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 Inpatient Fall Prevention Programs as a Patient Safety Strategy: A Myakie-Lye et al. 2013 Systematic Review Interventions for preventing falls in older people in care facilities and Cameron et al. 2012 hospitals. Meta-analysis: multidisciplinary fall prevention strategies in the acute DiBardio et al. 2012 care inpatient population Falls prevention in hospitals: an integrative review Spoelstra et al. 2012 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 ……. Myakie-Lye et al. 2013 • “Fall prevention needs multidisciplinary buy-in, including nursing, medical, pharmacy and therapy staff , and support staff responsible for housekeeping and building maintenance.” Oliver, Healey & Haines 2010 • Hospital or aged care?

Scale of the challenge 7 NHS | Presentation to [XXXX Company] | [Type Date]

Reported annual numbers of falls in hospital in England and Wales Degree of Acute Mental Rehabilitation harm hospitals health 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 fractured hip (proximal femur) 5% 2% upper limb fracture (humerus, 5% Colles, etc.) lower limb fracture (excluding hip) pelvic fracture (pubic rami) 24% 61% other fracture (rib, skull etc.) digit (finger, thumb, toes) fracture confirmed but site unclear

John’s story

Nature of the challenge 12 NHS | Presentation to [XXXX Company] | [Type Date]

Age of patients reported to have fallen in hospitals Breakdown by age of falls in acute clusters % of all reported acute falls 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 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+ 0 70 80 90 100 Age group

Which gender more likely to fall? Men 51% fallers but only 44% of beds occupied 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

A: Assessing risk of falls 16 NHS | Presentation to [XXXX Company] | [Type Date]

The importance of asking about falls history Anyone here fallen in past year? falls history (causes, consequences, & fear of falling)

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

Falls risk assessment • modifiable risk factor • falls risk prediction scores (numbers) 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) operationally 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 High risk Low Risk Medium risk 2% went 17% on to 28% fall didn't 72% 83% fall 98% 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..... aged 80+ aged 18-79 previous fall in hospital 3% fell during 14% next 7 days 32% did not fall 68% 86% in next 7 97% days

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” * Plus inpatients aged 50 to 64 years (if clinical judgement that underlying condition could cause falls)

Hospitals using falls risk scores 60% 50% 40% 30% 20% 10% 0% 2006 2009 2011 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

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

B. Individualised care planning 29 NHS | Presentation to [XXXX Company] | [Type Date]

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

“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?” “ Do not offer falls prevention interventions that are not tailored to address the patient’s individual risk factors for 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) 1.84 (1.04-2.67) SRRIs (yes vs. no) 3.26 (1.20-8.90) 2+ antipsychotic 1.59 (1.14-2.20) Opiate 1.53 (1.03-2.26) Diuretic  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