Implementing a range of interventions can help cut patient falls and improve safety
In this article
- The impact of falls on patients and the NHS
- Why multifactorial intervention is more successful than single intervention at preventing patient falls
- How to implement a multifactorial falls prevention programme
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Catherine Gibson is assistant risk manager; Laurel Simmons is associate director for quality improvement; both at Stockport Foundation Trust; Georgina Clark is assistant director for clinical governance at Aintree University Hospitals Foundation Trust, and former assistant director of nursing with lead for safety at Stockport Foundation Trust.
Gibson C et al (2011) Adopting a multifactorial approach to falls prevention. Nursing Times; 107: 17, early on-line publication.
Patient falls are the most commonly reported safety incidents in hospitals, leading to injury in around 30% of cases. Using a wide range of interventions to reduce the number of falls has proven to be more effective than single interventions. This article describes how a multifactorial falls prevention programme helped to significantly reduce the number of patient falls at Stockport Foundation Trust.
Keywords: Patient falls, Multifactorial, Collaborative, Prevention
- This article has been double-blind peer reviewed
5 key points
- Falls can have serious consequences for patients, including longer stays in hospital, physical harm, loss of confidence, and reduced independence;
- Multifactorial falls prevention programmes are more effective than single interventions;
- Interventions that can be incorporated into a multifactorial falls prevention programme include safety walk-rounds, medication reviews and environmental changes
- A multi-disciplinary team approach accelerates improvement by enabling testing of multiple interventions simultaneously;
- Trusts should undertake clinical research to understand more about patient risk factors for serious harm from falls. This can help identify unique characteristics which indicate a patient is at higher risk of serious injury should a fall occur
Tackling patient falls is a constant challenge for healthcare organisations (Box 1).
Box 1. Incident of patient falls
- More falls are reported to the National Patient Safety Agency than any other type of patient safety incident;
- Patient falls account for two-fifths of all patient safety incidents in hospitals;
- 1,000 patients a year sustain a fracture as a result of falls in hospitals in England and Wales;
- In an average 800-bed acute hospital trust there will be around 24 falls every week, and over 1,260 falls every year;
- Most falls are reported as causing no or low harm, but some falls result in significant injury and death.
Source: NPSA (2007)
Every year, acute hospitals across England and Wales report around 152,000 patient falls (Patient Safety First, 2009). This costs the NHS around £15 million a year; an average of £92,000 for an 800-bed acute hospital. According to the National Patient Safety Agency, falls also account for two fifths of all patient safety incidents in hospitals (NPSA, 2007).
The causes of patient falls are multifactorial and complex but the factors that appear to be most significant in hospital patients are:
- Walking unsteadily;
- Incontinence or need to use the toilet frequently;
- Previous falls;
- Taking sedatives or sleeping tablets (NPSA, 2007)
Falls can lead to longer stays in hospital, physical harm, loss of confidence, and reduced independence. Many older people are particularly vulnerable to falling because of reduced mobility and/or complex medical conditions.
Stockport Foundation Trust introduced a multifactorial falls prevention programme in November 2009 . This article describes the development, implementation and evaluation of the programme, which won the trust the patient safety award in the 2010 Nursing Times Awards.
Patient falls account for the highest number of reported incidents at Stockport Foundation Trust. Almost 20% of falls in 2009-2010 resulted in some harm, compared with a national rate of 30% (Healey et al, 2008).
Various studies on reducing the number of falls have shown that a single intervention is less effective than multifactorial intervention (Oliver et al 2010; Fonda et al, 2006)
Oliver et al reviewed systematic reviews, recent research and clinical evidence, and concluded that the most appropriate approach to falls prevention in the hospital environment include multi-factorial interventions with multi professional input. There is also some evidence that delirium avoidance programmes reducing sedative and hypnotic medications, in-depth patient education and sustained exercise programmes may reduce falls as single interventions, however, there is no convincing evidence that hip protectors, movement alarms or lo lo beds reduce falls or injury in the hospital setting.
