NORTHWEST PREVENTION & MANAGEMENT OF INPATIENT FALLS AUDIT

Transcription

1 PREVENTION & MANAGEMENT OF INPATIENT FALLS AUDIT

2 Regional audit is funded by the Supra-district Clinical Audit Committee All trusts should strive towards systems so that good practice based on local and/or national guidance is implemented across the organisation for every patient, every time CQC, Participating Acute Trusts

3 Participation in the Audit CODE NAME RWJ Stockport NHS FT RMP Tameside Hospital NHS FT RM2 University Hospital of South Manchester NHS FT RBL Wirral University Teaching Hospital NHS FT RJN East Cheshire NHS Trust RRF Wrightington, Wigan & Leigh NHS FT REM Aintree University Hospitals NHS FT RJR Countess of Chester Hospital NHS FT RBT Mid Cheshire Hospitals NHS FT RXN Lancashire Teaching Hospitals NHS FT RBN St Helens & Knowsley Hospitals NHS Trust RVY * Southport & Ormskirk Hospital NHS Trust RMC Royal Bolton Hospital NHS FT RW6 Pennine Acute Hospitals NHS Trust RXR East Lancashire Hospitals NHS Trust RW3 Central Manchester University Hospitals NHS FT RM4 Trafford Healthcare NHS Trust (NOW PART OF RW3) RM3 Salford Royal NHS FT

4 THROUGH THE YEARS 2004: USING FALLS RISK TOOLS 2006: IMPROVING FALLS RISK TOOLS 2009: ESTABLISHING A BASELINE 2011: EVALUATING IMPROVEMENTS PATIENT EXPERT VIDEO

5 2004 USING FALLS RISK TOOLS

6 2004: SAMPLE AND METHODS Prospective audit 52 Patients aged 65 and over, in hospital for 3+ days 12 trauma patients on Orthopaedicwards & 40 across 5 Care of Elderly/General Medical wards

7 2004: STANDARDS Falls risk assessment tool is used and completed appropriately Patients are provided a care plan and re-assessed at appropriate intervals An operational fall service has been set up in each local health economy with appropriate complement of staff An environmental audit tool and action plan is in place TAKEN FROM NSF FOR OLDER PEOPLE: STANDARD SIX: FALLS

8 2004: ASSESSMENTS The presentation in 2004 explored assessments of four key indicators: PERCENTAGE OF PATIENTS WHO HAD ASSESSMENT/REVIEW 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Medication review Mental test score Lying and standing BP 15.5% 10.4% 25.3% INTERVENTIONS Comparing years PERCENTAGE OF PATIENTS 0% 20% 40% Eye test 3.5% Bed in low position Footwear 4% 9% 12% 29% These indicators have not improved much since 2004, perhaps because they are not as easy to assess or treat. Compare to low-profiling beds or footwear.

9 2004: SUMMARY OF RESULTS Comparing falls risk assessments (FRA) completed to no FRA Percentage of Sample DOCUMENTATION MATTERS NEEDS WORK TO CHANGE PRACTICE

10 2006 IMPROVING FALLS RISK TOOLS

11 2006: IMPORTANCE OF RISK FACTORS From Rubenstein & Josephson, Clin Geriatr Med. 2002; 18(2): Summary of 12 major studies of fall causes Accident /Environment 31% Gait /Balance /Weakness 17% Dizziness vertigo 13% Drop attacks 9% Confusion 5% Postural hypotension 3% Visual disorder 2% Syncope 0.3% Other 15% Unknown 5% Individual risk factors: 16 controlled studies Weakness Balance deficit Mobility limitation Gait deficit Visual deficit Cognitive impairment Impaired ADL Postural hypotension Slide by Dawn Skelton in Evidence-Based Falls Prevention into Practice, 2006

