Falls and Fragility Fracture Audit Programme: National audit of inpatient falls (Spring 2015)
Clinical lead: Dr Shelagh O’Riordan
Proposed audit protocol
Audit will comprise 2 components: Organisational and Clinical.
 Organisational audit comprises of a review of policies and procedures and an environmental checklist- the organisational proforma will be distributed
separately.
 Clinical audit comprises of a notes review and patient/bedside observation with all clinical data to be collected from the same 30 patients.
Audit standards
Primarily derived from NICE CG 161 (Falls: assessment and prevention), with additional standards derived from evidence-based guidance from NICE, NPSA and
the MHRA.
Patient cohort
Consecutive non-elective admissions to acute hospitals, aged 65+, inpatient stay >48h (identified by your Patient Administration System (PAS)). The audit will
take place during on the 3rd calendar day post-admission.
Sample size
Plan to collect 30 sets of patient data over 2 days. If the total number of patients meeting the admission criteria is less than 30, data collection should be
extended to a third day.
Data collection and entry
Data collection will be via web-tool with audit questions being available as a printable PDF for local data collection on paper as required.
References
 NICE Clinical Guideline 161: Falls: assessment and prevention of falls in older people (National Institute for Health and Care Excellence, 2013).
 NICE Clinical Guideline 103: Delirium: diagnosis, prevention and management (National Institute for health and Clinical Excellence, 2010).
 NPSA: Slips trips and falls in hospital (National Patient Safety Agency, 2007).
 Patient Safety First: The How to guide for reducing harm from falls (Patient Safety First, 2009).
 MHRA Device Bulletin 2013: The safe use of bed rails (The Medicines and Healthcare products Regulatory Agency, 2013).
 RCP: Implementing FallSafe: care bundles to reduce inpatient falls (The Royal College of Physicians, 2009).
Clinical/Observational: Sections 1 to 2
The following pages can be printed off to collect your findings as you review the case notes.
You will be completing Sections 1 and 2 on the same patients.
For each patient, look at all clinical notes (medical, nursing, therapies), including those at the end of the bed or in the patient vicinity, and any
electronic record.
Evidence of assessments (and the outcome of each assessment) will be derived from the case notes (Section 1). Section 2 will be direct
observation on the same patients.
It is recommended by NICE that interventions for falls prevention should be individualised to the patient following assessment for modifiable fall
risk factors. For the purposes of the audit, we have tried to focus on a small number of assessments and associated interventions.
Where an assessment has been carried out and no intervention is required, this would be considered as compliant with NICE. Where an
assessment but no intervention has been carried out this is non- compliant. Where no assessment or intervention has been carried out, this
would be non-compliant. Certain interventions are good practice for nearly all patients (eg access to a call bell), in which case there is no
question on an associated assessment.
National Audit of Inpatient Falls (2015) – Clinical protocol and proforma: Page 2 of 10
Patient demographics
QUESTION
HELP NOTE
Hospital
Patient age
Date of admission
Gender
On the day of the audit
what type of ward was
the patient on?
Was this patient
admitted because of a
fall?
All patients should be aged 65 years and over.
Sunday 10 May / Monday 11 May / Tuesday 12 May
 Medical
 Surgical
 Admissions unit eg AMU, CDU or
equivalent
 Other (please specify)
Medical – any medical ward. Eg respiratory, gastroenterology, geriatrics/frailty etc.
Surgical – any type of surgical ward Eg general surgery, gynaecology, ophthalmology etc.
Admissions unit eg AMU, CDU or equivalent – a short stay department linked to the
emergency department
 Yes
 No
Please note the patients in this audit should be non-elective admissions for any
reason – not just falls. The purpose of this question is to ascertain whether
patients who are admitted following a fall are more likely to have a MFRA than
those admitted for other reasons.
National Audit of Inpatient Falls (2015) – Clinical protocol and proforma: Page 3 of 10
Section 1 – Evidence of assessment and intervention in case notes
Is it documented that the patient has:
HELP NOTE
GUIDANCE /
RATIONALE
1.01
been asked about any
history of falls
 Yes
 No
 N/A Impossible or
inappropriate to assess
NICE CG161 1.1.1.1
NICE CG161 1.2.2.3
1.02
had any assessment of
cognitive impairment
(eg AMT)
1.02a
a care plan to support
the patient with
cognitive impairment?
eg “This is me”(tailored
to patient, not generic)
been assessed for the
presence or absence of
delirium or a
documented diagnosis
of delirium
 Yes - Patient was
assessed (go to 1.2a)
 No – Patient was not
assessed (go to 1.03)
 N/A - Impossible or
inappropriate to assess
(go to 1.03)
 Yes
 No
 N/A Intervention not
required
Check their notes in all the places where you might reasonably expect this to
be recorded given your local paperwork (eg falls assessment form,
documentation on sections on problems with mobility) but don’t feel you
have to read their entire case notes. It doesn’t matter what area of notes
(nursing, medical physio or OT notes) or who asked the questions – nurse,
doctor or physio or OT equally fine, as long as it is in case notes accessible to
all the team.
