Prevention of inpatient falls has improved, but further change is needed

The Royal College of Physicians' (RCP's) National Audit for Inpatient Falls (NAIF) report 2017 shows that although the prevention of inpatient falls across hospitals in England and Wales has improved slightly, many patients are not receiving the required assessments which can help prevent falls in hospitals.

The report reveals that since 2015, many trusts and Local Health Boards (LHBs) have stopped using ‘falls risk screening or prediction tools’ (a drop from 74% in 2015 to 34%). These tools do not sufficiently predict who will fall in hospital and means patients may not be being assessed correctly and therefore at more risk of falling.

Everyone over the age of 65 should be regarded as being at risk of falling in hospital and considered for a multi-factorial falls risk assessment (MFRA), as recommended by NICE guidelines (CG161).* The MFRA aims to uncover anything that might make a person more likely to fall and to see whether there are specific things that can be done to prevent this. This may include checking their eyesight, looking at any prescribed medications and checking their balance and mobility.

Presence of delirium

The report also shows that while nearly all patients had their level of mobility recorded (72%), only 40% of patients were assessed for the presence of delirium. Delirium is a change in a person's mental state or consciousness, which is often observed as confusion, difficulties with understanding, problems with memory, as well as a change in personality. It is strongly associated with falls in hospital and can be prevented and treated if dealt with urgently.

Falls in hospitals result in longer hospital stays for patients and falls risk assessments can help in saving trusts resources at a time they are overstretched. NICE estimates the total cost of all falls to the NHS to be £2.3 billion.[1] NHS Improvement calculated that a reduction in inpatient falls of between 25 and 30 per cent could result in a saving of £170 million a year. [2]

Overall, the report highlights that some trusts and health boards are doing all they can to prevent falls in hospitals and they did improve in some or most of the key indicators. This shows that good practice is possible and should be prioritised in all trusts.

Key indicators

There are three key indicators that improved for patients most at risk between 2015 and 2017, including:

  • mobility aids in patient’s reach improved from 68% to 72%
  • delirium assessment improved from 37% to 40%
  • lying and standing blood pressure from 16% to 19%

However, there was no overall change in other areas to prevent falls in hospital including: continence and visual assessment, call bells within reach and medication reviews.

Recommendations

Key recommendations of the report include:

  • Do not use a fall risk prediction tool - these tools do not sufficiently predict who will fall in hospital.
  • Walking aids - trusts and LHBs to consider developing a workable policy to ensure that all patients who need walking aids have access to the most appropriate type from the time of admission, 24/7.
  • Visual impairment – if rates are low in the local audit result, consider using the RCP clinical practice tool to standardise practice. www.rcplondon.ac.uk/bedsidevisioncheck
  • Lying and standing blood pressure – if rates are low in the local audit result, consider using the RCP clinical practice tool to standardise practice. www.rcplondon.ac.uk/bp-measurement
  • Falls reporting - trusts and LHBs should ensure that all falls in hospitals are reported with the correct level of harm

Dr Shelagh O’Riordan NAIF Clinical lead, said:

This is the second time there has been a national audit of falls prevention in hospitals across England and Wales. Our results show that although there are areas of really good care, and significant improvements have been made by some hospitals, many hospitals are still not doing everything they can to prevent falls.

I hope this audit can help clinical teams work towards reducing the number of falls currently happening in hospitals in England and Wales.

The NAIF report is the second audit report and shows data on over 5,000 patients aged 65 years or older across 198 hospitals and 146 trusts in England and Wales. The report includes an assessment of the patient’s environment and the falls risk assessments they receive, set against the NICE guideline (CG161).* 

NAIF is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and managed by the RCP, as part of the Falls and Fragility Fracture Audit Programme (FFFAP).

[1] National Institute for Health and Care Excellence. Falls in older people: assessment after a fall and preventing further falls (QS86). Manchester: NICE, 2015.

[2] NHS Improvement: The incidence and costs of inpatient falls in hospitals, July 2017

Notes to editors

For more information or to arrange an interview, please contact Joanna Morgan, communications manager, RCP Care Quality Improvement Department by phone on 020 3075 1354 or email at joanna.morgan@rcplondon.ac.uk.

About HQIP

The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales.

HQIP holds the contract to manage and develop the National Clinical Audit Programme (NCA), comprising more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland and the Channel Islands.