North East regional survey of systems / pathways in place to identify patients age 65 and over presenting to the Emergency Department (ED) with falls / blackouts, and for onward referral to falls services.

North East Regional Falls Task Group: May 2013.

Y = Yes, N = No, N* = planned.

WGH: Wansbeck General Hospital, NTGH: North Tyneside General Hospital, HGH: Hexham General Hospital, NUTH: Newcastle Upon Tyne Hospitals Trust (RVI), QE: Queen Elizabeth Gateshead, STGH: South Tyneside General Hospital, CHS: City Hospitals Sunderland (SRI), UHND: University Hospitals North Durham, DAR: Darlington, NT: North Tees, ST: South Tees, FRI: Friarage.

WGH / NTGH / HGH / NUTH / QE / STGH / CHS / UHND / DAR / NT / ST / FRI
1. Is your trust signed-up to work to 2012/2013 ED Falls CQUIN? / N / N / N / N / Y / Y / Y / N / N / N / N / N
2. Is there a system / pathway in place in the ED to identify patients presenting with falls / blackouts? / Y / Y / Y / Y / Y / Y / Y / Y / Y / Y / Y / Y
3. Does the pre-printed ED documentation include questions about falls / blackouts? / Y / Y / Y / N / Y / N / Y / N / N / N / N / N
4. Are questions about falls / blackouts added to the ED documentation after it has been printed? E.g. by sticker or as separate sheet / N / N / N / Y / N / Y / N / N* / N* / Y / Y / Y
5. Who asks the questions about falls / blackouts in the ED? E.g. triage nurse / doctor / admin / all / etc.
6. Is there a specific person (group of people) working in the ED whose role it is to identify patients presenting with falls / blackouts? / N / N / N / N* / N / Y / Y / Y / Y / Y / N / N
7. Is there a specific person (group of people) working elsewhere in the hospital who respond to calls from the ED when patients who have fallen present there? E.g. is there a specific person (group of people) interfacing with the ED department who have a role in assessing patients who have fallen / blacked out in order to initiate referral to falls services or initiate management strategies for inpatient stays? / N / N / N / N / N / Y / Y / N / N / Y / Y / N
8. Is there provision of education on falls and blackouts as part of routine practice in the ED? / N / N / N / N* / Y / Y / Y / N / N / Y / Y / N
9. Do you have any audit figures of the proportion of patients with a fall / blackout presenting to the ED who are referred on to falls services? / Y / N / N / Y / Y / Y / N / N / N / Y / N* / N*
10. Approximately how many new falls / blackouts referrals do your services receive from the ED each week? / 5 / ? / ? / 9 / 2 / 20 / 34 / ? / ? / ? / 7 / 7
11. Approximately how many of these referrals (see Q 10) are sent appointments? / 3 / ? / ? / 4 / 2 / 10 / 3 / ? / ? / ? / 5 / 5
12. Approximately how many new falls / blackouts referrals do your services receive from fracture clinic each week? / ? / ? / ? / 1 / 0 / ? / 1 / ? / ? / ? / 7 / 7
13. Approximately how many of these referrals (see Q12) are sent appointments? / ? / ? / ? / 1 / 0 / ? / 1 / ? / ? / ? / 7 / 7
14. Do your falls services give appointments to patients presenting to the ED with a single fall but no fracture? / N / N / N / N / Y / N / Y / N / N / N / Y / Y
14a. Do your falls services give appointments to patients presenting to the ED with a single fall and a fracture? / Y / Y / N* / Y / Y / Y / Y / N / N / N / Y / Y
15. Do your falls services give appointments to patients presenting to the ED with a single blackout? / Y / Y / N* / Y / Y / Y / Y / N / N / Y / Y / N
16. Does your falls assessment routinely include assessment of bone health? / Y / Y / Y / Y / Y / Y / Y / Y / Y / Y / Y / Y
17. Please describe briefly how your falls service is organised – in particular splits between Community / Day Unit / AcuteHospital.
18. Which part of your service receives the initial referrals from the ED?
19. Do you have a triage / screening system to decide which part of the falls service patients referred from the ED should go to? / Y / Y / N / Y / Y / Y / Y / N / N / Y / N / N
20. Do you see patients who are admitted to hospital as part of this pathway? / Y / Y / N / N / Y / Y / N / Y / Y / N / N / N
21. Do you keep outcome data on referrals from the ED? / N / N / N / Y / N / Y / N / N / N / Y / Y / N
22. Do you have any outcome data to demonstrate benefits of the referral pathway from the ED? / N / N / N / Y / N / N / Y / N / N / Y / Y / N

