Falls Summit Queens Hotel, Leeds, Ballroom Monday 16 March 2015 e: - - PowerPoint PPT Presentation

1st North of England Falls Summit

Queens Hotel, Leeds, Ballroom Monday 16 March 2015

e: academy@yhahsn.nhs.uk / t: 01274 383926 www.improvementacademy.org Or visit to our Academy Office: Bradford Institute for Health Research Temple Bank House/Duckworth Lane/Bradford/BD9 6RJ

Welcome and Introduction

Dr Graham Sutton

Consultant in Geriatric and General Medicine Leeds Teaching Hospitals NHS Trust

1st North of England Falls Summit

16 March 2015

#t1noefs

Housekeeping

Our # for the Event

#t1noefs

Poster Competition

#t1noefs

Enter our poster quiz to win a box of chocolates or a bottle of fizz! Winner announced at the end of the day

Patient Safety Collaboratives: new opportunities to learn from the frontline of care

Tony Roberts

Patient Safety Collaborative Interim Programme Lead North East and North Cumbria AHSN Deputy Director (Clinical Effectiveness) South Tees Hospitals NHS Foundation Trust

1st North of England Falls Summit

16 March 2015

#t1noefs

“The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end.” Berwick Report, August 2013

Responding to Francis and Berwick

“Following Don Berwick’s recommendation, NHS England will establish a new Patient Safety Collaborative Programme across England to spread best practice, build skills and capabilities in patient safety and improvement science, and to focus on actions that can make the biggest difference to patients in every part of the country. They will be supported to systematically tackle the leading causes

• f harm to patients. The programme will start in April

2014.” The government’s response to Francis, November 2013

Responding to Francis and Berwick

• A network of 15 patient safety Collaboratives across England, with a five

year lifespan

• Tackle the leading causes of harm to patients using QI, innovation &

evidence based solutions, supported centrally

• Offer staff, users, carers and patients the opportunity to work together

locally to tackle specific safety concerns

• Build patient safety and improvement capability – quality and safety

science education across professional groups

• Raise awareness – create energy, build a safety movement
• Ambition - will be the largest and most comprehensive collaborative

improvement initiative in the world

• Will (must) work cross sector and cross service

What is the patient safety collaborative programme and what will the Collaboratives look like?

Topic area Patient Safety Topic The ‘essentials’ Leadership Measurement NHS Outcomes Framework improvement areas Venous Thrombo- embolism Healthcare Associated Infections Pressure Ulcers Maternity Medication Errors Deterioration in children Other major sources of death and severe harm Falls Handover and Discharge Nutrition and hydration Acute Kidney Injury Missed and delayed diagnosis Deterioration

• f patients

Medical Device Errors Sepsis Vulnerable groups for whom improving safety is a priority People with Mental Health needs People with Learning Disabilities Children Offenders Acutely ill older people Transition between paediatric and adult care

Collaborative priorities - proposals

Sign up to Safety

A national

campaign for the NHS in England Aim to reduce avoidable harm by half and save 6000 lives Everyone working together as never before to achieve large scale, long lasting change

11 Update as at 21 August 2014

The North East Legacy

• Many organisation-based initiatives, clinical networks and

partnerships and collaborative projects

• Safer Care North East (led by former NE SHA): Our falls group has

existed continuously since it was set up under this initiative

• Investing in Behaviours (led by NHS England North, in

collaboration with the Health Foundation)

• Leadership programme (led by North East Leadership Academy)
• Mortality monitoring
• Measurement tools commissioned from NEQOS
• Collaborating for better care - NICE Best Practice Partnership
• Academic experts

Baseline patient safety metrics

• An approach is being developed locally
• Indicators in the public domain (no new

measures at this stage)

• Helpful in identifying priorities
• Need to acknowledge the difficulty in answering

the two key questions:

– Is the NHS getting safer? – If it is, what contribution to that are PSCs making?

Progress so far

• Steering group has met 3 times, chaired by Professor Richard

Thomson and agreed TORs. Membership remains open to review but includes patient and public representatives.

• Process to appoint small team to run the PSC
• Call for proposals January 2015: ~£450K

– 22 projects received, 2 funded with request for 4 others to resubmit with alterations and 2 more for resubmission to next call

• Funded projects to begin in April 2015
• Link to Health Education North East Faculty of Patient Safety

Contacts

Tony Roberts Interim Programme Lead Tony.Roberts@stees.nhs.uk Cate Quinn Interim Programme Manager CQuinnSolutions@gmail.com

The Yorkshire and Humber Improvement Academy Patient Safety Collaborative

Dr Ali Cracknell

Consultant in Medicine for Older People, Leeds Teaching Hospitals NHS Trust

Alison Lovatt

Clinical Improvement Network Director, Improvement Academy Telephone: 01274 383926

#t1noefs

Yorkshire and Humber

“Bottom up from the top”

Improvement Academy Principles

• Compliment what is already happening and existing

safety priorities for frontline teams

• Everything we do informed by organisations
• Work on behalf of organisations:

– mobilising frontline teams to focus on safety areas important to them – Use evidence and practical support to increase capability – “bottom up from the top”

• Support partners to become High Reliability

Organisations

Foundations

• Building foundations since 2013
• Gaining intelligence from frontline teams
• Improving safety culture
• Generating capacity

– 115 Yorkshire & Humber Fellows

• Funding to build on this

– Resources to support – Share learning and scale up – Innovate, Implement, and spread improvement – Compliment what already doing wards, organisations

Reducing harm at the frontline

Managing tensions between learning and performance

RESULTS & LEARNING RESOURCING & ASKING PERTINENT QUESTIONS

Changing the conversation

RESOURCING & ASKING PERTINENT QUESTIONS

CQC Wider public NHSE

Engaging Patients PRASE

Team-working and culture

UK adaptation of Safety Climate Survey developed by researchers at University of Texas

29

Visual Data

Changing staff behaviours

Safety Huddles in Healthcare

Daily forum for staff to discuss any safety concerns

• Clinically led
• Multi-professional
• On time and brief (5-10 minutes)
• Reliable
• Fear free and inclusive

Focused meeting about one or more agreed patient harm/s Informed by QI tools and feedback

• Ideally followed by debrief at end of day/shift

The Safety Huddle …igniting a spirit of learning

“Excellent achievement given the history of falls on this ward”

