In a world of high-tech treatments and fast-moving medical advancements, it is ironic that something as simple as a patient falling over is such a problem for the NHS.
In an average 800-bed acute hospital trust, there will be some 24 falls every week, amounting to over 1,260 a year. The immediate annual cost of treating these is over £15m for England and Wales alone.
More importantly, at best, having a fall makes a huge dent in a patient’s confidence and independence. At worst it can result in serious fractures, litigation and even death. But although the financial and human cost is clear, expert opinion on how to best tackle falls is less clear cut.
Frances Healey, patient safety manager at the NPSA and lead author of Slips, Trips and Falls in Hospital (NPSA, 2007), insists a certain number of falls are necessary to promote rehabilitation and independence.
‘Patient falls are the single biggest reported patient safety incident,’ says Ms Healey. ‘When I was a staff nurse 25 years ago, we had very little rehabilitation and patients wouldn’t be allowed to walk alone. So patients didn’t fall very often because they didn’t walk very often. Many older patients would end up on long-stay geriatric wards with no thought they would ever return home,’ she recalls. ‘It’s not something we want to eradicate completely. The day patients never take a risk is the day they won’t be able to rehabilitate.’
Ms Healey’s NPSA report cites research by Oliver et al (2007) that shows that ‘individually targeted interventions’ could produce an 18% reduction in the number of falls – saving the average acute hospital £16,560 per year. She says that the phrase ‘individually targeted interventions’ is crucial. The report criticised healthcare professionals and an over-reliance on standard risk assessment tools that, it claimed, often over or underestimate risk.
Christine Pigford, falls coordinator at Sunderland PCT, believes that tools are still important, as long as they are adapted to suit the needs of each service or trust.
‘We feel there needs to be a framework. But it has to be practical and workable, and lead nurses and other healthcare professionals need to take action. The Sunderland trigger tool has seven questions. Patients who score three out of seven or more are asked to come into the day unit, given a falls assessment and the GP is informed. If their score is lower than three, they are still given falls prevention advice and a contact phone number.’
But Ms Pigford admits there is a danger of paperwork being reduced to ‘box-ticking’ if staff do not act on their findings: ‘People think “a fall is a fall” but don’t look at the reasons behind it. Often accident forms are filled in but staff don’t do a thorough assessment and initiate management. It is not good enough just writing “Patient fell. Doctor aware. No injuries”.’
She goes on to admit that falls prevention has generally been focused more in the community than acute hospitals and believes that if there was a coordinator in the acute trust in this area it would make a ‘massive difference’.
This problem is not just limited to Sunderland – the community setting has traditionally been the focus of falls prevention in recent years. For example, NICE (2004) guidance, The
Assessment and Prevention of Falls in Older People, focused solely on the community. ‘The NICE guidance left a vacuum in terms of the acute sector and also didn’t make recommendations about how to reduce falls,’ says Ms Healey.
Despite this, hospital patients are at a greater risk of falling than people in the community – mainly due to the new sets of risks that illness and hospital interventions can bring. Surgery can affect patients’ mobility and memory, and post-anaesthetic patients, as well as those with urinary tract infections, for example, can suffer delirium, which increases the risk of falling.
Hospital treatment can bring another huge falls risk factor – medication. Sedation, pain relief, anaesthetics and other medications all increase the risk of falling – as can changes to a patient’s regular medication.
For older patients, particularly those with dementia, an unfamiliar environment is extremely disorientating. As Loretta Young, falls practitioner at King’s College Hospital in London, explains: ‘They might just need someone to talk to them, so that they become less anxious’.
She acknowledges that staff shortages are also a major factor in preventing falls. ‘Nurses always say the main challenge is staffing levels. If you have four patients
who are confused, it is usually impossible to have nurses “specialling” each patient.’
At King’s, Ms Young and her colleagues have developed a ‘stratifying tool’ based on the extensive research of Dr David Oliver, senior lecturer at the University of Reading, and consultant physician at the Royal Berkshire NHS Foundation Trust. The tool uses five questions to assess risk and implement a care plan.
‘I always tell nurses to promote independence. Often nurses, myself included, have so much to do and it can be easier to get a commode or bedpan for Mrs Jones than walk her to the toilet. We’ve all done it.
‘I would always say, promote independence as your priority. Patients don’t all need to be washed in the morning but often we are still in that mindset. Walking the patient around is key to preventing muscle weakness and improving balance,’ she advises.
She also always reminds staff not to overlook some of the simplest ways of reducing risk. ‘Footwear is really important. Sometimes it is about looking at the environment, such as whether there is enough space around the beds,’ she says.
Ms Young also stresses that multidisciplinary input and cross-sector working is absolutely vital to reducing falls. This view is supported by the NPSA report but the report does emphasise that having a central coordinator such as Ms Young is vital to success. As she affirms, ‘I can’t do it on my own. I need nurses, doctors, OTs [occupational therapists], physios and pharmacists on board.’
Ms Young holds monthly training sessions for staff, including newly qualified nurses and HCAs. These sessions cover risk factors, how the tools are used and the trust’s falls guidelines, which are also on the King’s College intranet. ‘There is a lot that nurses can do. I am here to help, but everyone plays a part.’
Cross-sector working is also proving important in ensuring falls are properly assessed and followed up. At King’s, the specialised, multidisciplinary falls service in A&E has ensured there is follow up in the community for patients who are discharged. Patients admitted following a fall are assessed by Ms Young, an OT, a physiotherapist and a social worker.
In Sunderland, Ms Pigford is also now providing training sessions for staff in the acute sector and the local hospitals have agreed to use the same assessment tools as the community to promote continuity.
But much more still needs to be done. The National Clinical Audit of Falls and Bone Health in Older People Report (Royal College of Physicians, 2007) – the first national audit of its kind – confirmed widespread deficiencies in services. Ms Healey stresses that tackling falls cannot be achieved by the ‘passionate few’ alone.
‘Of all the trials we fight, falls prevention needs to be multidisciplinary but nurses have that leading and coordinating role. The right things are happening somewhere but it needs to be consistent.
‘With falls, there isn’t a magical fix.
There are almost always multiple reasons why someone falls, so there have to be multiple solutions. And sometimes common sense can be harder to implement than rocket science.’
How nurses can help prevent falls in hospital
Don’t rely on falls risk scores alone – even the best will under or overpredict risk. Always go on to assess modifiable risk factors as well
Always incorporate the patient’s views – balance a patient’s dignity and independence with risk of harm when planning interventions
Assess the environment – simple improvements to lighting, flooring, trip hazards, ward design and furniture may reduce the risk of falls
Detect and treat underlying injuries or illness that may be causes – unless this is done promptly after a ‘first fall’, the patient is likely to fall again
Ensure regular training on falls prevention – but make sure it is multidisciplinary. Practical, ward-based sessions can be more effective and easier to arrange
Source: NPSA, 2007