Falls in hospitals What worked for us, what didnt work so well, and - - PowerPoint PPT Presentation

Falls in hospitals

What worked for us, what didn’t work so well, and new (and old) ideas for tackling the challenges

Dr Frances Healey, RN, PhD Senior Head of Patient Safety Intelligence, Research & Evaluation NHS England

Focusing on falls today – but bone health equally critical

Systematic reviews

Reference Title

NICE CG 161 2013 Falls in older people clinical guideline update Appendix E Evidence tables Myakie-Lye et al. 2013 Inpatient Fall Prevention Programs as a Patient Safety Strategy: A Systematic Review Cameron et al. 2012 Interventions for preventing falls in older people in care facilities and hospitals. DiBardio et al. 2012 Meta-analysis: multidisciplinary fall prevention strategies in the acute care inpatient population Spoelstra et al. 2012 Falls prevention in hospitals: an integrative review Oliver, Healey et al. 2010 Preventing falls and fall-related injuries in hospital Oliver et al. 2007 Strategies to prevent falls and fractures in hospitals and care homes: systematic review and meta-analyses. Coussement et al. 2008 Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis.

Who is in the room?

• “Evidence about successful implementation of fall

prevention interventions suggests that the following are important factors: leadership support, engagement of front-line clinical staff …….

• “Fall prevention needs multidisciplinary buy-in, including

nursing, medical, pharmacy and therapy staff, and support staff responsible for housekeeping and building maintenance.”

• Hospital or aged care?

Myakie-Lye et al. 2013 Oliver, Healey & Haines 2010

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Scale of the challenge

Reported annual numbers of falls in hospital in England and Wales

Degree of harm Acute hospitals Mental health Rehabilitation hospitals Total No Harm 143,591 19,470 24,614 187,675 Low 57,306 15,194 12,047 84,547 Moderate 6,596 1,687 1,785 10,068 Severe 777 124 164 1065 Death 68* 7* 8* 83* Total 208,338 36,482 38,618 283,438

* death figures after apparent coding error corrected but before late mortality from injuries is known

c.2,000 fractures reported annually after hospital patients fall in UK

61% 24% 5% 2% 5%

fractured hip (proximal femur) upper limb fracture (humerus, Colles, etc.) lower limb fracture (excluding hip) pelvic fracture (pubic rami)

• ther fracture (rib, skull etc.)

digit (finger, thumb, toes) fracture confirmed but site unclear

John’s story

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Nature of the challenge

Age of patients reported to have fallen in hospitals

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99 100+ % of all reported acute falls Age group

Breakdown by age of falls in acute clusters

0 70 80 90 100

Which gender more likely to fall?

Men 51% fallers but

• nly 44% of beds
• ccupied by men

UK 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 disease
• 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.uk based 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

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A: Assessing risk of falls

The importance of asking about falls history

falls history (causes, consequences, & fear of falling)

Anyone here fallen in past year?

“….but most of our patients didn’t need assessment because their falls were just accidents”

Falls risk assessment

• falls risk prediction

scores (numbers)

• modifiable risk factor

checklists (prompts)

“...... widespread adoption of either [the Morse Falls Scale or STRATIFY] is unlikely to generate benefits significantly greater than that of nursing staff clinical judgment.” “…….sensitivity and positive predictive value were generally too low to make the use of such a tool (or similar ones)

• perationally useful in falls prevention in hospital.......”

“We did not identify any tool which had an optimal balance between sensitivity and specificity, or which were clearly better than a simple clinical judgment of risk of falling”

Systematic reviews: 1. Haines et al. 2007. 2. Oliver et al. 2008. 3. Harrington et al. 2010 4. Da Costa Rutjes et al. 2012

Morse validation study

2% 98% Medium risk

28% 72%

High risk

went

• n to

fall didn't fall 17% 83%

Low Risk Healey F & Haines T (2012) A pragmatic study of the predictive values of the Morse falls score Age & Ageing

For comparison if just age not Morse.....

