Falls Prevention in Palliative Care:Introducing the Avoiding Falls Level of Observation Assessment Tool (AFLOAT)

8th November 2019

Dr David A. Richardson, Consultant Geriatrician, Clinical Falls Lead

1. Background

Falls Prevention in Palliative CareBackground

• “Despite patient and family education aimed at safety promotion and fall prevention, fall incidents continue to occur and are the number one cause of injuries and hospitalizations among the palliative patient population.

• In palliative care patients, many of whom are elderly, the risk for falls is further increased by the patients’ multiple and often complex and debilitating disease processes.

• Side effects of multiple medications, dementia and other mental acuity altering conditions are also major factors associated with and contribute to the falls experienced by palliative patients.

• Head injuries and hip fractures suffered from a fall further increase health complications, hastening of death and increased distress for the already suffering patients and their families.

• Furthermore, in-patient care costs associated with fall-related injuries are devastatingly high, even for the injuries not categorized as life threatening”.

Pavlov, Katrina G., "Fall Prevention in Palliative Care: Improving Fall Prevention and Management at Point of Admission" (2017).Master's Projects and Capstones. 678.https://repository.usfca.edu/capstone/678

Falls and Palliative Care Patients - the importance of chronic diseases• Yorkshire Cancer Network survey of falls in palliative care inpatient settings.

We found that the incidence of falls in this context was 5.7 falls per occupied bed per year, noticeably higher than the incidence in nursing homes or in the community.

• This may reflect the patient population who are often elderlywith other coexisting pathologies.

• Our study identified cognitive impairment and low systolic blood pressure as the most important independent predictors of falls in this context.

• However, we did not find any association between falls and various medication groups such as opioid analgesics as Lovell et al demonstrated.

• In common with Lovell, we did not find an association betweenpostural hypotension and falls, despite our assumption that this would bea frequent association.

• Persistent low systolic blood pressure, while known to be a factor in cognitive impairment, is also seen more commonly in people with progressive disease.

• In palliative care patients, hypotension and cognitive impairment probably reflect failing physical systems and more strongly influence falling than medicines.

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7426.1288-a (Published 27 November 2003) Cite this as: BMJ 2003;327:1288

Falls Prevention in Palliative CareBackground: Hospice studies 2004

• Calculated fall rates in three hospices in the Yorkshire region, identified risk factors for falls based on previous studies in elderly patients, and then carried out a prospective study of inpatients in two of these hospices.

• Compared these risk factors in patients who subsequently fell with patients that did not fall during the study period. Information was recorded on 102 admissions.

• 12 patients fell, generating 23 falls; 6 patients fell more than once.

• Significant risk factors for falling were cognitive impairment, low systolic lying and standing blood pressure, visual impairment and age over 80. Males with these risk factors fell more often than female patients with these risk factors.

• Strategies to prevent falls in hospice inpatients need to be directed appropriately towards patients with cognitive and visual impairment and low systolic blood pressure.

Falls in hospice - a cancer network observational study of fall rates and risk factors. / Bennett, M. I.; Nicholson, L.; Pearse, H.In: Palliative Medicine, Vol. 18, No. 5, 01.07.2004, p. 478-481.

Falls Prevention in Palliative CareBackground: Hospice studies 2004

• Falls prevention is a critical priority in hospice and palliative care settings. To keep patients safe and comply with national standards, hospice professionals must have available appropriate assessment, prevention, and intervention tools.

• Existing procedures engaging patients in strengthening exercises and reducing or eliminating medications that cause dizziness, imbalance and confusion are fitting and useful in environments where first-line fall reduction efforts are possible.

• These current tools are based on research in facilities for non-hospice patients and run counter to the goals of palliative care.

• By definition, hospice patients have a terminal illness and are, or will become, too weak to manage strengthening exercises.

• Without their medications, many would experience intolerable pain and unmanageable anxiety and depression.

• This article proposes assessment guidelines and pragmatic interventions to reduce the risk of falling that are consistent with the hospice philosophy of comfort.