Clinical Director, Calderdale & Huddersfield NHS FT

Addressing Teamwork+Safety Culture Celebrating success Making measurement visible

Measuring for Improvement

www.improvementacademy.org @improve_academy

Exercise and Falls Prevention

Professor Pam Dawson

Dean of Health and Life Sciences York St John University

1st North of England Falls Summit

16 March 2015

#t1noefs

Falls: the scale of the problem

30% people >65yrs 50% people >80yrs fall at least once per year 5% of community dwelling fallers will experience a fracture Falls are the most commonly reported patient safety incident in NHS Trusts in England

Falls affect faller, family and carers: Injury, pain, distress, fear, loss

• f confidence and

independence, mortality

Falls cost the NHS >£2.3b per year

Evidence for falls prevention: the problem of the scale

Huge number of individual trials and studies globally over more than 2 decades Individual trials inform systematic reviews, Cochrane reviews, position statements, NICE guidelines, pt pathways …

Evidence doesn’t speak for itself – it has to be interpreted for the individual and their context

Outcome measures – Fall rates (falls per person year) or Fall risk (number

• f fallers in each

group of a trial)

Primary versus secondary prevention Community versus care settings

So what are the basic NICE guideline messages for exercise in falls prevention?

Exercise (strength and balance training)

• ffered as a single intervention

by an appropriately trained professional

Untargeted group based exercise has not been shown to be effective in these conditions

should be offered multiple component exercise (strength and balance training) in an individual or group programme

as a single falls prevention intervention individually prescribed and monitored

Older people living in the community

with a history of recurrent falls

and/or

an identified gait and balance deficit

NICE 2013

Exercise (strength and balance training) offered as a component of multidisciplinary falls prevention

should be offered individually prescribed exercise as a component of multidisciplinary falls prevention intervention Older people > 65yrs (or 50-64 yrs judged to be at higher risk of falls) admitted to hospital

where any identified muscle weakness or gait/balance problem can be treated, improved or managed with individualised intervention during the patient's expected stay

Older people living in extended care settings (e.g. nursing homes)

who are at risk of falling

NICE 2013

and

Considerations when designing and delivering evidence based exercise for falls prevention

• Previous falls (secondary prevention)
• Identified fall risk (primary prevention)
• Consider cognitive function
• Consider motivation and likely adherence

Target group

• Strength/resistance exercises
• Balance/gait training
• Individual or group based
• Trained professional

Type and setting

• f exercise
• How many times per week
• Over how many weeks

Frequency and duration

• The right degree of challenge for the individual
• Supervision/progression over time

Intensity

How evidence-based are our exercise programmes?

Survey of 1768 patients* referred to falls prevention services in England, Wales and NI wide shows two thirds were participating in group based exercise but wide variation in models of delivery of exercise interventions

• Most patients attended group-based classes of

short duration (<12 weeks) and only once/week Only 50% patients said their programme was progressed as they improved

Recommended exercise programmes should be individually tailored, progressive and delivered over long periods (Otago 1 year; FaME 35 wks)

• But lack of follow up afterwards

High levels of patient satisfaction with programme *Buttery et al 2014

#t1noefs

Where the evidence doesn’t help …

• Evidence is inconclusive that exercise prevents falls in

dementia/cognitive impairment*

• Poor adherence and loss to follow up*
• Cognitive impairment is frequently cited as a reason not to

refer or not to offer exercise**

Dementia

• Exercise alone may possibly reduce fear of falls but only in

the short term***

• Not all trials have fear of falling as an outcome***

Fear of falls

*Winter et al 2013 **Buttery et al 2014 ***Kendrick et al 2014

Adherence and compliance

Trials report uptake of exercise interventions can drop from as high as 80% in the first 10 weeks to 50% at one year* In practice adherence can be much lower Patient level barriers include transport, cost, motivation and injury Programme level barriers Group – Decreased adherence with duration of 20 weeks or more, two or fewer sessions per week, or a flexibility component** Home - Increased adherence with balance component, home visit support and physiotherapy led*** Decreased adherence with flexibility component*** * Nyman and Victor 2011 **McPhate et al 2013 ***Simek et al 2012

How can we promote and improve adherence?

Older people participate in exercise to remain independent and they value approaches that promote autonomy and self management Physiotherapists are fatalistic with a ‘take it or leave it’ attitude to the exercise they prescribe and instruct

Robinson et al 2013

Population-based interventions for prevention of fall related injuries in older people

Systematic review to assess the effectiveness of population-based interventions, defined as coordinated, community-wide, multi-strategy initiatives, for reducing fall-related injuries among older people. Preliminary claim that the population-based approach to the prevention

• f fall-related injury is effective and can form the basis of public health

practice. Randomised, multiple community trials of population-based interventions are indicated to increase the level of evidence in support of the population-based approach.

McClure et al 2008

Exercise and falls prevention: from evidence to implementation

Multiple agency commitment and older people involvement Population based and whole system approach Evidence based intervention applied consistently and with training Joined up approach with other pathways/ services, e.g. dementia Leadership and continuous innovation and quality improvement Joint commissioning

References

Buttery AK et al (2014) Older people’s experiences of therapeutic exercise as part of a falls prevention service: survey findings from England, Wales and Northern Ireland. Age and Ageing, 43: 369–374 Kendrick D et al (2014) Exercise for reducing fear of falling in older people living in the community (Review), Cochrane Library, Issue 11 McClure RJ (2005) Population-based interventions for the prevention of fall related injuries in older people (Review), Cochrane Library, Issue 1 McPhate L et al (2013)Program-related factors are associated with adherence to group exercise interventions for the prevention of falls: a systematic review. Journal of Physiotherapy, Australian Physiotherapy Association Vol. 59 NICE (2013) Falls: assessment and prevention of falls in older people, NICE clinical guideline 161. Nyman S and Victor CR (2012) Older people’s participation in and engagement with falls prevention interventions in community settings: an augment to the Cochrane systematic review, Age and Ageing, 41: 16–23 Robinson L et al (2014) Self-management and adherence with exercise-based falls prevention programmes: a qualitative study to explore the views and experiences of older people and physiotherapists. Disability and Rehabilitation, 36(5): 379– 386 Simek EM et al (2012) Adherence to and efficacy of home exercise programs to prevent falls: A systematic review and meta-analysis of the impact of exercise program characteristics. Preventive Medicine, 55: 262-75 Winter H et al (2013) Falls prevention interventions for community dwelling older persons with cognitive impairment: A systematic review. International Psychogeriatrics , 25(2):215–227

