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GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDIT

© Greater Manchester & Wirral Falls Risk Assessment Audit Group, 2004Clinical Effectiveness Unit, Stockport NHS Foundation Trust

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CONTENTS

Page1 Executive Summary 22 Project Board 43 Background 54 Aims and Objectives 75 Developing the Audit and Data Collection Strategy 86 Standards 97 Data Collection and Methodology 148 Results 199 Summary/Conclusions 4110 References 4611 Contact Details 4812 Acknowledgements 49

APPENDICESAppendix 1 List of Charts and Tables 50Appendix 2 Hospital wards – type and number of beds 51Appendix 3 Hospital Falls Services 53Appendix 4 Feedback Seminar Attendees 56Appendix 5 Proforma 57



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1. EXECUTIVE SUMMARY

The purpose of this report is to inform Trust Management/Executive Teams, PCTs,

Strategic Health Authorities and the Greater Manchester Clinical Audit Group of the

outcome of the recent Greater Manchester and Wirral Falls Risk Assessment Audit.

The principal aim is to audit current Falls Management and Prevention in a group of

Hospitals across Greater Manchester within the context of the National Service

Framework for Older People.

The main results of the audit concentrate on assessments and documentation, risk

factors, mobility assessments, interventions and prevention measures, and the

possible impact of falls risk assessment tools (FRA) in preventing falls in hospital.

• Patients in the sample were predominantly the very elderly, those aged 80 years or

more comprised almost 58% of the sample. This proportion varied by Trust from,

45% in MRI to 73% at the Wirral.

• Approximately 30% of patients in the sample were admitted with a fall.

• Between 85 - 95% of patients in 4 of the hospitals were assessed. The other 6

hospitals all fell below the mean value, which was less than 53%.

• Overall 34% of patients who had a risk assessment were reviewed.

• Some form of action to prevent falls was taken in 61% of patients who had a risk

assessment form in the 5 hospitals that used Falls Risk Assessment forms.

• Patients were more likely to have mobility and/or transfer assessments done than

other assessments such as Lying & Standing BP and Medication reviews.

• The most likely interventions included referral to a physiotherapist and/or an OT,

the patient was placed under close observation, and a call bell was at hand.

• Patients having a FRA completed were significantly more likely to have certain

prevention measures.

• Fewer patients fell in the group that had a FRA completed.



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The main conclusions from the audit are: using a FRA may have a protective effect;

the patients are more likely to have prevention measures targeted at them; in-patient

falls were less likely in hospitals using a FRA and patients with risk factors are not

necessarily being documented as being at risk of falling.

Following the feedback seminar a Falls Working Group will be set up to look at

multidisciplinary core skills in relation to an inpatient falls action plan and to explore

standardising falls risk assessment and intervention across Greater Manchester.

Funding for the audit was provided by the Greater Manchester Clinical Audit Leads

Group.



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2. PROJECT BOARD

Members Title Organisation

Mrs J Barnes Physiotherapist Tameside & Glossop AcuteServices NHS Trust

Dr D BourneConsultant in GeneralMedicine and ElderlyCare

Central Manchester & ManchesterChildren’s University HospitalsNHS Trust *

Dr G Cook ConsultantEpidemiologist Stockport NHS Foundation Trust

Mrs J Gray Falls Co-ordinator South Manchester UniversityHospitals NHS Trust

Mrs S Gunnion Lead Falls NurseCentral Manchester & ManchesterChildren’s University HospitalsNHS Trust **

Dr M Hanley Consultant in ElderlyMedicine Stockport NHS Foundation Trust

Mrs J Powell Falls Prevention Officer Pennine Acute Hospitals NHSTrust

Dr M Pritchard-Howarth

ConsultantOrthogeriatrician Wirral Hospital NHS Trust

Ms J Rodgers Audit Co-ordinator Stockport NHS Foundation Trust

Jacquie Ruddick Clinical Governance Co-ordinator Wirral Hospital NHS Trust

Mrs G Wakefield Clinical GovernanceFacilitator Trafford Healthcare NHS Trust

* Now employed by South Manchester University Hospitals NHS Trust** Now employed by Stockport PCT



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3. BACKGROUND

Injury is a leading contribution to the burden of disease in the world. In 1998 injury

from falls was the 14th leading contributor for all age groups (Myers, 2003). Falls are a

major cause of disability and the leading cause of mortality due to injury in people

aged over 75 in the UK. Up to 14,000 people a year die in the UK as a result of an

osteoporotic hip fracture (DoH, 2001). Falls prevention is a priority area for research

and interventions. Identification of high risk patients is an important component of falls

prevention measures (Myers, 2003).

NSF for Older People

The National Service Framework (NSF) for Older People, recognises the importance

of prevention (DoH, 2001). The NSF sets out the aims in standard six, to reduce the

number of falls which result in serious injury and to ensure effective treatment and

rehabilitation for those who have fallen. The NSF promotes the establishment of

specialist falls services within specialist multidisciplinary and multi-agency services for

older people including health and social care staff that target, especially, older people

who are at high risk of falling.

As part of the Service Model, the NSF states that staff in hospitals should be trained to

recognise when older people are at risk of falling and be able to refer them to the falls

service for assessment. Assessments should identify the risk factors for falls and

osteoporosis and offer appropriate interventions. Current practice should be examined.

New procedures should be agreed by a range of professionals involved in the falls

service. Finally, prior to discharge, the needs of the patient and their carers for care

and support at home should be identified. This includes making sure that patients are

advised about how they can reduce their risk of falling and therefore prevent further

falls or fractures. (DoH, 2001)

This audit aimed to assess whether or not such services were established in the

hospitals involved. Preventing falls in older people depends on identifying those most

at risk of falling and co-ordinating appropriate preventative action. The audit would



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examine how hospitals identify those at risk and whether this is routinely done and

what preventative measures are then put into place. The audit would examine current

practice and whether the standards developed within and through the NSF had been

met.



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4. AIMS & OBJECTIVES

AIM

To audit current falls management and prevention in a group of hospitals across

Greater Manchester in support of the National Service Framework for Older People.

OBJECTIVES

I. To conduct a multidisciplinary audit of the use of risk assessment tools for falls

prevention on Care of the Elderly and Trauma and Orthopaedics wards

II. To develop further the multidisciplinary clinical network between Care of the

Elderly, Trauma and Orthopaedics and Anaesthetics

III. To develop further links with the local collaborative initiatives around

orthopaedics and care of the elderly

IV. To establish a baseline of current services within each hospital setting



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5. DEVELOPING THE AUDIT AND DATA COLLECTIONSTRATEGY

5.1 Trusts participating in the audit

Six trusts from Greater Manchester and one from Wirral were recruited to the audit.

The trusts were Central Manchester & Manchester Children’s University Hospitals

NHS Trust, Pennine Acute Hospitals NHS Trust (across 4 hospital sites), South

Manchester University Hospitals NHS Trust, Stockport NHS Foundation Trust,

Tameside & Glossop Acute Services NHS Trust, Trafford Healthcare NHS Trust and

Wirral Hospital NHS Trust. In total 10 hospitals participated.

5.2 Progression and Development

A multidisciplinary project group comprising Care of the Elderly Physicians,

Physiotherapists, Nursing staff and Clinical Audit staff met on four occasions to agree

the audit questions, audit criteria and standards and methodology.

From discussions in the group it appeared that there are 2 main risk assessment tools

for falls currently in use in the hospitals involved, these are:

FRASE (Cannard, 1996): An adaptation of this un-validated tool is currently in use in

Stockport and Tameside.

STRATIFY (Oliver et al, 1997): A tool developed in an NHS setting with a good

evidence base, in use at South Manchester, Wirral and Pennine.

The audit criteria were derived largely from the NSF and the above tools. A few

additional criteria were decided upon by the project group using a variety of resources

(see section 6).

5.3 Other Information

Information was collected concerning resources about each individual hospital site to

enable a comparison of the structure of the hospitals’ falls service. Information

includes for example: whether or not there was a falls co-ordinator and what their role

was, was a falls risk assessment tool being used and the number of falls in a year.



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6. STANDARDS

6.1 The National Service Framework for Older People was published in 2001. It set

new national standards and service models of care across health and social services

for all older people. It addresses those conditions which are particularly significant for

older people - stroke, falls and mental health problems associated with older age. (For

further background information please refer to the NSF for Older People document

which be found on the Department of Health website).

The NSF focuses on:

• rooting out age discrimination

• providing person-centred care

• promoting older people’s health and independence

• fitting services around people’s needs.

