The STEEP (Staying Steady Exercise and Education Programme) is a 7 week programme consisting of an extensive multi-factorial falls assessment followed by 6 weeks of 30 min educational talks followed by 30 mins of exercise circuit. The aim of the programme was to provide a service that patients could attend following an admission due to fractured neck of femur to prevent further falls in the future and thus reducing readmissions.
This is based upon the guidance for hip fracture management (NICE CG124, 2014), which was updated in 2017, where it is indicated all patients with a fractured neck of femur should attend a strength and balance group on discharge.
The guidance for falls in older people: assessing risk and prevention, (NICE CG161, 2013) indicates strength and balance falls prevention groups should consist of an extensive multi-factorial assessment with education and exercise. There is currently no service in Surrey that provides this service of education and exercise.
Aims and objectives
NICE guidelines have indicated that all patients with a fractured neck of femur should be referred to a strength and balance group on discharge to prevent further falls in the future (NICE CG124, 2014 (updated 2017).
The NICE guidance for falls in older people: assessing risk and prevention, indicate that strength and balance groups for falls prevention should consist of an extensive multi-factorial assessment, education on a variety of topics and exercise (NICE CG161, 2013). It is the responsibility of all health care professionals to educate patients in the prevention of falls.
The aim of the programme was to set up and develop a strength and balance training programme for patients to attend following a fractured neck of femur. A further aim is to prevent readmissions as a result of a fall with improved psychological aspects associated with a fear of falling.
The objective of the programme is to reduce patients fear of falling, reduce risk of falls through education, improve balance through exercise, teach backward chaining to reduce ‘long lie’ rates and in turn reduce annual costs, mortality rates and referrals to other services.
Reasons for implementing your project
The project was implemented to continue the pathway of fractured neck of femur patients into the community following discharge to ensure they had appropriate falls education and strength and balance advice, as per the NICE Guidelines. The team liaised with Trusts within the locality to source appropriate groups but these did not exist, therefore a group was set up within the physiotherapy outpatient department at Ashford and St Peter’s Hospitals NHS Foundation Trust (ASPH).
Prior to the STEEP programme, community OTAGO balance groups and falls clinics provided regular exercising opportunities to improve balance and strength; however, there was no extensive falls risk assessment or education component. No outcome measures were used to monitor progress. Within the catchment area for ASPH (North West Surrey), extensive falls risk assessments by healthcare professionals, education and exercise is not provided, hence the NICE Guideline recommendations are not being met. This may have resulted in higher readmission rates and fractures as a result of falls. Consequently this may have increased the money spent by the Trust on managing falls admissions.
The falls programme aims to reduce admissions due to falls and fractures, creating a cost saving on those patients. The programme set up allows 6-10 patients to be assessed and educated within 7 weeks. All participants were assessed and re-assessed using the outcome measures, Timed Up and Go; Berg Balance Scale; 4 – Point Balance Scale and the Falls Efficacy Scale. Initial outcome measures did not recognise specific weaknesses and needs due to poor specificity and sensitivity. Orthopaedic patients were consulted to establish an interest in attending a falls prevention programme and most were keen to attend. Feedback is gained through a questionnaire at the end of the class to direct changes.
The catchment area for ASPH is 410,000 people (ASPH, 2017). 376 were admitted to ASPH with a fractured hip in January-December 2016, 59% of these were discharged back to their original residence. North West Surrey CCG states in their health profile of 2015 that 17% of residents are aged 65 and over and 3% are aged 85 and over.
The CCG predicts the proportion of people 85 years and over will increase by 43% by 2025. The CCG reports 400 residents break a hip each year and advise patients should attend falls prevention programme which was not available prior to the development of the STEEP Programme.
How did you implement the project
Patients were referred to the programme in accordance with an inclusion/exclusion criteria based on the current NICE Guidelines (2013) (See Appendix 1). Referrals were received from falls clinic, orthopaedic-supported discharge team (OSD), the orthopaedic therapy team and Bedser Hub on a specified referral form (See Appendix 2).
As the guidelines indicate a multi-factorial assessment covering various topics should be used, a single assessment form was created which included the outcomes measures (NICE CG161, 2013). (See Appendix 3). This form is used during the initial assessment, followed by 6 weeks of educational talks and exercise and there is a re–assessment in the final class. Educational talks cover topics advised by NICE (CG161, 2013).
