FALLS AND FRACTURES

Falls and fracturesEffective interventions in health and social care

DH INFORMATION READER BOX

Policy EstatesHR/Workforce CommissioningManagement IM&TPlanning/Performance FinanceClinical Social Care/Partnership Working

Document purpose BestPracticeGuidance

Gateway reference 11998

Title Fallsandfractures:effectiveinterventionsinhealthandsocialcare

Author DH/SC,LG&CPdirectorate/OlderPeopleandDementia

Publication date 22Jul2009

Target audience PCTCEs,NHSTrustCEs,SHACEs,CareTrustCEs,FoundationTrustCEs,MedicalDirectors,DirectorsofPH,DirectorsofNursing,LocalAuthorityCEs,DirectorsofAdultSSs,AlliedHealthProfessionals,GPs

Circulation list

Description Thisdocumentsetsoutfourkeyinterventionsthatcommissioners,workingacrosshealthandsocialcare,shouldconsiderinthecontextoflocalservicesforfalls,fallspreventionandfractures.Itaimstoinformlocaldialoguebetweencommissionersandserviceproviders.Olderpeopleandtheircarersmayalsouseittofindoutaboutservices.

Cross reference N/A

Superseded documents N/A

Action required N/A

Timing N/A

Contact details GillAylingOlderPeopleandDementiaDepartmentofHealthRoom8E28QuarryHouseQuarryHillLeedsLS27UE01132546068

For recipient use

Falls and fracturesEffective interventions in health and social care

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Fallsrepresentasignificantpublichealthchallenge,withincidenceincreasingatabout2%perannum.Increasedratesoffalling,andtheseverityoftheconsequences,areassociatedwithgrowingolderandtherisingrateoffallsisexpectedtocontinueasthepopulationages.

InEngland,thenumberofpeopleagedover65isduetorisebyathirdby2025,thenumberofpeopleover80willdoubleandthenumberagedover100willincreasefourfold.Asignificantriseinfallsandassociatedfracturesisthereforelikelywithoutpreventiveinterventions.

PreventingolderpeoplefromfallingisakeychallengefortheNHSandlocalauthorities.Itisnotthepreserveofoneagencyastheconsequencesofafallandresultantfragilityfracturecutacrossalllocalagenciesworkingwitholderpeople.Alllocalorganisationsworkingwitholderpeople,includingstatutoryandvoluntaryserviceproviders,areapartofthesolutionandmustbesupportedtounderstandtheircontributiontoreducingthenumberoffallslocally.

Using this guide

ThisguideispartoftheDepartmentofHealth’spreventionpackage,akeycomponentofthegovernment’sstrategyforanageingsociety.Thepackageaimstoraisethefocusonolderpeople’spreventionservicesandencouragetheiruse,ultimatelyimprovingolderpeople’shealth,well-beingandindependence.

Thisresourceaimstoinformlocaldialoguebetweenhealthandsocialcarecommissionersandserviceprovidersaboutfallsandfracturescare,settingoutthecontextandkeyinterventions.Otherstakeholders,includingolderpeopleandtheircarers,mayalsouseittofindoutaboutservices.Therearetoolstosupportthisguide,includinganeconomiccasefordevelopingfallsandfractureservices,atemplatetoassesslocalneed,modelfallscarepathways,referencesandpracticeexamples.

Therearefourkeyareasforinterventionthatcommissioners,ideallyworkingcollaborativelyacrosshealthandsocialcare,shouldconsiderinthecontextoflocalservicesforfalls,fallspreventionandfractures.

Introduction

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Theguidelooksatdevelopingservicestoachievethesefourobjectives,whicharelistedinpriorityorderintermsofimpactandevidence-base,althoughtheyeachhavearolefordifferentriskgroups.

●● Objective 1: Improve patient outcomes and improve efficiency of care after hip fractures through compliance with core standards.

●● Objective 2: Respond to a first fracture and prevent the second – through fracture liaison services in acute and primary care settings.

●● Objective 3: Early intervention to restore independence – through falls care pathways, linking acute and urgent care services to secondary prevention of further falls and injuries.

●● Objective 4: Prevent frailty, promote bone health and reduce accidents – through encouraging physical activity and healthy lifestyle, and reducing unnecessary environmental hazards.

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A systematic approach to falls and fracture preventionFour key objectives

June 11, 2009

Hipfracturepatients

Objective 1: Improve outcomes and improveefficiency of care after hip fractures – byfollowing the 6 “Blue Book” standards

Non-hip fragilityfracture patients

Objective 2: Respond to the first fracture,prevent the second – through FractureLiaison Services in acute and primary care

Individuals at high risk of1st fragility fracture orother injurious falls

Objective 3: Early intervention to restoreindependence – through falls care pathwaylinking acute and urgent care services tosecondary falls prevention

Older peopleObjective 4: Prevent frailty, preserve bonehealth, reduce accidents – throughpreserving physical activity, healthy lifestylesand reducing environmental hazards

Stepwiseimplementation- based on sizeof impact

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Falls and frailty among older people

Peoplefallformanyreasons.Activepeoplesometimesfall.Itisembarrassingbutnomore.

Fallsbecomeanissuehowever,whenthey:

●● occurdoingordinaryandnecessaryactivities

●● inducefearoffalling,whichrestrictsactivityandleadstolossofindependence

●● keephappening(‘recurrent’falls)

●● causeinjuries.

