Recommendations for NHS organisations: Make sure that the circumstances of falls are described completely and meaningfully in datix reports Analyse and use reports of falls to learn from ward to board level

Clinical Quality Indicators for Falls CQI: Falls Element Criterion Patient 1-5 Compliance Assessment Prevention Management 65+ Falls Risk Assessment Documentation Falls Plan / Action 100%

Falls in Edinburgh CHP 68,000 older people 73 GP practices 70 care homes Rehab hospital (AAH, RFU) Continuing care (Corstorphine hospital, Ellen’s Glen, Finlay House, Ferryfield) 3 day hospitals 7 day centres Voluntary organisations

Role of Falls Co-ordinator, Edinburgh CHP Co-ordination between organisations Linking with QIS (Quality Improvement Scotland) Implementation of NHS Lothian’s Falls Strategy Specific falls projects Falls in hospitals (rehab, continuing care) Falls in care homes Training Outcomes

Pathways for the Prevention and Management of Falls and Osteoporotic Fragility fractures (NHS QIS, draft 2009) Supporting health improvement and self management to reduce the risk of falls and fragility fractures Identifying individuals at high risk of falls and / or fragility fractures Responding to an individual who has just fallen and requires immediate assistance Co-ordinated management including specialist assessment (Carry out scoping exercise to audit how Lothian is meeting these recommendations)

NHS Lothian: Falls Prevention and Bone Health Strategy Falls group established (Sept 2008) with a designated chair (Corporate Falls Lead) that will be responsible for developing and implementing a Lothian wide action plan To be agreed by the board November 2009 Five year plan

Managing the fallen uninjured person Emergency services Edinburgh Council (CAS) Health & Social Care Direct GPS / Community Nurses NHS 24 Referral on for Falls Assessment (Rapid Response Teams)

Edinburgh Telecare Project NHS Lothian & CEC 150 free kits to those who have had a fall and have no alarm Referrals through Rapid Response Teams Equipment provided for 6 months Falls co-ordinator to evaluate: patient evaluation, Euroqual5D, JIT telecare evaluation Patient’s value of telecare equipment

Sayphone (CAS alarm) Falls detector Bed occupancy monitor Telecare equipment: Sayphone (CAS alarm) Falls detector Bed occupancy monitor Pressure mats Wander alarms Bathroom pull cords

Falls Awareness Training City of Edinburgh Council: Occupational therapists, social workers, home helps, social care workers, housing, telecare NHS: primary care (GPs, nursing staff, AHPs), hospital staff, continuing care Care Home staff: private, CEC Care agencies Voluntary sector Carers The public

Self management Edinburgh leisure Patient involvement Vocal Voluntary organisations Help the Aged & Age Concern

Establish a falls data base: A&E attendances Emergency admissions Emergency services GP contacts Referrals to Rapid Response teams Out-pt / day hospital referrals Telecare uptake National ISD support

Performance Measures reducing emergency service call-outs for uninjured patients reducing presentation at A&E / reducing emergency admissions increasing number referred for comprehensive falls assessments increasing number identified at risk of fracture prior to first fracture

The art of falling is never landing

Thank you Any questions?