connecting people working in falls prevention Issue 1 October 2014 Welcome to the first issue of Focus on Falls – a quarterly channel to connect with others publication for everyone interested in understanding across hospital, aged residential and preventing falls in older people. care, community care and , is the name and the broad aim of primary health care settings. the national programme led by the Health Quality & There is something in Focus on Safety Commission, working in partnership with key Falls for everyone – it features organisations such as ACC. news, patient perspectives, People working in falls prevention are our focus in this improvement projects and links issue – who they are, what they're doing and what to useful resources.
they've learned. We hope Focus on Falls becomes your Please pass it on!
News from the
Patient perspective: this story could have been different. • Reducing use of psychotics in aged residential care. Key people at Bupa share Risk assessment and care their story and resources. Meet a falls champion. How a hospice is re-invigorating its falls approach.
We're very encouraged t Just in: evidence-based publications and LET'S HEAR FROM YOU
and individualised care plans for older patients at risk of falling. "The improvement in this is Sign up to be on the mailing list . really good. The challenge now is to make sure Let us know what you think of Focus on Falls, every risk factor identified for an individual is what you'd like to hear about in future – or addressed in their care plan, and the care plan tell us about your improvement story. is put into action," says Sandy Blake RN, clinical Email us at [email protected] or lead for the national programme. Sandy has developed guidance for hospital and residential by 31 October 2014 go into the draw for a prize of morning tea for your team valued at e have just uploaded.
Analysing fall eventsSandy has also developed a template to guide o help ensure What exactly is a ‘mechanical fall'? we seek to fully understand factors contributing to a fall. "If we don't learn from these events, then it is less likely we will be able to prevent the next fall which harms a patient," says Sandy. focus on FALLS Issue 1 October 2014
Resources for primary care Learn more about falls
Fall prevention resources being developed by bpacNZ in partnership with the Commission are nearing completion. They will be road- educing harm from falls tested with a number of PHOs this year and be 1PIC An integrated appr
ready for roll-out as a total package f t is your par
Increased longevity can be ack nowledged as a public vement, but it is equally impor address the challenge of adding alls in older people: wher educing the impac iple Aim has been widely adopt sustainable and int , coping and independence ended to be people simultaneous and int e and efficient. 4, 5 erdependent aims need t ep is wider implementation. • improving the qualit A fall can be lif or an older person, e and patient exper verall health of a defined population veloped by the Commission ting on their independence and w e of influence and ectiveness in ser with implications f or their family or whānau and , amme has falls in older or the population of concer 's generally accept s themes – coor ing from those who ar elihood of falling f conditions or dementia, t or older adults incr ommission) as the lead agenc e with complex chr o those at the end of lif tnership with the A meaning of person- ying that falls ar C) and other stak roups of this population can be oss the health sec or people with multiple health e, population health-based tion of falls can be pr ention (such as home or communit o ask what the impac rehabilitation (such as or erventions can be put in place? ic care after hip fractur es a comprehensive when people of all Falls are the leading cause of injur e'll set the scene f ages fall and sustain or half of all health lost due t ogramme as falls in older people y the national pr ely and independently at home ting older people in living Falls in older people impac om individuals and their families/whānau t spending in health and communit set of consumer and clinician materials for use ' to define older people as those ganization, fall pr … those in ing older people the pr risk of falling
outcomes and exper with planning and national falls pr or the number of individuals who fall – ed as whether a person has an viding ser or no falls) within combines with high susceptibilit people e of falls
of the older person, their erspective otal number of falls in a par across all settings. It covers families/whānau and other car ical changes (such as slo e invited people int y not fall at all and another ma principle of ser valence of clinical conditions implicat e r e than once) measur of falling (such as postural h year or falls per 1000 bed/da ganisations happens at se , falls per person/ the first national alls quiz
els and/or dimensions: isk of falling and rat e of falls will r • clinical and ser king in a hospital e programmes also seek t or a patient and their family/whānau y of fall-r
care provider or communit ganisation, and near e and independence (micr 1500 people complet ent of our national organisational and pr ies in the quiz. Nationally screening older people for falls risk and alliances and par results showed that w tnerships (meso or middle le knowledge and commitment t o build on: 96 per ontinued o venting falls and r entional falls in childr tion of falls in older people encompasses the clinical what a fall can mean f e and wider suppor or an older person and think how to raise the subject of falls in a positive s true that older people ar e the best possible
or older people on pr for those who ha and information o fall and come t ibed vitamin D supplementation).
