FALLS PRESENTATION danny amended for community

Twelve facts about falls, fractures & bone health

1 Annually, about 30 per cent of over 65s will experience a fall; rising to nearly 50 per cent of people aged 80 and above.2 Seventy-five per cent of falls are not reported.3 Falls destroy confidence, increase isolation, and reduce independence; nine per cent of older people who fall become afraid to leave their home in case they fall again.4 In the UK, 1 in 2 women, and 1 in 5 men, will suffer a fracture at some point after the age of 50, mainly because of poor bone health.5 About 300,000 fragility fractures occur in the UK annually, including 89,000 hip fractures.

6 For women, the risk of sustaining a hip fracture is greater than the risk of developing breast cancer.7 The National Osteoporosis Society calculated that in the UK, in 2011, the annual cost of hospital and social care for patients with a hip fracture was £2.3 billion, or more than £6 million a day.8 Three million people in the UK are estimated to have osteoporosis.9 Each year in the UK, fractures in patients aged 60 years and over account for more than 1.5 million hospital bed days.10 Ten per cent of hip-fracture patients will die within one month of their fracture, and 30 per cent of them will die within a year; there are 13,800 hip fracture-related deaths every year in the UK.11 Women who sit for more than nine hours a day are 50 per cent more likely to have a hip fracture than those who sit for less than six hour a day.12 A tailored exercise programme can reduce an individual’s risk of falling by up to 50 per cent.

FALLSPREVENTION TRAINING

Definition of a ‘Fall’

DEFINITION:• Slip –to slide accidentally causing the patient to lose balance. This is either corrected or the patient falls.

• Trip – to stumble accidentally, often over an obstacle, causing the patient to lose their balance. This is either corrected or the patient falls

• Fall – an event that causes the patient or part of the patients body to come into contact with the floor or ground lower than them, that may or may not cause injury

Falls without injury can be upsetting & lead to loss of confidence, admission or increased length of stay in hospital & increased likelihood of discharge to a residential or nursing home

1 in 5 people die within 3 months of a hip fracture

Falls are the commonest cause of death from injury in the over 65s

Almost 90,000 hospital admissions a year are caused by falls, primarily in the elderly

Facts

Patients with osteoporosis or osteopenia are more at risk

of fractures if they fall & should have an alert in their notes.

200,000 falls were reported in acute hospitals in 2010 (NPSA)

Falls cost the NHS £2.3 billion each year

Falls and fractures in older people are costly: - Estimated cost of treating and caring for hip fractures

could reach £6 billion by 2036 (Falls and Fractures Alliance 2013)

What makes patients more at risk of falling?

Risk of Falls History of falls ● Environment factors Physical weakness - Wet floors Balance, transfers and - Clutter walking problems - Lack of physical activity - Lighting Nutrition and hydration Reduced confidence ● Alcohol or substance abuse Polypharmacy Inappropriate footwear Vision and hearing difficulties ● Reduced consciousness Continence Poor communication Medical conditions

Medication.• Sedation

– The patient is less aware of their surroundings, with slower reaction times and impaired balance

• Night sedation, strong pain killers, anxiety medications (diazepam/lorazepam), anti-epileptics, antihistamines)

– Anti-depressants and anti-psychotics have sedative effects and can also lower blood pressure

• Hypotension– Medications commonly cause postural hypotension and

vasovagal syndrome• Bradycardia

– Medications that slow the pulse reduce blood supply to the brain

• Digoxin, anti-arrhythmic drugs, beta blockers, cognitive enhancer medications

Confusion and Falls

• Confused patients are more vulnerable to falling because they may:– Forget they need to ask for help or how to ask for help– Put themselves at risk because of agitation or anxiety– Find it difficult to recognise hazards – Find it difficult to find the things they need and so may

wander until exhaustion making them unsteady– Be unable to adapt to new problems with their mobility

(stroke/fracture)– Forget how to safely use mobility aids

Facts about Falls and Dementia

• 40 – 60% of patients with dementia fall each year – twice the rate of those with no cognitive impairment

• Impairments of gait and balance, medication, cardiovascular problems and the environment can all contribute to falls.

