Falls and Fragility Fracture Audit Programme: National Audit of Inpatient Falls (Spring 2017)
Falls and Fragility Fracture Audit Programme: National audit of inpatient falls (Spring 2017)
Clinical lead: Dr Shelagh O’Riordan
Clinical/Observational: Sections 1 to 2
Patient demographicsQUESTION / HELP NOTE
Hospital
Patient age / All patients should be aged 65 years and over.
Date of admission / Sunday 14 May / Monday 15May / Tuesday 16 May
Gender
On the day of the audit what type of ward was the patient on? / Medical
Surgical
Admissions unit eg AMU, CDU or equivalent
Older person’s/frailty ward
Rehabilitation ward
Other (please specify) / Medical – any medical ward. E.g. respiratory, gastroenterology etc.
Surgical – any type of surgical ward e.g. general surgery, gynaecology, ophthalmology etc.
Admissions unit e.g. AMU, CDU or equivalent – a short stay department linked to the emergency department
Older person’s /frailty ward – a ward for older patients meeting frailty criteria usually under the care of a geriatrician.
Was this patient admitted because of a fall? / Yes
No / Please note the patients in this audit should be non-elective admissions for any reason – not just falls. The purpose of this question is to ascertain whether patients who are admitted following a fall are more likely to have a multifactorial falls risk assessment (MFRA) than those admitted for other reasons.
Section 1 – Evidence of assessment and intervention in case notes
Is it documented that the patient has: / HELP NOTENB - For community hospital audit only look at first three days of admission / GUIDANCE / RATIONALE
1.01 / been asked about any history of falls / Yes
No
N/A Impossible or inappropriate to assess / Check their notes in all the places where you might reasonably expect this to be recorded given your local paperwork (e.g. falls assessment form, documentation on sections on problems with mobility) but don’t feel you have to read their entire case notes. It doesn’t matter what area of notes (nursing, medical physio or OT notes) or who asked the questions – nurse, doctor or physio or OT equally fine, as long as it is in case notes accessible to all the team. / NICE CG161 1.1.1.1
NICE CG161 1.2.2.3
1.02a / had any assessment of cognitive impairment (e.g. AMT) / Yes - Patient was assessed (go to 1.2b)
No – Patient was not assessed (go to 1.03a)
N/A - Impossible or inappropriate to assess (go to 1.03a) / Any objective assessment acceptable (including AMT4, AMT10, MMSE, 6-CIT etc.)
YES includes checking the patient’s history and finding a previous diagnosis of a cognitive impairment e.g. dementia
Solely commenting in general terms on confusion/memory problems would count as not assessed. / NICE CG161 1.2.2.3
1.02b / a care plan to support the patient with cognitive impairment? / Yes
No
N/A Intervention not required / This is a care plan that is specific to the patient based on information from a carer and/or observation and assessment on the ward. / NICE CG 161 1.2.2.4
1.03a / been assessed for the presence or absence of delirium or a documented diagnosis of delirium / Yes -Patient was assessed (go to 1.3b)
No - Patient was not assessed (go to 1.04a)
N/A - Impossible or inappropriate to assess (go to 1.04a) / All patients will be >65 yrs old and hence be at risk of delirium as per NICE guidelines. Adults newly admitted to hospital or long-term care who are at risk of delirium should be assessed for recent changes in behaviour, including cognition, perception, physical function and social behaviour. As a minimum there should be a statement within the notes stating “no indictors of delirium”. Many clinicians still record delirium as “acute confusion”. This is not acceptable for the purpose of this audit as the term “delirium” should now be in routine use.
The presence or absence of indictors of delirium may also be recorded using a formal identification/screening tool e.g.
Delirium identification/screening may include the following:
•CAM – confusion assessment method (see below)
•4AT – The 4 ‘A’s test (currently being validated, but in increasing use)
•Review and record the patient’s alertness, attention, behaviour and cognition
AMTS, MMSE, etc. are only assessments of cognition and cannot be used for assessment of delirium without additional consideration of alertness, attention, behaviour and time course (i.e. acute or fluctuating mental state). / NICE CG103 1.3.2
NPSA: Slips, trips and falls
1.03b / a delirium care plan
(tailored to patient, not generic) / Yes
No
N/A - Intervention not required / Delirium management is multifactorial and should include the following actions as stated in NICE CG103:
- Sensory re-orientation (lighting, glasses, clocks hearing aids, etc)
- Bowel and bladder care (treating constipation, retention)
- Identification and treatment of any acute medical triggers (eg infection, hypoxia etc)
- Pain relief
- Address poor nutrition
- Promote good sleep patterns
Answer Yes - if notes record evidence of delirium AND a plan has been put in place / management given to address it, including at least one of the above actions.
