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GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
Page1 Executive Summary 22 Project Board 43 Background 54 Aims and Objectives 75 Developing the Audit and Data Collection Strategy 86 Standards 97 Data Collection and Methodology 148 Results 199 Summary/Conclusions 4110 References 4611 Contact Details 4812 Acknowledgements 49
APPENDICESAppendix 1 List of Charts and Tables 50Appendix 2 Hospital wards – type and number of beds 51Appendix 3 Hospital Falls Services 53Appendix 4 Feedback Seminar Attendees 56Appendix 5 Proforma 57
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
Table 3. General Demographics7 Trusts/10 Hospital Sites 518 Patients52 patients from 9 hospitals, 50 from 1 hospitalMean Age = 81.5 Age Range = 65 – 100Male:Female = 2:3 (3 gender unknown)Average time in hospital = 22 days Range = 3 days – 179 days
Chart 1. Age Group by Hospital
N = 518Comment
Patients included were predominantly the very elderly, those aged 80 years or more
comprised almost 58% of the sample. This proportion varied by Trust from, 45% in
MRI to 73% at the Wirral.
This degree of variation may be explained by the different types of wards used in each
hospital and the predominance of younger or older patients accordingly. Some
hospitals did not have specific Care of the Elderly wards and so General/Adult Medical
wards were used were there is a greater mix of ages, some had a mix of different
types of wards and one of the hospitals used all Care of the Elderly wards. See
appendix 2.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
BuryM
RI
NMGH
Oldham
Rochdale
Stockport
Tamesid
e
Traffo
rd
Wirr
al
Wyth
enshawe All
65-79
80+
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
Chart 3. Proportion of Patients Assessed & Documented
N = 518
Standard: All patients are assessed and a completed form is in each patient’s
sets of notes
Comment
This chart shows the percentage of patients assessed. Assessment could be either by
using a Falls Risk Assessment Form, or some other less structured format of
assessing patients such as a note or statement made in the patients records by the
attending doctor. Please see methodology section. Between 85 - 95% of patients in 4
hospitals were assessed. Less than 53% of patients were assessed in the remaining 6
hospitals.
Hospitals using a FRA completely were more likely to assess their patients for falls
risk.
Table 4. Percentages AssessedHospitals with formal documentation in usePatients assessed by formal documentation 67%Patients assessed by other method 9%Patients not assessed 24%Hospitals not using formal documentationPatients assessed by formal documentation 13%Patients assessed by other method 18%Patients not assessed 69%
0%10%20%30%40%50%60%70%80%90%
100%
BuryM
RI
NMGH
Oldham
Rochdale
Stockport
Tamesid
e
Traffo
rd
Wirr
al
Wyth
enshawe
% Other Assess.
% FRA
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
Table 7. Is there any evidence in the notes that any of the following
interventions/prevention measures have been started?
N = 518
Intervention % YesPhysiotherapist 72%OT 42%Call Bell at hand 34%Close Observation 25%Bed rails 23%Asking for help 17%Alarms 13%Educate 12%Frequent toileting 12%Discussed with relatives 11%Bed left in low position 10%Home visit 8%Dementia assessment 7%Chair 7%Intermediate Care 6%Trial without catheter 4%Special if frequent faller 4%Coloured wristband 3%Footwear Assessment 3%Hip Protectors 1%Balance Class 1%Falls Clinic 0%
Standard: The standard ideal was that in all patients’ records there was
documented evidence of including or excluding interventions
A list of intervention or prevention measures was devised (please see methodology
section for list and sources) using other lists that other groups had compiled such as
the action list from Stockport, and used on the proforma. Data collectors looked to see
whether or not these had been documented in a patient’s notes. It is important to note
that not all hospitals have the same intervention measures, for example very few
hospitals use coloured wristbands to identify patients at risk and some do not have
falls clinics.
