report to the board of directors 2014/15 · 2014. 9. 18. · attachment 6 report to the board of...

Attachment 6

Report to the Board of Directors 2014/15

Date 26 September 2014

Subject Falls Analysis

Report of Director of Nursing, Quality and Patient Experience

Author Julie Willison, Interim Patient Safety and Quality Manager

Previously considered by N/A

Board Action Required Approval Discussion X

Decision Information

Executive Summary and purpose

This paper provides an analysis of patient falls within the Trust and the further actions being taken to reduce falls and harm to patients from falls in hospital. The Board are asked to note the findings and actions identified. An action plan has been developed with the Divisional Lead Nurses. This will be reported and monitored through the Patient Safety Committee and by exception to Safety Quality Governance Committee.

26092014 Falls Analysis Julie Willison, Interim Patient Safety and Quality Manager September 2014 REP/BOD/JW1809/V1 of 12

Board Assurance Framework (link to strategic objectives)

1 Implement the first year's objectives of the Trust's Quality Strategy

This paper provides assurance against the Trust objective(s) identified X

This paper is to close a gap in control/assurance in relation to the objective(s)

Legal/regulatory CQC compliance

Equality Impact/risks: Equality Delivery System 2 – EDS2 Nov 2013)

Impact

Positive Negative Neutral

X

Assurance/monitoring Reporting from the Divisions to Patient Safety Committee with exception reporting to Safety and Quality Governance Committee

Explanation of Board action required: Information: no discussion required. Update to ensure Board has sufficient knowledge on subject matter Discussion: when seeking Board members’ views, potentially ahead of final course of action being agreed Decision: when being asked to choose between alternatives Approval: positive resolution required, to confirm paper is sufficient to assure the Board in its ongoing monitoring role


Inpatient Falls Incident Analysis 1. Introduction

Patients who have fallen after admission or who present to hospital following a fall are at a high risk of falling whilst an inpatient. Injuries resulting from falls range from soft tissue trauma, fractures, head injuries and sometimes death. However, falls also cause a loss of confidence and mobility resulting in a reduction in normal social activity, which can lead to social isolation and depression (Mitchell et al 1996). Inpatient falls therefore can have a dramatic impact on morbidity, extended lengths of hospital stay and culminate in complex discharge arrangements. Falls can lead onto formal complaints, coroner’s inquests, and litigation. It should also be recognised that very often patients and their families can feel anxiety and anger when a fall occurs. 2. Analysis Inpatient falls are the highest recorded patient harm at the James Paget University Hospital, and as a result the Trust has reviewed all the in-patient falls incidents in 2013-14 where patients have sustained moderate harm and above. These incidents should have triggered a comprehensive root cause analysis as per the Trust’s Adverse Incident Reporting Policy, and some will have initiated a serious incident investigation. To clarify the harm categories which the Trust reports against on the Safeguard system, the NPSA has defined these into 1-6 harm categories. Harm Category Definition

1 No Harm.

2 Minor/Low. Harm requiring first-aid level treatment or extra observation only. E.g. bruising or grazes.

3 Moderate/Semi Permanent. Harm requiring hospital treatment or a prolonged length of stay, but from which a full recovery is expected. E.g. # clavicle, laceration requiring suturing.

4 Major, Severe/Permanent. Harm causing severe permanent disability. E.g. brain injury, hip #, where the patient is unlikely to regain their former level of independence.

5 Catastrophic/Death. Where death is directly attributed to the fall.

6 Near Miss. Staff prevented the fall.


3. Number of Falls Reported The table below demonstrates the number of in-patient falls that have occurred in the Trust in 2012/13, and 2013/14. The table also breaks down the level of harm each patient suffered as a result of the fall. The figures clearly demonstrate falls have increased in the level 1 and 2 however the number of patients suffering considerable harm from a fall has significantly reduced, as there were no reported level 4 or 5 harm categories in 2013/14.

