Falls and Fragility Fractures Pathway Quality Standards
Self-Assessment
Introduction
With an ageing population, falls, fragility fractures and their consequences are a major and growing concern for older people and health and social care providers (Scottish National Falls Programme 2012). The human cost of falls and fragility fractures include distress, pain and injury, loss of confidence, loss of independence and mortality. Falls also affect family members and carers of people who fall. Falls are estimated to cost the NHS more than £2.3 billion per year (NICE 2015). Falls are not, however, an inevitable consequence of old age. Well-organised services, based on recommended practice and evidence-based guidelines, can prevent many falls and fractures occurring.
These Quality Standards have been developed with representatives of Sandwell and West Birmingham health and social care economy (Appendix 1) as part of their local programme of WMQRS work. The draft Standards were circulated to relevant organisations in the West Midlands and comments received have been included.
Aims of the Quality Standards
The Quality Standards aim to improve the quality of the falls and fragility fractures ‘pathway’ and to help answer the question: “At each point on the pathway, how will I know that national guidance and best practice have been implemented?” The Quality Standards are suitable for use in self-assessment, monitoring by commissioners and providers, and peer review visits. They describe what services should be aiming to provide and providers and commissioners should be moving towards meeting all applicable Quality Standards within the next two to five years. Appendix 2 lists the references sources on which the Quality Standards are based.
Through use of the Quality Standards we hope that:
a. The local community, service users and carers will know more about the services they can expect.
b. Commissioners will be supported in assessing and meeting the needs of their population, improving health and reducing health inequalities, and will have better service specifications.
c. Service providers and commissioners will work together to improve service quality.
d. Service providers and commissioners will have external assurance of the quality of local services.
e. Reviewers will learn from taking part in review visits.
f. Good practice will be shared.
g. Service providers and commissioners will have better information to give to the Care Quality Commission and NHS Improvement.
Pathway
Figure 1 summarises the ‘Falls and Fragility Fractures Pathway’. This pathway covers primary prevention, identification of those at higher risk, immediate response, links with other pathways and secondary prevention in all health and social care settings. Falls risk assessments, multi-factorial falls and fragility fracture assessments and interventions are key aspects of the pathway:
Falls and Fragility Fracture Risk Assessments
Falls and fragility fracture risk assessments should be undertaken by a wide range of services including voluntary and statutory health, social care and housing services. Individuals identified as at high risk of a fall or fragility fracture should be referred, or advised to self-refer, to a service providing multi-factorial falls and fragility fracture risk assessment.
Multi-Factorial Falls and Fragility Fracture Assessment
Multi-factorial falls and fragility fracture assessments may be undertaken by a range of services including district nurses, general practitioners, paramedics, care home staff, community matrons or other staff providing intermediate care, community mental health teams and other voluntary and statutory organisations. Multi-factorial risk assessments must include a general assessment, clinical review and home assessment. These do not need to be undertaken at the same time or by the same team but the outcome of all three parts of the assessment must be taken into account in developing and agreeing the personalised falls and fracture prevention plan. A detailed fragility fracture assessment and interventions should be undertaken if indicated.
Referrals for multi-factorial falls and fragility fracture assessment should be able to be made by self-referral, by carer referral (with the individual’s agreement) by any health or social care professional or by other relevant statutory and voluntary sector organisations
Falls-Specific Interventions
Falls-specific interventions may be provided by the same service as the multi-factorial falls and fragility fracture assessment or may be available from a different service.
Community-based multi-factorial falls and fragility fracture assessments and falls-specific interventions do not need to be available seven days a week. Services should be accessible during normal working hours (Monday to Friday, 9am to 5pm). Timescales for urgent and routine assessment should have been agreed with local commissioners.
Links with Other Quality Standards
The Quality Standards for the Falls and Fragility Fractures Pathway should sit within organisations’ overall clinical governance arrangements. The WMQRS Clinical Governance Quality Standards describe the clinical governance arrangements which should be in place. Compliance in NHS provider organisations will usually be assured through NHS Litigation Authority Standards. Non-NHS organisations may wish to use the WMQRS Clinical Governance Quality Standards to assure themselves of the robustness of their overall clinical governance arrangements.
The Falls and Fragility Pathway links with many other pathways and Standards, especially:
a. Other public health programmes, in particular, Public Health England’s ‘Falls and Fragility Fractures Population Healthcare Programme’
b. Primary care, including medicines management
c. Other WMQRS Quality Standards, in particular those for:
i. Urgent Care (covering Urgent Care Centres, Ambulance Services, Emergency Department, Acute Medical and Surgical Admissions Unit)
ii. Care of People Musculo-skeletal Problems, in relation to bone health as well as fractures
iii. Care of People with Long-Term Conditions, including sensory disabilities
iv. Care of Older People Living with Frailty
v. Problem Alcohol Use Pathway
vi. Transfer from Acute Hospital Care and Intermediate Care
The Quality Standards will be updated as new guidance and evidence of effectiveness is produced, including NICE guidance on falls in a care setting.
