falls prevention in palliative care
TRANSCRIPT
Falls Prevention in Palliative Care:Introducing the Avoiding Falls Level of Observation Assessment Tool (AFLOAT)
8th November 2019
Dr David A. Richardson, Consultant Geriatrician, Clinical Falls Lead
1. Background
Falls Prevention in Palliative CareBackground
• “Despite patient and family education aimed at safety promotion and fall prevention, fall incidents continue to occur and are the number one cause of injuries and hospitalizations among the palliative patient population.
• In palliative care patients, many of whom are elderly, the risk for falls is further increased by the patients’ multiple and often complex and debilitating disease processes.
• Side effects of multiple medications, dementia and other mental acuity altering conditions are also major factors associated with and contribute to the falls experienced by palliative patients.
• Head injuries and hip fractures suffered from a fall further increase health complications, hastening of death and increased distress for the already suffering patients and their families.
• Furthermore, in-patient care costs associated with fall-related injuries are devastatingly high, even for the injuries not categorized as life threatening”.
Pavlov, Katrina G., "Fall Prevention in Palliative Care: Improving Fall Prevention and Management at Point of Admission" (2017).Master's Projects and Capstones. 678.https://repository.usfca.edu/capstone/678
Falls and Palliative Care Patients - the importance of chronic diseases• Yorkshire Cancer Network survey of falls in palliative care inpatient settings.
We found that the incidence of falls in this context was 5.7 falls per occupied bed per year, noticeably higher than the incidence in nursing homes or in the community.
• This may reflect the patient population who are often elderlywith other coexisting pathologies.
• Our study identified cognitive impairment and low systolic blood pressure as the most important independent predictors of falls in this context.
• However, we did not find any association between falls and various medication groups such as opioid analgesics as Lovell et al demonstrated.
• In common with Lovell, we did not find an association betweenpostural hypotension and falls, despite our assumption that this would bea frequent association.
• Persistent low systolic blood pressure, while known to be a factor in cognitive impairment, is also seen more commonly in people with progressive disease.
• In palliative care patients, hypotension and cognitive impairment probably reflect failing physical systems and more strongly influence falling than medicines.
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7426.1288-a (Published 27 November 2003) Cite this as: BMJ 2003;327:1288
Falls Prevention in Palliative CareBackground: Hospice studies 2004
• Calculated fall rates in three hospices in the Yorkshire region, identified risk factors for falls based on previous studies in elderly patients, and then carried out a prospective study of inpatients in two of these hospices.
• Compared these risk factors in patients who subsequently fell with patients that did not fall during the study period. Information was recorded on 102 admissions.
• 12 patients fell, generating 23 falls; 6 patients fell more than once.
• Significant risk factors for falling were cognitive impairment, low systolic lying and standing blood pressure, visual impairment and age over 80. Males with these risk factors fell more often than female patients with these risk factors.
• Strategies to prevent falls in hospice inpatients need to be directed appropriately towards patients with cognitive and visual impairment and low systolic blood pressure.
Falls in hospice - a cancer network observational study of fall rates and risk factors. / Bennett, M. I.; Nicholson, L.; Pearse, H.In: Palliative Medicine, Vol. 18, No. 5, 01.07.2004, p. 478-481.
Falls Prevention in Palliative CareBackground: Hospice studies 2004
• Falls prevention is a critical priority in hospice and palliative care settings. To keep patients safe and comply with national standards, hospice professionals must have available appropriate assessment, prevention, and intervention tools.
• Existing procedures engaging patients in strengthening exercises and reducing or eliminating medications that cause dizziness, imbalance and confusion are fitting and useful in environments where first-line fall reduction efforts are possible.
• These current tools are based on research in facilities for non-hospice patients and run counter to the goals of palliative care.
• By definition, hospice patients have a terminal illness and are, or will become, too weak to manage strengthening exercises.
• Without their medications, many would experience intolerable pain and unmanageable anxiety and depression.
• This article proposes assessment guidelines and pragmatic interventions to reduce the risk of falling that are consistent with the hospice philosophy of comfort.
Falls Prevention in Palliative CareBackground: Hospice articles 2007
Jullie Gray. Protecting Hospice Patients: A New Look at Falls Prevention. First Published June 1, 2007 Research Article https://doi.org/10.1177/1049909106298721
• In their effort to identify the best fall prevention measures suited for the palliative patient population, Morgan, Cerdor, Brown, and Currow, (2015) bring up a study done on 100 palliative patients, out of which 32% had at least one recorded fall incident, however, only 4% of the study patients had falls risks identified in their routine risk assessment.
• The authors proceed to ask why only 4% had an identified falls risks, yet 32% experienced falls, why where these risks not detected in the other patients?
• In conclusion the authors say that the most effective falls intervention strategies include a combination of systematic risk screening tools regardless of the population base.
• The screening tools should include medication reviews, and follow-up on identified risks.
Falls Prevention in Palliative CareBackground: Hospice studies 2015
Deidre D. Morgan, Pauline A. Cerdor, Annabel Brown, and David C. Currow. Journal of Palliative Medicine, 2015, 18 (10), pp. 827 - 828 Issue Date: 2015-01-01
• Based on the latest guidance from National Institute of Clinical Excellence they developed:
1) a falls risk-assessment tool;
2) a care plan for falls prevention and management and
3) ten quality standards
• A practice focused approach was used to engage staff in the importance of the guidance and the use of the tools pre and post implementation.
• The tools were integrated into the e-Health recording system (Crosscare) and compliance with the standards were audited one year after implementation (February 2015).
Falls Prevention in Palliative CareBackground: Hospice studies 2015
Falls Prevention in Palliative CareBackground: Fall Prevention Booklets
Hospice launches a national toolkit to help prevent patient falls
• Other hospices across the country can benefit from the experience and expertise of a senior member of staff at Earl Mountbatten Hospice with this latest guide on other on managing and preventing falls among their patients.
• Becky McGregor, the hospice’s Head of Clinical Quality and Patient Experience, is a member of the National Quality Advisory Group of Hospice UK, an umbrella organisation which supports the work of more than 200 members including Earl Mountbatten Hospice.
National and international standards
• The original guidance had been published in 2010, and the aim of refreshing the advice has been to make sure it is consistent with national and international standards, relevant in all areas of hospice care (including at home and in care homes), and as user friendly as possible.
• The toolkit can be adapted and used to support each individual patient and includes links to national guidance.
https://onthewight.com/hospice-launches-a-national-toolkit-to-help-prevent-patient-falls/
Falls Prevention in Palliative CareBackground: Hospice National Falls Tool Kit 2016
3rd August 20161st May 2013
Falls Prevention in Palliative CareBackground: National standards NICE CG 161 2013
1.1 Preventing falls in older people1.1.1 Case/risk identification 1.1.1.1 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. [2004]1.1.1.2 Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance. (Tests of balance and gait commonly used in the UK are detailed in section 3.3 of the full guideline.) [2004]
1.1.2 Multifactorial falls risk assessment 1.1.2.1 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. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention. [2004]1.1.2.2 Multifactorial assessment may include the following:
identification of falls history assessment of gait, balance and mobility, and muscle weakness assessment of osteoporosis risk assessment of the older person's perceived functional ability and fear relating to falling assessment of visual impairment assessment of cognitive impairment and neurological examination assessment of urinary incontinence assessment of home hazardscardiovascular examination and medication review. [2004]
