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Case studies from the National Audit of Inpatient Falls

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Case studies from City Hospitals Sunderland, East Kent Hospital and Portsmouth Hospitals focusing on the prevention of falls in hospital wards.

Bedfordshire hospitals NHS Trust

As part of the falls improvement program to reduce the number of falls within the Bedfordshire hospitals NHS Trust, a ‘focus on falls’ month has been introduced based on the principles of falls risk assessment to ward areas- a bi-monthly program.

A number of broken down initiatives are circulated throughout the month with the aim to decrease the risk of a patient falling and reduce overall falls:

Week 1 - Ensure every patient over 65yrs old receives a Falls leaflet on admission and falls placemats are distributed at mealtimes for all high risk patients, as appropriate

Week 2 - Ensure every adult admitted patient has a lying/ standing BP and it is recorded in relation to falls

Week 3 - All patients over 65 yrs. have a medication review in relation to falls and it is recorded

Week 4 - Intentional rounding is in place and recorded throughout night shifts and at identified high risk times

Within the program there are reported daily quality falls rounds, undertaken by the falls lead or a nominated staff member, ensuring:

  • Patient has suitable footwear on
  • Call bell is in reach
  • Patient tray is in reach
  • Mobility aid is in reach if required
  • Patients are dressed if appropriate before 1130
  • Intentional rounding for identified at risk patients
  • Falls and bed rail assessments are completed
  • Increased staff support/ education via falls lead and champions
  • Introduction of mobility posters and vision assessments

This initiative has improved most areas falls numbers in comparison to the previous 3 month fall rate.  

Additional initiatives that have been introduced include:

  • Bed rail posters/ Footwear poster,  Patient leaflets
  • Falls bi monthly bulletins/ communication
  • Weekly reviews highlighting high risk areas with MDT
  • Falls information station visits with quiz and prizes for staff
  • Plan for trained Falls Champion on every ward
  • Ward accreditation/ assessment with falls standards incorporated
  • Post fall protocol to include Doctors section.  Future plans are to include a ward map to identify where staff/ patients where at time of fall
  • Slipper socks colour changes to identify patients at risk- Red for all patients, yellow for patients identified as at risk
  • 6 monthly thematic reviews to identify common themes
  • Bay watch scheme implementation and advanced training for staff that special
  • Changes in admission paperwork- Now includes within the falls risk assessment- lying standing BP and vision assessment
  • The SWARM concept- all patients that have more than one fall, a moderate or severe harm fall should have a SWARM completed by team members that are involved within the patients care.  The SWARM can identify gaps in practice and improve the investigation process in a timely manner
  • Falls prevention and management training is provided as part of the Moving and Handling training on Trust induction for all clinical staff

Clare Clarke, Moving/handling and falls prevention lead

City Hospitals Sunderland

City Hospitals Sunderland provides a falls and syncope service using tilt tests and other neurocardiovascular testing. We trained a specialist nurse in neurocardiovascular investigations and falls prevention 5 years ago. This nurse has embedded training of healthcare assistants into measurement of postural blood pressure (BP). She also visits high-risk ward areas and checks patient care plans and reiterates the techniques for measuring postural blood pressure.

The trust’s falls reduction group uses evidence from the NHS Safety Thermometer to take action, with a strong emphasis on supporting orthogeriatrics and working with wards that have a high numbers of patient falls. Following each group meeting, the service delivers a trust-wide ‘headlines’ email to ensure that clinical staff focus on the action plan to reduce falls. The focus has recently been on the measurement of postural BP, identification of high-risk medications and the introduction of ‘safe slippers’.                                                                                              

A combination of staff training, ongoing ward-based support by a credible expert, shared important messages across disciplines, and keeping falls rates at the centre of the hospital falls group, has driven sustained improvement in measuring lying and standing blood pressure and other falls interventions.

Dr Andy Davies, consultant physician, and Mrs Judith Hunter MBE, head of nursing and patient safety

East Kent Hospitals

The falls team at East Kent Hospitals has worked hard over the last 2 years to engage staff to improve assessment and knowledge of lying and standing measurement of blood pressure on the wards. The multifactorial falls risk assessment (MFRA) was updated in 2014 to the falls risk assessment care plan (FRACP) in accordance with NICE guidance. The FRACP clearly defines assessment of blood pressures, explaining that the assessment should be completed within 6 hours of admission.

We have really worked on our ‘Falls Link Nurse’ system. This link provides direct education to members of staff in their areas and there are regular audits performed by the staff in their area and they take responsibility for the results. The link workers are trained by the clinical nurse specialist (CNS) in both falls and osteoporosis and the CNS also provides training for both the preceptorship nurses and healthcare assistant inductions. Education for the junior doctors is led by the falls consultant.

Learning through datix feedback and root cause analysis (RCA) has proved to be a key change in culture and attitude towards blood pressure assessment. The staff on the wards now really understand the importance of measuring the blood pressures and what to do if there is a substantial drop.

Emma Bull – CNS falls and osteoporosis at Kent and Canterbury Hospital

Portsmouth Hospitals

At Portsmouth Hospitals, specialist clinicians worked together with a falls and fragility clinical nurse specialist to implement a carefully designed pathway that ensures that all patients entering the hospital are assessed and managed for their falls risk.

We introduced the FallSafe programme just over 3 years ago. It provided the framework needed to understand the importance of a multidisciplinary approach. Many elements of falls prevention were already part of our routine care, but the quality improvement and culture change emphasis in FallSafe provided a perfect opportunity to reach beyond nursing staff and to engage more effectively with the wider ward team. Nurses who were already established in the role of Falls Link on each ward were designated as FallSafe champions and given responsibility for increasing awareness of good falls management.

We worked together across different professional groups to develop several clever ideas to implement on the wards. Our falls foot logo was introduced several years ago and is now widely recognised. It is available as a badge and a magnetic sign, and is printed in falls-related sections of documentation. A chart of culprit medications was developed by nurses and pharmacists and is stuck to all the drug trolleys. Our pharmacists have a high awareness of falls risk and a good relationship with ward doctors, which means that they can implement an effective system for medication reviews. One of our pharmacists had the idea to design a little rubber stamp of our falls foot logo. The stamp fits within a line on the drug chart and can be used to make sure the doctor reviews culprit drugs.

Physiotherapists are excellent at recognising and responding to patients’ mobility issues, particularly with regard to falls prevention. They share their assessments effectively with the wards, especially those that have introduced magnetic boards over each bed, where moving and handling instructions can be posted.

Our regular teaching commitment has been key to sustaining our successful programme of effective falls management. All new trust employees have a falls teaching session as part of their induction. Registered nurses are expected to attend patient safety updates every 2 years. We promote the e‑learning programmes Preventing Falls in Hospital and CareFall, as well as offering ad hoc training tailored to specialty and bespoke sessions that reflect content of thematic analysis of reported falls events across the trust.

We are delighted with our work so far, and our audit results have helped us to identify areas where we need to consolidate and continue our strategy. Some areas still need further clarity and a better way of ensuring that all elements are in place, particularly measuring lying and standing blood pressure. We also need to settle on a delirium assessment that can be applied across the trust.

Debbie Sutton, research coordinator (falls), Dr Sue Poulton, orthogeriatrician, and Dr Ike Ugboma, geriatrician