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Falls Prevention in the Community:
Putting the evidence into practice
Dr Fiona Shaw
Chair, Safer Care North East Falls Task Group
Consultant Physician and Geriatrician
Newcastle upon Tyne Hospitals NHS Foundation Trust
(NHS Newcastle and North Tyneside Community Health)
Overview
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Safer Care North East
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Consensus good practice recommendations
Regionally suggested A&E Falls and Fractures CQUIN
Information sharing website
Care homes
(In-patient audit tool)
Regional outcome measures
Joint working with North East Ambulance Service
Staying Steady Community Exercise Classes
Key lessons
Future plans
Safer Care North East
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North East Patient Safety Strategic Forum - established by
North East SHA in February 2008
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Safer Care North East Strategy – 3 year programme
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Enabling strategy – regionwide developments
complemented by developments within individual trusts
and localities
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No avoidable deaths, injury or illness
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Linked with other programmes: Our Vision Our Future,
North East Transformation System
Safer Care North East
Priority themes identified by / from:
• SUI / NRLS
Leadership
• Local trusts
and
• National priorities
alignment
• Evidence based guidance
• Clinicians / managers
Improvement
8 (9) clinical safety themes:
• PSSF
deteriorating patient
drug safety
healthcare associated
infection
suicide
safe surgery
care transfers, handovers and
discharges
falls
Systems
action on outlying mortality
and
(safeguarding)
processes
People
Why falls (and fractures)?
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BIG cause of HARM
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Average PCT / LA: 2200 A&E attendances, 1,100 fractures
including 360 hip fractures per year
4x increased chance of admission to care home
Loss of confidence, social isolation, increased mortality
Cost = £2.5 million per annum
Falls and fractures are PREVENTABLE
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Multi-factorial intervention reduces falls in community dwellers,
hospital patients and care home residents by about 30%
Targeted exercise reduces falls in selected community dwellers
by about 30%
Osteoporosis treatment would prevent 105 fractures, including 55
hip fractures per PCT / LA area in 5 years
Money saved = estimated £750,000 per year
Safer Care Falls Task Group
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‘Do something’ to reduce falls and fractures
Across region
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Doctors, nurses, falls co-ordinators, physiotherapists,
OT’s, pharmacist, NEAS, osteoporosis specialists, third
sector, commissioners
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Link individuals and services to:
 Share good practice
 ‘Collective voice’ to argue for change
 Support change needed for wider implementation of
good practice
Safer Care Falls Task Group: OGIM
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To reduce the number of hip fractures and other adverse
outcomes following a fall
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To reduce the number of falls in hospitals / in-patient facilities
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To reduce the number of falls in care homes
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To promote use of multi-factorial falls assessment and
intervention, including diagnosis and treatment of osteoporosis
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To improve the quality of falls data collection and reporting of
falls
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To achieve a whole system approach to falls prevention by
collaborative working across primary and secondary health
care, independent care providers, social services and the
voluntary sector
So what did the Falls Task Group do?
F1.2.2 – Rate of secondary care admissions with fragility fractures, due to
a fall, by age and sex at a population level
Chart 1a (Time Series): Secondary care admissions with fragility fractures, due to a fall, per 100K people
Secondary careadmissions with fragility fractures, due to
afall per 100KPCT population
160
140
120
C o u n ty D u r h a m P C T
100
D a r lin g to n P C T
G a te s h e a d P C T
H a r tle p o o l P C T
80
M id d le s b r o u g h P C T
N e w c a s tle P C T
S to c k to n - o n - T e e s
60
N o r th T y n e s id e P C T
N o r th u m b e r la n d C a r e T r u s t
R e d c a r A n d C le v e la n d P C T
40
S o u th T y n e s id e P C T
S u n d e r la n d T e a c h in g P C T
20
0
Data obtained from ONS 2008 and HES 2008/09, 2009/10
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Consensus recommendations
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Organisational issues
Services delivered
In-patient / hospital falls
Care homes
Training
Information
Quality metrics
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Services mapped themselves against recommendations…
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Service mapping……
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Individual issues addressed:
 Funding for Osteoporosis Specialist Nurse
 Development of Falls Training
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Recurrent themes identified across region:
 Lack of robust pathways of referral from A&E to falls
services
 Assessment and treatment of osteoporosis
A&E Falls (and fractures) CQUIN
Any suggestions?