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
Title PageTable 1 Data collection dates at each hospital 17Table 2 Number of wards at each hospital by specialty 17Table 3 General Demographics 19Chart 1 Age group by hospital 19Chart 2 Proportion of Patients admitted due to a fall 20
Chart 3 Proportion of Patients assessed and documented 21Table 4 Percentages Assessed 21Chart 4 If a form was filled in was it fully completed? 22
Chart 5 If FRA was completed was the patient reviewed during theiradmission 23
Table 5 Percentages reviewed by Length of Stay 24Chart 6 Was the patient reviewed? By Length of stay 24
Chart 7 The proportion of patients with completed FRA for whom actionwas taken and documented 25
Table 6 Number of risk factors by action recommended 25Chart 8 Number of risk factors for whole population 26Chart 9 Have any of the following Key Risk Factors been assessed? 27
Chart 10 Number of patients having any documented mobilityassessments 28
Table 7 Is there any evidence in the notes that any of the followinginterventions/prevention measures have been started? 29
Chart 11 Intervention measures/FRA completed 30Chart 12 Proportion of patients considered at risk of falling by trust 32Chart 13 Proportion of patients assessed according to risk status by trust 33Chart 14 Patients at Risk/Risk Factors 34Table 8 Risk Factors assessed by each hospital 35Chart 15 Patients’ risk status by number of risk factors 35
Example of a Falls Risk Assessment tool 36Example of a Falls Risk Assessment tool 37
Chart 16 Has the patient fallen whilst in hospital? 38
Chart 17 Did the patient fall in hospital? Comparing trusts that use a FRAand those that don’t. 39
Chart 18 Did the patient fall in hospital? Comparing patients that had aFRA and those that didn’t. 40
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
Hospital Ward Ward Type Number of bedsWythenshawe A5 Orthopaedic 28
A7 General/Adult Medicine 28A8 General/Adult Medicine 28A9 General/Adult Medicine 28A10 General/Adult Medicine 28F11 General/Adult Medicine 32
Tameside 2 Orthopaedic 284 Orthopaedic 2840 General/Adult Medicine 3041 General/Adult Medicine 3042 General/Adult Medicine 3044 General/Adult Medicine 2446 General/Adult Medicine 24
Stockport A12 General/Adult Medicine 28A14 General/Adult Medicine 28A15 General/Adult Medicine 28D1 Orthopaedic 25D2 Orthopaedic 25E2 Care of Elderly 38E3 Care of Elderly 38
Wirral 20 Care of Elderly 3021 Care of Elderly 3022 Care of Elderly 3023 Care of Elderly 3024 Care of Elderly 2425 Orthopaedic 37
Bury 6 General/Adult Medicine 288 Orthopaedic 229 Orthopaedic 2818 General/Adult Medicine 3019 General/Adult Medicine 3229 General/Adult Medicine 2330 General/Adult Medicine 27
MRI 1 Orthopaedic *15 General/Adult Medicine *AM1 General/Adult Medicine *AM2 General/Adult Medicine *AM3 General/Adult Medicine *AM4 General/Adult Medicine *
Trafford 1 Care of Elderly 282 General/Adult Medicine 29
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
4 General/Adult Medicine 316 General/Adult Medicine 32Ortho Unit Orthopaedic 51Seymour Unit Care of Elderly 45
NMGH D4 General/Adult Medicine 21E3 General/Adult Medicine 28E4 General/Adult Medicine 22E6 General/Adult Medicine 22F3 General/Adult Medicine 19I5 Orthopaedic 28
Oldham C1 General/Adult Medicine 12D2 General/Adult Medicine 24F9 General/Adult Medicine 25T4 Orthopaedic 28T5 General/Adult Medicine 25T6 General/Adult Medicine 22
Rochdale Marland General/Adult Medicine 31Stonehill 1 General/Adult Medicine 27Stonehill 2 General/Adult Medicine 27Stonehill 3 General/Adult Medicine 27Stonehill 4 General/Adult Medicine 27Wolstenholme Orthopaedic 33
*Information not available at time of going to print
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
Bury Yes NK Noonly elderly Yes Yes Yes Yes † No NR 6770 897
NMGH No NA NA Yes No Yes No No NR 11715 1033
Oldham Yes STRATIFYNo(not
orthopaedic)- Yes Yes Yes
YesPilotstage
Yes 826 8665 1035
Rochdale Yes NK Yes NA Yes No Yes(Sept 04) - No 374 9447 1011
Stockport Yes FRASE Yes NA Yes Yes* No
YesOct 04
pilotstage
Yes 1393** 8316 1100
Tameside Yes Cannard NoPilot stage Yes Yes - No Yes
Oct 04
Develop-mentalstage
1161 4558 1039
Trafford Yes STRATIFYNo
Only Elderlyand Medical
- No No No Yes No 1308 3325 4512
SMUHT Yes STRATIFY
NoOnly Elderly,
Medical &Rehab
Yes Yes Yes Yes Yes Yes 852 5094 443
Wirral Yes STRATIFY Yes NA Yes Yes No - No 1939 14763 1219
^Information not available at time of going to print# Falls Co-ordinator in post at the time of the audit, position currently vacant† PCT based co-ordinator, doesn’t cover in-patients*Only in Day hospital and out-patients, not on wards**Cannot distinguish by age so number is all falls reported regardless of age
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
Central Manchester & Manchester Children’s University Hospitals NHS TrustInformation not available at the time of going to print
Pennine Acute Hospitals NHS TrustFairfield General Hospital• The hospital has a falls co-ordinator, but they are employed by the PCT. The falls
co-ordinator is based in the hospital and in the community, she receives referralsfrom A&E, GPs, District Nurses and Health Visitors, but they do not cover in-patients.