Details:

Q2:

  • WGH: ‘Pilot’ in place 18 months – now usual practice.
  • NTGH: system introduced as part of uniform Northumbria FT pathway for fallers in ED.
  • HGH: system introduced as part of uniform Northumbria FT pathway for fallers in ED.
  • NUTH: Pilot of additional ‘falls form’ in progress since Feb2012. Recently (May 2013) included Nurses from Single Point of Access whose main role is in accessing community services for older people to prevent re-admission.
  • QE: This is a new development which has now been in place for about 1 month. Whilst the A & E staff have been aware of how to refer to the falls service the numbers of referrals made remained low. We have followed Wansbeck in their use of a sticker on the cas card which allows for the number of falls to be recorded and to identify if the person gave consent for the falls service to contact them. At present the sticker is only used if someone remembers to stick it onto the cas card.
  • STGH: Falls sticker in place and staff identified to review paper work and ensure correct referral pathway is followed.
  • UHND: ED departments can refer any patients they are concerned about to the RIACT team for further assessment. RIACT teams actively screen patients presenting with a fall - admin staff print off a list for the RIACT team. The RIACT team then telephone triage all patients and followup as required.
  • DMH: ED departments can refer any patients they are concerned about to the RIACT team for further assessment. RIACT teams actively screen patients presenting with a fall - the RIACT team inreach and screen all ED notes for 0ver 65s. The RIACT team then telephone triage all patients and followup as required.

Q3:

  • WGH / NTGH / HGH: Printed questions on new ED documentation.
  • QE: Our A & E is changing their information system, which will mean that the cas card will also change. The information currently contained in the sticker will be pre printed onto the cas card which will eliminate the ‘randomness’ of the use of the sticker.
  • UHND / DAR: No currently but to have single documentation by August 2012 so could be considered for inclusion.

Q4: See appendix 1 for details.

  • WGH / NTGH / HGH: Questions on ED form replaced sticker.
  • QE – questions in sticker form.
  • Form used: NUTH, ST. ST use Cryer form but don’t triage on Cryer scoring. Instead triage on number of falls.
  • Falls risk sticker added: UHND, DAR.
  • ST: Also have self referral form – accompanying.
  • CHS: No longer necessary, integrated into ED documentation

Q5:

  • WGH / NTGH / HGH: All.
  • NUTH: Doctors / triage nurse / SPA nurse
  • QE: Triage Nurse, Emergency Nurse Practitioner, Doctor
  • STGH: Triage nurse / assessing Dr / any patient discharged is followed up with a telephone call regarding ongoing referral to either community falls service or medically led falls clinic.
  • UHND / DAR: nurse at triage or doctor at clerking.
  • NT: Nurse.
  • ST: Triage nurse mainly, some doctors.
  • FRI: All staff.
  • CHS: Assessing Clinician

Q6:

  • NUTH: Business case submitted for Falls Nurse in ED. One year pilot of admissions avoidance Nurse in ED Mon – Fri, screening of referrals other times, making referrals to falls services started April 2013.
  • STGH: Discharge team at present – a business case to develop a falls ED nurse is being developed.
  • UHND: RIACT teams actively screen patients presenting with a fall.The admin staff print off a list for the RIACT team. (Osteoporosis and falls referrals are identified by the community service who inreach to the fracture clinics ( fracture liaison service). Only rehab referrals are made by the orthropods). The CREST team are based in ED and are amongst the groups of patients they are asked to see would be potential discharges where staff were concerned about their mobility and safety. Also refer directly to the falls service, community therapists, community matrons and the RIACT teams.
  • DAR: RIACT teams actively screen patients presenting with a fall.The RIACT team in reach and screen all ED notes for 0ver 65s. (Osteoporosis and falls referrals are identified by the community service who inreach to the fracture clinics ( fracture liaison service) Only rehab referrals are made by the orthropods). The CREST team are based in ED and are amongst the groups of patients they are asked to see would be potential discharges where staff were concerned about their mobility and safety. Also refer directly to the falls service, community therapists, community matrons and the RIACT teams
  • CHS: Interface Team who signpost and refer to the Falls Team

Q7:

