Eileen Mitchell, MPhil, DipCOT, SROT, PGCAP. Occupational Therapy Advisor, Elderly Mental Health Services, North Dorset Primary Care NHS Trust, and Lecturer in Occupational Therapy, School of Health Professions, University of Southampton.
In 1998 the Dorset Health Authority audit programme identified the prevention of falls in older people as a project to be undertaken by the Dorset Community NHS Trust Clinical Effectiveness Team. The national focus on preventing falls in older people was a major impetus for this project. A specific Health of the Nation (1992) target is to reduce the death rate from accidents in people aged 65 and over by 33% by the year 2005.
Occupational therapists and physiotherapists undoubtedly have a part to play in achieving this target, together with other health and social care personnel involved in the care of older people. The Guidelines for the Collaborative Rehabilitative Management of Elderly People who have Fallen (Simpson et al, 1998), were drawn up and endorsed by three specialist organisations:- Chartered Physiotherapists Working with Older People (AGILE) - Association of Chartered Physiotherapists in the Community (ACPC)- Occupational Therapists working with Elderly People (OCTEP).
The aim of this paper is to show how, by raising awareness, staff can change the way falls risk is assessed. A reduction in falls over a given time can also be illustrated through the audit process.
The project facilitator gathered documentation and undertook a literature search to underpin the work so far before the audit process.
In previous times, falls by older people were accepted as a normal consequence of being unwell and were once considered an ‘accident’ and an unavoidable problem of advancing age or illness. However, over the past two decades there has been prolific research, and falls are now considered events that can be predicted with reasonable certainty and, therefore, prevented (Morse, 1996).
Predicting and preventing falls - The prediction of falls involves many factors, including taking indoor and outdoor environments, seating, footwear and medication into account. Clemson et al (1999) listed 72 hazard categories within the home using the Westmead Home Safety Assessment (WeHSA). The ability to stand from a sitting position, a very essential and basic activity of daily living, is a significant factor when assessing the risk of falls in older people (Chan et al, 1999).
There is evidence that exercises, particularly those with a balance component, reduce falls in older people (Effective Healthcare, 1996). If resulting fractures are to be avoided, clinicians have a duty to inform and design programmes to assist people to manage their own care. Between 1991 and 1992, the care of 56 613 people with hip fractures cost the NHS 288 million in direct costs alone. Without intervention, this figure could rise to 360 million by 2011, with 69 000 cases needing 539 000 extra hospital days a year (Legge, 1998).
Hip protectors, diet and vitamin D may have a role to play in reducing injury from falls. Hip protectors have been evaluated widely in the USA but their acceptability has yet to be established in the UK (Bannigan, 1997).
The Royal Society for the Prevention of Accidents has been working on a package for those who manage and work in residential care homes (Ogden and Hodges, 1998). The society reveals widespread ignorance about the scale of accidents, claiming many people underestimate the number significantly. Only one in 12 people surveyed had any idea of how many non-fatal injuries were treated in hospital and only one in five had any idea how many people died in home accidents.
Risk assessment - The fear of falling should not be underestimated as this can affect a person’s confidence, thus increasing the risk of falls in future.
Staggering on turning is predictive of recurrent falls (Tinetti, 1986). Nevitt et al (1989) report that taking more than five steps to turn 180 degrees increases the relative risk of two or more falls by 1.9. The assessment, identified as the ‘Assessment of Balance and Function: the 180 degree Turn’ (Turn) (Nevitt et al, 1989), is useful since it can be administered in most environments, simply, efficiently and cheaply.
The ‘Timed Unsupported Steady Standing’ (TUSS) assessment (Studenski et al, 1994) also has its merits. The ability to stand unsupported is a prerequisite for the satisfactory performance of many functional activities, while an inability to stand steadily while unsupported is associated with an increased risk of falling. The repeatability and choice of timed end-points for the TUSS has been established (Simpson et al, 1996). Once again, resources required for its implementation are minimal and its simplicity is attractive in a range of environments for a wide range of staff.
Cannard (1996) developed a Falls Risk Assessment Scale for the Elderly (FRASE) following a survey in Ireland. However, this does not take into account the fear of falling again. A more comprehensive assessment, the Tabs Mobility Monitor, developed by WanderGuard (UK), has features designed for use by nurses, requiring the user to monitor blood pressure; however, not all those caring for older patients would be trained to undertake this task.
Physical aids - Alarm monitors may assist care staff to respond quickly when potential risks have been identified.
Confused older people who are unable to comprehend that they need to ask for assistance when mobilising are one target group for consideration. Getting out of bed is considered a high-risk activity. The use of a bed alarm has been evaluated in a small trial and showed a reduction in falls, although this was not statistically significant (Tideiksaar et al, 1993). An evaluation of the use of identification bracelets given to high-risk patients did not reduce falls; in fact, there was an increased rate of falls (Effective Healthcare, 1996).
A range of strategies has been identified to reduce the incidence of falls. These include exercise programmes - now available on prescription locally in Dorset run by Healthworks, the county’s health promotion agency; environmental issues regarding indoor and outdoor hazards; practical physical aids; and risk assessments.