Harm 2012/13 2013/14 Externally Reported 2012/13

Externally Reported 2013/14

1 532 548 0 0

2 329 345 0 0

3 11 16 2/11 7/16 = Serious Incidents

4 14 0 14/14 0

5 1 0 1/1 0

6 2 2 0 0

Total 889 911 17 7

4. Inpatient Falls – 1000/Bed Days

The graph below demonstrates the inpatient falls per 1000 bed days from April 2013 to August 2014. The graph and chart show that the Trust is beginning to make progress, and has not recorded above 6.6 since January this year. For comparison the national acute Trust average for 2013 (NPSA Data), is 5.6, the Trust’s average for 2013/14 was 6.1, however this has progressed in the last 5 months (April – September) to 5.8.

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14

7.64 7.38 5.44 7.11 5.72 6.28 5.48 5.39 6.69 5.69 5.61 5.93 5.38 5.90 6.12 5.92 6.16

All Falls

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5. Trend over Time for Inpatient Falls 2012/13, 2013/14, 2014/15

In comparison to measuring inpatient falls against per 1000 bed days the graph below

demonstrates that there has been an increase in falls incidence overall since the beginning of

2012. However this does not take into account patient activity which the above data does. The

increase shown in this graph is seen to start from August 2012, when a significant reduction

had been achieved in the first five months of this year but then increases substantially and

never recovers. The 2014/15 line is much more stable than previous years and is beginning to

show a downward trend, this is also in line with the figures shown in the graph and chart above.

6. Analysis of Level 3 RCAs – Reported as a Serious Incident 2013/14 and 2014/15 The Trust had 16 level 3 inpatient falls incidents in 2013/14 of which seven were reported as a level 1 serious incidents. These seven incidents all had a root cause analysis investigation undertaken and the following table demonstrates the key areas of significance that were picked out from the investigations. The first point of consequence was that although all the patients in question underwent a full falls risk assessment, 4/7 (57%) did not take into account that the patient had either fallen before (in the past year), or their reason for admission was that they had fallen. Both of these points are extremely significant when assessing a patient’s risk and producing a holistic plan of care to prevent any further falls. The majority of patients that fell did so during the night shift and most of these were in the early hours of the morning, which points towards patients waking and needing the toilet. It is well documented that elderly patients with or without dementia can become confused when first

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Total IP falls 2012/13 (n=889)

Total IP Fall 2013/14 (n=911)

Total IP Fall 2014/15 (n=295)

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Comparison of Inpatient Falls

2012/13, 2013/14 and 2014/15


admitted to a ward especially during the night. In darkness patients can confuse the hospital ward with their own bedroom and consequently fall as a result. On two of the incidents the ward staffing was reduced by one registered nurse which could be argued had significant effects, however it cannot be concluded that the sole reason for these patients falling was down to this. Since these falls have taken place a full establishment and skill mix review has been undertaken and has resulted in the wards receiving varying uplifts of registered nurses. The three serious incident falls that occurred in 2014/15 continue to follow the pattern of patients falling in the early waking hours of the morning, with two of them witnessed. One of the incidents was associated with reduced staffing levels with inaccurate falls assessments continuing to be a problem. The following table reports on the level 3 falls that were not reported as serious incidents in 2013/14. There were also no Root Cause Analyses completed for these incidents therefore the data available for analysis is very limited. 7/9 of these falls were associated with patients wishing to go to the toilet with six of these happening in the early hours of the morning or very late at night. As previously reported all level 3 Falls’ Incidents will trigger the completion of a comprehensive Root Cause Analysis. 2013/14 SI Falls Assessment Previous Falls Witnessed Time of Day Staffing Injury Misc.