Any objective assessment acceptable (including short form AMTS, AMTS,
MMSE etc)
YES includes checking the patient’s history and finding a previous diagnosis of
a cognitive impairment eg dementia
Solely commenting in general terms on confusion/memory problems would
count as not assessed.
This is a care plan that is specific to the patient based on information from a
carer and/or observation and assessment on the ward.
NICE CG 161 1.2.2.4
Delirium identification/screening may include the following:
• CAM – confusion assessment method (see below)
• 4AT – The 4 ‘A’s test (currently being validated, but in increasing use)
• Review and record the patient’s alertness, attention, behaviour and
cognition
NICE CG103 1.3.2
NPSA: Slips, trips
and falls
1.03
1.03a
a delirium care plan
(tailored to patient, not
 Yes -Patient was
assessed (go to 1.3a)
 No - Patient was not
assessed (go to 1.04)
 N/A - Impossible or
inappropriate to assess
(go to 1.04)
 Yes
NICE CG161 1.2.2.3
AMTS, MMSE, etc are only assessments of cognition and cannot be used for
assessment of delirium without additional consideration of alertness,
attention, behaviour and time course (ie acute or fluctuating mental state).
Many clinicians still record delirium as “acute confusion”. This is not
acceptable for the purpose of this audit as the term “delirium” should now be
in routine use.
NICE CG103 1.3.2
Delirium management is multifactorial and should include the following
NPSA: Slips, trips
actions as stated in NICE CG103:
National Audit of Inpatient Falls (2015) – Clinical protocol and proforma: Page 4 of 10
generic)
 No
 N/A - Intervention
not required
and falls
1.
2.
3.
4.
Sensory re-orientation (lighting, glasses, clocks hearing aids, etc)
Bowel and bladder care (treating constipation, retention)
Assess for hypoxia
Identification and treatment of any acute medical triggers (eg
infection)
5. Pain relief
6. Address poor nutrition
7. Promote good sleep patterns
This may also include any evidence of enhanced nursing observations and
referral to appropriate specialist (eg old age/liaison psychiatry, delirium
team).
1.04
any assessment of
urinary
continence/frequency/u
rgency
1.04a
a continence or toileting
care plan (tailored to
patient, not generic)
1.05
any assessment of fear
of falling
 Yes – Patient was
assessed (go to 1.04a)
 No - Patient was not
assessed (go to 1.05)
 N/A Impossible or
inappropriate to assess
(go to 1.05)
 Yes
 No
 N/A Intervention not
required
 Yes - Patient was
assessed
Answer Yes - if notes record evidence of delirium AND a plan has been put in
place / management given to address it, including at least one of the above
actions.
Answer N/A - if patient assessed but no intervention was required
Answer No – If patient assessed but did not receive intervention.
An assessment of the history and nature of urinary incontinence.
NICE CG161 1.2.2.3
NPSA: Slips, trips
and falls
Where continence problems are identified there should be evidence of
continence care. This may be within a formal care plan or contained within
multidisciplinary notes. It is not acceptable to document a problem without
evidence of an action. Where a patient has new continence problems this
requires investigation. Where a patient has longstanding problems there
should be documentation in relation to how this is managed. Where a patient
has a catheter, there should be a catheter care plan.
NICE CG 161 1.2.2.4
NPSA: Slips, trips
and falls
Check their notes in all the places where you might reasonably expect this to
be recorded given your local paperwork (eg falls assessment form,
NICE CG161 1.2.2.3
NICE CG161 (full
guideline) 3.3.4.10
National Audit of Inpatient Falls (2015) – Clinical protocol and proforma: Page 5 of 10
 No – Patient was not
assessed
 N/A - Impossible or
inappropriate to assess
1.06
a record of level of
mobility
1.06a
a mobility care plan
(tailored to patient, not
generic)
1.07
a record of use of
walking aids
 Yes (go to 1.06a)
 No (go to 1.07)
 N/A Impossible or
inappropriate to assess
the patient for this No
(go to 1.07)
 Yes
 No
 N/A Intervention not
required
documentation on sections on problems with mobility) but don’t feel you
have to read their entire case notes. It doesn’t matter what area of notes
(nursing, medical physio or OT notes) or who asked the questions – nurse,
doctor or physio or OT equally fine, as long as it is in case notes accessible to
all the team. If you have a patient where asking the question would feel
embarrassingly inappropriate – eg a person who is very active and fully
independent, or a patient who is unconscious and dying – you can count as
NO but Impossible or inappropriate to assess the patient for this.
