Implementing NICE QS in practice. Using audit and Quality Improvement Projects to make changes

Transcription

1 Implementing NICE QS in practice. Using audit and Quality Improvement Projects to make changes Shelagh O Riordan- Consultant Geriatrician and RCP Falls Audit Lead

2 NICE Quality Standards for prevention Ask yourself the question Does the service I run/refer to offer these key interventions? What can I/we do to improve the service? of falls- March 2015

3 Quality Standards 1, 2 and 3 1. Checks for injury after an inpatient fall 2. Safe manual handling after an inpatient fall 3. Medical examination after an inpatient fall

4 Case history of Mr JG 86y old man admitted with delirium and urinary sepsis Fall on admissions unit- no injury Interventions to reduce falls (MFRA) Observable bed Clinically improved and started discharge planning Further fall- found on floor, no witness R/v by FY1- examination (painful hip) and arranged x- ray Hoisted onto bed

5 Case Mr JG cont Couldn t weight bear and bed bound over weekend Further r/v Monday- intertrochanteric fracture Died post operatively

6 Following a fall with suspected head or spinal injury Follow NICE guidelines for head injury (note: unwitnessed fall- assume head injury in over 65y) Urgent CT if GCS <13 Neuro-obs ½ hourly until GCS 15 Flat lift Urgent neck imaging if suspected injury

7 How do we ensure we are compliant? Audit against your post fall protocol Not currently included in RCP audit Quality improvement projects No easy answers/quick fixes! Repeat your audit/improvement cycle again and again!!

8 Quality standard 4 Older people who present for medical attention because of a fall have a multifactorial falls risk assessment (MFRA)

9 What is a MFRA and what isn t it? It is NOT a tool to see if you need to do anything! An assessment with multiple components that aims to identify a person's risk factors for falling and An intervention with multiple components that aims to address the risk factors for falling that are identified in a person's multifactorial assessment

10 Case history Mr JS Admitted following fall Known epilepsy, hypertension and COPD Previous head injury with sub-dural haemorrhage surgical evacuation 14 admissions this year!

11 Mr JS continued Vision- poor Shoes falling off feet L and S BP- no drop Physiotherapy assessment- not too unsteady (if uses his frame) Medication review (13-5) D/C after conversation with GP and case conference arranged Carers planned

12 How to implement? Everywhere an older person presents A and E Minor injuries GP practice DN visit Ambulance staff Carers visit etc etc

13 Seems too daunting? Where are you responsible for? Get your own house in order Visit places where it s working Aim to train many to deliver a little rather than a few to do it all! Commissioners have a responsibility to work with clinicians to see and commission the whole service

14 Quality Standard 5 Older people living in the community who have a known history of recurrent falls are referred for strength and balance training.

15 What is strength and balance training? Exercise must provide a moderate/high challenge to balance Sufficient exercise dose (50 hours) over 3 months Ongoing exercise Brisk Walking should not be prescribed to high risk individuals Tai Chi an option

16 Implementation Most places have some access Not always evidence based Problem lies in the scale PHE have taken this on as a project for next year NICE QS can be used to effect change

17 Quality statement 6 Older people who are admitted to hospital after having a fall are offered a home hazard assessment and safety interventions.

18 Case history Mr A Recurrent falls with minor injuries Seen in A and E with head laceration Admitted as ambulance team said home very unsafe Lives alone in one bedroom gf flat Owns 2 cats- can t bend down to sort cat litter tray and keeps window open to let them go out

19 Mr A continued No clear floor space Fouled and worn carpet not fixed to floor All worktops covered in papers, dosset boxes, food and drink (rotting) Narrow space along corridor Flies and evidence of mice (we hoped)

20 Mr A continued Deep clean arranged Liaison with social services Reduce medication and communicate with GP Re-house the cats? Re-house Mr A?

21 Do we have enough OT s? Does it have to be done by an OT? Does it have to be done in the patient s home?

22 NICE QS Look after patients who fall safely Offer MFRA and intervention Strength and balance training classes or 1:1 Home hazard assesment

23 #youknowyouareageriatrican When you are heard to say tell me- what exactly is a mechanical fall? When you are heard saying it s easier to get an MRI in this hospital than a l and s BP!

24 #drugswelovetostop Amitryptyline 10mg at night (or any dose!) Tamsulosin in patients with a long term catheter (or not) Bisphosphonates in patient s who have been on them for 10 years or have less than a year to live or who are immobile Diuretics for non-heart failure leg oedema Doxazosin- every time? Benzos/zopiclone started in 1987 for insomnia after the cat died

25 In-hospital falls prevention audit National audit completed by RCP FFFAP- >5000 patients audited 98% trusts collected data 30 patients per trust Results available in basic form now Full report due to be published October 2015

26 In summary Time to do a gap analysis Good evidence base for reducing falls Not everything suits everyone 95% hip fractures occur as a result of a fall and preventing falls works!!

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