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How to prevent inpatient falls: start by refusing to accept they’re inevitable

Falls should be seen as shocking, rather than normal hospital events

Nurses used reflection and after-action review to identify the small changes they could make to reduce risk and avoid normalisation of falls among inpatients

  • There are 250,000 falls each year in Englands hospitals, most among people over 65 and many of which result in serious injury or death
  • One trusts project shows how taking a proactive approach, rather than reacting after a fall, can enable nursing staff to reduce falls incidence
  • How team-wide involvement in after-action reviews and creative solutions helped the trust reduce falls in hospital by 46% over ten years
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Nurses used reflection and after-action review to identify the small changes they could make to reduce risk and avoid normalisation of falls among inpatients

  • There are 250,000 falls each year in England’s hospitals, most among people over 65 and many of which result in serious injury or death
  • One trust’s project shows how taking a proactive approach, rather than reacting after a fall, can enable nursing staff to reduce falls incidence
  • How team-wide involvement in ‘after-action reviews’ and creative solutions helped the trust reduce falls in hospital by 46% over ten years
The consequences of falls can be catastrophic for individuals and their loved ones Picture: iStock

In April 2009, a patient at Brighton and Sussex University Hospitals NHS Trust had a fall.

Data-wise, there is little unusual about that; falls are common. In hospitals and at home, there were more than 230,000 emergency admissions related to falls among people over 65 in England in 2019-20.

When a loved one dies as a result of a fall in hospital

And in the country’s hospitals, there are 250,000 falls each year, most involving patients aged 65-plus. Many result in serious injury and sometimes death.

Tragically, that was the case for the person at hospital in Brighton. The patient sustained a head injury and died, leaving a family bereft and staff plagued by guilt. More unusual was the family’s reluctance to let the matter rest.

They were not satisfied with the stock response of ‘investigation, report, lessons learned’ and pressed for further action. So the trust’s chief of safety made a promise to bring down the number of falls.

Pledge to reduce falls incidence among inpatients

Mark Renshaw

The task of making that happen fell to head of quality improvement Mark Renshaw and, initially, he was dismissive of the safety director’s pledge.

‘From my perspective, it was a ridiculous thing to agree,’ he says. ‘I was very much of the opinion that falls are inevitable. They are what happen to people when they are sick.’

But the commitment made to the family meant action was necessary, so a major project began across the trust with the aim of reducing falls.

It began with a big launch day. There were speakers and action plans and in the weeks that followed, the number of falls duly declined.

Numbers were down again in the second month, but not by as much, and thereafter ‘bounced around’, says Mr Renshaw – up a little, down a little.

Project evaluation revealed trust’s failure to reduce falls

‘And there was nothing there,’ he says. ‘We’d failed essentially. Falls hadn’t come down by anything we could claim to be a positive amount.’

1/3

of people aged over 65 fall at least once each year, rising to 50% of those aged over 80

Source: NICE

After a year, numbers were crunched ahead of a follow-up meeting with the family.

‘It felt like we’d proved my mind set when we’d started, that falls are inevitable. You can’t stop patients falling.’

Mr Renshaw says that might have been the end of the matter had the trust’s commissioners not taken an interest.

Under the auspices of CQUIN, the NHS Commissioning for Quality and Innovation framework, falls reduction became incentivised, with commissioners holding back funding if targets were not met – in this case, £650,000 against a reduction in falls of 18%.

The importance of nurse leadership

These were nervous times for Mr Renshaw.

‘To be brutally honest, I thought my career’s going down the pan here. I’ve failed the director of safety and I’m now going to fail the director of finance, who’s going to be unhappy that I’ve cost him £650,000.’

In response, and after much ‘cajoling and pleading’, he enlisted the support of Paula Tucker, a well-regarded senior nurse at the trust, later appointed deputy chief nurse at Surrey and Sussex Healthcare NHS Trust.

