Preventing Falls The South Tees

Journey

Mrs Glynis Peat – Spinal Services Lead, Trauma

Mrs Kathryn Hodgson – Clinical Lead Falls Team

Most common cause of death from injury on the over 65sBetween 10-25% of falls in hospitals and care homes result in fracture

Inpatient Falls26% of all national

patient safety incidents reported

840 550 30

Year Catastrophic Major ModerateInsignificant

/ MinorTotal

08/09 0 23 23 2457 2503

09/10 2 14 23 2130 2169

10/11 2 13 14 2113 2142

11/12 1 20 18 2034 2073

12/13 3 24 31 2469 2527

Number and Severity

2012 - 2013

08/09 09/10 10/11 11/12 12/13

Fractured Neck of Femur

24 14 11 18 27

Other Fractures 20 19 15 16 18

Total 44 33 26 34 45

Fractures

Themes From RCAs

10/11 11/1212/1

3

Risk Assessment completed

91% 97% 95%

Fall within 24 hours 12% 13% 15%

First fall 80% 81% 75%

Fall from bed – bed rails in use

17% 16% 16%

Confused at time of fall 37% 41% 35%

Fall witnessed 18% 19%

Observations recorded 97% 95%

Reporting

What is FallSafe

A quality improvement project led by the Health Foundation aimed at “closing the gap” between the evidence base for effective care and the care that patients actually receive.

Involves educating, inspiring and supporting Registered Nurses (FallSafe leads) to lead ward based MDTs in reliably delivering assessments and interventions through a care bundle approach

What is a Care Bundle?

A list of actions (called elements) that need to be applied consistently to patients for whom they are appropriate. The actions are selected because they have been shown to be effective through research.

Care Bundle - All Patients

• History of falls and fear of falling

• Urinalysis

• Avoidance of night sedation

• Call bell in reach

• Appropriate footwear

• Assessment and provision of walking aids

Care Bundles - Older Patients

• Cognitive assessment

• Delirium screening for those at risk

• Bed rails - risk vs benefit

• Visual assessment

• Lying and standing blood pressure

• Medication review

• Tailored toileting plan

• Post fall checklist–Assessments and neurological examination

• Post fall review to prevent further fall

• Incident report

• RCA for severe harm falls

Care Bundles – After a Fall

Hospital wide falls leadersLead Nurse for TraumaClinical Lead for FallsElderly care consultant

Executive board Overall monitoring

Hospital falls strategy group Clinical MatronsAHP leadClinical leadsPatient and carer representative

FallSafe leads working group FallSafe lead and deputies from each ward from each ward

FallSafe Lead on their ward

Hospital Falls Strategy

Overall monitoring

 

Planning, monitoring and feedback to executive board Policy

Action planningProblem solving Promotion trust wideAssurance Review RCA

Promotion at ward levelTraining at ward level Share learningPoint of contact

LearningUpdatesCommunicationAuditsAction planning Share learning

• Build a ward based MDT improvement team

• Share your knowledge

• Promote project and e-learning tool

• Understand your reported falls

• Undertake measurement of under reporting

• Measure care bundle compliance

Fallsafe Leads Priorities

FallSafe ProjectReducing Falls for all patients

South Tees Hospitals NHS Foundation Trust are implementing the FallSafe project across all inpatient areas. There are three key elements:

They personally reported the last patient fall on this ward that they are aware of (how certain %).

53 (100%)

They believe someone else reported the last fall on this ward that they are aware of (how certain %).

82 (96%)

Under Reporting Audit

Bell in sight and reach? 91%

Safe footwear on feet? 98%

Asked about history of falls? 97%

Asked about fear of falling? 89%

Urinalysis performed? 60%

Avoided night sedation last night? (‘Yes’ = not given, ‘No’ = given)

85%

Cognitive screen? 57%

Lying and standing BP recorded? 71%

Full medication review requested? 71%

Received all relevant bundle elements? 24%

Care Bundles Audit

Or are they any of the below:Have high heelsBacklessNovelty slippers which may be a tripping hazardUnsupportiveIf you have ticked one of the above you would benefit from a different pair of slippers

Do they:Fit well: not loose and baggy or too tight?Have fastenings such as laces, buckle or velcro to help keep your feet insideHave non-slip, lightly padded solesHave soft supple uppersThis would be a “safe” pair of slippers

The Slipper ChallengeHow safe are your slippers?

If you feel your slippers are “unsafe” please ask a visitor to bring you in a different pair. Ask a member of staff for further advice

Results of slipper audit

63% patients wearing

SAFE SLIPPERS

Bell in sight and reach? 91% 99%

Safe footwear on feet? 63% 90%

Asked about history of falls? 90% 92%

Asked about fear of falling? 87% 87%

Urinalysis performed? 60% 70%

Avoided new night sedation last night? 85% 96%

Cognitive screen? 57% 98%

Bed rails risk Assessment 96%

Lying and standing BP recorded? 40% 50%

Full medication review requested? 71% 86%

Received all relevant bundle elements? 24% 44%

Care Bundles Audit

Achievements 2013/14

19.3% reduction in number of falls

20% reduction in the number of patients who sustained a fracture (58% reduction hip fractures)

Falls per patient bed day: Trust - All Divisions between April 2012 & March 2014

0.0000

0.0010

0.0020

0.0030

0.0040

0.0050

0.0060

0.0070

0.0080

0.0090

Fa

lls

pe

r b

ed

da

yFalls per 1,000BD

What is Quest?