The programme was set up, using current establishment from the orthopaedic and outpatient therapy team using the outpatient gym. Due to the extensive multi-factorial assessments and outcome measures used, the assessment took between 30-45mins per patient. One physiotherapist and 2 therapy techs can only assess 6 patients within the allocated 1hr 30mins. Therefore, we are currently looking to acquire an additional physiotherapist to assess 10 patients within 1hr 30mins.
Further expansion of the service has been identified as there is a need within outpatient physiotherapy and other inpatient therapy teams; however, we currently hold a long waiting list. There are plans to expand the service to include a class at Ashford and Woking hospitals. Telephone assessments are used to verbally manage inappropriate referrals and our referral paperwork has been adjusted to improve appropriateness of referral. If there is any uncertainty of the patient’s suitability they are invited to attend the initial assessment only. If the patient has high risk of falls indicator on the Berg and requires 1:1 support they are not appropriate for group and a referral is made to the community rehabilitation team.
The exercise circuit was originally based on the OTAGO balance exercises; however, these were good for increasing balance and strength but did not address functional tasks. Consequently, the exercises were re-designed to also include functional tasks such as reaching, carrying and turning. Due to some patients being of higher falls risk it was necessary to re-design the layout to ensure the safety of all patients during the exercise circuit.
The programme did not incur any costs, as current facilities, equipment and staffing were used to provide the service.
The aims of the programme were to prevent readmissions as a result of a fall by improving a person’s falls risk and fear of falling and then subsequently reducing annual costs for admissions, mortality rates and referrals to other services.
To date, 20 patients have been invited to attend the programme over 4 classes, 15 completed the course and 5 did not complete the course. On assessment, 10 patients presented as medium risk of fall, 1 patient presented a high risk of falls and 9 patients presented with low risk of falls.
At the end of the programme all patients were categorised as low risk of falls, with the exception of 1 who was categorised as medium risk of falls. 8 of these had a significant increase of ≥8 in their score. 9 patients had a reduced time on their ‘Timed up and go’, 5 had no change and 1 patient had an increase in their time. Average change -2.4 secs (likely to be larger as many used walking aids initially but not on re-assessment). 11 patients had improved falls efficacy, 2 had no change and 2 had increased fear of falls (this may be due to a misunderstanding of the question). Average change in falls efficacy = -31%.
Running a falls prevention programme has made significant cost savings to the therapy service and trust as a whole. There has been an increased capacity within the outpatient physiotherapy department as these groups of patients are now not requiring 1:1 treatment sessions and the patient is also now receiving a more specialist programme of therapy. Preventing hospital admissions for fractured femur as a result of a fall would make significant cost savings to the NHS.
Patients admitted with a fractured hip would, on average stay 15.6 days at £300 per day, therefore for every fall resulting in a fractured NoF prevented would be a save £4680 per patient. STEEP Falls Prevention programme received 127 referrals between October 2016 and November 2017. 79 of these were from the falls clinic, 7 from the Bedser Hub, 39 from orthopaedic therapies and 2 from the OSD Team (Appendix 4).
Currently 7 groups run per year with 6 patients per group, assessing 42 patients per year. We hope to increase this to 10 patients per group on increased staffing and allow increase of referrals with 3 groups per week resulting in 1,470 assessments per year. 6 month follow up results so far have revealed 4 out of 10 patients have fallen again but only 2 of these were admitted to hospital. 4 of these patients continue to do their exercises.
Key learning points
The key things that have been learnt from the setup of this service are that, appropriate referrals and communication are key in ensuring all patients are appropriate. As there is an increased risk associated with this patient group, extra time is required to make a full thorough, timely multi-factorial assessment. Effective and appropriate knowledge of services for onward referral is required to ensure momentum is continued on discharge from the service.
On reflection a thorough meeting and presentation with all professionals involved and referring professionals would be useful to ensure only appropriate referrals were received with a good understanding of what the service entails. Additional time should be factored in with additional staffing to make multi-factorial assessments due to the high risk client group. It would be useful to discuss with other falls prevention services from other trusts to see what service they provide and learn from their experience. For effective onward referral, improved communication with community services such as OTAGO balance exercise groups and seated exercise groups is required.
For other organisations that do not currently provide a falls prevention service I would emphasise the importance of setting up the group with plenty of time, keeping exercises simple and easy to understand and would emphasise the importance of having a multi-disciplinary team to speak and present throughout the course to give a well-rounded presentation. Paper hand outs are recommended to be available for all educational talks to ensure carry over. Using appropriate literature to evidence base the use of relevant outcome measures for the appropriate group is recommended to ensure effective data analysis.