The trust’s multifactorial falls prevention programme included changes to the physical environment, medication reviews, leadership walk-rounds, and falls risk assessments. We also introduced low profiling beds, alarms, and additional training to help reduce the number of falls. The trust had already achieved positive results in reducing the number of repeated falls; the rate of repeat fallers fell from 51% in 2006 to 20% in 2009-2010, but we were keen to build on this success; there was strong support for further improvement from the board of directors and health professionals on the wards.
Falls prevention programme
The trust’s multifactorial falls prevention programme included new equipment, such as low profiling beds and sensor alarms, ward-based training, and a four-ward collaborative improvement project.
The trust reviewed various companies bed/chair sensor alarms, prior to conducting a trial on three wards (two medical and one surgical ward). Evaluations were completed, and the results/feedback from staff were positive. 10 bed alarms and five chair alarms were then purchased and distributed to four medical wards, where usage/feedback was again positive.
In summer 2010, the trust purchased 43 bed and 17 chair alarms for all high-risk wards. The alarms alert staff when a patient is about to get up, providing an early warning system for patients at risk of falling. They are connected to the ward nurse call system, allowing remote monitoring, and can be heard while nurses are working elsewhere on the ward. To support implementation, we produced a standard operating procedure for using the alarms, and a flowchart to help nurses to ensure the right patient receives the right alarm. The trust’s risk department and the company supplying the alarms provided training in using the alarms, which have been well received by staff.
Low profiling beds
We also trialled various low profiling beds, the most successful of which are now rented when required, for example for patients who have a high risk of falls, repeated fallers, or patients who are likely to fall out of bed. A standard operating procedure was developed to assist nursing staff in ensuring patients receive the appropriate bed, and the supplier and and the risk department again provided staff training. The risk department monitors appropriateness of low profiling bed use to ensure costs are controlled and balanced against patient safety.
A specialised falls management and prevention training programme was developed in 2008. This supplements falls education provided at induction and mandatory training and takes place on the wards to minimise the impact on staffing levels. All grades of nursing staff, from students to ward managers, receive training. Topics covered include the correct use of the falls risk assessment tool and care plan, use of equipment, and feedback on specific incidents. Training has also been developed for physiotherapists, occupational therapists and medical staff.
Reducing patient falls collaborative
In 2009, the trust expanded on the programme by launching an improvement programme using a collaborative model. Teams from different disciplines, including physiotherapy, occupational therapy, nursing and medicine, work together towards common goals, sharing lessons learned and testing new ideas. In October 2009, four wards (three medical and one surgical) began a 12-month “reducing patient falls collaborative”. A driver diagram describing the different areas of testing that could help reduce falls was used to direct practice developments (Fig 1). It is important the driver diagram represents the best available evidence, but also that each team has the opportunity to test and adapt each initiative to their area.
At the first project meeting, teams from each ward reviewed the driver diagram, discussed challenges and successes in preventing falls, and agreed which improvements they wanted to test first.
The groups were introduced to PDSA cycles - plan, do, study, act. This is an improvement method which allows front line staff to test changes quickly and with low risk, and feedback to the larger group. This gave staff ownership in designing solutions.
An improvement goal of reducing harm from patient falls was agreed, and activity planned to achieve it. Throughout the 12-month project, a support team met with the wards regularly to provide guidance and mentorship on gathering results, and coach staff on taking the next steps and overcoming obstacles.
Between November 2009 and May 2010 the four wards involved in the collaborative project achieved a 33% reduction in patient falls (Fig 2). Most of the changes came from dramatic improvements on one ward, where the number of patient falls fell from 25 in November 2009 to just three in March 2010. There was an increase in falls on this ward in April 2010, but this was due to re-configuration of the ward to include acute patients, and changes in staffing. All wards involved in the collaborative project showed some reduction in the number of falls, but the number of falls reported trust-wide did not decline significantly during the project period. The trust therefore developed an action plan to spread successful changes from the four pilot wards, and share best practice across the trust.