A Hybrid Approach to Falls Rehab

Dean W Metz, BSc MPH

Falls Specialist Physiotherapist South Tyneside Foundation Trust 1st North of England Falls Summit

16 March 2015

#t1noefs

#t1noefs A Unique Approach

• 1. A multifactorial Assessment done jointly by a

nurse and a physiotherapist

• 2. A home programme to address specific

identified weaknesses

• 3. A six stage progressive exercise programme

administered by HCA and rehab nurses

• 4. Physio interventions not already included in

the six stage programme

The Six Stage Programme

• 1. Supine
• 2. Seated in armchair
• 3. Seated on edge of mat table
• 4. Standing using rail for support
• 5. Standing using no upper extremity support
• 6. Dynamic standing on challenging surfaces

BP and medications are monitored throughout

People need to function in challenging environments

People don’t walk solely on linoleum.

People need to reach and balance to perform everyday tasks

Our Programme

• Builds on static strength training and

incorporates trunk (core) exercises on gym balls and standing on alternative surfaces

• Emphasizes quick reactions to stimuli
• Is transferable to day to day functional

activities

Tossing a ball whilst on pliable surface

Reaching and placing whilst on unstable surface

Kicking a ball or Playing football

Our Audit Results

• Reduced Risk of Falling

Timed up and go: Mean decreased by 8.2 seconds Tinetti: Mean score increased by 5.8 points FES-I: Mean score decreased by 5.9 points

• Reduced Rate of Falling

Self reported falls decreased by 81% 6 months after discharge

Refreshments and Networking

#t1noefs

Dr John Davison FRCPE PhD Falls & Syncope Service Newcastle-upon-Tyne Hospitals NHS Trust

Multifactorial Falls Prevention

F A S S

A fall is not a diagnosis

“A fall may occur as a consequence of summative interaction of pathologies with reduced adaptive reserve”

Swift C 2006

Falls may signal

• unidentified medical problems
• unresolved underlying medical conditions

Resultant of ≥1 intrinsic and / or extrinsic factors

• A cumulative risk
• Risk factors predispose events

Steinweg KK. Am Fam Physician 1997;56:1815-22

Epidemiology of falls

the most common cause of accidents and associated morbidity in older people 35% aged >65 years will fall in any given year Up to 75% in those > 85 years Up to 45% of Emergency attendances in those >65 years are associated with a fall 20 % of these are admitted 25 -60% result in injury 2 - 5% lead to a fracture

Richardson 1997

Cummings 1988, Tinetti 1988, Nevitt 1991 Tinetti 1988, Luukinen 1995 Campbell 1981, Blake 1988, Prudham 1981 Lehtola 2006

Non-Fallers 59% No Data 7% Subjects > 50 Years attending A&E (n = 71,279) Fallers 34% (n = 24,251)

Richardson 1997

Sequelae of a fall

Loss of confidence to perform ADLs

Tinetti M et al 1994, Vellas B et al 1997

Changes in health status

Cwikel J et al 1992

Social isolation Increased hospitalisation Mortality at 1 year increased - recurrent fallers (OR 2.6, CI 1.4-4.7) Increased Risk of admission to long-tem care

single fallers (OR 3.8, CI 1.8-8.3) recurrent fallers (OR 4.5, CI 1.7-12)

Donald, Bulpitt 1999

Intrinsic

Lower limb muscle weakness (OR 4.4) Gait abnormalities (OR 2.9) Balance abnormalities (OR 2.9) Visual impairment (OR 2.5) Arthritis (OR 2.4) Cognitive impairment (OR 1.8) Neurocardiovascular abnormalities

Extrinsic

Walking aids (OR 2.6) Polypharmacy (OR 1.6 – 3.0) Culprit medication (OR 1.5 – 2.0) Environmental hazards (OR 1.5)

10 20 30 40 50 60 70 80 90 100

% with risk factor Balance Gait Home Hazards Carotid Sinus Hypersensitivity Orthostatic Hypotension Vision Neurological Vasovagal Depression Medication

Median 5 fall Risk Factors identified (Range 1-10) ( n=146)

Davison J, Age Ageing 2005;34:162-8

Fall Risk Factors

Synergism

• f risk

Perell 2001, Leipzig 1999, Cesari 2002, Tinetti 1993

Fall risk

No risk factors 3 or more risk factors

Nevitt, 1989; Robbins, 1989; Tinetti, 1988

Overlap Between Syncope and Falls

Unreliability of history 32% of elderly with documented falls were unable to recall the event 3 months later

(Cummings 1988)

Lack of witness account Only 40-60% of syncopal events are witnessed (McIntosh 1993) Amnesia for loss of consciousness

(Kenny 1991)

Which population?

Older community dwelling adults

+/- fall risk factors Recruitment population for majority of exercise only interventions

7 RCT (n = 2361) RR 0.72 (0.58 – 0.90)

Older adults who have sustained a fall

Multifactorial intervention studies indicate benefit

17 RCT – pts selected for higher risk of falling (n = 5954) RR 0.77 (0.66 – 0.90) Benefit not seen in multifactorial Rx when patients not selected for high falls risk

Group exercise in higher risk group (n = 1261, 9 studies)

RR 0.70 (0.58 – 0.85)

Key Intervention Studies

• Community

Tinetti NEJM 1994

Age 70+ with at least 1 fall risk factor (30% prev fallers) Multifactorial intervention 31% reduction in percentage falling (35% v 47%)

Campbell BMJ 1997

Women age 80+ (40% prev fallers) Individually tailored strength & balance training programme 152 falls in control gp (n=117) v 88 in exercise gp (n=116)

Robertson BMJ 2001

Age 75+ (36% prev fallers) nurse delivered strength & balance training programme 109 falls in control gp (n=119) v 80 in exercise gp (n=121)

Community dwelling – present with a fall

• PROFET study
• Age 65+
• Attending A&E with fall (72% single fallers)
• Medical and OT intervention
• Day hospital referral for identified risk factors
• Falls
• 510 falls in control gp (n=163) vs. 183 (n=141)
• RR 0.39 (95% CI 0.23 - 0.66)
• Fallers