This audit focuses on Standard Six: Falls. The aim of standard six is: to reduce the

number of falls which result in serious injury and ensure effective treatment and

rehabilitation for those who have fallen. (DoH, 2001)

The standard set by the NSF was as follows: the NHS, working in partnership with

councils, takes action to prevent falls and reduce resultant fractures or other injuries in

their populations of older people. Older people who have fallen receive effective

treatment and, with their carers, receive advice on prevention through a specialised

falls service. (DoH, 2001)

Prevention

Preventing falls in older people depends on identifying those most at risk of falling and

co-ordinating appropriate preventative action. Older people may be identified as being

at risk through the presence of certain risk factors. Interventions which target both

multiple risk factors for individuals (intrinsic risk factors) and environmental hazards

are most successful.



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Specialist assessment should be carried out by the falls service in collaboration with

primary and social care professionals. This should build on the single assessment

process. It should identify risk factors associated with an older person’s health. (DoH,

2001)

Two particular criteria addressed by the audit are:

• An operational falls service has been set up in each local health economy with

appropriate complement of staff. (DoH, 2001)

• The falls service has access to dieticians, optometrists, orthotists,

ophthalmologists, audiologists, bi-linguists, and to bone densomitry. Older

people who fall should, with their consent, be referred to a specialist falls

service. (DoH, 2001)

Interventions

Interventions should be agreed with the individual concerned. These may include:

• diagnosis and treatment of underlying medical problems such as eye

examinations, correction of postural hypotension or cardiac rhythm abnormality,

changes in medication etc.

• rehabilitation, including physiotherapy to improve confidence in mobility,

occupational therapy to identify home and environmental hazards

• equipment to improve the safety of the older person at home

• repairs or improvements to the home and an assessment for home adaptations

if warranted

• social care support.

Falls prevention programmes for individuals should contain more than one intervention

and focus on the individual’s particular risk factors. These interventions are focused

upon in the audit and are identified on the audit form in sections F, G and H (see

appendix 5 for a copy of the proforma).

Falls in hospitals should be recorded on registers. Although we did not look at this

specifically in the audit it is an important part of falls prevention. Critical incident



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analysis, following a fall will develop an awareness and learning culture amongst staff

and will ensure that action taken will minimise future incidents.

6.2 Other documents used:

Scottish Intercollegiate Guidelines Network (SIGN)

The SIGN guidelines number 56 Prevention and Management of Hip Fracture in

Older People suggest older people should be assessed for risk of falling by using

identified risk indicators (patient and environment) and any interventions should be

based on this risk assessment.

The guidelines also suggest that those at increased risk should be offered multiple

interventions, e.g. exercise programme, balance training, modification of identified

hazards etc, aimed at reducing the identified individual and environmental risks.

The British Orthopaedic Association’s document The Care of Fragility Fracture

Patients has a small section on falls prevention. It suggests that a full clinical history

should identify possible factors predisposing to falls such as postural hypotension,

diabetes and alcohol excess. They also suggest that if a risk remains then hip

protectors should be considered.

The Best Practice document Falls in Hospital also suggested a number of risk

factors, which were looked at by the project group and incorporated into the proforma.

It also suggests that education should be part of the falls program, targeting staff,

patients and relatives to increase their awareness of the risk of falling during

hospitalisation and to try and minimise this risk.

The British Geriatrics Society’s Guideline for the Prevention of Falls in Older

Persons aims to assist health care professionals in their assessment of falls risk and

in their management of older patients who are at risk of falling and those who have

fallen. The guideline listed certain interventions and analysed how effective they were,

for example exercise, review of medications, environmental modifications, footwear

etc.



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6.3 Standards set by the Project Group

Risk Factors

The project group identified specific risk factors that were incorporated into the

proforma, these include for example:

• taking four or more medications, especially sedative hypnotics

• visual impairment

• impaired cognition, confusion, depression

• history of falls

• Particular medical conditions, e.g. Diabetes, Parkinson’s, Stroke

The extent to which these clinical risk factors are documented through the risk

assessment tool will be audited.

Intervention Measures

The group also identified a number of intervention measures that can be used to

prevent falls. Sources included the Action Plan used by Stockport NHS Foundation

Trust. See section 7.1 for further details regarding interventions. Examples of

interventions include:

• Using a coloured wristband to identify those at risk

• Frequent toileting

• Educating the patient and relatives

• Bed Rails

• Home visit to assess the patient’s home for risk factors

The standard ideal for both of these factors was that in all patients’ records there was

documented evidence of checking for the risk factors and including or excluding

interventions.

The full list risk factors and interventions can be found on the proforma in appendix 5.



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Other standards:

• A falls risk assessment tool is in use on the appropriate wards in each hospital.

• An environmental audit tool and action plan is in place

• All patients are assessed and a completed form is in each patient’s set of notes.

• Each form is fully completed.

• In appropriate cases patients will have been re-assessed after one week, and their

care plan reviewed.

• All patients who are classified at high risk have an appropriate care plan and

preventive steps outlined and acted upon.

Other issues that would be looked for:

• All ward staff have been formally trained on how to use the tool

• The use of health promotion material

• The provision of Falls clinics, patient sitter programmes and response systems

• The issue of patient information, for example Falls Prevention: Your safety

checklist and guide.



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7. DATA COLLECTION & METHODOLOGY

7.1 Developing the Proforma

Section A asks for demographic information such as the date of birth and gender.

Section B was designed to capture details about the episode such as date of

admission, reason for admission and whether the admission was due to a fall.

Section C was designed using the various risk assessment tools; it is to assess how

thoroughly the risk assessment form has been completed for each patient. It should

cover all aspects of all the different tools.

Section D was designed for hospitals that didn’t use a tool and for patients who had

not had a formal assessment using a falls risk assessment tool. The questions were

designed to see if any other assessment for falls risk had been carried out or to see if

any staff had noted that the patient was at risk of falling.

Section E the list of risk factors was identified as detailed in Section 6 Standards. It

was noted on the proforma if the patient had had any of these risk factors recorded or

excluded anywhere in the patient’s notes.

Section F is used to record whether or not assessments for certain indicators of falls

risk have been carried out. Again the project group decided upon these indicators after

looking through the guidelines.

Section G was included to determine whether or not certain assessments usually

done by Physiotherapists and Occupational Therapists had been carried out as

appropriate. The project group devised the list, members advised the group as to what

assessments their particular hospital used so that the section would cover all possible

assessments



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Section H was mainly taken from the action plan used at Stockport NHS Foundation

Trust. Additional interventions came from the various guidelines and papers reviewed

by members of the group. Project group members added other interventions to the

proforma, in accordance to what is in place specifically at their particular hospitals.

The purpose of this section was to ascertain whether or not any interventions, which

are believed to help reduce the risk of falls, were implemented and whether or not the

decision had been recorded in the casenotes. Some of the interventions are only

appropriate for a patient with specific risks e.g. dementia, the need to ‘special’ the

patient, trial without catheter etc. Some were only appropriate if the patient had been

assessed as being at risk or at high risk of falling.

The following interventions from the list were taken from the Action Plan used at

Stockport

• Close observation of patients in an appropriate area.

• Assess for the use of alarms on bed/chair.

• Assess the need for hip protectors

• Assess the need to “special” the patient if they are a frequent faller.

• Undertake in-depth assessment of patients’ dementia.

• Frequent toileting of high-risk patients.

• Coloured wristband to alert staff of risk of patient falling.

• Inform physiotherapist of patients at high risk.

• Call bell is at hand

• If appropriate explain to the patient the importance of asking for help whenwalking

• Leave bed in low position when patient is unattended

• Use a chair, of appropriate height for the individual (Hips should be flexed at90° and feet should be flat on the floor)

• Footwear assessment documented

• Discuss patients’ risk of falling with relatives, if appropriate.

Section I included other related information such as whether or not the patient fell

during the time they were in hospital and specific details regarding the fall. This would



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be used to determine whether or not using a risk assessment tool was effective in

preventing falls in hospital.

The proforma for collecting audit data was piloted twice, in February and March 2004,

with help from members of the project board, before a final version was agreed.

A copy of the proforma can be found in appendix 5.

7.2 Sample

The project board members decided upon the sample size and inclusion criteria. It was

decided to take 52 patients from each trust aged 65 and over. These 52 patients would

be spread over Care of the Elderly and/or General Medical wards and Orthopaedic

wards, with 40 from Care of the Elderly/Medical and 12 from Orthopaedics. It was

agreed that the patients in the sample must have been in hospital for at least 3 days.

For a list of wards and number of beds please see appendix 2.