12 2006: FALLS RISK ASSESSMENT TOOLS RISK FACTOR CMFT TRAFFORD UHSM MACC BOLTON STOCKPORT TAMESIDE WIGAN FEDER STRATIFY FRASE Falls History Mobility, Gait, or Balance Mental State Visual Impairment Incontinence or Frequency Medical Condition Medications Hearing Impairment Postural Hypotension

13 2006: WHAT SORT OF FALLS RISK TOOL? SIMPLE: Lower cost Shorter Less technical COMPREHENSIVE: More information on modifiable risk factors Slide from Falls Risk Assessments by Nicola Rice, CMFT, 2006

14 2006: STANDARDS Falls risk assessment tool is used and completed appropriately Patients are provided a care plan and re-assessed at appropriate intervals An operational fall service has been set up in each local health economy with appropriate complement of staff (NSF para6.37). An environmental audit tool and action plan is in place Check for risk factors in all patients TAKEN FROM NSF FOR OLDER PEOPLE: STANDARD SIX: FALLS AND NICE CLINICAL GUIDELINE 21 FALLS

15 2006: SAMPLE AND METHODS Prospective audit 60 Patients aged 65 and over, in hospital for 3+ days 12 trauma patients on Orthopaedicwards & 40 across Care of Elderly/General Medical wards 8 from Surgical wards Data collected from case notes on ward Selection of patients was randomized Each hospital allocated 1 week -started in May 2006

16 2006: RISK FACTORS Percentage of sample with risk factors documented (N=540) Impaired mobility/gait/balance Impaired mental status Urinary incontinence Medical Conditions History of falls Visual impairment >4 meds Hearing impairment Alcohol problems Postural Hypotension 7% 6% 21% 19% 29% 48% 46% 42% 41% 69% 0% 20% 40% 60% 80% 100% PERCENTAGE OF PATIENTS

17 2006: INTERVENTIONS Comparing falls risk assessment (FRA) completed to not completed (N=540) PERCENTAGE OF PATIENTS 0% 20% 40% 60% 80% 100% Physio Referral Discharge planning OT Referral Bed rail assessment Call Bell Urine dipstix Bed in low position Close Obs Asking for help Educate Aids to hand Discussed with relatives Toileting Cognition Assessment Home Visit Footwear Alarms Wristband TWOC Special Hip Protectors % FRA completed % No FRA

18 2006: SUMMARY Increased number of Falls Risk Assessments Increased numbers of interventions but still room to improve. Some improved re-assessment of falls risk. Positive cultural change overall

19 2009 ESTABLISHING A BASELINE

20 2009: NEW GUIDANCE

21 2009: SAMPLE AND METHODS Retrospective audit 80 patients aged 65 and over, in-patient for 3+ days Orthopaedic, Elderly, General Medical, Surgical wards Discharged or deceased in May 2011

22 2009: STANDARDS S % of patients are asked about any recent falls within 24 hours of admission. S % of patients are screened for other risk factors within 24 hours of admission 2.1, after each in-patient fall 2.2, after a marked change in patient condition 2.3, and after each ward transfer 2.4 through one of the following: a) a standard elderly admission screening tool including mobility, memory & continence. b) NPSA s four questions c) a locally validated risk prediction tool S % of patients on psychotropic medications receive a risk/benefit review of the psychotropic medication. TAKEN FROM: NSF FOR OLDER PEOPLE: STANDARD SIX: FALLS (2001), NICE CLINICAL GUIDELINE 21 FALLS (2004), NPSA SLIPS, TRIPS AND FALLS IN HOSPITALS (2007), PATIENT SAFETY FIRST HOW-TO GUIDE FOR REDUCING HARM FROM FALLS (2009)

23 2009: SUMMARY Hospitals struggle with the same things. Continued gaps for assessing certain modifiable risk factors Falls services continue to develop well Stratifying risk (scores, low/medium/high) is less important than finding the balance between education and the right prompts.

