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Setting up and running an Effective Falls Service: News and updates

Chaired by Carrie Tyler, Falls Practitioner at Mid Essex Hospital Services NHS Trust today’s conference focuses on setting up and running effective falls services and falls clinics. Through national updates, practical case studies and extended in depth sessions the conference will look at what excellence in falls services looks like, setting up and running an effective falls service, improving referrals, developing proactive preventative programmes such as exercise and balance training, delivering the individual multidisciplinary assessment, medication assessment, meeting the psychological needs of those who have fallen, developing links between community and acute falls services including in-reach and out reach, understanding the relationship between falls and syncope, developing your skills in RCA, and measuring and monitoring the quality of your falls service.

Speaker presentations and updates: 

Dr Martin Vernon, Consultant Geriatrician and Associate Head of Division, National Clinical Director for Older People & Integrated Person Centred Care, NHS England

Ageing well and avoiding falls in Older People: NHS England Update 

  • improving care and services for older people
  • ensuring all clinicians acquire the knowledge and skills appropriate for safe and competent care of older people with comorbidities and frailty

Dr Martin Vernon Full Presentation Click Here 

In his presentation Dr Martin Vernon stated: 

Older population expansion in England will accelerate in the next 20 years – so by 2035 there will be a million plus people aged 90 plus – this will affect the NHS in the long term.

15 million live with a long term condition (LTC), 58% people with a LTC are over 60 (14% under 40)

A&E attendances by people aged 60+ by two thirds 2007 to 2014

2010-15: there has been a 18% rise in emergency hospital older people admissions 

For people aged 70 plus the primary challenge will be maintaining physical connectivity

Older people have highest risk of falling - 30% people aged 65+ fall at least once/year, 50% of people aged 80+, Globally 37 million falls/year need medical attention and 424 000 worldwide deaths/year: 80% in low/middle income countries

The impacts of falls include pain, distress, injury, lost of confidence/independence.

NWAS (2013) states 10.5% of ambulance call outs were falls related

1 in 2 women, 1 in 5 men in the UK will suffer fractures after the age of 50 – most fractures in older people follow a fall and 10% of falls result in a fracture.

Falls is associated with a rise in mortality in adults over the age of 65

Not all old people are frail: not all people with frailty are old

Frailty indentations include - Distinguishing fit from frail & frail from fit…is the most pressing clinical task of our age. Frailty is linked to acquisition of multiple Long Term Conditions. Can be achieved  for individuals or populations and Can therefore help target interventions more effectively.

Frailty is a long term condition. It is common in 25-50% of people over the 80, its progressive for over 5 to 15years, it episodic deterioration (delirium, falls, immobility), it has preventable components, it has an impact on quality of life and is expensive.

What ever you do not call people the frail elderly – its is an older person living with frailty, a long term condition. This is how we should see frailty now.

New publication on Fracture Liaison service Audit released this year – key findings show variation in FLS staffing/ funding and under-recognition of caseload.

Key Recommendations

  • CCGs ensure effective FLS is part of FF pathway for 20 prevention
  • CCGs ensure FLS identify and treat ALL fracture groups
  • Providers to address gaps in:
    • Identification of patients 50+ with FF
    • All FF patients assess & treat in line with NICE
    • FLS-falls prevention services link: 50 hours evidence based exercise (NICE)
    • System wide communication  of core information (risk factors, fracture risk score)
    • Effective monitoring of those on drug therapy (4months, then yearly)

There are challenges presented by Frailty  

  • eFI so far only validated in primary care (not secondary care)
  • Frailty diagnosis requires clinical assessment & judgement to validate
  • The frailty evidence base is still developing
  • Interventions evidence not subject to large scale RCT (and may never be)
  • Economic & trajectory impacts of known interventions not yet understood
  • Other health system priorities

What NHS England are doing at the moment:

  • Age well approach
  • Promotion of electronic frailty index & diagnosis within summary care record
  • Economic modelling of impact of frailty
  • Ambulance & police consensus statements: MECC
  • Care homes commissioning guidance
  • Falls consensus with PHE
  • NICE multi-morbidity clinical guideline: tailored care planning
  • Supporting winter planning and keeping well
  • Serious illness conversation programme
  • Sustaining intermediate care data series

Professor Cameron Swift, Emeritus Professor and Consultant Physician, King’s College London

What does excellence in falls services look like? Critical elements of an effective Falls Service

  • what do consultants want when they refer someone to falls service
  • the critical elements of an effective falls services
  • how can falls services be improved? learning from the national audit

Professor Cameron Swift Full Presentation Click Here

In his presentation Professor Cameron Swift Stated: 

The key factors to an effective falls service include understanding the phenomenon, adhering to the evidence, coordination across all the boundaries (primary, secondary and social care) and finally measuring the outcome.

NICE is reviewing the quality standard for falls and an update is currently in progress

Falls in later life is a threat – a preventable threat that can be identified and prevented

Adherence to the evidence of the guidelines is key as there are things that do not work

The evidence is that we need case/risk assessment when ever there is a risk falls and then you need the networked falls service.