Fallsarenotaninevitableconsequenceofoldage;rathertheyarenearlyalwaysduetooneormoreunderlyingriskfactors.Recognisingandmodifyingtheseriskfactorsiscrucialinpreventingfallsandinjuries.Commonriskfactorsincludeoccurrenceofapreviousfall,gaitandbalanceproblems,muscleweakness,cognitiveimpairment–forexamplefromdementiaordelirium,multiplemedications(notablysedatingdrugs,withasignificantlinktopeoplewithdementia),visualimpairment,faintingandacutemedicalillness.

Recurrentfallsareoftenamanifestationofimpairedposturalstability.Thiscanresultfromacombinationoffactors,suchasconditionslikearthritis,strokeorParkinson’sdisease,age-relatedfrailtyandlong-termcardio-respiratoryconditionsleadingtolossofstrength,balanceandconcentrationorinsight.

Externalfactorscancontributetofalls,suchaspoororcoldhousingorbehaviouralissuessuchasexcessivealcoholconsumption.

Fragility fractures

Themajorityoffracturesinolderpeopleoccurasaresultofafallfromstandingheight.Thesearelowtraumafragilityfracturescommonlyaffectingthepelvis,wrist,upperarmorhip.Currently,almosthalfofallwomenandoneinsixmenexperienceapainfulanddisablingfragilityfractureinlaterlife.

Background

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Hipfracturesremainthemostseriousconsequenceofafallandthecommonestcauseofaccident-relateddeathinolderpeople–20%diewithinfourmonthsand30%withinayear.Approximatelyhalfofthosewhowerepreviouslyindependentbecomepartlydependentfollowingahipfracture,whileone-thirdbecometotallydependent.

Underlyingmanyoftheriskfactorsisacommonconditionknownasosteoporosis,whichweakensbonestrength.Itisachronicdiseasethataffectsoneinthreewomenandonein12menagedover50.Osteoporosisparticularlyaffectspost-menopausalwomen.Theincidenceinbothsexesrisesrapidlyasthepopulationages.Itsonsetisasymptomaticanditisoftenonlyrecognisedafteranolderpersonfallsandsustainsafragilityfracture.OsteoporosiscanbediagnosedandtreatedusingspecialistbonedensityorDXAscansanddrugs,althoughmanyfragilityfracturesoccurinpeoplewithamilderformofthedisease,knownasosteopenia.

Older people’s perspectives on falls

Someolderpeoplearefearfuloffalling,buttheyaremostconcernedaboutlossofmobilityandindependence.Thisshouldinfluencehowprofessionaladviceispromoted.

Onestudy1foundthat80%ofolderwomensurveyedsaidtheywouldratherbedeadthanexperiencethelossofindependenceandqualityoflifethatresultsfromabadhipfractureandsubsequentadmissiontoanursinghome.

Yetolderpeoplecanberesistanttolifestyleadvicelinkedtothethemeof‘falls’,asthewordhasconnotationsformanyofgettingfrail,andlosingtheirprideinbeinguprightandindependent.Ingeneral,thereisabetterresponsetothethemeof‘improvingstrengthandbalance’andstayingactive.

ResearchcommissionedbyHelptheAged2,whichdrawsonfeedbackfromolderpeoplethroughfallspreventionfocusgroups,hasfoundthatthekeymessagestomaximisetheimpactoflifestyleadvicerelevanttopreventingfallsare:

●● focusonimprovingstrengthandbalance,notfalls

●● encouragepeopletopersonallychoosetheadviceandactivitiesthatsuitthem

●● don’tfocusonavoiding‘hazards’orphysicalrestrictionsuchaswearinghipprotectors–thisisperceivedasoverbearing.

1 (Salkeldetal(BMJ2000))2 Don’t Mention the F- Word HelptheAged2005http://www,helptheaged.org.uk

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Withinthiscontexttheheadlinemessagesforolderpeople,familyandcarersarethat:

●● fallsareariskasyougetolder,butarenotinevitable

●● stayingactiveanddealingproactivelywithanylong-termconditionwillreducefrailtyandpreserveindependence

●● ifyouaregettingunsteady,seekadvicesounderlyingfactors,suchaseyesight,medications,strengthandbalance,canbeaddressed.

Prevalence of falls and fractures

Fallingisaseriousandfrequentoccurrenceinpeopleaged65andover.Eachyear,35%ofover-65sexperienceoneormorefalls.About45%ofpeopleagedover80wholiveinthecommunityfalleachyear.Between10and25%ofsuchfallerswillsustainaseriousinjury.

Thenumbersarelarge.AlocalauthorityandPCTpopulationof300,000maycurrentlyinclude45,000peopleagedover65.Ofthese:

●● 15,500willfalleachyear

●● 6,700willfalltwiceormore

●● 2,200fallerswillattendanaccidentandemergency(A&E)departmentorminorinjuriesunit(MIU)

●● asimilarnumberwillcalltheambulanceservice

●● 1,100wiIlsustainafracture,360tothehip.

BasedonNICEguidelinesandpopulationmodelling,amongstapopulationof300,000around10,000peopleperyearwhofallshouldreceiveafallsassessment,withafurther5,000potentiallyrequiringabriefscreeningofgaitandbalance.