14% 86% aged 80+ 3% 97% aged 18-79 32% 68% previous fall in hospital fell during next 7 days did not fall in next 7 days

Patients’ risk of falling in hospital

“Regard all inpatients aged 65 years or

• lder as being at risk of falling in

hospital” * Plus inpatients aged 50 to 64 years (if clinical

judgement that underlying condition could cause falls)

“Do not use fall risk prediction tools to predict inpatients’ risk of falling in hospital”

Hospitals using falls risk scores

Healey F & Treml J 2012 Changes in falls prevention policies in hospitals in England and Wales Age & Ageing May 9 2012 Royal College of Physicians 2012 Clinical Effectiveness and Evaluation Unit Report of the 2011 inpatient falls pilot audit www.rcplondon.ac.uk

0% 10% 20% 30% 40% 50% 60% 2006 2009 2011

I find it useful to dismantle my prejudices from time to time………. ………. so I can reconstruct them more firmly than ever Bertrand Russell 1872-1970

Risk factors that can be treated, improved or managed

• Miss A was a retired ballet teacher aged 79
• Admitted after a series of emergency calls following falls at
• home. Ambulance staff say her speech was slurred and

think she may have been drinking.

• Has a spectacular black eye, but no other injuries.
• Brings in a carrier bag with a range of prescribed

medication, sleeping tablets, and herbal remedies

• Appears very unsteady on her feet but refuses to relinquish

her steel-tipped ebony walking stick for a frame

• Will ring for help before mobilising, but considers three

seconds too long to wait, and so sets off without staff

• Deflects any attempts to formally assess her memory or

self-care skills; ‘maybe tomorrow, darling, I’m just too tired’.

• Is extremely thin but says she always has been, rejects

everything on the menu except toast

Multifactorial assessment may include:

• continence problems
• cognitive impairment
• 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

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• B. Individualised care planning

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.” “How can we prevent patients falling?” may be the wrong

• question. Perhaps we just need to

repeatedly ask “How can we reduce the risk of this patient falling?”

49% of fallers were on ‘culprit’ medication 23% did not have medication reviewed

Risk factors in hospital fallers

Hospital inpatients Odds Ratio (95% CI) History of falls 2.85 (1.14–7.15) Sedatives 1.89 (1.37–2.60) Antidepressants (yes vs. no) 1.98 (1.00–3.94) Cognitive impairment 1.52 (1.18–1.94) Age (for 5 years increase) 1.04 (1.01–1.06)



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 Gerontol Geriatr 56 (2013) 407–415

Risk factors for injury in hospital fallers

Hospital inpatients Odds Ratio (95% CI)

SRRIs (yes vs. no) 1.84 (1.04-2.67) 2+ antipsychotic 3.26 (1.20-8.90) Opiate 1.59 (1.14-2.20) Diuretic 1.53 (1.03-2.26)

 Mion et al. Is it possible to identify risks for injurious falls in hospitalized

patients? Jt Comm J Qual Patient Saf; 2012 Sep;38(9):408-13

Reducing sedative medication reduces falls rates

Study Effect on medication use Falls Haumschild et

• al. 2003

Through ward visits by pharmacists, significantly reduced prescribing rate

• f “culprit” medication

Reduced by

47% (p<0.05)

Peterson et al. 2005 Through computerised medication

• rdering system alerts, significant

reductions in prescriptions of neuroleptics and sedatives Reduced by

55% (p <0.001)

Healey et al. 2013 Through educating nurses to influence colleagues as part of multifactorial intervention, reduced night sedation from 34% to10% of patients Reduced by

25% (p<0.01)

Use pharmacy accounts to monitor initiatives to drive down your levels

• f sedative use

Don’t just reconcile, review

Dementia affects falls risk:

• Difficulty in recognising hazards, understanding
• wn limitations
• Neurological changes - in walking patterns,

postural drops in BP, delayed reflexes

• Sedative medication
• High susceptibility to delirium

65% of fallers were cognitively impaired 24% of patients had no cognitive assessment

How good at spotting confusion are……

• Doctors?
• Nurses?
• Therapists?

