1 st North of England Falls Summit

Transcription

1 1 st North of England Falls Summit Queens Hotel, Leeds, Ballroom Monday 16 March 2015 e: / t: Or visit to our Academy Office: Bradford Institute for Health Research Temple Bank House/Duckworth Lane/Bradford/BD9 6RJ

2 Welcome and Introduction Dr Graham Sutton Consultant in Geriatric and General Medicine Leeds Teaching Hospitals NHS Trust 1 st North of England Falls Summit 16 March 2015 #t1noefs

3 Housekeeping

4 Our # for the Event #t1noefs

5 Poster Competition Enter our poster quiz to win a box of chocolates or a bottle of fizz! Winner announced at the end of the day #t1noefs

6 Patient Safety Collaboratives: new opportunities to learn from the frontline of care Tony Roberts Patient Safety Collaborative Interim Programme Lead North East and North Cumbria AHSN Deputy Director (Clinical Effectiveness) South Tees Hospitals NHS Foundation Trust 1 st North of England Falls Summit 16 March 2015 #t1noefs

7 Responding to Francis and Berwick The most important single change in the NHS in response to this report would be for it to become, more than ever before, a system devoted to continual learning and improvement of patient care, top to bottom and end to end. Berwick Report, August 2013

8 Responding to Francis and Berwick Following Don Berwick s recommendation, NHS England will establish a new Patient Safety Collaborative Programme across England to spread best practice, build skills and capabilities in patient safety and improvement science, and to focus on actions that can make the biggest difference to patients in every part of the country. They will be supported to systematically tackle the leading causes of harm to patients. The programme will start in April The government s response to Francis, November 2013

9 What is the patient safety collaborative programme and what will the Collaboratives look like? A network of 15 patient safety Collaboratives across England, with a five year lifespan Tackle the leading causes of harm to patients using QI, innovation & evidence based solutions, supported centrally Offer staff, users, carers and patients the opportunity to work together locally to tackle specific safety concerns Build patient safety and improvement capability quality and safety science education across professional groups Raise awareness create energy, build a safety movement Ambition - will be the largest and most comprehensive collaborative improvement initiative in the world Will (must) work cross sector and cross service

10 Collaborative priorities - proposals Topic area Patient Safety Topic The essentials Leadership Measurement NHS Outcomes Framework improvement areas Venous Thromboembolism Healthcare Associated Infections Pressure Ulcers Maternity Medication Errors Deterioration in children Other major sources of death and severe harm Falls Handover and Discharge Nutrition and hydration Acute Kidney Injury Missed and delayed diagnosis Deterioration of patients Medical Device Errors Sepsis Vulnerable groups for whom improving safety is a priority People with Mental Health needs People with Learning Disabilities Children Offenders Acutely ill older people Transition between paediatric and adult care

11 Sign up to Safety A national campaign for the NHS in England Aim to reduce avoidable harm by half and save 6000 lives Everyone working together as never before to achieve large scale, long lasting change 11 Update as at 21 August 2014

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14 The North East Legacy Many organisation-based initiatives, clinical networks and partnerships and collaborative projects Safer Care North East (led by former NE SHA): Our falls group has existed continuously since it was set up under this initiative Investing in Behaviours (led by NHS England North, in collaboration with the Health Foundation) Leadership programme (led by North East Leadership Academy) Mortality monitoring Measurement tools commissioned from NEQOS Collaborating for better care - NICE Best Practice Partnership Academic experts

15 Baseline patient safety metrics An approach is being developed locally Indicators in the public domain (no new measures at this stage) Helpful in identifying priorities Need to acknowledge the difficulty in answering the two key questions: Is the NHS getting safer? If it is, what contribution to that are PSCs making?

16 Progress so far Steering group has met 3 times, chaired by Professor Richard Thomson and agreed TORs. Membership remains open to review but includes patient and public representatives. Process to appoint small team to run the PSC Call for proposals January 2015: ~ 450K 22 projects received, 2 funded with request for 4 others to resubmit with alterations and 2 more for resubmission to next call Funded projects to begin in April 2015 Link to Health Education North East Faculty of Patient Safety

17 Contacts Tony Roberts Interim Programme Lead Cate Quinn Interim Programme Manager

18 The Yorkshire and Humber Improvement Academy Patient Safety Collaborative Dr Ali Cracknell Consultant in Medicine for Older People, Leeds Teaching Hospitals NHS Trust Alison Lovatt Clinical Improvement Network Director, Improvement Academy #t1noefs Telephone:

19 Yorkshire and Humber

20 Bottom up from the top

21 Improvement Academy Principles Compliment what is already happening and existing safety priorities for frontline teams Everything we do informed by organisations Work on behalf of organisations: mobilising frontline teams to focus on safety areas important to them Use evidence and practical support to increase capability bottom up from the top Support partners to become High Reliability Organisations

22 Foundations Building foundations since 2013 Gaining intelligence from frontline teams Improving safety culture Generating capacity 115 Yorkshire & Humber Fellows Funding to build on this Resources to support Share learning and scale up Innovate, Implement, and spread improvement Compliment what already doing wards, organisations

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24 Reducing harm at the frontline

25 Managing tensions between learning and performance RESULTS & LEARNING RESOURCING & ASKING PERTINENT QUESTIONS

26 Changing the conversation CQC Wider public NHSE RESOURCING & ASKING PERTINENT QUESTIONS

27 PRASE Engaging Patients

28 Team-working and culture UK adaptation of Safety Climate Survey developed by researchers at University of Texas

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30 Visual Data

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32 Changing staff behaviours

33 Safety Huddles in Healthcare Daily forum for staff to discuss any safety concerns Clinically led Multi-professional On time and brief (5-10 minutes) Reliable Fear free and inclusive Focused meeting about one or more agreed patient harm/s Informed by QI tools and feedback Ideally followed by debrief at end of day/shift

