Falls in Bristols residential and nursing care Rob Benington
Injury Prevention Manager Bristol Public Health
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Todays presentation 1.Falls in Bristol 2.NICE guidance 3.Falls
in Bristols care homes 4.Bristols service specification 5.Examples
of falls reduction projects from local providers 6.Building
external links (postural stability, diet, nutrition,
hydration)
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Falls are the leading external cause of death for the
over-75s
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1. Falls in Bristol Every year between 33% and 50% of people
over the age of 65 suffer a fall, (estimates from Help the Aged)
20% of fallers will need medical help and just under 10% will
sustain a fracture Fractured hips cost the NHS 1.8 billion every
year: All smoking 5bn, (2009). All obesity 4.2bn, (2007).
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Emergency admissions Bristol residents aged 65+ due to falls in
2012/13 All Bristol (65+) residents 390Hip fractures 1215Other fall
related injury 4.4Admissions every day 2.8% % of all 65+ Bristol
residents admitted following a fall (57,200 2012 ONS MYE)
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Emergency admissions per day (over 65s) 2008/9 3.9 2009/10 4.4
2010/11 4.0 2011/12 4.3 2012/13 4.4 In 2012/13, 390 people over 65
were admitted to hospital with hip fracture, of which 15-30% die
within 1 year, (60-121 deaths). 39% of Bristols 65+ admissions are
from 7,082 beds 1. Falls In Bristol
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2. NICE Guidance Assessment and prevention of falls in older
people Issued: June 2013 NICE clinical guideline 161
guidance.nice.org.uk/cg161
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Identification of vulnerable people Older people in contact
with healthcare professionals should be asked routinely whether
they have fallen in the past year and asked about the frequency,
context and characteristics of the fall/s. Older people in contact
with healthcare professionals should be asked routinely whether
they have fallen in the past year and asked about the frequency,
context and characteristics of the fall/s. Older people who present
for medical attention because of a fall, or report recurrent falls
in the past year, or demonstrate abnormalities of gait and/or
balance should be offered a multifactorial falls risk assessment.
Older people who present for medical attention because of a fall,
or report recurrent falls in the past year, or demonstrate
abnormalities of gait and/or balance should be offered a
multifactorial falls risk assessment. The multifactorial fall risk
assessment should be performed by a clinician (or clinicians) with
appropriate skills and training. The multifactorial fall risk
assessment should be performed by a clinician (or clinicians) with
appropriate skills and training.
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Biggest risk factor? Having had a fall in the last 12 months.
If youre 65 or older, your health professional or practitioner
should regularly ask whether youve had a fall in the past year. And
if youve had a couple of falls, you should see your doctor anyway,
even if you feel okay. This is because someone who has already had
a fall is more likely to fall in the future. But there are ways of
helping a person avoid having a fall so they can feel more
confident in their daily lives, and perhaps live independently for
longer. NICE Clinical Guideline 21, 2004.
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Fear of falling 'boosts elderly's fall risk' Worry about
falling Restricted activity Functional decline Increasing
unsteadiness / loss of balance Fall
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1.1.3 Multifactorial interventions 1.1.3 Multifactorial
interventions All older people with recurrent falls or assessed as
being at increased risk of falling should be considered for an
individualised multifactorial intervention. 1.1.4 Strength and
balance training 1.1.4 Strength and balance training Strength and
balance training is recommended. 1.1.5 Exercise in extended care
settings 1.1.5 Exercise in extended care settings Multifactorial
interventions with an exercise component are recommended for older
people in extended care settings who are at risk of falling. 1.1.7
Psychotropic medications 1.1.7 Psychotropic medications Older
people on psychotropic medications should have their medication
reviewed, with specialist input if appropriate, and discontinued if
possible to reduce their risk of falling. 1.1.8 Cardiac pacing
1.1.8 Cardiac pacing Cardiac pacing should be considered for older
people with cardioinhibitory carotid sinus hypersensitivity who
have experienced unexplained falls. Most relevant guidance
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Multifactoral interventions In successful multifactorial
intervention programmes the following specific components are
common (against a background of the general diagnosis and
management of causes and recognised risk factors): strength and
balance training strength and balance training home hazard
assessment and intervention home hazard assessment and intervention
vision assessment and referral vision assessment and referral
medication review with modification/withdrawal. medication review
with modification/withdrawal.
