The Royal College of Physicians National Audit of Inpatient Falls (NAIF) took place in May 2015 and the results were published in October. Data were collected at both organisational and individual patient level.
Organisational data comprised of governance around falls, falls policies and the components of falls assessment and intervention in such protocols. Data were collected from acute Trusts and Health Boards in England and Wales. Participating organisations were also asked for their figures for falls per 1000 occupied bed days (OBD) as well as falls resulting in moderate or severe harm or death per 1000 OBD.
The clinical component of the audit included a review of the notes as well as an observation at the patient’s bedside for 15 consecutive admissions per day over two consecutive days in May. To be eligible for the clinical audit patients had to be; aged >65, a non-elective admission and have been an inpatient for 48 hours. Data collection was performed 48 hours post admission. The audit items were taken from NICE falls guidelines (CG161),NICE guidance on delirium and the NPSA guidance on prevention and management of inpatient falls.
The response to the audit was good with nearly all trusts and health boards submitting data. All Trusts and HBs had falls policies. However, there was no clear relationship between what was written in a policy and what was found to have happened in the notes and bedside audits. Most (73%) Trusts / HBs were still using risk assessment tools despite this not being recommended by NICE. This audit was able, for the first time to publish falls rates for English Trusts and Welsh Health Boards. The mean rate of falls was 6.63 per 1000 OBD and the rate of falls with moderate or severe injury or death was 0.19 per 1000 OBD. There was some variability nationally within these figures.
The audit work stream chose 7 key indicators from notes and bedside data to provide a snapshot of performance. The proportion of datasets (patients) for whom this was appropriate and achieved is illustrated below:
Recommendations for organisations:
1. Falls steering groups should meet regularly to discuss their data on falls rates.
It is important that Trusts / HBs do not invest too much in comparing their falls rates to other organisations. Each organisation should look at their circumstances. It may be that low rates reflect reporting culture and that work is initially done to improve reporting which may result in an increase in rates. The idea of collecting this data as part of the audit cycle is to guide strategy and performance within the organisation.
2. Falls working groups should be multi-disciplinary
3. Prediction tools should not be used.
The NICE guidelines recommend not using prediction tool. That is, a tool that is designed purely to screen patients and decide whether they are high, medium or low risk. None of the existing tools are good enough at doing this; therefore there is the risk that patients screened as low risk will not have an adequate assessment and management plan. NICE suggest that all inpatients aged over 65 and those aged between 50 and 64 with reason to suspect risk of falls should all be treated as high risk and have a multi-factorial risk assessment (MFRA).
MFRAs involve assessment of all domains of fall risk and implementation of a management plan for identified risk factors.
4. Bed rail use should be audited regularly.
5. MFRAs should be reviewed, particularly looking at how to ensure they are implemented into practice on all hospital wards.
Recommendations for 7 key indicators:
- Review dementia and delirium policies; what tools are used and how assessments and care plans are documented. Work closely with dementia and delirium teams for this high risk group of patients.
- All patients aged >65 should have a lying / standing BP and the results dealt with appropriately. The falls work stream will provide some consensus on how this should be performed.
- All patients aged >65 should have a medication review particularly looking for medications that increase the risk of falling.
- All patients aged >65 should have a documented assessment of vision and if impairment is identified, care plans modified to take this into account.
- Policies should be in place to ensure patients who require walking aids have access to an appropriate aid from the time of admission. Regular audits should be undertaken to ensure that, if they are needed, walking aids are within patients’ reach.
- Patients aged >65 who have continence issues should have a continence care plan that considers fall risk.
- Regular audits of whether call bells are within reach should take place.
The RCP will be holding two quality improvement events in January 2016.
Click here to see the full report and the results from your Trust or Health board.
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