Trish Prady – Lead Nurse for Quality Safety and Innovation Reducing Falls at RCHT Trish Prady – Lead Nurse for Quality Safety and Innovation Patricia.Prady@rcht.cornwall.nhs.uk

“THE FIRST REQUIREMENT OF A HOSPITAL IS THAT IT SHOULD DO THE SICK NO HARM” Nightingale (1863) Ask students to consider the history of the nhs and how things have changed in terms of patient and public expectations as well as moves forward with technology. Then think about the way we care for patients in terms of ie. environments and staffing CARE. Then ask question about our own values and patients coming to harm in our care.

To understand why patients fall in hospital Aims To understand why patients fall in hospital Understand falls prevention in the Context of the National Harmfree care agenda (“Safety Thermometer”) CQUIN Promote the Falls policy and implement the Fallsafe Care Bundle as a method of enhancing patient safety and care 1.The harmfree care agenda is a national initiative and looks at all the most common harms that can happen in hospital ward environments. (National initiative uses the safety thermometer once a month to measure harm on all inpatient wards – measures every patient for harm falls pressure ulcers, CAUTI and VTE) 2. Understand why patients fall (so that we can protect them better) 3. Make sure that we use our policy correctly by proper application so that patients are protected.

How do we change what we do to ensure that vulnerable people in our care are safe from Falls? Ask your students to think personally about someone in your own life who is elderly and vulnerable to falls? A mother, grandmother, neighbour….tell a story about yourself and someone that you know in your life. I usually talk about my mother in law who is 84 has mild dementia and lives alone. She fell one very sunny day because she went out to feed the birds and stumbled on ill fitting shoes (not done up properly.) The long term consequences - she is now frightened to go out and do things for herself. (Discuss a couple of students scenarios if you have time)

“Just one of those things that happens in hospital” What do you think? “Not what you want to happen, but an inevitable part of getting patients mobile” “Falls are a nurse’s responsibility, not a doctor’s” “A normal part of a hospital stay” Look at the way we ourselves view falls incidents and the way others view them that students work with. Give time to reflect … and finish with the understanding that; Falls are every ones responsibility – whole MDT. Falls are not an expected part of care they are a failure to protect adequately. Falls are mostly avoidable and risk can be reduced. Patients who are encouraged to be mobile need the correct support around them while they are mobilising – not taking chances. Use the care round routine to encourage patients to ask for help etc.

Drivers for Change Falls make up 65% of all reported incidents at RCHT The majority of falls are on high risk/high dependence inpatient adult wards – Over 90% are on 12 wards (120 per month) Falls with harm - There have been 20 falls with moderate to severe harm since 1st April 2013 of these 7 people have died as a result of the fall A review of SI’s incidents and concerns over timely initial assessment , reassessment, handover of risk from one shift to another and between wards and has led to a question over our documentation process Documentation Subgroup and Pilot on Frailty and Wheal Coates (Change cycle testing)

The Patients Perspective…… “after my fall I was scared to get out of bed or even reach for my drink” “I was in hospital for another 3 weeks after I fractured my hip” The facts …but think about the personal consequences to….! Think about how you would feel if this happens on your ward in your care? Because it does happen on our wards and in our care. Each serious incident is investigated so that lessons can be learned

Mapping the Changes Periods of high activity in the organisation Implementation of trust wide care rounds The journey to making our wards safer by reducing falls incidents; Our own trustwide (monthly falls rate is telling us that we have only lately made improvements to falls rate. Activity concentrates on; Improving compliance with falls risk assessment and plan of care to prevent falls – Do this within 4 hours of admission Ensure all falls risk patients are CARE rounded. – Make sure this is thorough patient focused and consistent (not a paper exercise) High falls happen when we have high activity and staff challenges – concentrate on basic care during these periods and who is at risk in your care. Be very vigilant to prevent repeat falls – people who fall more than once?? What have you done to assist prevention? Communicate risk to other staff so that it also becomes a priority for them. No greater priority than safety! Tool box talk rollout Documentation Review Improved data assurance (safety cross roll out)

Sharing the improvement… ………………….How do we sustain the improvement?

Why Do Patients Fall in Hospital? Medical Problems Confusion Environmental Ward Clutter! Lighting Toileting Food/ fluid Heights Flooring Call Bells CVS Neuro ENT Visual Biomechanical Metabolic Pharmacological Dementia & Delerium Illustrates the multidimensional nature of falls risk and prevention. Needs to be addressed from all angles – What can you do in your sphere to prevent falls??

Falls Safety Cross Month: Ward:   Ward: INCIDENT FREE DAY Safety cross – on your knowing how we are doing board. Use at team safety brief so that all staff are aware of falls incidents. They will know who needs protecting even if not on their own workload. Plot and report all incidents on datix and on your safety cross PATIENT FALL MULTIPLE FALLS

What Can you Do? Assess appropriately – Make sure each patient has a prevention plan in place? Consider the Environment (Clutter, property, obstacles) Keep the environment clear! Has a Multifactorial falls assessment been done? (Meds reviewed, urinalysis, glasses, hearing aid available…?) Appropriate footwear? (Yellow socks as a temporary solution) Appropriate (Familiar) Walking aid ? Line of sight – Particularly Dementia Patients Safe Observation policy – escalate if you are concerned for a patients safety Falls prevention aids where appropriate Use of relatives and carer’s to assist you to protect patients. Increase direct care time – PW keep working at the bedside (reduces patient anxiety) Team Focus on who is at risk – Safety Briefings CARE ROUNDING What you can do to prevent fallsSelf explanatory – but labour the point that its often the simple and commonsense things that protect patients. Improving direct care time high nursing visibility makes patients safer!

Advantages of CARE Rounding Higher patient satisfaction levels Higher staff satisfaction Reduction in call bell use Reduction in falls and pressure ulcers More effective use of nursing time Cost savings in reducing harms (Meade et al 2006; Gardener et al 2009) CARE campaign – delivering compassionate care. Keeping nurses at the bedside doing those caring things that nurses like to do. Improved direct care time aggregate 46% across all wards and we are working on improving this further. Key nursing priority is at the bedside. (Not doing other back office things…!) The balance to be struck is between ensuring staff recognise the need to maintain individualised care and meeting routine basic care needs in busy environments. Challenge - if you feel this is a paper exercise? (Paper excercises do not protect patients – high nursing Direct care time and Staff visibility does protect them.) 13

Prompts Basic care in busy environments Rationale Provides Reassurance Prompts Basic care in busy environments Early response to patients changing condition Involves the whole team Promotes Independence While maintaining safety

Any Questions?? Help and advice on falls prevention Trish Prady Ext 3050 email patricia.prady@rcht.cornwall.nhs.uk