Close et al, Lancet 1999;353:93-7

Recurrent Fallers – Emergency Dept

Davison et al, Age Ageing 2005;34:162-8

Recurrent Fallers – Emergency Dept

• Recurrent fallers (median 3 falls)
• Medical, PT and OT intervention
• Neurocardiovascular risk factor assessment & intervention
• 387 falls intervention gp (n=144) vs. 617 (n=149)
• Mean rate of falls 3.3 (SD 5.0) vs. 5.1 (SD 7.9)
• RR 0.64 (95% CI 0.46 - 0.90) = 36% reduction
• No effect on fallers (68% control vs 65% intervention)

Community dwelling fallers – ambulance response

204 adults > 60 years ambulance called - subject not conveyed Randomised to community falls prevention (PT, OT, Nurses, medical review) or standard care Incidence rate of falls per year 3.46 vs 7.68 IRR 0.45 (95% C.I. 0.35 – 0.58) – negative binomial regression Number of further ambulance calls reduced – IRR 0.60 (95% C.I. 0.40 – 0.92)

Logan PA et al, BMJ 2010;340:2102

Pooled RR = 0.71 (95%CI 0.62-0.80)

A J Campbell, Age & Ageing 2007:36:656-62

Exercise (Tai Chi, multiple component group, individually prescribed home) is effective as a single intervention

Pooled RR = 0.76 (95%CI 0.67-0.86)

Gillespie LD et al: Cochrane Systematic Review 2012

Multifactorial interventions reduce rate of falls

Hospital Inpatients

Assess for Risk of Falls

cognitive impairment continence problems falls history, including causes and consequences (such as injury and fear of falling) footwear that is unsuitable or missing health problems that may increase risk of falling medication postural instability, mobility problems and/or balance problems syncope syndrome visual impairment

Hospital Inpatients

10 20 30 40 50 60 70 80 90 100 multi-professional > five components post-fall review toileting plans medication review staff education urine screening environment footwear numerical risk score exercise hip protectors wristband alarms beside sign patient information perecentage of trials significant reductions in falls no significant reductions in falls

Act on risks identified

Multifactorial intervention – Fall rate reduction 20 – 30%

Oliver D, Healey F, Haines T (2010) Clinics in Geriatric Medicine 26 (4) 645-92

Fall rate ratio 0.75 (0.68-0.84)

Contributing Interventions that work

• Vitamin D – in those with low Vit D levels – > 800 units / day
• Home safety interventions – only effective in visual impairment

and if at ‘high risk’ of falling

• First eye cataract surgery

Harwood BJO 2005

• Pacemakers for carotid sinus hypersensitivity?

Kenny JACC 2001, Parry 2009, Ryan 2010

3 studies, n=349, RR 0.73 (0.57 – 0.93)

• Podiatry for those with foot problems

Spinks BMJ 2011

• Integration of balance & strength training into daily life activity

Clemson BMJ 2012

When is multifactorial intervention less effective?

• Patients with dementia
• ‘Treat the reversible’ – look at medication change, BP

control, behaviour management, # risk Shaw BMJ 2003;326:73

• Single assessor intervention

Kingston 2001, Lightbody 2002, Hendricks 2008

• Generalist multifactorial intervention? Spice, Age Ageing 2009

Single assessor intervention

Nurse-led multifactorial intervention F/U after ED attendance with fall 348 patients > 65 years multifaceted assessment trend towards reduction in falls - 89 in 36 intervention vs. 145 in 39 controls (ns)

Lightbody et al Age Ageing 2002;31:203-10

medication ECG blood pressure cognition visual acuity hearing vestibular dysfunction Balance Feet and footwear Mobility

Hendricks MR et al, JAGS 2008; 56(8):1390-7

Single assessor assessment & intervention after ED attendance with fall – modelled on PROFET N=333 fallers age > 65 years individualised intervention

OR of further falls = 0.86 (0.50-1.49) Medication review education environmental risk ax exercise advice referrals

Cluster randomised controlled trial Community dwelling recurrent fallers age >65 yrs not presenting to ED Intervention: 18 general practices randomly allocated

1.

Primary care group – nurse assessment in the community, using risk factor review and targeted referral

2.

Secondary care group – day hospital multi-disciplinary assessment and intervention

3.

Controls – usual care

Results:

505 recruited (complete FU in 83%) Fewer fallers in secondary care group - 75%, (158/210) vs. 84%, (133/159) adjusted OR = 0.52 (95% CI 0.35–0.79) P = 0.002 Primary care group similar to controls - 87%, 118/136, OR 1.17 (95% CI 0.57–2.37)

What to do in practice?

• 1. Assessment

Case find for falls Get up and go test

History

Previous falls Arthritis Muscle weakness Gait / balance problems Stroke / PD Medication Cognition Sensation Vision

Examination

Cardiovascular Orthostatic hypotension murmurs Neurological Muscle strength Sensation Locomotor Gait inc feet / footwear Vestibular Dix-Hallpike

Is there a medical cause ?

Is the fall unexplained? Does the patient recall the fall? Are the injuries proportionate? Are there other clinical pointers from the history?

Lightheadedness Think…white coat hypertension – beware single BP symptoms with posture change Think….OH, culprit meds Symptoms when lying back / turning in bed Think….BPPV

What to do in practice?

Investigations

Visual acuity / Contrast Active Stand ECG Haematology / biochemistry CSM if syncope Dix-Hallpike DEXA

Treatment

Medication modification Treat Orthostatic Hypotension Targeted muscle strengthening exercise

Duration > 12 weeks

Balance exercise Environment modification Vitamin D if deficient Treatments for specific conditions

Epley PPM

Visual assessment

Verbaken A, Johnston A.W. Am J Optom 63: 724-732, 1986.