Conclusions from the RCP National Audit in 2011 showed

  • Unacceptable variation in the quality of falls and fracture services
  • Major gap between what organisations report and actual services
  • Patients with non-hip fragility fractures only 50% assessment & management v hip # patients
  • Important deficiencies remain in the commissioning, organisation and provision of care

Conclusions – QS 86 uptake 2013

Royal College of Physicians - Fracture Liaison Service Database (FLS-DB) Feasibility Study Summary Report

  • Proportion of index fractures that had evidence in the GP electronic records of a formal falls risk assessment = 3.9%
  • Proportion of older people living in the community with a known history of recurrent falls reporting to their GP who are referred for strength and balance training  = 0.8%

Falls diagnosis, Management and preventions is

  • Falls, effective and cost-effective
  • Specialised – integral to clinical gerontology
  • Multifactorial and multidisciplinary
  • Coordinated, focused and commissioned
  • Insufficiently implemented but achievable

Professor Cameron Swift Biography

Cameron Swift is a physician and clinical pharmacologist, Emeritus Professor of Health Care of the Elderly at King’s College School of Medicine, London, and a past President of the British Geriatrics Society.  He was a member of the UK Medicines Commission from 2001-5.  As Physician to the DOH External Reference Group for the England National Service Framework for Older People, he chaired the Working Party for Standard 6 (Falls & Fractures).   Subsequently he has served on the NICE Clinical Guideline Development Group (GDG) for Falls Prevention (CG24/161; 2004/2013), and has been Chairman of the NICE GDG, & subsequent Quality Standard Topic Expert Group for Hip Fracture (CG124, QS86)(2011, 2012).  He remains involved as an expert member in current reviews of NICE guidance (2014) and Quality Standards (2016) on both of these topics.

Michelle Nolan Falls Prevention Nurse Aintree University Hospital NHS Foundation Trust​

Setting up and running a Falls Servcie/Clinic and developing an effective service

  • setting up and running an effective falls service
  • communicating the service and ensuring appropriate referrals, ensuring all those who have fallen or are at risk of falls are referred to the service
  • the support you will need and the role of the falls service in educating and training frontline staff
  • developing competence for the role
  • an overview of our falls services and clinics

Michelle Nolan’s Full Presentation Click Here

In her presentation Michelle stated: 

Action planning is key to a Falls Service - Develop a falls service action plan, What are your KPIs? What are the challenges?,  Job role and responsibilities, Risk register data base, Horizon scan, Operational document, Key role and responsibilities and finally be realistic.

Getting started with a falls service you need to think about your vision, the  evidence, getting your commissioners on board,  planning, finance department, who is going to be involved / staffing and the skills needed, the resources you will need, the demographic area of the clinic, KPIs, the environmental factors, equipment, referral Criteria - to clinic and to CNS, times ie the frequency of clinic and patient attendance at clinic, communication, documentation and finally -  Submitting the Business Proposal

When launching your services use your communications team, local media, posters / flyers, word of mouth, hold an event – market style, drop in sessions and make sure you have a visible presence

“Work together is really important you can reduce falls as a one man band”

My assessment form includes a history of falls, fear of falling, footwear/advice, dietary and fluid intake, balance and mobility, falls information leaflet, OT/PT assessment required, feet sensation/plantar reflexes, medication review, asses for postural hypertension, cognitive impairment, hip protectors, continence assessment (these goes hand in hand), sensory impairment, home hazard advice, visual acuity, investigations, FRAX-osteoporosis, medical history, measurements, falls history, activity before the fall and then an action plan on the results.

“I think we set patients up for falls when they come is we take away there glasses and hearing aids. My idea is a sensory box – with all the bits they need – glasses, hearing aids etc – so they know were everything is and they can go back to box when ever they want to”

Staff training, the learning and development team are key to help with this, are you going to request mandatory training, e-learning are you going offer this, face to face training, trust induction so you catch every one including the consultants, RN/HCA updates, Junior doctors induction and study session. Make the training fun and know your target audience.  

“I show pictures in m y mandatory training as some times people just think of its just a fall – but I like to show falls do cause injuries.”

“This is a video I like to use in my training also – is this what you would want from a service”

“If you are going to set up a falls service I would start with a pilot site first”

Where we are now – a one stop falls prevention clinic, multifactorial, reduce falls, referral to specialist clinics – Neuro, cardiology, patient, carers and staff training, collaborative working with community services, collaborative working with NWAS, timely referral response (48 hrs) and Education and training.

“Some one needs to bang the drum for falls prevention otherwise it gets lost”

The clinic team includes – falls prevention nurse, consultant lead – falls, 2 physiotherapists, 2 occupational therapist, 1 HCA, 1 registrar (rotates), and 4 receptions staff.

The Hospital team includes – falls prevention nurse, consultant lead – falls, lead nurse, falls link nurses and 1 reception staff.

Referrals (criteria) accepted from GPs and hospital staff - Unexplained falls, Falls with Loss of consciousness, Falls that have resulted in serious injury, Discharged patients, Frequent falls and Complex patients.

In Summary - Build a business case, Define your aims & objectives, Establish patient criteria, Plan your publicity, Select the location, Who can help – MDT?, Consider medicines management / competencies, Plan, audit & evaluation, Facilitate ongoing improvement and Learning and development team.

“The most important thing is to try not to fall at the last first hurdle and if you do get back on the horse”

Michelle Nolan’s Biography:

Michelle started training as a nurse in 2000 and qualified as a registered nurse in 2003. Since then Michelle has undertaken a Degree in Health and Social care and went on to complete a Master’s degree in Advancing Practice. Michelle has been working as a falls prevention nurse since 2014 which Michelle has found to be both challenging and rewarding, Michelle has developed and implemented a multi-disciplinary nurse-led falls clinic, including the design and launch of the Multi factorial falls risk assessment tool that is used at Aintree University Hospital. Prior to this position Michelle worked as a community based continence and urology specialist nurse where she was responsible for setting up nurse-led clinics and initiating patient group directives within the clinic environment.

Future conferences of interest:

Falls Prevention and Management in Older People
Tuesday 6 December 2016 
Manchester Conference Centre

21 October 2016


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