Falls Prevention in Palliative CareBackground: Hospice articles 2007

Jullie Gray. Protecting Hospice Patients: A New Look at Falls Prevention. First Published June 1, 2007 Research Article https://doi.org/10.1177/1049909106298721

• In their effort to identify the best fall prevention measures suited for the palliative patient population, Morgan, Cerdor, Brown, and Currow, (2015) bring up a study done on 100 palliative patients, out of which 32% had at least one recorded fall incident, however, only 4% of the study patients had falls risks identified in their routine risk assessment.

• The authors proceed to ask why only 4% had an identified falls risks, yet 32% experienced falls, why where these risks not detected in the other patients?

• In conclusion the authors say that the most effective falls intervention strategies include a combination of systematic risk screening tools regardless of the population base.

• The screening tools should include medication reviews, and follow-up on identified risks.

Falls Prevention in Palliative CareBackground: Hospice studies 2015

Deidre D. Morgan, Pauline A. Cerdor, Annabel Brown, and David C. Currow. Journal of Palliative Medicine, 2015, 18 (10), pp. 827 - 828 Issue Date: 2015-01-01

• Based on the latest guidance from National Institute of Clinical Excellence they developed:

1) a falls risk-assessment tool;

2) a care plan for falls prevention and management and

3) ten quality standards

• A practice focused approach was used to engage staff in the importance of the guidance and the use of the tools pre and post implementation.

• The tools were integrated into the e-Health recording system (Crosscare) and compliance with the standards were audited one year after implementation (February 2015).

Falls Prevention in Palliative CareBackground: Hospice studies 2015

Falls Prevention in Palliative CareBackground: Fall Prevention Booklets

Hospice launches a national toolkit to help prevent patient falls

• Other hospices across the country can benefit from the experience and expertise of a senior member of staff at Earl Mountbatten Hospice with this latest guide on other on managing and preventing falls among their patients.

• Becky McGregor, the hospice’s Head of Clinical Quality and Patient Experience, is a member of the National Quality Advisory Group of Hospice UK, an umbrella organisation which supports the work of more than 200 members including Earl Mountbatten Hospice.

National and international standards

• The original guidance had been published in 2010, and the aim of refreshing the advice has been to make sure it is consistent with national and international standards, relevant in all areas of hospice care (including at home and in care homes), and as user friendly as possible.

• The toolkit can be adapted and used to support each individual patient and includes links to national guidance.

https://onthewight.com/hospice-launches-a-national-toolkit-to-help-prevent-patient-falls/

Falls Prevention in Palliative CareBackground: Hospice National Falls Tool Kit 2016

3rd August 20161st May 2013

Falls Prevention in Palliative CareBackground: National standards NICE CG 161 2013

1.1 Preventing falls in older people1.1.1 Case/risk identification 1.1.1.1 Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s. [2004]1.1.1.2 Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance. (Tests of balance and gait commonly used in the UK are detailed in section 3.3 of the full guideline.) [2004]

1.1.2 Multifactorial falls risk assessment 1.1.2.1 Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention. [2004]1.1.2.2 Multifactorial assessment may include the following:

identification of falls history assessment of gait, balance and mobility, and muscle weakness assessment of osteoporosis risk assessment of the older person's perceived functional ability and fear relating to falling assessment of visual impairment assessment of cognitive impairment and neurological examination assessment of urinary incontinence assessment of home hazardscardiovascular examination and medication review. [2004]

1.1.3 Multifactorial interventions 1.1.3.1 All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention. [2004]

NICE Quality Statements

1. Older people are asked about falls when they have routine assessments and reviews with health and social care practitioners, and if they present at hospital.[new 2017]

2. Older people at risk of falling are offered a multifactorial falls risk assessment. [new 2017]

3. Older people assessed as being at increased risk of falling have an individualised multifactorial intervention.[new 2017]

4. Older people who fall during a hospital stay are checked for signs or symptoms of fracture and potential for spinal injury before they are moved.[2015]