34 The Safety Huddle igniting a spirit of learning Making measurement visible Addressing Teamwork+Safety Culture Celebrating success Excellent achievement given the history of falls on this ward Clinical Director, Calderdale & Huddersfield NHS FT

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36 Measuring for Improvement

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38 Exercise and Falls Prevention Professor Pam Dawson Dean of Health and Life Sciences York St John University 1 st North of England Falls Summit 16 March 2015 #t1noefs

39 Falls: the scale of the problem 30% people >65yrs 50% people >80yrs fall at least once per year 5% of community dwelling fallers will experience a fracture Falls are the most commonly reported patient safety incident in NHS Trusts in England Falls affect faller, family and carers: Injury, pain, distress, fear, loss of confidence and independence, mortality Falls cost the NHS > 2.3b per year

40 Evidence for falls prevention: the problem of the scale Huge number of individual trials and studies globally over more than 2 decades Individual trials inform systematic reviews, Cochrane reviews, position statements, NICE guidelines, pt pathways Outcome measures Fall rates (falls per person year) or Fall risk (number of fallers in each group of a trial) Evidence doesn t speak for itself it has to be interpreted for the individual and their context Primary versus secondary prevention Community versus care settings

41 So what are the basic NICE guideline messages for exercise in falls prevention?

42 Exercise (strength and balance training) offered as a single intervention Older people living in the community with a history of recurrent falls and/or an identified gait and balance deficit should be offered multiple component exercise (strength and balance training) in an individual or group programme as a single falls prevention intervention individually prescribed and monitored by an appropriately trained professional Untargeted group based exercise has not been shown to be effective in these conditions NICE 2013

43 Exercise (strength and balance training) offered as a component of multidisciplinary falls prevention Older people living in extended care settings (e.g. nursing homes) who are at risk of falling and Older people > 65yrs (or yrs judged to be at higher risk of falls) admitted to hospital where any identified muscle weakness or gait/balance problem can be treated, improved or managed with individualised intervention during the patient's expected stay should be offered individually prescribed exercise as a component of multidisciplinary falls prevention intervention NICE 2013

44 Considerations when designing and delivering evidence based exercise for falls prevention Target group Type and setting of exercise Frequency and duration Previous falls (secondary prevention) Identified fall risk (primary prevention) Consider cognitive function Consider motivation and likely adherence Strength/resistance exercises Balance/gait training Individual or group based Trained professional How many times per week Over how many weeks Intensity The right degree of challenge for the individual Supervision/progression over time

45 How evidence-based are our exercise programmes? Survey of 1768 patients* referred to falls prevention services in England, Wales and NI wide shows two thirds were participating in group based exercise but wide variation in models of delivery of exercise interventions Recommended exercise programmes should be individually tailored, progressive and delivered over long periods (Otago 1 year; FaME 35 wks) Most patients attended group-based classes of short duration (<12 weeks) and only once/week Only 50% patients said their programme was progressed as they improved High levels of patient satisfaction with programme But lack of follow up afterwards *Buttery et al 2014 #t1noefs

46 Where the evidence doesn t help Dementia Evidence is inconclusive that exercise prevents falls in dementia/cognitive impairment* Poor adherence and loss to follow up* Cognitive impairment is frequently cited as a reason not to refer or not to offer exercise** Fear of falls Exercise alone may possibly reduce fear of falls but only in the short term*** Not all trials have fear of falling as an outcome*** *Winter et al 2013 **Buttery et al 2014 ***Kendrick et al 2014

47 Adherence and compliance Trials report uptake of exercise interventions can drop from as high as 80% in the first 10 weeks to 50% at one year* In practice adherence can be much lower Patient level barriers include transport, cost, motivation and injury Programme level barriers Group Decreased adherence with duration of 20 weeks or more, two or fewer sessions per week, or a flexibility component** Home - Increased adherence with balance component, home visit support and physiotherapy led*** Decreased adherence with flexibility component*** * Nyman and Victor 2011 **McPhate et al 2013 ***Simek et al 2012

48 How can we promote and improve adherence? Older people participate in exercise to remain independent and they value approaches that promote autonomy and self management Physiotherapists are fatalistic with a take it or leave it attitude to the exercise they prescribe and instruct Robinson et al 2013

49 Population-based interventions for prevention of fall related injuries in older people Systematic review to assess the effectiveness of population-based interventions, defined as coordinated, community-wide, multi-strategy initiatives, for reducing fall-related injuries among older people. Preliminary claim that the population-based approach to the prevention of fall-related injury is effective and can form the basis of public health practice. Randomised, multiple community trials of population-based interventions are indicated to increase the level of evidence in support of the population-based approach. McClure et al 2008

50 Exercise and falls prevention: from evidence to implementation Multiple agency commitment and older people involvement Population based and whole system approach Evidence based intervention applied consistently and with training Joined up approach with other pathways/ services, e.g. dementia Leadership and continuous innovation and quality improvement Joint commissioning