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Table 1: Bone health and post-menopausal women

InaPCTof300,000,therewillbe:

a.55,000Post-menopausalwomen

b.17,400Post-menopausalwomenwithundiagnosedosteoporosis

c.6,900Post-menopausalwomenwithapreviousfractureofanykind

d.900Post-menopausalwomenwithnewfractureeachyear

Groupscanddaboveconstitutejust16%ofthelocalpopulationbutitisfromtheseclearlyidentifiablegroupsthat50%ofhipfracturesoccur.Targetingthesegroupsinprimarycareandthroughfractureliaisoncase-findingservicesbasedinhospitalprovidesreadyaccesstothoseatgreatestriskofhipfractures.

Health and social care: a joint interest in falls and fractures

Theconsequencesoffallscanbesignificant–lifechanging,andinmanycaseslifethreateningforolderpeople.TheyhaveanimpactonbothNHSandonsocialcareservices.Fallingcanprecipitatelossofconfidence,theneedforregularsocialcaresupportathome,orevenadmissiontoacarehome.Fracturesofthehiprequiremajorsurgery,andinpatientcareinacuteandoftenrehabilitationsettings,ongoingrecuperationandsupportathomefromNHScommunityhealthandsocialcareteams.Inaddition,hipfracturesaretheeventthatpromptsentrytoacarehomeinupto10%ofcases.Indeed,fracturesofanykindcanrequireacarepackageformostolderpeopletosupportthemathome.

Theadditionaldirectcosttocommissionersforhipfracturesaloneisestimatedtobe£10,000totheNHSplusthecostsoflocalauthoritysocialcare.Thisisinadditiontoexistingcapacitythatisreleased,forexampleinintermediatecareservicesorcommunityhospitals,butdoesnotnecessarilybecomeadirectsaving.

Thismeansthereisajointinterestbetweenhealthandsocialcareservicesindevelopingeffectivefallsandfracturepreventativeservices,andtoworktogethertoidentifywhereandbyhowmuchdirectcostsandotherkindsofsavings–releasingstafforservicetime,forexample–aregenerated.

Seetheaccompanyingeconomic evaluationformoredetailsoffallsandfracturecostsandtheeconomicbenefitsofeffectiveinterventions.

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Theevidencebaseforhipfracturecarehighlightsthattimelyandco-ordinatedmulti-disciplinarymanagementcanimproveoutcomesandefficientuseofresources.

Improvedoutcomesandreductionsinvariabilityintimetosurgery,lengthofstayandotherkeyindicatorscanbesecuredviacommissioningtomeetsixkeystandards.Therationaleforthesestandardsissetoutin The Care of Patients with Fragility Fracture,publishedin2007bytheBritishOrthopaedicAssociationandBritishGeriatricsSocietyandknownasthe‘BlueBook’.ProgresstowardscompliancecanbecontinuouslymonitoredbyparticipationintheNationalHipFractureDatabase(NHFD)3.CommissionerscanensureafocusonqualityandoutcomesbyrequiringproviderstoparticipateinandsharewithcommissionerstheircomparativedatafromNHFD.

Thestandardsare:

1. All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation.

2. All patients with hip fracture who are medically fit should have surgery within 48 hours of admission, and during normal working hours.

3. All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer.

4. All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to acute ortho-geriatric medical support from the time of admission.

5. All patients presenting with fragility fracture should be assessed to determine their need for anti-resorptive therapy to prevent future osteoporotic fractures.

6. All patients presenting with a fragility fracture following a fall should be offered multi-disciplinary assessment and intervention to prevent future falls.

3 NationalHipFractureDatabasehttp://www.nhfd.co.uk

Objective 1: Improving the experience of hip fracture surgery

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TheNHSInstitute’sOrthopaedicRapidImprovementProgramme4hashighlightedamarkedvariationinoutcomes,includingmortality,associatedwithhipfracturecare,andidentifiesinFocus On: Fractured Neck of Femur5 severalcharacteristicsoforganisationsprovidinghigh-qualitycareandvalueformoney,andthisshouldbeusedtopromoteimplementationofbestpractisethroughserviceredesign.

●● Thepathwayisco-ordinatedanddesignedtoreducevariationinlengthofstay,reducemortalityandre-admissions.

●● Treatinghipfracturepatientsinadedicatedunitwithafocusonrapidrehabilitationensuresoptimalhealthoutcomes,andhasprovedtoreducetheaveragelengthofstaybyuptoeightdaysperpatient.Theyavoid‘superspell’staysacrossacuteandrehabilitationsettingsandaimtocarefor90%ofpatientsonanappropriateclinicalwardareawithnursing,ortho-geriatricmedicineandsurgicalexpertiseappropriateforthisoftenfrailpatientgroup.

●● Everyeight-hourdelaytosurgeryaftertheinitial48hoursequatestoanextradayinhospital.Ifpatients’fluidstatusandsignificantco-morbiditiesareoptimisedinatimelyandappropriateway,morepatientsreceivesurgerywithin24hours,resultinginbetterheathoutcomesandreducedpost-operativestay.

●● Patientsshouldbemobilisedwithin12-18hourspostopandreceiveseven-daytherapyinput.Forthisstandardtheaimshouldbe95%compliance.

●● Patientsaredischargedbacktotheirusualaddressusingacriteria-baseddischargeprocess.Theaimshouldbeatleast60%‘hometohome’within30days.

●● Healthandsocialcareteamsareco-ordinatedandintegratedacrossthepatientpathwayandworkinpartnershipwithanortho-geriatrician.

Influencing hip fracture care through commissioning

Thereareanumberofkeyopportunitiestoinfluencehipfracturecarethroughcommissioning,includingthefollowing.

●● Commissioninganintegratedortho-geriatricservicetospecifiedqualitystandards,wherebyalloldertraumapatientsareseenbyateaminvolvingbothorthopaedicsurgeonsandgeriatricians,plusregularmultidisciplinaryassessmentandinputtowardsdischargeplanning,rehabilitation,andmanagementofco-existentmedicalproblems

●● Commissioningpost-acutecarewithappropriatemulti-disciplinaryinputs

4 http://www.institute.nhs.uk5 Focus on: Fractured Neck of FemurNHSInstituteforInnovationandImprovement2006

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●● Monitoringlocalservicesagainstthesixstandards(seeabove)

●● UsingtheFocusonFracturedNeckofFemurguide

●● RequiringcontinuousqualitybenchmarkingviatheNationalHipFractureDatabase

●● ApplyingWorldClassCommissioningcompetencieswhencommissioningfracturecareservices.

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Preventing recurrent falls and fractures

Themosteffectivewayofidentifyingpeopleatriskofhipfractures,andorganisingappropriatetreatment,istofocusontwoparticulargroups:

●● patientswithnewfragilityfractures

●● patientswhohavefracturedinthepastorareatriskofosteoporoticfracturesinthefuture.

Thenatureofthediseaseprogressionofosteopeniaandosteoporosisprovidesanopportunityforinterventioninupto50%offuturehipfracturecases.StudiesfromtheUKandabroadconsistentlyreportthathalfofhipfracturepatientshaveahistoryofprevious,clinicallyapparent,fragilityfracture,suchasthewrist,ankleorvertebra.Treatmentofosteoporosisfromthetimeofthefirstfractureinthesepatientswouldhavepreventedaroundhalfofthesubsequenthipfractures.

ThelatestNICEtechnologyappraisalonsecondaryprevention,TA1616advocatesosteoporosisassessmentandtreatments,whereappropriatebasedonbonemineraldensityandclinicalfactors,forallfemalepatientsagedover50whohavesufferedfragilityfractures.

Fracture liaison, working with acute care

Forpatientswithnewfragilityfracturesaserviceknownasfractureliaisoncantargetthehighestriskgroup.Patientsagedover50,whoareadmittedtohospitalorwhoattendoutpatientclinicsorA&Eduetoalowimpactfracture,gainedfromafall,sliportripfromastandingheightorlower,arehighlightedtotheservice,andassessedbyaspecialistosteoporosisnurse.Fora300,000populationtheservicewouldassessaround1000olderpeoplewithfragilityfractureseachyear,andoftheseabouthalfwouldberecommendedforosteoporosistreatment.

6 NICETechnologyAppraisal(TA)161Review of treatments for the on secondary prevention of osteoporotic fragility fractures in post-menopausal women(updatingTA87)

Objective 2: Respond to the first fracture and prevent the second

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Thenursecan:

●● investigatebonedensityusingscansandmeasurements

●● startdrugandothertreatmentstoreducetheriskofafuturebreakifsomeonehasosteoporosis

●● liaisedirectlywithfallsservices

●● monitorandmaintainmedicationadherence.

Around30%ofhospitalsinEnglandcurrentlyoperatethisservice,andthereisstrongresearchevidenceforitseffectivenessinreducinghipfracturesinthisgroupofpatients.Seetheaccompanyingeconomic evaluationformoredetails.

Fracture liaison, working with primary care

Forpatientswhohavefracturedinthepastorareatriskofosteoporoticfractures,aprimarycare-basedfractureliaisonprogrammecanundertakeproactivecasefindingofunassessedfragilityfractureandotherhigh-riskpatientsacrossamuchwidergroup.

UsingprimarycarerecordsandtheFRAXTMosteoporosisriskassessmenttool7,theservicecanproactivelyidentifypeoplewhosefragilityfractureshavenotpreviouslybeenassessed,andotherpatientsathighriskofprimaryfractures.

Aprimarycare-basedfractureliaisonnurse,workingtoagreedprotocolsundertheguidanceofaGPwithaspecialistinterestinosteoporosis,can:

●● carryoutassessments

●● reviewpatients’medication

●● recommendtreatmentforlong-termmanagementofosteoporosis.

7 http://www.shef.ac.uk/FRAXTM

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Thisenablesmorecomprehensivecase-finding,usingprimarycarerecordsandtheFRAXTMtooltoidentifypatientsathighriskofprimaryfractures,plussystematicannualfollow-uptoensuremedicationcompliance.

Table 2: Bone health and post–menopausal women in a PCT and local authority of 300,000 population

FractureLiaison:

acute-carebased 55,000

17,400

6,900

900

Post-menopausalwomen

Post-menopausalwomen with a priorfracture history

Post-menopausalwomen with new fracture each year

PrimaryCare based

fractureliaison

Post-menopausalwomen with osteoporosis

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Interventionsinthecommunitywiththehighestqualityevidencebaseinclude:

●● afallscarepathway

●● afallsservice

●● afallsco-ordinator

●● multi-factorialinterventions

●● community-basedtherapeuticexercise.