Investigations

Spacelabs 90207

Any new medications? Timing of tablets? Culprit medications - FRID?

antidepressants (esp SSRI on initiation) benzodiazepines neuroleptics /antipsychotics sedatives / hypnotics antihypertensives diuretics

Ziere Br J Clin Pharm 2006, Leipzig JAGS 1999, Ensrud JAGS 2002, Woolcott Arch Int Med 2009, Sterke Br J Clin Pharm 2012

Medication review

Medication Change

• Gradual withdrawal of psychotropic meds

Community group with fall risk factors n = 93 Relative Risk of falling at end of intervention 0.34 [0.16, 0.73] Not sustained

• Withdrawal of Fall Risk Increasing Drug

n = 139 with one or more falls in previous year FRID stopped in 67, reduced in 8 All FRID (n = 75) 0.48 (95% CI 0.23, 0.99) Cardiovascular Drugs 0.35 (95% CI 0.15, 0.82) Psychotropics (n = 29) 0.56 (95% CI 0.23–1.38)

Campbell JAGS 1999 Van der Velde, Br J Clin Pharm 2007; 63(2): 232-7)

Don’t forget about bone health !

www.shef.ac.uk/FRAX

Take Home Messages

Both single and multifactorial interventions reduce fall rates by about 30% Single interventions esp exercise work in community settings – early targeting of those with risk factors Multifactorial intervention is effective for specific patient groups - when delivered by specialist teams Multifactorial intervention essential for hospital inpatients Heterogeneity of interventions remains large Consider specific interventions for sub-groups Look out for ‘easy wins’

Posture induced symptoms

• Lightheaded on standing?
• Unsteady on standing?
• Symptoms on lying flat or

turning?

Facial or head injury

• Disproportionate injury

Fall with no apparent hazard Loss of consciousness

East Riding Falls Service

Jon Duckles – Service Manager Claire Sellers– Clinical Therapy Lead

Humber NHS Foundation Trust

1st North of England Falls Summit

16 March 2015

#t1noefs

Local Drivers

Why change?

• Circa 20,000 people in the East Riding fall each year (POPPI data)
• 30% of admissions to A&E are as a result of a fall
• Limited falls service

The new model:

• Evidence based
• Community focused, patient centred
• Multi disciplinary, multi agency approach

Investment:

• £340k investment
• Risk share agreement

Benefits:

• Improved patient care
• 12% reduction in unplanned admissions = £400k savings

Risk Share

1130 Acute Admissions due to Falls Risk £’s Admissions relative to 1130

Falls Pathway

Otago Type Programme

• Specific set of exercises performed in a set programme.
• Clear ways of progressing the programme.
• Approximately 1 hour in duration.
• Focusing on balance and strengthening as identified in the NICE guidance

2013.

• To be completed daily.
• TOMs utilised for assessment and reassessment.
• Once the patient is assessed and commenced on the programme, the

rehabilitation assistants continue with the programme.

Rehabilitation Programme

• An individualised programme.
• Designed by the therapists.
• Including balance and strengthening exercises but also functional activities
• f daily living.
• Providing a holistic approach as depicted by NICE guidance 2013.
• Patient centred goals drive rehabilitation programme.
• TOMs utilised for assessment and reassessment.
• Once the patient has been assessed and commenced on the programme,

the rehabilitation assistants continue with the programme and progress accordingly.

Complex Programme

• For patients with co-morbidities, who lack consent or are non compliant.

Dementia and Alzheimer patients.

• For medicine management.
• Multi agency involvement – lifeline, tele care, Neighbourhood Care

Services, First Contact Practitioners.

• Safe systems.
• TOMs for assessment and reassessment – to identify maintenance.
• Holistic approach to care.

Step-Up/Step-Down – Ward.

• For comprehensive monitoring and assessment of patients.
• Make patients safe – if medically unstable.
• Medical management.
• Falls suites – tele care.
• Ward round – all falling patients.
• Challenges in integrating 2 services with different drivers.
• Integrated Hospital Team – links.

Falls Prevention and Fracture Liaison Service

Christina Heaton Nurse Consultant

Bridgewater Community Healthcare Foundation NHS Trust

1st North of England Falls Summit

16 March 2015

#t1noefs

Falls & Osteoporosis

• NICE guidance Falls CG21 (2004) CG 161

(2013) undertake assessment of Osteoporosis risk

• National Osteoporosis Society 2010 NOS:

Highlighted need for osteoporosis and falls assessment to be provided to patients with a history of fragility fracture RCP audit 2010

• The majority of high-risk patients miss the

best or only opportunity for their falls and fracture risk to be identified in the majority of hospitals and most primary care organisations

• Lack adequate services for secondary falls

and fracture prevention.

• BOA-BGS 2007 Blue Book

http://www.nhfd.co.uk/

• National Hip Fracture Database

http://www.nhfd.co.uk/

• NICE guidance fragility fractures CG 146

(2012)

• Primary prevention of osteoporosis CG

160 NICE(2008)

• Secondary prevention of osteoporosis

TA87/ TA161 NICE (2011) BRITISH ORTHOPAEDIC ASSOCIATION: STANDARDS for TRAUMA (BOAST) August 2013: BOAST 7: FRACTURE CLINIC SERVICES

• Fragility fracture and falls prevention

services should be fully integrated

Osteoporosis

• 3 million people in the UK

have osteoporosis

• 1 in 2 women & 1 in 5 men
• ver 50 will break a bone,

mainly due to osteoporosis

• It costs the NHS and

government 2.5 billion a year, 6 million a day

• 230,000 fragility fractures
• Locally it is estimated that

there could be 17,400 people undiagnosed

• Half of hip fracture patients

suffer a prior “herald” fragility fracture

• 20% of patients with hip

fracture die within 90 days.

• Only 50% of people regain

full mobility in a year following an hip fracture

Morbidity attributable to ageing alone

Additional morbidity due to fragility fracture event

Fragility fracture through the life span 1 Osteoporosis + falls = fragility fractures

Falls Prevention Service

Falls & Balance assessment clinic Falls Prevention Fracture Liaison service

Falls Prevention and Fracture Liaison Service

• Specialist falls multidisciplinary team assessment
• Focused medical assessment, investigation and diagnosis
• Multi-factorial assessment and treatment
• Full medicine review
• Osteoporosis risk assessment undertaken using FRAX & NOGG. Ordering

and reviewing DEXA scan and suggesting or prescribing bone replacement therapy with counselling provided

• Specialist Physiotherapy assessment and treatment, based on national

guidance.