24 2011 EVALUATING IMPROVEMENTS

25 2011: SAMPLE AND METHODS Retrospective audit 60 patients aged 65 and over, in-patient for 3+ days Orthopaedic/ Elderly / General Medical / Surgical wards Discharged/deceased in May 2011 Data collected from case notes by clinical and audit staff

26 2011: STANDARDS S % of patients are screened for falls risk factors by the end of the first full day following admission, including: Falls History Patient anxiety about falling Gait/mobility Cognition/mental states S % of patients receive a review of their medication with their falls risk in mind. Standard on medication reviews to be re-established based on 2011 audit results. TAKEN FROM: NSF FOR OLDER PEOPLE: STANDARD SIX: FALLS (2001), NICE CLINICAL GUIDELINE 21 FALLS (2004), NPSA SLIPS, TRIPS AND FALLS IN HOSPITALS (2007), PATIENT SAFETY FIRST HOW-TO GUIDE FOR REDUCING HARM FROM FALLS (2009)

27 2011 Results: One Slide Summary Hospitals are still using un-validated tools. Most hospitals maintained or improved performance from 2009 to 2011 Clear need for improved education of staff. Biggest improvers: Aintree, Stockport, Macclesfield Challenges for Tameside & Wirral Consistent audit participation better results.

28 2011: DEMOGRAPHICS MOBILITY COMPARING THE YEARS 2009 (14 Trusts) 2011 (15 Trusts) Unknown Bed Mobile Restricted (With Aid) Independently Mobile Percentage of Sample 0% 50% 100% 34.0% 33.5% 6.9% 9.0% Immobile 33.4% 37.1% Wheelchair Mobile Restricted (No Aid) Length of stay Range: 3 days to 139 days Median: 9 days Age Range: 65 years to 109 years Median: 79 years Sex 58.1% Female, and 41.9% Male

29 2011: RISK ASSESSMENT TOOLS DEVELOPED INTERNALLY DEVELOPED INTERNALLY, BASED ON STRATIFY DEVELOPED INTERNALLY, BASED ON NPSA 2007 DEVELOPED INTERNALLY, BASED ON FRASE IN USE SINCE DATE (AS REPORTED IN 2011 SERVICE EVALUATION)

30 NPSA S FOUR QUESTIONS From Slips, Trips and Falls in Hospital : If YES to any of the four questions, assess for further risk factors and provide interventions where appropriate: History of Falls In-patient Fall Unsteady gait, tries to walk alone Anxious about falls

31 2011: FALLS RISK ASSESSMENT TOOLS IN USE DURING AUDIT (MAY 2011) TRUST VERSION IN USE SINCE STRATIFICATION SCORE VALIDATION MID-CHESHIRE 2006 MULTIPLE RISK GROUPS SCORE NOT VALIDATED AINTREE 2006 MULTIPLE RISK GROUPS SCORE NOT VALIDATED STOCKPORT 2004 MULTIPLE RISK GROUPS SCORE VALIDATED STHK 2009 TWO RISK GROUPS SCORE VALIDATED REMINDER: BASED ON FRASE BASED ON STRATIFY BASED ON NPSA 2007 DEVELOPED INTERNALLY PENNINE 2010 TWO RISK GROUPS SCORE VALIDATED WIRRAL 2000 SCORE NOT VALIDATED WIGAN 2005 MULTIPLE RISK GROUPS SCORE NOT VALIDATED LANC TEACH 2010 MULTIPLE RISK GROUPS SCORE NOT VALIDATED SOUTHPORT 2008 MULTIPLE RISK GROUPS SCORE NOT VALIDATED UHSM 2010 TWO RISK GROUPS NO SCORE NOT VALIDATED CHESTER 2007 MULTIPLE RISK GROUPS SCORE NOT VALIDATED