A falls care pathway

Afallscarepathway,commissionedlocallybyhealthandsocialcarefromamulti-agencyteam,shoulddrawontheDepartmentofHealthpathwaysaccompanyingthisguide.Alocalexercisetomapandreviewcurrentfallsprovision–whereandbywhom,estimatingunmetneedandadditionalinformationaboutactivity,andinvolvingkeystakeholders–isrecommended.Besidesmedical,nursing,socialcareandtherapystaff,otherprofessionalgroupsshouldincludepodiatrists,exerciseco-ordinators,ambulancestaff,A&E,pharmacists,occupationaltherapistsandHomeImprovementAgencystaff.

Thepathwayshouldagree:

●● thecontributionofeachprofessionalgrouptothepathway

●● specificproposalsforincorporatingfallspreventionandawarenessintomainstreamhealthandsocialcareservices,withcriteriaforidentifyingpeoplesuitableforfallsassessment,includingbonescanningwhereappropriate

●● whatsortofassessmentactivityisundertakenbetweenGPs,aprimarycare-basedfallsteam,andsecondarycarebasedfallsclinics.

●● opportunitiestoconsideranyadaptationsneededtoahomeenvironment,includingtheuseofaidsandadaptations,communityequipmentandassistivetechnology,suchasfalldetectorsandrelatedcommunityalarmortelecarepackages

Developingthepathwaycanhelpcommissionersmakealocaldecisionaboutwhattheywantfromeachsector.

Objective 3: Early intervention to restore independence and reduce future injuries

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A falls service and falls co-ordinator

Afallsservicecantriageandassessolderpeoplewhohavefallenorareathighriskoffalling.

Anyonepresentingwithafallorfractureinanyurgentcaresetting–A&E,minorinjuryunits,primarycareoutofhoursservice,orambulanceservicenon-conveyedfaller–shouldbeassessedforthefollowing.

●● Fallsrisk,viaamulti-factorialriskassessment.Thisshouldincludeareviewofanymedicalconditions,strengthandbalancetests,visualimpairmentandmedicationreview.Staffprovidingafallsassessmentshouldhaveaccesstospecialistmedicalinputtoassistinestablishingthereasonwhyapersonhasfallen.

●● FractureriskusingprofessionalconsensusguidancesuchastheFRAXTMassessmenttool.NICEtechnologyappraisals160and161provideguidanceonthetreatmentofprimaryandsecondaryosteoporosisandNICEguidanceonassessmentandtreatmentstopreventfragilityfracturesisanticipated.Meanwhile,FRAXTMallowsthecalculationofariskscoreandwhereriskishighdoesnotrequireaDXAscaninordertoinitiatetreatment.

Fallsassessmentservicecanberunfromarangeofsettingsincludingcommunityhospitals,GPsurgeries,intermediatecareteamsorsecondarycare.Thekeyrequirementispractitionerswithappropriateskills,includingaccesstosecondarycarespecialistsandfacilitieswhereappropriate.Commissionersshouldconsidercurrentarrangementslocallyasastartingpointforservicedevelopment,aswellasknownpatientpreferenceforlocalvenues.

Alternatively,individualscouldbereferredtoprimarycareorcommunityteamsforassessment,basedonalocallydesignatedprocessorpathway.

Falls co-ordinator

Afallsco-ordinatorcanensurethathospitalandcommunityeffortstopreventfallsareco-ordinatedandintegrated.Thispostalsohasakeycommunicationsrole,promotingfallsmanagementandpreventiontootheragencies,basedontheeffectivemessagestoolderpeoplehighlightedbytheHelptheAgedresearch(seeOlder people’s perspectives on fallsabove).

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Multi-factorial targeted interventions

Multi-factorialtargetedinterventionsarebasedonriskassessment,andarelikelytoincludeoptimisingmedication,reducingvisualdisability,avoidingunnecessaryenvironmentalhazardsinthecontextof lifestyleadviceandsupportto preventfrailty,preservingbonehealth,andpromotingindependence.Themosteffectivecomponentofmulti-factorialinterventionsistherapeuticexercise.

Community-based therapeutic exercise

ThenationalphysicalactivitystrategyBe Active, Be Healthy: A plan for getting the nation moving8 highlightsthebenefitsofstrengthtrainingprogrammesforolderpeople,whichcanproducesignificantimprovementsinmusclestrength,leadingtobetterfunctionalmobilityandareductioninfalls.

Community-basedtherapeuticexerciseisthereforeaneffectiveintervention.Thisshouldincludeprogrammestailored to:

●● fallerswhoattendurgentcare

●● peoplewithfragilityfractures

●● peoplewithhipfractures.

Theoverallaimoftheseprogrammesistoimproveposturalstabilitythroughincreasingstrengthandbalance.Whilesomeindividualswillneedphysiotherapy-ledmodificationsbasedontheirparticularco-morbidity,thereisgoodevidenceforbothdomiciliaryandgroup-basedapproachesthatcanbedeliveredbytrainedexerciseinstructorsandincludepeoplewithcognitiveimpairment.Theseapproachesincludetargetingandindividualprogressionofexercises.

Itisimportanttomanagepatientswhofailtorespondtoevidence-basedexercise,asdemonstratedbyfurtherdecliningposturalinstabilityorincreasedfalls.Thisincludesinvestigationforunderlyingcausesofbonelossandconsiderationofalternativetreatmentsandtherapy-ledtechniquestoensurepatientsavoidlong-liesfollowingafall.