7/7 Completed Falls Risk Ass

4/7, not taken into account on RA

7/7 not witnessed

4/7 after 11pm & before 6am

2/7 ↓Registered Nurse

5 x NOF 1 x Disc Hip 1 x HI & Spinal #

1. Sensocare Failure. 2. Slipped off side of bed, when air mattress deflated. 3. Parkinson patient – medication not given on time

2013/14 Level 3 Moderate Harm Falls Number Time of Day Injury Reasons

9 6 either early hours or very late at night. 2 during day. 1 not documented

6 x # Wrist/Arm 1 x # pelvis 1 x # ankle 1 x Dislocated hip

7 of the falls are associated with patients wishing to go to the toilet

2014/15 SI Falls (2- Level 5) Assessment Previous Falls Witnessed Time of Day Staffing Injury Misc.

5/5 Yes

4/5 Yes x3 No x 2

05:00 06:30 06:50 02:30 06:30

X4 No problems X1 Reduced staffing x1RN

2x #NoF 1x # Femur 2x Head Injuries

Poor night lighting. Inaccurate assessments. Reduced observation.


7. Location of Inpatient Falls

It is well documented that the elderly are most at risk of falling when they come into hospital for varying reasons. The pattern of patient falls at the Trust certainly is in line with this theory. In 2013/14 the Trust had in total 911 inpatient falls with two thirds of these occurring in eight wards. All of these wards care for acutely unwell elderly patients who are quite often frail and sometimes confused and/or have some degree of dementia.

8. Falls Progress for the Top 3 Reporting Wards in 2014/15 In 2013/14 EADU, Ward 12, and Ward 1 were the top reporting wards for all levels of inpatient falls. The following five graphs show the progress these three wards have been making over the first five months of 2014/15. The three wards’ figures have been combined to demonstrate the number of ‘Falls Free Days’ they have had. In April this was 12 days, but this has increased to 18 days in August.

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EADU Falls

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Ward 1 Falls

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Fri Sat SunMon TueWed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat SunEADU Falls

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9. Analysis Quarter 1 2013/14 – 2014/15 Month and Year

Actual Impact 14/15 April - June (Total = 235)

2013/14 % progress

Apr-14 1 - No Harm 57 Total = 97

↓ 26% 2 - Minor/Non-Permanent

Harm 15 Total = 72

May-14 1 - No Harm 57 Total = 91

↓ 11%

2 - Minor/Non-Permanent Harm

19

3 – Moderate/Semi-Permanent

5 Total = 81

Jun-14 1 - No Harm 57 Total = 62

↑ 24%

2 - Minor/Non-Permanent Harm

22

3 – Moderate/Semi-Permanent Harm

2

5 - Catastrophic/Death 1 Total = 82

1st Quarter 2013/14 – Number of Falls

1st Quarter 2014/15 – Number of Falls

Progress

250 235 ↓6% The table above makes a direct comparison on all the inpatient falls that occurred in the Trust in the first quarter of 2013/14 and 2014/15. The data demonstrates that the falls rate this year is 6% better than last year. It also reveals that in April and May this year significant progress was being made. However this was marred by June when a 24% increase was reported. 10. Timeframes for Inpatient Falls The reporting system (Safeguard) allows staff to input the time that an incident occurs, however this has not always been a mandatory field, (mandatory since October 2013). There was a circumstantial feel that most falls were occurring in the early hours of the morning and very late at night. To validate this, a review of all inpatient fall times was undertaken. This analysis was across all harm categories however if the time had not been reported it has been left out. The line graph below reports on all the inpatient falls, by harm category, and demonstrates that there is a higher incidence of falls occurring during the night, peaking between 04:00 hours – 07:00 hours. This trend is supported from research carried out by Hsu et al 2004, who stated that most inpatient falls happen on the night shift as it is during this time that patients require frequent toileting. The next peak in all levels of falls is from 09:00 hours – 12:00 hours, when there is increased activity on the wards including patient hygiene care, doctors’ ward rounds, and medication rounds. All of these activities can take nurses behind patient curtains at any one time. Therefore it is crucial that safe patient care including watching out for patients who are at high risk of falling is seen as the multidisciplinary team’s responsibility and not just the nursing staff. The numbers are seen to decrease during the afternoon which could be due to visiting hours, as this often means there are additional people in the ward area that can either stop their own relative from falling or alert ward staff that other patients are moving and appear quite unsteady. However the numbers peak again for both harms between 17:00 hours – 18:00 hours which is a common time again for patients requiring the toilet before their mealtime. This may also be due to the ‘sundowning’ syndrome which affects some people with Alzheimer’s disease and Dementia. A person with Dementia who ‘sundowns’ can get confused and agitated as the sun goes down, and this feeling can also carry on through the night. Sundowning may