Any record of the patient’s mobility (safety, need for assistance, exercise
capacity)
‘fear of falling is a
significant predictor
of future falling and
should be
considered in falls
assessment of older
people.’
This could be a therapy or nursing documentation that specifies patient’s
mobility, including use of aid and need for supervision.
NICE CG161 1.2.2.4
NICE CG161 1.2.2.3
Select N/A if the patient is unable to get out of bed.
 Yes
 No
 N/A Impossible or
inappropriate to assess
the patient for this
Any record of the patient’s need for walking aid prior to admission, on the
ward, or both.
NICE CG161 1.2.2.3
Select N/A if the patient is unable to get out of bed.
NICE CG161 1.2.2.2
NPSA: Slips, trips
and falls
1.08
measurement of lying
and standing blood
pressure
 Yes - Patient was
assessed
 No – Patient was not
assessed
 N/A Impossible or
inappropriate to assess
the patient for this
Must be lying and standing, in that order (and not sitting instead of either
lying or standing). Should use a manual sphygmomanometer, if available.
1.09
an assessment for
medications that
increase falls risk
 Yes - Patient was
assessed (go to 1.09a)
NICE CG161
Help notes for 1.09 and 1.09a - Yes
1.9 is asking whether the patient’s medications were assessed to identify any drugs 1.2.2.3
NPSA: Slips,
that might contribute to falls. This could be by doctor, pharmacist or any other
National Audit of Inpatient Falls (2015) – Clinical protocol and proforma: Page 6 of 10
1.09a
a medication review
(beyond medicine
reconciliation) with
regard to falls risk
 No – Patient was not
assessed (go to 1.10)
 N/A Impossible or
inappropriate to assess
the patient for this (go
to 1.10)
 Yes
 No
 N/A Intervention not
required
appropriate member of staff. 1.9.1 is asking whether any changes were made in
light of this, or if a decision was recorded that no changes were required/possible.
Medication that could increase the risk of falls include psychotropics (eg
benzodiazepines and tricyclic antidepressants); anti-hypertensives (eg diuretics
and beta blockers); anti-arrythmics (eg digoxin); sedating antihistamines (eg
Chlorphenamine); sedating analgesia (eg Codeine, Morphine).
The auditor is politely reminded that the term "medication review" may not always
be present in the patients notes and that quite often this may be deemed to have
taken place by the following:
(1) Discontinuation of a drug- documented in the patients notes but often
more obvious from the medication chart
(2) Reduction of the dose of the drug administered- documented in the
patients notes but often more visible on the medication chart
(3) Review the patients TTO/TTA prescription (as this should comment on
any medications alterations for GP) NB- The patients first drug chart, taken
from admission, should have a medicines review or reconciliation
completed and will often be the most appropriate drugs chart to review
for changes to the patients medicines. Reduced/discontinued culprit drugs
to score as ' Yes - Patient was assessed’ even if a medication review was
not formally recorded.
trips and falls
NICE CG161
1.2.2.3
NICE CG103
1.3.3.7
NPSA: Slips,
trips and falls
Help note for 1.09 – NA and No
N/A can be used if the patient was not on any medication or only topical
medication and/or inhalers
No should be used if patient was on at least one of the medicines noted to
increase risk of falls prior to admission and no comment or attempt to switch drug
or reducing dose (in notes or on the drug chart) was made during their admission
1.10
night sedation or other
sedative medication
administered since
 Yes, but – Patient on
long term sedatives
Help note for 1.9a – NA
N/A can be used if patient was on at least one of the medicines noted to increase
risk of falls however there was no changes required and this is clearly stated in the
notes eg the patient does not get drowsy/does not suffer from side effect when
taking drug.
Night sedation is medication defined within the BNF Central Nervous System
section: Hypnoptics and anxiolytics. Examples of sedative medications are:
National Audit of Inpatient Falls (2015) – Clinical protocol and proforma: Page 7 of 10
admission
1.11
any assessment of
vision and/or need for
visual aids, including
spectacles
1.12
a falls care plan, or
equivalent (tailored to
patient, not generic)
1.13
1.14
Is there evidence that
the patient and/or their
family/carer was given
written information
about falls risk or falls
prevention?
Is there evidence that
the patient and/or their
family/carer was given
oral information about
falls risk or falls
prevention?
