Reducing the Harm Resulting from Inpatient Falls A

Reducing the Harm Resulting from Inpatient Falls A (sort of) “How To” Guide Rob Morris Pathway Lead Clinician for Older People

Agenda • Truly Understand the Problem • Try things out • Turn Data to Information (KHWAD) • Be vigilant, honest and (healthily) sceptical • Nurture and develop what works

Truly Understand the Problem • Research Evidence • Incident Reporting • Recording Harm • Engage with front line staff • Listen

Truly Understand the Problem Evidence - What works in the community • Exercise programmes (group or individual ) • Individualised multifactorial interventions • Medication review (esp. psychotropic drugs) • Vitamin D for those who are Vit D deficient/insufficient • Pacemakers in CSH • Cataract surgery in individuals with cataracts • Home hazard assessment (poor vision)

Truly Understand the Problem Evidence - What Have We Learned? Fall prevention programmes can be successful BUT…… • The factors which affect an individuals risk of falling are many and various • Very complex problem • Our best “drug” requires lots of time and effort • Definitely NOT one size fits all • The problem of falls is still not “sexy” to commissioners

Truly Understand the Problem Evidence Base Multifactorial interventions reduced the rate of: Falls (4 trials 6478 subjects) RR 0. 72 (95%CI 0. 55 – 0. 95) Risk of Falling (3 trials 4824 subjects) RR 0. 73 (95%CI 0. 56 – 0. 96) BUT Only 1 trial in acute hospital setting included

Truly Understand the Problem Incident Reporting

Truly Understand the Problem Incident Reporting Culture of candour Information and audit Accurate reporting of harm

Truly Understand the Problem Recording Harm Agree trigger level - Moderate/Severe - Fractures, Head Injuries, Deaths Update and review level of harm unreliable Validation NHFD Radiographers Validation Dashboard

Truly Understand the Problem Engage with Front Line Teams • Front line staff • No holds barred • Designed around patients

Truly Understand the Problem Listen to Patients and Carers Patient stories Involve patients in training/education

Truly Understand the Problem Patient Safety First CNO High Impact Actions Brainstorming /Engagement Risk Assessment & Care Plan Visibility/Geography Footwear Vision Continence Medications/Prescribing High Risk Cohorting Hourly Safety Rounds Data Quality – DATIX Orthostatic Hypotension What to do following a fall Medical review following a fall Head injuries Root Cause Analyses Patient Information Leaflets Audit Internal SHA RCP Knowledge Base Expert Advisers Patient/Carers Stories

Try Things Out Trials Design and Trial Risk Assessment Successful Care Plan Document Successful Cohorting Failed High Risk Cohorting Useful Learning Hourly Safety Rounds Successful Footwear Useful learning Medication/Prescribing Guidance Useful learning Visibility/Geography Useful learning

Fall RCA Medical Review Comfort Rounds Medication Review Footwear Guidance Falls Prevention Toolkit Lying & Standing BP Visual Problems Post Fall Algorithm Falls Care Plan Head Injury Guidance

Truly Understand the Problem “For every complex problem there is an answer that is clear, simple, and wrong. ” H. L. Mencken …or at least not completely correct Henry L. Mencken 1880 -1956

Turn Data into Information Falls Reported date x 1000 bed Cent days UCL LCL Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 6. 52 6. 74 7. 44 6. 39 6. 16 5. 81 5. 68 6. 55 5. 40 5. 76 6. 53 5. 81 5. 66 6. 69 6. 91 6. 96 6. 54 7. 47 6. 12 7. 35 7. 39 9. 11 7. 51 6. 83 6. 84 6. 82 6. 96 6. 87 5. 63 6. 11 6. 85 6. 63 6. 04 6. 88 6. 04 5. 86 6. 55 6. 46 5. 87 5. 36 5. 40 5. 67 5. 73 5. 38 4. 91 4. 93 5. 05 4. 92 4. 98 7. 66 7. 66 7. 66 7. 66 4. 92 4. 92 4. 92 4. 92 6. 29 6. 29 6. 29 6. 29 Target No. of Falls Bed days Reduction 6. 20 6. 20 300 320 335 294 275 257 268 304 255 278 304 270 237 289 46042 47464 45053 45991 44616 44210 47166 46430 47185 48294 46577 46481 41896 43231 292 274 279 318 269 314 326 402 333 319 307 312 319 243 262 313 304 275 336 295 282 306 298 267 245 248 260 273 257 238 246 228 243 236 42231 39395 42628 42587 43971 42719 44123 44328 46697 45178 45008 44803 46421 43161 42897 45689 45826 45549 48816 48101 46730 46133 45498 45741 45893 45866 47625 47783 48434 49892 45177 49341 47371 Fallers Reported date x 1000 bed Cent days UCL LCL Apr 10 May 10 Jun 10 Jul 10 Aug 10 Sep 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 Mar 11 Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 3. 50 3. 58 4. 26 4. 07 3. 90 4. 03 3. 46 3. 94 3. 33 3. 46 3. 93 4. 09 3. 68 4. 21 4. 05 4. 37 4. 22 4. 46 4. 30 4. 45 4. 67 5. 73 4. 67 4. 43 4. 40 4. 35 4. 31 4. 42 4. 22 3. 75 4. 18 4. 36 4. 02 4. 59 4. 04 3. 87 4. 60 4. 31 4. 15 3. 94 3. 88 3. 92 4. 12 3. 85 3. 68 3. 57 3. 83 3. 89 4. 24 4. 91 4. 91 4. 91 4. 91 3. 31 3. 31 3. 31 3. 31 4. 11 4. 11 4. 11 4. 11 Target No. of Reduction Fallers 3. 90 3. 90 Bed days 161 170 192 187 174 178 163 183 157 167 183 190 154 182 46042 47464 45053 45991 44616 44210 47166 46430 47185 48294 46577 46481 41896 43231 172 180 190 189 190 206 253 207 199 196 193 205 182 161 191 200 183 224 197 186 215 199 180 178 180 196 184 178 173 192 201 42231 39395 42628 42587 43971 42719 44123 44328 46697 45178 45008 44803 46421 43161 42897 45689 45826 45549 48816 48101 46730 46133 45498 45741 45893 45866 47625 47783 48434 49892 45177 49341 47371