prevent people with dementia from sleeping well, and it may also make them more likely to wander.

11. Patients Affected by Falls The graph below defines the number of patients affected by falling in the Trust since 2012. Analysis of the figures determine that 21% of the patients that fell in 2012/13 fell more than once, and 23% of the patients that fell in 2013/14 did so more than once. On the data collected so far for 2014/15 the Trust can reveal a reduction of patients who have multiple falls by 6% on last year’s figures, (currently standing at 17%). The Trust has recently (August 2014) developed a new advice leaflet for patients which aims to help prevent patients from falling while they are in hospital. It advises on appropriate footwear, the hazards that are associated with the ward environment and the importance of patients wearing their glasses and hearing aids. Demographic data for the Trust demonstrates that approximately 27% of the people of Great Yarmouth and Waveney aged 65 years and above were admitted to the James Paget University Hospital in 2013/14. It is widely accepted that the population area has an above average representation of ages above 65 years and therefore expects to see many more patients with challenging cognitive impairment including dementia, which has previously been highlighted as a high risk group of patients.

02468

10121416182022242628303234363840424446

No Harm 2013/14 (n=800 patients - 32 falls with unrecordedtimes)

Minor/Non Permanent Harm 2013/14 (n=455 patients - 21falls with unrecorded times)

Moderate/Semi Permanent Harm 2013/14 (n=18 - 2 falls withunrecorded times)

Maj/Permanent Harm 2014/15 (n=5 patients)

Catastrophic Harm 2014/15 (n=2 patients)

Near Miss Harm 2013/14 (n=3 patients)

Times of Patient Falls

Time Frames for all Inpatient falls April 2013 - August 2014

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12. Patient Safety Thermometer

Developed by the NHS as a point of care survey instrument, the NHS Safety Thermometer provides a ‘temperature check’ on harm that can be used alongside other measures of harm to evaluate local and system progress in providing a care environment free of harm for our patients. The Trust measures the prevalence of any fall that the patient has experienced which is marked as one day a month in time and the previous 72 hours leading up to it. This prevalence falls data is reported monthly via the Trust’s Quality and Safety Report as well as the incidence data detailing the total number of falls by harms.

13. Falls Prevention CQUINs 2014/2015 It has been well recognised nationally that the number of patients presenting to A&E Departments having fallen (with no direct reason) has risen year on year. The CCG has stated that it is fundamental to their priorities to reduce patient harm, one of which is patients that fall. To this end a falls prevention (Commissioning for Quality and Innovation) CQUIN has been agreed which sees the hospital and East Coast Community Health care (ECCH) working collaboratively to achieve this aim. Since May of this year the Trust has been working with ECCH on a system wide project plan to develop a falls prevention improvement pathway. This pathway aims to ensure all patients that attend the A&E or are admitted to the hospital are tracked through to the community and are referred to the newly established Falls Prevention Team. A Falls Clinic is fundamental to this objective, which will be led by a Trust doctor who will take referrals for some of the most complex patients that fall. This clinic will be run by the hospital however it will be supported by community services such as Physiotherapists and

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NHS Safety Thermometer Falls April 2013 - June 2014