  • STGH: Early and late shift only – Discharge team (as above).
  • CHS: Interface Team

Q8:

  • NUTH: Limited input at junior docs induction and occ. presentation at teaching meetings.
  • QE: Falls training is provided routinely to all band 5 nurses across the Trust (including A & E) as part of their preceptorship. We have recently been invited to undertake falls training on bespoke basis to groups of nursing staff starting to work in to A & E. Teaching to junior doctors is undertaken by the Consultant in the falls team.
  • STGH: Included in ED Staff induction programme and 4 x year for junior doctors.
  • UHND: This would be ad hoc from the clinician. Junior doctor induction has session on RIACT (and community service) service.
  • DAR: This would be ad hoc from the clinician. Junior doctor induction has session on RIACT (and community service) service.
  • ST: Approximately annually by the Falls Team.
  • CHS: Mandatory modules for all wards/units of the hospital including A&E

Q9:

  • WGH: see appendix 2 – 1 week audit.
  • NUTH: see appendix 2 – 1 week audit.
  • QE: 2010 = 84; 2011 = 66. ? total referrals only.
  • STGH: Ongoing data collection.
  • ST: Receive monthly data as regards number of attendees due to falls and work out percentage falls team has received. Gap is in relation to blackout services. Accuracy of falls attendees data unknown.
  • CHS: No audit because procedure dictates that all identified fallers be referred to either falls team or syncope clinic depending upon presentation.

Q10:

  • WGH: see graph, Appendix 3
  • NUTH: see graph, Appendix 3.
  • STGH: At present up to 20 with the potential rising to 50 if all stickers were actioned.
  • ST: Receive approx 7 each week – screen out for admitted patients and those with only one fall and no risk factors.
  • CHS: All falls are recorded on referral forms for data collection, the community falls team then triages them to determine if an appointment should be offered.

Q11:

  • QE: At present we will offer appointments to all of the referrals from A & E to the falls team. It is anticipated that the number of referrals will increase with the use of the sticker and with the developments on the new CAS card. We are planning to develop a phone triage system so that we can identify those patients who will need further assessment and give falls advice or signpost others who do not require further full assessment.

Q12:

  • UHND / DAR: Osteoporosis and falls referrals are identified by the community service who in reach to the fracture clinics ( fracture liaison service) and are seen in their own homes or in a local clinic setting.
  • ST: Fracture clinic refer to the osteoporosis nurse (part of the falls service) who completes a falls assessment.

Q14:

  • QE: Often if they have had an injurious fall or have developed fear of falling as a consequence of the fall.
  • UHND / DAR: Patients with functional problems resulting from a first fall are more generally seen by RIACT, community rehab and then referred to falls as secondary referral if significant problems/ risks are identified.
  • ST: If also fractured or have other risk factors. Aiming for standard pathway across whole of South Tees.
  • CHS: Only post telephone triage assessing level of risk.

Q14a:

  • HGH: Currently no designated ED pathway but will do when one available.
  • CHS: Only post telephone triage assessing level of risk.

Q15:

  • WGH / NTGH: Depending on clinical circumstances.
  • HGH: Currently no designated ED pathway but will do depending on clinical circumstances when one available.
  • QE: Only following discussion with the consultant. If the consultant does not feel that the referral is appropriate then an appointment is not offered.
  • STGH: Clinicians discretion.
  • ST: Would advise TLOC clinic. Runs separately to Falls Clinic and referral must be made via GP.
  • CHS: Only after telephone triage assessing level of risk and that no referral made to Care of the Elderly Consultant for falls.

Q16:

  • WGH: NOT OP guidelines.
  • NTGH: NOT OP guidelines.
  • HGH: NOT OP guidelines.
  • NUTH: FRAX / Clinical judgement. Special DEXA session (1/2 day weekly) at Fracture Clinic and another DEXA scanner housed in Belsay Day Unit.
  • QE: Currently using the Black tool but are moving to using FRAX.
  • STGH: FRAX.
  • UHND / DAR: FRAX.
  • ST: Risk factors and referral on to osteoporosis nurse for FRAX and DXA as required.
  • CHS: FRAX.

