Report to: Board of Directors Date of Meeting: 26 th October 2016 Report Title: Inpatient Falls Report Status: Mark relevant box with X Prepared by: Executive Sponsor (presenting): For information x Discussion Assurance Approval Regulatory requirement x Elaine Andrews, Assistant Director of Nursing & Safety and Caroline Booton Quality Analyst Jill Asbury, Acting Director of Nursing Purpose of the Report In-patient falls remain a great challenge within Airedale NHS Foundation Trust and we remain committed to ensure that our multidisciplinary team tailor interventions to the needs of the individual patient. Research demonstrates if this is done then falls may be reduced by 20-30%. Quality improvement work has been ongoing on Ward 4 and the approach has now been scaled up to include Wards 6, 7 and 9. Focusing on the Elderly Ward (Ward 4) and working in collaboration with the Yorkshire & Humber Improvement Academy, core safety improvement principles are being implemented, including providing support within the clinical environment and recognising the clinical expertise and knowledge of the team. Current evidence shows that multiple interventions (used in conjunction) are effective in reducing falls, including chair and mattress alarms, advice on footwear and toileting schedules (including nocturnal continence). A key intervention is a falls safety briefing (or huddle). These are led by a senior clinician with the objective of identifying those patients at high risk of falling and determining how to prevent such a fall. The report outlines the progress that we have made to date and the ongoing work that we intend to undertake. Key points for discussion Measurement over time is essential in quality improvement with benchmark data necessary to demonstrate improvement. Following key interventions that have been undertaken on Ward 4 the average number of weekly falls has improved. Work is already ongoing to scale up the QI work stream on the other wards Since March, there have been no further instances of a serious fall on Ward 4. There appears to be a cultural shift away from accepting inpatient falls as normal and part of a proactive approach to prevention. Our current falls rate in the Trust is below both the Trust and national average for the second consecutive month. (August and September 2016) (Figure 2) Continuous improvement is built on small incremental changes, using a systematic approach to
test their impact and feasibility - Plan-Do-Study-Act. Recommendation The Board are asked to: Acknowledge the significant work that we have already undertaken to date. Acknowledge the areas upon which we have improved upon. Continue to support the scaling up work and acknowledge that more focussed work is required.
Update for Trust Board October 2016 Current Position regarding inpatient falls in ANHSFT - October 2016 1.0 Introduction In-patient falls remain a great challenge within Airedale NHS Foundation Trust (ANHSFT) and we are committed to ensuring that our multidisciplinary team tailor interventions to the needs of the individual patient. Research demonstrates if this is done then falls may be reduced by 20-30%. National evidence also suggests that patient harm is likely to occur at the second fall and therefore it is paramount that interventions are put in place at this time in order to minimise the risk of a further fall. This paper will describe the focussed approach that is being taken within ANHSFT using the science of improvement. Individuals who fall tend to have multiple interacting risk factors, and so we should not be surprised that falls prevention is a complex rather than straightforward challenge. Falls prevention programmes in hospital settings are usually only successful when multiple interventions are included. The Falls Steering Group continues to coordinate the falls related work. Quality improvement work has been taking place on Ward 4 as part of the Ward Development Plan since March 2016 and is now being scaled up to include Wards 6, 7 and 9. 2.0 The falls quality improvement project on the complex medical elderly ward (4) 2.1 The challenge and aim: Falls are a cause of injury, pain, distress, delay in discharge and loss of independent living. Evidence suggests that the effect is particularly pronounced for people over the age of 65. 1 The aim is to effectively manage and reduce the number of falls sustained by inpatients. A key objective is a concurrent improvement in falls that result in significant harm (head injury, severe laceration) and fracture. 2.2 Interventions taken: Focusing on the Elderly Ward (Ward 4) and working in collaboration with the Yorkshire & Humber Improvement Academy, core safety improvement principles have been implemented, including providing support within the clinical environment and recognising the clinical expertise and knowledge of the team. Current evidence shows that multi-component interventions are effective in reducing falls. Ward 4 has introduced chair and mattress alarms, advice on footwear and toileting schedules with a particular focus on nocturnal continence. A key intervention is a falls safety briefing (or huddle). These are led by a senior clinician and take place each morning with 1 Department of Health (2009) Falls and Fractures: effective interventions in health and social care. Crown copyright: COI for DH. 1
the multidisciplinary team (MDT). The objective is to identify those patients at high risk of falling and determining how to prevent such a fall. 2.3 How we will know that a change is an improvement: Measurement over time is essential in quality improvement. Benchmark data can augment evaluation. Figure 1: Special Process Control Chart number of falls on Ward 4 commencing 26/01/15 (Week 1) 9 8 7 6 5 4 3 2 1 0 Week 63 Week 66 1 3 5 7 9 1113151719212325272931333537394143454749515355575961636567697173757779818385 No of falls Overall average UCL Week 75 Source: Ulysses. The special process control chart shows the number of fall incidents reported each week on Ward 4, commencing 26 th January 2015 (Week 1). A 64 week baseline period provides a reliable value against which progress can be evaluated. In the baseline period, there were on average 2.9 falls a week. Three points in this period show the number of fall incidents above the expected range (upper control limit [UCL] denoted by the green line), a finding that cannot be explained by random variation or chance. Key project intervention milestones are as follows: Week 63 (2016) weekly safety huddles commence. Week 66 (2016) Dr Ali Cracknell from The Improvement Academy visits Ward 4. Week 75 (2016) Chair and mattress alarms are introduced. In the subsequent period (Week 65 onwards), the average number of weekly falls has improved to 1.7. Two out of three data points are more than two standard deviations below the average and three out of five points are more than one standard deviation below the 2