51 References Buttery AK et al (2014) Older people s experiences of therapeutic exercise as part of a falls prevention service: survey findings from England, Wales and Northern Ireland. Age and Ageing, 43: Kendrick D et al (2014) Exercise for reducing fear of falling in older people living in the community (Review), Cochrane Library, Issue 11 McClure RJ (2005) Population-based interventions for the prevention of fall related injuries in older people (Review), Cochrane Library, Issue 1 McPhate L et al (2013)Program-related factors are associated with adherence to group exercise interventions for the prevention of falls: a systematic review. Journal of Physiotherapy, Australian Physiotherapy Association Vol. 59 NICE (2013) Falls: assessment and prevention of falls in older people, NICE clinical guideline 161. Nyman S and Victor CR (2012) Older people s participation in and engagement with falls prevention interventions in community settings: an augment to the Cochrane systematic review, Age and Ageing, 41: Robinson L et al (2014) Self-management and adherence with exercise-based falls prevention programmes: a qualitative study to explore the views and experiences of older people and physiotherapists. Disability and Rehabilitation, 36(5): Simek EM et al (2012) Adherence to and efficacy of home exercise programs to prevent falls: A systematic review and meta-analysis of the impact of exercise program characteristics. Preventive Medicine, 55: Winter H et al (2013) Falls prevention interventions for community dwelling older persons with cognitive impairment: A systematic review. International Psychogeriatrics, 25(2):

52 A Hybrid Approach to Falls Rehab Dean W Metz, BSc MPH Falls Specialist Physiotherapist South Tyneside Foundation Trust 1 st North of England Falls Summit 16 March 2015 #t1noefs

53 A Unique Approach 1. A multifactorial Assessment done jointly by a nurse and a physiotherapist 2. A home programme to address specific identified weaknesses 3. A six stage progressive exercise programme administered by HCA and rehab nurses 4. Physio interventions not already included in the six stage programme #t1noefs

54 The Six Stage Programme 1. Supine 2. Seated in armchair 3. Seated on edge of mat table 4. Standing using rail for support 5. Standing using no upper extremity support 6. Dynamic standing on challenging surfaces BP and medications are monitored throughout

55 People need to function in challenging environments

56 People don t walk solely on linoleum.

57 People need to reach and balance to perform everyday tasks

58 Our Programme Builds on static strength training and incorporates trunk (core) exercises on gym balls and standing on alternative surfaces Emphasizes quick reactions to stimuli Is transferable to day to day functional activities

59 Tossing a ball whilst on pliable surface

60 Reaching and placing whilst on unstable surface

61 Kicking a ball or Playing football

62 Our Audit Results Reduced Risk of Falling Timed up and go: Mean decreased by 8.2 seconds Tinetti: Mean score increased by 5.8 points FES-I: Mean score decreased by 5.9 points Reduced Rate of Falling Self reported falls decreased by 81% 6 months after discharge

63 Refreshments and Networking #t1noefs

64 F A S S Multifactorial Falls Prevention Dr John Davison FRCPE PhD Falls & Syncope Service Newcastle-upon-Tyne Hospitals NHS Trust

65 A fall is not a diagnosis A fall may occur as a consequence of summative interaction of pathologies with reduced adaptive reserve Swift C 2006 Falls may signal unidentified medical problems unresolved underlying medical conditions Resultant of 1 intrinsic and / or extrinsic factors A cumulative risk Risk factors predispose events

66 Steinweg KK. Am Fam Physician 1997;56:

67 Epidemiology of falls the most common cause of accidents and associated morbidity in older people 35% aged >65 years will fall in any given year Up to 75% in those > 85 years Campbell 1981, Blake 1988, Prudham 1981 Lehtola 2006 Up to 45% of Emergency attendances in those >65 years are associated with a fall 20 % of these are admitted 25-60% result in injury Cummings 1988, Tinetti 1988, Nevitt 1991 Subjects > 50 Years attending A&E (n = 71,279) Non-Fallers 59% Richardson % lead to a fracture Tinetti 1988, Luukinen 1995 No Data 7% Fallers 34% (n = 24,251) Richardson 1997

68 Sequelae of a fall Loss of confidence to perform ADLs Tinetti M et al 1994, Vellas B et al 1997 Changes in health status Cwikel J et al 1992 Social isolation Increased hospitalisation Mortality at 1 year increased - recurrent fallers (OR 2.6, CI ) Increased Risk of admission to long-tem care single fallers (OR 3.8, CI ) recurrent fallers (OR 4.5, CI ) Donald, Bulpitt 1999

69 Intrinsic Lower limb muscle weakness (OR 4.4) Gait abnormalities (OR 2.9) Balance abnormalities (OR 2.9) Visual impairment (OR 2.5) Arthritis (OR 2.4) Cognitive impairment (OR 1.8) Neurocardiovascular abnormalities Synergism of risk % with risk factor Fall Risk Factors Balance Gait Extrinsic Walking aids (OR 2.6) Polypharmacy (OR ) Culprit medication (OR ) Environmental hazards (OR 1.5) Medication Home Hazards Median 5 fall Risk Factors identified (Range 1-10) ( n=146) Carotid Sinus Hypersensitivity Orthostatic Hypotension Vision Perell 2001, Leipzig 1999, Cesari 2002, Tinetti 1993 Neurological Depression Vasovagal Davison J, Age Ageing 2005;34:162-8

70 Fall risk No risk factors 3 or more risk factors Nevitt, 1989; Robbins, 1989; Tinetti, 1988

71 Overlap Between Syncope and Falls Unreliability of history 32% of elderly with documented falls were unable to recall the event 3 months later (Cummings 1988) Lack of witness account Only 40-60% of syncopal events are witnessed (McIntosh 1993) Amnesia for loss of consciousness (Kenny 1991)

72 Which population? Older community dwelling adults +/- fall risk factors Recruitment population for majority of exercise only interventions 7 RCT (n = 2361) RR 0.72 ( ) Older adults who have sustained a fall Multifactorial intervention studies indicate benefit 17 RCT pts selected for higher risk of falling (n = 5954) RR 0.77 ( ) Benefit not seen in multifactorial Rx when patients not selected for high falls risk Group exercise in higher risk group (n = 1261, 9 studies) RR 0.70 ( )