Manyexerciseinterventionsprovidedaspartoffallsservicescurrentlyfallshortofthesestandards.Commissioningtotherequiredqualityandcapacitycouldincludearangeofproviders,includinglocalleisureservicesandthevoluntarysector.

8 Be Active, Be Healthy: A plan for getting the nation moving HMGovernment2009

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ThisexerciseapproachshouldbemustbedeliveredinthecontextofBe Active, Be Healthywithaviewtoongoingincreasesinhabitualphysicalactivity,resultinginphysicalandpsychologicalbenefits.Thebestsimplepredictorofneedfortargetedtherapeuticexerciseinterventionsisagedistribution,inparticularnumbersofpeopleagedover65,withpost-menopausalwomenathighestrisk.Furtherdetailedadviceonevidence-basedexerciseinterventionsisoutlinedintheaccompanyingDHadvicenoteExercise Training to Prevent Falls.

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Preventing falls in the community, home and hospital

Fallsandassociatedfracturesoccurregularlyinavarietyofsettings,principallythecommunity,homeandhospital.Promotinghealthylifestyleand‘strongbones’amongolderpeopleisakeyactivity,asisearlyinterventiontorestoreindependencewhenfallsoccur.Localfallsstrategiesshouldalsoincludeapproachestoimprovingbalanceandstrength,suchthatwhetherlivingathomeorincarehomesolderpeoplecantakeadvantageofawiderangeofactivitiesdesignedtoimproveposturalstabilityandincreasestrength.

Localfallsstrategiesalsoneedtoconsider‘environmental’approachestofallsprevention,actingontherisksthatsurroundolderpeopleintheirhomesandthecommunity.Arecentreview9concludedthat:“Homemodificationintheabsenceofotherinterventionapproachesmaybeeffectiveforpersonswithahistoryoffallingbutislikelytobemosteffectivewhenintegratedintoamulti-facetedinterventionprogramthatalsofocusesoneducation,exercise,andnutritionalstatus.”

Thereisnotconclusiveevidencethataddressinghomehazardsalone–egpoorlymaintainedstairways,poorlightingandvisibility,hardsurfacesonwhichtofall,andlackofsafetydevicessuchasgrabbars–willreducefallsandfractures.Butthesehazardsshouldbeaddressed,usingprofessionallyprescribedenvironmentalassessmentandmodification,becauseproblemswithvision,balance,chronicconditionsandsideeffectsofmedicationthatincreasewithagewillhinderpeople’sabilitytonegotiatethesehomehazardsandincreasetheriskoffallsandfractures.

Homeassessmentsshouldbeaninterventionoptionfollowingastructuredfallsassessment,inasimilarwayasforexerciseinterventions.Demandfortheseinterventionswillbeaby-productofmoreeffectivecase-finding,andcommissionerswillneedtoconsiderthepotentialadditionaldemandgeneratedfortherapyservices.

9 Corinne Peek-Asa and Craig Zwerling – EpidemiolRev2003;25:77–89

Objective 4: Prevent frailty, promote bone health and reduce accidents

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Thereisawiderenvironmentaldimensioninensuringthatpeopleliketownplannersandarchitectstakeaccountoftheriskoffallstoolderpeopleindesign.Forinstance,thereisemergingevidenceoftheimportanceofphysicaldesigninpreventingfallsamongpeoplewithdementia,withparticularattentionpaidtocolourcontrast,floorsandlighting.Thegovernment’snationalhousingstrategyforanageingsociety,Lifetime Homes, Lifetime Neighbourhoods,promotestheimportanceofinclusivehousingdesignstandards.

Falls in hospitals and other care settings

Fallsofolderpeopleinhospitalsandothercaresettingsisanimportantareawhereappropriatesystemsandawarenesscanreducerisk.ApatientfallinginhospitalisthemostcommonpatientsafetyincidentreportedtotheNationalPatientSafetyAgency(NPSA).TheNPSAestimatesthatinanaverage800-bedacutehospitaltherewillbeover1,260fallseachyear,withsignificantassociateddirectandlitigationcosts.

TheNPSAreportSlips, Trips and Falls in Hospital10highlightsthedilemmathat“achievingzerofallsisnotrealistic,becauserehabilitationalwaysinvolvesrisk”.However,thereportalsoidentifiesthat“someNHSorganisationsdonothaveafallspreventionpolicy,orareplacingtoomuchemphasisoncompletingfallsriskscores,ratherthanpreventingfalls”.

ManyoftheissuesandgoodpracticeexampleshighlightedbytheNPSAfortheNHSalsoapplytocarehomes,wherethereisgenerallyaconcentrationofolderpeoplewithaprevioushistoryoffallsorwhoareatriskoffalling.Involvementofcommunitypharmaciststoreviewmedicationsisparticularlyuseful.

Incarehomestherateoffallsisalmostthreetimesthatofolderpeoplelivinginthecommunity.Injuryratesarealsoconsiderablyhigher,with10-20%ofinstitutionalfallsresultinginahipfracture,and30%ofpeopleadmittedtoanacutehospitalwithahipfracturecomingdirectlyfromacarehome.

