Falls Assessment and Prevention in the Health and Ageing Unit (HAU) in a Large Central London Teaching Hospital

Emma Lewin, Ruth Evans, MaitriShilaTursiniHarriet Howard

Background and Aims

Falls are a common hospital presentation in the ageing population, with 30% of over 65s and 50% of over 80s suffering with at least one fall a year. A fall can lead to negative physical and psychological sequelae and falls are estimated to cost the NHS more than £2.3 billion per year. NICE has produced guidelines advising on the multifactorial assessment that should be carried out in patients presenting to hospital following a fall in the community, in order to prevent subsequent falls in the future and further hospital admissions.

The aim of this project is to evaluate how well the department at King's College Hospital was completing the multifactorial falls assessment as described in the NICE guidelines on falls prevention and identify specific areas for improvement.

Methods

A retrospective review of all inpatients, over the age of 65, admitted on a randomly chosen week into the Health and Patients were screened and included if they were identified as presenting with a fall or having a history of falls. Adherence to NICE guidelines for falls assessments was then checked. Clinical notes were reviewed for evidence of the following by any of the multidisciplinary team: eight specific multifactorial assessments gait assessment, FRAX score, medications review, visual assessment, cognitive assessment, home environment assessment, ECG and lying-standing blood pressure (LSBP), and whether done correctly)

Four multifactorial interventions increased package of care or adaptation of home environment, vision referral or intervention, referral to strength and balance training (including community physio), medication changes

Four interventions were put in place with the aim of improving the quality of falls assessments. The performance of the department was then re-audited for patients admitted in a random week in June 2021 following the interventions. The results were tested for statistically significant change using a chi square test.

Results Cycle 1

The data analysis demonstrated a completion rate of : >90% was demonstrated for ECG, assessment of home environment and medications review. <30% was demonstrated for lying-standing blood pressure, visual assessment and FRAX score calculation

Therefore, teaching on how to perform these assessments and tips for making these easier were specifically including in a departmental teaching session.

E.g. signposting to the Sheffield FRAX score calculator, teaching on how to perform a bedside vision assessment and lying-standing blood pressure correctly

Interventions

In between the two audit cycles, the following interventions were put in place with the aim of improving multifactorial falls assessments:

1. Teaching session to share findings with the department, remind of the guidelines and give suggestions on how to improve assessments

2. Creation of posters to put up around HAU as a visual reminder

3. Creation of an electronic proforma to be used to aid falls assessments and ensure all elements completed prior to discharge

4. Survey of staff on HAU to identify barriers to completing the assessment

Results Cycle 2

Statistically significant improvements demonstrated in gait assessment (83% to 89%), visual assessment (29% to 36%) and FRAX score calculation (21% to 34%)

All other areas improved or were unchanged, but with no statistical significance

Statistically significant improvements demonstrated in intervention of adaptation of home environment

The staff survey demonstrated the following barriers to completing a comprehensive falls assessment:

Limited time available to complete assessments

Lack of clarity on which member of the MDT was responsible for completing the different assessments

Not having all the elements required to complete an assessment (e.g. Snellen chart for vision assessment, height and weight measurement for FRAX score)

Lack of knowledge on how to perform and interpret certain assessments (e.g. performing LSBP, interpreting FRAX score)

Conclusions and Next Steps

An assessment for risk factors/cause should be done for all patients at high risk of falls or admitted with a fall followed by any interventions deemed necessary

This project demonstrates how surveying staff can help us understand why certain aspects of our practice are not being carried out consistently and how continuous education can improve our care for patients

Nextstepsincludeplan

A Quality Improvement Project aimed at improving catheter documentation in electronic patient notes by implementing an Inpatient Catheter Chart form.

Dr. Ishtar Redman, Dr. Jennie Han, Dr. Edward Hoy

Introduction: Healthcare-associated infections (HCAI’s) are responsible for approximately 300,000 deaths per year in England, costing the NHS an estimated £1 billion per annum.1

The major predisposing factor for healthcare associated UTI is the presence of an indwelling urinary catheter and in the acute setting, the risk of developing bacteriuria increases by 5% each day in catheterised patients.2

We recognized that poor inpatient catheter documentation led to significant patient safety issues-delayed discharges, CAUTI’S, iatrogenic incontinence and catheter dependence-the need to be discharged with a catheter due to TWOC failure.

SMART OBJECTIVE: To improve catheter documentation in electronic patient notes by implementing an Inpatient Catheter Chart proforma which will be ICHNT senior clinical leadership sanctioned, hospital wide, mandated and created in accordance with bothTrust and national guidelines.

Qualitative data collected; NIC of 4 wards surveyed, how does poor catheter affect patient safety ?

• Delay in TWOCs

To achieve 100% catheter documentation on inpatient notes.

Poster(s); educational posters in doctor’s office, bulletin boards on ALL first floor wards.

Education sessions targeting nurses, Fy1 doctors.

Software updateMeeting with CERNER education lead; to update electronic charts.

Update the trust-wide Catheter guidelines on our intranet.

• Unsure of clinical indication for catheter.

• Inappropriate removal of LTC causing urinary retention and pain.

• Incorrect/no size(s) documented as leading to urinary by-passing and bed wetting.

• Removed due to unknown indication, requiring re-catheterization.

• Realizing a patient has acatheterbefore discharge and arranging for TWOC as outpatient, or delaying discharge as needed to wait for TWOC.

• Causing physiological dependence on catheters-patients being admitted continent, but subsequently discharged reliant on catheters.

STANDARD DOCUMENTATION AS PER TRUST GUIDELINES

1.Reason for the catheterisation, on-going need for a catheter

2.Health status of the patient prior to catheterisation i.e. well, ill, febrile

3.If febrile –antibiotic cover

4.Discomfort i.e. retention

5.Indicated if a fluid chart is required

6.Allergy status (for example latex, gels and medication)

7.Consent obtained

8.Meatal or genital abnormalities observed, including discharge

9.If the insertion was easy or difficult and in men if obstruction felt at prostatic area, patient reaction to passing the prostate

10.Indications used to ensure catheter was inserted correctly (in men –amount of catheter inserted i.e. to the hilt)

11.Residual urine drained, colour, smell and, if necessary, dipstick and record the result

12.No resistance to balloon inflation, no patient reaction or pain related to balloon inflation, free movement of the catheter once balloon inflated

Future work- PDSA Cycle (3)

P: Convene meeting with trust CERNER softwarelead.

D: Augment pre-existingsoftware to include(7) data sets.

S/A: Re-audit theabove and useresults to update thetrustwide guidelineson Catheterdocumentation in conjunction with theUrologyteam.

Conclusions/Lessons Learnt:

•Poor documentation can have clinical implications for patients.

•Human factors cannot be ignoredChanging systems is far more effective than trying to change people

•Trust guideline is not being well followed –does this need to be updated?

•Automated form would likely lead to better adherence to current guideline

References: