Push to reduce falls

1 July 2013

In the last two years, 170 patients fell while in public hospital care and broke their hips, and 22 of those people died earlier than expected. FIONA CASSIE talks to Sandy Blake about the new national drive to reduce falls and her pilot of a bedside electronic falls risk assessment tool using TrendCare.

Patient falls in hospital can be devastating, expensive, and preventable.

It is a given that district health boards want to reduce falls, which are the most commonly reported serious and sentinel event in our public hospitals.

Sandy Blake, clinical lead to the Health Quality & Safety Commission’s Reducing Harm from Falls programme, says a survey of the 20 boards found not one region taking the same approach.

“They are all different. There’s great variety. Everybody says they have an evidence-based policy and no two policies are the same,” says Blake.

From now on, one common component of falls policy – carrying out falls risk assessments – will be used as a quality marker and the percentage of elderly hospital patients receiving falls risk assessments will be reported back on a six-monthly basis (see sidebar). Data will also be collected on how many at risk patients receive an individualised care plan and how the country is doing in reducing the harm and cost from falls.

When seconded into the falls programme role a year ago Blake visited hospitals around New Zealand spending some time on the ward with nurses and found lots of good ideas about reducing falls but yet again no one risk assessment or care planning tool was quite the same.

Some tools spat out the same falls risk rating and care plan whether the patient was at risk because of Parkinson’s disease or only having one leg. Some tools also resulted in lengthy ‘tick-box’ style care plans that were hard for the nurse to scan and find the individually pertinent advice, like ensuring a patient’s artificial leg was handy.

One of Blake’s responses was to research and write a paper suggesting evidence-based guidelines for falls risk assessment and care planning (to be released shortly and discussed at a workshop in July) and also to use her findings to develop an electronic falls assessment and planning tool that is shortly to be piloted at several DHBs including her own. The falls programme is also supported by a cross-sector, multi-disciplinary expert advisory group and other aspects of the programme include promoting DHBs sharing the learning from their analysis of falls reported to the commission as serious or sentinel events.

“The prevention of falls is a tough nut to crack, and I’m not saying we’ve got all the answers,” says Blake. “But I certainly know from my experience that if we had a bit more standardisation, and we shared the things that really worked well with each other, we’d have more of a chance of keeping our patients safer.”

Blake returned to New Zealand three years ago to become the director of nursing for Whanganui DHB after 22 years nursing in Queensland, with her last job being a state-wide nursing director role for patient safety.

Using her patient safety background, she has analysed the current risk assessment tools in use, plus the latest international evidence, to draw up the core components of what she believes falls risk assessment and care planning should involve, including room to allow a nurse’s own clinical judgment and for patient and family input.

She says risk assessment is aided by having a tool that asks the right questions, so she has drawn up evidence-based guidelines of what an effective risk assessment tool should cover including a patient’s medications, history of falling, and mobility.

The risk assessment also needs to lead to a individualised care plan to meet and highlight the patient’s own unique set of needs. Blake argues that the suite of good care that every patient should expect – whether at risk of falling or not – should not need to be separately listed in every care plan.

“Things like having their call bell within reach, having their environment uncluttered, having their personal stuff within reach, knowing the way to the toilet, and having their bed at the right level for them,” says Blake.

“Those are things that I would expect, and any director of nursing should expect, are the standards expected for all patients.”

Soon 16 out of the 20 DHBs will be using the patient acuity software TrendCare and Blake saw the potential for including a standardised falls risk assessment process within TrendCare.

The resulting electronic tool is to be piloted at Whanganui and MidCentral DHBs. Wearing her director of nursing hat, Blake believes strongly in having patient and family involvement in the assessment process and so is wary that the shift from a paper tool to an electronic tool may result in nurses doing the risk assessment at the nursing station computer rather than at the patient’s bedside.

She is holding off starting the pilot at Whanganui until she has the wireless technology and laptops on trolleys that will allow bedside assessments.

But she is hoping this winter will see the pilot begin and is also looking forward to workshopping and debating her paper’s proposed guidelines as another step in the patient safety and quality campaign to reduce the harm from falls.

Open for better care: national patient safety campaign

  • Open for better care is a national patient safety campaign co-coordinated by the Health Quality & Safety Commission and aligned with existing patient safety initiatives.
  • It was officially launched on May 17 by associate health minister Jo Goodhew and focuses on reducing harm in the four areas of: falls, surgery, healthcare associated infections and medication
  • The first area of focus is the prevention and reduction of harm from falls.
  • Falls resources developed for the campaign can be found at: www.open.hqsc.govt.nz/falls/publications-and-resources
  • DHBs’ first baseline data of how well they are achieving the campaign’s quality and safety markers were due to be released in late June and from here on in will be reported six monthly.
  • The quality marker for falls will be the percentage of patients 75 years or older given a falls risk assessment with the desired level being 90 per cent or more.