73 Key Intervention Studies - Community Tinetti NEJM 1994 Age 70+ with at least 1 fall risk factor (30% prev fallers) Multifactorial intervention 31% reduction in percentage falling (35% v 47%) Campbell BMJ 1997 Women age 80+ (40% prev fallers) Individually tailored strength & balance training programme 152 falls in control gp (n=117) v 88 in exercise gp (n=116) Robertson BMJ 2001 Age 75+ (36% prev fallers) nurse delivered strength & balance training programme 109 falls in control gp (n=119) v 80 in exercise gp (n=121)

74 Community dwelling present with a fall PROFET study Age 65+ Attending A&E with fall (72% single fallers) Medical and OT intervention Day hospital referral for identified risk factors Falls 510 falls in control gp (n=163) vs. 183 (n=141) RR 0.39 (95% CI ) Fallers Close et al, Lancet 1999;353:93-7

75 Recurrent Fallers Emergency Dept Davison et al, Age Ageing 2005;34:162-8

76 Recurrent Fallers Emergency Dept Recurrent fallers (median 3 falls) Medical, PT and OT intervention Neurocardiovascular risk factor assessment & intervention 387 falls intervention gp (n=144) vs. 617 (n=149) Mean rate of falls 3.3 (SD 5.0) vs. 5.1 (SD 7.9) RR 0.64 (95% CI ) = 36% reduction No effect on fallers (68% control vs 65% intervention)

77 Community dwelling fallers ambulance response 204 adults > 60 years ambulance called - subject not conveyed Randomised to community falls prevention (PT, OT, Nurses, medical review) or standard care Incidence rate of falls per year 3.46 vs 7.68 IRR 0.45 (95% C.I ) negative binomial regression Number of further ambulance calls reduced IRR 0.60 (95% C.I ) Logan PA et al, BMJ 2010;340:2102

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79 Exercise (Tai Chi, multiple component group, individually prescribed home) is effective as a single intervention Pooled RR = 0.71 (95%CI ) A J Campbell, Age & Ageing 2007:36:656-62

80 Multifactorial interventions reduce rate of falls Pooled RR = 0.76 (95%CI ) Gillespie LD et al: Cochrane Systematic Review 2012

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82 Hospital Inpatients Assess for Risk of Falls cognitive impairment continence problems falls history, including causes and consequences (such as injury and fear of falling) footwear that is unsuitable or missing health problems that may increase risk of falling medication postural instability, mobility problems and/or balance problems syncope syndrome visual impairment

83 perecentage of trials Act on risks identified Multifactorial intervention Fall rate reduction 20 30% Hospital Inpatients significant reductions in falls no significant reductions in falls multi-professional > five components post-fall review toileting plans medication review staff education urine screening environment footwear numerical risk score exercise hip protectors wristband alarms beside sign patient information Oliver D, Healey F, Haines T (2010) Clinics in Geriatric Medicine 26 (4) Fall rate ratio 0.75 ( )

84 Contributing Interventions that work Vitamin D in those with low Vit D levels > 800 units / day Home safety interventions only effective in visual impairment and if at high risk of falling First eye cataract surgery Harwood BJO 2005 Pacemakers for carotid sinus hypersensitivity? 3 studies, n=349, RR 0.73 ( ) Kenny JACC 2001, Parry 2009, Ryan 2010 Podiatry for those with foot problems Spinks BMJ 2011 Integration of balance & strength training into daily life activity Clemson BMJ 2012

85 When is multifactorial intervention less effective? Patients with dementia Treat the reversible look at medication change, BP control, behaviour management, # risk Shaw BMJ 2003;326:73 Single assessor intervention Kingston 2001, Lightbody 2002, Hendricks 2008 Generalist multifactorial intervention? Spice, Age Ageing 2009

86 Single assessor intervention Nurse-led multifactorial intervention F/U after ED attendance with fall 348 patients > 65 years multifaceted assessment trend towards reduction in falls - 89 in 36 intervention vs. 145 in 39 controls (ns) medication ECG blood pressure cognition visual acuity hearing vestibular dysfunction Balance Feet and footwear Mobility Lightbody et al Age Ageing 2002;31: Medication review education environmental risk ax exercise advice referrals Single assessor assessment & intervention after ED attendance with fall modelled on PROFET N=333 fallers age > 65 years individualised intervention OR of further falls = 0.86 ( ) Hendricks MR et al, JAGS 2008; 56(8):1390-7

87 Cluster randomised controlled trial Community dwelling recurrent fallers age >65 yrs not presenting to ED Intervention: 18 general practices randomly allocated Results: 1. Primary care group nurse assessment in the community, using risk factor review and targeted referral 2. Secondary care group day hospital multi-disciplinary assessment and intervention 3. Controls usual care 505 recruited (complete FU in 83%) Fewer fallers in secondary care group - 75%, (158/210) vs. 84%, (133/159) adjusted OR = 0.52 (95% CI ) P = Primary care group similar to controls - 87%, 118/136, OR 1.17 (95% CI )

88 Case find for falls Get up and go test History Previous falls Arthritis Muscle weakness Gait / balance problems Stroke / PD Medication Cognition Sensation Vision What to do in practice? 1. Assessment Examination Cardiovascular Orthostatic hypotension murmurs Neurological Muscle strength Sensation Locomotor Gait inc feet / footwear Vestibular Dix-Hallpike

89 Is there a medical cause? Is the fall unexplained? Does the patient recall the fall? Are the injuries proportionate? Are there other clinical pointers from the history? Lightheadedness Think white coat hypertension beware single BP symptoms with posture change Think.OH, culprit meds Symptoms when lying back / turning in bed Think.BPPV

90 What to do in practice? Investigations Visual acuity / Contrast Active Stand ECG Haematology / biochemistry CSM if syncope Dix-Hallpike DEXA Treatment Medication modification Treat Orthostatic Hypotension Targeted muscle strengthening exercise Duration > 12 weeks Balance exercise Environment modification Vitamin D if deficient Treatments for specific conditions Epley PPM