Latest versions of WMQRS Quality Standards are available on the WMQRS website www.wmqrs.nhs.uk
Structure of the Quality Standards
Each Standard is structured as follows:
Reference Number (Ref) / This column contains the reference number for each Standard which is unique to these standards and is used for all cross-referencing. Each reference number is composed of two letters and three digits (see below for more detail).The reference column also includes a guide to how the Standard will be reviewed:
BI / Background information for the review team
Visit / Visiting facilities
MP&S / Meeting patients, carers and staff
CNR / Case note review or clinical observation
Doc / Documentation should be available. Documentation may be in the form of a website or other social media.
The shaded area indicates the approach that will be used to reviewing the Quality Standard. Appendix 4 summarises the evidence needed for review visits.
Quality Standard (QS)
Notes / This describes the quality that services are expected to provide.
The notes give more detail about either the interpretation or the applicability of the Standard.
Pathway and Service Letters:
The Quality Standards for the Falls and Fragility Fractures Pathway use the pathway letter M which is also used for Quality Standards for the Care of Older People Living with Frailty. People at risk of falls and fragility fractures are not all old, but older people are the main group following this pathway. The Standards are in the following sections:
M*- / Falls and Fragility Fractures Pathway / All Services (except hospital in-patients)MQ- / Falls and Fragility Fractures Pathway / Services Providing Multi-Factorial Falls and Fragility Fracture Assessment and Interventions
MC- / Falls and Fragility Fractures Pathway / General In-Patient Services (including acute and community hospitals)
MD- / Falls and Fragility Fractures Pathway / Mental Health In-patient Services
MZ- / Falls and Fragility Fractures Pathway / Commissioning
Topic Sections: Each section covers the following topics:
-200 / Staffing
-300 / Support Services
-400 / Facilities and Equipment
-500 / Guidelines and Protocols
-600 / Service Organisation and Liaison with Other Services
-700 / Governance
Policies, Protocols, Guidelines and Procedures:
The Quality Standards use the words policy, protocol, guidelines and procedure based on the following definitions:
Policy: A course or general plan adopted by an organisation, which sets out the overall aims and objectives in a particular area.
Protocol: A document laying down in precise detail the tests or steps that must be performed.
Guidelines: Principles which are set down to help determine a course of action. They assist the practitioner to decide on a course of action but do not need to be automatically applied. Clinical guidelines do not replace professional judgement and discretion.
Procedure: A method of conducting business or performing a task, which is made up of a series of actions or steps to be taken.
For simplicity, some Quality Standards use the term ‘guidelines and protocols’, which should be taken as referring to policies, protocols, guidelines and procedures. All clinical guidelines should be based on national guidance, including NICE guidance where available. Local guidelines and protocols should specify the way in which national guidance will be implemented locally and should show consideration of local circumstances. Guidelines and protocols should be organised in the way that is most helpful to the local service; for example, one guideline may cover several Quality Standards or several guidelines may relate to one Quality Standard.
Appendix 3 gives a glossary of terms and abbreviations used in the Quality Standards.
Comments on the Quality Standards
The Quality Standards will be revised as new national guidance becomes available and as a result of experience of their use in peer review. Comments on the Quality Standards are welcomed and will be taken into account when the Quality Standards are updated. Comments should be sent to .
More information about WMQRS and its Quality Standards and reviews is available at www.wmqrs.nhs.uk or by calling 0121 612 2146.
© December 2016 West Midlands Quality Review Service
These Quality Standards may be reproduced and used freely by NHS and social care organisations in the West Midlands for the purpose of improving health services for residents of the West Midlands and those who use West Midlands’ services. No part of the Quality Standards may be reproduced by other organisations or individuals or for other purposes without the permission of the West Midlands Quality Review Service. Organisations and individuals wishing to reproduce any part of the Quality Standards should email the West Midlands Quality Review Service on: .
Whilst the West Midlands Quality Review Service has taken reasonable steps to ensure that these Quality Standards are fit for the purpose of reviewing the quality of services in the West Midlands, this is not warranted and the West Midlands Quality Review Service will not have any liability to the service provider, service commissioner or any other person in the event that the Quality Standards are not fit for this purpose. The provision of services in accordance withthese Standards does not guarantee that the service provider will comply with its legal obligations to any third party, including the proper discharge of any duty of care, in providing these services.
Review by: December 2019
WMQRS FFF QS V1 20161220 - SA 1
All Services (except hospital in-patients)
Falls and fragility fracture risk assessments should be undertaken by a wide range of services including voluntary and statutory health, social care and housing services. Individuals identified as at high risk of a fall or fragility fracture should be referred, or advised to self-refer, to a service providing multi-factorial falls risk assessment.