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Occupational Therapists. To support this pathway the CQUIN also stipulates that a Fracture Liaison Nurse is recruited to drive through these changes. The Trust is in the process of recruiting to this position and believes this will not only support this CQUIN project but will also be central in preventing patients falling in hospital as well. 14. Recommendations and Improvement Aims for 2014/15 1. Reducing the risks of patient falls can be achieved by comprehensive and systematic risk identification and a positive co-ordinated multidisciplinary management and intervention. Guidance from the National Institute of Clinical Excellence (2013) states that all people aged 65 or older who are admitted to hospital have the highest risk of falling along with people aged 50 to 64 who are judged to be at a higher risk due to an underlying condition. To enable the Trust to achieve its purpose of reducing inpatient falls, an integrated inter-professional approach needs to be adopted for the management of all patients aged 50 or older who are at risk of falling, or who have already had an unexplained fall, regardless of the height from which they have fallen. This will ensure that each individual patient has an adequate Multifactorial Falls Assessment undertaken and appropriate multi-disciplinary interventions implemented. The MFRA will centre on assessment and interventions on;

Poly-pharmacy

Balance and Gait

Syncope and Postural Hypotension

Continence

Medical Diagnosis, including cognitive impairment

Falls History

Visual or hearing impairment

2. The awareness of staff on the wards regarding the resources available is much improved and this is clear from Safeguard reporting. Through ward ‘Knowing How We Are Doing’ boards where each individual ward’s numbers of falls are graphically recorded each month, the wards have the ability to focus on quality improvement at ward level rather than directorate level. The message that falls are preventable and not inevitable will be reinforced in all future initiatives with the ultimate aim of reducing falls/1000 bed days and to reduce the harm that can be associated with falls. 3. The Trust has a Falls CQUIN this year which is multi-faceted and recommends the requisite for the hospital to employ a Fracture Liaison Nurse which when progressed should be developed to encompass the role of a Trust Falls Nurse. It is crucial, for the new assessments and falls pathway to be successful, that there is a person within the Trust that can drive the falls prevention improvement work. 4. A Falls Prevention Clinic is currently being developed as part of the Trust’s CQUIN scheme. There has been a clinician identified and there has been considerable progress made with the pathway management and the criteria associated with the referral process. 5. The Falls Prevention Policy is currently being reviewed to encompass the 2013 NICE Guidance and will produce patient pathways for patients who either attend the A&E Department or are admitted and are at risk of falling. These pathways will include the new Multifactorial Falls Risk Assessment and Interventions.


6. To improve learning and comply with the Adverse Incident Policy – all level 3 falls will undergo a comprehensive RCA. These should be managed within the divisions and the outcomes will be reported through to the Strategic Risk Group. 7. As part of the Site Strategy for improving the ward environment, there is a recommendation that when this is undertaken, patients with cognitive impairment such as Dementia, and visually impaired patients are taken into consideration to ensure the wards and corridors are conducive in supporting safe patient care. 8. A high percentage of patients that fall in the Trust do so more than once, which implies that the strategies employed from the initial risk assessment and the further assessments the patient has had as a result of the fall were not helpful or instrumental in preventing further falls. It is recommended that a strategic falls response group is formed from key multi-disciplinary staff to help patients who have either had several ‘near miss’ falls or who have had more than one fall during their hospital stay. This group will help, advise and suggest additional measures that may not have been previously considered. The Falls Prevention Nurse will be instrumental in driving this initiative forward. 9. Matrons and Ward Sisters/Charge Nurses will be emphasising with nursing staff that many patients are falling as a result of needing the toilet, (especially in the early hours of the morning) and that the action to minimise this is to ensure Intentional Rounding is completed effectively. 10. To make falls prevention a standard agenda item at Matrons and Ward Sister /Charge Nurse Meetings. 15. Conclusion

The Board is asked to note the findings and actions identified. An action plan has been developed with the Divisional Lead Nurses. This will be reported and monitored through the Patient Safety Committee and by exception to the Safety and Quality Governance Committee.

report to the board of directors 2014/15 · 2014. 9. 18. · attachment 6 report to the board of...

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