Falls (and fractures) CQUIN 2011/2012
written by Falls Group
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Capture of falls information in A&E
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Evidence of timely referral to falls service for patients who
present to A&E with:
 A fall
 A blackout
 A fracture relating to a fall
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Evidence of timely and appropriate assessment by falls
service including:
 Initial falls assessment
Falls
 Screening for osteoporosis
Service
Falls (and fractures) CQUIN: Pilot data
Wansbeck General Hospital
Led by Dr. David A. Richardson (Falls Service) and Dr. Phil Stamp (A&E)
Northumbria Healthcare NHS Foundation Trust
Referrals from A&E per week
30
2
20
1
1 – full
pilot
begins
10
2 – new
staff
QC
Falls (and fractures) CQUIN: Pilot data
Wansbeck General Hospital
Fallers Presenting to Wansbeck General Hospital A&E Department 13/04/11 - 19/04/11
Total patients 65 years and over = 316
Number of Patients
50
40
30
20
10
Refs
n = 12
60
Actual number of fallers n = 63
70
0
PRESENTING WITH A
FALL OR TLOC
STICKER ON A&E RECORD STICKER COMPLETED ON
A&E RECORD
STICKER REQUESTED
FOLLOW-UP
REFERRAL ACTUALLY
RECEIVED BY FASS
Falls (and fractures) CQUIN: Pilot data
Wansbeck General Hospital
Outcomes of attendees to WGH A&E who have had a fall or TLOC (previously or
index episode) and agreed to further referral for investigation (n = 133)
Other 3%
Reviewed on ward 19%
No follow-up required 20%
Contacted GP 8%
Referred to FASS OPD 50%
Falls (and fractures) CQUIN 2011/2012:
uptake
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Regionally suggested …..
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Adopted much as written without the specific targets:
South of Tyne and Wear: x3 A&E departments
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‘Something on falls’ adopted in 3 of remaining 4 North East
Primary Care Trusts
Information sharing website
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Policies, protocols,
assessment tools,
training documents,
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patient information 
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from group
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Share with
professionals –
regionally and
nationally
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Live May / June 2011
Falls
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prevention services for older people within the Northern Region.
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Remove myself from this group
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Information / resources for professionals under the headings:
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Advice for Patients / People at risk of falls
Care Homes
Community Falls
Documents produced by NHS North East Safer Care Falls Task
Group
Falls Service Quality Metrics and Local Audit Tools
In-Patient Falls
Risk Assessment, Intervention and Referral Tools
Training Resources
Collection of links to relevant information for public and
professionals on other sites
Care Homes: sharing of good practice
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Quality Standards: Sunderland
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Similar process in progress in
MRCPCT and Newcastle
Middlesbrough, Redcar
and Cleveland
Primary Care Trust
Newcastle Care Homes Project
2010 - 2011
In-patient falls
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Tried to get trusts to match best local practice on
incident reporting …. variable success
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In-patient audit tool based on
Reducing Harm From Falls
 Trusts performed well
 Consistent gaps:
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Root cause analysis
Peer support
Measurement of implementation
Exercise programmes
Communication of risk at
discharge
Appropriate footwear
In-Patient Falls Prevention Policies
Audit Against Patient Safety First: Reducing Harm From Falls Standards
Safer Care North East Falls Group July 2010
Trust: ..............................................................
Hospital: ………………………………………………..
Standard
Yes
Is the trust working towards the Patient Safety First
Reducing Harm From Falls Standards?
Does the trust measure rate of patients harmed by
falls?
Does the trust measure % of staff with falls
management training?
Does the trust measure % of patients with
appropriate observations after a fall?
Does the trust measure the % of high risk patients
with a falls action plan?
Does the trust measure the % of patients who
receive the four basics (ask about a fall, avoid
unnecessary hypnotics / sedative medication,
ensure appropriate footwear, call bell visible and in
reach)
Does the trust have an executive lead for falls
(someone on the board)?
Does the trust have a multidisciplinary strategic
falls group (suggested membership: executive
lead, doctor, nurse, physiotherapist, occupational
therapist, facilities, governance / risk, training and
development, pharmacy, primary care, social care,
patient rep)?
Have the governance team got a robust method of
falls reporting?
Does the governance team regularly analyse
No
Partly N/A
Comment
Date: ...................