Immediate assessment and care of someone who has fallen may be undertaken by carers, GPs, the ambulance service and a range of voluntary and statutory community services who may be in contact with the individual. Calls may be taken by GP reception staff, NHS 111, ambulance service call-handlers or by other ‘help-lines’. Mental as well as physical health services may need to respond to someone who has fallen.
Demonstration of compliance (DoC): BI - Background Report; Visit - Visiting Facilities; MP&S - Meeting Patients and Staff; CNR - Case Note Review; Doc - Document
Y/N / Comments /
M*-102
BI
Visit
MP&S
CNR
Doc
/ Falls Prevention Information
Information about falls and fragility fractures should be widely displayed covering at least:
a. Risk factors
b. Actions to prevent falls and fragility fractures
c. Who to contact for further advice and information
This information should also be offered to anyone referred for a multi-factorial falls assessment and their carers. / 1 This QS duplicates part of QS M*-102 of the WMQRS Quality Standards for the Care of Older People Living with Frailty but is applicable if these Standards are used separately from the Care of Older People Living with Frailty Quality Standards.
2 Patients at risk of a fall or fragility fracture are those:
a. admitted following a fall, aged over 65 or aged 50 to 64 with underlying conditions which increase their risk of falls,
b. who have fallen while in hospital,
c. at high risk of fragility fracture (see QS MQ-505).
M*-297
BI
Visit
MP&S
CNR
Doc
/ Training Programme
A programme of training should be available covering at least:
a. Conducting a falls risk assessment, including falls prevention advice to be given
b. Indications for referral, or advising self-referral, for multi-factorial falls assessment or re-assessment
a. Local services providing multi-factorial falls assessment or re-assessment
M*-506
BI
Visit
MP&S
CNR
Doc
/ Falls Risk Assessment
Services should conduct a falls risk assessment on anyone aged over 65 or at high risk of falls on first contact and at least annually thereafter. The falls risk assessment should comprise:
a. Asking if the individual has fallen in the past year and, if so, the number of falls and their characteristics
b. Observing balance and gait
c. ‘Timed Up and Go’ or ‘Turn 180o’ test
d. Giving falls prevention advice, including advice on home safety and hazards
e. If indicated, refer or advise self-referral for multi-factorial falls assessment or re-assessment
f. Recording the falls risk assessment and whether referred for multi-factorial falls assessment / 1 Appendix 6 includes supporting materials for local services conducting falls risk assessments.
2 Indications for referral or advising self-referral for multi-factorial falls assessment or re-assessment should be based on locally agreed guidance (QS MZ-606).
MA-507
BI
Visit
MP&S
CNR
Doc
/ Falls and Fragility Fracture Risk Assessment – General Practice
In addition to the requirements of QS M*-506, as part of the falls risk assessment general practices should:
a. Review the individual’s medication
b. Measure blood pressure lying and standing
c. Consider further investigation of cardiac rhythm and, if indicated, cardiac pacing
d. Fracture risk screen using a validated screening tool
e. Ensuring all patients who have had hospital treatment for a fall have received a multi-factorial falls and fragility fracture assessment including a clinical review and home assessment / 1 Blood pressure measurement should, ideally, involve three readings a) after resting supine for five minutes, b) repeat the blood pressure reading at one and three minutes later standing. (Centre for Disease Control STEADI accessed 20160204).
2 Examples of validated fracture risk screening tools are FRAX® (https://www.shef.ac.uk/FRAX/tool.jsp) and QFracture® (https:/www.qfracture.org).
3 General practices may wish to audit whether all patients presenting for medical attention after a fall have received a multi-factorial falls assessment.
M*-508
BI
Visit
MP&S
CNR
Doc
/ Falls: Immediate Assessment and Care
Guidelines on immediate assessment and care after a fall should be in use covering at least:
a. Indications for an emergency ‘999’ ambulance response
b. Indications and arrangements for contacting ‘help up and check’ services
c. Advice to be given to people who have fallen
d. Indications and arrangements for urgent and routine referral for community-based multi-factorial falls and fragility fracture assessment / 1 Direct referral for community-based multi-factorial falls and fragility fracture assessment should be available. Referrals should not need to go via the individual’s GP although the GP should be informed of the referral.
2 ‘Help up and check’ may be provided by ambulance services or by other services, such as community nursing teams or voluntary sector organisations. Arrangements may differ in different places and at different times of day but 24/7 coverage should be available.
Services Providing Multi-Factorial Falls and Fragility Fracture Assessment and Interventions
Multi-factorial falls and fragility fracture assessments may be undertaken by a range of services including district nurses, general practitioners, paramedics, care home staff, community matrons or other staff providing intermediate care, community mental health teams and other voluntary and statutory organisations. Multi-factorial risk assessments should include a general assessment, clinical review and home assessment. These do not need to be undertaken at the same time or by the same team but the outcome of all three parts of the assessment must be taken into account in developing and agreeing the personalised falls and fracture prevention plan. A detailed fragility fracture assessment and interventions should be undertaken if indicated.