The Atlas of Shared Learning

Case study

A falls improvement programme for people with Dementia

Leading change

A Ward Manager at Harplands Hospital, North Staffordshire Combined Healthcare NHS Trust, developed a programme of work to reduce falls on the ward through active identification of predisposing factors. The programme has shown improved experiences and outcomes for the service users on the ward.

Where to look

The National Service Framework: older people (2001) sets quality standards for health and social care. It is hoped these standards will help older people to stay as healthy, active and independent as possible, for as long as possible. The framework recognises that, although older people are significant users of health and social care services, sometimes services do not fully address their ongoing neds. NICE (2013) report that falls and fall-related injuries are a common and serious problem for older people. People aged 65 and older have the highest risk of falling, with 30% of people older than 65 and 50% of people older than 80 falling at least once a year. The NICE report outlines the key implications of falling for the older person: distress, pain, injury, loss of confidence, loss of independence, and mortality. Falling also affects the family members and carers of people who fall. Falls are estimated to cost the NHS more than £2.3 billion per year.

The Ward Manager used the above evidence to identify there was unwarranted variation on their ward. Service users were experiencing a higher incidence of falls. There was an opportunity to address this variation in practice and to introduce measures to reduce the incidence of falls.

What to change

The ward at Harplands Hospital specifically provides care to the older persons’ population with service users admitted directly from the neighbouring acute Trust for up to 28 days for a period of assessment. The ward cares for people with complex physical health needs alongside organic illnesses. Many of these service users have a diagnosis of organic illness, namely Alzheimer’s and Dementia. These conditions present with other co-morbidities putting service users at increased risk of falls.

Using Quality Improvement methodology, the nursing lead considered trends in recent falls to establish whether a set of risk factors could be identified. These might include impairments across multiple areas. The predisposing factors identified included vision and hearing impairment, incontinence, food and nutrition, lighting, seating and environment. These likely predisposing factors became the focus of the improvement programme.

The ward already emphasised a person-centred approach, utilising the bio-psychosocial model. The team focus on all factors influencing a service user’s presentation to understand the service users’ needs and support them to reach their maximum potential. Being mindful of the symptomatology of these service users, and concerns about the reliability of self-report, the nursing team developed an approach that included both service users, families and carers to complete “What I like” posters.

How to change

The predisposing risk factors identified important domains relative to functioning, sensory, psychological wellbeing, physical performance, nutrition and environment. These domains were used to target key areas of a person’s likes and needs. The posters support staff to work with service users, families and carers to identify risk factors on a personalised basis to ensure care is then tailored to meet the service user’s needs. It also strives to highlight specific areas that are important to the service user during their stay on the ward. Recognising the importance of a multi-disciplinary approach, nursing, physiotherapy and occupational therapy support the completion of the posters. Staff were supported through staff meetings and reflective practice to feel empowered and confident in completing the posters. The posters offer the opportunity to enhance the experience of service users by tailoring their stay on the ward to their needs and existing routines where possible. They also collect information on what support they feel is needed to highlight to staff possible risk factors.

In addition to the “What I Like” posters, the ward is championing the use of:

  • a ‘nurse call’ system which service users are issued with to keep on their person. This call system is a pendant with a symbol of a nurse on and can be pressed to request assistance;
  • Assorted coloured wristbands to identify which aid (e.g. walking stick or walking frame) the service user should have with them; and,
  • Leaflets and resources to support service users to get up and out of bed, where possible, to maintain and/or develop physical strength.

These features combine to make up the falls prevention programme on the ward. A Plan-Do-Study-Act cycle is in place to ensure the programme is developed and evolves as needed to meet the aim of reducing falls across the ward.

Adding value

Better outcomes – The introduction of “What I Like” posters provided an eye-catching snapshot of what service users like and need. In the early stages of roll-out, the ward is identifying a reduction in fall incidence. The incidence will always fluctuate due to many factors but there is a downward trend routinely. The team reflect that the improvements are ongoing and the various elements of the programme are complementing one another; as this evolves and becomes further co-ordinated and standardised, falls improvement is expected to continue. The team also found that that if a service user’s nutritional and hydration needs are met, the potential risk of a fall can be reduced. There has been a reduction in readmission to acute services over the last 12 months.

Better experience – The programme has been well received on the ward. Examples of feedback includes:

To all the team on ward 4. Thank you for all the amazing care that you gave to are dear dad during his stay with you. We know he became very fond of you all. We as a family during our dads last few days couldn’t have asked for more support from you all. The endless cups of tea, the endless are you alright, ask if you need anything. You never made us feel we were in the way.

On behalf of my family I wanted to thank you all for the kindness, compassion and care shown to Mum during her stay on ward 4. After the first few weeks she settled in and enjoyed being with you especially doing her colouring of patterns and her trips to bowling which she really enjoyed. Your dedication and care shown to all your patients and their families us there for all to see. I am pleased to say that Mum is now settled in at her new home for the future. Thank you again and we wish all of you the best for the future.

Better use of resources – The rapid falls improvement initiative has started to show benefits in reducing the need to transfer a service user to the acute Trust following a fall – both in terms of a reduction in the number of falls, and being better equipped to support a service user if they have had a fall. Further, there is early evidence to suggest that the programme has reduced readmission and avoidable admission to the local acute Trust which will be a significant improvement on use of resources.

Challenges and lessons learnt for implementation

There is increased understanding of shared risk factors for falls which is crucial in managing and reducing the risk of falls.

Initially some staff were cautious to complete the posters and unclear on how the key areas could result in targeting falls reduction. This was addressed in staff meetings and reflective practice to ensure everyone felt confident in the reasons and practice of collecting this additional information.

This programme continues to develop and evolve. Due to early success, environmental challenges are now going to be addressed.

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