1. Falls in hospitals / Falls in the community
Lisa Stewart, Falls Co-ordinator, Edinburgh CHP
Tel:

2. Falls Falls in older people Falls in hospital Edinburgh CHP
Role of Falls Co-ordinator
Performance measures

3. Definition of a fall
‘Have you had any fall including a slip or trip in which you lost your balance and landed on the floor or ground or lower level?’
(Lamb et al, 2005)

4. Incidence of Falls Age over 65 years: 28 - 35% per year
(Population set to rise to 1 in 4 by 2031)
Age over 80 years: >40% per year
Nursing home residents: ~60% per year
Dementia sufferers % per year

5. Consequences 95% of people with a hip fracture have sustained a fall
5% of falls result in a fracture
1% of falls result in a hip fracture
Approx cost of hip fracture: £12,000
Around 1/3 of those with a hip fracture die within a year
Around half of all hip fracture patients will not return to their previous state of health and independence
Fear of further falls

6. Scottish Hip Fracture Audit (2007)
A Borders General Hospital 165
B Dumfries and Galloway Royal Infirmary 166
C Queen Margaret Hospital, Dunfermline 375
D Forth Valley 354
E Ninewells Hospital, Dundee 464
F Aberdeen Royal Infirmary 491
H Hairmyres Hospital 196
I Glasgow Royal Infirmary 374
J Wishaw General Hospital 290
K Dr Gray’s Hospital, Elgin 140
L Western Infirmary, Glasgow 322
M Crosshouse Hospital 206
N Raigmore Hospital, Inverness 325
O Royal Alexandra Hospital, Paisley 421
P Inverclyde Hospital, Greenock 216
Q Monklands Hospital 232
R Perth Royal Infirmary 185
S Victoria Infirmary, Glasgow 212
T Ayr Hospital 175
U Southern General Hospital, Glasgow 139
V Royal Infirmary of Edinburgh 921
Total 6369

7. Emergency Hospital Admissions: City of Edinburgh (aged 65 and over with a fall)
1998
2001
2006
2007
1270
1280
1488
1558

8. National / local guidelines:
BOA & BGS (2008):The care of patients with a fragility fracture
NICE Clinical Guideline 21 (2004)
SIGN Guideline 111 (2009): Management of hip fracture in older people
Rehabilitation Framework (2007):
Co-ordinated, integrated and fit for purpose
National Patient Safety Agency
(2007): Slips, trips and falls in hospitals
NHS Lothian: Policy & Protocol for the assessment and management of adult hospital patients with falls

9. Falls in hospitals Patients most vulnerable to falls:
Older patients, particularly those over 80
Relative to the proportion of men and women in hospital, there are more reported falls of men than women*
*National Patient Safety Agency, 2007

10. Falls in LUHD 2009

11. Damned if you do damned if you don’t?

12. Types of risk factors Intrinsic factors: Extrinsic factors:
Examples
Intrinsic factors:
Personality & lifestyle
Activities, attitudes to risk, independence and receptiveness to advice
Age-related changes
Changes in mobility, strength, flexibility and eyesight that occur even in healthy old age
Illness & Injury
Stroke, arthritis, dementia, cardiac disease, acquired brain injury, delirium, Parkinson’s disease, dehydration, disordered blood chemistry
Extrinsic factors:
Medication
Sleeping tablets, sedation, painkillers, medication that causes low blood pressure, medication with Parkinsonian side effects, alcohol
Environment
Lighting, wet floors, loose carpets, cables, steps, foot wear, distances and spaces

13. Why patients fall
Most falls are the result of a combination of factors
Poor mobility and confusion are often contributing factors
Environmental hazards such as wet floors or steps are identified in only a small proportion of patient falls

14. When patients are most likely to fall
Weekdays, when there are more patients in hospital
Mid-morning, when patients are more likely to be active
Fewer falls occur at mealtimes and in the early hours of the morning

15. Staff witnessing patient falls
Only a minority of falls are witnessed by staff
Even when a member of staff witnesses a fall, they are unlikely to be able to stop the patient from falling

16. What patients were doing when they fell
Most falls occur whilst patients are walking
Patients are particularly likely to fall whilst using the toilet or commode
Falls from trolleys may be more likely to lead to serious injury and litigation