91 Visual assessment Verbaken A, Johnston A.W. Am J Optom 63: , 1986.

92 Investigations Spacelabs 90207

93 Medication review Any new medications? Timing of tablets? Culprit medications - FRID? antidepressants (esp SSRI on initiation) benzodiazepines neuroleptics /antipsychotics sedatives / hypnotics antihypertensives diuretics Ziere Br J Clin Pharm 2006, Leipzig JAGS 1999, Ensrud JAGS 2002, Woolcott Arch Int Med 2009, Sterke Br J Clin Pharm 2012

94 Medication Change Gradual withdrawal of psychotropic meds Community group with fall risk factors Campbell JAGS 1999 n = 93 Relative Risk of falling at end of intervention 0.34 [0.16, 0.73] Not sustained Withdrawal of Fall Risk Increasing Drug n = 139 with one or more falls in previous year FRID stopped in 67, reduced in 8 All FRID (n = 75) 0.48 (95% CI 0.23, 0.99) Cardiovascular Drugs 0.35 (95% CI 0.15, 0.82) Psychotropics (n = 29) 0.56 (95% CI ) Van der Velde, Br J Clin Pharm 2007; 63(2): 232-7)

95 Don t forget about bone health!

96 Take Home Messages Both single and multifactorial interventions reduce fall rates by about 30% Single interventions esp exercise work in community settings early targeting of those with risk factors Multifactorial intervention is effective for specific patient groups - when delivered by specialist teams Multifactorial intervention essential for hospital inpatients Heterogeneity of interventions remains large Consider specific interventions for sub-groups Look out for easy wins

97 Posture induced symptoms Lightheaded on standing? Unsteady on standing? Symptoms on lying flat or turning? Facial or head injury Disproportionate injury Fall with no apparent hazard Loss of consciousness

98 East Riding Falls Service Jon Duckles Service Manager Claire Sellers Clinical Therapy Lead Humber NHS Foundation Trust 1 st North of England Falls Summit 16 March 2015 #t1noefs

99 Local Drivers Why change? - Circa 20,000 people in the East Riding fall each year (POPPI data) - 30% of admissions to A&E are as a result of a fall - Limited falls service The new model: - Evidence based - Community focused, patient centred - Multi disciplinary, multi agency approach Investment: - 340k investment - Risk share agreement Benefits: - Improved patient care - 12% reduction in unplanned admissions = 400k savings

100 Admissions relative to 1130 Risk Share 1130 Acute Admissions due to Falls Risk s

101 Falls Pathway

102 Otago Type Programme Specific set of exercises performed in a set programme. Clear ways of progressing the programme. Approximately 1 hour in duration. Focusing on balance and strengthening as identified in the NICE guidance To be completed daily. TOMs utilised for assessment and reassessment. Once the patient is assessed and commenced on the programme, the rehabilitation assistants continue with the programme.

103 Rehabilitation Programme An individualised programme. Designed by the therapists. Including balance and strengthening exercises but also functional activities of daily living. Providing a holistic approach as depicted by NICE guidance Patient centred goals drive rehabilitation programme. TOMs utilised for assessment and reassessment. Once the patient has been assessed and commenced on the programme, the rehabilitation assistants continue with the programme and progress accordingly.

104 Complex Programme For patients with co-morbidities, who lack consent or are non compliant. Dementia and Alzheimer patients. For medicine management. Multi agency involvement lifeline, tele care, Neighbourhood Care Services, First Contact Practitioners. Safe systems. TOMs for assessment and reassessment to identify maintenance. Holistic approach to care.

105 Step-Up/Step-Down Ward. For comprehensive monitoring and assessment of patients. Make patients safe if medically unstable. Medical management. Falls suites tele care. Ward round all falling patients. Challenges in integrating 2 services with different drivers. Integrated Hospital Team links.

106 Falls Prevention and Fracture Liaison Service Christina Heaton Nurse Consultant Bridgewater Community Healthcare Foundation NHS Trust 1 st North of England Falls Summit 16 March 2015 #t1noefs

107 Falls & Osteoporosis NICE guidance Falls CG21 (2004) CG 161 (2013) undertake assessment of Osteoporosis risk National Osteoporosis Society 2010 NOS: Highlighted need for osteoporosis and falls assessment to be provided to patients with a history of fragility fracture RCP audit 2010 The majority of high-risk patients miss the best or only opportunity for their falls and fracture risk to be identified in the majority of hospitals and most primary care organisations Lack adequate services for secondary falls and fracture prevention. BOA-BGS 2007 Blue Book National Hip Fracture Database NICE guidance fragility fractures CG 146 (2012) Primary prevention of osteoporosis CG 160 NICE(2008) Secondary prevention of osteoporosis TA87/ TA161 NICE (2011) BRITISH ORTHOPAEDIC ASSOCIATION: STANDARDS for TRAUMA (BOAST) August 2013: BOAST 7: FRACTURE CLINIC SERVICES Fragility fracture and falls prevention services should be fully integrated

108 Osteoporosis 3 million people in the UK have osteoporosis 1 in 2 women & 1 in 5 men over 50 will break a bone, mainly due to osteoporosis It costs the NHS and government 2.5 billion a year, 6 million a day 230,000 fragility fractures Locally it is estimated that there could be 17,400 people undiagnosed Half of hip fracture patients suffer a prior herald fragility fracture 20% of patients with hip fracture die within 90 days. Only 50% of people regain full mobility in a year following an hip fracture

109 Fragility fracture through the life span 1 Osteoporosis + falls = fragility fractures Additional morbidity due to fragility fracture event Morbidity attributable to ageing alone