Interventionstoreducefallsandfracturesincarehomesinclude:

●● providinghigh-strengthvitaminDandcalciumsupplements

●● stafftrainingeginformationonmodifiableriskfactorsandotherpreventivemeasures

●● educationforresidentseginformationonexerciseandfallprevention,recommendationtowearhipprotectors

10Slips, Trips and Falls in Hospital NationalPatientSafetyAgency2007http://www.npsa.nhs.uk

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●● fallspreventionenvironmentalassessmentseglighting,bedheight,floorsurfaces

●● therapeuticexerciseprogrammes.

CommissionersofNHSandsocialcareservicescanincorporatefallsandfallspreventionasakeyqualityindicatororoutcomeinmonitoringproviderservices,andtheNPSAidentifiesthatbenchmarkingispossiblebetweenhospitals.

The role of ambulance services

Localambulanceservicescanplayakeyroleinsecuringthepatientcarepathwayforfallslinkingurgentcaretosecondaryprevention.Nationallyambulanceservicesreceivearound700,000callsannuallyconcerningpeoplewhohavefallen,10%oftotalcalls.AmbulancestaffassesstheneedforpatientstobeconveyedtoA&Edepartmentsofacutehospitals,andaround25%arenotconveyed.Thisassessmentoffersstaffdirectexperienceofaperson’slivingconditions,includingenvironmentalsafetyandotherriskfactors.

Forthese‘non-conveyed,patientsthereisaclearopportunitytoflaguptheeventandpatient’scircumstancestoprimarycareorthecommunityfallsservices,dependingonthelocalpathway,andavarietyofmechanismstodothishavealreadybeendeveloped.Someserviceshavegoneastepfurtherandambulancestaffcanconveysuitablepatientsdirecttoappropriatealternateurgentcareservices(egoutofhoursprimarycare)orrefernon-conveyedpatientsdirectlytoasinglepointofaccesstoPCTcommunityfallsorintermediatecareservices.Asafirststep,systematicinformationsharingcouldbeincentivisedbycommissionersadoptingthisthemeasacommissioningforqualityandinnovation (CQUIN)11targetforambulanceservices.

Home Improvement Agencies and handyperson services

HomeImprovementAgenciesandhandypersonservicesplayanessentialroleinthedeliveryofaidsandadaptations,andofrepairsandmaintenanceservices,whichcanhelppreventfuturefallsfromtakingplace.Indeed,withthediverserangeofserviceswhichHIAsprovideinmanycommunities,includinginformationandadviceservicesaboutlocalhousingandsupportoptions,HIAsarecriticalpartnerswithwhomcommissionersshouldengageaspartofanintegratedapproachtofallspreventionservices.ThereisanHIAserviceavailableinalmosteverylocalauthorityarea.

11Using the Commissioning for Quality and Innovation (CQUIN) payment frameworkDepartmentofHealth2008http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091443

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Key outcomes

Themainmeasurableoutcomesforfallsandfracturesservicesare:

●● theincidenceofhipandotherfractures,basedonstandardisedadmissionsratio.TheregionalprofileofhipfracturesisshowninTable3.

●● benchmarkingnumbersofpeoplereceivingafallsassessmentannually,basedonknownriskgroups

●● thenumberofpeopleintargetgroupsundergoingacommunity-basedtherapeuticexerciseprogramme

●● thenumberofpeopleundergoingfractureriskassessmentafterafragilityfracture,withrecommendationforosteoporosistreatmentwhereappropriate

●● compliancewiththesixBlueBookstandardsforhipfracturetreatmentandcare(seeObjective 1above)

●● incidenceofrecurrentfragilityfracturesinthelongerterm.

Table 3: National and regional rate (per 100,000) of hip fractures in over 65s, 2006/7 (source: Health Profile of England, 2008)

400

425

450

475

500

525

550

575

rate

s pe

r 10

0,00

0

England NorthEast

NorthWest

Yorkshireand theHumber

EastMidlands

WestMidlands

East ofEngland

London SouthEast

SouthWest

Making a difference: outcomes, metrics and levers for change

Fallsandfractures:effectiveinterventionsinhealthandsocialcare

22

Evidence-basedinputstodeliverthesekeyoutcomesinclude:

●● case-findingsystemsinhospitalandcommunitysettingstoidentifyhigh-riskfallers

●● adherencetoNICEappraisalguidancewithmonitoringbylocalaudit

●● identifiedclinicalleadersincludingaconsultantwithjobplancommitment

●● afractureliaisonservicetoensureinitiationofsecondarypreventionmedicaltreatmentsforosteoporoticfragilityfractures

●● widespreadandaccessibleevidence-basedexerciseprogrammes

●● targeteduseofvalidatedhomesafetyassessments.

Accessing local data

Thereareseveralnationalauditsprovidinglocalcomparativedatathatwillbeusefultocommissionersandproviderindevelopingandmaintainingservices.

●● TheNationalHipFractureDatabase(NHFD)–web-basedaudit,atwww.nhfd.co.uk,designedtorecordcase-mix,careandoutcomesforhipfracturepatientsandproperlymonitortheuseofsecondarypreventioninterventions.ThedatabaseisbasedonthesuccessfulMyocardialInfarctionNationalAuditProject(MINAP)andforparticipatingsitesallowsthenationalbenchmarkingofhipfractureforthefirsttime.