To follow on from the quiz, and realistic way we offered 10 topics on reducing harm from falls suitable for self- in team meetings.
assessing falls risk factors, including a self-assessment and tests for balance and gait, The ver core issues in falls prevention to and postural hypotension update you on current evidence and best practice • taking action to address an individual's and can count as learning activities for professional identified risk factors, including referral development hours.
to specialists or exercise programmes to improve balance and strength.
Test your knowledge on falls and falls retraining exercises are a key element in Clinical lead: Sandy Blake prevention in the effective exercise 2014 April Falls
preventing fal s in older people.
Senior portfolio manager: Carmela Petagna …or the National Part-time programme advisors: Julene Hope and Shelley Jones ATIONAL ANNUAL APRIL FALLS QUIZ • Anyone interested in falls prevention and ril Falls Quiz — w elcome entries* fr viders or community And we'd like to introduce Bridgette Connor • Everyone can win b y testing their knowledge about f ies qualify for one of three p elopment activity whic as project manager for the Reducing Harm ganisation. The p The Quiz r
from Falls programme. Bridgette is a fulltime om 10 April to 5pm on 9
e announced mid-Ma at the same time.
• Enter via smar employee of the Commission and can be tphone, online at www ersion to return by freepost.
contacted by phone (04 913 1743) or email More information at www.hqsc.govt.nz * Staff and contractors (and their relatives) of the Health Quality & Safety Commission are not eligible to enter this sur ‘Reducing Harm from Falls' programme. The prizes are intended to build capability in health and related ser Winners of the prizes will be New Zealand-based and work with their organisations to propose an activity (which could be person vey and competition, nor members of the exper vice/organisation development) acceptable to the Commission in order to receive the prize. Arrangements for uptake must be com vices in New Zealand, preferably related to falls prevention or quality improvement. al professional development, or which suppor pleted within a year of announcement of the prizes.
Place your orderThe is going for its third reprint – please contaco place your order.
focus on FALLS Issue 1 October 2014 Patient perspective:
this story could have
Patient stories help keep the focus on the user's
perspective, which is important in planning and
providing integrated services. Ie suggested readers think about ‘an older
person you know who has had a fall and an injury which
required hospitalisation' and then look at their patient
journey to assess how well services are integrated to
prevent falls in older people and reduce harm from falls.
One of the programme team members did that exercise in relation to a parent's recent fall and fracture, using some quotes from the parent's experience. Here's their story.
Did this person have any risk factors for falling? What were the key features in their patient journey? Mum had been advised at the time of her hip replacement operation (13 years prior to this fall) that her balance was poor – she was unable to maintain her balance standing on one leg. Although the hip replacements were successful in relieving pain, she was worried about her balance. "I became very conscious of not putting myself in a position where I might overbalance, trip over or fall! Stairs were a nightmare, and I avoided going anywhere I had to negotiate stairs." it was cancelled twice.I was happy to be transferred to Mum was also much less active while she waited for the rehabilitation ward. But when I got home it took surgery to correct a painful osteoarthritic problem in her some time for someone to come and assess my needs. spine, and then ongoing osteoarthritis in most of her Then the helpers from the support organisation didn't joints meant her mobility decreased markedly, which come when they were supposed to. and after three meant her muscle strength diminished. And as she weeks of no action on that, we decided to employ our went outside less, time spent in sunlight reduced also. own helper. Then my hip dislocated and I had to go to "With painkillers I was able to lead a reasonable life, A&E to have it re-set. I didn't really know what I should but I wasn't able to participate in the many activities I and shouldn't do in case it happened again, and it was once enjoyed. Then we moved to a new town. It was there that while preparing the evening meal, I over- So, in summary, mum had problems with balance, balanced and fell heavily on my side, fracturing my strength (particularly lower limb muscle strength), gait femur and detaching my hip replacement. I was taken and mobility. Also, the chronic musculoskeletal pain by ambulance to hospital. I thought I would have associated with osteoarthritis is a significant risk factor surgery very soon as I felt my injuries were reasonably for falls – it affects mobility, gait and balance.1 severe, but I was in traction with a catheter for six days and seven nights before I finally went for surgery after 1 Leveille SG, Jones RN, Kiely DK et al. 2009. Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA 302(20): 2214-21.
