FALLS PREVENTION ANALYSIS
Falls are a major cause of disability and the leading cause of injury in Older People aged over 75 in the UK. Older people are at a particular risk of falling when in hospital or residential or nursing home care. Pennine Care NHS Foundation Trust’s Falls Prevention strategy aims to reduce the number of falls occurring across Trust services and to minimise the impact which falls can have on patients. It considers research evidence for effective falls prevention and also takes into account the learning from falls, which have occurred within the Trust. In addition the Strategy has incorporated the guidance provided by The Patient Safety First Campaign (2009) The How to Guide for Reducing Harm from falls.
The Strategy is not limited to Older People Services and the principles are applied to all areas and care settings. Other patients may also present a risk of falling, for example those patients receiving new/multiple drug treatment. The impact and risks of falling are acknowledged to be greater for older people, and the severity of falls related complications increases with age.
The aim of the Falls Prevention and Management Strategy is to continually review, monitor and reduce the number of slips, trips and falls of service users including falls from height occurring across Pennine Care NHS Foundation Trust by ensuring staff are aware of risks and implement preventative measures.
Pennine Care has a Trust wide Falls Strategy Group that meets on a bi-monthly basis to support and monitor the implementation of the Strategy, reduce the number of slips trips and falls involving service users and that the strategy complies with any new National guidance and legislation
The Trust has established a Community Falls Implementation Group, to identify issues, risks and opportunities for improvement in relation to services provided to people within community settings, either through outpatient or domiciliary service delivery.
In addition the Trusts established inpatient Falls Implementation Group, identifies issues, risks and opportunities in relation to services provided within PCFT inpatient facilities. The group will agree and monitor the Trust Action Plan against falls prevention and support the process for raising awareness about preventing and reducing the number of falls involving service users in inpatient settings.
These groups will review investigations completed for falls classified as a Serious Untoward Incident for shared learning and recommendations and informs the current training content provided by the Trust on falls prevention.
The Trust has developed a risk assessment screening tool for use in all inpatient areas which is completed as part of the admissions Procedure for all older people and for young people and adults of working age where particular risk factors have been identified, e.g. pre-existing mobility problems. The Trust recognises there may be different requirements for different client groups and service areas, and that a particular patient group may present a complex range of different risks. This is recognised where some falls prevention strategies may be incompatible with suicide prevention strategies in particular the installation of grab rails within a ward environment. Analysis of the incident data from within the Trust and nationally, has highlighted that the risk of serious injury resulting from a fall in hospital is much higher than the risk of suicide for patients within older people’s inpatient services. Therefore the consideration of anti-ligature design within inpatient services may be different within older people’s inpatients areas.
To get a more accurate picture falls data is also measured against the number of bed occupancy days to give an accurate account on whether falls are reducing both across the organisation and specific in patient service areas.
Please find attached previous report which shows a general falls reduction up to August 2013.
The table above shows the gender of patients for those incidents reported under the category for slips trips and falls (total 1071).
The table above shows the ethnicity of patients of incidents reported under the category of slips trips and falls.
Inpatient STF Incidents – Older People and Intermediate Care 01/09/13 to 31/08/14Directorate / Department / Total
Bury / Ramsbottom Ward / 58
Oldham / Ward - Cedars / 54
Ward - Rowan / 50
Rehabilitation & High Support / Bevan Place RHSD / 33
Rochdale / Beech & Hazel Ward / 39
Stockport / Bevan Place RHSD / 1
Davenport Ward / 71
Rosewood Ward / 124
Saffron Ward / 97
Tameside & Glossop / Hague Ward (Saxon Ward) / 41
Summers Ward (21) / 68
Community Services Bury / Bealey Community Hospital Bury / 18
Community Services Oldham / Grange View - Int. Care (Tameside) / 195
Intermediate Care Team OCHS / 83
Grand Total / 932
The above table and graph below gives a breakdown on the number of slips trips and falls within inpatient facilities for older people and intermediate care facilities across the Trust. It is worth noting that not all of these figures represent incidents where harm has occurred to the patient and in the majority of cases the patient did not occur any significant injury.
Out of a total of 1071 incidents reported under the category of slips trips and falls across all service areas for patients a total of 23 patients sustained a serious injury such as a fracture and therefore required further investigation. On completion and closure of this investigation the report and any recommendations are then shared at the identified falls prevention group.
Whilst the information acknowledges that as there is an increase in the patients age the number of incidents of slips trips and falls increases the total of the number of females and males reported within this category has no significant difference.