5. Older people who fall during a hospital stay and have signs or symptoms of fracture or potential for spinal injury are moved using safe manual handling methods.[2015]

6. Older people who fall during a hospital stay have a medical examination.[2015]

7. Older people who present for medical attention because of a fall have a multifactorial falls risk assessment.[2015]

8. Older people living in the community who have a known history of recurrent falls are referred for strength and balance training.[2015]

9. Older people who are admitted to hospital after having a fall are offered a home hazard assessment and safety interventions.[2015]

Falls Prevention in Palliative CareBackground: National standards NICE Falls QS86 2017

Falls Prevention in Palliative CareBackground: National standards NICE CCG7 2019

2. Fall prevention

NHFCT

Falls Prevention in Palliative Care:So what to do ….. ward/department level

Palliative Care Unit WGH

Palliative Care Unit NTGH

• Back to basics on admission• Falls history (identify High risk

groups in A&E, “falling star” logo, Falls care plan)

• Mobility / ADL assessment

• Vision / hearing problems

• Continence

• Footwear

• Cognition

• Agreed alert system to call for help

• Patient placement within ward

• Medication review (e.g. avoid hypnotics/sedatives)

Falls Prevention in Palliative Care:So what to do ….. ward/department level

X

Medication Class Examples Fall Mechanism

Benzodiazepines

***

Diazepam

Lorazepam

Cognitive impairment, confusion,

dizziness, sedation, drowsiness

Motility agents Metoclopramide Gait abnormalities, extrapyramidal

reactions

Neuroleptics

***

Haloperidol Gait abnormalities, extrapyramidal

reactions, dizziness, sedation,

drowsiness, agitation, balance

problems, visual disturbances

Opioids Morphine

Oxycodone

Cognitive impairment, dizziness,

Falls Prevention in Palliative Care:Culprit medication

Medication Class Examples Fall Mechanism

Anticholinergic Agents

***

Hyoscyamine

Diphenydramine

Amitryptiline

Cognitive impairment, confusion,

visual disturbances

Anticonvulsants Gabapentin Cognitive impairment, confusion,

blurred vision, gait abnormalities

Antihypertensives *

• Beta–blockers

• Calcium channel blockers

• ACE inhibitors

• ARB agents

• Nitrates

• Alpha1 antagonists

• Diuretics **

Metoprolol

Verapamil

Lisinopril

Irbesartan

Nitroglycerin

Doxazosin

Furosemide

Orthostatic hypotension,

dizziness, syncope

**Increased ambulation with diuretics due to need to use the

bathroom!!

Falls Prevention in Palliative Care:Culprit medication

Medication Class Examples Fall Mechanism

Antidepressants Agents

***

• Tricyclics

• Tetracyclics

• Monoamine Oxidase Inhibitors

• SSRI’s

• SNRI’s

Amitryptiline

Mirtazepine

Phenelzine

Citalopram

Venlafaxine

Cognitive impairment, confusion,

visual disturbances,

postural hypotension

Stimulants Caffeine

Methylphenidate

Agitation

Use of multiple medications ***

Falls Prevention in Palliative Care:Culprit medication

• Habits and patterns of routine care• Avoid night transfers

• Routines to meet individual toileting needs (intentional rounding)

• Handover of needs, risks and plan of care (SBAR)

• Family involvement

• Appropriate discharge information

• Training and skills

Falls Prevention in Palliative Care:So what to do ….. ward/department level

• High risk groups “Fast track to safety”• Focus on modifiable risks

• Escalate medical and medication review

• MSU and L&S BP

• Physiotherapy / OT review

• Cohort nursing

• Specialist equipment (e.g. high-low beds, glide sheets, etc.)

