Falls in Bristol’s residential and nursing care Rob Benington Injury Prevention Manager Bristol Public Health

Today’s presentation 1.Falls in Bristol 2.NICE guidance 3.Falls in Bristol’s care homes 4.Bristol’s service specification 5.Examples of falls reduction projects from local providers 6.Building external links (postural stability, diet, nutrition, hydration)

Falls are the leading external cause of death for the over-75s

1. Falls in Bristol Every year between 33% and 50% of people over the age of 65 suffer a fall, (estimates from Help the Aged) 20% of fallers will need medical help and just under 10% will sustain a fracture Fractured hips cost the NHS £1.8 billion every year: All smoking £5bn, (2009). All obesity £4.2bn, (2007).

Emergency admissions Bristol residents aged 65+ due to falls in 2012/13 All Bristol (65+) residents 390Hip fractures 1215Other fall related injury 4.4Admissions every day 2.8% % of all 65+ Bristol residents admitted following a fall (57, ONS MYE)

Emergency admissions per day (over 65’s) 2008/ / / / / In 2012/13, 390 people over 65 were admitted to hospital with hip fracture, of which 15-30% die within 1 year, ( deaths). 39% of Bristol’s 65+ admissions are from 7,082 beds 1. Falls In Bristol

2. NICE Guidance Assessment and prevention of falls in older people Issued: June 2013 NICE clinical guideline 161 guidance.nice.org.uk/cg161

Identification of vulnerable people Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s. Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s. Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. The multifactorial fall risk assessment should be performed by a clinician (or clinicians) with appropriate skills and training. The multifactorial fall risk assessment should be performed by a clinician (or clinicians) with appropriate skills and training.

Biggest risk factor? Having had a fall in the last 12 months. “If you’re 65 or older, your health professional or practitioner should regularly ask whether you’ve had a fall in the past year. And if you’ve had a couple of falls, you should see your doctor anyway, even if you feel okay. This is because someone who has already had a fall is more likely to fall in the future. But there are ways of helping a person avoid having a fall so they can feel more confident in their daily lives, and perhaps live independently for longer”. NICE Clinical Guideline 21, 2004.

Fear of falling 'boosts elderly's fall risk' Worry about falling Restricted activity Functional decline Increasing unsteadiness / loss of balance Fall

1.1.3 Multifactorial interventions Multifactorial interventions All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention Strength and balance training Strength and balance training Strength and balance training is recommended Exercise in extended care settings Exercise in extended care settings Multifactorial interventions with an exercise component are recommended for older people in extended care settings who are at risk of falling Psychotropic medications Psychotropic medications Older people on psychotropic medications should have their medication reviewed, with specialist input if appropriate, and discontinued if possible to reduce their risk of falling Cardiac pacing Cardiac pacing Cardiac pacing should be considered for older people with cardioinhibitory carotid sinus hypersensitivity who have experienced unexplained falls. Most relevant guidance…

Multifactoral interventions In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors): strength and balance training strength and balance training home hazard assessment and intervention home hazard assessment and intervention vision assessment and referral vision assessment and referral medication review with modification/withdrawal. medication review with modification/withdrawal.

3.Falls in Bristol’s care homes Public Health Outcome Indicators Public Health Outcome Indicators Admissions, postcodes Admissions, postcodes Occupancy and rates Occupancy and rates Confidentiality Confidentiality

Falls admissions from ECH, Care Homes, CH with Nursing, sheltered accommodation (2011/12) Extra Care Housing54 Care Homes with Nursing129 Residential care homes107 Supported housing91 Total % (One in 12)% of 65+ care home residents admitted 39% Of all Bristol’s 65+ falls admissions are from 7,082 beds

Falls by accommodation type

Residential on average smaller than nursing homes (33 beds vs 57 beds) Residential on average smaller than nursing homes (33 beds vs 57 beds) Older building / conversions Older building / conversions Risk = hazard x exposure Risk = hazard x exposure

Variation of falls admission rates (residential and nursing homes) by home Of 15 with sig higher than city av ad rates, 12 are residential homes

Variation by type (Nursing Homes)

Variation by type (Residential care)

Dementia 4 year admission rate CHwNursing 4 year admission rate CHwNursing = 6.7% 4 year average rate residential care =12.2% 4 year average rate residential care =12.2% Average admission rate from homes for people with dementia Average admission rate from homes for people with dementia=15.7%

4.Joint service specification Falls risk management The Provider ensures that Service Users are assessed for risk of falls within 24 hours of admission and the outcome recorded in their Care and Support Plan. Those Service Users who are vulnerable to falls are actively supported by their key worker or equivalent member of care / nursing staff to reduce / prevent the risk of a fall occurring and thereby supporting a reduction in unnecessary emergency admissions related to falls. The Provider maintains a falls register recording such information as the causes of fall (injurious or otherwise) and this register is regularly audited to ensure that necessary actions are taken to reduce falls within the home.

Medicines management Reducing polypharmacy and proactively seeking 6-monthly medicines reviews by GP. Hydration/nutrition Provides access to training on the identification of dehydration. General Users registered with General Practitioner within 7 days of admission. Initial Care and Support Plan drawn up on the first day of admission. Person centred care (and reviews) Care and Support plans are kept and maintained It is likely that meeting outcomes will require addressing falls risk factors Wellbeing needs Support to attend appointments 4.Joint service specification

Footcare Ensure footcare needs are assessed by an appropriately trained person (podiatrist where appropriate) Moving on Service Users are involved in assessing risk for them or others if they move. Management and leadership …effective leadership… Working with the local community The Provider will be knowledgeable of the services available in the local community and where identified in the SDS Support plan / CHC Care plan will ensure the Service User is enabled to access these services. The environment of the care home (various)

Summary: Factors affecting variation in falls rates Housing type Client group (frailty, co-morbidities) Relationship with and quality of local services? Staff turnover? ( Correlated with decreases in nursing care, Castle and Engberg, 2005 ). Management practices?

FALLS PROJECT 2012

Falls Auditing  Falls audits in the care homes had traditionally focused upon the number of falls per month – was a paper exercise with no visible positive outcomes  Merely looking at the number of falls does not enable you to establish any trend or cause behind the number  Falls audits in their old format were time consuming, duplicated information already held and were of no value to the staff or residents  Staff understanding and ownership of falls management was limited with a perception that ‘falls happen’ and without preventing residents from mobilizing they would continue to fall

Plotting the Location

Plotting the Time

Number of falls – in context

The key to success has been involving the staff as they are the ones who will make the difference on the floor. Staff really understand the plotting and the concept of days between falls. The information is visual, has an immediate impact and does not have to be computer generated. Looking at a number of different factors enables you to gather a true picture of what the actual issues are – a number on its own merely provides a snapshot that can be misleading – you may put the wrong corrective or preventative measure in place if you do not have the full information. Falls happen for a reason and a pattern can almost always be established for those residents who repeatedly fall. The patterns and trends you uncover can be surprising! Auditing in this way adds real value and makes a positive difference for residents What have we learnt?

Sandra Payne Head of Clinical Excellence Brunelcare – Mob – 0778

Falls in Bristol’s residential and nursing care Rob Benington Injury Prevention Manager Bristol Public Health