Delivering … Public health through emergency and secondary services partnerships

1. Delivering … Public health through emergency and secondary services partnerships A Model for Older People who Fall Mr Phil Kyle Dr John Davison

2. Mrs MD • 61 years old • Walking home on day of retirement from school • Next recollection is being on the ground picking herself up • Carries on with life…

3. …next 20 years • Intermittent falls • Sees GP – tests normal • 2005 - injures face with 1 fall – taken by ambulance to A&E • Facial injury treated, Mrs MD heads home…

4. North East Ambulance Service • NEAS serves all of NE region • population ~ 2.6 million • 3230 square miles • 1750 employees • 63 locations - 51 stations

5. Awareness of high number of emergency calls for falls • Prospective study - June-Dec 2004 • NEAS data bank of patients > 65 years reporting a fall • Assistance only calls • All calls for a fall conveyed to A&E • Proportions calculated from Census population data • All fallers seen on site received standardised assessment - history, injury assessment, BP and pulse

6. Results • Newcastle upon Tyne = 276 000 • Population > 65 years = 42 000 • NEAS attended 1504 falls in 7 month data period equivalent to 2600 annually • Conveyed = 1339 (89%) • Assistance only = 165 (11%) • Median attendance time – 40 mins • 62 falls per 1000 head of population > 65 years coming to NEAS per year … Service delivery target • 8 minutes Category A call response time

7. Time on scene • Mean time on scene for non-conveyed = 30 mins (SD +\- 10) • Mean time on scene for A&E conveyed = 14 mins (SD +\- 16) • 377 hours of crew time on site in 7 mth period • £123 per hour on site • £117 per call out • Annualised cost in 2004 = £376 000 • 26% of those conveyed to A&E admitted • only 10% referred to liaison nurse • 64% discharged from A&E with no falls follow up

8. Subjects > 50 Years attending A&E(n = 71,279) Non-Fallers 59% Missing Data 7% Fallers 34%(n = 24,251) Richardson et al PACE 1997;20:820-3

9. National Data - 999 calls for falls • 34% of patients with falls not conveyed after 999 call • In Newcastle – 34% of sheltered housing residents not conveyed • Median 34 minutes spent at scene Marks PJ. Emergency Medical Journal 2002;19:449-52 • Non-conveyed patients more likely to be • older • housebound • poorer cognition Close JC. Age Ageing 2002;31:488-9 • 25% of all calls aged >65 years to London Ambulance Service due to a fall n = 534 / 2151 (2003-4) • 49% made contact with medical services in next 2 weeks • 47% called 999 again at least once Snooks HA, Quality & Safety in Health Care 2006;15(6):390-2

10. Risk Factors - Falls Presenting to A&E ( n=146) Balance Median 5 fall Risk Factors identified (Range 1-10) Gait Medication % with risk factor Home Hazards Carotid Sinus Hypersensitivity Orthostatic Hypotension Vision Neurological Depression Vasovagal Davison et al, Age Ageing 2005;34:162-8

11. Falls can be prevented… PROFET study - 1999 • > 65 years attending A&E with fall (72% single fallers) • Medical and OT intervention • Day hospital referral for identified risk factors • 61% reduction in falls 510 falls in control gp (n=163) vs. 183 (n=141) - RR 0.39 (95% CI 0.23 - 0.66) • Reduction in number continuing to fall – 59/141 vs 111/163 – RR 0.61 (95% CI 0.41 – 0.77) Recurrent fallers attending A&E – 2005 • Medical, PT and OT intervention • 36% reduction in falls – 387 falls intervention gp (n=144) vs. 617 (n=149) - RR 0.64 (95% CI 0.46 - 0.90) • No effect on fallers (68% control vs 65% intervention) Close et al, Lancet 1999;353:93-7 Davison et al, Age Ageing 2005;34:162-8