110 Falls Prevention Service Falls & Balance assessment clinic Falls Prevention Fracture Liaison service

111 Falls Prevention and Fracture Liaison Service Specialist falls multidisciplinary team assessment Focused medical assessment, investigation and diagnosis Multi-factorial assessment and treatment Full medicine review Osteoporosis risk assessment undertaken using FRAX & NOGG. Ordering and reviewing DEXA scan and suggesting or prescribing bone replacement therapy with counselling provided Specialist Physiotherapy assessment and treatment, based on national guidance. Occupational Therapy undertake assessment and treatment which including environmental and functional factors Health promotion, lifestyle advice and information Provided in health centre's and patients home across the borough Timely and appropriate referrals to other services and agencies

112 Key outcomes KPI % of patient seen within 6 weeks All patients in FLS who require bone health medication are followed up at 1 and 12 months to improve medication adherence, utilising Telehealth system FLO DNA (FLS 2014/2015)= 15% (national average 30%) DNA (falls 2013/2014)= 4% 10% of patients seen in the medical Falls clinic needed onward referral to hospital Consultant Patient satisfaction = 100%

113 Falls Prevention Service & Osteoporosis awareness new website

114 References BOA-BGS 2007 Blue Book BRITISH ORTHOPAEDIC ASSOCIATION: STANDARDS for TRAUMA (BOAST) August 2013 BOAST 7: FRACTURE CLINIC SERVICES National Hip Fracture Database NICE guidance Falls CG21 (2004) CG 161 (2013) NICE 2012 guidance fragility fractures CG 146 NICE 2008 Primary prevention of osteoporosis CG 160 NICE 2011 Secondary prevention of osteoporosis TA87/ TA161 NICE Protecting fragile bones: A strategy to reduce the impact of osteoporosis and fragility fractures in the UK RCP 2010 Falling standards, broken promises - Royal College of Physicians 1. J Endocrinol Invest 1999;30: Kanis JA & Johnell O 2. Osteoporosis Review. 2009;17(1):14-16 Mitchell PJ

115 Thank you any question? #t1noefs

116 Lunch and Networking #t1noefs

117 Patient Safety Julie Windsor Patient Safety Lead Older People and Falls Patient Safety Division, Nursing Directorate NHS England 1 st North of England Falls Summit 16 March 2015 #t1noefs

118 Falls Update Julie Windsor Patient Safety Lead Older People and Falls. National Advice & Guidance Team 16 th March 2015

119 What I m going to cover. Update on national falls and harms data National policy and guidance What we need to improve on What's on the horizon

120 There's no shortage of policies and guidance..! Quality & Outcomes Framework NICE GG 81 Hip# NICE Hip # QS NICE 161 Falls NICE TA s 204, 160,161 CQUIN # prevention. Dementia Comprehensive Spending Review NHS Operating Framework Best Practice Tariff Hip # Prevention Package Older People Musculoskeletal Services Framework RCN Lets Talk about Restraint Active for Life NSF Older People Commissioning Toolkit Falls & Fracture Prevention RCP National Falls & # Audit BGS/AGS Falls Guideline Blue Book ( hip#) Silver Book ( urgent Care) NPSA Slips, Trips & Falls in Hospital NPSA RRR post fall response NPSA Safer Practice Notice ( Bedrails) MHRA Use of Bedrails guidance NPSA How To Guide Reducing Harm from Falls

121 No wonder it seems daunting!

122 And so are the numbers.. Acute and Community Hospitals. England PD09 Degree of harm (severity) Total No Harm 170, , , , ,359 Low 64,121 64,669 61,484 57, ,258 Moderate 6,922 7,017 6,389 5,274 25,602 Severe 874 1,024 1,070 1,113 4,081 Death Total 242, , , , ,793

123 Mental Health Hospitals. England PD09 Degree of harm (severity) Total No Harm 18,370 17,241 17,093 16,120 68,824 Low 12,935 12,160 11,207 10,682 46,984 Moderate 1,425 1,368 1,431 1,292 5,516 Severe Death Total 32,835 30,886 29,872 28, ,

124 Age of patients reported to have fallen in hospital % of all reported acute falls Breakdown by age of falls in acute clusters 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Age group

125 Types of moderate and severe falls harms

126 Scale of the problem: death & severe harm Over 8,000 reported fatal or severe harm incidents each year 5% 6% 6% 6% 9% 8% 14% 19% 17% Suicide/severe self harm Fall (hip #/sub-dural) Pressure ulcer grade 4 Treatment error or delay Obstetric-specific incident Operation/procedure related Clinical diagnostic error/delay Missed deterioration Medication incident Healthcare associated infection Pulmonary embolus Test results not acted on Transfer or discharge incident Other/unclear NRLS post clinical review (after clear reporting errors excluded) April 2013-March 2014 England data: 8,018 incidents

127 NRLS definitions Moderate requiring hospital treatment or prolonged length of stay but from which a full recovery is expected. Severe Causing permanent disability where the patient is unlikely to recover former level of independence or impairment which is not likely to be temporary (i.e. has lasted, or is likely to last for a continuous period of at least 28 days).

128 What does a serious harm look like?

129 National Hip Fracture Database Variance in numbers reported to NRLS and Hip # database 2015/16 NHS Outcomes Framework likely to have IP acquired hip fracture in it.