32 PATIENT S RISK LEVEL COMPARING THE YEARS Percentage of Sample 0% 20% 40% 60% 80% 100% 2004 (7 Trusts) 27.1% 9.7% 2006 (9 Trusts) 30.6% 27.6% 2009 (14 Trusts) 50.7% 35.8% 2011 (15 Trusts) 73.2% 15.4% At risk* Not at risk Unknown * IN 2009 & 2011, AT RISK WAS DEFINED AS NEEDING FURTHER ASSESSMENTS/INTERVENTIONS

33 AT LEAST ONE REVIEW OF FALLS RISK COMPARING THE YEARS Percentage of Sample 0% 20% 40% 60% 80% 100% 2004 (7 TRUSTS) 2006 (9 TRUSTS) 2009 (14 TRUSTS) 2011 (15 TRUSTS) 2011* (11 TRUSTS) 53% 63% 87% 89% 92% Range: 0% to 92% Range: 10% to 95% Range: 60% to 99% Range: 57% to 100% Range: 67% to 100% * TRUSTS THAT PARTICIPATED IN BOTH 2009 AND 2011

34 2011: FIRST REVIEW OF FALLS RISK SORTED BY PERCENT MEETING STANDARD CHESTER WIGAN STOCKPORT UHSM LANC TEACH BOLTON SOUTHPORT LEIGHTON AINTREE STHK 2011 ALL MACC PENNINE WIRRAL TAMESIDE EAST LANC PERCENTAGE OF PATIENTS REVIEWED 0% 20% 40% 60% 80% 100% 82% 88% 92% 85% 80% 91% 78% 70% 54% 58% 67% 65% 56% 59% 21% 32% 20% 6% 31% 25% 11% 7% 13% 13% 15% 17% 7% 3% 10% 13% 10% ON ADMISSION ON THE FIRST FULL DAY FOLLOWING ADMISSION

35 2011: FIRST REVIEW OF FALLS RISK SORTED BY PERCENT MEETING STANDARD (2011) PERCENTAGE OF PATIENTS REVIEWED 0% 20% 40% 60% 80% 100% CHESTER WIGAN STOCKPORT UHSM LANC TEACH BOLTON SOUTHPORT LEIGHTON AINTREE STHK 2011 ALL MACC PENNINE WIRRAL TAMESIDE EAST LANC 98% 95% 95% 95% 93% 91% 88% 85% 85% 83% 80% 78% 67% 66% 41% 38% 26% 19% 13% 15% 5% 2% 5% 5% 4% 5% 13% 10% 3% 9% 13% BY END OF FIRST FULL DAY FOLLOWING ADMISSION ON THE SECOND FULL DAY OR LATER

36 FIRST REVIEW OF FALLS RISK BY END OF FIRST FULL DAY FOLLOWING ADMISSION ( ) DIFFERENCE IN PERCENTAGE OF PATIENTS REVIEWED ( ) -30.0% -10.0% 10.0% 30.0% 50.0% MACC STOCKPORT AINTREE CHESTER WIGAN LANC TEACH UHSM 2011 (ALL) (ALL) STHK TAMESIDE LEIGHTON WIRRAL -21.4% -5.2% -8.5% -0.2% 33.7% 25.8% 18.1% 10.8% 10.5% 8.3% 6.3% 1.6%

37 STANDARD 1.0: FALLS RISK FACTORS 100% OF PATIENTS (65+) SHOULD RECEIVE AN ASSESSMENT OF FALLS RISK FACTORS BY THE END OF THE FIRST FULL DAY FOLLOWING ADMISSION. AT LEAST: History of Falls In-patient Fall Gait/mobility Anxious about falls ALSO CONSIDER: Cognition/mental state Medication

38 PATIENTS RECEIVING NO ASSESSMENTS COMPARING THE YEARS Percentage of sample who received no assessments 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% HISTORY OF FALLS GAIT/MOBILITY COGNITION ANXIETY ABOUT FALLS 71% 74% 47% 26% 24% 15% 13% 10% 11% 7%

