WELCOME TO THIS SIGN UP TO SAFETY

WEBINAR

Stepping up to the challenge

of falls at Basildon Hospital

All participants lines are muted to reduce background noise

Stepping Up to the challenge of falls

Anne Hendry

Lead Nurse

Osteoporosis & Falls

‘Falling is a symptom’

Functional decline

Medical decline

Social factors

Environment

System failure

What does the data mean?

• Falls per 1,000 bed days

• 5.6 falls/1,000 bed days – NPSA standard 2010

• BTUH evidence

2010/11 2011/12 2012/13 2013/14 2014/15

Falls 6.3 5.1 4.4 5 4.4

Falls per 1,000 bed days (source Quality Report) The figure above is for all patient falls, there is no test for avoidability

Seasonal variation

FallSafe started FallSafe education

cancelled = Black Alert

NB

Nov to Feb = Black / Red alert

4 injurious falls –

severe harm

3 injurious falls –

moderate harm

5 injurious falls

– 4 severe harm

Falls & injury

• Severe Harm

fracture – spine, hip, pelvis, humerus

intra-cranial bleed

• Moderate Harm

other long bone fractures

lacerations that need suturing

Extent of ‘Harm’

Calculate the

percentage of injury

against the total number

of falls per month

Royal College of Physicians National Falls Audit

Their challenges are ours!

• Delirium

• Lying & Standing BP

• Medication Review

FallSafe

• An RCP QI initiative… • evidence-based falls prevention

• assessment and intervention

• multidisciplinary approach

• reduce falls & injury

• improve knowledge & quality care delivery.

Year 2 results

25% reduction in falls

small not significant decrease in injurious falls

Our road to FallSafe?

• Challenges of injurious falls

• Incomplete falls assessments & plans of care

• Poor post falls protocol adherence

• Inadequate multi-disciplinary engagement

• Compromised patient experience

Out of the 1,143 falls in Oct 2012 – Sept 2013

• 20 harmful events

– 2 deaths from subdural haematoma

– 12 hip fractures

– 3 wrist fractures

– 2 shoulder fracture

– 1 tibia fracture

– 1 ankle fracture

The power of patient stories

86-year-old male admitted to AMU

• Chest infection

• Fast atrial fibrillation

• Abbreviated mental test score: 10/10

• No falls assessment or plan completed

20 hours post transfer

• Became unwell with fast atrial fibrillation

• Administered beta blockers

24 hours post transfer

• Unwitnessed fall - suspected fractured neck of femur

• Fracture excluded but monitor neurologically

• No post falls protocol completed

4 hours post fall

• Became unconscious, unresponsive

• 45 minutes later: cardiac arrest

Every hospital has a patient story

Mrs Andrews experience demonstrates a failed care pathway

https://www.youtube.com/watch?v=Fj_9HG_TWEM

How we started

Rise to the pressure

Turn challenges into opportunities

Recruit your supporter

Broaden your horizons

Next steps – need investment

• Agreed a 4 day ‘Foundation’ programme and monthly study days

• Champion recruitment - sell it as a development role too!

• Identify colleagues to help

• Develop relationship with comms

• Invent a branding

• Don’t compromise on quality

This will take time – set realistic timescales

Raising the profile

Champions Foundation Programme

QI v Audit

ward reports

how to gather data

how to use results

FallSafe Champions Contract 2014

• Raise awareness of the FallSafe Care Bundles

• Educate and empower our colleagues, patients and carers

• Improve falls related incident reporting

• Facilitate a multi-disciplinary approach to Falls Risk Management

• Ensure the continuation and development of FallSafe

We will utilise the experience of the last 4 days, to work with our colleagues and clinical teams to create a domino effect of …

Knowledge

Support

and

Practice Improvement

FallSafe Quality Improvement Sessions

AM

• Reflection on the month

• Analysis of the figures

• Knowledge session

• Projects

PM

• Ward QI metric assessment

• Ward based teaching

Engagement – be inventive!

http://www.youtube.com/watch?v=PuVti2TtNS8

Acronym 2014

FallSafe Friday

Monthly QI Falls Assessment

Commitment yields improvement

Championing QI

• Lying & Standing BP / manual pulse

• Local data analysis

• Ward falls communication standard

• Falls on ‘2 @ top’ agenda

• ‘Flash Huddles’

• Message of the week

• FallSafe folders

• Falls as one bundle

• Acronym & film

• Champion team reflection

• Alert to falls injurious risk – slippers and magnets

Knowledge & Engagement

Challenges

• Time

• Activity

• Staff turnover

• Engagement

• Facilitating the team approach

• Sustainability

Where next?

Charter 2015 -16 “Leading the way in falls improvement”

As a team the FallSafe aspirations for this year are to:- Demonstrate falls leadership trust wide and strengthen the visibility of FallSafe Champions. Promote the early identification, assessment and management of falls risk. Reduce harm experienced from falls. Improve the communication of patients falls risk and care planned to reduce risk. Develop strategies to improve multi-disciplinary involvement in falls. Embrace Quality Improvement methodology and identify areas for improvement and implement tests of change.

Sign up to Falls

Put safety first By December 2017 to reduce severe harm from falls, by 50%. 25% reduction in year 1

40% from baseline in year 2

50% by year 3

Continually learn Contribute to the organization’s risk reduction strategy by…

Evaluating outcomes - activity, care delivery and incidents

Implement a falls based competency & education strategy

Novel approach’s to falls alert technology

Partnership working

Honesty Ensure the patients/carers are fully informed by… Involving the patient/carers in risk assessing and planning care for falls

When an incident/injury occurs communicate findings

Collaborate Ensure a successful multi-disciplinary approach to falls… FallSafe multi-disciplinary Care Bundle

Falls Safety Huddles/ Board Rounds

Implement strategies to communicate falls risk

Util ize data to influence corporate and divisional falls improvement plans

Establish patient alert strategies for those at highest risk

Support support clinical care delivery, ensure success is celebrated and when things go wrong we improve…

Demonstrate falls clinical leadership

Ward based leadership and succession planning FallSaf e Champions & FallSafe Buddy team

Implement robust peer review strategies

Deliver falls education in the clinical environment.

Develop an electronic resource to support clinical care

Monthly communiques

In their words…