130 A bit about benchmarking.

131 Triangulated data over time is important = the whole picture. Falls incidence Falls rate per 1000 OCBD Moderate & severe number and rate Multiple fallers per specialty Falls by patients with diagnosis of dementia Falls involving bedrails Complaints involving falls Safety thermometer can help individual wards with QI improvements but has limitations

132 Who should we assess? All patients aged 65 years or older Patients aged 50 to 64 years who are identified by a clinician as being at higher risk of falling e.g. o Sensory impairment o Dementia o Fall o Stroke o Syncope, o Delirium o Gait disturbances 133

133 NICE CG161 recommendations ₓ Do not use risk prediction tools esp those that assign a numerical score or hierarchy of risk. ₓ Do not offer one size fits all blanket interventions. Do use individual multifactorial assessment. Do use multifactorial intervention plans. Do provide relevant oral and written information about individual falls risk factors & bedrail use 134

134 Large high quality cluster RCT 43,837 patient ward admissions, 31,398 patients, 1,839 falls and 613 fall injuries. = Nursing interventions not as part as MDT intervention do not reduce falls or injuries.

135 Essential care after an inpatient fall 2011 guidance based on safety reports rather than research but is accredited by NICE. Have a post-fall protocol specifying: Checks for injury before moving Safe manual handling if fracture Neurological observations Timescales for medical review Provide: Flat-lifting/immobilisation equipment Glasgow Coma Scale formats Fast track to CT/x-ray/theatre

136 Not always getting it right yet.. a typical narrative from NRLS. Patient in room, on chair beside bed. Buzzer in reach & wearing non slip blue slipper socks. Some staff having hand - over two other nursing staff with patient in room 9. They heard thump noise from room 7. Patient on floor on his left side. Left arm under body. Skin tear / bleeding left arm. Slide sheet to roll onto back & hoist sling. Left leg rotated, shortened & unable to stretch out. Pain ++ to left outer hip & left groin. Patient states : no loss of consciousness, didn't bang head..

137 So what else is on the horizon? NHS Outcomes Framework 2015/16 Falls practitioners network

138 Does inpatient audit suggest we are doing well? Significant variation in adherence to standards of care were found in a large proportion of patients for whom falls preventative actions were indicated.

139 Education.

140 Post fall actions

141 Education

142 Understanding & improving poor vision Page 143

143 F Falls and Fracture Programme A survey of 20 areas to establish the feasibility of gathering and making available information about their local FFF system. Conducted by Local Authority Public Health teams in partnership with clinicians Purpose: Providing support to local FFF initiatives Assessing and tracking performance Learn from best practice Strengthen local partnerships

144 NHSE SIRI Framework update unexpected or avoidable injury to one or more people that has resulted in serious harm unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional in order to prevent the death or serious harm of the service user

145 Serious harm is defined as resulted in permanent harm chronic pain (continuous, long-term pain of more than 12 weeks) psychological harm, impairment to sensory, motor or intellectual function or impairment to normal working or personal life which is not likely to be temporary (i.e. has lasted, or is likely to last for a continuous period of at least 28 days).

146 NICE Falls Quality Standard

147 Thanks for listening, any questions?

148 INPATIENTS FALLS THE LEEDS STORY Graham Sutton Consultant Geriatrician Leeds Teaching Hospitals NHS Trust 1 st North of England Falls Summit 16 March 2015 #t1noefs

149 October 2012

150 Acute Floor initiatives and changes Change culture to think about what does this patient need Toileting Acute Medicine Falls Group Sharing of initiatives Trajectory setting RCA learning Falls champions

151 Collaboration with Improvement Academy Understanding how powerful patient safety culture can be

152 Interventions

153 Interventions

154 Celebrating Success

155 Progress on the Acute Medical Admissions Floor

156 Latest Figures for Acute Medicine CSU/Acute Floor Total Number Reduction % Reduction (11 months) Acute Medicine CSU Acute Floor Moderate or significant falls

157 Collaboration with Haelo

158 Incidence of falls per 1000 bed days Mean = 8.2 Start of collaborative Mean = 5.7 Start of collaborative

159 ANY QUESTIONS?

160 Staying Steady on the Buses Jill Poole - Health & Wellbeing Manager Roger Goode Arriva Yorkshire Risk Manager 1 st North of England Falls Summit 16 March 2015 #t1noefs

161 The beginning of a perfect partnership Arriva A need to decrease falls on buses Driver/ passenger relationship needed to be improved Public Health Decrease falls Prevent social isolation Contact made Consultation events held A plan began

162 Where to begin? Understand the issues for both groups Develop appropriate methods of consultation Driver health checks, relationship building Discus with community groups and older people forums and health professionals In brief the findings were: Drivers Passenger to speak to them Stay seated whilst the bus is moving Ring the bell Think safety! Older Adults Driver to speak to them Bus not to move until they were seated Stop when they ring the bell Think about their safety

163 Resolving the issues Older Adults Feedback from consultations Developed information leaflet Developed poster Cascaded messages to the community Falls awareness campaign

164 Campaign Posters

165 Resolving the issues Bus Drivers Feedback from consultations Certificate of Professional competence (CPC) training Driver education campaign Continued with health checks Arriva Angels and drivers part of the falls campaign

166 Results Positive feedback from older adults Positive feedback from drivers Statistics = Falls on buses have dropped 16% Continue to work together on: Dementia Awareness Safer Places Other Public Health campaigns Passenger support cards

167 Refreshment Break #t1noefs

168 The Prevention of Falls Injury Trial (PreFIT) An Update Julie Bruce PhD Principal Research Fellow University of Warwick 1 st North of England Falls Summit 16 March 2015 #t1noefs

169 Background Why was the trial funded? - Known risk factors for falling - Less known about optimal strategies for different populations Evidence for community-dwelling adults: (Gillespie 2012, 2008) trials of falls prevention - 34 trials of multifactorial falls prevention (MFFP) interventions - can reduce number of falls (rate); but NOT the number of people who fall (falls risk) - many trials small & underpowered

