Oh I Do Like to be Beside the Bedside...

My holidays are here and it's time to dust off the suitcase and drag out the shorts from the bottom drawer. Like many British households it's time to jump in the car, fire up the Sat Nav and race to the nearest seaside resort. What we are presented with is over fifty different options to get to our destination. Dodge the tolls, keep off the "B" roads and swerve past the annual village fête. The same is true for the guidance on falls prevention. There are multiple interventions to apply to patients to reduce falls with harm but difficult to know what direction to take. So what advice should we all be following?

The latest Cochrane review on "Interventions for preventing falls in older people" tells us that there is a vast sea of uncertainty around interventions for falls. The report found that there was uncertainty around the effect of additional physiotherapy, questions around the effect of bed sensor alarms and that multifactorial interventions may reduce rate of falls, but it was difficult to say whether this had an impact on the risk of falling. I'm more certain that it will be a sunny day in Britain in June than researchers are on the evidence for the prevention of falls.

So then what is there left to do? Well, falls represent a huge cost to NHS hospitals and the wider healthcare system, with annual total costs to the NHS alone from falls among older people estimated by the National Institute for Health and Care Excellence (NICE) at £2.3 billion. Falls can cause physical harm to patients resulting in prolonged hospital stays, complaints and sometimes litigation but can also cause psychological distress with patients fearing further falls. Clearly action needs to be taken and in Scotland they have just launched a new consultation paper looking at the "Falls and Fracture Prevention Strategy for Scotland". And whilst it is useful to reflect on national policies and plan strategies for the upcoming years we need to be careful how this translates into the day to to day working on an NHS ward. If the evidence is saying that there is a giant question mark over how best to tackle falls in older people, what are busy patient-facing clinicians supposed to do when they don't have hours to trawl through library books hunting for the holy grail. 

A recent article in the HSJ told a very moving and difficult to read story about the poor care an elderly relative received whilst being treated for a fall at home. This is really disappointing, and unfortunately is not an uncommon story in the NHS. So clearly there is something that needs to be done about the prevention and treatment of falls in our hospitals. These wider strategies need to be translated down to the granularity of the daily working lives of nurses, doctors, physios and the teams on the front lines caring for patients. We need to breakdown these overarching policy documents into something that can be realistically achieved on the ward and intertwined with improvement methodology that wards can manage. 

There are heaps of interventions that wards can implement and then locally study the impact of their interventions. The issue that policy has is that there is not a one size fits all cure for improving falls with harm. There is too much local variance for a national improvement ideas to work across the NHS. The optimal bundle of components is not established, but common components include risk assessments for patients, patient and staff education, bedside signs and wristband alerts, footwear advice, scheduled and supervised toileting, and a medication review. Guidance produced by the National Institute for Health and Care Excellence encourages the participation of older people in falls prevention programmes and falls present a perfect opportunity for wards to involve patients in improvement work. Both patients and staff respond positively to education being delivered on their wards and raising awareness can empower staff and patients to work as a team to address falls prevention on hospital wards.

Preventing falls in patients can only be achieved through strong engaged clinical leadership. Going forward we will need to empower the whole multidisciplinary team to make improvement to their own environments and senior mangers to help build a climate for improvement to thrive. Teams must feel able to take ownership of delivering improvement work but be provided with the support of the organisation. By working with patients, teams can begin to develop customised falls bundles to their patient demographics and make recommendations to improve falls in their areas.