The Deputy Director of Nursing at Newcastle upon Tyne Hospital NHS Foundation Trust led on the development and implementation of a falls improvement programme across the Older Peoples Medicine (OPM) wards to reduce unwarranted variation in practice. The programme has led to better outcomes and experiences for people using their services.
Where to look
During a review of the Trust’s guidance for falls and the policies associated with managing head injuries to ensure they were compliant with new NICE guidance, several necessary changes to practice at the Trust were identified. Simultaneously, a Root Cause Analysis (RCA) investigation into falls highlighted unwarranted variation in how existing falls protocols were being used. The deputy director of nursing used the evidence base embedded within the NICE guidance to work with the nursing team to improve the process moving and handling and minimise delayed or missed diagnosis of injury. The nursing lead identified an opportunity to develop and strengthen existing processes to enhance outcomes for patients.
What to change
Before introducing change, the nursing lead conducted a baseline audit of post fall care against the revised protocol over a 2-week period as well as gathering learning from additional falls RCAs that had been carried out. Specific areas of unwarranted variation in practice that were identified were computerised tomography (CT) head scans for patients who had either had non-witnessed falls or who had been prescribed blood thinning medicines, as well as patients’ neurological observations following falls and moving and handling practices for patients with suspected hip fractures or spinal injury.
The nursing lead and falls improvement lead identified an opportunity to address this unwarranted variation by advocating additional education/training and support for staff, so to improve compliance with best practice and subsequently improve outcomes for patients who may fall.
How to change
The nursing leads identified the need for a checklist post-fall, to ensure standardisation of assessment and associated pathways for staff to follow alongside the provision of education and support to help staff to use this effectively in practice.
The leads investigated the evidence base from similar work at other Trusts in the region, via the North East Regional Falls Taskforce Group. However, only one other trust had a post-fall checklist. The Post Falls Assessment Checklist (PFAC) was developed based upon NICE guidance and was trialled on the Older People’s Medicine (OPM) wards. This checklist includes key assessments, moving and handling techniques post fall as well as providing guidance as to required clinical interventions such as neurological observations, x-rays and CT head scans within the optimal timeframes. After the initial trial phase, an audit was conducted to identify impact and reveal further areas of learning.
A focus group was held with a group of nursing and medical staff from across the OPM wards to aid engagement and improve iterations of the PFAC in a bid to improve its effectiveness in practice. This initial engagement increased compliance more than 35%.
Nursing leads in collaboration with the falls improvement lead delivered a programme of staff education based upon the PFAC which was rolled out across all OPM wards and concurrent support was offered to help this to be embedded into routine practice.
The falls improvement lead also drafted and shared a briefing paper on the falls improvement programme and circulated this to key stakeholders across the organisation to ensure support was in place. A digital copy was also circulated to the Ward Clerk on each ward so that further copies could be printed as required and that these were held centrally for staff to be able to access at all times.
Better outcomes – Using a Plan-Do-Study-Act cycle methodology, the checklist has been audited at each stage of its development to ensure learning is evidenced and monitored effectively. Following the roll out of the checklist across the OPM wards, compliance in using the list has increased to 95% which is an increase of more than 60% from when it was first piloted. This increase in compliance has had a positive impact upon outcomes as patients across the Trust now receive best practice, evidence based care post falls. They routinely receive the correct assessments, optimal moving and handling techniques post fall and receive the recommended interventions within the advised timeframes.
Better experience – Whilst patient/relative feedback wasn’t formally collated as part of the project, the PFAC is regularly audited through the RCA investigation process and this helps to reassure patients and relatives that they have received the recommended care. This feedback is given formally to patients and/or relatives when they request copies of the investigation as part of the Duty of Candour process. Incidentally, if the PFAC has not been completed and the protocol has not been followed, this is also shared with patients and relatives and forms part of a formal action plan.
Anecdotally, staff report that they like the checklist and feel it is easy to use and helpful, which is a positive indication of how it has been embedded so far.
Better use of resources – The focus of this programme has been to improve the pathway for patients who fall and although identifying the resource implications of the checklist is difficult, it is anticipated that the enhanced service provision will also improve the efficacy of use of resources for falls management.
Challenges and lessons learnt for implementation
It is important to remember that effective and sustainable change does not happen quickly so starting off with a small project area and then scaling it up, or rolling it out further can be advantageous.
There was resistance initially to completing ‘another form’, however this changed over time as staff received additional support and training and began to see early successes from using the tool.
A key to success is making sure a multidisciplinary approach is taken, especially with areas such as falls, where AHP colleagues have a wealth of knowledge and truly enhance a successful implementation of the checklist in practice.
Find out if anyone else is doing a similar project (locally or nationally); there is already a vast amount of Quality Improvement work being done which can be shared and learnt from.
Due to the success of the programme, all adult in-patient wards at the Trust now use the documentation, with the PFAC is audited every 6 months over a 2-week period.
Find out more
For more information contact:
- Rachel Carter, Clinical Improvement Lead (Falls and Pressure Ulcers), Rachel.firstname.lastname@example.org