170 Exercise & falls prevention Evidence up to 30% reduction in falls rate & risk if well-designed exercise programme (Gillespie 2012; Sherrington 2008; 2011) Must be of moderate to high challenge Must be of sufficient dose & duration, can be home or group - frequency >2hrs week, progressive - duration 6 months

171 Uncertainty No direct comparison of exercise and MFFP No large UK study ever conducted Other trials too small to detect effects on injurious falls - fracture, injury and disability These outcomes important patient & NHS burden need for high quality economic evaluation

172 Weak evidence base for fracture prevention e.g. 6 exercise RCTs measured fractures Study Randomised Fractures Definitions % Bischoff, Hip only, in post-hip # 5.2% Haines, Any fracture 5.6% Korpelainen, Includes 2 vertebral 12.5% McMurdo, Any fracture 2.2% Robertson, Non-vertebral 3.8% Smulders, Non-vertebral 2.2% Total % Despite 59 trials of exercise, only 6 include fracture as outcome

173 Research questions What is the effectiveness of advice, exercise and MFFP for preventing fractures and falls? What is the effectiveness in subgroups by age, sex and fall history? What is the cost of each strategy & which is most costeffective? What is feasible and acceptable to patients?

174 Methods Design: 3-arm, cluster RCT Setting: primary care, 60 general practices, England 9,000 participants Participants: aged > 70 years community dwelling Exclusions: nursing / residential homes / terminal illness -

175 Interventions Control arm Age UK Leaflet Otago Home Exercise Programme Duration 6 months Multifactorial falls assessment conducted in primary care / falls team Assess identify factors treat or refer

176 PreFIT Exercise - Otago Programme Features Delivered individually in out-patient setting Lower limb muscle strength and balance exercises selected from a set programme Participants continue at home Frequency 3 x per week Intensity moderately challenging Duration 30 minutes Designed to be progressive Includes walking (30 minutes x 2 per week)

177 Multifactorial Falls Assessment

178 Study Design Advice only General Practices Exercise Balance survey MFFP Low risk - no treatment Intermediate High risk Otago Home Exercise MFFP Fractures, falls, quality of life, 18 months

179 Balance self-screener Risk classification Q. In the last 12 months have you had any fall including a slip or trip following which you came to rest on the ground floor or lower level? I have not fallen in last year I have fallen once in last year I have fallen more than once in last year Q. Do you have any difficulties with your balance whilst walking or dressing? No, or just occasionally Yes, often or always? Q. Do have any difficulties with daily activities, such as getting dressed, going to toilet? No, or just occasionally Yes, often or always? Lamb et al., J Gerontol A Biol Sci Med Sci., 2008

180 PreFIT Data Collection Questionnaires & Falls Diaries Baseline 4 months 8 months 12 months 18 months Consent Demographics Balance & mobility Difficulty ADLs Walking Falls & fractures EQ-5D SF-12 Comorbidity Frailty measure Falls diaries x 4 Primary outcome Fractures ~ HES / GP / Self-report

181 Total 63 practices Progress to date Newcastle City (n=11) N=1689 participants - 4 regions recruited! - Recruitment closed West Midlands (n=28) Warwickshire/ Herefordshire Worcestershire Birmingham Black Country N=4327 participants Cambridgeshire (n=6) N=982 participants Devon (n=18) N=2823 participants

182 - Trial ongoing.

183 Preliminary data Sample characteristics N = 9821 Age: mean 78 years (SD 5.7), range years Females 53% / Males 47% Balance screening in primary care feasible? Sent (subset only) Returned All other regions (85%) Newcastle Region (88%) Total (85%)

184 Frequency (%) Risk distribution N (%) Referred for Exercise or MFFP Falls history in last year N = % N = 2167 referrals % 11% 0 Low risk (no falls) Intermediate risk High risk (>1 fall) N=3624 N=1542 N=625 Risk profile Intermediate risk 5% Balance problems only 17% Single fall only 5% Single fall & balance problems

185 Risk distribution Newcastle Region vs Others All other regions Balance screeners returned Low Risk Intermediate risk High Risk (63%) 1295 (27%) 506 (10%) Newcastle (61%) 247 (26%) 119 (13%) Total (63%) 1542 (27%) 625 (11%) Survey of 5791 community-dwelling adults > 70 years:- - 60% not fallen / no balance problems in last year - 40% balance problems or fallen

186 How many attended PreFIT treatment? Interim data. N = 1088 Exercise referrals N = 1078 MFFP referrals 35% declined 65% Assessments completed 785 (73%) Completed MFFP 27% declined

187 Challenges - Remote sites - Busy clinical teams workload / staff changes Exercise - Is Otago challenging enough? MFFP - Variability in service models across regions - Standardising intervention materials - Medication reviews commitment from GPs

188 Successes - Getting started! - Good retention - Well received by therapists, falls teams & participants - Positive feedback pts. personalized exercise booklets - Input to all intervention materials - Trial documentation kept to minimum (MFFP = 1 page) - More to come..

189 To be continued. Thank you Thanks to all participating teams -

190 Acknowledgements Warwick team: Newcastle FASS team Grant-holders Sallie Lamb (CI) Dr Fiona Shaw Sandra Eldridge Emma Withers Dr John Davison + others Claire Hulme Susanne Finnegan Finbarr Martin Ranjit Lall Devon PI Dawn Skelton Martin Underwood Dr Ray Sheridan Lucy Yardley Susie Hennings.. Keith Willett West Midlands Thanks to: Jonathon Treml John Campbell, NZ Ruma Dutta Claire Robertson, NZ Kitty Westacott Mary Tinetti, USA + numerous participating general practices & falls teams

191 Summary and Close Prize draw Fiona Shaw #t1noefs

192 Thank you for attending Please complete the evaluation form in your pack, and return your badges before leaving #t1noefs

193 Contact t: e: #t1noefs