Management of the Fallen Uninjured Person NHS 24 Wednesday 17 th December Ann Murray National Falls Programme Management ann.murray3@nhs.net
Management of the fallen uninjured person From a national perspective: • Current situation • Background • Falls • National Programme • Development work in this area to date • Assessment of the current situation • Existing pathways for the fallen uninjured person • Proposed plan
Management of the fallen uninjured person Current situation • From NHS 24, there have been reports of frail and/or elderly people being left lying on the floor for long periods of time, after requesting immediate assistance following a fall. • Historically, and by default, the Scottish Ambulance Service (SAS) has undertaken the role of assisting an uninjured person from the floor following a fall. • This has been in the absence of alternative arrangements (and in the interests of the person). This is not their remit and it can delay ambulance crews from attending life threatening situations. With growing demands, this approach is not sustainable for SAS. • With SAS continuing to provide assistance for uninjured fallen persons, in many health and social care partnership areas the need for robust alternative arrangements is sometimes hidden.
Management of the fallen uninjured person Current situation In many health and social care partnership areas, there are no formal arrangements in place for responding to people who fall in their home, are uninjured, do not have a community alarm/telecare, but require urgent assistance to get up.
Management of the fallen uninjured person Background: why falls matter For an older person a fall can be… • trivial, profound or fatal, • the first sign of a new or worsening health problem, • a marker for the onset of frailty , • a ‘tipping point’ leading to loss of confidence and independence, and increased dependence on family, and “I was never the same after the fall” health and social services. “I suddenly became an old person” “I don’t really feel the same person” “I was thoroughly demoralised” A fall is a symptom, not a diagnosis. NHS QIS Focus Groups, October 2008
Management of a fallen uninjured person Background : scale and cost In people 65 years and over: • Largest single presentation to the Scottish Ambulance Service (over 35,000 attendances) . • One of the leading causes of Emergency Department attendance. • Responsible for over 390,000 emergency bed days. • Implicated in up to 40% care home admissions . • Highest reported incident in hospital settings. Costs to health and social care services in Scotland estimated to exceed £471m each year (est. rising to £666m by 2020): – 45% long term care – 40% NHS – 15% care at home 6 ( £39,500 per hip fracture) (Craig 2012)
Management of a fallen uninjured person Background: National Falls Programme in Scotland (2010-present) Aims • To reduce the personal , system and societal costs associated with falls and harm from falls in Scotland. • For every health and social care partnership area in Scotland (32 partnerships) to have a local, integrated falls prevention and management pathway in operation . • Working with CH(C)P Falls Leads. The Up and About Pathway (2010) http://www.healthcareimprovementscotland.org 7
Management of a Fallen Uninjured Person Background: the Up and About Pathway (2010) The Up and About Pathway (2010) http://www.healthcareimprovementscotland.org 8
Stages 2 and 4 The evidence base .
Management of the fallen uninjured person Background: not a new issue Stage Three The aim is to provide: • a rapid response to avoid a long lie on the floor, and • an appropriate response, which includes both : safe and effective management of the immediate situation , and consideration of further health and care needs. The Up and About Pathway (2010) http://www.healthcareimprovementscotland.org 10
Management of the fallen uninjured person Background: Developments at Stage 3 of the Pathway 2013 2012 11
Management of the fallen uninjured person B ackground: complications of a ‘long lie’ A ‘long lie’ following a fall is defined as remaining on the ground or floor for one hour or more. Complications include: – Pressure ulcers – Kidney damage caused by muscle breakdown – Pneumonia – Hypothermia – Dehydration – Psychological harm • Depression • Fear of falling • Anxiety • Loss of self confidence – Death 12 [Todd and Skelton, 2004]
Management of the fallen uninjured person Background: Community Alarm and Telecare Services • Nearly all services are provided or commissioned by local authorities. • Many, but not all telecare services/community alarm services provide a response service for clients who have fallen and used their alert. • In many local authorities (24) there is a charge for this service (£1.10 - £8.40 p/w). There is some evidence that this can deter older people from using the service. 13
Management of the fallen uninjured person Background: Stage 3 of the Up and About Pathway 14
Management of the fallen uninjured person Background: example in Up and About 15
Management of the fallen uninjured person Background: ‘Mapping’ and the Up and About Report (2012) “A growing number of partnerships are identifying alternatives to an SAS response for fallers who are assessed on telephone triage as uninjured, but are unable to get up from the floor without assistance. This is in addition to the service provided by telecare/community alarm teams to existing clients”. Scottish Government, 2012 16
In your CH(C)P is there formal local agreement on which service providers are responsible for assisting an uninjured person from the floor (24 hours/day)? This is for people who do not have a community alarm/telecare service. Don’t Know No Need Work in Yes identified; progress no work yet in progress N Ayrshire W Isles Dumf & G’way Shetland Falkirk S Ayrshire Dundee Stirlingshire Borders Edinburgh E Ayrshire NE Glasgow Clackmann. Aberdeen East Lothian SE Highland NW Glasgow Argyll & Bute Aberdeenshire Mid Lothian Angus N Highland Inverclyde Dunf & WF S Glasgow Mid Highland West Lothian Kir’dy & Lev E Renfrew Moray Perth & Kinross Glenr & NEF N Lanarkshire Orkney S Lanarkshire W Dunbarton E Dunbarton Renfrewshire State of play at end of 2011 17
Management of the fallen uninjured person A Framework for Action 2014/16 About the Framework • The Framework describes 16 key actions for health and social care services across the four stages of the Up and About pathway. • These actions represent the minimum standard of care an older person should expect to receive, regardless of where and when they present to health and social care services following a fall. • At points throughout the pathway, statutory services will work with third and independent sector partners to deliver the actions described. As such, the Framework is relevant to all partners involved in the falls and fracture prevention and management pathway. 18 http://www.scotland.gov.uk/Publications/2014/10/9431
The National Falls Programme in Scotland A Framework for Action 2014/2016 Action 3.1 Responding services have a standard operating procedure for responding to an older person who has fallen and has or has not sustained injuries. Principles • There is absolute clarity and agreement amongst all local responding services on arrangements for responding to uninjured individuals following a fall. • NHS 24 is informed of local arrangements for responding to an uninjured person following a fall so it can respond to emergency calls appropriately and in a timely manner. Implementation note: Local variation in ‘responding services’ provision often results in the Scottish Ambulance Service becoming the default responder to people who have fallen and only need help to get up again. This is inappropriate use of a service for emergency health care. Local service provision requires to be mapped and understood before a SOP can be agreed. 19
Management of the fallen uninjured person Assessment of situation • Although many people who fall will require a ‘face to face’ assessment to determine their health status and subsequent needs, there will be a group of people whose status and circumstances can be established over the phone, and an appropriate ‘non SAS’ response arranged. We have limited data on the size of this group. • A continued lack of a co-ordinated and consistent approach is placing at risk people who fall and lie for long periods without assistance. • There are successful, sustainable care pathways for people who have fallen and are uninjured in operation in some areas of Scotland. These can provide useful models to help develop and implement pathways elsewhere. • Partnership areas where robust arrangements are not in place need to be identified and action taken to bridge this gap in service provision.
Edinburgh example 21
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