• Occupational Therapy undertake assessment and treatment which

including environmental and functional factors

• Health promotion, lifestyle advice and information
• Provided in health centre's and patients home across the borough
• Timely and appropriate referrals to other services and agencies

Key outcomes

• KPI 95-100% of patient

seen within 6 weeks

• All patients in FLS who

require bone health medication are followed up at 1 and 12 months to improve medication adherence, utilising Telehealth system ‘FLO’

• DNA (FLS 2014/2015)= 15%

(national average 30%)

• DNA (falls 2013/2014)= 4%
• 10% of patients seen in

the medical Falls clinic needed onward referral to hospital Consultant

• Patient satisfaction =

100%

Falls Prevention Service & Osteoporosis awareness new website

• www.bridgewater.nhs.uk/fallsprevention

References

BOA-BGS 2007 Blue Book http://www.nhfd.co.uk/ BRITISH ORTHOPAEDIC ASSOCIATION: STANDARDS for TRAUMA (BOAST) August 2013 BOAST 7: FRACTURE CLINIC SERVICES https://www.boa.ac.uk/wp-content/uploads/2014/12/BOAST-7.pdf National Hip Fracture Database http://www.nhfd.co.uk/ NICE guidance Falls CG21 (2004) CG 161 (2013) NICE 2012 guidance fragility fractures CG 146 NICE 2008 Primary prevention of osteoporosis CG 160 NICE 2011 Secondary prevention of osteoporosis TA87/ TA161 NICE Protecting fragile bones: A strategy to reduce the impact of osteoporosis and fragility fractures in the UK. 2009. http://www.nos.org.uk/NetCommunity/Page.aspx?pid=818&srcid=311 RCP 2010 Falling standards, broken promises - Royal College of Physicians https://www.rcplondon.ac.uk/sites/default/files/national_report.pdf

• 1. J Endocrinol Invest 1999;30:583-588 Kanis JA & Johnell O
• 2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ

Thank you

any question?

christina.heaton@bridgewater.nhs.uk

#t1noefs

Lunch and Networking #t1noefs

Patient Safety

Julie Windsor

Patient Safety Lead Older People and Falls Patient Safety Division, Nursing Directorate NHS England

1st North of England Falls Summit

16 March 2015

#t1noefs

Falls Update

Julie Windsor Patient Safety Lead Older People and Falls. National Advice & Guidance Team

16th March 2015

www.england.nhs.uk

What I’m going to cover.

 Update on national falls and harms data  National policy and guidance  What we need to improve on  What's on the horizon

www.england.nhs.uk

There's no shortage of policies and guidance …..!

Quality & Outcomes Framework NICE GG 81 Hip# NICE Hip # QS NICE 161 Falls NICE TA‟s 204, 160,161 CQUIN # prevention. Dementia Comprehensive Spending Review NHS Operating Framework Best Practice Tariff Hip # Prevention Package Older People Musculoskeletal Services Framework RCN „ Lets Talk about Restraint‟ Active for Life‟ NSF Older People Commissioning Toolkit Falls & Fracture Prevention RCP National Falls & # Audit BGS/AGS Falls Guideline Blue Book ( hip#) Silver Book ( urgent Care) NPSA Slips, Trips & Falls in Hospital NPSA RRR post fall response NPSA Safer Practice Notice ( Bedrails) MHRA Use of Bedrails guidance NPSA How To Guide – Reducing Harm from Falls

www.england.nhs.uk

No wonder it seems daunting !

www.england.nhs.uk

And so are the numbers….. Acute and Community Hospitals.

PD09 Degree of harm (severity) 2010 2011 2012 2013 Total No Harm 170,655 168,479 167,475 164,750 671,359 Low 64,121 64,669 61,484 57,984 248,258 Moderate 6,922 7,017 6,389 5,274 25,602 Severe 874 1,024 1,070 1,113 4,081 Death 118 105 120 150 493 Total 242,690 241,294 236,538 229,271 949,793 England

www.england.nhs.uk

Mental Health Hospitals.

124

PD09 Degree of harm (severity) 2010 2011 2012 2013 Total No Harm 18,370 17,241 17,093 16,120 68,824 Low 12,935 12,160 11,207 10,682 46,984 Moderate 1,425 1,368 1,431 1,292 5,516 Severe 92 107 134 105 438 Death 13 10 7 13 43 Total 32,835 30,886 29,872 28,212 121,805 England

www.england.nhs.uk

Age of patients reported to have fallen in hospital

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99 100+ % of all reported acute falls Age group

Breakdown by age of falls in acute clusters

www.england.nhs.uk

Types of moderate and severe falls harms

www.england.nhs.uk

Scale of the problem: death & severe harm

19% 17% 14% 8% 6% 6% 6% 5% 9%

Suicide/severe self harm Fall (hip #/sub-dural) Pressure ulcer grade 4 Treatment error or delay Obstetric-specific incident Operation/procedure related Clinical diagnostic error/delay Missed deterioration Medication incident Healthcare associated infection Pulmonary embolus Test results not acted on Transfer or discharge incident Other/unclear NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England data: 8,018 incidents

Over 8,000 reported fatal or severe harm incidents each year

www.england.nhs.uk

Moderate “ requiring hospital treatment or prolonged length of stay but from which a full recovery is expected”. Severe “Causing permanent disability where the patient is unlikely to recover former level of independence” or impairment which is not likely to be temporary (i.e. has lasted, or is likely to last for a continuous period of at least 28 days).

NRLS definitions

www.england.nhs.uk

What does a serious harm look like?

www.england.nhs.uk

National Hip Fracture Database

• Variance in numbers reported to

NRLS and Hip # database

• 2015/16 NHS Outcomes

Framework likely to have IP acquired hip fracture in it.

www.england.nhs.uk

A bit about benchmarking ….

www.england.nhs.uk

 Falls incidence  Falls rate per 1000 OCBD  Moderate & severe number and rate  Multiple fallers per specialty  Falls by patients with diagnosis of dementia  Falls involving bedrails  Complaints involving falls  Safety thermometer can help individual wards with QI improvements but has limitations

Triangulated data over time is important = the whole picture.

www.england.nhs.uk

Who should we assess?

133

 All patients aged 65 years or older  Patients aged 50 to 64 years who are identified by a clinician as being at higher risk of falling e.g.