Inclusion Criteria:

• Patients aged 65 and over

• In-patient for 3 or more days

• On General/Adult Medical, Care of the Elderly and Orthopaedic wards

Exclusion Criteria:

• Patients under 65 years of age

• In patient for less than 3 days

• On any other ward not stated above

• Elective patients

• On rehab wards

7.3 Data Collection

The project co-ordinator visited staff at each hospital before data collection started to

discuss how and when the data collection would be conducted in each hospital.



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Data collection began in the first hospital in May 2004, each hospital was allocated a

certain week when data collection would take place, data collection was complete by

the end of the first week of August 2004. See table 1.

Table 1. Data Collection dates at each hospital

HOSPITAL DATA COLLECTION START DATESouth Manchester Tuesday 4 May 2004

Oldham Wednesday 2 June 2004Wirral Tuesday 8 June 2004

Stockport Monday 14 June 2004Trafford Tuesday 22 June 2004

MRI Monday 28 June 2004Rochdale Thursday 15 July 2004Tameside Tuesday 20 July 2004

North Manchester Monday 26 July 2004Bury Tuesday 3 August 2004

Up to 5 Medical/Care of Elderly wards were selected, as can be seen in the table 2.

Some hospitals used all Care of the Elderly wards, some did not have specific Elderly

wards and so used 5 General/Adult Medical wards, those that had both types of wards

used a mix of the two types.

Table 2. Number of Wards at each hospital by specialty

HOSPITAL CARE OFELDERLY

GENERAL/ADULTMEDICAL T&O

South Manchester 0 5 1Oldham 0 5 1Wirral 5 0 1

Stockport 2 3 2Trafford 2 3 1

MRI 0 5 1Rochdale 0 5 1Tameside 0 5 2

North Manchester 0 5 1Bury 0 5 2

Lists of all patients on the appropriate wards were generated from the Information

departments or PAS systems. All inappropriate patients, i.e. those with exclusion

criteria, were removed from the lists. Using Microsoft EXCEL each ward list was

randomised and the first 8 patients on each of the lists were selected from each of the

5 wards, making 40 in total. If a patient’s notes were unavailable on arrival on the

wards the next patient on the randomised list was selected and so on.



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Most of the hospitals had one main trauma ward but a few had more than one ward.

Where there was more than one trauma ward all the patients from both wards were

added together and the sample of 12 patients was randomly selected from the list.

Lists were randomised in the same way as the Medical wards. The first 12 patients

were randomly selected from the orthopaedic wards.

The Audit co-ordinator worked with staff from various departments including Clinicians,

Clinical Audit staff, Physiotherapists and Occupational Therapists at each hospital to

complete the proformas for the data collection.

Data from completed proformas was entered onto an Access database by the Audit

Co-ordinator. Data was then analysed using Excel spreadsheets and pivot tables.

Some hospitals were not using a falls risk assessment tool or were only just

implementing a tool. For part of the analysis the hospitals were split into 2 groups. The

first group included those hospitals where the tool was established and should have

been in use throughout the hospital. The second group consisted of those hospitals

not using the tool or only just introducing it.

Information regarding falls services, incident reporting of falls and the use of falls risk

assessments was also collected from each hospital. Information gathered can be

found in appendix 3.

The project board met again in September 2004. The purpose of the meeting was to

agree a format for feeding back the results, to discuss the preliminary results of the

audit and to discuss any specific issues raised by the results and clarify what should

be presented at the main feedback seminar.

The main feedback seminar was held on 1st November 2004 at Stepping Hill Hospital,

Stockport and was well attended by representatives from various NHS Trusts and

other NHS organisations. The results of the audit were presented to the audience.

Trusts will also be able to present their results to staff at their own meetings.



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8. RESULTS

8.1 General Demographics

Table 3. General Demographics7 Trusts/10 Hospital Sites 518 Patients52 patients from 9 hospitals, 50 from 1 hospitalMean Age = 81.5 Age Range = 65 – 100Male:Female = 2:3 (3 gender unknown)Average time in hospital = 22 days Range = 3 days – 179 days

Chart 1. Age Group by Hospital

N = 518Comment

Patients included were predominantly the very elderly, those aged 80 years or more

comprised almost 58% of the sample. This proportion varied by Trust from, 45% in

MRI to 73% at the Wirral.

This degree of variation may be explained by the different types of wards used in each

hospital and the predominance of younger or older patients accordingly. Some

hospitals did not have specific Care of the Elderly wards and so General/Adult Medical

wards were used were there is a greater mix of ages, some had a mix of different

types of wards and one of the hospitals used all Care of the Elderly wards. See

appendix 2.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

BuryM

RI

NMGH

Oldham

Rochdale

Stockport

Tamesid

e

Traffo

rd

Wirr

al

Wyth

enshawe All

65-79

80+



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Chart 2. Proportion of Patients admitted due to a fall

N = 518

Comment

The mean percentage of patients admitted with a fall is just over 30%. 6 hospitals fell

below this average, 3 were just above the average, and 1 hospital had nearly 20%

more patients admitted with a fall than the average.

0%

10%

20%

30%

40%

50%

60%

Bury

MRI

NMGH

Oldham

Rochdale

Stock

port

Tamesid

e

Traffo

rd

Wirr

al

Wyth

ensha

we

% FALL

MEAN



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8.2 Assessment and Documentation

Chart 3. Proportion of Patients Assessed & Documented

N = 518

Standard: All patients are assessed and a completed form is in each patient’s

sets of notes

Comment

This chart shows the percentage of patients assessed. Assessment could be either by

using a Falls Risk Assessment Form, or some other less structured format of

assessing patients such as a note or statement made in the patients records by the

attending doctor. Please see methodology section. Between 85 - 95% of patients in 4

hospitals were assessed. Less than 53% of patients were assessed in the remaining 6

hospitals.

Hospitals using a FRA completely were more likely to assess their patients for falls

risk.

Table 4. Percentages AssessedHospitals with formal documentation in usePatients assessed by formal documentation 67%Patients assessed by other method 9%Patients not assessed 24%Hospitals not using formal documentationPatients assessed by formal documentation 13%Patients assessed by other method 18%Patients not assessed 69%

0%10%20%30%40%50%60%70%80%90%

100%

BuryM

RI

NMGH

Oldham

Rochdale

Stockport

Tamesid

e

Traffo

rd

Wirr

al

Wyth

enshawe

% Other Assess.

% FRA



22

Chart 4. If a form was filled in was it fully completed?

(5 hospitals using a FRA)

N = 258

Standard: Each form is completed fully

Comment

This chart just uses the 5 hospitals that were supposed to be using a FRA all the time

(Oldham, Rochdale, Stockport, Wirral and Wythenshawe).

Where forms were filled in the majority of them were done so completely.

2% 8%

90%

No

Partially

Yes



23

Chart 5. If FRA was completed was the patient reviewed during their admission?


N = 172

Standard: In appropriate cases patients will have been re-assessed after one

week, and their care plan reviewed.

Comment

Among the 5 hospitals using a FRA, 1 reviewed over 60% of the patients with a

completed FRA, 2 other hospitals reviewed just over 30%. The lower re-assessment

rates may reflect the length of time patients were in hospital. Overall 34% of patients

who had a risk assessment were reviewed.

The criteria stated that if appropriate all patients should be reassessed after one week,

so some of the patients not reviewed might have been in less than one week. Table 5

shows the percentage of patients reviewed by the length of time they were in hospital,

this is also shown for each hospital.

0%

20%

40%

60%

80%

100%

Oldham Rochdale Stockport Wirral Wythenshawe

No/NR

Yes



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Table 5. Percentages reviewed by Length of stay

Stay Number Number (%)with FRA

Number (%)reviewed

<7 days 54 37 (69%) 4 (11%)> 7 days 204 135 (66%) 54 (40%)By hospital number staying >7 daysOldham 47 3 (6%) 0 (0%)Rochdale 42 36 (86%) 25 (69%)Stockport 33 28 (85%) 12 (43%)Wirral 43 41 (95%) 16 (39%)Wythenshawe 39 27 (69%) 1 (4%)

The longer the patients have been in the more likely they are to have been reviewed.

Chart 6. Was the patient reviewed? By Length of stay (in weeks)

N = 172

Average Length of time in hospital

Oldham = 23 days

Rochdale = 25 days

Stockport = 13 days

Wirral = 25 days

Wythenshawe = 19 days

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

<1 week 2 weeks 3 w eeks 4 w eeks >4 weeks

No

Yes



25

Chart 7. The proportion of patients with completed FRA for whom action was

taken and documented


N = 172

Comment

The proforma was used to assess how well the FRA was used and this included the

question was any action taken to prevent falls. 61% did take some type of preventative

action, but 37% didn’t.