To design an audit tool, the project facilitator met with a team leader who, on a part-time basis, acted as a clinical effectiveness facilitator for the trust. The audit tool was intended to identify how many falls occurred in a total of 15 physical and elderly mental health wards/units within the trust over a three-month period in the summer of 1998. The location of the fall was requested, together with the numbers of patients and staff present at any one time. Any falls-risk assessments used were to be identified, with the risk status of patients recorded as appropriate.
A half-day workshop was run one month later, with invited participants from each of the wards/units involved in the audit. The project facilitator used this workshop as an opportunity to introduce the national guidelines (Simpson et al, 1998) and encourage staff to agree on strategies to reduce the incidence of falls for patients aged over 65 in their care. Concurrent work in a neighbouring trust’s A&E department was highlighted, together with a presentation on the need to record all incidents and near-misses for the trust database.
Small working groups considered various ideas presented to them on the day. These included: falls-risk assessments, running safety groups, alarms/monitors, the TUSS and Turn functional assessments, exercise programmes, the environment and, finally, options for coping with a fall. A consensus was then reached on the way forward. It was agreed that the team leader/clinical effectiveness facilitator would further consider the falls risk assessments shared throughout the day and consolidate them into a format for use in the trust. (Box 1).
Some staff in the North Dorset service use a neurological assessment that provides a more detailed risk of falling (Webster, 1968). However, this is not available to all staff and only a limited number of people are trained in its use. In light of this, the TUSS and Turn assessments were used instead. The assessment document itself went through many stages of metamorphosis, including one project within a local primary care group, which was used as a pilot.
Following the workshop, a further three-month audit was undertaken to ascertain whether any change in practice had occurred. The project facilitator anticipated an initial increase in the recording of falls, since awareness about the risks had been raised.
A subsequent audit took place one year later, over one week, in order to take a snapshot view of the implementation status. During this period, a separate baseline audit was undertaken trust-wide to determine the use of falls alarms and monitors.Figure 1 illustrates this audit process. Table 4 provides part of the falls-risk assessment.
The initial pre- and post-workshop audits identified an increase in falls, as predicted, as a result of the increased awareness post-course. Table 1 illustrates the ratio of staff to patients - averaging 1:4.The risk status and assessments in use are illustrated in Table 2. Owing to the lack of a specific falls-risk assessment tool these are subjective measures only, based on clinical judgement and the general assessment of the patient.
Table 2 demonstrates that there was limited use of risk-assessment tools, with only one additional unit - which was involved in the development of the fall-risk assessment tool - considering a formal assessment post-course.
Risk areas were identified on the initial pre- and post-audit: the main ones, in priority order, were:
- Bed area
- Other areas, which included corridors, gardens and doorways
- Toileting area
- Unknown - found on floor.
One year later, a one-week snapshot view was undertaken (Table 3). This illustrates a small reduction in falls a year after the initial audit. Incidents of falls were recorded in the same areas as before. Ten out of the original 15 wards/units returned the audit tool.
The work undertaken in the Dorset Community Trust over 18 months has begun to demonstrate a small reduction in the number of falls in the units co-operating in the project. Awareness through study days and the use of evidence-based assessment tools has now offered clinicians a means of measuring outcome in a standardised way, so that patients’ records throughout the area will be more meaningful to staff. Before the audit, no specific falls-risk assessments were being used, although manual-handling procedures were followed and used as part of the overall assessment of patients. Access to the falls-risk assessment, via the trust’s Policy Portfolio (updated annually) ensures that the assessment is reviewed appropriately.
The ability to rate risk status, by using the falls-risk assessments, can enable staff to highlight concerns and be more pro-active in recording care plans. This could influence staffing levels in areas where there are greater risks. Staff and patient ratios did not alter during the study period, although this subject is constantly under review. Objective rating of risk was clearly identified, rather than including personal opinions in patients’ records.
Not all clinical areas are fully using the falls-risk assessment, and further work needs to be done, through team education programmes and ongoing audit. All manual-handling trainers now assess all staff as part of the trust core training requirement, thus disseminating all information relevant to staff caring for those at risk of falling. Subsequent audits are likely to show an increase in awareness among staff, plus a higher adherence rate in the use of the falls-risk assessment.
Regular audits are undertaken in order to determine implementation of the policy. The falls-risk assessment is also currently undergoing validation by the authors and the Research and Development Support Unit based at Poole Hospital in Dorset.
Local guidelines have now been made available to all staff working with people over the age of 65 in all clinical areas as a consequence of the work undertaken by the Dorset wide sub-groups (Dorset Healthcare, 2000).
The aims of the audit were to raise staff awareness, establish safer working practices and identify, or develop, a suitable falls-risk assessment for use across clinical professions.
Ongoing audit across West Dorset is helping to establish good practice in all areas caring for older people. With the launch of the National Service Framework for Older People last year (DoH, 2001) there are many milestones to reach, but these initial changes in practice demonstrate how clinicians can be effective in identifying and, ultimately, reducing risk of falling for older people.
Much work has yet to be undertaken in the hope that The Health of the Nation target of reducing the death rate from accidents in older people by 33% will be achieved in under five years’ time.
Tabs Mobility Monitor, WanderGuard (UK) Ltd. Tel: 0500-500 667.Royal Society for the Prevention of Accidents (RoSPA), RoSPA House, Edgbaston Park, 353 Bristol Road, Birmingham B5 7ST. Tel: 0121-248 2000. Website: www.rospa.co.uk
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