1.1.3 Multifactorial interventions 1.1.3.1 All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention. [2004]
NICE Quality Statements
1. Older people are asked about falls when they have routine assessments and reviews with health and social care practitioners, and if they present at hospital.[new 2017]
2. Older people at risk of falling are offered a multifactorial falls risk assessment. [new 2017]
3. Older people assessed as being at increased risk of falling have an individualised multifactorial intervention.[new 2017]
4. Older people who fall during a hospital stay are checked for signs or symptoms of fracture and potential for spinal injury before they are moved.[2015]
5. Older people who fall during a hospital stay and have signs or symptoms of fracture or potential for spinal injury are moved using safe manual handling methods.[2015]
6. Older people who fall during a hospital stay have a medical examination.[2015]
7. Older people who present for medical attention because of a fall have a multifactorial falls risk assessment.[2015]
8. Older people living in the community who have a known history of recurrent falls are referred for strength and balance training.[2015]
9. Older people who are admitted to hospital after having a fall are offered a home hazard assessment and safety interventions.[2015]
Falls Prevention in Palliative CareBackground: National standards NICE Falls QS86 2017
Falls Prevention in Palliative CareBackground: National standards NICE CCG7 2019
2. Fall prevention
NHFCT
Falls Prevention in Palliative Care:So what to do ….. ward/department level
Palliative Care Unit WGH
Palliative Care Unit NTGH
• Back to basics on admission• Falls history (identify High risk
groups in A&E, “falling star” logo, Falls care plan)
• Mobility / ADL assessment
• Vision / hearing problems
• Continence
• Footwear
• Cognition
• Agreed alert system to call for help
• Patient placement within ward
• Medication review (e.g. avoid hypnotics/sedatives)
Falls Prevention in Palliative Care:So what to do ….. ward/department level
X
Medication Class Examples Fall Mechanism
Benzodiazepines
***
Diazepam
Lorazepam
Cognitive impairment, confusion,
dizziness, sedation, drowsiness
Motility agents Metoclopramide Gait abnormalities, extrapyramidal
reactions
Neuroleptics
***
Haloperidol Gait abnormalities, extrapyramidal
reactions, dizziness, sedation,
drowsiness, agitation, balance
problems, visual disturbances
Opioids Morphine
Oxycodone
Cognitive impairment, dizziness,
Falls Prevention in Palliative Care:Culprit medication
Medication Class Examples Fall Mechanism
Anticholinergic Agents
***
Hyoscyamine
Diphenydramine
Amitryptiline
Cognitive impairment, confusion,
visual disturbances
Anticonvulsants Gabapentin Cognitive impairment, confusion,
blurred vision, gait abnormalities
Antihypertensives *
• Beta–blockers
• Calcium channel blockers
• ACE inhibitors
• ARB agents
• Nitrates
• Alpha1 antagonists
• Diuretics **
Metoprolol
Verapamil
Lisinopril
Irbesartan
Nitroglycerin
Doxazosin
Furosemide
Orthostatic hypotension,
dizziness, syncope
**Increased ambulation with diuretics due to need to use the
bathroom!!
Falls Prevention in Palliative Care:Culprit medication
Medication Class Examples Fall Mechanism
Antidepressants Agents
***
• Tricyclics
• Tetracyclics
• Monoamine Oxidase Inhibitors
• SSRI’s
• SNRI’s
Amitryptiline
Mirtazepine
Phenelzine
Citalopram
Venlafaxine
Cognitive impairment, confusion,
visual disturbances,
postural hypotension
Stimulants Caffeine
Methylphenidate
Agitation
Use of multiple medications ***
Falls Prevention in Palliative Care:Culprit medication
• Habits and patterns of routine care• Avoid night transfers
• Routines to meet individual toileting needs (intentional rounding)
• Handover of needs, risks and plan of care (SBAR)
• Family involvement
• Appropriate discharge information
• Training and skills
Falls Prevention in Palliative Care:So what to do ….. ward/department level
• High risk groups “Fast track to safety”• Focus on modifiable risks
• Escalate medical and medication review
• MSU and L&S BP
• Physiotherapy / OT review
• Cohort nursing
• Specialist equipment (e.g. high-low beds, glide sheets, etc.)