Of the patients included in this analysis, 117 were either said to be at risk or were in a

category of medium or high risk. Of these patients 68% were documented on the

proforma as having action taken to prevent falls.

Of the patients classified as being not at risk, in the low risk category or where level of

risk was not recorded 45% were documented on the proforma as having action taken

to prevent falls. See chart 12 for proportion of patients at risk.

Table 6. Number of risk factors by action recommendedNumber of Risk Factors % Action recommended (FRA completed)

0-2 43%3-5 60%6+ 77%

61%

37%

2%

YesNoNR



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8.3 Risk Factors, assessments and interventions

Chart 8. Number of Risk Factors for whole population

N = 518

Standard: The standard ideal was that in all patients’ records there was

documented evidence of checking for the risk factors.

Comment

This chart shows the distribution of patients according to the number of risk factors

recorded. The graph has a normal distribution. The majority of patients 57% had

between 3 -5 risk factors, 15 patients had 8 or more risk factors, 1 of these had 11 (the

maximum on the list).

9

24

63

101 10291

76

37

15

0

20

40

60

80

100

120

0 1 2 3 4 5 6 7 8+

No of Risk Factors



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Chart 9. Have any of the following Key Risk Factors been assessed?(whole population)

N = 518Comment

This chart shows if certain key risk factors identified by the working group had been

assessed.

Specific assessments such as lying & standing BP and medication review were not

commonly done.

Medication review and mental test score were the most likely to have been completed.

It was also discovered that a patient was no more likely to have these assessments

completed whether they had had a FRA or not.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Lying andstanding BP

Eye Test Mental TestScore

Medications

NA

NO

NR

YES



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Chart 10. Number of patients having any documented mobility assessments

N = 518

Comment

This chart shows the numbers of patients having Physiotherapy or Occupational

Therapy assessments completed. Patients were more likely to have a mobility and/or

transfer assessment done than other assessments such as Lying/Standing BP and

Medication reviews. It is worth noting that the high level of assessments reflects that

these are routine assessments done by PAMs, whereas other assessments are more

specific to a patient’s particular needs.

0

50

100

150

200

250

300

350

400

Bartell

Mobilit

y

T ransfe

rsGait

T innetti

EMS

GU&G

180 tu

rn

Func Reac

hDG

I

Berg B

Stairs



29

Table 7. Is there any evidence in the notes that any of the following

interventions/prevention measures have been started?

N = 518

Intervention % YesPhysiotherapist 72%OT 42%Call Bell at hand 34%Close Observation 25%Bed rails 23%Asking for help 17%Alarms 13%Educate 12%Frequent toileting 12%Discussed with relatives 11%Bed left in low position 10%Home visit 8%Dementia assessment 7%Chair 7%Intermediate Care 6%Trial without catheter 4%Special if frequent faller 4%Coloured wristband 3%Footwear Assessment 3%Hip Protectors 1%Balance Class 1%Falls Clinic 0%

Standard: The standard ideal was that in all patients’ records there was

documented evidence of including or excluding interventions

A list of intervention or prevention measures was devised (please see methodology

section for list and sources) using other lists that other groups had compiled such as

the action list from Stockport, and used on the proforma. Data collectors looked to see

whether or not these had been documented in a patient’s notes. It is important to note

that not all hospitals have the same intervention measures, for example very few

hospitals use coloured wristbands to identify patients at risk and some do not have

falls clinics.



30

Comment

The most likely interventions were the patient was referred to a physiotherapist and/or

an OT, the patient was under close observation, and a call bell was at hand.

Some of these interventions may have been carried out but not recorded in the notes

which could explain the low percentages.

Unfortunately it is impossible to deduce from the data which patients should have had

certain interventions. Each hospital uses different care plans or action plans so what

one hospital deems as an appropriate action for a patient at risk another may not.

Chart 11. Intervention measures/FRA completed

N = 518Comments

Chart 11 compares those patients who had a FRA completed (regardless of hospital

group) with those that didn’t. It was noteworthy that a higher percentage of patients

who had a FRA completed had certain interventions (e.g. Close Observation, Bed

Rails, Asking for help, Alarms on bed/chair). The difference in use of these specific

interventions is statistically significant.

0%

5%

10%

15%

20%

25%

30%

35%

Close o

bs

Bed ra

ils

Asking

for h

elp

Alarms

Educa

te

Discus

sed w

ith re

lative

s

Bed in

low po

sition

Wris

tband

Specia

l

Footw

ear

Hip Pro

tector

s

Toileti

ng

Chair h

eight

Balanc

e clas

s

Falls c

linic

FRA completed (all hosp) %No FRA %



31

Chi-Squared tests

Close observation = P = 0.04

Bed Rails = P = 0.01

Asking for help = P = 0.01

Alarms = P = <0.01

Educate = P = 0.01

Wristband = P = <0.01

Therefore if a patient has a FRA completed they are more likely to have these certain

prevention measures.

� A patient who had a FRA completed had an average of 4 Interventions whereas

a patient who didn’t had an average of 3 interventions.

� Patients who fell in hospital had an average of 5 interventions and those that

didn’t had an average of 3 interventions.

� Also those at risk of falling had an average of 4 interventions whereas those

that weren’t at risk had an average of 3.

� The average number of interventions for the whole population was 3.



32

8.4 Patients At Risk of Falling

Chart 12. Proportion of patients considered at risk of falling by trust

N = 518Comment

This shows the proportion of patients assessed as ‘at risk’ either by falls risk

assessment or otherwise noted in the patients’ documentation.

There is a non-standard approach to classifying patients at risk. Some falls risk

assessment forms classify patients in one of 3 categories either low, medium or high

risk. Others simply classify patients either at risk of falling or low risk/no risk.

For the purpose of this analysis At Risk included patients assessed as medium or high

risk, patients assessed as being ‘at risk’ of falling and those for whom it was noted

elsewhere in the notes (not as part of a formal risk assessment form) that they were at

risk.

There may be some variation between hospitals, as to how a patient comes to be

assessed as being at risk of falling, due to the different forms, some take into account

more or different factors than others

0%

10%

20%

30%

40%

50%

60%

70%

80%B

ury

MR

I

NM

GH

Old

ham

Ro

chd

ale

Sto

ckp

ort

Tam

esid

e

Tra

ffo

rd

Wir

ral

Wyt

hen

shaw

e

% at Risk



33

Certain hospitals had more patients classified as at risk than others - this coincides

with the proportion of patients who were actually assessed. See chart 13 below which

combines the data from charts 12 and 3 and highlights the risk status of those patients

who were assessed (assessment includes both the formal method and informal).

Chart 13. Proportion of population assessed, by risk status by hospital

N = 518

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Bury

MRI

North

Manch

ester

Oldham

Rochd

ale

Stockp

ort

Tames

ide

Traffo

rdW

irral

Wyth

ensh

awe All

% Not at Risk% At Risk



34

Chart 14. Patients At Risk/Risk Factors

N = 518Comment

This chart shows the number of risk factors per patient for those diagnosed as being at

risk of falling, compared with those who had no diagnosis or were deemed not to be at

risk. The question needs to be asked why were some patients not diagnosed at risk

yet they had high numbers of risk factors?

There are differences in the way each hospital is identifying patients at risk of falling

due in part to the use of different FRA forms. However there are also differences

between those hospitals that are using a variation of the same form. The explanation

may lie in differences in the number of risk factors assessed. This varies on each form.

Nonetheless all assess History of falls, sensory deficits and mobility. Other risk factors

assessed include age, sex, medication, mental state, toileting requirements, medical

history etc. The patients are then categorised depending on the score. Some falls risk

assessment forms classify patients in one of 3 categories either low, medium or high

risk. Others simply classify patients either at risk of falling or low risk/no risk.

The audit proforma looked for a more comprehensive list of risk factors (11 in total)

than the falls risk assessment forms at each trust. The project group identified the list

0%

20%

40%

60%

80%

100%

0 1 2 3 4 5 6 7+

No of R isk Factors

Not diagnosed

At Risk



35

of risk factors from various sources including the FRAs. Therefore it is possible that

the proforma would have picked up a number of other risk factors mentioned in the

casenotes that the FRA did not prompt the person assessing the patient to pick up.

Therefore a patient might have had 7+ risk factors according to the audit proforma, but

not all were picked up on the FRA and the patient might not been classified ‘at risk’.