Even more of a risk if no one realises the patient is cognitively impaired…………….

Doctors’ guesstimates……..

“………many doctors do not administer the full 10 questions, preferring to estimate the patient's score instead. We asked doctors to predict the patient's AMTS during the admission

• interview. A true AMTS was then recorded.”

Burleigh et al. Can doctors predict patients' abbreviated mental test scores? Age & Ageing 2002 31 (4): 303-306.

• Fairly accurate at extremes
• Overall, 69% of the ‘estimated’ AMTS incorrect
• 32% of the ‘estimated’ AMTS very incorrect:
• 13% were underdiagnosed (cognitive impairment missed)
• 19% were overdiagnosed (not actually cognitively impaired)

But nurses have to plead guilty too…..

Patients nurses know are forgetful or confused Patients with AMTS <6/10 AMTS 0/10

Not just recording it, sharing it, and adapting care to it

36% of fallers had delirium 41% of patients had no delirium assessment

Differences between delirium & dementia

Delirium treatment = falls prevention Falls prevention = delirium treatment

• Multifactorial and multidisciplinary approach
• Identify and treat underlying health problems
• Manage pain but minimise medication
• Hydration/nutrition
• Minimise unintended restraints (catheters, IVs, etc.)
• Orientation/reduce noise/lighting
• Tolerate/anticipate/don’t agitate (TA-DA)

Inouye SK. Delirium in older persons. The New England Journal of Medicine 2006;354(11):1157-65.

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.uk based 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

In your policies and care plans and guidance, focus on cognitively impaired patients as the norm, with interventions for cognitively intact patients as the exception

Anytown Hospital Falls prevention policy

• We don’t know how many of the rest had it done

properly:

• a skill with specific technique
• sitting and standing is pointless
• equipment selection…

36% of fallers had orthostatic hypotension 61% of patients had no L&S BP taken

Which do you prefer?

0% 5% 10% 15% 20% 25% 30% 35% A t h it l 0% 5% 10% 15% 20% 25% 30% 35% A t h it l

Whilst walking From beds Circumstances unclear From chairs From toilet or commode Other Whilst walking From beds Circumstances unclear From chairs From toilet or commode Other

NPSA 2007 Slips trips and falls in hospital NPSA: London

58% of fallers had continence problems/urgency 24% of patients - no continence assessment

Privacy and dignity or safety first?

Keep it simple

Ask your patients if they want you to stay with them, wait outside, or go right away. If they can no longer express preferences, ask family/friends about their attitudes to privacy.

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

I am not going to trespass on my physiotherapy colleagues’ expertise…

Do we really encourage mobility?

• Older hospital patients in the USA who could mobilise

averaged 332 steps a day (about 20 steps each waking hour)

• Mobile pre-discharge older patients in UK spent 25 minutes

a day standing or walking; most times when they walked, they walked less than 20 steps

• “…….[these patients] had a lack of opportunity to

mobilise rather than a lack of ability to mobilise”

Fisher et al, 2012 factors that differentiate level of ambulation in hospitalised older adults Age & Ageing 41 (1) 107-111 Roberts et al. 2012 Measuring activity in older inpatients Age & Ageing research letters Feb 1 2012

“ ....... the alarm was brilliant – after we’d been using it for a few days he didn’t even try to stand up any more.”

Ward sister, overheard at a conference

http://www.nrls.npsa.nhs.uk/resources/?EntryId45=94850

“Ultralow bed ordered to ensure he cannot get to his feet without nurses.”

“.... if we can get the intentional rounding right none

• f our patients will ever have to get out of their

chairs except for the toilet.”

Snelling 2013 ‘Ethical and professional concerns in research utilisation: Intentional rounding’ Nursing Ethics 1–14

Do we mobilise 24/7?