• Serious injury is more common

• ¼ of patients who fall sustain a fracture - 3 times more likely than the expected fracture incidents

• Poorer prognosis – less likely to make a satisfactory recovery from injury and 5 times more likely to be institutionalised

Falls & deliriumWhat is delirium?

Delirium (sometimes called ‘acute confusional state’) is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception. It usually develops over a few days. It is a serious condition that is associated with poor patient outcomes. However, it can be prevented and treated if dealt with urgently.

There are three forms of delirium:

• Hyperactive (agitated, wandering, aggressive/irritable, easy to spot)• Hypoactive (drowsy, not engaging, not easy to spot)• Mixed (a combination of the two)

Falls & delirium

Causes of Delirium

Infections Metabolic disturbance, renal failure, dehydration Polypharmacy Alcohol withdrawal Pain Sensory impairment – vision and hearing Constipation Sleep deprivation 

Delirium usually last a few days or a week or two, but can last up to six months!

Identify the risks particular to

your department

What can we do to reduce falls?

What Can we do to Reduce Falls?

• Risk assessment• Handover to carers/family on safe ways to mobilise the patient• Actively manage incontinence – refer to services – commodes - • Discuss need for check of Obs; lying/standing BP, ECG, BM’s• Ensure bed rails are only used when indicated• Safety monitors & sensor alarms – assisted technology referals• Lighting day & night • Pain assessments and review of medication by GP• Encourage fluids and a balanced diet• Advise the patient to ask for help – writing it down may help• Observe for confusion/ delirium/ distress• Advise patient/family on appropriate footwear• Uncluttered environment as possible

Possible Interventions

• Use of low bed• Sensor alarms• Put drinks, snacks, tissues etc within easy reach• If agitated try to find out why• Consider location of bed for ease of access to

toilet/commode• Items in Tiptree box could be used to distract

patients

Bed Rails

Ensure bed rails are in good working order each time they are used

To avoid entrapment ensure the gaps between the bed rail & bed the head & foot of bed, and the gap between the mattress & the bed rail meet national guidelines

Ensure bed rails are cleaned according to the bed rail policy

Bumpers should be used for patients who may hurt their limbs on the rails or who may become trapped in the rails

Consequences of Falls • Psychological effects

– Fear of falling can cause reduced activity, reduced confidence

• Prolonging hospital stays• Secondary complications

– Leg ulcers from grazes / DVT or PU from immobility

• Loss of independence– Fractures can have an effect on patients ability to maintain

independence/could lead to admission to a care home

• Low survival rates

• Staff − Staff feel guilty, distressed, recrimination. Possible visits to Coroner’s court

What should you do if a patient does fall?

What do you do if a person falls?

‘Never catch a falling patient’

Remove hazards and ensure the area is safe Check for injury Do not move the person if you think they may

have fractured a limb Request ANP/GP review Ascertain why the fall occurred Apply measures that can reduce the risk of

further falls Discuss with Carers/Family (with consent) Complete incident form if required Document

Consider future referral to Falls Program

Falls Occurrences on IDU?Incident Form Prompt Sheet

Guidance for Incident Reports- Slips Trips and Falls

Reporting FactorsLocation/Activity/ Time

•Where and when did fall happen? (bed space, bay, bathroom)•Was the fall witnessed or not witnessed?•What was patient doing at the time/what was the intended task? (Mobilising/going to the toilet)•What was the outcome of investigations recorded (x-ray/what did the review doctor say)•What type of injury was sustained?

EnvironmentalFactors

•Call bell available within reach before fall?•If fall from abed, were bedrails in use? – was bed rail assessment undertaken?•Was the floor wet or slippery?•Did they have any footwear on? What type?•Walking aid in use/in reach?•Was any equipment involved in the incident? (chair type and height/commode)•Were there any obstruction or clutter in the area?•Was there a lack of equipment before the fall? (ultra low bed)•What was the lighting like?•Was the fall from a height?•What were staffing levels at the time?