Table 8 shows which risk factors from the audit were actually on the local risk

assessment forms:

Table 8. Risk Factors assessed by each hospital

Risk Factor Bury Oldham Rochdale Stockport Tameside Trafford Wythen

shawe Wirral

Falls 4 4 4 4 4 4 4 4

Meds 4 X X 4 4 4 X XIncontinence X 4 X 4 4 4 4 4

Mental state 4 4 4 4 4 4 4 4

Mobility 4 4 4 4 4 4 4 4

Vision 4 4 4 4 4 4 4 4

Hearing 4 X 4 4 4 X X XAlcohol 4 X X X X X X XPosturalHypotension X X X X X X X X

Medicalcondition X X X 4 4 X X X

Seizures X X X 4 4 X X X

Chart 15. Patients’ risk status by number of risk factors

N = 205

832

45

4513

923

24

6

0

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 2 3 4

Not at Risk

At Risk



36

Chart 15 includes only those patients who had a formal falls risk assessment. It

incorporates the four risk factors included by all the hospitals on their falls risk

assessment forms. There is an increasing proportion of patients assessed as at risk

with an increasing number of risk factors the patient was noted to have. It is gratifying

that 100% of those patients with all four risk factors were deemed to be at risk of

falling. However almost 50% of those with ‘no risk factors’ in this analysis were also

deemed as at risk. These patients only numbered 8, of these 8 6 had 2 other risk

factors, 1 patient had 1 other risk factor and 1 patient had 0 risk factors whatsoever.

(The risk assessment form for this patient with no risk factors had not been completed

fully and only stated that the patient was at risk without reasoning why). This

observation reflects the inclusion of other risk factor assessments in some trusts.

There is a need to develop a standardised approach to this part of the assessment

process.

Two examples of Risk Assessment Forms are given here:

Example of a Falls Risk Assessment tool

Taken from Falls Risk Assessment, The Pennine Acute Hospitals NHS Trust (Rochdale)

IF NO * SCORED, ASSESS AS LEVEL 1IF ONE OR MORE * SCORED, ASSESS AS LEVEL 2

HISTORY OF RECENT FALLS*YES NO

COGNITIVE STATEALERT* CONFUSED* UNABLE TO IDENTIFY DANGERS

SENSORY DEFICITSNONE* VISUAL IMPAIRMENTS (NOT CORRECTED BY GLASSES)* HEARING IMPAIRMENTS (NOT CORRECTED BY HEARING AID)* LIMBS; AMPUTATION

NEUROPATHY

GAITSTABLE AND SAFE* STABLE WITH WALKING AIDS* UNSTABLE OR UNSAFE WITH WALKING AIDS* UNABLE TO WALK SAFELY

ASSESSED AS LEVEL …



37

Example of a Falls Risk Assessment tool

Falls Risk AssessmentTO BE COMPLETED ON ADMISSION TO WARD FOR ALL PATIENTS

(Refer to full guidelines)

Score on admission ………….

Date/time Score Action Initial Review Time

Sex Sensory Deficit AgeFemale 2 2 2 Sight 1 1 1 <60 0 0 0Male 1 1 1 Hearing 1 1 1 60-70 1 1 1

Balance 2 2 2 71-80 2 2 281+ 3 3 3

Fall History Mobility Medical History

None 0 0 0 Full 1 1 1 Alcohol/unconscious 3 3 3At home 2 2 2 Uses aid 2 2 2 Overdose 2 2 2In ward 1 1 1 Restricted 3 3 3 Assault/head injury 1 1 1Both/frequentfalls 3 3 3 Bed bound 1 1 1 Organic brain

disease/confusion 1 1 1

Purgative 1 1 1 Incontinence/frequency 1 1 1laxatives Seizures 1 1 1

Diabetes 1 1 1Gait Medication

Steady 0 0 0 Hypnotic 1 1 1 3-8………….... LOW RISKHesitant 1 1 1 Tranquillisers 1 1 1 9-12………….. MEDIUM RISKPoor transfer 3 3 3 Hypotensives 1 1 1 13+……….….. HIGH RISKUnsteady 3 3 3 Diuretics 1 1 1

Taken from Falls Risk Assessment, Stockport NHS Foundation Trust



38

8.5 Falls in hospital

Chart 16. Has the patient fallen whilst in hospital?

N = 518

Comment

This shows the percentage of patients who fell during the hospital episodes under

scrutiny.

Stockport and Wythenshawe had no falls at all. This observation may be genuine or

the result of under-recording of falls in the notes.

In Oldham 15% of the sample fell, and just slightly less so in Bury and Rochdale.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

BuryM

RI

NMGH

Oldham

Rochdale

Stockport

Tamesid

e

Traffo

rd

Wirr

al

Wyth

enshawe All

Yes

No



39

Chart 17. Did the patient fall in hospital?

Comparing trusts that use a FRA and those that don’t.

N = 518

P=0.051 (chi-squared test)

Comment

This graphs looks at the two hospital groups and the incidence of falls.

Interestingly only 14 patients fell out of the group using FRAs whereas 26 fell in the

other group. A chi-squared test just failed to reach statistical significance.

See chart 18 on the following page.

234244

14 26

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FRA No FRA

Yes

No



40

Chart 18. Did the patient fall in hospital?

Comparing patients that had a FRA and those that didn’t.

N = 518

P=0.03 (chi-squared test)

Comments

This graph compares the group of patients who had a FRA regardless of which

hospital group they belong to and those who didn’t. A very small number of patients

fell before a FRA was completed so these patients were put into the group of no FRA

patients.

An interesting observation can again be made that fewer patients fell in the group that

did have a FRA. A chi-squared test found this to be significant. Therefore a patient

may be less likely to fall in hospital if they had a FRA completed.

The suggestion that using formal documentation does have an effect on preventing

falls is supported to extent by the literature (Haines, 2004, Healey, 2004 and Oliver,

2004). However there are concerns about completeness of ascertainment of in-

hospital falls data.

931

287191

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

FRA completed before Fall No FRA

Fell in Hospital

No Fall



41

9. SUMMARY/CONCLUSIONS

9.1 Key Results

• Patients in the sample were predominantly the very elderly, those aged 80 years or

more comprised almost 58% of the sample. This proportion varied by Trust from,

45% in MRI to 73% at the Wirral.

• The mean percentage of patients admitted with a fall is just over 30%. 6 hospitals

fell below this average, 3 were just above the average, and 1 hospital had nearly

20% more patients admitted with a fall than the average.

• Between 85 - 95% of patients in 4 of the hospitals were assessed. The other 6

hospitals all fell below the mean, which was just below 53%.

• Overall 34% of patients who had a risk assessment were reviewed.

• The proforma was used to assess how well the FRA was used and this included

the question was any action taken to prevent falls. 61% did take some type of

preventative action, but 37% didn’t.

• Patients were more likely to have mobility and/or transfer assessments done than

other assessments such as Lying & Standing BP and Medication reviews.

• The most likely interventions were the patient was referred to a physiotherapist

and/or an OT, the patient was under close observation, and a call bell was at hand.

• With regards to interventions, Chi-squared tests were done on a number of the

results and found them to be significant. Therefore if a patient has a FRA

completed they are more likely to have these certain prevention measures.

• An interesting observation can be made that fewer patients fell in the group of

patients that did have a FRA. A chi-squared test found this to be significant.

Therefore a patient may be less likely to fall in hospital if they had a FRA

completed.



42

9.2 Aims and Objectives

The project aimed to audit current Falls Management and Prevention in a group of

Hospitals across Greater Manchester in support of the National Service Framework for

the Elderly. The audit has been successfully completed and therefore the aim has

been met.

Another objective was to establish a baseline of current services within each hospital

setting. The results of this can be found in appendix 3.

9.3 Criteria and Standards

� A falls risk assessment tool is in use on the wards in each hospital.

8 out of 10 hospitals had a falls risk assessment form in use, however in some of the

hospitals it was only in a pilot stage or not in full use. 5 out of these 8 hospitals had a

tool in full use.

� An environmental audit tool and action plan is in place

The audit was unable to address this standard on this occasion.

� All patients are assessed and a completed form is in each patient’s set of notes.

Each form is fully completed.

53% of the whole population were assessed, 40% of the whole population were

assessed using a formal risk assessment form. 90% of all assessment forms were fully

completed.

� In appropriate cases patients will have been re-assessed after one week, and their

care plan reviewed.

Of the 5 hospitals where a risk assessment form was in full use 34% of those patients

who had a risk assessment completed were reassessed. Please note that due to the

data collected it has not been possible to distinguish how long it took before the patient

was reassessed.



