VOL: 103, ISSUE: 41, PAGE NO: 30-31
Christine Pigford, RGN, DipN, BA, is falls coordinator, Sunderland Teaching PCT
This article describes the development of an integrated falls strategy within Sunderland Teaching Primary Care Trust.
Abstract Pigford, C. (2007) Developing an integrated falls strategy. www.nursingtimes.net
This article describes the development of an integrated falls strategy within Sunderland Teaching Primary Care Trust. It outlines the setting up of a group to implement the recommendations of the National Service Framework for Older People on falls, and also describes the use of two risk-assessment tools.
Falls among older people are a large and increasing cause of injury, treatment costs and death; in many cases these falls occur in the home environment and are preventable. The consequences of injuries sustained in older age are more severe than among younger people: for injuries of the same severity, older people experience more disability, longer hospital stays, extended periods of rehabilitation, a higher risk of subsequent dependency and a higher risk of dying (WHO, 2002).
Comprehensive risk assessment and multi-agency intervention represent the most effective strategy to identify those at risk and initiate multi-faceted management strategies to reduce the incidence and impact of falls for older people (NICE, 2004).
Sunderland Teaching Primary Care Trust covers a population of approximately 300,000 with 54 GP practices, one acute hospital with approximately 900 inpatient beds, and two primary care centres. The falls strategy therefore provides a community-wide, population approach and encompasses a specialist falls service within which specialist multi-disciplinary and multi-agency services target older people at high risk of falling (American Geriatrics Society et al, 2001). There was extensive collaboration among all relevant local agencies to support its development and implementation.
The National Service Framework for Older People (DH, 2001) is the key vehicle for ensuring the needs of older people are at the heart of health and social services. It provides an agenda to work in collaboration to specifically tackle falls prevention and promote active lives for older people.
Standard 6 of the NSF on falls requires healthcare providers to work in partnership with councils to prevent falls and reduce resultant fractures or other injuries in older people. It states that those who do fall must receive effective treatment and rehabilitation and, with their carers, receive advice on prevention through a specialist falls service.
A group with representatives from adult services, the independent sector, intermediate care services, City Hospitals Sunderland NHS Foundation Trust, Age Concern Sunderland, North East Ambulance Service and the Sunderland Carers’ Centre was established to look at how these objectives could be achieved. The overall aim was not only to meet the NSF requirements but also to achieve the strategic objectives identified within the Sunderland falls strategy. These were to:
- Empower patients and carers in falls prevention, service access and involvement in continued service development;
- Develop the community infrastructure through the coordinated implementation of community-based programmes to prevent falls;
- Identify older people at risk before they fall, in addition to providing appropriate assessment and treatment for those who have sustained a fall;
- Achieve a coordinated, multi-agency approach to falls prevention in all settings with strong community involvement;
- Reduce the number of falls in older people in the residential care, nursing home, community and home settings.
Although services had been developed to support patients across the organisational boundaries between secondary and primary care, the actual care pathway was fragmented. It also became apparent that staff were unsure how to risk assess patients holistically and consequently about where to refer them for further assessment and treatment.
There was a general lack of awareness of the various services available to support those either at risk of a fall or who had actually sustained a fall. Major training gaps were identified across the city, especially in residential care, nursing home and community care settings.
The group felt that the appointment of a falls coordinator with a designated delivery plan would be the first stage in pulling the work together to make it user-friendly for those in community and acute care. An appointment was made in December 2006. The overall aim was to reduce emergency admissions and re-admissions of people aged 65 and over due to falls. The delivery plan included specific objectives such as:
- Review the use of risk assessment tools;
- Disseminate falls risk assessment tools across all agencies involved in the delivery of care to older people at risk of falling;
- Provide training to ensure the development of appropriate skills and competencies in accordance with NICE guidance;
- Update marketing and publicity materials;
- Develop and consolidate a falls register;
- Develop an integrated falls pathway.
In partnership with the NSF standard 6 group, work began to coordinate the foundations of this plan.
There was a need to ensure patients were assessed in a consistent and coordinated manner. Regardless of where they presented within the pathway, the same documentation should be used to ensure a systematic assessment which would follow the patient throughout their journey.
Although much debate centres on the use of risk assessment tools, it was decided that we needed a standardised framework that would allow staff to assess patients in a consistent manner (Lord et al, 2000). In order to achieve this, two tools were developed.
The first tool is the Sunderland trigger tool (STT; Fig 1), which is used to identify patients at risk of or as a result of a fall. This was based on the ‘Cryer tool’ (PACE, 2006) and adapted to meet local needs. It asks professionals to answer seven questions to identify whether the patient requires a more comprehensive assessment.
The STT was implemented with professional groups who come into contact with patients for a brief episode of care and therefore do not have the time to perform a comprehensive risk assessment of patient need but are able to identify those at risk and refer them appropriately. Previously patients were not identified and consequently never received the assessment they required, which could have prevented a fall.
This tool allows many healthcare professionals to become actively involved in falls prevention and management, even if they do not manage a clinical caseload. These include A&E staff, ambulance crews, the 24/7 team and urgent care teams. Further training has led to other groups using the STT such as staff in the care alarm and telecare service, home help staff and practice nurses.
Information gained from the STT is sent to the falls coordinator. If it indicates three or more positive indicators, the patient is offered a falls assessment at a day unit. This service filled a gap within the care pathway, as patients are now identified as being at risk and referred appropriately for an assessment.
This is a nurse-led service whereby patients are given a comprehensive assessment that involves:
- Holistic assessment of the patient;
- Collection of routine bloods;
- Completion of an ECG;
- Lying and standing BP;
- Baseline weight;
- Full risk assessment;
- Moving and handling assessment;
- Nutritional assessment (if the patient’s diet gives cause for concern);
- Pressure ulcer assessment;
- Functional assessment.
