Implementing the FallSafe bundle

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Implementing the FallSafe bundle

• Dr Frances Healey, RGN, RMN, PhD
• Associate Director for Patient Safety, NHS
  England
• (past) Associate Director, Clinical Effectiveness
  and Evaluation Unit, RCP

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Plan

• My brief share the experience of piloting in
  England, how it was approached , what was
  successful, what the challenges were
• Time for sharing thoughts, questions and answers

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FallSafe Quality Improvement Project

• Led by the Royal College of Physicians
• Funded by the Health Foundation
• Supported promoted by

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FallSafe The Project

• Can a ward-based nurse influence all disciplines
  to embed evidence-based falls prevention care
  bundles into regular ward practice using a
  quality improvement approach?
• Original project 16 sites, variety of
  specialities
• Extended evaluation (9 sites 9 controls)
  awaiting publication
• Formally assessed rapid spread at Portsmouth
• Informal spread in a range of hospitals

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Headline results original project

• Patients without a call bell in reach reduced by
  78
• Twice as many requests for medication review
• Patients without safe footwear reduced by 67
• Twice as many patients had their LS BP checked
• 56 more patients assessed for confusion
• Twice as many patients asked if they were worried
  they might fall
• 41 decrease in patients given night sedation

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60 certain last fall was reported
77 certain last fall was reported
Reported falls rate per 1000 bed days rolling
12 month average Reported injurious falls rate
per 1000 bed days rolling 12 month average
Falls rate ratio 12 months before full bundle
v.12 months after 0.75 (0.68-0.84), plt0.001
Injurious falls rate ratio 12 months before full
bundle v.12 months after 0.86 (0.71-1.03), P0.11
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http//www.rcplondon.ac.uk/resources/falls-prevent
ion-resources http//www.rcplondon.ac.uk/projects
/fallsafe
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What was different about the FallSafe approach?

• 1. It was evidence-based

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Multi-factorial assessment and intervention
reduces falls rates by 20-30
Reference Title Details
NICE 2013 Falls in older people clinical guideline update Appendix E Evidence tables http//www.nice.org.uk/guidance/index.jsp?actiondownloado62252
Myakie-Lye et al. 2013 Inpatient Fall Prevention Programs as a Patient Safety Strategy A Systematic Review http//annals.org/article.aspx?articleid1656443
Cameron et al. 2012 Interventions for preventing falls in older people in care facilities and hospitals. doi 10.1002/14651858.CD005465.pub3
DiBardio et al. 2012 Meta-analysis multidisciplinary fall prevention strategies in the acute care inpatient population J Hosp Med. 20127497-503
Spoelstra et al. 2012 Falls prevention in hospitals an integrative review Clin Nursing research 21 (1) 92-112
Oliver et al. 2010 Preventing falls and fall-related injuries in hospitals (narrative update of Oliver et al. 2007)  Clin Geriatr Med. 201026645-9
Oliver et al. 2007 Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment systematic review and meta-analyses.  BMJ. 200733482
Coussement et al. 2008 Interventions for preventing falls in acute- and chronic-care hospitals a systematic review and meta-analysis.  J Am Geriatr Soc. 20085629-36
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Oliver D, Healey F, Haines T (2010) Preventing
falls and falls related injuries in hospital
Clinics in Geriatric Medicine (26 4 645-692)
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• Having been doing this nursing for 30 years
  its the first time evidence based meant
  anything to me. I was evidence based and proud of
  it!

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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

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Multifactorial intervention

• Ensure that any multifactorial intervention
• promptly addresses the patients individual risk
  factors
• takes into account whether the risk factors can
  be treated, improved or managed during the
  patients expected stay
• Do not offer falls prevention interventions that
  are not tailored to address the patients
  individual risk factors for falling.

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FallSafe The care bundle1) For all patients

• Ask on admission about history of falls and fear
  of falling
• Urinalysis on admission (just one element of
  underlying illness adding to falls risk)
• Avoid new night sedation
• Ensure call bell in reach
• Ensure appropriate footwear available and in use
• Bedrails assessment of risks and benefits

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FallSafe The care bundle2) high risk patients
(all patients on FallSafe wards for older people)

• Cognitive assessment (AMTS or MMSE)
• Test for delirium if cognitively impaired (as per
  NICE guidelines on delirium)
• Visual assessment recognising objects from end
  of bed
• Lying and standing blood pressure using manual
  sphygmomanometer (as part of syncope
  identification)
• Nurse to request medication review by medical
  staff according to agreed guidelines
• Toileting assessment and plan

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Predicting 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
inpatients aged 50 to 64 years (if clinical
judgement that underlying condition could cause
falls) i.e. now recommend one bundle for all
aged 65 years
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Falls risk assessment

• falls risk prediction scores

modifiable risk factor checklists
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What was different about the FallSafe approach?

1. It was evidence-based
2. It prioritised the things we struggle with

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• http//www.rcplondon.ac.uk/projects/national-audit
  -falls-and-bone-health-older-people
•  

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National pilot audit

• All older patients
• 11 not asked about history of falls
• 10 could use a call bell but did not have one in
  reach
• 9 used a mobility aid but had their mobility aid
  out of reach
• 6 had no safe footwear
• Even for super-high risk patients (fallers)
• 23 did not have medication reviewed
• 46 did not have LS BP checked
• 18 no cognitive screening

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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

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Risk factors for falling in hospital
Hospital inpatients Odds Ratio (95 CI)
History of falls 2.85 (1.147.15)
Sedatives 1.89 (1.372.60)
Antidepressants (yes vs. no) 1.98 (1.003.94)
Cognitive impairment 1.52 (1.181.94)
Age (for 5 years increase) 1.04 (1.011.06)
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)
407415
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Risk factors for being injured in a fall in
hospital
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 Sep38(9)408-13
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Baseline Project end Six months later
1 Call Bell in reach 91 98 99
2 Cognitive screen 50 78 63
3 Asked about fear of falling 29 68 71
4 History of falls taken 81 89 96
5 Lying Standing BP 25 50 43
6 Medication review 42 84 72
7 Night sedation not given 82 87 90
8 Safe footwear on feet 91 97 99
9 Urine dip-test 63 78 82
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What was different about the FallSafe approach?

• It was evidence-based
• It prioritised the things we struggle with
• It was multidisciplinary

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