• Sensory impairment
• Dementia
• Fall
• Stroke
• Syncope,
• Delirium
• Gait disturbances

www.england.nhs.uk

NICE CG161 recommendations

ₓ Do not use risk prediction tools esp those that assign a numerical score or hierarchy of risk. ₓ Do not offer “one size fits all” blanket interventions.  Do use individual multifactorial assessment.  Do use multifactorial intervention plans.  Do provide relevant oral and written information about individual falls risk factors & bedrail use

134

www.england.nhs.uk

Large high quality cluster RCT 43,837 patient ward admissions, 31,398 patients, 1,839 falls and 613 fall injuries. = Nursing interventions not as part as MDT intervention do not reduce falls or injuries. http://www.falls6pack.monash.org/node/38

www.england.nhs.uk

Essential care after an inpatient fall

2011 guidance based on safety reports rather than research but is accredited by NICE. Have a post-fall protocol specifying:

• Checks for injury before moving
• Safe manual handling if fracture
• Neurological observations
• Timescales for medical review

Provide:

• Flat-lifting/immobilisation equipment
• Glasgow Coma Scale formats
• Fast track to CT/x-ray/theatre

www.england.nhs.uk

Not always getting it right yet.. a typical narrative from NRLS.

Patient in room , on chair beside bed . Buzzer in reach & wearing non slip blue slipper socks . Some staff having hand - over two other nursing staff with patient in room 9 . They heard thump noise from room 7 . Patient on floor on his left side . Left arm under body . Skin tear / bleeding left arm . Slide sheet to roll onto back & hoist sling . Left leg rotated , shortened & unable to stretch out . Pain ++ to left

• uter hip & left groin . Patient states : no loss of

consciousness , didn't bang head . .

www.england.nhs.uk

So what else is on the horizon?

• NHS Outcomes Framework 2015/16
• Falls practitioners network

www.england.nhs.uk

Does inpatient audit suggest we are doing well?

Significant variation in adherence to standards of care were found in a large proportion of patients for whom falls preventative actions were indicated.

www.england.nhs.uk

Education.

www.england.nhs.uk

Post fall actions

www.england.nhs.uk

Education

www.england.nhs.uk Page 143

Understanding & improving poor vision

www.england.nhs.uk

F Falls and Fracture Programme

 A survey of 20 areas to establish the feasibility of gathering and making available information about their local FFF system.  Conducted by Local Authority Public Health teams in partnership with clinicians Purpose:

• Providing support to local FFF initiatives
• Assessing and tracking performance
• Learn from best practice
• Strengthen local partnerships

www.england.nhs.uk

NHSE SIRI Framework update

 unexpected or avoidable injury to one or more people that has resulted in serious harm  unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional in order to prevent the death or serious harm of the service user

www.england.nhs.uk

Serious harm is defined as

 resulted in permanent harm  chronic pain (continuous, long-term pain of more than 12 weeks)  psychological harm, impairment to sensory, motor or intellectual function or impairment to normal working

• r personal life which is not likely to be temporary (i.e.

has lasted, or is likely to last for a continuous period

• f at least 28 days).

www.england.nhs.uk

NICE Falls Quality Standard 2015

www.england.nhs.uk

Thanks for listening, any questions? j.windsor@nhs.net

INPATIENTS FALLS – THE LEEDS STORY

Graham Sutton

Consultant Geriatrician Leeds Teaching Hospitals NHS Trust

grahamsutton@nhs.net 1st North of England Falls Summit

16 March 2015

#t1noefs

October 2012

Acute Floor initiatives and changes

• Change culture to think about what does this

patient need

• Toileting
• Acute Medicine Falls Group
• Sharing of initiatives
• Trajectory setting
• RCA learning
• Falls champions

Collaboration with Improvement Academy Understanding how powerful patient safety culture can be

Interventions

Interventions

Celebrating Success

Progress on the Acute Medical Admissions Floor

Latest Figures for Acute Medicine CSU/Acute Floor

2012-13 2013-14 Total Number Reduction % Reduction 2014-15 (11 months) Acute Medicine CSU 2044 1543 501 24.5 1074 Acute Floor 719 503 216 30.0 317 Moderate or significant falls 25 18 7 28.0 24

Collaboration with Haelo

Incidence of falls per 1000 bed days

Mean = 8.2 Mean = 5.7

Start of collaborative Start of collaborative

ANY QUESTIONS?

Staying Steady on the Buses

Jill Poole - Health & Wellbeing Manager Roger Goode – Arriva Yorkshire Risk Manager

1st North of England Falls Summit

16 March 2015

#t1noefs

Arriva

• A need to decrease falls
• n buses
• Driver/ passenger

relationship needed to be improved

The beginning of a perfect partnership

Public Health

• Decrease falls
• Prevent social isolation
• Contact made
• Consultation events held
• A plan began

• Understand the issues for both groups
• Develop appropriate methods of consultation
• Driver health checks, relationship building
• Discus with community groups and older people forums and health professionals

In brief the findings were:

Where to begin?

Drivers

• Passenger to speak to them
• Stay seated whilst the bus is

moving

• Ring the bell
• Think safety!

Older Adults

• Driver to speak to them
• Bus not to move until they were

seated

• Stop when they ring the bell
• Think about their safety

Resolving the issues

Older Adults

• Feedback from consultations
• Developed information leaflet
• Developed poster
• Cascaded messages to the community
• Falls awareness campaign

Campaign Posters

Resolving the issues

Bus Drivers

• Feedback from consultations
• Certificate of Professional

competence (CPC) –training

• Driver education campaign
• Continued with health checks
• Arriva Angels and drivers part of

the falls campaign

• Positive feedback from older adults
• Positive feedback from drivers
• Statistics = Falls on buses have dropped 16%
• Continue to work together on:
• Dementia Awareness
• Safer Places
• Other Public Health campaigns
• Passenger support cards

Results

Refreshment Break #t1noefs

The Prevention of Falls Injury Trial (PreFIT) An Update

Julie Bruce PhD

Principal Research Fellow University of Warwick

1st North of England Falls Summit 16 March 2015

#t1noefs

Background

Why was the trial funded?