focus on FALLS Issue 1 October 2014 She was at risk of vitamin D insufficiency or deficiency. 4. Surgery would be carried out within 48 hours, in Her surgery was delayed and bedrest caused a lot accordance with the of problems for mum. I felt that she lost confidence not knowing what she could and couldn't do and 5. Recovery and getting ‘back on her feet' at home she was quite cautious until she arranged a private would be supported by timely home care support consultation for advice.
and advice from her clinical team.
6. The GP would be advised of discharge and Now change the key features in this the practice would be in touch for a follow-up patient story, beginning a year or two appointment within 48 hours.
before the person fell. What would their 7. Mum would have further support and information, journey be like through an integrated she could talk through her concerns and become system working as well as it can? confident instead of anxious about her recovery.
1. Mum would be screened for risk of falling at least yearly at her general practice. We'd like to thank the writers for sharing their experience and insights. This is a powerful example 2. A multi-factorial risk assessment and plan of care of how ‘changing the story' can highlight where would be undertaken when she turned 75 and/ improvements in care would make for a different or when she changed GP, including assessment patient journey – in this case across preventing falls, of her bone health and whether she needed reducing severity of injury and care after a fall.
3. Mum would be referred to a local balance and strength programme and be considered for a home safety assessment. And she would be made aware of her risks and what she could do about fect for this.
Why not try the same exercise in relation to a case or story
you're familiar with? Find it on page 4,
focus on FALLS Issue 1 October 2014 Reducing use of antipsychotics in aged
Providers of aged residential care (ARC) and community Nursing staff influence prescribing care face two important challenges: in residential care – it's the RN • People living with dementia fall at twice the rate who'll call the GP to say "We need as cognitively intact people and their falls are more an antipsychotic for this resident.". likely to result in injury.1 We've focussed on increasing A large proportion of people living with dementia the skill and knowledge of our (up to 90 percent) will develop behavioural and staff and how we respond. We've psychological symptoms of dementia (BPSD) for some part of their dementia journey.2,3 involved all team members in education – understanding the Behavioural symptoms include repetitive questioning and wandering, and psychological symptoms include person is the key to understanding anxiety, agitation and aggression.3 These symptoms the behaviour, and responding to impact on quality of life, but respond to appropriate them as an individual.
interventions.4 Non-pharmacological strategies such as person-centred approaches are recommended as the first intervention – this is a definite shift away from earlier practices of routinely prescribing antipsychotics such as risperidone, quetiapine, and haloperidol. ‘behaviours that challenge' as needs to be met rather Antipsychotics must be used with great care as they than problems to be managed.
increase the risk of stroke and urinary incontinence, and Maree: The whole sector has taken a step up on this
side effects such as sedation, dizziness and postural – we're all trying to find better ways of understanding hypotension can increase the risk of falls. 4 behaviours in people with dementia. At Bupa we've When Sandy Blake, Clinical Lead, recently visited Bupa's been working on reducing antipsychotics since Broadview Rest Home and Hospital in Whanganui, she 2009 and though it fluctuates, overall, the trend is a was interested to find that none of the residents in reduction of up to 20 percent (7 percent in hospital the dementia unit had been on antipsychotics during care, 12.4 percent in dementia care and 20 percent in that month. Following up, Focus on Falls talked with psychogeriatric care). key people at Bupa about how they've been working Beth: We have software which enables monthly
to reduce antipsychotic use. We talked with Gina reporting on antipsychotic prescribing across our care Langlands (Director – Quality and Risk, Bupa Care homes, which have about 3700 residents. Each care Services), Dr Maree Todd (Geriatrician), Beth McDougall home can monitor and benchmark its own rates. We (Dementia Care Advisor) and Delwyn Gedye (Facility know you can't aim for zero use, so we introduced Manager). Here's their story.