Q17:

  • WGH: Falls services geographically based with community therapy assessment and community hospital OPCs. Tilt room at WGH.
  • NTGH: Falls services hospital based with therapy assessment in day hospital. Tilt room at NTGH.
  • HGH: Acute hospital.
  • NUTH: Integrated service comprising core services: Falls and Syncope Service RVI and Day Unit based Multidisciplinary Services at Melville Day Unit (FRH) and Belsay Day Unit (CAV). Close reciprocal working with community falls services: Community Resource Teams, Domiciliary Physiotherapy and Staying Steady Exercise Classes (joint working with 3rd Sector).
  • QE: The falls service is based in Acute hospital but also covers community/care homes/outpatient services.
  • STGH: Integrated falls service between hospital and community based falls services. Single clinical lead with community based falls nurse specialist working closely to manage demand.
  • UHND / DAR: Each locality has access to a either a falls specialist or a multi-disciplinary falls service for further assessment and management. Some of these are within and part of the day hospital /community hospital setting.
  • ST: The Falls and osteoporosis service is based in the community division of the trust. The falls and osteoporosis teams work closely together but see different groups of people. Where required they do refer to each other (particularly those who require further falls input from therapists following the osteoporosis nurse input). Elderly care consultants see falls patients but no distinct “Falls clinic” at present and falls team are unable to refer direct due to funding issues. There is also a TLOC clinic which see anyone over 18 years of age with blackout who link with falls service as required.
  • FRI: Hambleton and Richmondshire falls service is a community nurse service who complete falls assessments and link closely with intermediate care services. ED refer a lot of patients direct to intermediate care and work is currently underway to clarify who goes where and to update the pathway.
  • CHS: Falls service based in community with weekly joint clinics with Care of Elderly consultant falls specialist physio for care home assessments and education. Close working relationship with intermediate care team in the community as well.

Q18:

  • WGH: Secondary care – hospital consultant.
  • NTGH: Acute hospital – hospital consultant.
  • HGH: Acute hospital.
  • NUTH: Falls and Syncope Service RVI.
  • QE: Triage at weekly MDT.
  • STGH: Discharge team triage and sort referrals.
  • UHND / DAR: RIACT only as referrals. Most are through screening by the teams inreaching.
  • NT: ECCT.
  • ST: CommunityFalls Team.
  • CHS: CommunityFalls Team.

Q19:

  • NUTH: See Appendix 4 and see also outcome data.
  • QE: Triage is made at the weekly MDT meeting. Referrals are screened as follows:MDT out-patient clinic, Medical out-patient clinic, Home visit – by either OT, Physio or Nurse, Need to be contacted by phone for further information to assist effective triage, Not appropriate.
  • STGH: See Appendix 4.
  • UHND / DAR: No triage - it is more appropriate that a referral is made and then the community staff will deliver the most appropriate pathway to the patients needs.
  • CHS: All falls are recorded and forwarded to the Community Falls Team who then triage for an appointment or signposting.

Q20:

  • NUTH: Separate pathway for inpatient referrals. Orthogeriatric input includes falls / osteoporosis.
  • QE: Falls nurse will see patients who are admitted and who have fallen whilst they are in hospital.
  • STGH: Inpatients with a fracture are followed up by Trauma nurse who arranges all necessary tests / referrals. Dependent on age of patient orthogeri involvement.
  • UHND / DAR: Yes when referred by ward staff.

Q22:

  • NUTH: See Appendix 5.
  • ST: See Appendix 5. ED patients included in these outcomes but outcomes are not specific to patients referred from ED.
  • CHS: Ongoing audit of all patients in the programme which includes those referred from the ED.

1

Appendix 1.

Q4: Stickers / forms added to ED documentation

Stickers:

WGH (now pre-printed on ED form):

QE (now pre-printed on ED form):

A&E Sticker for 65 years old and over:
This attendance: / Fall? / Y / N
Blackout? / Y / N
IF answer YES to either:
Including this attendance how many falls and blackouts have you had in past year? / Falls:
Blackouts:
Does the patient have a new fracture on this attendance? / Y / N
Does the patient agree to referral to falls and syncope services? / N/A / Y / N

The Newcastle upon TyneHospital NHS Foundation Trust

Falls and Syncope Service Screening Form

To be attached to notes of all patients 65 years old and over at reception:
Date of attendance: / Fall? / Y / N
Blackout? / Y / N
IF answer NO place form only in Box at reception/nurses desk
IF answer YES to either question :
Including this attendance how many falls and blackouts have you had in past year? / Falls:
Blackouts:
Does the patient have a new fracture on this attendance? / Y / N
Does the patient agree to referral to falls and syncope services? / N/A / Y / N