Essential care after an inpatient fall: summary of a safety report from the National Patient Safety Agency

Dear Editor,

As directed by the Rapid Response Report issued by the National Patient Safety agency in January 2011, NHS organisations with inpatient beds were asked to make system changes by July 2011 to reduce the risk of harm post inpatient falls [1].

In March 2011, we audited the quality of medical assessments done after a fall and the recording of neurological observations. Preventative measures identified and implemented prior to the fall as well as post fall managements including fall outcomes, access to urgent investigations and secondary prevention were also included. We used the Datix system to retrieve the last 24 fall incidents that took place in March 2011 in a district hospital in Greater London and referred to the corresponding patient notes for qualitative assessment. We presented our findings at the local Clinical Governance meeting. A post-fall protocol was formulated and introduced to the nursing staff as guidance for response to a fall. The protocol was uploaded on the hospital policy database in July 2011 and was included in the Induction for the new doctors starting in August 2011. We re-audited in 20 patients who had a fall in August 2011. The following comparative points were raised.

Pre-fall assessment: The demographics of the patient population who suffered a fall before and after the above recommendations were implemented were similar. In March amongst the 24 cases of inpatient falls, 19 falls were unwitnessed and 8 involved head injuries. In August, 20 cases were audited, amongst which 17 were unwitnessed and 5 involved head injuries. In both population samples 80% of cases were identified with gait, balance and muscle weakness and 70% cognitive and/or neurological impairment.

Peri- fall assessment. ; In March 2011, the median interval between fall and medical assessment was 90 minutes in comparison to 50 minutes in August 2011. However, in August 2011 a greater number of falls did not receive a medical review. In particular, 5 out of 20 cases were not reviewed for fall and 3 out of 20 cases were assessed by the Hospital at Night coordinator (HaN). None of the falls were assessed by HaN in March, and 4 cases did not receive medical review at all. 60-70% of falls took place during night and weekend shifts in both patient samples.
For patients who sustained a head injury in March 2011, 4 out of 8 cases had the minimum acceptable neurological observations and only 2 out of 8 cases had neurological observations recorded as directed by the NICE guidelines [2]. By contrast, in August 2011, the content and frequency of neurological observations followed the NICE guidelines in all 5 cases of inpatient falls resulting in head injury.

Imaging and outcomes; In the patient sample from March 2011 there were 3 CT head requests; one CT head was requested within 30 minutes the other 2 CT head scans requested 2 days post fall. No acute haemorrhage was reported in any of these investigations. A left wrist radiograph performed 3 days post fall, revealed Left Colle’s fracture.
In August 2011, there was a single CT head request, placed and performed within 30 minutes of the event. It revealed a left sided intraparenchymal bleed. Pubic rami fractures, right hip and left patellar fracture were other positive findings of imaging requested for different patients within 1 day post fall. It might be worth mentioning here that in August 2011, as a result of medical review of a fall, the assessing doctors identified medical emergencies precipitating the event such as Acute Coronary syndrome and Type 2 Respiratory failure.

STF (Slips, Trips and Falls) plan was reassessed in 4 out of 24 cases in March, and 11 out of 20 cases in August.

These results suggest that after the implementation of system changes, although not all patients who had a fall were reviewed by a doctor, the quality of medical reviews that did take place were at a higher standard. Effective SBAR between doctors and nurses enabled identification of potential triggers leading to the fall. Nursing staff and doctors demonstrated awareness and adherence to the NICE and NSPA guidelines in terms of neurological observations and imaging requests as well as secondary prevention. Effective communication and contribution of qualified healthcare workers such as HAN in assessing falls ‘out of hours’, might facilitate identification and prioritisation of cases that require prompt action.

Sincerely,

Marilina Antonelou

References
1. National Patient Safety Agency. Essential care after an inpatient fall. NPSA/2011/RRR001. NPSA, 2010. www.nrls.npsa.nhs.uk/alerts/?entryid45=94033.
2. National Institute for Health and Clinical Excellence 2007 Clinical Guideline 56: Head injury, triage, assessment, investigation and early management of head injury in infants, children and adults.