39 PATIENTS RECEIVING NO ASSESSMENTS OF FALLS HISTORY COMPARING THE YEARS Percentage of sample who received no assessments 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% SAMPLE AVERAGE MAX % MIN % 79% NEW TRUSTS JOINED 47% 29% 17% 11% %

40 2011: FIRST REVIEW OF FALLS HISTORY SORTED BY PERCENT MEETING STANDARD PERCENTAGE OF PATIENTS REVIEWED 0% 20% 40% 60% 80% 100% WIGAN CHESTER LEIGHTON LANC TEACH STOCKPORT UHSM BOLTON AINTREE STHK 2011 ALL MACC SOUTHPORT WIRRAL PENNINE EAST LANC TAMESIDE 100% 97% 95% 93% 93% 93% 93% 91% 90% 84% 82% 76% 73% 69% 61% 47% 11% 10% 5% 5% 4% 3% 5% 5% 7% 4% 4% BY END OF FIRST FULL DAY FOLLOWING ADMISSION ON THE SECOND FULL DAY OR LATER

41 RISK FACTORS: HISTORY OF FALLS MAX-MIN MRI 79% 33% 9% 70% AINTREE 57% 4% 53% WIRRAL 60% 32% 18% 22% 41% STOCKPORT 48% 35% 21% 7% 41% WIGAN 33% 8% 0% 33% MACC 32% 46% 16% 30% TRAFFORD 44% 25% 15% 29% TAMESIDE 33% 17% 42% 28% 25% PENNINE 50% 25% 25% UHSM 17% 3% 5% 0% 17% BOLTON 20% 4% 16% LANC TEACH 8% 2% 7% LEIGHTON 5% 0% 5% CHESTER 5% 2% 3% STHK 3% 10% -8% SOUTHPORT 22% EAST LANC 29% SALFORD 1% PERCENTAGE OF PATIENTS WHOSE FALLS HISTORY WAS NOT CHECKED. SORTED BY CHANGE OVER TIME.

42 PROPOSED STANDARD 2.0: MEDICATION PATIENTS (65+) SHOULD RECEIVE A MEDICATION REVIEW WITH THEIR FALLS RISK IN MIND. 100% 50% 0% 94% of patients had an increased falls risk due to medications 47% with increased risk had their medication reviewed 64% with medication reviewed had their medication changed

43 STILL STRUGGLING POSTURAL HYPOTENSION COMPARING THE YEARS Percentage of sample 100% 90% had lying & standing blood pressure taken 80% showed signs of postural hypotension 70% were provided advice (2011) or interventions (2009) 60% 50% 40% 30% 20% 10% 9% 11% 6% 0% 6% 8% 4% 2%

44 BUT ALSO IMPROVING STANDARD: FIRST REVIEW OF PATIENT ANXIETY BY END OF FIRST FULL DAY FOLLOWING ADMISSION ( ) DIFFERENCE IN PERCENTAGE OF PATIENTS REVIEWED ( ) -30.0% -10.0% 10.0% 30.0% 50.0% 70.0% 90.0% UHSM WIGAN WIRRAL MACC STHK LANC TEACH CHESTER STOCKPORT 2011 (ALL) (ALL) AINTREE TAMESIDE LEIGHTON -11.7% 39.0% 34.8% 33.2% 29.5% 19.2% 19.2% 15.3% 11.3% 6.8% 1.4% 65.8%

45 STANDARD: FIRST REVIEW OF PATIENT ANXIETY SORTED BY PERCENT MEETING STANDARD (2011) PERCENTAGE OF PATIENTS REVIEWED 0% 20% 40% 60% 80% 100% UHSM LANC TEACH MACC WIGAN STHK WIRRAL 2011 ALL STOCKPORT CHESTER EAST LANC SOUTHPORT BOLTON TAMESIDE AINTREE PENNINE LEIGHTON 73% 5% 72% 5% 38% 3% 37% 2% 32% 2% 29% 8% 22% 4% 22% 13% 8% 11% 9% 7% 2% 4% 3% 3% 7% 2% BY END OF FIRST FULL DAY FOLLOWING ADMISSION ON THE SECOND FULL DAY OR LATER

46 VIDEO PATIENT EXPERT

47 VIDEO: PATIENT EXPERT People who have long stays in hospital don t realise how weak they are from just being in bed. Your mind feels exactly the same as it always did and you assume your muscles are going to do the same thing. There s always that feeling --am I going to slip?-- and this stays with you.