management plans for antipsychotic use, which are Gina: We were influenced by what was happening in
reviewed monthly as part of the regular medication the Bupa group internationally, notably a government review in residential care. commissioned review in the United Kingdom on Delwyn: You've got to look for the meaning behind
the behaviour – there always is a meaning – and by Professor Sube Banerjee. We also respond to that. It means you try to understand the passionately promote the person-centred approach – person before their dementia. If we think a resident developed by Docuses on
would benefit from an antipsychotic, we think 1 Taylor ME, Delbaere K, Close JC et al. 2012. Managing falls in older patients with about it very carefully because there's quite a lot cognitive impairment. Aging Health 8(6): 573-88.
involved in setting up an individualised antipsychotic 2 Cerejeira J, Lagarto L, Mukaetova-Ladinska EB. 2012. Behavioral and psychological symptoms of dementia. Frontiers in neurology 3(73): 1-21.
management plan. The antipsychotic management 3 Banerjee S. 2009. The use of antipsychotic medication for people with dementia: record includes a behaviour observation chart that is Time for action. London: Department of Health.
4 Liperoti R, Pedone C, Corsonello A. 2008. Antipsychotics for the treatment reviewed monthly along with the prescription, with a of behavioral and psychological symptoms of dementia (BPSD). Current view to reducing the dose by 25 percent.
Neuropharmacology 6(2): 117–24.
focus on FALLS Issue 1 October 2014 Maree: Antipsychotics are used appropriately for relief
of psychotic features of dementia, such as persistent
delusions, hallucinations, paranoia or persistent
agitation and aggression. And since behaviours and
symptoms may change as the degenerative processes in the brain progress, it's necessary to review medicine use regularly.
Bupa (NZ) has kindly made some key Declercq T, Petrovic M, Azermai M et al. 2013. Withdrawal versus resources on antipsychotic reduction available continuation of chronic antipsychotic drugs for behavioural and psychological symptoms in older people with dementia. Cochrane to all – find a flowchart, antipsychotic Database of Systematic Reviews (3): CD007726. management plan and an update report Antipsychotics in Dementia: Best practice guide from bpac via or .
The Use of Antipsychotics in Residential Aged Care, clinical recommendations from the Royal Australian and New Zealand [email protected] College of Psychiatrists via .
Ministry of Health. 2013. New Zealand Framework for Dementia Care. Wellington: Ministry of Health.
Kim Hill interview with More about medicines that increase the risk of falling 13 September 2014 on the Radio NZ website.
Look up the rate of antipsychotic use in your DHB area in the quick guide on how to look at the a Just in: evidence-based publications and resources
Looking for best practice in hip fracture care?
Looking for recent research on falls in older
The Australian and New Zealand Guideline for Hip Fracture Care for do, news item .
Looking to improve balance and strength
e are options for searching and with normal daily activities?
Looking for up-to-date statistics and figures
Professor Lindy Clemson and her colleagues found on falls?
balance and strength tasks integrated into everyday activities were effective in reducing the rate of falls in older, high-risk people living at home. Falls were find the Serious injury outcome indicators: 2000–12 reduced by 31 percent in the From the Ministry of Health, to a matched group. Programme publications can be or Table 5, codes W00-W19 for falls.
focus on FALLS Issue 1 October 2014 Meet a falls champion
How one hospice is re-invigorating its falls approach
Mary Potter Hospice inpatient unit in Wellington has 18 beds and just over 500 admissions a year. Focus on Falls went to meet the falls champion, and found there were two: physiotherapist Jo Graham and health care assistant Chrissy James. They're part of the falls working party, which includes inpatient unit nurse manager Donna Gray, occupational therapist Tanya Loveard, RNs Di Evans and Amanda Goddard and quality manager Teresa Read.