North Manchester General HospitalNo other information
The Royal Oldham Hospital• The hospital has a falls co-ordinator. This is mainly a community role with a wide
remit to reduce falls incidence in Oldham• Hospital falls service – has input from Physiotherapists and Occupational
Therapists in A&E. There are falls exercises and education sessions for outpatients. There is a pilot falls clinic with the falls co-ordinator (physio) and aSpecialist Registrar.
• There is an educational programme for staff at the trust regarding falls riskassessment. This is offered on a regular basis, it is a half day including prevalence,risk factors, interventions, use of STRATIFY, use of falls action prompt,osteoporosis and fractures.
Rochdale Infirmary• The hospital has a falls co-ordinator who was newly appointed in September 2004
(after the audit). Their role is to develop and co-ordinate a falls care pathway, toprovide specialist advice and teaching and to develop an integrated falls serviceand community falls clinic.
• Hospital falls service – there is a pathway for fallers admitted to A&E. Patients arereferred to the intermediate care team for assessment. When patients are admittedto the ward a falls risk assessment form is completed by nursingstaff/physiotherapists. Patients are discharged home for follow-up by communityfalls service.
• The Falls Service involves Physiotherapists, Nurses and Occupational Therapists.
Stockport NHS Foundation Trust• The hospital is currently piloting a Falls Clinic from October 2004 to December
2004. The aim is to continue the clinic after the pilot. The clinic is divided into 2sessions, patients initially attend Tuesday pm for medical and nursing, then returnfollowing Tuesday am for physio and OT, this is followed by a MDT meeting. Thereis a business case for therapy input and falls co-ordinator.
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
• The Falls Service involves Clinicians, Physiotherapists, Nurses, OccupationalTherapists, links for pharmacy advice and Accident Prevention officer from AgeConcern. It is hoped that there will be podiatry input in January 2005
• There is an educational programme for staff at the trust regarding falls riskassessment. This is given at the mandatory training sessions which all staff attendonce a year.
Tameside & Glossop Acute Services NHS Trust• Use a Falls Risk Assessment tool based on Cannard which is currently being
piloted on one ward in each specialty before it is introduced across all wards ineach hospital.
• Hospital falls service – a clinician led falls clinic will be commencing in October2004. There is also a falls group
• The Falls Service involves Physiotherapists, Nurses, Doctors (from Oct 04) andOccupational Therapists.
• There is no educational programme for staff at the trust regarding falls riskassessment; this is in a developmental stage at the moment.
Trafford Healthcare NHS Trust• Hospital falls service – 1 session a week in the Altrincham rehab unit where there
is podiatry, physiotherapist, occupational therapist, doctor, nurse and pharmacist.Follow up sessions run over 7 weeks for patients who will benefit from the exercisegroup, this involves OTs and Physios + Care and Repair, Age Concern andDietician.
South Manchester University Hospitals NHS Trust• The hospital has a falls co-ordinator whose role is to triage all falls clinic referrals,
organise waiting list and help to draw together integrated pathways for fallers. Theyalso have to map current situation for the trust, help areas where fallers passthrough evaluate their service in line with the NSF and adjust accordingly, providelinks with the PCT, develop pathway, update standards and protocols, audit inpatient fallers and develop links with other trusts.
• Hospital falls service – there is a MDT falls clinic, a falls consultant, links in A&E,falls medication group. Departmental falls groups.
• The Falls Service involves Consultant Geriatrician, Lead Nurse, Physiotherapists,Senior Podiatrist and Occupational Therapists and Dieticians as required.
• There is an educational programme for staff at the trust regarding falls riskassessment. There are quarterly sessions as part of the NSF lasting half a day,falls take up about 1/5 of the programme. Routine education for physios. Ad hoceducation.
Wirral Hospital NHS Trust• Hospital falls service is led by Physiotherapists. The Community Assessment and
Rehabilitation Team (CART) are also involved. Exercise classes are held atVictoria Central Hospital.
• The Falls Service involves Physiotherapists, Nurses and Occupational Therapists.
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
Name Job Title OrganisationElsie Lynch Head of Physiotherapy Birkenhead and Wallasey PCTHelen Home Therapy Rehab Co-ordinator Birkenhead and Wallasey PCTDebbie Monaghan Supt II Physiotherapist Bolton Hospitals NHS TrustChristine Atkinson Clinical Governance Manager Bolton Primary Care TrustPaul Campbell Audit Co-ordinator Bury PCTDr David Bourne Consultant Physician Central ManchesterJoanne Makin Physiotherapist Central ManchesterNicola Brown Senior Physiotherapist Central ManchesterPam Leah Occupational Therapist Central ManchesterRomaine Short Physiotherapist Central ManchesterDr Sethi Consultant Physician Pennine Acute Hospitals NHS TrustJanet Powell Falls Prevention Officer Pennine Acute Hospitals NHS TrustMargaret Carney Senior Physiotherapist Pennine Acute Hospitals NHS TrustPatricia Mitchell Clinical Audit Facilitator Pennine Acute Hospitals NHS TrustShirley Naylor Clinical Audit Co-ordinator Pennine Acute Hospitals NHS TrustSue Plevey OT Manager Pennine Acute Hospitals NHS Trust
Dr Keith Harkins Consultant Geriatrician South Manchester University HospitalsNHS Trust
Janet Brennan Nurse Manager South Manchester University HospitalsNHS Trust
Jenny Rawcliffe Modern Matron South Manchester University HospitalsNHS Trust
Julia Gray Falls Co-ordinator South Manchester University HospitalsNHS Trust
Mrs Susan O'Flynn Senior I Physiotherapist South Manchester University HospitalsNHS Trust
Dr Gary Cook Consultant Epidemiologist Stockport NHS Foundation TrustDr M Hanley Consultant in Elderly Medicine Stockport NHS Foundation TrustJanine Lewis Senior Occupational Therapist Stockport NHS Foundation TrustLinda Woolley Ward Sister Stockport NHS Foundation TrustDr Marie McDevitt Public Health Specialist Stockport PCTSue Gunnion Case Management Lead Stockport PCTSarah Hince Stockport PCTDr Luciano Garcia-Allen Consultant Physician Tameside & Glossop Acute Services
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDITPROFORMA
Proforma completed by (name and designation): ………………………………………………
Date proforma completed: _ _ / _ _ / _ _ _ _
A. Patient Details: (please fill in details below)Hospital
Ward Name Specialty
Date of Birth _ _ / _ _ / _ _ _ _ Gender M F
B. Episode DetailsDate of Admission _ _ / _ _ / _ _ _ _Reason for Admission (presenting complaint / diagnosis)
Was the admission due to a fall? Yes NoPreadmission Walking Ability (e.g. walked unaided,one aid, two, frame, wheelchair etc):
C. Please complete this section if your trust uses a Risk Assessment Tool (Go tosection D if your trust doesn’t have a risk assessment tool)(please delete / fill in as appropriate)Has the patient had a falls assessment completed for this episode? Yes No(If no, please fill in Section D)What date was the form completed on? _ _ / _ _ / _ _ _ _Has it been fully completed? Yes No Partially
What was the patient’s falls assessment score?
