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Preventing Falls The South Tees Journey. Mrs Glynis Peat – Spinal Services Lead, Trauma Mrs Kathryn Hodgson – Clinical Lead Falls Team. Inpatient Falls 26% of all national patient safety incidents reported. 840. 550. 30.
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Preventing Falls The South Tees Journey Mrs Glynis Peat – Spinal Services Lead, Trauma Mrs Kathryn Hodgson – Clinical Lead Falls Team
Inpatient Falls 26% of all national patient safety incidents reported 840 550 30 Most common cause of death from injury on the over 65s Between 10-25% of falls in hospitals and care homes result in fracture
What is FallSafe A quality improvement project led by the Health Foundation aimed at “closing the gap” between the evidence base for effective care and the care that patients actually receive. Involves educating, inspiring and supporting Registered Nurses (FallSafe leads) to lead ward based MDTs in reliably delivering assessments and interventions through a care bundle approach
What is a Care Bundle? A list of actions (called elements) that need to be applied consistently to patients for whom they are appropriate. The actions are selected because they have been shown to be effective through research.
Care Bundle - All Patients • History of falls and fear of falling • Urinalysis • Avoidance of night sedation • Call bell in reach • Appropriate footwear • Assessment and provision of walking aids
Care Bundles - Older Patients • Cognitive assessment • Delirium screening for those at risk • Bed rails - risk vs benefit • Visual assessment • Lying and standing blood pressure • Medication review • Tailored toileting plan
Care Bundles – After a Fall • Post fall checklist • Assessments and neurological examination • Post fall review to prevent further fall • Incident report • RCA for severe harm falls
Hospital Falls Strategy Hospital falls strategy group Clinical Matrons AHP lead Clinical leads Patient and carer representative FallSafe Lead on their ward Executive board Overall monitoring Hospital wide falls leaders Lead Nurse for Trauma Clinical Lead for Falls Elderly care consultant FallSafe leads working group FallSafe lead and deputies from each ward from each ward Overall monitoring Promotion at ward level Training at ward level Share learning Point of contact Planning, monitoring and feedback to executive board Learning Updates Communication Audits Action planning Share learning Policy Action planning Problem solving Promotion trust wide Assurance Review RCA
Fallsafe Leads Priorities • Build a ward based MDT improvement team • Share your knowledge • Promote project and e-learning tool • Understand your reported falls • Undertake measurement of under reporting • Measure care bundle compliance
FallSafe ProjectReducing Falls for all patients South Tees Hospitals NHS Foundation Trust are implementing the FallSafe project across all inpatient areas. There are three key elements:
The Slipper ChallengeHow safe are your slippers? • Do they: • Fit well: not loose and baggy or too tight? • Have fastenings such as laces, buckle or velcro to • help keep your feet inside • Have non-slip, lightly padded soles • Have soft supple uppers • This would be a “safe” pair of slippers • Or are they any of the below: • Have high heels • Backless • Novelty slippers which may be a tripping hazard • Unsupportive • If you have ticked one of the above you would benefit • from a different pair of slippers If you feel your slippers are “unsafe” please ask a visitor to bring you in a different pair. Ask a member of staff for further advice
Results of slipper audit 63% patients wearing SAFE SLIPPERS
Achievements 2013/14 19.3% reduction in number of falls 20% reduction in the number of patients who sustained a fracture (58% reduction hip fractures)
What is Quest? • NHS QUEST is the first member-convened network for Foundation Trusts who wish to focus relentlessly on improving quality and safety. • The NHS QUEST membership is currently made up of 16 Foundation Trusts from across England. • Falls collaborative has been set up to work together to address the complex issue of reducing falls in inpatient setting.
Primary Drivers Secondary Drivers Driver diagram • Multi media falls prevention strategy • Human factors • Staff and patient education • Engagement of patients and staff in falls prevention strategies Culture & behaviour – falls prevention AIM To reduce harm from falls by 50% by June 2015 • Dynamic, individualised risk assessment • Dynamic communication plan • Individualised plan of care to manage at risk patients • Management of confused patients Reliable falls care processes • Assessment of environment • Visual management of risk • Patient placement on ward • No night-time transfers • Management of the patient at night • Toileting Environmental factors • Rapid review for every patient post-fall • Safe staffing in the management of falls • Falls measurement • Reliability with falls bundle interventions Leadership
PDSAs Levels and Interventions
Next Challenge? • Improve (sustaining is a challenge in itself) • Share and Spread • Documentation • RCP Audit • AHSN