17. Components of multifaceted interventions (Oliver et al BMJ 2007) –
Medical/Nursing care plans for common reversible risk factors e.g.
Medication
Syncope/presyncope
Delirium/Agitation
Urinary frequency/incontinence
Gait/Balance
Visual impairment
Staff/Patient/Carer education/training
High risk alert bands/stickers
Post fall assessment and plan (medical or nursing)
Environmental Safety/Equipment: increasing range of beds and chairs to suit different needs
Continuous learning from incidents
Policies/Guidelines (inc restraint/bedrail minimisation)

18. STRATIFY (Oliver BMJ 1997 and subsequent e.g. Vassallo 2004 JAGS)
Did the patient fall as a cause for admission or during this admission?
Are they agitated?
Do they have urinary frequency/frequent assisted toileting?
Visual impairment?
Gait instability (able to stand and transfer with difficulty/assistance?)
Total Score 0-5

19. Risk Assessment Tools Are any of them good enough?
False reassurance that something is being done?
Better to concentrate on reviewing each person post fall and modifying reversible risk for everyone
Some of the better trials didn’t bother with them
Why we are so addicted to “off the shelf” tools
Assessment ≠ intervention!
(Oliver, 1997)

20. Recommendations for NHS organisations:
Make sure that the circumstances of falls are described completely and meaningfully in datix reports
Analyse and use reports of falls to learn from ward to board level

21. Clinical Quality Indicators for Falls
CQI: Falls
Element
Criterion
Patient 1-5
Compliance
Assessment
Prevention
Management
65+
Falls Risk Assessment
Documentation
Falls Plan / Action
100%

22. Falls in Edinburgh CHP 68,000 older people 73 GP practices
70 care homes
Rehab hospital (AAH, RFU)
Continuing care (Corstorphine hospital, Ellen’s Glen, Finlay House, Ferryfield)
3 day hospitals
7 day centres
Voluntary organisations

23. Role of Falls Co-ordinator, Edinburgh CHP
Co-ordination between organisations
Linking with QIS (Quality Improvement Scotland)
Implementation of NHS Lothian’s Falls Strategy
Specific falls projects
Falls in hospitals (rehab, continuing care)
Falls in care homes
Training
Outcomes

24. Pathways for the Prevention and Management of Falls and Osteoporotic Fragility fractures (NHS QIS, draft 2009)
Supporting health improvement and self management to reduce the risk of falls and fragility fractures
Identifying individuals at high risk of falls and / or fragility fractures
Responding to an individual who has just fallen and requires immediate assistance
Co-ordinated management including specialist assessment
(Carry out scoping exercise to audit how Lothian is meeting these recommendations)

25. NHS Lothian: Falls Prevention and Bone Health Strategy
Falls group established (Sept 2008) with a designated chair (Corporate Falls Lead) that will be responsible for developing and implementing a Lothian wide action plan
To be agreed by the board November 2009
Five year plan

26. Managing the fallen uninjured person
Emergency services
Edinburgh Council (CAS)
Health & Social Care Direct
GPS / Community Nurses
NHS 24
Referral on for Falls Assessment (Rapid Response Teams)

27. Edinburgh Telecare Project
NHS Lothian & CEC
150 free kits to those who have had a fall and have no alarm
Referrals through Rapid Response Teams
Equipment provided for 6 months
Falls co-ordinator to evaluate: patient evaluation, Euroqual5D, JIT telecare evaluation
Patient’s value of telecare equipment

28. Sayphone (CAS alarm) Falls detector Bed occupancy monitor
Telecare equipment:
Sayphone (CAS alarm)
Falls detector
Bed occupancy monitor
Pressure mats
Wander alarms
Bathroom pull cords

29. Falls Awareness Training
City of Edinburgh Council: Occupational therapists, social workers, home helps, social care workers, housing, telecare
NHS: primary care (GPs, nursing staff, AHPs), hospital staff, continuing care
Care Home staff: private, CEC
Care agencies
Voluntary sector
Carers
The public

30. Self management Edinburgh leisure Patient involvement Vocal
Voluntary organisations
Help the Aged & Age Concern

31. Establish a falls data base:
A&E attendances
Emergency admissions
Emergency services
GP contacts
Referrals to Rapid Response teams
Out-pt / day hospital referrals
Telecare uptake
National ISD support

32. Performance Measures
reducing emergency service call-outs for uninjured patients
reducing presentation at A&E / reducing emergency admissions
increasing number referred for comprehensive falls assessments
increasing number identified at risk of fracture prior to first fracture

33. The art of falling is never landing

34. Thank you
Any questions?