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
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 Foundation
Supported & 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
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), 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
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
Multi-factorial assessment and intervention reduces
falls rates by 20%-30%
Reference
NICE 2013
Title
Details
Falls in older people clinical guideline update
Appendix E Evidence tables
http://www.nice.org.uk/guidance/in
dex.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?articl
eid=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 metaanalyses.
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
m
ul
> ti-p
fiv ro
e fes
co s
i
po mp on
st o n a l
-fa e
l n
t
m oile l re ts
ed ti vi
i c ng ew
at p
st ion lan
af re s
f
ur ed vie
i n uc w
e
sc atio
en ree n
vi nin
ro g
nu
n
m
er fo me
ic o nt
al t w
ris ea
k r
sc
e
hi x ore
p er
pr ci
ot se
e
w cto
ris rs
tb
an
pa b ala d
tie es rm
nt ide s
in s
fo ig
rm n
at
io
n
perecentage of trials
significant reductions in falls
no significant reductions in falls
100
90
80
70
60
50
40
30
20
10
0
Oliver D, Healey F, Haines T (2010) Preventing falls and falls related injuries in hospital Clinics in
Geriatric Medicine (26 4 645-692)
“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
“Ensure that any multifactorial intervention:
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.”
1
6
FallSafe: The care bundle
1) 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 bundle
2) ‘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
“Do not use fall risk prediction tools to
predict inpatients’ risk of falling in
Predicting patients’
hospital”risk of falling in
hospital
2
0
“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-based
2. It prioritised the things we struggle with
http://www.rcplondon.ac.uk/projects/national-auditfalls-and-bone-health-older-people
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 L&S BP checked
• 18% no cognitive screening
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
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-based
2. It prioritised the things we struggle with
3. It was multidisciplinary