Changes to practice
The collaborative project to reduce patient falls resulted in a number of changes to practice at the trust, including safety walk-rounds, medication reviews and environmental changes.
Leadership support is vital if improvements are to be successful so the senior nursing team and trust executive directors conduct safety walk-rounds every month. These are used to check in with teams, address barriers, and provide support where necessary. The number of patient falls, and any harm resulting from falls, is reported to the trust board every month.
A consultant geriatrician developed and tested on the collaborative wards, an enhanced medication review and pharmacy staff developed a list of medications that could increase the risk of falls. The list was added to the trust’s existing medication review process to help reduce unnecessary administration of medications. This was well received by pharmacy and ward staff and resulted in many unnecessary medications being stopped.
The four collaborative wards worked together to improve staff information relating to falls, which included:
- Creating standard use of ward notice boards containing specific ward falls information/statistics, and in line with the Productive Ward “Knowing How We are” Module;
- Increasing patient observation for high risk patients;
- Changes to ward environments, such as bathrooms;
- Increasing toileting regimes for high risk patients. Staff were educated through training regarding the number of patients falling on the way to the bathroom/toilet, and this has also been included on the Falls Risk Assessment/Care Plan;
- Improving communication with families to gain a detailed history of patients.
Not all the changes tested were ultimately included in the programme. For example, one ward provided socks with rubber treads for patients to wear at night, with the aim of protecting those who may wake up and forget to put on slippers. Physiotherapists tested patients’ gait when wearing either slippers or the socks, and while the socks had no adverse effect on gait, they were found to roll during the night leaving the sole of the foot unprotected, and were therefore abandoned. We are currently working with Age UK (Stockport) regarding a “Slipper Project” , which will include full footwear assessment and providing of footwear for use both in the hospital during their stay, and back in the Community.
The collaborative project initiated a number of changes to the physical environment. Falls risk assessment information and data was standardised for patient information boards, and ward staff met with estates to plan small renovations that they believed would reduce the likelihood of and harm from falls. For example, staff identified the location of toilet roll holders as a concern because patients had to bend awkwardly to reach them, increasing their risk of falling.
The reducing falls collaborative has confirmed to us that falls reduction requires a multifactorial approach. Introducing state-of-the-art equipment and improving staff training is not enough to reduce falls. However, when combined with medication reviews, leadership engagement, improvements in staff information and changes in the physical environment, it can make a difference to patients. We are currently spreading these changes across the trust so that patient care can be enhanced. A joint Falls Collaborative between the Trust and Community has also commenced in April 2011, as part of the Safety Express Project – Reducing Harm. We are also looking at further areas of work to complement the initial changes, such as addressing patients’ eyesight, lying and standing blood pressure, and continence.
The trust also plans to undertake clinical research to understand more about the factors that put patients at risk of serious harm from falls. The aim is to identify unique patient characteristics that indicate a patient is at higher risk of serious injury should a fall occur. We continually strive to improve patient safety and patient experience, and by implementing a multifactorial falls prevention programme we hope to make a positive difference for every patient.
Fonda D et al (2006) Reducing serious falls-related injuries in hospital Medical Journal of Australia; 184: 379-382.
Healey F et al (2008) Falls in English and Welsh Hospitals. Results of national observational study based on retrospective analysis of 12 months’ incident reporting. Quality and Safety in Healthcare; 17: 6, 424–430.
National Patient Safety Agency (2007) Slips, Trips and Falls in Hospital. The third report from the Patient Safety Observatory. London: NPSA.
Oliver D et al (2010) Preventing Falls and Fall-Related Injuries in Hospitals. Clinics in Geriatric Medicine; 26: 4, 645-692.
Patient Safety First (2009) The ’How to’ Guide for Reducing Harm from Falls. Version 1. London: Patient Safety First.