43

� All patients who are classified at high risk have an appropriate care plan and

preventive steps outlined and acted upon.

As each hospital uses a different assessment form some do not classify their patients

by risk categories such as Low/Medium/High and simply categorise them as ‘At risk’ or

‘Not at risk’. Also each hospital uses different care plans or action plans so what one

hospital deems as an appropriate action for a patient at High Risk another hospital

may not. Not all hospitals have the same intervention measures; for example very few

hospitals use coloured wristbands to identify patients at risk and some do not have

falls clinics. Therefore it has not been possible to assess this criteria using the data

collected. Analysis of the data has shown that for those patients who had a falls risk

assessment form completed they are more likely to have certain interventions than

those patients who did not. Please see chart 11 for more information.

� The standard ideal for both of these factors was that in all patients’ records there

was documented evidence of checking for the risk factors and including or

excluding interventions.

Please see chart 8 which shows the distribution of patients according to the number of

risk factors recorded, and table 7 which shows what percentage of the population had

an intervention.

� All ward staff have been formally trained on how to use the tool

Appendix 3 shows that 3 hospitals have an educational programme to train staff how

to identify those at risk of falling and how to prevent falls. One hospital’s education

programme is only in a developmental stage. Interestingly 4 of the 8 hospitals using a

tool had no educational programme for staff.

� The use of Health promotion material

� The issue of patient information concerning for example Falls prevention: Your

safety checklist and guide

6 out of the 10 hospitals had some sort of information regarding falls available for

patients.



44

� An operational falls service has been set up in each local health economy with

appropriate complement of staff.

In light of the information provided it would appear that each hospital has some form of

falls service. 4 out of 10 had a falls co-ordinator. 5 out of 10 have falls clinics, but 2 of

these were still in a pilot stage and 2 began in October 2004 (after the audit took

place). 2 hospitals have neither a clinic nor a co-ordinator. 1 hospital had a falls co-

ordinator at the time of the audit but, at the time of this report, the post was vacant.

� The fall service has access to dieticians, optometrists, orthotists, ophthalmologists,

audiologists, access to bi-linguists, access to bone densomitry. Older people who

fall should, with their consent, be referred to a specialist falls service.

Most of the hospitals have a multi-disciplinary team working towards preventing falls

as part of the falls service provided at the hospital. The staff involved are

predominately nurses, physiotherapists, occupational therapists and clinicians,

although some hospitals had podiatrists, dieticians, pharmacists and Age Concern

involved in the service.

Information regarding hospitals falls services can be found in Appendix 3.

� The provision of Falls clinics, patient sitter programmes and response systems

5 out of 10 hospitals now have falls clinics, but 2 of these were still in a pilot stage and

2 began in October 2004 (after the audit took place). The audit was unable to assess

the implementation of patient sitter programmes and response systems, however

neither of these were recorded on the forms as part of the hospitals’ service so it could

be presumed that they aren’t used by the hospitals.

9.4 In summary

� Using a FRA may have a protective effect

� The patients are more likely to have prevention measures targeted at them if a

FRA has been completed

� In-patient falls appear less likely in hospitals using a FRA



45

� Patients with a high number of risk factors are not necessarily being documented

as being at risk of falling

9.5 Questions to be asked

� What other pertinent features should we be addressing with the data?

� Is the evidence strong enough to suggest we should implement risk assessment

forms or is there more that we could do to justify implementation?

� What recommendations & actions can be made?

� Can falls prevention be standardised across Greater Manchester? Including Falls

Risk Assessment and Action Plans.

� Should we do another falls risk assessment audit?

� What other pertinent measurable factors should be collected in future audits?

9.6 Future Plans

As a result of the feedback seminar a Falls Working Group will be set up to look at

multidisciplinary core skills in relation to an inpatient falls action plan and to look at

standardising falls risk assessment and intervention across Greater Manchester. A

variety of staff from the meeting volunteered to be part of the group and the first

meeting will be held in early 2005.

A Fracture Neck of Femur re-audit is planned for 2005 with 4 other trusts joining the 7

trusts from the original audit.

The Falls Risk Assessment Audit could be re-visited in 2006 to see if changes have

been successfully implemented.



46

10. REFERENCES

American Geriatrics Society, British Geriatrics Society, and American Academy of

Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the Prevention of Falls

in Older Persons. AGS Panel on Falls Prevention. Vol 49, No. 5. 2001.

Cannard G. Fall risk assessment scale for the elderly F.R.A.S.E. Nursing Development

Unit, General Hospital, Tullamore, 1996.

Department of Health. National Service Framework for Older People, 2001.

Doughty, K. Fall Prevention and Management Strategies Based on Intelligent

Detection, Monitoring and Assessment. Technology in Healthcare. 2000.

Dyer, C. A. Risk-factor assessment for falls: from a written checklist to the penless

clinic. Age and Ageing. 27(5), 569-72. 1998.

Haines, T et al. Effectiveness of targeted falls prevention programme in subacute

hospital setting: randomised controlled trial. BMJ, 328, 676. 2004.

Healey, F et al. Using targeted risk factor reduction to prevent falls in older in-patients:

a randomised controlled trial. Age and Ageing, 33, 390. 2004.

Huda, A and Wise, L.C. Evolution of compliance within a fall prevention program.

Journal of Nursing Care Quality. 12(3): 55-63, 1998.

Joanna Briggs Institute for Evidence Based Nursing and Midwifery. Falls in Hospital.

Best Practice. Evidence Based Practice Information Sheets for Health Professionals.

Adelaide: JBIEBNM, 1998.

Kinn, S. and Kood, K. A falls risk-assessment tool in an elderly care environment.

Myers, H. Hospital falls risk assessment tools: A critique of the literature. International

Journal of Nursing Practice. 9, 223. 2003.

Oliver, D. Risk factors and risk assessment tools for falls in hospital in-patients: a

systematic review. Age and Ageing, 33, 122. 2004.

Scottish Intercollegiate Guidelines Network. Prevention and Management of Hip

Fracture in Older People, 2002.



47

The Royal College of Physicians of London. Fractured Neck of Femur Prevention and

Management, 1989.



48

11. CONTACT DETAILS

If you have any comments/feedback or you require any further information please seecontact details below.

Ms Joanna RodgersAudit Co-ordinatorClinical Audit Department6th Floor, MaternityStepping Hill HospitalStockportSK2 7JE

Tel. No. 0161 419 4692Email: [email protected]

Dr Gary CookConsultant Epidemiologist/R&D LeadThe WillowsStepping Hill HospitalStockportSK2 7JE

Tel. No. 0161 419 5984Email: [email protected]



49

12. ACKNOWLEDGEMENTS

The following staff collected data at their respective hospitals:

South ManchesterJulia Gray

PennineSue Baxter (O, R)Margaret Carney (N)Emma Clarke (F)Julie Fraser (F)Reehana Khan (F)Mark Lammas (N, F)Trish Mitchell (O, R, N, F)Janet Powell (O)Aviva Richards (N)Michael Sullivan (R)

(Key: O = The Royal Oldham Hospital, R = Rochdale Infirmary, N = North ManchesterGeneral Hospital, F = Fairfield General Hospital

TamesideJanice BehrSheetal Sureen

WirralBev HawkesJane MarriottJacquie Ruddick

StockportDr Marie Hanley

TraffordGill CritchleyMaggie HughesGaynor Wakefield

Thank you to all of the above for all the hard work they put into the data collection.

