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Improving the Assessment of Falls at BSUH

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Maissa Rosie

on 13 May 2014

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Transcript of Improving the Assessment of Falls at BSUH

A walk through the development of a falls assessment proforma for all on call
Our Proposal....
Our Findings
By Maissa Rosie, Alice Brooke & Rosalind Haire
Frequent Request of Junior Doctors
Often at difficult times of day
- in the middle of a busy on call
- on nights
Daunting task for juniors (especially new F1s)
Difficult assessment to carry out
- patient population varied
- not a one size fits all approach
Can forget key things to check (e.g. hips)
Can forget to DOCUMENT things you have checked
(e.g. GCS)
Access to Guidelines
Post-Fall Management
Audit Findings
Interesting Observations
No documentation
6 patients had no documentation of a visit from a doctor following their fall.
Sedative drugs
2 patients had had sedative drugs on the night they fell (Zopiclone) – this was not acknowledged or stopped. One of these patients went on to have a fall a few nights later.
To ECG or not to ECG
In the documentation of one patient who had fallen, the impression was "fall ?secondary to bradycardia" but HR not documented, no ECG done. An ECG done 6 days later found a HR of 30.
Poor documentation of GCS
1 patient was acutely confused post fall, yet their GCS was not recorded. They later required a CT head due to confusion.
Poor addressing of anticoagulation state
Poor follow up by team post-fall/ next day
Lack of acknowledgment of fall by day team

The 'BSUH Falls Proforma'
2 sided A4 document
Includes
- Key aspects of assessment.
- GCS
- Sections for bony injury, neurological
- CT head flow chart for head injury
- Prompts to look at medication
- Prompts for nursing handover & obs
The Plan
Look at
Guidelines available
Resources at BSUH
Ideas from existing proformas at other trusts
Audit of current documentation
Survey of junior doctors
you can help?!
- Validation/endorsement of the proforma

- Your opinion and suggestions for improvement

- Raising awareness of it, and importance of use

- Establishing it as a trust document


- Introduce proforma to junior doctors at compulsory teaching, November 2013.
- Make available
intranet (junior doctors page)
electronically (via email to junior doctors)
Falls may lead to a variety of harms
- ie. Head injury, fractures, musculoskeletal injury
Guidance available from ie NICE
- can be time consuming and difficult to find the relevant parts
Nursing staff have flow charts available
- role for aids like this for doctors?
Not always obvious to the day team that a fall has occurred.
Uncertainty of appropriate management
Nursing staff have been main mediator to reducing falls set out by guidance/expert opinion/bundles

Are doctors involved enough in preventing falls?
Why?
Benefits of :
Supporting junior doctors whilst on-call:
- guiding them in their assessment
- aiding their management
- improving post fall management
Drs playing a more active role in the reduction of falls
Facilitates clear and comprehensive documentation of assessment as well as management
Better signposting to medical team that fall has occurred
Hence improved management of falls by day team also
Improving patient safety
The future...
Re-audit & Re-survey
Address any suggestions/teething problems
Establish the 'BSUH falls proforma' as an effective, efficient document, used for assessment of all falls at the trust


Knowledge Gathered
1. Experience at BSUH

2. Literature available

3. Other trusts
BsUH
2009
-Policy developed
- changing behaviours & attitudes
Have reduced inpatient falls dramatically
-7.02 falls/1000 bedstay days 2009 to current prediction of 3.82
-45% reduction currently
-Some real successes, one ward from 11.5 to 0.6
Mark & Paula keen to infiltrate!
Dr Bradshaw
- Web and paper survey of 30 FY1/2s

Audit of falls in the month of July at RSCH - 50 patients, 53 falls
(Notes available for 30 patients)
- Documentation
- Extent of examination (e.g. hips/GCS/sepsis/delirium)
- Medication review
- Management plans in line with guidance (e.g. CT head, frequency of obs)

Survey Findings
Literature
Fallsafe (RCP 2010)
NPSA (2007 Slips trips & falls & 2011 guidance)
NICE June 2013 (Assessment & prevention of Falls in Older person)
Patient safety First 2009
- Multifactorial causes which require multidisciplinary input to prevent
- Prevention should not be just a nursing problem
- Inconsistency in falls assessment
- Focus on assessing & treating by using clear protocols

"Unless after initial fall a medical review occurs, likely to fall again"
Worthing
Ashford
Portsmouth
Torbay
Clinical Excellence Commission New South Wales
Ideas from other Trusts
"Could you come and review this patient please? They've had a fall."
A Word From Our Sponsors...
The development of a 'Falls Proforma'
Assessment for
CT Head

Management, Prevention and VTE
GCS and Examination
Details and Hx
Survey of junior doctors
- Ascertain current management
- Would they find it useful??
Thank you for listening and taking this walk with us!


Review following a Fall
CNS Examination Performed
Documentation of GCS
Examination of Hips
Documented Management Plan
Documented Frequency of Neurological Observations
Only 7 patients had documented a plan for neuro obs
Only 1 of these was in line with NICE guidelines
Would you find a proforma to assess inpatient falls useful?
How confident do you feel reviewing patients who have had a fall?
Have you been given formal teaching on how to assess a patient post-fall?
Are you aware of the guidelines regarding CT head following an inpatient fall?
Nobody could correctly state frequency of Neuro Obs following a fall

How often post-fall should neuro-obs be done if a patient has a GCS of
- 15/15
- <15
Mark Renshaw, Deputy Chief of Safety BSUH
Dr Bradshaw, Consultant in Elderly Medicine, BSUH
"After careful thought and discussion Ros, Maissa and Alice have produced a proforma....to fully assess a patient after [a fall] and also identify possible risk factors leading to the incident. The form is crucially only 1 piece of A4 but has vital information with regards to the clinical examination, things to look for in the history- delirium, drugs, sedation and the risk of anticoagulation or VTE prophylaxis. It also has links to useful websites on falls and head injury assessments."

"I think it is a brilliant piece of work for inexperienced junior doctors who are under pressure in the middle of the night and I look forward to seeing it in use on the wards.

I am only sorry I am not able to be present for the presentation of this work."
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