Answer N/A - if patient assessed but no intervention was required
Answer No – If patient assessed but did not receive intervention. / NICE CG103 1.3.2
NPSA: Slips, trips and falls
1.04a / any assessment of urinary continence/frequency/
urgency / Yes – Patient was assessed (go to 1.04b)
No - Patient was not assessed (go to 1.05)
N/A Impossible or inappropriate to assess (go to 1.05) / An assessment of the history and nature of urinary incontinence. / NICE CG161 1.2.2.3
NPSA: Slips, trips and falls
1.04b / a continence or toileting care plan (tailored to patient, not generic) / Yes
No
N/A Intervention not required / Where continence problems are identified there should be evidence of a continence care plan.
Where a patient has a catheter, there should be a catheter care plan. / NICE CG 161 1.2.2.4
NPSA: Slips, trips and falls
1.05 / any assessment of fear of falling / Yes - Patient was assessed
No – Patient was not assessed
N/A - Impossible or inappropriate to assess / As a minimum, concern about falling would be documented in the notes. / NICE CG161 1.2.2.3
NICE CG161 (full guideline) 3.3.4.10
‘fear of falling is a significant predictor of future falling and should be considered in falls assessment of older people.’
1.06a / a record of level of mobility / Yes (go to 1.06b)
No (go to 1.07)
N/A Impossible or inappropriate to assess the patient for this(go to 1.07) / Any record of the patient’s mobility (safety, need for assistance, exercise capacity) / NICE CG161 1.2.2.3
1.06b / a mobility care plan / Yes
No
N/A Intervention not required / Any record that specifies patient’s mobility, including use of aid and need for supervision. Tailored to patient, not generic.
Select N/A if the patient is unable to get out of bed. / NICE CG161 1.2.2.4
1.07 / measurement of lying and standing blood pressure / Yes - Patient was assessed
No – Patient was not assessed
N/A Impossible or inappropriate to assess the patient for this / Must be lying and standing, in that order and not sitting. Should use a manual sphygmomanometer, if available.
/ NICE CG161 1.2.2.2 NPSA: Slips, trips and falls
1.08a / an assessment for medications that increase falls risk / Yes - Patient was assessed (go to 1.8b)
No – Patient was not assessed (go to 1.9)
N/A Impossible or inappropriate to assess the patient for this (go to 1.9) / Help notes for 1.08a and 1.08b- Yes
1.08a is asking whether the patient’s medications were assessed to identify any drugs that might contribute to falls. This could be by doctor, pharmacist or any other appropriate member of staff. 1.08bis asking whether any changes were made in light of this, or if a decision was recorded that no changes were required/possible.
Medication that could increase the risk of falls include psychotropics (e.g. benzodiazepines and tricyclic antidepressants); anti-hypertensives (e.g. diuretics and beta blockers); anti-arrhythmics (e.g. digoxin); sedating antihistamines (e.g. Chlorphenamine); sedating analgesia (e.g. Codeine, Morphine).
The auditor is politely reminded that the term "medication review" may not always be present in the patients notes and that quite often this may be deemed to have taken place by the following:
(1) Discontinuation or reduction of a drug- documented in the patients notes but often more obvious from the medication chart
(3) The patient’s first drug chart, taken from admission, should have a medicines review or reconciliation completed and will often be the most appropriate drugs chart to review for changes to the patients medicines. Reduced/discontinued culprit drugs to score as ' Yes - Patient was assessed’ even if a medication review was not formally recorded.
Help note for 1.08a– No and NA
No should be used if patient was on at least one of the medicines noted to increase risk of falls prior to admission and no comment or attempt to switch drug or reducing dose (in notes or on the drug chart) was made during their admission
N/A can be used if the patientwas not on any medication or only topical medication and/or inhalers
Help note for 1.08b– NA
N/A can be used if patient was on at least one of the medicines noted to increase risk of falls however there was no changes required and this is clearly stated in the notes e.g. the patient does not get drowsy/does not suffer from side effect when taking drug. / NICE CG161 1.2.2.3
NPSA: Slips, trips and falls
1.08b / a medication review (beyond medicine reconciliation) with regard to falls risk / Yes
No
N/A Intervention not required / NICE CG161 1.2.2.3
NICE CG103 1.3.3.7
NPSA: Slips, trips and falls
1.9 / night sedation or other sedative medication administered since admission / Yes, but – Patient on long term sedatives
Yes – Patient given new sedative
No – No sedation given / Night sedation is medication defined within the BNF Central Nervous System section: Hypnotics and anxiolytics. Examples of sedative medications are: Diazepam (Valium), Chlordiazepoxide (Librium), Lorazepam, Oxazepam, Nitrazepam (Mogadon), Loprazolam, Lormetazepam, Temazepam, Zaleplon, Zolpidem, Zopiclone, Chloral BetaineWelldorm), Chloral Hydrate.