30% 9% 26% 35%

• n all wards
• n most wards
• n one or some

wards not on any wards

Bring together medical, therapy and nursing staff to find practical solutions that deliver everyday rather than weekday remobilisation

Take the early and frequent mobilisation of medical patients as seriously as we take the early and frequent mobilisation of surgical and trauma patients

5 before-and-after studies of bedrail reduction

Falls (% change) Injuries (% change) Serious injuries (change in N) Stat sig? Si 1999 +61% No change +1 Yes (falls)

• esp. stroke

Hoffman 2003

• 7%
• 2%

+1 No (but bedrail use not reduced much) Brown 1997 +118% ~ ~ Yes (falls)

• esp. visually

impaired Hanger 1999 +25% +3% +1 (if taking neuro obs ≠ SI) Yes (falls) Capezuti 2007  46% int.  38% cont. ~ ~ 2 1 7 4 Yes & no….

Design change

www.npsa.nrls.nhs.uk/alerts www.rcn.org.uk

• Used as restraint
• Injuries from floor-level

furniture or fittings

• Entrapment gaps
• Left at working height in

error

• Trips over crash mats
• Used with bedrails raised

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Safer care environments,

• bservation, and ‘standard

care’

Information for patients should include:

• Explaining about the patient's individual risk

factors for falling in hospital

• Showing the patient how to use the nurse call

system and encouraging them to use it when they need help

• Informing family members and carers about when

and how to raise and lower bed rails

• Providing consistent messages about when a

patient should ask for help before getting up or moving about

• Helping the patient to engage in any multifactorial

intervention aimed at addressing their individual risk factors.

• It feels painfully symbolic of my loss of independence
• I know how busy the staff are and feel guilty
• I sense staff disapprove of patients who buzz too often

and fear the reaction of whoever responds @GrangerKate

I will always remember the first time I ever pressed my buzzer in hospital. It was a couple of days into my admission to the Gynaecology Unit and I woke up with excruciating abdominal pain. I was in proper agony. The reaction I received from the staff nurse was one of

• indifference. I think this experience has conditioned me

to be an infrequent buzzer.

Make specialing special

• Training with recognised skills and status
• Teach personal resilience and coping skills
• Rotation and rest periods
• Access to diversion materials

Zone

• bservation

Attention to the environment

“Ensure that aspects of the inpatient environment that could affect patients’ risk of falling are systematically identified and addressed.” Including:

• flooring
• lighting
• furniture
• fittings such as hand holds

Use the skills of your occupational therapists & physiotherapists to look at fittings, flooring and lighting as if they were conducting a home hazard assessment, and order minor works to improve the environment

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• D. After a fall

Falls aftercare ‘Have they hurt themselves falling, or fallen because of new illness?’ Post-fall review and care planning ‘How do I stop THIS patient falling again?’

All are important ……

Root Cause Analysis (RCA) ‘How do I learn from this fall to help stop OTHER patients falling in the future?’

Essential care after an inpatient fall

• Have a post-fall protocol specifying:
• Checks for injury before moving
• Safe manual handling if fracture
• Neurological observations
• Timescales for medical review
• Provide:
• Flat-lifting equipment
• Glasgow Coma Scale formats
• Fast track to CT/x-ray/theatre

Nearly done …..

If you’ve gained any new ideas….. Make haste slowly

Would like to do one day Absolutely must do

Make haste slowly and do less but do it well

Key UK falls resource links:

• www.patientsafetyfirst.nhs.uk
• www.nice.org.uk/CG161
• www.nrls.npsa.nhs.uk/alerts
• www.rcplondon.ac.uk/resources/falls-prevention-resources
• http://www.ageuk.org.uk/professional-resources-home
• http://www.nos.org.uk/

Easy reading with hyperlinks to other resources

http://britishgeriatricssociety.wordpress.com/2013/05/16/all-down-to- numbers/ http://britishgeriatricssociety.wordpress.com/2013/12/19/fallsafe-are-culture- clashes-good-for-us/

(or google Healey BGS blogs)

I can’t promise you that you can prevent every fall I can promise there is always something more we can do to prevent falls

Thank you for listening

frances.healey@nhs.net @FrancesHealey