12. NICE guidance NICE CG021, 2004

13. NEAS response… • Approaches to existing falls services - Falls & Syncope Service • Development of secure database (single PC – data backup) • Recording of all ambulance calls for falls • Raw data transfer from NEAS mainframe • Single operator data cleansing • Caldicott approvals sought • Data captured on – demographics, location, history of injury, recurrent fallers

14. Hurdles • Data sharing Further Caldicott approvals sought to share information with other organisations • Consent – Patient consent to data sharing • Politics and Trust – Falls services in Newcastle provided by different service providers Transparency and trust to be established and maintained Agreed single point of referral – use of FASS as ‘hub’ for referrals • Referral mechanism and commissioning GPs informed of identification of faller (as per NICE guidance) and given opt-out, not opt in

15. Screening tool used – Fall Risk Assessment Tool (FRAT) • FRAT - valid within community fallers population • Developed with involvement of variety of health care workers, social workers, hospital discharge team, OT, PT • Designed for clinical or non-clinical staff • 3 or more risk factors +ve predictive value for a fall in the next 6 months = 0.57 (95 % CI 0.43-0.69) i.e. over half identified as high risk by tool, will fall • 2 or more risk factors sensitivity increases to 0.59 (from 0.42) +ve predictive value of 0.43 (95% CI 0.34 - 0.53) Development and preliminary examination of the predictive validity of the Falls Risk Assessment Tool (FRAT) for use in primary care. Nandy S. Parsons S. Cryer C. et al. Falls Prevention Pilot Steering Group. Journal of Public Health. 26(2):138-43, 2004 Jun.

17. Initial Deployment • Pilot with Newcastle frontline crews - 2005 • Initial take-up slow • Investigation to identify reasons for non-use Crews thought it was paper exercise only Crews thought it would be time consuming No feedback initially in place – this had to be developed to sustain crew involvement Politics - establishing trust for single point of access to falls services • Training – yearly refresher training - Paramedic / Technician / Emergency Care Support Worker • Feedback Crucial to motivate crews to continue referring

18. Partnership working… no, really! Community Care Alarm Services • Started in Newcastle with ‘Your Homes Newcastle’ • Joint agency training • ‘everybody has a part to play’ • Empowerment of frontline staff • ‘your input can really make a difference for your client’ • Feedback • Ongoing Education District & Community Nurses and General Practitioners • Modified training, but using the same tools • Recognition of need to adapt to incorporate their existing expertise ‘empower, but not disenfranchise’ Social Services • Making the tool universal • ‘every key worker in every service’ • City and region • Cascade training and service delivery model • Local modification and personalisation of documentation to suit every need • Empowerment of ‘social carers’ to identify and signpost client need

19. How to maintain… • Keep communicating • Cascade training and shared training opportunities • ‘Give and get’ – data sharing for mutual benefit • Enter awards - teambuilding • Additional promotion within NEAS newsletters • Maintaining high profile at CEO level downwards • Regular updates in light of service developments and roll out to other agencies • Feedback

20. The impact on 999 ambulance use 999 calls for falls Falls assessments

21. Ambulance savings… Fallers who have fallen 2 times within this period = 7 Fallers who have fallen 3 or more times within this period = 5 All repeat fallers have been referred to falls services 10 Calls from YHN with 9 admissions and 1 refusal staying at home

22. …and Mrs MD • March 2009 • Walking when suddenly fell into bed of daffodils • Ambulance called • Referral received by FASS – 12.3.09 • Prolonged heart rate monitor shows pauses of 2.5 seconds, heart rate down to 38bpm • Pacemaker implanted – no further unexplained falls

23. New challenges • Maintaining partnership working in the face of ‘any willing provider’ • Embedding the model within Joint Strategic Needs Assessments • Cultivating the commissioner • Reduction in hospital admissions • How to address non-responders • Maintaining trust and communication – developing shared priorities

24. Questions?

25. FASS Partners… Dr Fiona Shaw, Consultant Physician