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Implementing the FallSafe bundle

Implementing the FallSafe bundle. Dr Frances Healey, RGN, RMN, PhD Associate Director for Patient Safety, NHS England (past) Associate Director, Clinical Effectiveness and Evaluation Unit, RCP. Plan.

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Implementing the FallSafe bundle

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  1. Implementing the FallSafe bundle Dr Frances Healey, RGN, RMN, PhD Associate Director for Patient Safety, NHS England (past) Associate Director, Clinical Effectiveness and Evaluation Unit, RCP

  2. Plan • My brief: share the experience of piloting in England, how it was approached , what was successful, what the challenges were • Time for sharing thoughts, questions and answers

  3. FallSafe Quality Improvement Project • Led by the Royal College of Physicians • Funded by the Health Foundation • Supported & promoted by:

  4. FallSafe: The Project • “Can a ward-based nurse influence all disciplines to embed evidence-based falls prevention care bundles into regular ward practice using a quality improvement approach?” • Original project: 16 sites, variety of specialities • Extended evaluation (9 sites + 9 controls) awaiting publication • Formally assessed rapid spread at Portsmouth • Informal spread in a range of hospitals

  5. Headline results: original project • Patients without a call bell in reach reduced by 78% • Twice as many requests for medication review • Patients without safe footwear reduced by 67% • Twice as many patients had their L&S BP checked • 56% more patients assessed for confusion • Twice as many patients asked if they were worried they might fall • 41% decrease in patients given night sedation

  6. 60% certain last fall was reported 77% certain last fall was reported Reported falls rate per 1000 bed days + rolling 12 month average Reported injurious falls rate per 1000 bed days + rolling 12 month average Falls rate ratio 12 months before full bundle v.12 months after 0.75 (0.68-0.84), p<0.001 Injurious falls rate ratio 12 months before full bundle v.12 months after 0.86 (0.71-1.03), P=0.11

  7. http://www.rcplondon.ac.uk/resources/falls-prevention-resourceshttp://www.rcplondon.ac.uk/projects/fallsafehttp://www.rcplondon.ac.uk/resources/falls-prevention-resourceshttp://www.rcplondon.ac.uk/projects/fallsafe

  8. What was different about the FallSafe approach? • 1. It was evidence-based

  9. Multi-factorial assessment and intervention reduces falls rates by 20%-30%

  10. Oliver D, Healey F, Haines T (2010) Preventing falls and falls related injuries in hospital Clinics in Geriatric Medicine (26 4 645-692)

  11. “Having been doing this [nursing] for 30 years it’s the first time ‘evidence based’ meant anything to me. I was evidence based and proud of it!”

  12. Multifactorial assessment may include: • cognitive impairment • continence problems • falls history (causes, consequences, & fear of falling) • footwear that is unsuitable or missing • health problems that affect falls risk • medication • postural instability, mobility and/or balance problems • syncope syndrome • visual impairment

  13. Multifactorial intervention • “Ensure that any multifactorial intervention: • promptly addresses the patient’s individual risk factors • takes into account whether the risk factors can be treated, improved or managed during the patient’s expected stay • Do not offer falls prevention interventions that are not tailored to address the patient’s individual risk factors for falling.”

  14. FallSafe: The care bundle1) For all patients • Ask on admission about history of falls and fear of falling • Urinalysis on admission (just one element of underlying illness adding to falls risk) • Avoid new night sedation • Ensure call bell in reach • Ensure appropriate footwear available and in use • Bedrails: assessment of risks and benefits

  15. FallSafe: The care bundle2) ‘high risk’ patients (all patients on FallSafe wards for older people) • Cognitive assessment (AMTS or MMSE) • Test for delirium if cognitively impaired (as per NICE guidelines on delirium) • Visual assessment: recognising objects from end of bed • Lying and standing blood pressure using manual sphygmomanometer (as part of syncope identification) • Nurse to request medication review by medical staff according to agreed guidelines • Toileting assessment and plan

  16. Predicting patients’ risk of falling in hospital “Do not use fall risk prediction tools to predict inpatients’ risk of falling in hospital” • “Regard all inpatients aged 65 years or older as being at risk of falling in hospital” • + inpatients aged 50 to 64 years (if clinical judgement that underlying condition could cause falls) • i.e. now recommend one bundle for all aged 65 years+

  17. Falls risk assessment modifiable risk factor checklists • falls risk prediction scores

  18. What was different about the FallSafe approach? • It was evidence-based • It prioritised the things we struggle with

  19. http://www.rcplondon.ac.uk/projects/national-audit-falls-and-bone-health-older-peoplehttp://www.rcplondon.ac.uk/projects/national-audit-falls-and-bone-health-older-people

  20. National pilot audit • All older patients: • 11% not asked about history of falls • 10% could use a call bell but did not have one in reach • 9% used a mobility aid but had their mobility aid out of reach • 6% had no safe footwear • Even for super-high risk patients (fallers): • 23% did not have medication reviewed • 46% did not have L&S BP checked • 18% no cognitive screening

  21. High levels of dementia and delirium in inpatient fallers • 88% had mobility problems • 65% were cognitively impaired • 65% had bone health problems • 58% had continence problems/urgency • 49% culprit medication • 42% had orthostatic BP/cardiovascular • 37% impaired vision • 36% had delirium Royal College of Physicians 2012 Clinical Effectiveness and Evaluation Unit Report of the 2011 inpatient falls pilot audit www.rcplondon.ac.ukbased on case note review of 447 patients in 46 hospitals who fell in September 2011 – data drawn from those where assessment was not omitted, so potentially skewed

  22. Risk factors for falling in hospital Deandra S, Bravi F, Lucenteforte E et al. Risk factors for falls in older people in nursing homes and hospitals; a systematic review and meta-analysis Arch GerontolGeriatr56 (2013) 407–415

  23. Risk factors for being injured in a fall in hospital Mionet al. Is it possible to identify risks for injurious falls in hospitalized patients? JtComm J Qual Patient Saf; 2012 Sep;38(9):408-13

  24. What was different about the FallSafe approach? • It was evidence-based • It prioritised the things we struggle with • It was multidisciplinary

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