●● TheRoyalCollegeofPhysiciansClinicalEffectivenessandEvaluationUnit(CEEU)NationalClinicalAuditofFallsandBoneHealthinOlderPeoplehasauditedlocalservicessince2005.Its2009reporthighlighteda“large variation in the quality of services…Some services are doing well but for most there are important deficiencies in both commissioning and provision of specialist care”.Opportunitiesforwidespreadimprovementsinseveralareasareraised,includingriskassessments,case-findingsystemstoidentifyhigh-riskfallers,knowledgeoflocalfragilityfractureratesandevidence-basedexerciseprogrammes.Theimportanceofcommissioningtherightservicesattherightqualityishighlighted,

●● TheQResearchprojectevaluationofstandardsofcareforosteoporosisandfallsinprimarycareindicatesthepotentialforidentifyingpatientsatriskofosteoporosisandfallsusingelectronichealthcarerecordsfromprimarycare.

Fallsandfractures

23

NICE guidance

NICEhaspublishedthefollowingrelevantguidance.

●● NICE Clinical Guidance 21 Clinical practice guideline for the assessment and prevention of falls in older people12.

●● NICE Technology Appraisal (TA) 87 The clinical effectiveness and cost effectiveness of technologies of the secondary prevention of osteoporotic fractures in post-menopausal women13

●● NICE Technology Appraisal (TA) 161 Review of treatments for the on secondary prevention of osteoporotic fragility fractures in post-menopausal women14

Levers for change

LocalAreaAgreementsinsomecommunitieshavebeenusedtodriveimprovement,withfallsandfallspreventionprioritisedbyagreementbetweenthelocalauthorityandhealthpartners.

Fallsandfracturesshouldbeprioritisedforearlyinclusionineacharea’sjointstrategicneedsassessment(JSNA).Theneeds assessmentguideaccompanyingthisguideprovidesaJSNAtemplateandminimumdatasetrelatingtofallsandfractureservices.

FromApril2010newqualitypaymentswillbeintroducedunderpaymentbyresults,followingthecommitmentinHigh Quality Care for All15,forproviderswhomeetkeyqualitystandardsforhipfracturecare.Thebestpracticetariffwillbestructuredandpricedtoincentiviseandenablebestpractice.

Adirectlyenhancedservicebeganin2008/9,aimingtoencourageprimarycaretoconfirmthediagnosisandprescribeappropriatepharmacologicalsecondarypreventioninpatientswithosteoporosis.Practicesareexpectedtocompileanauditofolderwomenwithadiagnosisofosteoporosis,andreceivingtreatment.

12NICEClinicalGuidance21:Clinical practice guideline for the assessment and prevention of falls in older people

13NICETechnologyAppraisal(TA)87:The clinical effectiveness and cost effectiveness of technologies of the secondary prevention of osteoporotic fractures in post-menopausal women(January2005).

14NICETechnologyAppraisal(TA)161Review of treatments for the on secondary prevention of osteoporotic fragility fractures in post-menopausal women(updatingTA87)

15High quality care for all: NHS Next Stage ReviewDepartmentofHealth2008http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825

Fallsandfractures:effectiveinterventionsinhealthandsocialcare

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Inaddition,reducingtheincidenceoffallsandfracturesusinginterventionswithastrongevidencebasecanimprovelocalperformanceinseveralnationalperformanceindicators.Theseinclude:

●● NI134–thenumberofemergencybeddaysperheadofweightedpopulation

●● NI124–peoplewithalong-termconditionsupportedtobeindependentandincontroloftheircondition

●● NI120–allage,allcausemortalityrate.

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NyeHarries(Co-Chair),NationalProgrammeManager,DepartmentofHealth

DrFinbarrMartin,(Co-Chair),ActingNationalClinicalDirectorforOlderPeople,DepartmentofHealth

DrElizabethAitken,ConsultantGeriatrician,LewishamUniversityHospitalsNHSTrust

GaryCook,ConsultantEpidemiologistandDirectoroftheClinicalEffectivenessUnit,StockportNHSFoundationTrust

DrAlunCooper,GeneralPractioner,BridgeMedicalCentre,WestSussexPrimaryCareTrust

RobinDavis,18WeeksProgramme,DepartmentofHealth

MarkDinsdale,ProjectOfficer,DepartmentofHealth

ProfessorRogerFrancis,ConsultantPhysician,FreemanHospital,TheNewcastleUponTyneHospitalsNHSFoundationTrust

ClaireGoodchild,NationalProgrammeManager,DepartmentofHealth

JudyHillier,DirectorofClinicalandCommunityServices,NHSPortsmouth

DrSteveLaitner,GeneralPractitioner&AssociateMedicalDirector,EastofEnglandSHA

ProfessorDavidMarsh,ProfessorofClinicalOrthopaedics,UniversityCollegeLondonHospitalsNHSFoundationTrust

DrPaulMitchell,AssociateLecturer,UniversityofDerby

ProfessorDavidOliver,ConsultantGeriatrician,RoyalBerkshireNHSFoundationTrust

CarlPetrokofsky,SpecialistinPublicHealth,DepartmentofHealthSouthEast

SarbjitPurewal,Associate,NHSInstituteforInnovationandImprovement

DrOpinderSahota,ConsultantPhysician,NottinghamUniversityHospitalsNHSTrust

ProfessorKeithWillett,NationalClinicalDirectorforTrauma,DepartmentofHealth

Appendix: List of members of the DH Falls and Fractures Working Group

©Crowncopyright2009

297173July09

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