48 VIDEO: PATIENT EXPERT

49 ANY QUESTIONS?

50 NEXT BREAK FOR TEA & COFFEE RETURN FOR TRUST PRESENTATIONS 2012+: INTO THE FUTURE LUNCH

51 PREVENTION & MANAGEMENT OF INPATIENT FALLS AUDIT

52 OTHER SLIDES

53 2009: RISK ASSESSMENT TOOLS DEVELOPED INTERNALLY DEVELOPED INTERNALLY, BASED ON STRATIFY FRASE DEVELOPED INTERNALLY, BASED ON NPSA 2007 DEVELOPED INTERNALLY, BASED ON MORSE MORSE DEVELOPED INTERNALLY, BASED ON MORSE & NPSA IN USE SINCE DATE (AS REPORTED IN 2009 SERVICE EVALUATION)

54 PATIENT DEMOGRAPHICS: SEX COMPARING THE YEARS Percentage of Sample 0% 20% 40% 60% 80% 100% 2004 (7 Trusts) 60.4% 39.6% 2006 (9 Trusts) 64.3% 35.7% 2009 (14 Trusts) 60.0% 40.0% 2011 (15 Trusts) 58.1% 41.9% FEMALE MALE

55 PATIENT DEMOGRAPHICS: LENGTH OF STAY COMPARING THE YEARS Percentage of Sample 40% 35% 30% 25% 20% 15% 10% 5% 0% 35.0% 35.3% 33.8% 32.0% 20.7% 18.7% 9.3% 8.8% 3.8% 0.4% 2.0% 0.2% 3 to 7 8 to to to to to 224 DAYS IN HOSPITAL

56 2011: REASSESSMENTS PROMPTS FOR TOOLS IN USE DURING AUDIT (MAY 2011) TRUST TOOL TYPE AFTER A FALL AFTER A CHANGE IN CONDITION AFTER A WARD TRANSFER AFTER A PRE- DETERMINED TIME PERIOD HAS PASSED MID-CHESHIRE BASED ON FRASE AINTREE BASED ON FRASE STOCKPORT BASED ON FRASE STHK BASED ON FRASE PENNINE BASED ON STRATIFY WIRRAL BASED ON STRATIFY WIGAN BASED ON STRATIFY LANC TEACH BASED ON NPSA 2007 SOUTHPORT BASED ON NPSA 2007 UHSM BASED ON NPSA 2007 CHESTER DEVELOPED INTERNALLY

57 2011: FALLS RISK ASSESSMENT TOOLS THE TOOL: IDENTIFIES MODIFIABLE RISK FACTORS INVOLVES CLINICAL JUDGMENT TO IDENTIFY RISK CHECKS GAIT/INSTABILITY ADVISES RECOMMENDED ACTIONS OR INTERVENTIONS INVOLVES CLINICAL JUDGMENT TO IDENTIFY INTERVENTIONS CHECKS COGNITIVE/ MENTAL STATES GIVES THE OPPORTUNITY FOR STAFF TO GENERATE PRACTICAL METHODS TO REDUCE RISK OF FALLS DOCUMENTS WHEN INTERVENTIONS ARE IMPLEMENTED ASKS PATIENT* ABOUT FALLS HISTORY MID- CHESHIRE AINTREE STOCKP STHK PENNINE WIRRAL WIGAN LANC TEACH SOUTHP UHSM CHESTER