 Yes – Patient given
new sedative
 No – No sedation
given
 Yes - Patient was
assessed
 No – Patient was not
assessed
 N/A Impossible or
inappropriate to assess
the patient for this
 Yes - Patient was
assessed
 No – Patient was not
assessed
 N/A Impossible or
inappropriate to assess
the patient for this
 Yes
 No
 N/A
 Yes
 No
 N/A
Diazepam (Valium), Chlordiazepoxide (Librium), Lorazepam, Oxazepam,
Nitrazepam (Mogadon), Loprazolam, Lormetazepam, Temazepam, Zaleplon,
Zolpidem, Zopiclone, Chloral Betaine Welldorm), Chloral Hydrate.
Any objective assessment acceptable (including basic ability to identify
objects, read print). Solely asking patient if they have eyesight problems
would count as not assessed.
NICE CG161 1.2.2.3
NPSA: Slips, trips
and falls
This may be a stand-alone falls care plan or could be part of a general care
plan
NICE CG161 1.2
A falls care plan would be one that contains either all elements of a
multifactorial assessment or partially contain elements if those other
elements are contained in other unidisciplinary notes, for example, physio
assessment may be contained in one or the other or both
http://www.nice.org.uk/guidance/cg161/chapter/recommendations#multifac
torial-intervention
Information should include:
 explaining about the patient's individual risk factors for falling in
hospital
 showing the patient how to use the nurse call system and
encouraging them to use it when they need help
 informing family members and carers about when and how to raise
and lower bed rails
 providing consistent messages about when a patient should ask for
help before getting up or moving about
 helping the patient to engage in any multifactorial intervention aimed
at addressing their individual risk factors.
NICE CG161 1.2.3.1
National Audit of Inpatient Falls (2015) – Clinical protocol and proforma: Page 8 of 10
Section 2 - Bedside/Patient environment observation
QUESTION
ANSWER
For each patient, look at their bedside and immediate
environment and record: Y (yes), N (no), or N/A (No, but not
clinically relevant)
2.01 Is call bell in sight and in  Yes
reach of patient?
 No
 N/A - Patient unable
to use call bell
2.02 Is safe footwear on
patient’s feet?
 Yes
 No
 N/A - Patient in bed
GUIDANCE /
RATIONALE
HELP NOTES
‘Not applicable’ can only be used for clinical reasons, not logistic ones - eg
ward spaces too small for patient to have walking frame in reach count as
‘No’, rather than ‘N/A’.
Measure applies to anywhere patients are sitting or lying at the time you do
the check.
N/A can be used for any patient too ill or too confused to use a bell and for
patients walking around at the time.
Answer NO if you have patients in beds, chairs or day rooms where no bells
can be made to reach, or bells are missing or out of order.
Take this observation at a time when most of your patients who are well
enough are likely to be out of bed. Collect by walking around to observe your
patients.
N/A can be used for any patient in bed and under the covers, any hoistdependent patient, and any patient who has been offered safe footwear but
declines to wear it (not just forgets to wear it).
NPSA: Slips, trips and
falls
Patient Safety First
‘How to’ Guide
NPSA: Slips, trips and
falls
Patient Safety First
‘How to’ Guide
NO should be recorded if patient has:
• Bare feet
• Socks only (but treaded non-slip socks are acceptable)
• Anti-embolism stockings only (unless they have non-slip treads)
• Bandages or dressings only
• Shoes or slippers that are visibly too big
• Shoes or slippers that are visibly too small
• Lace up shoes without laces, or with trailing laces
• Shoes or slippers worn with squashed backs
• Novelty slippers (as they are unlikely to promote safe mobility)
• Backless shoes or slippers except for very confidently mobile patients
• High heeled shoes except for very confidently mobile patients.
Anything else should be good enough footwear to count as YES.
For mobile patients sitting or resting on the bed but too polite to wear their
shoes/slippers on the bed, you can count YES as long as they have safe
shoes/slippers within their reach.
National Audit of Inpatient Falls (2015) – Clinical protocol and proforma: Page 9 of 10
2.03 Is the immediate
environment (including
route to nearest toilet)
free from
clutter/trip/slip hazards?
2.04 Is the appropriate (based
on Section 1 or 2)
mobility aid in reach?
 Yes
 No
 N/A - Patient
bedbound
 Yes
 No
 N/A - Patient
bedbound or
documented to be mobile
without any aid
Look for uneven floor surfaces, clutter, training cables, oxygen tubing etc.
Cables count as trip hazards even if covered with a cable cover, spills/wet
floor from cleaning count as hazards even if there is a warning cone, uneven
floor counts as a trip hazard even if yellow hazard taped.
N/A can be used if the patient is bedbound
N/A should be used if patient bedbound or documented to be mobile without
any aid
NICE CG161 1.2.2.1
NPSA: Slips, trips and
falls
NPSA: Slips, trips and
falls
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