Leading change

The Matron and nurses in the falls team at Northumbria Healthcare NHS Foundation Trust (NHCFT) identified unwarranted variation in the practice of observation for patients who may be at risk of falling. The matron, in collaboration with the nursing team, developed a new system of observation ‘Avoiding Falls Level of Observation Assessment Tool’ (AFLOAT). The aim was to reduce risk, improve patient safety and improve patient outcomes and experience.

Where to look

NHS Improvement (2017) report on the incidence and cost of falling in hospital for a patient, which includes distress, pain, injury, loss of confidence, loss of independence and increased morbidity and mortality. Falling also affects the family members and carers of people who fall and has an impact on quality of life as well as health and social care costs. Indeed, falls represent a significant use of resources to Trusts and the wider healthcare system. The National Institute for Health and Care Excellence (NICE, 2015) estimated the annual total costs to the NHS from falls among older people to be £2.3 billion.

Public Health England (2017) indicate that people often view the problem of falls as happening to those older and in poorer health than themselves. Many dislike the word ‘falls’, preferring concepts such as ‘staying steady’ or ‘remaining active’. It is important that preventative activity is carried out in a way that is meaningful to and appropriate for the people that it is targeted at. There is also a need for greater general awareness of falls as a public health issue and that falls are not an inevitable aspect of older age. There is an ask of population health to support older people to remain mobile, have their needs met, continue to learn, develop and maintain relationships and contribute to society. These factors can be delivered, at least in part, through proactive falls and fracture prevention.

NHCFT have had a Supportive Observation policy since January 2018. This policy is designed to provide Trust staff with guidance on the required level of observation to patients, based on their falls risk. The levels of observation are identified below:

• Level 1: Routine observation with care rounding 2 hourly interventions;
• Level 2: Enhanced observation with increased care rounding at 15-90 minute interventions;
• Level 3: Enhanced observation with the patient kept within line of sight;
• Level 4: In exceptional circumstances close care is used with the patient kept within arms-reach.

The matron at NHCFT identified unwarranted variation in the assessment and setting of observation levels at the Trust. The matron took this opportunity to address the variation so to ensure that patients receive the right level of enhanced support – tailored to their needs. Implementing a programme to address this aimed to keep patients safe using the least restrictive level of observation.

What to change

Prior to the change, nurses established the patient’s individual falls risk factors as part of the admission process. They then used their clinical judgement to set an observation level from 1-4. The nursing team established a Task and Finish group to review the implementation of the NHCFT Supportive Observation policy. The analysis completed by the falls team identified that some nurses had a degree of risk blindness (patients having an insufficient level of observation provided) or risk aversion (patients having an unnecessarily restrictive level of observation).

The Matron lead a discussion with ward nurses in a Trust meeting and the nurses identified that a clinical decision-making support tool would be useful in helping to guide them to the correct level of observation. Although there is evidence associated with falls assessment and prevention, the team could not identify an appropriate, validated tool which could be used to advise the correct level of observation that a patient required, as informed by the risk factors.

How to change

The Matron and wider falls team joined NHS Improvement’s Falls Collaborative in June 2018 and used this to support the development of this improvement project. Nurses from across the wards identified which patients required enhanced observations to reduce the risk of falls, enabling the falls team to learn from the experience of the staff on the wards caring for the patients. Identified risk factors included: confusion, being unsteady on their feet, a previous history of falls (including in hospital) or had postural hypotension.

The falls team devised the Avoiding Falls Level of Observation Assessment Tool (AFLOAT) based on the learning from the nurses. The falls team developed an initial clinical assessment tool, which they piloted in specific areas of the hospital identified to have a high number of patients who may identify to the risks listed above.

The nurses on the ward trialled the tool and provided feedback to the falls team where they felt there could be improvements. The final version is now being implemented but it will continue to be reviewed and improved in collaboration with the ward nurses and the falls team.

Adding value

Better outcomes – The overarching outcome is that increased observation levels are patient-centred based on clinical need and judgement. An increase from 60% accuracy to 80% was identified through a monthly audit repeated from July to October in the first instance.

Better experience – Through continued development and enhancement of the nursing skillset, as well as enabling a consistent approach to the risk of falls, the Trust has provided better patient safety, better experience for patients and staff, and reduced unwarranted variation across the Trust. There has been positive feedback from staff, patients and relatives:

“AFLOAT is easy to use and helps assess level of falls”

“An objective tool to help decide level of observation needed but level can change at any time. Good as a guideline”

“As a healthcare assistant we do not make clinical decisions, but AFLOAT lets us judge the patient’s clinical presentation”

Better use of resources – One pilot ward has shown a reduction in observation levels, whilst the other has seen an increase. The Matron and nursing team suggest that AFLOAT does not impact the number of patients on increased observation, but ensures that patients who need the support are receiving increased observation – tailored, patient-centred care.

Challenges and lessons learnt for implementation

The Trust has learned a lot about QI methodology, about supporting staff and patients as well as sharing work through the Falls Collaborative.

This project has increased the visibility of nursing and midwifery leadership and input in prevention and centred on individuals experience high value care.

The Trust is due to roll out AFLOAT trust-wide and continue to monitor the impact and need for improvement through audit and nursing feedback.

For more information contact

David Dawson
Matron, Northumbria Healthcare NHS Foundation Trust
david.dawson@nhct.nhs.uk