Was the patients assessed as being ‘at risk’? Yes NoIf appropriate, what risk category did thepatient fall into? High Medium Low
What action has been recommended?
Was any action taken? Yes No
Was a review date set? Yes No
What was the date? _ _ / _ _ / _ _ _ _
If yes, has the patient been reviewed? Yes NoNow go to section E
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
D. Please complete this section if you do not have a risk assessment tool in use at yourtrust.Is there written evidence in the notes that the patient has beenassessed for falls risk? Yes No
If yes:
Date of assessment/diagnosis _ _ / _ _ / _ _ _ _Has it been noted anywhere in the patient’s notes that/is there adiagnosis of “At risk of falling”? Yes No
Has any action been recommended in the notes with regards torisk of falling? Yes No
Is there documented evidence to suggest that the patient hasbeen reassessed for falls risk? Yes No
Date of review/reassessment? _ _ / _ _ / _ _ _ _
E. Are any of the following risk factors noted in the patient’s records?(Please tick box – Y=Yes, N=No, NR=No record)Risk Factor Y N NR NAHistory of fallsMultiple medications (>4 per day, including hypnotics)Urinary incontinence/frequency/assisted toiletingImpaired mental status (confusion/disorientation/depression etc)Impaired mobility/balance/gait (unsteady on feet, requires frame/stickto walkVisual ImpairmentHearing impairmentAlcohol problems (>1 unit of alcohol per day)Postural HypotensionMedical Conditions (e.g. Diabetes, Stroke, Parkinson’s)Seizures*Yes = it has been noted that the patient has the risk factor, No = it has been noted that thepatient doesn’t have this risk factor, No record = there is no record in the notes either way,NA=Not applicable
F. Have any of the following Key Indicators been carried out?(Please tick box – Y=Yes, N=No, NR=No record)
Indicator Y N NR DateLying and standing BPEye TestMental Test ScoreMedications (4+ inc. psychotropic, plan/review,any recommendations/comments)Extra Info re medications – write here
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
G. Are any of the following assessments documented in the record/case notes for thisepisode?
Assessment Y N NR NA Date of 1st assessment (ifapplicable)
Score (ifapplicable)
BartellMobility/FunctionTransfersGait/BalanceTinnettiEMSGet up and go180° turnFunctional reachDynamic gait indexBerg balanceStairs*Yes = it has been noted that the patient has the assessment, No = it has been noted that thepatient hasn’t had this assessment, No record = there is no record in the notes either way.
H. Is there evidence in the notes that any of the following interventions/preventionmeasures have been started?Action Please Indicate below
Yes/No/Norecord/NA/Other*
Close observation of patients in an appropriate area.Have other relevant health care professionals been informed?a. Physiotherapistb. Occupational TherapistPatient assessed for the use of alarms on bed/chairPatient assessed for the need for hip protectorsAssess the need to “special” for the patient if they are a frequentfaller. (One-to-one nursing)In-depth assessment of patients’ dementia undertaken, if applicable.Frequent toileting if a high-risk patientColoured wristband (or similar) to alert staff that the patient is at riskof fallingA Call Bell at handIf appropriate, has the importance of asking for help when walkingbeen explained to the patient?Educate patient/family/carer about risk of falling, safety issues &The patient’s risk of falling has been discussed with relatives, ifappropriate.Bed left in low position when patient is unattendedBed rails in useA chair, of appropriate height for the individual (Hips should bepositioned at 90° and feet should be on the floor) is being used.
GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT
Has a home visit been arranged to assess home?Patient referred to Intermediate Care?Patient referred to Balance ClassHas the patient been referred to a falls clinic?Footwear assessment documentedHas there been a trial without catheter (if applicable)Any other actions noted not on this list (give details)
*Yes = it has been noted that the patient has had this intervention, No = it has been noted thatthe patient hasn’t had this intervention, No record = there is no record in the notes either way,NA = not applicable.
I. Other related informationHas the patient fallen whilst in hospital? Yes / No
If yes, Date patient fell: _ _ / _ _ / _ _ _ _Details of fall (where, was the incident reported, etc)
Comments (anything else mentioned in notes regarding falls)
Patient Id _ _ _/_ _ _(to be filled in by audit facilitator)