‘I could have immersed myself in the library and learned everything possible about falls, or I could go to the wards and look at what they were doing. That’s what I chose to do’

Paula Tucker, senior nurse

Ms Tucker took some persuading. Colleagues advised her that leading a falls-reduction project team – highly visible, with an ‘unachievable’ goal – would be professionally damaging.

Coupled with that, she was, by her own admission, no expert in falls. But she was a leader and staff respected her. She took the job.

Understanding how adverse events can become endemic

10%

probability of death within a year of a fall among older people

Source: NHS

Around that time, Winterbourne View, a private hospital for people with learning disabilities in South Gloucestershire, was in the news because of abuse of residents by staff.

Mr Renshaw and Ms Tucker were interested in the process in which minor events can become significant. ‘Units don’t start out bad,’ he says. ‘These things start from small acts and maybe other staff then start to participate in those small acts.

‘Our theory was it then spirals out of control. And we had an interest in whether that could be engineered in reverse.’

Behaviours, he says, are ‘a bit like viruses – you can catch them’.

So the idea took hold that the solution to reducing falls lay in encouraging minor shifts in staff behaviour rather than writing endless action plans.

Taking a proactive rather than reactive approach to falls

Paula Tucker

Although that was the broad aim, Ms Tucker admits she didn’t know where to start when she began her new role.

‘I could have immersed myself in the library and learned everything possible about falls – and there’s a plethora of literature out there. Or I could go to the wards and look at what they were doing. That’s what I chose to do.’

She worked alongside staff and observed them, building a detailed picture of what was happening on the ward and which patients might be at risk and why.

‘And what I saw early on was teams being reactive rather than proactive. They were waiting for a patient to fall rather than thinking about it in a different way.’

For example, only after a patient had been admitted would nurses consider whether the allocated bed space was safe for that patient.

Astonishingly, one patient had fallen 15 times, thankfully without injury, but Mr Renshaw says that case was an example of ‘how we normalise deviance’.

‘None of us were shocked. It was just, “Oh, she’s fallen again”.’

NICE guidance on preventing falls

National Institute for Health and Care Excellence clinical guidance includes recommendations on assessment and interventions for falls prevention among people aged 65 and over.

The guideline covers both community and hospital settings. It says all patients over 65 admitted to hospital should be regarded as at risk of falling.

Picture: iStock

Assessment should cover a range of risk factors including:

  • Cognitive impairment
  • Continence problems
  • Health problems that may increase the risk of falling
  • Falls history
  • Medication
  • Footwear

Common components of successful intervention programmes for any older person at increased risk of falling include strength and balance training, vision assessment and medication review, with modification or withdrawal as required.

After-action review – a chance to debrief and reflect

The project team knew that although risks can be minimised, there is no magic bullet for preventing falls, so they did not claim to have all the answers.

50%

of older people experience serious mobility impairments following a fall

Source: NHS

But as Ms Tucker continued to work alongside ward nurses, a surprisingly powerful approach to reducing falls began to gain traction: reflection.

Every time a fall occurred, it was followed by an ‘after-action review’ (AAR), a debrief in which staff were encouraged to reflect and feed back on individual and team performance.

The process was designed to reveal gaps between expectations and the facts surrounding the fall.

The aim was to learn, not blame, and from each review, small changes in behaviour would emerge as staff were encouraged to consider practical ways to prevent further falls.

Reflection is essential when behaviour change is needed to achieve care quality improvements Picture: iStock

Encouraging reflection through simulated scenarios

This process is not without risk. Honest reflection and feedback can be bruising – which is where a Danish improvisational theatre company enters the picture.

Karen Norman is visiting professor at the school of nursing, Kingston University, and former chief nurse for Gibraltar. She is also a former director of nursing at the Brighton trust, so had worked with Mr Renshaw and Ms Tucker before.

Mr Renshaw asked Professor Norman for advice on producing an academic paper on the ongoing falls prevention work in Brighton, which by now was achieving success.