• Osteoporosis considered / treated
Falls Prevention in Palliative Care:So what to do ….. ward/department level
Falls Prevention in Palliative Care:NHFCT FallSafe Care Bundle Compliance Audit October 2018 of 38 wards
0 10 20 30 40 50 60 70 80 90 100
Call Bell in reach
Safe Footwear
Walking aid in reach
Lying and standing BP
Vision
Cognition
Routine Urinalysis
History of falls documented
Fear of falling documented
Bed rail assessment documented
No new night sedation prescribed
Medication review
Bone health assessed
Falls care plan in place
Annual snapshot data (Oct & Nov 18)
• Environment and technologies• Accessible toilets / commodes
• Range of chairs / beds Lighting and light gradients
• Monitoring / visibility of bed areas
• Call bells accessible and visible
• Trip hazards and clutter removed
• Specialist equipment available (e.g. high-low beds, slippers, etc.)
• Temporary hazards have warning signs
33% bed stock are single rooms
13% beds visible from nursing station
Falls Prevention in Palliative Care:So what to do ….. ward/department level
• After a fall• Post in-patient fall pathway, “Simple
Fall? Think Trauma”
• Checks for injury and observations (NEWS)
• Checks for new or deteriorating illness precipitating fall
• Reported and all MDT aware
• Repeat medical and medication review
• Review patient environment and sensory / mobility / cognitive deficits
• Review pattern if repeat falls (refer to Falls Nurses*)
• “Medical Report Following a Fall” sticker compliance audited by Falls Nurses
• 6 monthly report of common themes found in falls related SIs
Falls Prevention in Palliative Care:So what to do……learning from in-patient falls
* Consider Community Falls team if within the Hospice setting
Falls Prevention in Palliative Care:NHFCT FASS specialist nurse post fall reviews
0
100
200
300
400
500
600
700
Apr 2017 -Jun 2017
Jul 2017 -Sep 2017
Oct 2017 -Dec 2017
Jan 2018 -Mar 2018
Apr 2018 -Jun 2018
Jul 2018 -Sep 2018
Oct 2018 -Dec 2018
Jan 2019 -Mar 2019
Apr 2019 -Jun 2019
Number of Falls
Number of FASS Reviews
3. AFLOAT and Bay
Watch
Falls Prevention in Palliative Care:NHFCT Supportive Observation Policy
Rolled out January 2017
In response toSI reports whichshowed patients did not alwaysreceive an adequatelevel of observation
Describes 4 levelsof observation
Falls Prevention in Palliative Care:NHFCT Task and Finish Group
Task and finish group set up to look at
• Current falls observation policy
• Current psychological observation policy
• Any overlap between the 2 groups (baseline audit)
• Variation in setting level of observation
• Staff engagement
• Find a tool to support staff in setting observations
• Join NHSI Falls Collaborative 2018
Falls Prevention in Palliative Care:NHFCT Enhanced Care Support Baseline Audit April 2018
Key findings for patients on Level 3 and 4 observations
82% had delirium OR dementia
37% had delirium AND dementia
Lack of standardised assessment tool for delirium or dementia
Tools poorly understood
89% of patients had FASS specialist nurse review
54% of patients had MHSOP specialist nurse review
Little evidence of therapeutic interventions
Service users and advocates keen to see PINCHME and therapeuticinterventions used
Variation in nurses setting the level of observation
Falls Prevention in Palliative Care:Enhanced Care Support Baseline Audit April 2018
Key recommendations
Ensure observation levels are being set correctly by ward staff
The Trust should review the number of cognitive assessments currently in use and attempt to standardise approach
Review the possibility of incorporating the cognitive assessments digitally into Nerve Centre
Stimulate discussion of joint working between Falls Group and Dementia Steering Group
Joint working from both groups to feed into Frailty Board
Stimulate discussion of moving from an “Observational” to “Enhanced Care Support” model
Falls Prevention in Palliative Care:NHSI Falls Collaborative pilot project 2018
What do patients who need supportive observation “look like”?