PatientFactors

•Is the patient confused? (Cognition, mental health, dementia, delirium)•Have the family been informed?•Was this the 1st fall this admission or a repeat fall?•Could any medication affected the risk of falls?•Did the patient collapse? (postural-hypotension )

Documentation

•Was the falls risk assessment completed before the fall?•Has the risk assessment been updated post fall? What are the actions to prevent further falls?•Was the patient on a yellow FIR chart?•What were the post fall observations? Were neurological observations required?•If the fall was not witnessed then ask patient what happened•Has the fall and post fall actions been documented in the notes?

LPTROLE OF THE FALLS CHAMPION

1. Aim of role

To assist in the reduction of falls within the clinical settings by ensuring staff adhere to the Policy for the prevention and Management of Falls (2014)

2. ROLE

1. To attend quarterly meetings – falls to be reviewed, Serious Untoward Incidents (fractures), lessons learnt, audit, and audit results and action plans, training issues, new guidance and technology.

2. To work with line manager in identifying causes for falls in the clinical area – environment, staffing, patient need and to take appropriate actions.

3. To escalate problems in managing a patient who is a “frequent faller”4. To assist in root cause analysis following serious injury.5. Cascade information on falls into your clinical area.6. To challenge bad practice in the management of falls.7. To monitor the clinical environment for potential hazards that may contribute for

falls.8. To act as a role model and a resource in the clinical area.9. To attend identified training to support the role of the Falls Link Person.

Case/risk identification

We should be asking routinely whether:

• Fallen in the past year and asked about the frequency, context and characteristics of the fall/s.

• Fallers or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance

– using outcome measures to assess and review

NICE GUIDELINE (CG161)

Multifactorial individualised falls risk assessments

• identification of falls history• ax of gait, balance and mobility, and muscle weakness• ax of osteoporosis risk• ax of the older person's perceived functional ability and fear relating

to falling• ax of visual impairment • ax of cognitive impairment and neurological examination• ax of urinary incontinence• ax of home hazards• cardiovascular examination and medication review.

NICE GUIDELINE (CG161)

Multifactorial interventions

• Strength and balance training• Home hazard assessment and intervention• vision assessment and referral• Medication review with modification/withdrawal.• Encouraging the participation into falls services

NICE GUIDELINE (CG161)

NICE GUIDELINE (CG161)

Education and information giving

• What measures they can take to prevent further falls• How to stay motivated with exercise • The preventable nature of some falls• The physical and psychological benefits of modifying falls risk• Where they can seek further advice and assistance• How to cope if they have a fall, including how to summon

help and how to avoid along lie.

NICE GUIDELINE (CG161)

NICE GUIDELINE (CG161)

Interventions that cannot be recommended to reduce the risk of

patients fallingBrisk walkingLow intensity exercise with continence

programmesGroup exercisesHip protectorsCorrection of visual disturbances

Ensure all areas of your home are well lit, especially stairs and bedrooms. Use nightlights where available

Keep your rooms and stairs free from unnecessary clutter. Remove any loose rugs and secure trailing wires.

Choose low heeled, well fitting shoes and slippers. Try and arrange to visit a chiropodist regularly, either privately or through your GP

Try to manage an eye test every year if aged 75 and over, or every 2 years for 65 – 75 years. Report any sudden deterioration to your GP

Have medication reviewed every 12 months

Ensure every patient receives a copy of the Falls leaflet.

Advice following discharge

Advice for people who fall

Take care when you first stand up. If you experience any loss of balance, see your GP

Ensure you drink plenty of fluid, approximately 8 cups/glasses every day to prevent dehydration.

Ensure you eat a balanced diet, including foods rich in calcium and vitamin D for healthy bones. Avoid skipping meals

Keep as active as possible

If you have fallen ensure you inform your GP and Health and Social Care Professionals

Use mobility aids correctly!!

Finally…

• “Patients safety has to be balanced against their right to make their own decisions about the risks they are prepared to take, their dignity and their privacy………. Staff need to work with patients and their carers to strike the right balance between preventing falls and rehabilitation”

National Patient Safety Agency

References

• LPT (2012) Using Bedrails safely and effectively

• LPT (2014) Prevention and Management of Slips, Trips and Falls Policy

• The Kings Fund (2013)

• NICE (2004)

• NICE (2013)

• WHO (2007)