But articulating how that success was being achieved – essentially through candid discussion of events leading to a patient’s fall – was proving problematic.

Professor Norman had experience of working with the Danish theatre group and believed it might be helpful in enabling the project team and ward staff to see what could be done differently to prevent falls.

‘It’s in moments of conflict that we question our beliefs and values. Organisations change when patterns of conversation change’

Karen Norman, visiting professor at the school of nursing, Kingston University

‘We started doing these improvised scenes about patients falling,’ she says. ‘They were based on real-life scenarios but were changed enough so that those in the room didn’t feel they were meant to be an exact replication of what happened.’

It was hoped that by acting out scenarios and focusing not just on what happened before a fall but also on expectations of what should have happened, staff might reflect on what they do in practice and so initiate change.

When conflict and disruption generate change

It was at times an uncomfortable experience, with some participants feeling their professionalism was being questioned. But it was also an ‘ah-ha’ moment, a catalyst for change.

‘Sometimes you need that disruption,’ says Ms Tucker.

Professor Norman agrees. ‘Conflict can be generative. It’s in those moments that we question our beliefs and values. Organisations change when patterns of conversation change.’

For Mr Renshaw, the process confirmed the critical role reflection plays in learning.

‘We constantly talk about learning but don’t articulate what that is or how it happens. We say we’re doing this investigation to “learn lessons” so it doesn’t happen again.

‘But if you look through all the seminal papers written by the NHS Executive and the National Patient Safety Agency, none of them really articulate what learning is.

‘All of the work we’ve done so far has tried to give an explanation for why it is that some of those facilitated debriefs we held after a fall seemed to have quite a big impact.’

The FallSafe project: nurses championing prevention

The Health Foundation’s FallSafe project, which ran from 2010 to 2012, provided a model for falls prevention, and its impact continues to resonate.

Nurses were appointed leads for 16 inpatient wards in a number of trusts. The nurses were responsible for championing falls prevention through the introduction of evidence-based care bundles.

These care bundles covered a range of assessments and interventions, with a new one introduced every six to eight weeks for nine months. They covered topics such as falls history, bedrails, night sedation and placing call bells within reach.

The project resulted in an estimated 25% reduction in falls.

The Health Foundation says FallSafe also demonstrated that staff nurses and junior sisters/charge nurses can lead improvement projects and succeed in changing the behaviour of their peers.

Dignity dilemmas and patient agency

Reflection and feedback also threw up dilemmas, such as how to balance safety with dignity. For example, if a patient is at risk of falling, what does the nurse do if that patient requests privacy in the toilet?

For Ms Tucker the answer is clear: talk to the patient and find a creative solution.

Explaining the rationale for accompanying a patient to the toilet may be helpful to those concerned about their privacy and dignity Picture: iStock

Creativity is one of nursing’s great strengths, she argues.

So the answer may lie in explaining the potential impact of a drop in lying and standing blood pressure, for example, and for the nurse to remain near – but outside – the toilet, with the door ajar.

Reducing falls is clearly about more than debriefing after the event. Practical interventions play a part too, such a lowering beds, use of non-slip footwear and ensuring call bells and personal belongings are within reach.

But the Brighton team’s approach, which began as a pilot on eight of the trust’s wards, has achieved remarkable success.

Simply by focusing – and reflecting – on behaviours and expectations, the overall reduction in falls in the ten years to 2019 was 46%, saving the trust an estimated £13 million, as well as reducing the human cost.

Lessons we learned from our falls prevention project

Know your data and start small, but involve everyone, including patients, says Paula Tucker.

‘Start where you’re going to get the biggest bang for your buck,’ says Mark Renshaw. ‘That’s your high falls areas.’

And talk about falls constantly, he says. One of his best moments during the project was when a nurse approached him in the trust car park and asked what the falls rate was for a particular ward.

‘That was fantastic. It had reached the point where people really wanted to know how they were doing.’


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