Regional outcome measures
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Work with NEQOS (North East Quality Observatory System)
to use routine data as regional outcome measures
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Admissions with fractures
F1.2.2 – Rate of secondary care admissions with fragility fractures, due to
a fall, by age and sex at a population level
Chart 1a (Time Series): Secondary care admissions with fragility fractures, due to a fall, per 100K people
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In hospital mortality for
patients admitted with a
fracture
Split into fragility fracture
and fracture neck of femur
Secondary careadmissions with fragility fractures, due to
afall per 100KPCT population
160
140
120
C o u n ty D u r h a m P C T
100
D a r lin g to n P C T
G a te s h e a d P C T
H a r tle p o o l P C T
80
M id d le s b r o u g h P C T
N e w c a s tle P C T
S to c k to n - o n - T e e s
60
N o r th T y n e s id e P C T
N o r th u m b e r la n d C a r e T r u s t
R e d c a r A n d C le v e la n d P C T
40
S o u th T y n e s id e P C T
S u n d e r la n d T e a c h in g P C T
20
0
Data obtained from ONS 2008 and HES 2008/09, 2009/10
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Joint work with North East
Ambulance Service
Joint work with Mr. Philip Kyle, North East Ambulance Service, Justine Lockey, Your Homes
Newcastle and Dr. John Davison, Newcastle upon Tyne Hospitals NHS Foundation Trust
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New referral pathway
established Jan 2007
(Newcastle) and now in
place across whole of
North East region
Direct referrals from
ambulance crews to Falls
Services
Falls Assessment Tool
Notes for users,
Complete assessment tool below. The more positive factors indicate a higher of falling
FALLERS NAME………………………………. DOB………………………………….
FALLERS ADDRESS…………………………………………………………………….
TELE No……………………………….GP Practice…………………………………….
1
(PLEASE TICK)
Is there a history of any fall in the previous year? How assessed
(ask the faller)
2
Is the individual on four or more medications per day? How
assessed? (Identify the numbers of prescribed meds)
3
Does the individual have a diagnosis of stroke or Parkinson’s
disease? How assessed? (ask the faller)
4
Does the individual report any problems with their balance?
How assessed? (ask the faller)
5
Is the individual unable to rise from a chair of knee height?
How assessed? (Ask the faller to stand up from a chair of knee
height without using their arms)
If there is a positive response to three or more questions on the form, then please
forward to fax number 0191 2825338 on return to base.
Does the person, complain of blackouts, loss of consciousness or is
unable to recollect the mechanism of falls (not due to memory?)
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And also link to local
Community Care Alarm
providers
Referred for falls assessment: YES OR NO?
I give permission for this information to be shared with my GP and other health
care professionals if appropriate.
Fallers Signature……………………………………………...Date……………………...
*If the person is unable to sign, a representative must sign indicating verbal consent has
been obtained*
Attendant / Other Health Care Professional / YHN/ :
Name…………………………………… Signature…………………………………
Referred to: FASS, Melville Day Unit, Belsay Unit, CRT’s
(Please Circle)
Joint work with North East
Ambulance Service
And this was what happened to 999 calls for falls …….
250
200
150
Start of Screening
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100
50
0
b
6
ar Apr May Jun
n-0 Fe M
Ja
l
Ju Aug Sep Oct Nov Dec n-07 Fe b Mar Apr May Jun
Ja
l
Ju Aug Sep Oct Nov Dec
Joint work with North East
Ambulance Service
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Maintained 4 years out …….
250
200
999 calls for falls
150
Falls assessments
100
50
0
y
-06 2006
Ma
Jan
p
-07 May
Se an2007
J
p 2008
-08 May
Se a
J n
p
-09
Se2009
Jan
y
Ma
p
-10
Se2010
Jan
Ma
y
p
-11
Se2011
Jan
Staying Steady Community
Exercise Classes
Joint work with HealthWORKS Newcastle
www.hwn.org.uk
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Network of evidence-based exercise classes
(FaME – Skelton) in community venues (June 2010)
Delivered by Postural Stability Instructors from
3rd Sector Organisation
Older people living in the community – falls, fear of falls, risk
of falls, osteoporosis
Been to falls services – on-going exercise needed
Could do with going to falls service but won’t
Nothing unexplained about fall / seem too well to go to falls
service
Screened by NHS physio – referred to falls services if needed
Staying Steady – initial outcomes
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36 week programme – early results …….
Referral base – ‘self’ biggest category, followed by range
of falls services and then GPs
Improved objective measures – 30 sec sit to stand, TUG
Improved QoL measures – walking outside, fear of falling
Improved social contacts
Key lessons
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Importance of consensus approach
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Benefits of working together and sharing ideas / good
practice
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Importance of identifying the right people to influence and
help get things done
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Need to tackle a problem (falls) from all possible angles
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Importance of determination and a positive attitude!
Future plans
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Regional falls work – hosted by CDDFT
Implementation – group expanded to include relevant
trust managers from across the region
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Regional Falls and Fracture Prevention Strategy
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Implementation of A&E CQUIN
Actions from in-patient falls audit
Completion of website
Further development of regional falls indicators
Active engagement with NEAS
Re-audit against Good Practice Recommendations
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Final comments
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Thank you for listening
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Questions?
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Contact [email protected]
or [email protected]