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3.Falls in Bristols care homes Public Health Outcome Indicators
Public Health Outcome Indicators Admissions, postcodes Admissions,
postcodes Occupancy and rates Occupancy and rates Confidentiality
Confidentiality
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Falls admissions from ECH, Care Homes, CH with Nursing,
sheltered accommodation (2011/12) Extra Care Housing54 Care Homes
with Nursing129 Residential care homes107 Supported housing91
Total381 8.4% (One in 12)% of 65+ care home residents admitted 39%
Of all Bristols 65+ falls admissions are from 7,082 beds
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Falls by accommodation type
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Residential on average smaller than nursing homes (33 beds vs
57 beds) Residential on average smaller than nursing homes (33 beds
vs 57 beds) Older building / conversions Older building /
conversions Risk = hazard x exposure Risk = hazard x exposure
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Variation of falls admission rates (residential and nursing
homes) by home Of 15 with sig higher than city av ad rates, 12 are
residential homes
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Variation by type (Nursing Homes)
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Variation by type (Residential care)
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Dementia 4 year admission rate CHwNursing 4 year admission rate
CHwNursing = 6.7% 4 year average rate residential care =12.2% 4
year average rate residential care =12.2% Average admission rate
from homes for people with dementia Average admission rate from
homes for people with dementia=15.7%
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4.Joint service specification Falls risk management The
Provider ensures that Service Users are assessed for risk of falls
within 24 hours of admission and the outcome recorded in their Care
and Support Plan. Those Service Users who are vulnerable to falls
are actively supported by their key worker or equivalent member of
care / nursing staff to reduce / prevent the risk of a fall
occurring and thereby supporting a reduction in unnecessary
emergency admissions related to falls. The Provider maintains a
falls register recording such information as the causes of fall
(injurious or otherwise) and this register is regularly audited to
ensure that necessary actions are taken to reduce falls within the
home.
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Medicines management Reducing polypharmacy and proactively
seeking 6-monthly medicines reviews by GP. Hydration/nutrition
Provides access to training on the identification of dehydration.
General Users registered with General Practitioner within 7 days of
admission. Initial Care and Support Plan drawn up on the first day
of admission. Person centred care (and reviews) Care and Support
plans are kept and maintained It is likely that meeting outcomes
will require addressing falls risk factors Wellbeing needs Support
to attend appointments 4.Joint service specification
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Footcare Ensure footcare needs are assessed by an appropriately
trained person (podiatrist where appropriate) Moving on Service
Users are involved in assessing risk for them or others if they
move. Management and leadership effective leadership Working with
the local community The Provider will be knowledgeable of the
services available in the local community and where identified in
the SDS Support plan / CHC Care plan will ensure the Service User
is enabled to access these services. The environment of the care
home (various)
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Summary: Factors affecting variation in falls rates Housing
type Client group (frailty, co-morbidities) Relationship with and
quality of local services? Staff turnover? ( Correlated with
decreases in nursing care, Castle and Engberg, 2005 ). Management
practices?
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FALLS PROJECT 2012
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Falls Auditing Falls audits in the care homes had traditionally
focused upon the number of falls per month was a paper exercise
with no visible positive outcomes Merely looking at the number of
falls does not enable you to establish any trend or cause behind
the number Falls audits in their old format were time consuming,
duplicated information already held and were of no value to the
staff or residents Staff understanding and ownership of falls
management was limited with a perception that falls happen and
without preventing residents from mobilizing they would continue to
fall
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Plotting the Location
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Plotting the Time
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Number of falls in context
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The key to success has been involving the staff as they are the
ones who will make the difference on the floor. Staff really
understand the plotting and the concept of days between falls. The
information is visual, has an immediate impact and does not have to
be computer generated. Looking at a number of different factors
enables you to gather a true picture of what the actual issues are
a number on its own merely provides a snapshot that can be
misleading you may put the wrong corrective or preventative measure
in place if you do not have the full information. Falls happen for
a reason and a pattern can almost always be established for those
residents who repeatedly fall. The patterns and trends you uncover
can be surprising! Auditing in this way adds real value and makes a
positive difference for residents What have we learnt?
