Falls are common amongst patients in hospital. Research has shown that patient falls are the most adverse event reported in acute care environments, affecting 10% of annual hospital admissions. It has been identified that one third of the population aged over 65 will fall at least once every year. 10% of these will result in serious injury. (Parker 2000)

One of the milestones in this standard is that by April 2003, local healthcare providers should have audited their procedures and put into place risk management strategies to reduce the risk of older people falling.

Many of the patients admitted to the General and Emergency Medicine (GEM) wards are admitted with falls and often continue to fall whilst they are inpatients. Other patients are not necessarily admitted with falls but the environment that they are in, or as a result of their medical condition may lead to such patients experiencing falls.

The Slips, Trips and Falls Forum within the Surgical Directorate had devised a standard of Clinical Practice for Slips, Trips and Falls. Although this was not formally implemented it subsequently reduced their amount of inpatient falls through increased awareness. GEM built on this work and incorporated an assessment tool, nursing care plan and patient information leaflet.

The group also liased with an Independent Falls Advisor and other London Hospitals, such as St. Mary's NHS Trust in Paddington.

The group met on a monthly basis and looked at various issues surrounding in-patient falls. It was agreed to carry out a small audit on presenting conditions and use the information from this audit as part of a tool to identify patients at risk of falls. The group, were interested in keeping any tool devised user friendly and quick to use. They agreed on using a tool similar in principle to the Waterlow Score tool used in pressure area care, to identify patients at risk of falls.

A small audit was carried out on the seven GEM wards, the audit tool used during this period of time was a 'checklist', which the staff completed if a patient experienced a Slip, Trip or Fall. The issues identified were footwear, inadequate lighting, floors, and medications amongst others.

It was felt that the audit would help us gather data needed for an assessment tool.

A literature review was carried out to provide information on any existing tools. Although some tools were found, it was not clear where and how the authors had got their evidence of their scores, as this was not discussed in their papers. The group then devised their own 'assessment tool' based on the information collected from the small audit. Difficulties arose, when it came to scoring the tool and there were a number of debates as to whether the scores needed to be research based or evidence based.

The Consultant Geriatrician then introduced us to the STRATIFY assessment tool. This tool had been validated in two other London Hospitals. The group decided that instead of 'reinventing the wheel' we would adapt this tool to our needs. When the group looked at the tool closely it identified the same primary causes of falls that we had during our initial audit. The factors included in the STRATIFY assessment tool were the same factors that we had included in our draft tool. Another positive aspect of this tool was that in GEM we could also use it for our patients who were at risk of falls due to substance (drugs & alcohol) withdrawal, as it was not focused on the elderly.

A nursing care plan was then written to be implemented if a patient was identified as being 'at risk' of falls and 'pink' falls risk stickers were also devised to assist the nurses in highlighting the problem at handover times. A patient information leaflet was also written and validated.

The pilot originally commenced on two wards within GEM and was eventually extended to four wards.

The first two wards to commence piloting the documentation were Wellington ward and Phyllis Friend ward. These wards were chosen, as they  had the lowest and highest incidence of falls in the three months leading up to the pilot.

Currie and Cambridge then joined the pilot three months after it initially began for a short period of time.

The reasons for this include Wellington ward moving to St. Bartholomew's Hospital at the beginning of the pilot. The patients they had on the ward at this time were slightly less acute, therefore less dependent, and they also had less beds during their time there.

Also, initially the uptake of the project and adherence to the policy was not as good on Phyllis Friend Ward, following discussions with the senior team and with the steering group, the pilot was extended to the two other wards.

All the wards were given teaching on the pilot documentation in the weeks running up to the pilot. The teaching was provided by the Practice Development Nurse, it included why we were trying to reduce the amount of falls, how to use the Standard of Clinical Practice & assessment tool, when a care plan needed to be implemented for a patient and what to do to help reduce the risk of Slips, Trips and Falls in the ward area.

 The attendance at the pre arranged teaching varied on the different wards, in both the amounts of people who attended and the disciplines who attended (e.g. Doctors, physiotherapists, OT).

The Incident books of the wards were monitored closely during the pilot. Risk management were also asked if they could assist in providing us with the number of falls that occurred on these four wards prior to the pilot commencing and then during the time of the pilot. The results were as follows

As you can see out of the four wards, three have a large reduction in the number of falls reported during the pilot period. One ward had an increase. This could be due to a number of factors such as the ward now having better incident reporting and better understanding of the importance of reporting a slip, trip or fall. Also as mentioned earlier the ward had moved site and the acuteness of the patients had changed.

On all of the wards where the documentation was piloted there was a mixed opinion from those who were using it. In general the feedback was positive. The majority of the staff found the documentation easy and quick to use. They also found that they were more aware of the patients that were identified as at risk of falls as they had been highlighted more.

On all of the four wards the process took a while to implement, even though teaching occurred and was required prior to the documentation going into use, it took some staff a while before they became confident in using it.

Other issues included documentation not always been filled in correctly and was sometimes of poor quality. Once the wards became familiar and it became part of their ward culture, the process became easier.

Comments from wards included that the risk assessments were carried out only if they remembered to do so, it was not always a priority to their care, other things were more important, others found it important but didn't always remember to use it.

The patients were often seen as at risk but this was not always seen as a potential problem. One comment included that it is difficult to get documentation completed if it is not seen as important, and if staff don't value the importance of reducing patient falls they won't see the importance of completing the risk assessments.

The pilot demonstrated that the use of this documentation highlighted to the nurses those patients that were at risk of Slips, Trips and Falls. It could therefore be said that over time that this would then reduce the amount of in-patient falls. It is expected that due to better reporting of actual/near miss Slips, Trips and Falls that the amount of incidences reported will increase before it actually decreases.

In February 2003, we hope to implement the documentation across the Directorate to all seven GEM wards. Prior to doing this we will provide further teaching for the wards and ask the wards to identify a falls 'link' so that we can keep them updated and informed. We also hope to have the documentation taken to various boards to be validated and approved.

 We also hope to link to other groups that are doing work on falls prevention, and join forces so that the issue can be looked at Trust Wide.