• NHS QUEST is the first member-convened network for Foundation Trusts who wish to focus relentlessly on improving quality and safety.

• The NHS QUEST membership is currently made up of 16 Foundation Trusts from across England.

• Falls collaborative has been set up to work together to address the complex issue of reducing falls in inpatient setting.

Synplex Influence Map

Note: arrows depict negative impact.

127.Ward/Department environment is hazardous (fixed and physical environment)

88a. Falls prevention is not being recognised as everyone's responsibility131. Staff do not have sufficient skills to prevent patients from falling

6. The challenge of maintaining safety for patients who are confused (for whatever reason) 146. Challenge of toileting150. Not minimising the intrinsic risks (individualised) identified

131b.Insufficient staff

132. Inability to adapt the environment within constraints of finance and infrastructure

128. Non reliability of interventions due to human factors (everyone)75. Patients choosing not to follow advice (no cognitive impairments)147. Inadequate communication between staff and patients148. Inadequate communication between staff

149. Not identifying the individuals intrinsic risk factors145. Risk assessment tools being used as a paper exercise151. Not thinking outside of the box (tendency to tick the box)157. Inability to follow the whole process/cycle

155. Poor engagement of staff to be 'falls aware'159. Competing priorities (falls prevention is just one of many challenges)

AIMTo

reduce harm from

falls by 50% by

June 2015

Culture & behaviour – falls

prevention

Reliable falls care processes

Environmental factors

Leadership

Primary Drivers Secondary Drivers

• Multi media falls prevention strategy

• Human factors• Staff and patient education• Engagement of patients and

staff in falls prevention strategies• Dynamic, individualised risk assessment

• Dynamic communication plan• Individualised plan of care to

manage at risk patients• Management of confused patients• Assessment of environment• Visual management of risk• Patient placement on ward• No night-time transfers• Management of the patient at

night• Toileting• Rapid review for every patient post-

fall• Safe staffing in the management of

falls• Falls measurement• Reliability with falls bundle

interventions

Driver diagram

CHANGE TESTED

“DO” DATE

PREDICTION & RESULTS NEXT STEPS

SWARM Ongoing All actions identified within falls risk assessment will not have been completed.RESULTS - footwear - alcohol - confused patients

Footwear trialReview care of confused patients

PDSAs

PDSAsCHANGE TESTED

“DO” DATE

PREDICTION & RESULTS NEXT STEPS

PATIENT EDUCATION

22/09/14 The use of information leaflets will increase patient awareness of falls risks and actions they can take to minimise their risk.

Observation and patient interviews.

PDSAsCHANGE TESTED

“DO” DATE

PREDICTION & RESULTS NEXT STEPS

ENHANCED OBSERVATION

10/11/14 The policy will not have been implemented fully. Implementation will reduce falls for confused patients.

Raise staff awareness at ward meeting. Improve Implementation of documentation and processes.Levels and

InterventionsLevel 0

General observation. No behavioural concerns. Staff are expected to be aware of the whereabouts of the patient in their care

Level 1

Regular behavioural observations. Record triggers and plan therapeutic interventions to prevent escalation.

Level 2

Patient(s) within sight at all times and observed at a minimum frequency of every 15 minutes.

Level 3

The patient is within arm’s reach (security to be informed of the need for possible rapid response).

PDSAsCHANGE TESTED

“DO” DATE

PREDICTION & RESULTS NEXT STEPS

FOOTWEAR 01/11/14 Patients will not have appropriate footwear on admission. Providing footwear will reduce falls.

To roll out.

CHANGE TESTED

“DO” DATE

PREDICTION & RESULTS NEXT STEPS

RAISING STAFF AWARENESS

10/11/14 Staff will have an increased awareness of the QUEST falls project and be more proactive.

Distribute posters and newsletters.

PDSAs

PDSAsCHANGE TO BE TESTED

WHEN? PREDICTION

NURSING DOCUMENTATION

November Nursing time will be freed up. This will positively influence ability to improve implementation of enhanced guidance

CHANGE TO BE TESTED

WHEN? PREDICTION

STAFF EDUCATION December Increased knowledge will assist in reducing patient risk.

PDSAs

CHANGE TO BE TESTED

WHEN? PREDICTION

WALKING AID SIGNS February Usage will improve patient compliance with instructions provided

PDSAs

Falls per 1,000 BD

Next Challenge?

• Improve (sustaining is a challenge in itself)

• Share and Spread

• Documentation

• RCP Audit

• AHSN

Life is a journey, not a destination

Aerosmith