Depending on the findings this assessment could lead to a rehabilitation exercise programme, education and/or specialist referral such as medication review, occupational therapy, social services, handyman service, optician, referral to the hospital’s falls clinic, community matron and specialist physiotherapy.
The patient’s GP is also informed by letter of the assessment and subsequent referral. The engagement with primary care is vital to ensure all professionals are kept informed. Since the launch of this work the number of patients assessed has steadily increased (Table 1). This increase suggests many patients may previously have slipped through the net.
Table 1. Number of falls assessments
The falls coordinator writes to patients who have fewer than three risk factors with advice on falls prevention andontact details in case the patient wishes to speak to anyone further.
Sunderlandfalls risk assessment tool
This tool provides a more comprehensive assessment and allows patients to receive holistic risk assessments (Fig 2). It was developed by the standard 6 group following a review of the risk assessment tools already available (PACE, 2006), to be used by those professionals who manage a caseload, such as community matrons, district nurses, inpatient staff and nursing home staff.
Following assessment a risk score is attributed. Previously staff had not been given appropriate information on how to manage at-risk patients, so guidance notes were developed to help them initiate appropriate management/ referral (American Geriatrics Society, 2001).
The guidance identifies actions for patients living in their own homes or residential/nursing homes, those in hospital and those in mental health settings. It offers specific actions for referral and stresses the need to implement some actions whether the patient is at low or high risk. It was piloted in two clinical areas – intermediate care and mental health services – to ensure clinical credibility. The guidance was then ratified through the NSF standard 6 group and the older persons action group.
Sunderlandfalls resource packs
In order to identify a consistent approach to falls management, a resource pack was developed containing the risk assessment tools and guidance notes and a policy outlining how all the services link together. The pack was distributed to 54 GP practices, 67 residential and nursing homes, and all relevant agenciies such as adult services, intermediate care, community matrons,the ambulance service and the hospital.
The pack also includes a falls directory of all the services across the city that provide a falls service or support for patients who may be at risk of a fall or who have sustained a fall. It outlines the referral criteria for each service, important contact details, aims of the service and the specific care provided.
This means all staff can risk assess patients, use the guidance notes to initiate a management strategy and implement referrals using the falls directory.
In order to meet NSF requirements, we needed to establish a falls register to record the number of falls across the city. Previously information was received from the care alarm and telecare service, ambulance service and the hospital, but this information did not provide exact details on demographics, type of fall sustained, risk assessment performed or referral to other services. In order to capture this information, a database package was purchased to establish a fully operational falls register.
Information is to be submitted by the various groups identified by the risk assessment tools. Staff will return either the STT or the Sunderland falls risk assessment tool to the falls coordinator and the information will be placed on the register. This will allow us to recognise trends and to identify people with repeat falls and referral pathways. This has been now completed and is just awaiting access once contractual agreement is obtained.
A number of training gaps were identified and as a result monthly training sessions have been held at Sunderland Teaching PCT since March 2007 (Table 2), while in-house training is also offered in different settings (Table 3).
Table 2. Attendance at training sessions
|Month||No. of staff|
|May||13 (care home staff only)|
|July||10 (care home staff only)|
|Organisation/staff group||No. of staff|
|Community alarm and telecare||19|
|Age Concern discharge coordinators||4|
|Community matrons (induction)||6|
|Hetton Home Care Services||80|
|St Benedict’s Hospice staff||16|
|Maple Lodge Nursing Home||13|
|Pavillion Care Centre||5|
|Sunderland Carers’ Centre||7|
|Moor House Residential Home||17|
|Physical disabilities unit||16|
|Marquis Court Nursing Home||15|
|Elizabeth Flemming Care Centre||3|
|Southern Cross Training||18|
Additional training purely for nursing/residential home care staff was also identified and in total 126 have been trained, with further in-house training organised within the individual care homes. Each member of staff who attends the training is given a falls resource pack which outlines everything covered within the training and is fully referenced for further reading. They also receive a certificate of attendance, which can be used to meet professional requirements in accordance with code of conduct guidelines.
User and carer involvement
All falls publicity information has been reviewed across the city and leaflets/posters have been produced to explain the purpose of the falls register, provision of home safety advice, falls prevention booklets and advice on how to get up safely following a fall. Sunderland Age Concern staff have shown the publicity materials to their clients to seek their views on the quality of the information and how effective the materials will be.
They are soon to be published and distributed across the city to raise awareness.
It is only through collaborative working and multidisciplinary involvement that we have achieved an integrated falls service whereby patients are assessed appropriately and referred if they are at risk or have sustained a fall (Gillespie et al, 2003). This supports primary care in meeting its obligations to assess older people at risk of falling. In addition, the strategy contributes to a reduction in fragility fractures and a reduction in emergency admissions/re-admissions, as well as developing potential for practice-based commissioning.
American Geriatrics Society et al (2001) Guidelines for the prevention of falls in older persons. Journal of the American Geriatrics Society; 49: 664–672.
Department of Health (2001) National Service Framework for Older People. London: DH.
Gillespie, L.D. et al (2003) Interventions for preventing falls in elderly people. Cochrane Database of Systematic Reviews; 4: CD000340.
Lord, S.R. et al (2000) Falls in Older People: Risk Factors and Strategies for Prevention. Cambridge: CambridgeUniversity Press.
NICE (2004) Clinical Practice Guideline For The Assessment And Prevention Of Falls In Older People. London: NICE.
PACE (2006) Identification, Assessment and Coding of Fallers. Promoting Action on Clinical Effectiveness: Falls Took Kit. www.learnonline.nhs.uk
World Health Organization (2002) Active Ageing: A Policy Framework. Geneva: WHO.