Falls in Bristol’s residential and nursing care

Rob BeningtonInjury Prevention ManagerBristol Public Health

Today’s presentation1. Falls in Bristol2. NICE guidance 3. Falls in Bristol’s care homes 4. Bristol’s service specification 5. Examples of falls reduction projects from local providers6. Building external links (postural

stability, diet, nutrition, hydration)

Falls are the leading external cause of death for the over-75s

1. Falls in Bristol

Every year between 33% and 50% of people over the age of 65 suffer a fall, (estimates from Help the Aged)

20% of fallers will need medical help and just under 10% will sustain a fracture

Fractured hips cost the NHS £1.8 billion every year: All smoking £5bn, (2009). All obesity £4.2bn, (2007).

Emergency admissions Bristol residents aged 65+due to falls in 2012/13

All Bristol (65+) residents

390 Hip fractures1215 Other fall related injury4.4 Admissions every day

2.8% % of all 65+ Bristol residents admitted following a fall (57,200 2012 ONS MYE)

Emergency admissions per day (over 65’s)

2008/9 3.92009/10 4.42010/11 4.02011/12 4.32012/13 4.4

In 2012/13, 390 people over 65 were admitted to hospital with hip fracture, of which 15-30% die within 1 year, (60-121 deaths).

39% of Bristol’s 65+ admissions are from 7,082 beds

1. Falls In Bristol

2. NICE Guidance

Assessment and prevention offalls in older people

Issued: June 2013

NICE clinical guideline 161guidance.nice.org.uk/cg161

Identification of vulnerable people Older people in contact with healthcare professionals

should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s.

Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment.

The multifactorial fall risk assessment should be performed by a clinician (or clinicians) with appropriate skills and training.

Biggest risk factor?

Having had a fall in the last 12 months.“If you’re 65 or older, your health professional or practitioner should regularly ask whether you’ve had a fall in the past year. And if you’ve had a couple of falls, you should see your doctor anyway, even if you feel okay.

This is because someone who has already had a fall is more likely to fall in the future. But there are ways of helping a person avoid having a fall so they can feel more confident in their daily lives, and perhaps live independently for longer”.

NICE Clinical Guideline 21, 2004.

Fear of falling 'boosts elderly's fall risk'

Worry about falling

Restricted activity

Functional decline

Increasing unsteadiness / loss of balance

Fall

1.1.3 Multifactorial interventionsAll older people with recurrent falls or assessed as being at

increased risk of falling should be considered for an individualised multifactorial intervention.

1.1.4 Strength and balance trainingStrength and balance training is recommended.

1.1.5 Exercise in extended care settingsMultifactorial interventions with an exercise component are

recommended for older people in extended care settings who are at risk of falling.

1.1.7 Psychotropic medicationsOlder people on psychotropic medications should have their

medication reviewed, with specialist input if appropriate, and discontinued if possible to reduce their risk of falling.

1.1.8 Cardiac pacingCardiac pacing should be considered for older people with

cardioinhibitory carotid sinus hypersensitivity who have experienced unexplained falls.

Most relevant guidance…

Multifactoral interventions

In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors):

strength and balance training home hazard assessment and intervention vision assessment and referral medication review with

modification/withdrawal.

3. Falls in Bristol’s care homes

Public Health Outcome Indicators

Admissions, postcodes

Occupancy and rates

Confidentiality

Falls admissions from ECH, Care Homes, CH with Nursing,

sheltered accommodation (2011/12)

Extra Care Housing 54Care Homes with Nursing 129Residential care homes 107

Supported housing 91Total 381

8.4% (One in 12) % of 65+ care home residents admitted

39% Of all Bristol’s 65+ falls admissions are from 7,082 beds

Falls by accommodation type

Residential on average smaller than nursing homes (33 beds vs 57 beds)

Older building / conversions Risk = hazard x exposure

Variation of falls admission rates (residential and nursing homes) by home

Of 15 with sig higher than city av ad rates, 12 are residential homes

Variation by type (Nursing Homes)

Variation by type (Residential care)

Dementia

4 year admission rate CHwNursing

= 6.7%

4 year average rate residential care =12.2%

Average admission rate from homes for people with dementia

=15.7%

4. Joint service specificationFalls risk managementThe Provider ensures that Service Users are assessed for risk of falls within 24 hours of admission and the outcome recorded in their Care and Support Plan. Those Service Users who are vulnerable to falls are actively supported by their key worker or equivalent member of care / nursing staff to reduce / prevent the risk of a fall occurring and thereby supporting a reduction in unnecessary emergency admissions related to falls.

The Provider maintains a falls register recording such information as the causes of fall (injurious or otherwise) and this register is regularly audited to ensure that necessary actions are taken to reduce falls within the home.

Medicines managementReducing polypharmacy and proactively seeking 6-monthly medicines reviews by GP.

Hydration/nutritionProvides access to training on the identification of dehydration.

General Users registered with General Practitioner within 7 days of admission.Initial Care and Support Plan drawn up on the first day of admission.

Person centred care (and reviews)Care and Support plans are kept and maintained It is likely that meeting outcomes will require addressing falls risk factors

Wellbeing needs Support to attend appointments

4. Joint service specification

FootcareEnsure footcare needs are assessed by an appropriately trained person (podiatrist where appropriate)

Moving onService Users are involved in assessing risk for them or others if they move.

Management and leadership…effective leadership…

Working with the local communityThe Provider will be knowledgeable of the services available in the local community and where identified in the SDS Support plan / CHC Care plan will ensure the Service User is enabled to access these services.

The environment of the care home (various)

Falls admissions

are indicators

of…

Medicines manageme

nt

Management of health

and wellbeing

Housing type and

client group

Contact with GP

and other services

Record keeping and care planning

Leadership

Summary: Factors affecting variation in falls rates

Housing typeClient group (frailty, co-morbidities)

Relationship with and quality of local services?Staff turnover? (Correlated with decreases in nursing care, Castle and Engberg, 2005).Management practices?

FALLS PROJECT2012

Falls Auditing Falls audits in the care homes had traditionally focused upon the

number of falls per month – was a paper exercise with no visible positive outcomes

Merely looking at the number of falls does not enable you to establish any trend or cause behind the number

Falls audits in their old format were time consuming, duplicated information already held and were of no value to the staff or residents

Staff understanding and ownership of falls management was limited with a perception that ‘falls happen’ and without preventing residents from mobilizing they would continue to fall

Plotting the Location

Plotting the Time

Robinson Falls 2012

0

10

20

30

40

50

60

70

Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec

Month

Num

ber o

f fal

lsNumber of falls – in context

The key to success has been involving the staff as they are the ones who will make the difference on the floor.

Staff really understand the plotting and the concept of days between falls. The information is visual, has an immediate impact and does not have to be computer generated.

Looking at a number of different factors enables you to gather a true picture of what the actual issues are – a number on its own merely provides a snapshot that can be misleading – you may put the wrong corrective or preventative measure in place if you do not have the full information.

Falls happen for a reason and a pattern can almost always be established for those residents who repeatedly fall.

The patterns and trends you uncover can be surprising!Auditing in this way adds real value and makes a positive difference for residents

What have we learnt?

Sandra PayneHead of Clinical ExcellenceBrunelcare

email – sandra.payne@brunelcare.org.ukMob – 0778 6706227

Falls in Bristol’s residential and nursing care

Rob BeningtonInjury Prevention ManagerBristol Public HealthRobert.benington@bristol.gov.uk