• Known risk factors for falling
• Less known about optimal strategies for different populations

Evidence for community-dwelling adults: (Gillespie 2012, 2008)

• 159 trials of falls prevention
• 34 trials of multifactorial falls prevention (MFFP) interventions
• can reduce number of falls (rate); but NOT the number of people who

fall (falls risk)

• many trials small & underpowered

Exercise & falls prevention

Evidence

• up to 30% reduction in falls rate & risk if well-designed

exercise programme (Gillespie 2012; Sherrington 2008; 2011)

• Must be of moderate to high challenge
• Must be of sufficient dose & duration, can be home or

group

• frequency >2hrs week, progressive
• duration 6 months

Uncertainty

• No direct comparison of exercise and MFFP
• No large UK study ever conducted
• Other trials too small to detect effects on injurious falls -

fracture, injury and disability

• These outcomes important
• patient & NHS burden
• need for high quality economic evaluation

Weak evidence base for fracture prevention

e.g. 6 exercise RCTs measured fractures Study Randomised Fractures Definitions %

Bischoff, 2010 86 87 9 Hip only, in post-hip # 5.2% Haines, 2009 19 34 3 Any fracture 5.6% Korpelainen, 2006 84 76 20 Includes 2 vertebral 12.5% McMurdo, 1997 44 48 2 Any fracture 2.2% Robertson, 2001 121 119 9 Non-vertebral 3.8% Smulders, 2010 47 45 2 Non-vertebral 2.2%

Total 810 45 5.5%

Despite 59 trials of exercise, only 6 include fracture as outcome

Research questions

• What is the effectiveness of advice, exercise and MFFP for

preventing fractures and falls?

• What is the effectiveness in subgroups by age, sex and fall

history?

• What is the cost of each strategy & which is most cost-

effective?

• What is feasible and acceptable to patients?

Methods

Design: 3-arm, cluster RCT Setting: primary care, 60 general practices, England 9,000 participants Participants: aged > 70 years community dwelling Exclusions: nursing / residential homes / terminal illness

Control arm

• Age UK Leaflet

Otago Home Exercise Programme

• Duration 6 months

Multifactorial falls assessment

• conducted in primary care / falls team
• Assess  identify factors  treat or refer

Interventions

PreFIT Exercise - Otago Programme

Features

• Delivered individually in out-patient setting
• Lower limb muscle strength and balance exercises selected from

a set programme

• Participants continue at home
• Frequency – 3 x per week
• Intensity – moderately challenging
• Duration – 30 minutes
• Designed to be progressive
• Includes walking (30 minutes x 2 per week)

Multifactorial Falls Assessment

Study Design

General Practices

Exercise Advice

• nly

MFFP

Balance survey

Low risk - no treatment Intermediate High risk Fractures, falls, quality of life, costs @ 18 months

Otago Home Exercise

MFFP

• Q. In the last 12 months have you had any fall including a slip or trip following which you came to rest on

the ground floor or lower level? I have not fallen in last year I have fallen once in last year I have fallen more than once in last year

• Q. Do you have any difficulties with your balance whilst walking or dressing?

No, or just occasionally Yes, often or always?

• Q. Do have any difficulties with daily activities, such as getting dressed, going to toilet?

No, or just occasionally Yes, often or always?

Balance self-screener

Risk classification

Lamb et al., J Gerontol A Biol Sci Med Sci., 2008

PreFIT Data Collection

Questionnaires & Falls Diaries

Falls diaries x 4

Consent

4 months 8 months 12 months 18 months Baseline

Demographics Balance & mobility Difficulty ADLs Walking Falls & fractures EQ-5D SF-12 Comorbidity Frailty measure Primary outcome Fractures ~ HES / GP / Self-report

• 4 regions
• 9821 recruited!
• Recruitment closed

Newcastle City (n=11) N=1689 participants Cambridgeshire (n=6) N=982 participants West Midlands (n=28)

Warwickshire/ Herefordshire Worcestershire Birmingham Black Country

N=4327 participants Devon (n=18) N=2823 participants

Progress to date

Total 63 practices

Trial ongoing….

Preliminary data

Sample characteristics N = 9821

Sent (subset only) Returned

All other regions 5359 4556 (85%) Newcastle Region 1071 945 (88%) Total 6778 5791 (85%)

Balance screening in primary care – feasible? Age: mean 78 years (SD 5.7), range 70 - 101 years Females 53% / Males 47%

63%

27% 11%

10 20 30 40 50 60 70 Low risk (no falls) Intermediate risk High risk (>1 fall) Frequency (%)

Risk profile

Falls history in last year N = 5791

N=3624 N=1542 N=625

Risk distribution

N (%) Referred for Exercise or MFFP

N = 2167 referrals

Intermediate risk 5% Balance problems only 17% Single fall only 5% Single fall & balance problems

Risk distribution

Newcastle Region vs Others

Balance screeners returned

Low Risk Intermediate risk High Risk All other regions 4556 3045 (63%) 1295 (27%) 506 (10%) Newcastle 945 579 (61%) 247 (26%) 119 (13%) Total 5791 3624 (63%) 1542 (27%) 625 (11%)

Survey of 5791 community-dwelling adults > 70 years:-

• 60%

not fallen / no balance problems in last year

• 40%

balance problems or fallen

N = 1088 Exercise referrals

35% declined 65% Assessments

completed

How many attended PreFIT treatment?

Interim data ….

27% declined 785 (73%) Completed MFFP

N = 1078 MFFP referrals

• Remote sites
• Busy clinical teams – workload / staff changes

Exercise

• Is Otago challenging enough?

MFFP

• Variability in service models across regions
• Standardising intervention materials
• Medication reviews – commitment from GPs

Challenges

• Getting started!
• Good retention
• Well received by therapists, falls teams & participants
• Positive feedback  pts. personalized exercise booklets
• Input to all intervention materials
• Trial documentation kept to minimum (MFFP = 1 page)
• More to come ………..
• Successes 

Thank you  Thanks to all participating teams

• To be continued….

Acknowledgements

Warwick team: Newcastle FASS team Grant-holders Sallie Lamb (CI) Dr Fiona Shaw Sandra Eldridge Emma Withers Dr John Davison + others Claire Hulme Susanne Finnegan Finbarr Martin Ranjit Lall Devon PI Dawn Skelton Martin Underwood Dr Ray Sheridan Lucy Yardley Susie Hennings ….. Keith Willett West Midlands Thanks to: Jonathon Treml John Campbell, NZ Ruma Dutta Claire Robertson, NZ Kitty Westacott Mary Tinetti, USA + numerous participating general practices & falls teams

Summary and Close Prize draw

Fiona Shaw

#t1noefs

Thank you for attending

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and return your badges before leaving

Contact Details

www.improvementacademy.org t: 01274 383926 e: academy@yhahsn.nhs.uk @Improve_Academy

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