An inpatient neurological rehabilitation unit had a high incidence of falls so used the Patient Safety First campaign to address this issue.
Citation: Maltby L (2012) Preventing and managing falls in a neurology unit. Nursing Times [online]; 108: Online issue.
Author: Lorraine Maltby is clinical governance facilitator and registered general nurse, Rehabilitation Service, Specialist Division, Birmingham Community Healthcare Trust.
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The inpatient neurological rehabilitation unit, which is part of Birmingham Community Healthcare Trust Specialist Division, used Patient Safety First’s (2009) resource on reducing harm fro m falls to tackle the ward’s high incidence of falls. We also used recommendations from the NHS Institute for Innovation and Improvement’s Productive Ward series and the National Patient Safety Agency (2011), as well as guidance from the National Institute for Health and Clinical Excellence (2004), and local risk-management policies.
The rehabilitation unit is a 20-bed ward that provides specialist assessment and intensive rehabilitation for people with disabilities resulting from neurological conditions. The majority of patients have suffered head injuries, subarachnoid haemorrhages, stroke or other forms of brain injury.
We obtained data on the incidence of falls from the Datix incident reporting system; this is an electronic system for staff to record incidents and their investigations within the organisation. This identified that falls had been the highest-recorded incident every month from April 2009 until March 2010, and had risen by 68% from the first to the third quarter of the period. As a result we decided to pilot the Patient Safety First campaign to improve patient safety.
Patient Safety First advises that a team committed to reducing harm from falls should be in place, and that falls management should not be treated solely as a nursing problem. As such, we set up a short-life working group involving nursing staff, therapy staff and members of corporate and local governance teams. Setting a goal helps break a mindset in which falls are seen as inevitable, so the group set a realistic goal to reduce falls by 10% within one year, based on 2009-2010 data.
Actions to reduce falls
The Patient Safety First campaign says consistent and good-quality reporting is fundamental to understanding where improvements can be made to reduce falls.
Previously falls were monitored through local governance arrangements; although this meant the governance team and ward staff were aware of those patients who fell frequently, this process did not prompt staff to review individual falls-prevention care plans and cross reference them with other Datix incidents to identify trends. We added extra mandatory fields to the Datix incident form so when staff completed a falls incident they could not submit the form until they had indicated that the falls care plan had been reviewed and contributing factors had been identified.
Validating risk-assessment tools
The campaign also suggests validating falls risk-assessment tools. The key aims were to determine whether the assessment tool used on the unit is suitable for this setting and type of patients, and whether patients who were known fallers (data taken from Datix) had been predicted to fall.
We audited a sample of 50 inpatient casenotes from April 2010 to March 2011; of these, 25 were known fallers and 25 were selected at random and not known fallers. We found the tool was likely to pick up 96% of all actual fallers, thereby proving it does predict a high percentage of likely fallers. Based on these results, the group agreed the unit should continue to use the tool.
Patient Safety First also advises that a “one-size-fits-all” approach is not appropriate for managing falls, and falls documentation should prompt a review of each risk factor as well as actions to reduce that risk. The falls care plan previously used comprised a set template of actions to manage patients at risk of falling; although it included all the necessary risk factors it did not allow staff to add individualised actions for each risk factor. We adapted the unit’s care plan to include all suggested risk factors and allow staff to document individualised actions.
The NPSA (2011) published a rapid response report on essential care following an inpatient fall. Compliance with the report requires local protocols to include necessary actions for managing patients who have fallen. Although this impacts on corporate policy, the unit implemented a falls pathway that included local guidance specific to the type of complex patients nursed on the ward, instead of a generic organisational approach.
The campaign suggests implementing a training programme for preventing and managing falls. Previously no training was readily available for clinicians on the unit. When exploring training options, it became evident that most training was geared towards preventing and managing falls in older adults; this meant some principles may not apply to patients on our unit. We introduced a bespoke training programme that supports caring for patients of all ages with complex neurological conditions.
The campaign highlights the importance of reviewing the care environment. Retrospective data from 2009-2010 was used to identify visual trends for fall “hot spots” in terms of location and time of day, as well as actions to address these.
The data showed that bays and bedrooms were hot spot fall areas. Fig 1 identifies when falls are most likely to occur; most happen during evening shifts (2pm-7pm). When this was discussed with the group, it was evident that this time of day is busy due to there being fewer staff on the ward in the evenings to complete tasks such as patient evening meals and the 6pm medicine rounds. Staff time during the evening shift was also taken up answering the ward intercom after reception staff had left at 5pm.
It was clear that increasing the number of nursing staff on evening shifts and extending the time reception staff were available would help reduce demands on individual nurses and allow for more direct care. The service manager has since employed a receptionist who works 8am-8pm weekdays and also covers weekends; a housekeeper is available in the evenings to help with evening meals, allowing nurses to focus on nursing. Every effort is made to ensure shifts have enough staff members.
The ward is also piloting “care rounds”, using one checklist for a range of hourly observations for each patient. We also carried out a bed audit to determine whether the ward had the right beds to meet patients’ needs. The ward has purchased three ultra-low floor-line beds on which the mattress platform can be lowered to 100mm.
It is important to put in place a sustainability plan both to ensure the actions introduced continue to meet patient and staff needs, and that staff continue to implement them. The sustainability plan, which is a collaborative approach between frontline staff and the rehabilitation governance team, includes spot checks, audits and reporting processes.
From the start of the project until April 2011, the unit has exceeded the goal set for reducing falls by 10% based on 2009-2010 data in all but one month. Before the project began, the unit averaged 11.13 falls per thousand occupied bed days for 2009-2010; for 2010-2011 this decreased to an average of 6.9 per thousand occupied bed days. We will continue to monitor falls incidence with the potential to put in place a more challenging goal.
The Patient Safety First campaign was extremely useful in guiding the process to improve falls prevention and management on the inpatient neurological rehabilitation unit. The challenge has been meeting the needs of these patients while ensuring staff are not overloaded with new processes and paperwork. Involving frontline staff has been integral to ensuring the actions introduced work for patients and staff, and are sustainable.
- Patient Safety First is a national campaign that aims to create safer and more reliable systems of care
- A team committed to reducing harm from falls is a vital part of any falls prevention initiative
- Falls management should not be treated solely as a nursing problem
- Taking a “one-size-fits-all” approach is not an appropriate way to manage falls
- Involving frontline staff is integral to ensuring new actions work for both patients and staff
National Institute for Health and Clinical Excellence (2004) Falls (CG21): The Assessment and Prevention of Falls in Older People. London: NICE.
National Patient Safety Agency (2011) Essential Care After an Inpatient Fall. London: NPSA.
Patient Safety First (2009) Reducing Harm From Falls ‘How to’ Guide.