• Osteoporosis considered / treated

Falls Prevention in Palliative Care:So what to do ….. ward/department level

Falls Prevention in Palliative Care:NHFCT FallSafe Care Bundle Compliance Audit October 2018 of 38 wards

0 10 20 30 40 50 60 70 80 90 100

Call Bell in reach

Safe Footwear

Walking aid in reach

Lying and standing BP

Vision

Cognition

Routine Urinalysis

History of falls documented

Fear of falling documented

Bed rail assessment documented

No new night sedation prescribed

Medication review

Bone health assessed

Falls care plan in place

Annual snapshot data (Oct & Nov 18)

• Environment and technologies• Accessible toilets / commodes

• Range of chairs / beds Lighting and light gradients

• Monitoring / visibility of bed areas

• Call bells accessible and visible

• Trip hazards and clutter removed

• Specialist equipment available (e.g. high-low beds, slippers, etc.)

• Temporary hazards have warning signs

33% bed stock are single rooms

13% beds visible from nursing station

Falls Prevention in Palliative Care:So what to do ….. ward/department level

• After a fall• Post in-patient fall pathway, “Simple

Fall? Think Trauma”

• Checks for injury and observations (NEWS)

• Checks for new or deteriorating illness precipitating fall

• Reported and all MDT aware

• Repeat medical and medication review

• Review patient environment and sensory / mobility / cognitive deficits

• Review pattern if repeat falls (refer to Falls Nurses*)

• “Medical Report Following a Fall” sticker compliance audited by Falls Nurses

• 6 monthly report of common themes found in falls related SIs

Falls Prevention in Palliative Care:So what to do……learning from in-patient falls

* Consider Community Falls team if within the Hospice setting

Falls Prevention in Palliative Care:NHFCT FASS specialist nurse post fall reviews

0

100

200

300

400

500

600

700

Apr 2017 -Jun 2017

Jul 2017 -Sep 2017

Oct 2017 -Dec 2017

Jan 2018 -Mar 2018

Apr 2018 -Jun 2018

Jul 2018 -Sep 2018

Oct 2018 -Dec 2018

Jan 2019 -Mar 2019

Apr 2019 -Jun 2019

Number of Falls

Number of FASS Reviews

3. AFLOAT and Bay

Watch

Falls Prevention in Palliative Care:NHFCT Supportive Observation Policy

Rolled out January 2017

In response toSI reports whichshowed patients did not alwaysreceive an adequatelevel of observation

Describes 4 levelsof observation

Falls Prevention in Palliative Care:NHFCT Task and Finish Group

Task and finish group set up to look at

• Current falls observation policy

• Current psychological observation policy

• Any overlap between the 2 groups (baseline audit)

• Variation in setting level of observation

• Staff engagement

• Find a tool to support staff in setting observations

• Join NHSI Falls Collaborative 2018

Falls Prevention in Palliative Care:NHFCT Enhanced Care Support Baseline Audit April 2018

Key findings for patients on Level 3 and 4 observations

82% had delirium OR dementia

37% had delirium AND dementia

Lack of standardised assessment tool for delirium or dementia

Tools poorly understood

89% of patients had FASS specialist nurse review

54% of patients had MHSOP specialist nurse review

Little evidence of therapeutic interventions

Service users and advocates keen to see PINCHME and therapeuticinterventions used

Variation in nurses setting the level of observation

Falls Prevention in Palliative Care:Enhanced Care Support Baseline Audit April 2018

Key recommendations

Ensure observation levels are being set correctly by ward staff

The Trust should review the number of cognitive assessments currently in use and attempt to standardise approach

Review the possibility of incorporating the cognitive assessments digitally into Nerve Centre

Stimulate discussion of joint working between Falls Group and Dementia Steering Group

Joint working from both groups to feed into Frailty Board

Stimulate discussion of moving from an “Observational” to “Enhanced Care Support” model

Falls Prevention in Palliative Care:NHSI Falls Collaborative pilot project 2018

What do patients who need supportive observation “look like”?