average. These are tests for special cause variation and indicate a favourable shift in performance. 2.4 The progress made: The data indicates improvement in both the number of falls and, on closer inspection, their severity. Between April 2015 and March 2016, four falls resulted in significant harm and two in fractures. Since March, there have been no further instances of such falls on Ward 4. Whilst these are small numbers and variation due to case mix between years can be expected, findings suggest a change in culture. Work to sustain the progress made is being supported by an initiative to measure the days between falls; Ward 4 has had an episode of 26 consecutive falls free days in July into August 2016. There has been a cultural shift away from accepting inpatient falls as normal and part of a proactive approach to prevention. 3.0 Current falls rate Trust-level view of performance 2016/17 The following special process control chart shows the Trust-level inpatient falls rate per 1000 occupied bed days (depicted as a blue line). The red line indicates the RCP Falls Audit national average to enable comparison. The rate in August shows variation (better than expected) below the predicted summary range (denoted by the red triangle). Whilst the September value is within expected limits, the rate is below both the Trust and national average for the second consecutive month. Figure 2: Airedale NHS FT falls per 1000 occupied bed days 12.00 10.00 8.00 6.00 4.00 2.00 - Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Falls per 1000 OBD Average LCL UCL RCP Falls Audit/1000 bed days Source: Information Services and Ulysses. 3
Of all the falls that have occurred since April 2016 (n=473), the following stack chart shows those that have resulted in significant harm (n=9) and/or fracture by location (n=7). Figure 3: Reported falls resulting in fracture and/or significant harm by location - year to date 8 7 6 5 4 3 2 1 0 Ward 1 Ward 2 Ward 6 Ward 7 ACU Source: Ulysses. Number Ward 16 [CCU] Significant Harm 1 4 2 2 Fractures 1 4 2 It is noted that the majority of the falls that result in significant harm have occurred on the medical wards so further focussed work will be undertaken as an extension to the work described in this paper. 4.0 Progress of the Wards as part of the scaling up phase Ward 9 has had an episode of 34 consecutive falls free days in August 2016. Ward 4 has had an episode of 26 consecutive falls free days in July into August 2016. Ward 4 is presently (as of 14 th October 2016) at 9 falls free days. Ward 6 has had an episode of 14 consecutive falls free days in September 2016. Ward 7 is presently (as of 14 th October 2016) at 38 consecutive falls free days. 5.0 Next steps The Assistant Director of Nursing and Safety meets with the Senior Sisters weekly and will continue to identify any themes/trends relating to the patient falls from the preceding week. Scaling up the Quality Improvement work will continue across the wards. Work will continue as part of the scaling up to embed a cultural shift away from accepting inpatient falls as normal and part of a proactive approach to prevention. Following a further visit from Dr Ali Cracknell from the Improvement Academy in September 2016 other wards will be introducing the Safety Huddles; these being Wards 5, 6, 7 and 9. Planning is taking place to set up a local engagement event with the Improvement Academy, with Ward 4, to talk about our progress with Safety Huddles. 4
Dr Ali Cracknell will visit again on the 18 th November and work will commence with the rest of the inpatient areas. All patients who are at risk of falls continue to be assessed and have a higher level of observation prescribed within the Intentional Rounding/Safety Bundle A Task and Finish Group is leading work on enhanced supervision (also known as specialling ) throughout the Trust Carers and families are being encouraged to participate in care. This is part of the implementation of John s Campaign (this is a national campaign the aim of the campaign is for the right for carers and families to stay with people with dementia within the hospital setting). ANHSFT have pledged commitment to this. The Falls Steering Group have commissioned a Task & Finish Group to improve the Falls Care Plan It is noted that the majority of the falls that result in significant harm have occurred on the ground floor wards so further focussed work will be considered. The University of Portsmouth are embarking on a piece of work around cushioned flooring (Hip Hop flooring) for high risk areas in clinical wards and they are looking at Centres to participate. Airedale is hoping to participate in this. The Post falls proforma has now been rolled out Trust wide. 6.0 Summary Continuous improvement is built on small incremental changes, using a systematic approach to test their impact and feasibility - Plan-Do-Study-Act. We are intending to roll out safety huddles across Wards 5, 6, 7 and 9 in the coming weeks. To scale up and spread the lessons learned the support of the Quality Improvement Team (specialists in improvement science) is required to ensure effective implementation. 7.0 Recommendations The Trust Board is asked to receive and note the work being undertaken related to falls in order to reduce the number of falls and the severity of the same. Elaine Andrews Assistant Director of Nursing and Safety Caroline Booton, Clinical Quality Analyst 17 th October 2016 5