58 2011: FALLS RISK ASSESSMENT TOOLS THE TOOL: LINKS DIRECTLY TO INTERVENTIONS FOLLOWING ASSESSMENT OF RISK FACTORS RECORDS PATIENT FALLS DURING CURRENT ADMISSION TRIGGERS CRITICAL INCIDENT REPORTING FOR EACH FALL REFERS TO A SPECIALIST ADVISES FALLS EDUCATION ISPROVIDED TO PATIENT* REFERS TO A FALLS COORD OR FALLS NURSE PRESCRIBES INTERVENTIONS DOCUMENTS WHEN INTERVENTIONS ARE AGREED WITH PATIENT* ASKS PATIENT* ABOUT FEAR OF FALLING MID- CHESHIRE AINTREE STOCKP STHK PENNINE WIRRAL WIGAN LANC TEACH SOUTHP UHSM CHESTER

59 2011: FALLS RISK ASSESSMENT TOOLS TOOL LINKS TO: MID- CHESHIRE AINTREE STOCKP STHK PENNINE WIRRAL WIGAN LANC TEACH SOUTHP UHSM CHESTER BED RAILS GUIDANCE MOVING AND HANDLING CONTINENCE MANAGEMENT MEDICINE(S) MANAGEMENT DELIRIUM DETECTION AND MANAGEMENT DEMENTIA MANAGEMENT PRESSURE ULCER MANAGEMENT AGITATION MANAGEMENT

60 2011: FALLS RISK ASSESSMENT TOOLS TOOL LINKS TO: NUTRITION MANAGEMENT BONE HEALTH MANAGEMENT FALLS CLINIC REFERRALS INTERMEDIATE CARE REFERRALS SOCIAL CARE ASSESSMENT AND EQUIPMENT REFERRALS ORTHOGERIATRIC MID- CHESHIRE AINTREE STOCKP STHK PENNINE WIRRAL WIGAN LANC TEACH SOUTHP UHSM CHESTER LIAISON REFERRALS HOME VISIT REFERRALS

61 2011: FIRST REVIEW OF FALLS HISTORY SORTED BY PERCENT MEETING STANDARD PERCENTAGE OF PATIENTS REVIEWED 0% 20% 40% 60% 80% 100% WIGAN CHESTER LEIGHTON LANC TEACH STOCKPORT UHSM BOLTON AINTREE STHK 2011 ALL MACC SOUTHPORT WIRRAL PENNINE EAST LANC TAMESIDE 90% 82% 79% 80% 90% 82% 93% 70% 69% 72% 74% 66% 65% 56% 54% 28% 19% 14% 7% 21% 21% 12% 8% 10% 7% 15% 16% 13% 12% 10% 3% 0% ON ADMISSION ON THE FIRST FULL DAY FOLLOWING ADMISSION

62 2011: FIRST REVIEW OF FALLS HISTORY BY END OF FIRST FULL DAY FOLLOWING ADMISSION ( ) DIFFERENCE IN PERCENTAGE OF PATIENTS REVIEWED ( ) -30.0% -10.0% 10.0% 30.0% 50.0% 70.0% AINTREE MACC STOCKPORT WIGAN 2011 ALL LANC TEACH LEIGHTON UHSM CHESTER TAMESIDE WIRRAL STHK -0.2% -3.6% -7.7% 14.7% 7.9% 7.1% 6.6% 5.3% 5.0% 1.7% 30.0% 51.4%

63 2011 RISK FACTORS: MEDICATION 100% 80% 60% 40% 20% 0% 88% 66% 50% 26% 25% 24% on four or more medications on cardiac medications on antibiotics on psychotropic medications on sedative medications on bone-strengthening medications

64 OPPORTUNITY: PATIENT ENGAGEMENT Give patients more responsibility. Ask patients: What do you want? What do you need? How is this treatment working for you? Involve patients in: Creating pathways Developing training Inform patients about changes.