Turn Data into Information • Data Sources • Data Format • Data Presentation

Turn Data into Information Total Incidents / Total Falls 1800 1600 1400 1200 800 600 Number 1000 400 200 0 Apr. May. Jun Jul Aug. Sep Oct. Nov. Dec Jan Feb. Mar Apr. May. Jun 10 10 10 11 11 11 12 12 12 Month Reported Number of Falls/Fallers per 1000 Bed Days Falls, Falls Resulting in Harm, Fractures and Deaths. 450 1, 9 Falls 400 Falls (Harm - Low, Moderate, Severe and Death) 350 Number 1, 6 1, 5 150 1, 4 100 1, 3 50 0 Rate 200 1, 8 1, 7 300 250 All No. of Falls 1, 2 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 10 10 10 10 10 11 11 11 11 11 11 12 12 12 Month Fall Reported

KHWAD NUH Nursing Dashboard Dec 2011 – July 2012 December January February March April May June July NUH Overall Score (%) 83 84 84 86 86 84 NUH Scores by Metric (%) Bowel & Bladder 81 84 83 83 84 84 84 85 76 77 79 77 77 81 80 86 93 92 75 84 75 72 96 92 92 78 86 77 75 97 92 91 80 85 75 76 97 94 92 80 85 78 78 96 92 93 81 86 78 77 96 93 93 85 85 79 83 96 92 93 80 87 79 80 96 95 93 84 91 82 62 97 1303 624 1 1395 663 14 1387 685 5 1367 682 1 1417 690 2 1354 674 2 1366 691 3 467 170 11 Falls Infection Prevention & Control Medication Safety Nutrition Pain Patient Observations Pressure Ulcers Respect and Dignity Patients Metric status: Occupied beds at time of visit: Metric sets Completed Metric sets In Progress

KHWAD NUH Nursing Dashboard Dec 2011 – July 2012 December January February March April May June July Falls Risk Assessment within 24 hrs 81 81 84 87 84 88 90 94 Care Plan in place 67 71 74 80 81 86 80 91 Risk Re-assessed 71 73 81 84 80 85 85 87 A Post Fall Check List, Falls Risk & Assessment reviewed 65 79 86 71 79 84 82 75 Risk Assessment Bed Rails 92 94 94 93 95 97 97 99 64 63 64 66 61 69 66 71 N/A 0 22 0 38 0 54 0 N/A N/A 52 59 61 63 74 Falls Risk Assessment within 4 hrs Bed Rails Critical Care Risk Assessment Reviewed every 24 hours

KHWAD 15% Reduction Falls Prevention Toolkit Launched Falls Incident Reporting through Datix with Inbuilt Audit Nov 2010 Jan 2011 Falls Metrics included in Nursing Dashboard Mar 2011 Falls Metrics included in IBR Jun 2011 Falls Thematic Review Sept 2011 TIMELINE Falls Action Plan Dec 2011 Falls Operational Group Feb 2012 Marketing Re-Launch Poster Campaign May 2012

Truly Understand the Problem “For every complex problem there is an answer that is clear, simple, and wrong. ” H. L. Mencken …or at least not completely correct Henry L. Mencken 1880 -1956

Be vigilant, honest and (healthily) sceptical

Be vigilant, honest and (healthily) sceptical • Responsibility and Accountability • Root Cause Analysis • Thematic Review • Ward Safety Visits • Teaching and Training

Governance TRUST BOARD Falls Operational Group Clinical Risk Committee NUH Inpatient Falls Committee MSKN H&N Sp. S Ac. Med DIRC DIAG CAS Fam. H DDT Clinical Directorates Staff Training Clinical Education Medical Guidelines Wards and Frontline Clinical Staff Audit & Performance Measures