1.10a / any assessment of vision and/or need for visual aids, including spectacles / Yes - Patient was assessed (go to 1.10b)
No – Patient was not assessed (go to 1.11)
N/A Impossible or inappropriate to assess the patient for this (go to 1.11) / Any objective assessment acceptable (including basic ability to identify objects, read print). Solely asking patient if they have eyesight problems would count as not assessed. This does not mean you have to use a formal chart such as a Snellen chart.
/ NICE CG161 1.2.2.3
NPSA: Slips, trips and falls
FallSafe
CareFall
1.10b / A vision care plan / Yes
No
N/A Intervention not required / Any documentation that refers to addressing visual difficulties for example the need to ensure spectacles are close at hand, larger print information to be supplied, need for additional lighting for reading information, visual cue cards. / NICE CG161 1.2.2.3
NPSA: Slips, trips and falls
FallSafe
CareFall
1.11 / Is there documented evidence that the patient and/or their family/carer was given written information about falls risk or falls prevention? / Yes
No
N/A / Information should include:
- explaining about the patient's individual risk factors for falling in hospital
- showing the patient how to use the nurse call system and encouraging them to use it when they need help
- informing family members and carers about when and how to raise and lower bed rails
- providing consistent messages about when a patient should ask for help before getting up or moving about
- helping the patient to engage in any multifactorial intervention aimed at addressing their individual risk factors.
1.12 / Is there documented evidence that the patient and/or their family/carer was given oral information about falls risk or falls prevention? / Yes
No
N/A
Section 2 - Bedside/Patient environment observation
QUESTION / ANSWER / HELP NOTES / GUIDANCE / RATIONALEFor each patient, look at their bedside and immediate environment and record: Y (yes), N (no), or N/A (No, but not clinically relevant) / ‘Not applicable’ can only be used for clinical reasons, not logistic ones - eg ward spaces too small for patient to have walking frame in reach count as ‘No’, rather than ‘N/A’.
For community hospital audit, this is on the day of the audit, not the first three days
2.01 / Is call bell in sight and in reach of patient? / Yes
No
N/A - Patient unable to use call bell / Measure applies to anywhere patients are sitting or lying at the time you do the check.
N/A can be used for any patient too ill or too confused to use a bell and for patients walking around at the time.
Answer NO if you have patients in beds, chairs or day rooms where no bells can be made to reach, or bells are missing or out of order. / NPSA: Slips, trips and falls
Patient Safety First ‘How to’ Guide
2.02 / Is safe footwear on patient’s feet? / Yes
No
N/A - Patient in bed / Take this observation at a time when most of your patients who are well enough are likely to be out of bed. Collect by walking around to observe your patients.
N/A can be used for any patient in bed and under the covers, any hoist-dependent patient, and any patient who has been offered safe footwear but declines to wear it (not just forgets to wear it).
NO should be recorded if patient has:
•Bare feet
•Socks only (but treaded non-slip socks are acceptable)
•Anti-embolism stockings only (unless they have non-slip treads)
•Bandages or dressings only
•Shoes or slippers that are visibly too big or too small
•Lace up shoes without laces, or with trailing laces
•Shoes or slippers worn with squashed backs
•Novelty slippers (as they are unlikely to promote safe mobility)
•Backless shoes or slippers except for very confidently mobile patients
•High heeled shoes except for very confidently mobile patients.
Anything else should be good enough footwear to count as YES.
For mobile patients sitting or resting on the bed but not wearing their shoes/slippers on the bed, you can count YES as long as they have safe shoes/slippers within their reach. / NPSA: Slips, trips and falls
Patient Safety First ‘How to’ Guide
2.03 / Is the immediate environment (including route to nearest toilet) free from clutter/trip/slip hazards? / Yes
No
N/A - Patient bedbound / Look for uneven floor surfaces, clutter, training cables, oxygen tubing etc. Cables count as trip hazards even if covered with a cable cover, spills/wet floor from cleaning count as hazards even if there is a warning cone, uneven floor counts as a trip hazard even if yellow hazard taped.
N/A can be used if the patient is bedbound / NICE CG161 1.2.2.1
NPSA: Slips, trips and falls
2.04 / Is the appropriate (based on Section 1 or 2) mobility aid in reach? / Yes
No
N/A - Patient bedbound or documented to be mobile without any aid / N/A should be used if patient bedbound or documented to be mobile without any aid / NPSA: Slips, trips and falls