Thank you to:

Sylvia Cooper, P&G Pharmaceuticals UK Ltd for sponsoring the Feedback Seminar

Dr David Bourne and Julia Gray for presenting at the Feedback Seminar



50

Appendix 1: List of Charts and Tables

Title PageTable 1 Data collection dates at each hospital 17Table 2 Number of wards at each hospital by specialty 17Table 3 General Demographics 19Chart 1 Age group by hospital 19Chart 2 Proportion of Patients admitted due to a fall 20

Chart 3 Proportion of Patients assessed and documented 21Table 4 Percentages Assessed 21Chart 4 If a form was filled in was it fully completed? 22

Chart 5 If FRA was completed was the patient reviewed during theiradmission 23

Table 5 Percentages reviewed by Length of Stay 24Chart 6 Was the patient reviewed? By Length of stay 24

Chart 7 The proportion of patients with completed FRA for whom actionwas taken and documented 25

Table 6 Number of risk factors by action recommended 25Chart 8 Number of risk factors for whole population 26Chart 9 Have any of the following Key Risk Factors been assessed? 27

Chart 10 Number of patients having any documented mobilityassessments 28

Table 7 Is there any evidence in the notes that any of the followinginterventions/prevention measures have been started? 29

Chart 11 Intervention measures/FRA completed 30Chart 12 Proportion of patients considered at risk of falling by trust 32Chart 13 Proportion of patients assessed according to risk status by trust 33Chart 14 Patients at Risk/Risk Factors 34Table 8 Risk Factors assessed by each hospital 35Chart 15 Patients’ risk status by number of risk factors 35

Example of a Falls Risk Assessment tool 36Example of a Falls Risk Assessment tool 37

Chart 16 Has the patient fallen whilst in hospital? 38

Chart 17 Did the patient fall in hospital? Comparing trusts that use a FRAand those that don’t. 39

Chart 18 Did the patient fall in hospital? Comparing patients that had aFRA and those that didn’t. 40



51

Appendix 2: Ward types and number of beds

Hospital Ward Ward Type Number of bedsWythenshawe A5 Orthopaedic 28

A7 General/Adult Medicine 28A8 General/Adult Medicine 28A9 General/Adult Medicine 28A10 General/Adult Medicine 28F11 General/Adult Medicine 32

Tameside 2 Orthopaedic 284 Orthopaedic 2840 General/Adult Medicine 3041 General/Adult Medicine 3042 General/Adult Medicine 3044 General/Adult Medicine 2446 General/Adult Medicine 24

Stockport A12 General/Adult Medicine 28A14 General/Adult Medicine 28A15 General/Adult Medicine 28D1 Orthopaedic 25D2 Orthopaedic 25E2 Care of Elderly 38E3 Care of Elderly 38

Wirral 20 Care of Elderly 3021 Care of Elderly 3022 Care of Elderly 3023 Care of Elderly 3024 Care of Elderly 2425 Orthopaedic 37

Bury 6 General/Adult Medicine 288 Orthopaedic 229 Orthopaedic 2818 General/Adult Medicine 3019 General/Adult Medicine 3229 General/Adult Medicine 2330 General/Adult Medicine 27

MRI 1 Orthopaedic *15 General/Adult Medicine *AM1 General/Adult Medicine *AM2 General/Adult Medicine *AM3 General/Adult Medicine *AM4 General/Adult Medicine *

Trafford 1 Care of Elderly 282 General/Adult Medicine 29



52

4 General/Adult Medicine 316 General/Adult Medicine 32Ortho Unit Orthopaedic 51Seymour Unit Care of Elderly 45

NMGH D4 General/Adult Medicine 21E3 General/Adult Medicine 28E4 General/Adult Medicine 22E6 General/Adult Medicine 22F3 General/Adult Medicine 19I5 Orthopaedic 28

Oldham C1 General/Adult Medicine 12D2 General/Adult Medicine 24F9 General/Adult Medicine 25T4 Orthopaedic 28T5 General/Adult Medicine 25T6 General/Adult Medicine 22

Rochdale Marland General/Adult Medicine 31Stonehill 1 General/Adult Medicine 27Stonehill 2 General/Adult Medicine 27Stonehill 3 General/Adult Medicine 27Stonehill 4 General/Adult Medicine 27Wolstenholme Orthopaedic 33

*Information not available at time of going to print



53

Appendix 3: Hospital Falls Services

Hospital FRAin use Type Used on all

wardsPlan to

useCareplan

Info forpatients

Falls Co-ordinator

FallsClinic

Educationfor staff

No of falls2003/04

(aged 65+)

Medicalin-

patients65+

Ortho in-patients65+ (notelective)

MRI No NA NA ^ ^ ^ Yes # ^ ^ 1088 ^ ^

Bury Yes NK Noonly elderly Yes Yes Yes Yes † No NR 6770 897

NMGH No NA NA Yes No Yes No No NR 11715 1033

Oldham Yes STRATIFYNo(not

orthopaedic)- Yes Yes Yes

YesPilotstage

Yes 826 8665 1035

Rochdale Yes NK Yes NA Yes No Yes(Sept 04) - No 374 9447 1011

Stockport Yes FRASE Yes NA Yes Yes* No

YesOct 04

pilotstage

Yes 1393** 8316 1100

Tameside Yes Cannard NoPilot stage Yes Yes - No Yes

Oct 04

Develop-mentalstage

1161 4558 1039

Trafford Yes STRATIFYNo

Only Elderlyand Medical

- No No No Yes No 1308 3325 4512

SMUHT Yes STRATIFY

NoOnly Elderly,

Medical &Rehab

Yes Yes Yes Yes Yes Yes 852 5094 443

Wirral Yes STRATIFY Yes NA Yes Yes No - No 1939 14763 1219

^Information not available at time of going to print# Falls Co-ordinator in post at the time of the audit, position currently vacant† PCT based co-ordinator, doesn’t cover in-patients*Only in Day hospital and out-patients, not on wards**Cannot distinguish by age so number is all falls reported regardless of age



54

Hospital Falls Services (cont.)

Central Manchester & Manchester Children’s University Hospitals NHS TrustInformation not available at the time of going to print

Pennine Acute Hospitals NHS TrustFairfield General Hospital• The hospital has a falls co-ordinator, but they are employed by the PCT. The falls

co-ordinator is based in the hospital and in the community, she receives referralsfrom A&E, GPs, District Nurses and Health Visitors, but they do not cover in-patients.

North Manchester General HospitalNo other information

The Royal Oldham Hospital• The hospital has a falls co-ordinator. This is mainly a community role with a wide

remit to reduce falls incidence in Oldham• Hospital falls service – has input from Physiotherapists and Occupational

Therapists in A&E. There are falls exercises and education sessions for outpatients. There is a pilot falls clinic with the falls co-ordinator (physio) and aSpecialist Registrar.

• There is an educational programme for staff at the trust regarding falls riskassessment. This is offered on a regular basis, it is a half day including prevalence,risk factors, interventions, use of STRATIFY, use of falls action prompt,osteoporosis and fractures.

Rochdale Infirmary• The hospital has a falls co-ordinator who was newly appointed in September 2004

(after the audit). Their role is to develop and co-ordinate a falls care pathway, toprovide specialist advice and teaching and to develop an integrated falls serviceand community falls clinic.

• Hospital falls service – there is a pathway for fallers admitted to A&E. Patients arereferred to the intermediate care team for assessment. When patients are admittedto the ward a falls risk assessment form is completed by nursingstaff/physiotherapists. Patients are discharged home for follow-up by communityfalls service.

• The Falls Service involves Physiotherapists, Nurses and Occupational Therapists.

Stockport NHS Foundation Trust• The hospital is currently piloting a Falls Clinic from October 2004 to December

2004. The aim is to continue the clinic after the pilot. The clinic is divided into 2sessions, patients initially attend Tuesday pm for medical and nursing, then returnfollowing Tuesday am for physio and OT, this is followed by a MDT meeting. Thereis a business case for therapy input and falls co-ordinator.



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• The Falls Service involves Clinicians, Physiotherapists, Nurses, OccupationalTherapists, links for pharmacy advice and Accident Prevention officer from AgeConcern. It is hoped that there will be podiatry input in January 2005

• There is an educational programme for staff at the trust regarding falls riskassessment. This is given at the mandatory training sessions which all staff attendonce a year.

Tameside & Glossop Acute Services NHS Trust• Use a Falls Risk Assessment tool based on Cannard which is currently being

piloted on one ward in each specialty before it is introduced across all wards ineach hospital.

• Hospital falls service – a clinician led falls clinic will be commencing in October2004. There is also a falls group

• The Falls Service involves Physiotherapists, Nurses, Doctors (from Oct 04) andOccupational Therapists.

• There is no educational programme for staff at the trust regarding falls riskassessment; this is in a developmental stage at the moment.

Trafford Healthcare NHS Trust• Hospital falls service – 1 session a week in the Altrincham rehab unit where there

is podiatry, physiotherapist, occupational therapist, doctor, nurse and pharmacist.Follow up sessions run over 7 weeks for patients who will benefit from the exercisegroup, this involves OTs and Physios + Care and Repair, Age Concern andDietician.

South Manchester University Hospitals NHS Trust• The hospital has a falls co-ordinator whose role is to triage all falls clinic referrals,

organise waiting list and help to draw together integrated pathways for fallers. Theyalso have to map current situation for the trust, help areas where fallers passthrough evaluate their service in line with the NSF and adjust accordingly, providelinks with the PCT, develop pathway, update standards and protocols, audit inpatient fallers and develop links with other trusts.

