Shared learning database

University Hospitals Birmingham NHS Foundation Trust
Published date:
May 2013

The Trust has implemented an evidenced based multifactorial and multidisciplinary falls care bundle; the interventions are individualised for each patient and account for complexities in regards to the reason for their admission and prior co morbidities. The falls care bundle enables staff to choose from various falls interventions and apply these interventions to their patients care requirements at different stages of their recovery. The interventions include medical causes, medication reviews, mobility and footwear, environmental factors/hazards, cognitive assessment, consideration of delirium, continence assessment and appropriate use of equipment. The communication of a patient's risk of falls to the Multidisciplinary team is enabled by an electronic communication system; this is then linked by a number of alerts to the medical and pharmacy teams.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Our aim was to understand by robust reporting systems the reasons why patients fell and then use this analysis to consider solutions to the preventable causes. The implementation of a mulifactorial/ multidisciplinary falls care bundle enabled the Trust to demonstrate patient outcomes. We utilise the electronic DATIX reporting system for falls; we have added a falls specific page capturing the causes and interventions required to prevent further falls. This enables an understanding by analysis of the causes of patients' falls; we then use this data to influence falls prevention strategies in the ward area to prevent falls and reduce harm from the falls we cannot prevent.

An example of this is in regards to patients falling during transfer or mobilisation; when we looked at the equipment the staff had as an option to help patients with this, it was felt as well as the existing equipment there was a need for a simple transfer aid to help the more able but, who are not able to walk the complete distance to bathrooms. The Acute setting is fortunate to have ensuite bathrooms and bathrooms located in four bedded bays; we found that patients in recovery benefited from the transfer aids during their rehabilitation.

The Falls care bundle/multifactorial assessment and prevention strategy aligns with the NICE Guidance as it identifies a patient's individual risk factors for falling in hospital that can be treated, improved or managed during their stay. This includes cognitive impairment, continence problems, falls history including fear of falling, footwear, pre existing health problems that may increase their risk of falling, assessment of Osteoporosis risk, medication both existing and new, postural instability, balance and mobility problems with the recognition of how these can change throughout the care journey and visual impairment.

Our main focus as a Trust was to prevent patients falling and sustaining harm from falls, there has been a great deal of investment in both staff and resource, environment and equipment to support the prevention interventions; such as the purchase of beds that have under bed lighting, beds that go to floor level, a supply of patient slippers that are firm fitting for those who cannot supply or afford their own.

Reasons for implementing your project

We feel it is important to be able to pause on a periodic basis to look at why you are doing things in a certain way. Is it the right way? Is there new evidence that you need to consider to challenge the way you are preventing falls? What do we need to change and how are we going to implement the changes required. When I started in this role I felt it was important to understand the data set and falls prevention strategy, including the communication to the staff at all levels of the organisation. A baseline assessment of our data, including level of data such as times of patient falls for both day and night, wards with increased incidence of falls and contributory factors.

Whilst the new NICE Guidance stresses the requirement for patients over 65 years of age or 50-64 years of age with clear indication of risk of falls to have multifactorial interventions. We made the decision to assess all patients for their risk of falls as we have specialist services such as major trauma, burns and neurological patients that would demonstrate a higher risk inpatient population.

The introduction of the mulifactorial management plan gave MDT staff a clear direction in regards to which interventions they could consider for their patients. There was also quality assurance in terms of implementing evidence based interventions, moving away from a risk scoring system which indicated which interventions where appropriate depending upon a score.

Demonstrating patient outcomes has enabled the Falls group to request further funding for falls prevention equipment such as high/low beds, transfer aids and patient footwear (slippers) which are given free to patients who do not have anyone to supply them.

How did you implement the project

In regards to making the changes, I feel that there has to be the willingness at the top of the organisation drive the changes through at all levels. It is imperative to have executive level involvement in the Falls Steering Group as well as a lead Consultant, Lead Nurse Falls Prevention, Nursing, Physiotherapy, Occupational Therapy, Pharmacy, Governance and Health and Safety representatives. This group was essential to delivering the falls prevention agenda across the organisation and ensuring that falls prevention remained a key focus for staff at the ward and departmental levels.

Staff groups have different priorities to their resource and it was essential to gain their acceptance of their role within the wider falls prevention strategy. In order to get meaningful engagement of staff from other disciplines, it is important to recognise the pressures they have to deliver their own outcomes, to understand if there is a cross over with the outcomes that can be delivered as part of the falls prevention strategy. Therefore it is not delivering falls prevention as an isolated harm reduction but as part of a wider patient safety and outcome led initiative. Staffs understand this as part of their role on a day to day basis rather than an extra requirement to their already pressured workload.

As part of this strategy it was essential to facilitate each of the staff groups in finding their own solution as to how to deliver on the falls prevention strategy including how they measured their own success including audit of the standards they set to deliver. We have managed to do this with Physiotherapy, Occupational Therapy, Pharmacy and Medical staff as well as having key quality indicators for nursing staff to achieve. These reports are fed back as to the Falls Steering Group.

We also utilise our patient electronic systems to enable MDT communication of a patient's risk of falls; this for example will enable the ward pharmacist to know who was at risk of falls, so during their review of the patient consider medications that could be altered, with medication advice review notes added for medical teams. The number of medication reviews then can be audited to individual level data. We have a program of Falls prevention training, which includes mandatory training for nursing staff and key note lectures to AHP staff groups.

Key findings

We monitor progress in a variety of different ways, from patient medical notes audit for AHP assessments to clinical dashboards that identify numbers of falls assessments on an individual ward basis. A variety of falls audit tools have been developed including falls benchmarking, this is then Benchmarked against previous years achievements on a ward level, spot audits to monitor falls care bundle standard, use of bed rails assessment and care planning and back to the floor tools for Matrons and ward managers to use to assess falls prevention standards.

We have been able to monitor the number of falls assessments completed for ward level data, this is then published on a clinical dashboard which all staff have access to, we actively encourage staff to view their dashboard to review their compliance to standard required. We have seen an increase in the number of assessments that have taken place. The dashboard can be monitored remotely enabling all levels of staff within the Trust access to this information. Ward Managers utilise this information as part of their quality delivery agenda as it includes patient feedback and complaints as well as other clinical quality indicators. This information for assessments is updated every 15 minutes and is available as a 30 day rolling data set. This system also captures the number of patient falls within an area.

The DATIX system enables a real time monitoring of patient falls which is sent via an email to the falls prevention team; it is the aim of the team to review every patient who has fallen supporting clinical staff with post falls care and ongoing falls prevention strategies. The quality of assessments and interventions occurs at this point and staffs are given targeted support to maintain the required standard. For detailed results, please see the support material

Key learning points

I would suggest that they have a key individual that falls prevention is their main role and that working with a strategic group made up of members detailed above to drive the falls prevention agenda at all levels within the Trust. This key individual should drive National and local falls prevention strategies with the Trust at both ward and senior levels.

There should be robust system to analyse the patient falls trends and the knowledge and understanding to apply this information to patient outcomes on a day to day basis. Understanding how to undertake investigations of serious harm and ensure that learning from these incidents are communicated to all groups across the organisation.

I would suggest that looking at the processes that are in place to enable staff to do the right thing is imperative in reviewing the overall falls prevention strategy; start with simple interventions and build it into a fully comprehensive falls prevention program, it has taken four years to be where we are today, build on each success to maintain momentum.

Contact details

Alison Doyle
Falls and Fractures Prevention Nurse Specialist
University Hospitals Birmingham NHS Foundation Trust

Primary care
Is the example industry-sponsored in any way?