• The Avoiding Falls Level of Observation Assessment Tool (AFLOAT) recognised these clinical presentations and used a scoring system
Unsteady
Confused
Falls at home
Urinary or faecal urgency
Falls in hospital
Orthostatic hypotension
Falls Prevention in Palliative Care:AFLOAT
Falls Prevention in Palliative Care:AFLOAT PDSA findings
• Seven PDSA cycles undertaken - Final pilot results
• Implication being safety and better use of scarce resource
Falls Prevention in Palliative Care:Add Bay Watch to AFLOAT
• We have scaled up and adapted into Trust policy
• Now have trust wide roll out
• All patients are assessed using AFLOAT to set correct level of observation
• Bay Watch initiative
used to carry out the
observations
• We have demonstrated that higher levels of observation can be effective in reducing falls
Falls Prevention in Palliative Care:Bay Watch and AFLOAT launched at our Nursing Conference
Falls Prevention in Palliative Care:Local and national recognition of AFLOAT
Falls Prevention in Palliative Care:NHFCT Falls per 1000 bed days timeline
1. RMP 37a specific policy for in patient falls Nov 2015
2. RCP Fall Safe care bundle cohort of 10 wards May 2016
3. RMP 60 Supportive Observation Policy Jan 2017
4. Change to falls team leadership structure June 2017
5. Roll out of Fall Safe trust wide via Datix and digital falls care plan Mar 2018
6. NHSI Falls Collaborative May 2018
7. AFLOAT and Bay Watch Dec 2018
1 432 5 6 7
Falls Prevention in Palliative Care:NHFCT Hip fracture reduction
• Represents a significant reduction in human suffering• Potential savings of £3.6m due to falls reduction from
2016-17 in last 2 years * based on NHSI Incidence and cost of in-patient falls in hospital 2017
• Reduction partially due to observation policy• BUT still seeing cases in Datix, RCA and SI reports where patients had
not received the correct level of observation
0
10
20
30
40
50
2012-2013 2013-2014 2014-2015 2015-2016 2016-2017 2017-2018 2018-2019
Number of In-Patient Hip Fractures
31 6 74 52
1. RMP 37a specific policy for in patient falls Nov 20152. RCP Fall Safe care bundle cohort of 10 wards May 20163. RMP 60 Supportive Observation Policy Jan 20174. Change to falls team leadership structure June 20175. Roll out of Fall Safe trust wide via Datix and digital falls care plan Mar 20186. NHSI Falls Collaborative May 20187. AFLOAT and Bay Watch Dec 2018
4. What next?
• We can now set the correct level of observation
• Now need to move from model of “Observation” to therapeutic interventions and “Enhanced Care Support”
• Provide better dementia and delirium care which are drivers of patients requiring high levels of observation (e.g. PINCHME: Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment)
Falls Prevention in Palliative Care:NHFCT plan for next 12 months
Falls Prevention in Palliative Care:NHFCT plan for next 12 months
• Joint working between Dementia Steering Group and Falls Steering Group
• How do we operationalise therapeutic interventions from within the current resource?
• What are the therapeutic interventions?
• Knowledge sharing FASS and MHSOP nurses
• Patient and carer involvement
Falls Prevention in Palliative Care:Radical thought………….
• May turn out that the care costs of implementing falls observation policy are in part, actually the unmet care costs of providing safe care to frail older people in hospital/hospice who have cognitive impairment
Falls Prevention in Palliative Care:Summary
• Older people should be routinely asked about falls
• Older people should have a multifactorial assessment and an individualised intervention (including a medication review, lying/standing blood pressure and mobility assessment)
• Providing supportive observations and post-fall reviews saves money and misery
• AFLOAT helps to set the correct level of observation and ensures best use of resource
• Those who receive L3/4 observations have cognitive impairment
Falls Prevention in Palliative Care:Summary
• If you switch from “observing” to “intervening”, you may reduce the number of days that people need high levels of observation by better management of cognitive impairment (e.g. PINCHME)
• Decrease falls and fractures
• Decreased costs
• Overall provide better care for the older patient and especially the cognitively impaired in palliative care
Questions?