• Hospital falls service – there is a MDT falls clinic, a falls consultant, links in A&E,falls medication group. Departmental falls groups.

• The Falls Service involves Consultant Geriatrician, Lead Nurse, Physiotherapists,Senior Podiatrist and Occupational Therapists and Dieticians as required.

• There is an educational programme for staff at the trust regarding falls riskassessment. There are quarterly sessions as part of the NSF lasting half a day,falls take up about 1/5 of the programme. Routine education for physios. Ad hoceducation.

Wirral Hospital NHS Trust• Hospital falls service is led by Physiotherapists. The Community Assessment and

Rehabilitation Team (CART) are also involved. Exercise classes are held atVictoria Central Hospital.

• The Falls Service involves Physiotherapists, Nurses and Occupational Therapists.



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Appendix 4. Feedback Seminar Attendees

Name Job Title OrganisationElsie Lynch Head of Physiotherapy Birkenhead and Wallasey PCTHelen Home Therapy Rehab Co-ordinator Birkenhead and Wallasey PCTDebbie Monaghan Supt II Physiotherapist Bolton Hospitals NHS TrustChristine Atkinson Clinical Governance Manager Bolton Primary Care TrustPaul Campbell Audit Co-ordinator Bury PCTDr David Bourne Consultant Physician Central ManchesterJoanne Makin Physiotherapist Central ManchesterNicola Brown Senior Physiotherapist Central ManchesterPam Leah Occupational Therapist Central ManchesterRomaine Short Physiotherapist Central ManchesterDr Sethi Consultant Physician Pennine Acute Hospitals NHS TrustJanet Powell Falls Prevention Officer Pennine Acute Hospitals NHS TrustMargaret Carney Senior Physiotherapist Pennine Acute Hospitals NHS TrustPatricia Mitchell Clinical Audit Facilitator Pennine Acute Hospitals NHS TrustShirley Naylor Clinical Audit Co-ordinator Pennine Acute Hospitals NHS TrustSue Plevey OT Manager Pennine Acute Hospitals NHS Trust

Dr Keith Harkins Consultant Geriatrician South Manchester University HospitalsNHS Trust

Janet Brennan Nurse Manager South Manchester University HospitalsNHS Trust

Jenny Rawcliffe Modern Matron South Manchester University HospitalsNHS Trust

Julia Gray Falls Co-ordinator South Manchester University HospitalsNHS Trust

Mrs Susan O'Flynn Senior I Physiotherapist South Manchester University HospitalsNHS Trust

Dr Gary Cook Consultant Epidemiologist Stockport NHS Foundation TrustDr M Hanley Consultant in Elderly Medicine Stockport NHS Foundation TrustJanine Lewis Senior Occupational Therapist Stockport NHS Foundation TrustLinda Woolley Ward Sister Stockport NHS Foundation TrustDr Marie McDevitt Public Health Specialist Stockport PCTSue Gunnion Case Management Lead Stockport PCTSarah Hince Stockport PCTDr Luciano Garcia-Allen Consultant Physician Tameside & Glossop Acute Services

NHS Trust

Heather Leyland Clinical Audit Officer Tameside & Glossop Acute ServicesNHS Trust

Jan Barnes Team Leader Orthopaedics Tameside & Glossop Acute ServicesNHS Trust

Maggie Tate Clinical Governance Info Manager Tameside & Glossop Acute ServicesNHS Trust

Deborah Maloney Trafford Healthcare NHS Trust



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GREATER MANCHESTER & WIRRAL FALLS RISK ASSESSMENT AUDITPROFORMA

Proforma completed by (name and designation): ………………………………………………

Date proforma completed: _ _ / _ _ / _ _ _ _

A. Patient Details: (please fill in details below)Hospital

Ward Name Specialty

Date of Birth _ _ / _ _ / _ _ _ _ Gender M F

B. Episode DetailsDate of Admission _ _ / _ _ / _ _ _ _Reason for Admission (presenting complaint / diagnosis)

Was the admission due to a fall? Yes NoPreadmission Walking Ability (e.g. walked unaided,one aid, two, frame, wheelchair etc):

C. Please complete this section if your trust uses a Risk Assessment Tool (Go tosection D if your trust doesn’t have a risk assessment tool)(please delete / fill in as appropriate)Has the patient had a falls assessment completed for this episode? Yes No(If no, please fill in Section D)What date was the form completed on? _ _ / _ _ / _ _ _ _Has it been fully completed? Yes No Partially

What was the patient’s falls assessment score?

Was the patients assessed as being ‘at risk’? Yes NoIf appropriate, what risk category did thepatient fall into? High Medium Low

What action has been recommended?

Was any action taken? Yes No

Was a review date set? Yes No

What was the date? _ _ / _ _ / _ _ _ _

If yes, has the patient been reviewed? Yes NoNow go to section E



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D. Please complete this section if you do not have a risk assessment tool in use at yourtrust.Is there written evidence in the notes that the patient has beenassessed for falls risk? Yes No

If yes:

Date of assessment/diagnosis _ _ / _ _ / _ _ _ _Has it been noted anywhere in the patient’s notes that/is there adiagnosis of “At risk of falling”? Yes No

Has any action been recommended in the notes with regards torisk of falling? Yes No

Is there documented evidence to suggest that the patient hasbeen reassessed for falls risk? Yes No

Date of review/reassessment? _ _ / _ _ / _ _ _ _

E. Are any of the following risk factors noted in the patient’s records?(Please tick box – Y=Yes, N=No, NR=No record)Risk Factor Y N NR NAHistory of fallsMultiple medications (>4 per day, including hypnotics)Urinary incontinence/frequency/assisted toiletingImpaired mental status (confusion/disorientation/depression etc)Impaired mobility/balance/gait (unsteady on feet, requires frame/stickto walkVisual ImpairmentHearing impairmentAlcohol problems (>1 unit of alcohol per day)Postural HypotensionMedical Conditions (e.g. Diabetes, Stroke, Parkinson’s)Seizures*Yes = it has been noted that the patient has the risk factor, No = it has been noted that thepatient doesn’t have this risk factor, No record = there is no record in the notes either way,NA=Not applicable

F. Have any of the following Key Indicators been carried out?(Please tick box – Y=Yes, N=No, NR=No record)

Indicator Y N NR DateLying and standing BPEye TestMental Test ScoreMedications (4+ inc. psychotropic, plan/review,any recommendations/comments)Extra Info re medications – write here



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G. Are any of the following assessments documented in the record/case notes for thisepisode?

Assessment Y N NR NA Date of 1st assessment (ifapplicable)

Score (ifapplicable)

BartellMobility/FunctionTransfersGait/BalanceTinnettiEMSGet up and go180° turnFunctional reachDynamic gait indexBerg balanceStairs*Yes = it has been noted that the patient has the assessment, No = it has been noted that thepatient hasn’t had this assessment, No record = there is no record in the notes either way.

H. Is there evidence in the notes that any of the following interventions/preventionmeasures have been started?Action Please Indicate below

Yes/No/Norecord/NA/Other*

Close observation of patients in an appropriate area.Have other relevant health care professionals been informed?a. Physiotherapistb. Occupational TherapistPatient assessed for the use of alarms on bed/chairPatient assessed for the need for hip protectorsAssess the need to “special” for the patient if they are a frequentfaller. (One-to-one nursing)In-depth assessment of patients’ dementia undertaken, if applicable.Frequent toileting if a high-risk patientColoured wristband (or similar) to alert staff that the patient is at riskof fallingA Call Bell at handIf appropriate, has the importance of asking for help when walkingbeen explained to the patient?Educate patient/family/carer about risk of falling, safety issues &The patient’s risk of falling has been discussed with relatives, ifappropriate.Bed left in low position when patient is unattendedBed rails in useA chair, of appropriate height for the individual (Hips should bepositioned at 90° and feet should be on the floor) is being used.



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Has a home visit been arranged to assess home?Patient referred to Intermediate Care?Patient referred to Balance ClassHas the patient been referred to a falls clinic?Footwear assessment documentedHas there been a trial without catheter (if applicable)Any other actions noted not on this list (give details)

*Yes = it has been noted that the patient has had this intervention, No = it has been noted thatthe patient hasn’t had this intervention, No record = there is no record in the notes either way,NA = not applicable.

I. Other related informationHas the patient fallen whilst in hospital? Yes / No

If yes, Date patient fell: _ _ / _ _ / _ _ _ _Details of fall (where, was the incident reported, etc)

Comments (anything else mentioned in notes regarding falls)

Patient Id _ _ _/_ _ _(to be filled in by audit facilitator)

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