Understanding fall risk in acute mental health settings for older people. Deborah Humphrey, Caroline Griffiths and Angela Dickinson. Funded by: NIHR Research for Patient Benefit Research Team • Angela Dickinson (PI), Senior Research Fellow, University of Hertfordshire • Deborah Humphrey, Head of Nursing Older Adult Mental Heath, Oxford Health NHS Foundation Trust • Venkat Narayanan, Research Physiotherapist, Oxford Health NHS Foundation Trust • Caroline Griffiths, Lead Physiotherapist, Oxford Health NHS Foundation Trust • Charles Simpson, Research Fellow, University of Hertfordshire • Christina Victor, Professor of Gerontology and Public Health, Brunel University Background • 36,000 falls in mental health units in UK every year (NPSA 2010). • Falls and fear of falling lead to anxiety and loss of confidence for older people. • Affect rehabilitation, physical and mental function, increase length of stay in hospital settings and likelihood of discharge to long term care settings. • Impaired mental status adds further risk, particularly if treated with psychotropic medication. • Depressive symptoms, control and reduced morale increase risk of falls in older people with mental health problems. Research Aims: 1. To evaluate how falls prevention and management are understood and experienced, in inpatient mental health settings providing care for older people. 2. To analyse current local and national falls policy and guidelines specific to mental health settings. 3. To develop local policy, practice guidelines and patient and carer information which is fit for purpose and relevant to mental health settings for older people, and make recommendations for national policy. Research Design: Overview Phase 1: Exploratory Case Study • • • • Falls incident report (3 years) Non-participant observation (over 300 hours) Focus groups-staff (n=45) Interviews- managers (n=6) Phase 2 ‘Patient Tracking’ • • • • Incident fall Interviews with patient and/or carer (n=22/5) Interviews with ward staff (n=48) Notes review Phase 3: Developments of guidelines • Working groups • Dissemination Conference Setting Ward Type No beds Sex No falls reported 2010 No falls No falls reported reported 2011 2012 Environment: Purpose built A Mixed 17 Female 54 72 62 Yes B Organic 17 Mixed 59 69 44 No C Mixed 17 Mixed 31 70 61 No D Functional 21 Mixed 77 63 62 No E Mixed Male 69 41 86 Yes 17 Who falls, when and where? • 40% had a primary functional diagnosis, 46% an organic mental health diagnosis (14% non specific mental health diagnosis/problems) • Mean Age of those falling 81.7yrs (Range 59-99) • Patients fell on average on their 50th day of admission (43 days for organic diagnosis and 65 days for functional illness). • Only 27% of falls were directly observed by staff • There were temporal and spatial patterns to falls. • Most falls were in bedrooms (42%), day rooms (20%) and corridors (12%). Peaks in falls occur in morning and early afternoon. Limitations of using routinely collected data • Most falls are unobserved: ‘found on floor’ (57%) • Not all falls (slips and trips) reported • Fall incident reports often lack detail I would have probably just put it in the progress notes, ... because you would be doing notes anyway, so it’s not really any extra work. To fill out the critical incident forms are very timeconsuming, and staff really haven’t got the time to do this unless it’s something major. Need to look at perceptions of staff and patients Theme 1: Co-morbidity of patients (physical and mental health) • Complex mix of mental & physical health problems • Challenge to MH trained staff (skills & training) • Physical problems can be missed/interpreted as MH • Poly-pharmacy (Most of patients taking more than 4 medicines, max n=12) Theme 2: Perception of falls • Physical problem Perceived to be remit of Doctor/physio (Can limit use of MH skills in fall prevention) • ‘Behavioural’ falls • ‘Accidental’ in nature • Influence of environment Theme 3: Prevention and management of falls • Focus on limited repertoire of ‘interventions’ • Heavy reliance on surveillance: ‘level 2’ observations and ‘referral to physio’. • Reducing risk of injury vs prevention of falls • Medication review, but all patients tracked continued to be prescribed medications associated with fall risk. • Some use of equipment- patchy (beds, hip protectors) • Exercise opportunities could be extended. • Little evidence of patient educational interventions. Theme 4: Risk and Falls • Challenges of balancing risk and independence at patient level • Differences in thinking about risk across organisation, disciplines and within teams • Much of thinking around risk is ‘hidden’. • Perception of poor fit of fall policy/assessment tools with ‘real world’ of practice Risks: Staff • ‘no fall is the same’ • But inevitably my patient group are old, they’re frail, they have lots of physical comorbid problems, in addition to their mental health problems which increase the risk of them falling. It’s a fairly high probability that people will fall, it’s just about trying to reduce the damage that happens. Risks: Manager • And it’s not about blame it’s about trying to learn, can we do this better, can we prevent this sort of thing happening again... • but I think we are quite aware of risk. I’m not sure we’re always as good at documenting it as well as it could be, and I think sometimes risk assessments, a lot of risk assessment happens but it’s going on in people’s head and it’s not always clearly documented. Conclusions & Implications • Poor but improving quality of fall reporting. • Understanding temporal and spatial patterns could help in planning care. • Complex co-morbidity and poly-pharmacy • Does mental health nurse training prepare nurses to care for the current demographic of older people? Disclaimer This paper presents independent research commissioned by the National Institute for Health Research (NIHR) under the Research for Patient Benefit programme. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Where next? education • Development of the Older People’s Education and Research Network (OPERN) • Development and evaluation of an educational programme focusing on understanding falls and the changing health and care needs of older patients. • Programme will be web-based, using data from the research as a basis, include podcasts, lectures, quizzes and film. Where Next? Research • Study to understand and explore acceptability and feasibility of using technologies such as video and accelerometers to learn more about ‘unseen falls’. Where Next? Research • Development of fall prevention interventions appropriate for the complex group of patients being cared for in acute mental health settings (not just patients with dementia). What next? Your ideas… • How can OPERN work with us to develop ideas into education/research and to make a difference to older people’s care and wellbeing?