Falls Operational Group Chair: CEO Acute Medicine Cancer and Associated Specialties Diabetes, Infectious Diseases, Renal and Cardiovascular Number of falls 143 34 34 Number of falls/1000 Bed Days 10. 4 7 Number of Fallers 122 No of all fractures 2 No of Hip Fractures Head and Neck Musculoskeletal and Neurosciences Specialist Support 42↑ 4 47 1 5. 4 8. 6↑ 5. 1 5. 6 1 21 23 36↑ 3 7 1 0 0 1↑ 0 0 0 1 0 0 0 Head Injuries 0 0 0 0 Deaths 0 0 0 0 81% 96% inpatient areas (89% directorate) 96% 97% 85% overall ( Potential figure 96% when theatres all trained)* June 2012 % Staff trained in Falls Risk Assessment and Falls Care Planning NUH 82 % 85. 5 %* Diagnostics and Clinical Support Digestive Diseases and Thoracics Family Health NURSING DASHBOARD % Risk Assessment completed within 24 hours of admission % Patients at Risk of falls with a completed Falls Care Plan % of Falls Risk Assessments reviewed weekly %of fallen patients with Post Falls Checklist completed % of fallen patients falls Risk Assessment Reviewed % of patients with a Bed Rails Assessment completed 90% 93% 86 91%↑ ↓ 67% 87% 95% (May 73%) 100% 75% 76 79%↑ ↓ 67% 81% 75% (May 91%) 89% 76 100%↑ ↓ 67% 82% 94% (May 100%) 0% 82% N/A 75% 67% 33 100% ↔ 89% 85% 33 na 82% N/A 100% 97% 96 100%↑ ↓ 71% 97% 100% (May 91%) Within four hours 66% 83% 63 71%↑ ↓ 67% 58% 74% (May 82%) Bed rails risk assessment reviewed every 24 hours 66% 61% 52 79%↑ ↓ 20% 61% Comments *(down from 87) 87% overall 78% overall *Critical care has been focus for targeted training for June and these figures have increased considerably. Overall figure now 93%. Theatres 33% trained (daycase only need training) they are still awaiting specialist input for a falls risk assessment for day case patients currently 20 staff outstanding for training.

Be vigilant, honest and (healthily) sceptical • Responsibility and Accountability • Root Cause Analysis • Thematic Review • Ward Safety Visits • Teaching and Training • Collective Memory • Learning to the Front Line • HM Coroner

Be vigilant, honest and (healthily) sceptical Root Cause Analysis An investigation not a simple chronology • • What went wrong What could have prevented the incident How are we to stop a recurrence Robust action plan with clear accountability Thematic Review • • Hot spots “ 3 strikes” Recurrent themes

Be vigilant, honest and (healthily) sceptical • Responsibility and Accountability • Root Cause Analysis • Thematic Review • Ward Safety Visits • Teaching and Training • Collective Memory • Learning to the Front Line • HM Coroner

Be vigilant, honest and (healthily) sceptical Ward Safety Visits • • • Ward layout Ward routine Toilets and bathrooms Clutter Single sex considerations Teaching and Training • • Not just nursing teams Not just junior doctors Not just process Falls Champions

Be vigilant, honest and (healthily) sceptical • Responsibility and Accountability • Root Cause Analysis • Thematic Review • Ward Safety Visits • Teaching and Training • Collective Memory • Learning to the Front Line • HM Coroner

Be vigilant, honest and (healthily) sceptical Collective Memory • Knowledge and learning held by small group Learning to the Front Line • • • Fall incident summaries Theme keywords Searchable knowledge bank

Nurture and Develop What Works • Cohort Nursing • Toileting • Management of Delirium

Nurture and Develop What Works Cohort Nursing • Rapid response to change in condition • An active process • Requires knowledge and understanding • Constant vigilance (24/7) • It’s a multiprofessional sport • Interventions • Zero tolerance

Nurture and Develop What Works Toileting • 50% of falls • Commodes behind curtains • Privacy and Dignity vs Safety • Zero tolerance to toilet “buzzers”

Nurture and Develop What Works Management of Delirium • Education and training • Delirium Toolkit • Falls Prevention Team

Nurture and Develop What Works Falls Prevention Team • Supports Cohort Nursing • Disseminates good practice • Tangible “Trust” support

Falls Prevention Toolkit Introduced November 2010 Apr 2010 Falls Prevention Team Introduced February 2013 July 2015

Moderate/Severe Harm Events YEAR Falls/1000 Bed Days (Average) Hip Fractures Other Fractures Head Injuries Deaths 2010/2011 6. 23 12 11 5 7 2011/2012 7. 04 51 29 12 22 2012/2013 6. 46 33 39 17 17 2013/2014 5. 52 18 26 14 6 2014/2015 4. 31 29 29 25 2

Summary • No right or wrong way to do things • Listen to front line staff, patients and carers • Develop and use information – KHWAD • Investigate don’t simply record events • Be ever vigilant • Maintain the prevention of harm as the focus • Never rest on your laurels!

Acknowledgements IPFC Members Bev Brady – PDM Acute Medicine Nicky Lindley – Matron for Harm Free Care Jenny Leggott & John Gray Peter Homa NUH Colleagues