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Implementing the FallSafe bundle
Dr Frances Healey, RGN, RMN, PhDAssociate Director for Patient Safety, NHS England (past) Associate Director, Clinical Effectiveness and Evaluation Unit, RCP
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
FallSafe Quality Improvement Project
Led by the Royal College of Physicians Funded by the Health FoundationSupported & promoted by:
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
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 L&S 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
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), p<0.001
Injurious falls rate ratio 12 months before full bundle v.12 months after 0.86 (0.71-1.03), P=0.11
60% certain last fall was reported
77% certain last fall was reported
http://www.rcplondon.ac.uk/resources/falls-prevention-resources http://www.rcplondon.ac.uk/projects/fallsafe
What was different about the FallSafe approach?1. It was evidence-based
Reference Title Details NICE 2013 Falls in older people clinical guideline update
Appendix E Evidence tables http://www.nice.org.uk/guidance/index.jsp?action=download&o=62252
Myakie-Lye et al. 2013
Inpatient Fall Prevention Programs as a Patient Safety Strategy: A Systematic Review
http://annals.org/article.aspx?articleid=1656443
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. 2012;7:497-503
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. 2010;26:645-9
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. 2007;334:82
Coussement et al. 2008
Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis.
J Am Geriatr Soc. 2008;56:29-36
Multi-factorial assessment and intervention reduces falls rates by 20%-30%
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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significant reductions in falls no significant reductions in falls
“Having been doing this [nursing] for 30 years it’s the first time ‘evidence based’ meant anything to me. I was evidence based and proud of it!”
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
Multifactorial intervention “Ensure that any multifactorial intervention:
– promptly addresses the patient’s individual risk factors
– takes into account whether the risk factors can be treated, improved or managed during the patient’s expected stay
Do not offer falls prevention interventions that are not tailored to address the patient’s individual risk factors for falling.”
16
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
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
Predicting patients’ risk of falling in hospital
“Do not use fall risk prediction tools to predict inpatients’ risk of falling in hospital”
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“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+
Falls risk assessment falls risk prediction scores modifiable risk factor
checklists
What was different about the FallSafe approach?1. It was evidence-based2. It prioritised the things we struggle with
http://www.rcplondon.ac.uk/projects/national-audit-falls-and-bone-health-older-people
National pilot auditAll 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 footwearEven for super-high risk patients (fallers):•23% did not have medication reviewed•46% did not have L&S BP checked •18% no cognitive screening
High levels of dementia and delirium in inpatient fallers88% had mobility problems 65% were cognitively impaired 65% had bone health problems 58% had continence problems/urgency 49% culprit medication42% had orthostatic BP/cardiovascular37% 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
Risk factors for falling in hospital
Hospital inpatients Odds Ratio (95% CI)
History of falls 2.85 (1.14–7.15)
Sedatives 1.89 (1.37–2.60)
Antidepressants (yes vs. no) 1.98 (1.00–3.94)
Cognitive impairment 1.52 (1.18–1.94)
Age (for 5 years increase) 1.04 (1.01–1.06)
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) 407–415
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 Sep;38(9):408-13
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%
What was different about the FallSafe approach?1. It was evidence-based2. It prioritised the things we struggle with3. It was multidisciplinary
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