• The Avoiding Falls Level of Observation Assessment Tool (AFLOAT) recognised these clinical presentations and used a scoring system

Unsteady

Confused

Falls at home

Urinary or faecal urgency

Falls in hospital

Orthostatic hypotension

Falls Prevention in Palliative Care:AFLOAT

Falls Prevention in Palliative Care:AFLOAT PDSA findings

• Seven PDSA cycles undertaken - Final pilot results

• Implication being safety and better use of scarce resource

Falls Prevention in Palliative Care:Add Bay Watch to AFLOAT

• We have scaled up and adapted into Trust policy

• Now have trust wide roll out

• All patients are assessed using AFLOAT to set correct level of observation

• Bay Watch initiative

used to carry out the

observations

• We have demonstrated that higher levels of observation can be effective in reducing falls

Falls Prevention in Palliative Care:Bay Watch and AFLOAT launched at our Nursing Conference

Falls Prevention in Palliative Care:Local and national recognition of AFLOAT

Falls Prevention in Palliative Care:NHFCT Falls per 1000 bed days timeline

1. RMP 37a specific policy for in patient falls Nov 2015

2. RCP Fall Safe care bundle cohort of 10 wards May 2016

3. RMP 60 Supportive Observation Policy Jan 2017

4. Change to falls team leadership structure June 2017

5. Roll out of Fall Safe trust wide via Datix and digital falls care plan Mar 2018

6. NHSI Falls Collaborative May 2018

7. AFLOAT and Bay Watch Dec 2018

1 432 5 6 7

Falls Prevention in Palliative Care:NHFCT Hip fracture reduction

• Represents a significant reduction in human suffering• Potential savings of £3.6m due to falls reduction from

2016-17 in last 2 years * based on NHSI Incidence and cost of in-patient falls in hospital 2017

• Reduction partially due to observation policy• BUT still seeing cases in Datix, RCA and SI reports where patients had

not received the correct level of observation

0

10

20

30

40

50

2012-2013 2013-2014 2014-2015 2015-2016 2016-2017 2017-2018 2018-2019

Number of In-Patient Hip Fractures

31 6 74 52

1. RMP 37a specific policy for in patient falls Nov 20152. RCP Fall Safe care bundle cohort of 10 wards May 20163. RMP 60 Supportive Observation Policy Jan 20174. Change to falls team leadership structure June 20175. Roll out of Fall Safe trust wide via Datix and digital falls care plan Mar 20186. NHSI Falls Collaborative May 20187. AFLOAT and Bay Watch Dec 2018

4. What next?

• We can now set the correct level of observation

• Now need to move from model of “Observation” to therapeutic interventions and “Enhanced Care Support”

• Provide better dementia and delirium care which are drivers of patients requiring high levels of observation (e.g. PINCHME: Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment)

Falls Prevention in Palliative Care:NHFCT plan for next 12 months

Falls Prevention in Palliative Care:NHFCT plan for next 12 months

• Joint working between Dementia Steering Group and Falls Steering Group

• How do we operationalise therapeutic interventions from within the current resource?

• What are the therapeutic interventions?

• Knowledge sharing FASS and MHSOP nurses

• Patient and carer involvement

Falls Prevention in Palliative Care:Radical thought………….

• May turn out that the care costs of implementing falls observation policy are in part, actually the unmet care costs of providing safe care to frail older people in hospital/hospice who have cognitive impairment

Falls Prevention in Palliative Care:Summary

• Older people should be routinely asked about falls

• Older people should have a multifactorial assessment and an individualised intervention (including a medication review, lying/standing blood pressure and mobility assessment)

• Providing supportive observations and post-fall reviews saves money and misery

• AFLOAT helps to set the correct level of observation and ensures best use of resource

• Those who receive L3/4 observations have cognitive impairment

Falls Prevention in Palliative Care:Summary

• If you switch from “observing” to “intervening”, you may reduce the number of days that people need high levels of observation by better management of cognitive impairment (e.g. PINCHME)

• Decrease falls and fractures

• Decreased costs

• Overall provide better care for the older patient and especially the cognitively impaired in palliative care

Questions?