What does a fall champion do, and why is the working party re-launching Mary Potter Hospice's inpatient falls programme? Chrissy James and Jo Graham
As falls champion, Jo Graham keeps up-to-date with the literature and is responsible for falls completion – that's been well-received. The Ask, assess, education and coaching for the multi-disciplinary team. act process is covered in , and Jo explains, "We're relaunching the programme for a number of reasons – first, falls are one of the top 's where Chrissy's role is critical." three patient safety incidents. There are some strong parts to what we have already done, for instance, our Chrissy James was asked to represent health care information folders for patients include material on falls assistants on the falls working party and it's become and footwear, we reviewed our incident forms after a ". a passion, now I notice potentially unsafe situations comprehensive audit of falls and we have been looking all the time, everywhere. The falls working party at how handover can highlight falls risks. but we adapted the or our environment, thought we could be doing even better for our patients. and after doing an initial informal audit with Donna, I'll do that monthly. Donna and Tanya also developed "One area for improvement was the falls risk assessment a falls risk minimisation checklist that health care tool – it seemed to me that you ticked the boxes and assistants use each morning and afternoon shift. But it's found your patient was high risk – but all our patients not a once only task – it's helped us ‘keep our falls eyes are at a high risk of falling! It wasn't helping us look at on' through the whole shift. We're also looking at using what to actually do for their particular risk factors. And – the individualised message recent literature says that scoring tools aren't useful and on what mobilising safely means for this person is very an individualised approach is. We're looking at whether useful because patients' conditions are so changeable." assessment of falls risk should be separate or integrated with the full nursing assessment on admission.
"We had an event to re-launch the programme, and sessions in our multi-disciplinary study days. Donna has asked all the staff to do the learning activities in Topics 2, 3 and 4 in paid study time with a certificate of focus on FALLS Issue 1 October 2014 In contrast, falls in older people are frequently an What exactly is a ‘mechanical fall'?
interaction between the person's risk factors for falling and an environmental hazard. It follows that an ‘accidental fall' by an older person is also This term derives from an early attempt to define a a problematic idea – it implies that the fall was a fall as the mechanical process of tipping over from completely random or chance event that could not an upright position ‘.when the vertical line which have been prevented. passes through the centre of mass of the human Clinical lead Sandy Blake was surprised to find body comes to lie beyond the support base and the term ‘mechanical fall' still given as the root correction does not take place in time'.1 cause in the root cause analyses she reviewed in a A current and useful operational definition of a fall is this one from interRAI assessment protocols: ‘Any 't know what was meant by that. If unintentional change in position where the person you can't find any causes of the fall, you have no ends up on the floor, ground, or other lower level; recommendations on how to prevent falls in similar includes falls that occur while being assisted by circumstances and we can't learn from that fall'." others'.2 The national falls programme is promoting Finding out how and why an older person fell this definition for consistenc includes looking at the risk factors particular to them, and noting whether any environmental Geriatrician David Oliver discounts the idea of hazards contributed to the fall. Identifying mechanical falls in relation to older people. In a the cause(s) means you can says a truly mechanical fall happens only when a fit that will be effective in reducing the likelihood of person without any risk factors is unable to regain another fall, or reduce the severity of injury. their balance after slipping on ice or a banana skin. IN SUMMARY
1 Issacs 1985 cited in Masud T, Morris RO. 2001. Epidemiology of falls. Age and The term ‘mechanical fall' doesn't explain the cause Ageing 30(suppl 4):3-7.
2 Morris JN, Berg K, Bjorkgren M et al. 2010. interRAI Clinical Assessment Protocols of a fall in an older person, and should be banned (CAPs) for Use with Community and Long-Term Care Assessment Instruments. from falls incident reports.
Version 9.1. Washington DC: interRAI. focus on FALLS Issue 1 October 2014
Spring 2012 The Guide Dogs for the Blind Association Trimming the sails One guide dog owner's success against Also inside: Specsavers Guide Dog of the Year Awards • Guide Dogs' Paralympic hopefuls • Royal Go Walkies Remember a life Change a life
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