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National Audit of Inpatient Falls (NAIF) context page

  • CQC have collaborated with audit bodies and agreed to present these ‘key’ metrics about the quality of services.
  • This document provides guidance to assist interpretation of the key metrics from the National Audit of Inpatient Falls (NAIF) as selected by the Royal College of Physicians. Full audits can be reviewed where it is necessary to further inform an inspection.
  • A total of 170 hospitals in England participated in the audit in 2017 (the clinical audit was a snapshot of the care provided to a sample of up to 30 patients (15 consecutively admitted patients over 2 days) aged over 65, who were in hospital for over 48 hours, after being admitted for a non‐elective reason).

National Clinical Audit data is reported in Evidence Appendices under the Effective key question, in particular as it relates to how people’s care and treatment outcomes are monitored and how they compare with other similar services. For each key metric it may also be appropriate to consider how the data relates to other key questions, such as safety or responsiveness and therefore the key lines of enquiry are presented under the CQC prompt as a guide.

Audit website: www.fffap.org.uk

Metrics

1. Does the trust have a multi-disciplinary working group for falls prevention where data on falls per 1,000 occupied bed days are discussed at most or all the meetings?

  • Rationale: The Patient Safety First ‘How to’ Guide for Reducing harm from falls suggests that trusts should have a team in place that is committed to reducing harm from falls. This is also identified as an action for the Executive Team[1]. Falls and fall-related injuries are a common and serious problem for older people. The human cost of falling includes distress, pain, injury, loss of confidence, loss of independence and mortality. Falls are estimated to cost the NHS more than £2.3 billion per year[2].[1] Patient Safety First; The ‘How to’ Guide for Reducing harm from falls’, p15[2] NICE CG161, June 2013
  • Guideline/mapping: No guideline exists, however the audit recommends that the trust’s multidisciplinary falls group reviews all incidents to develop and share learning.
  • Quality improvement prompt question: The audit recommends that all trust have a trust- or hospital-wide patient safety group, which includes falls prevention in its remit and reports to the board. This group should regularly review their trust’s data on falls and moderate harm, severe harm and deaths per 1,000 occupied bed days and assess the success of their practice against trends in these figures[1]. KLOE – E2[1] Inpatient Falls Audit 2017, p8

2. Crude proportion of patients who had a vision assessment (if applicable)

  • Rationale: No research-based data are available to enable a weighting to be given – overall or for a particular patient – to the relative contribution of any one of the many factors that impact falls risk. However, the audit’s multidisciplinary advisory group (MAG), which includes patient representation, identified this as a key indicator on the basis that it is indicative of good practice and is an achievable aim for quality improvement[1].[1] Inpatient Falls Audit 2015, p 16
  • Guidelines/mapping: This metric maps approximately to NICE CG 161[1], relating to multifactorial falls risk assessment. Trusts are rated according to the percentage of patients who received the assessment.Red/poor: 0-49%
    Amber/fair: 50-79%
    Green/good: 80-100%[1] NICE CG161, section 1.2.2.3
  • Quality improvement prompt question: The audit recommends that if the trust’s rates of vision assessment are low, they should consider using the Royal College of Physicians’ clinical practice tools to standardise practice.[1] KLOE – S2[1] Inpatient Falls Audit 2017, p23

3. Crude proportion of patients who had a lying and standing blood pressure assessment (if applicable)

  • Rationale: Some people have blood pressure that drops on standing which can increase their chances of falling due to dizziness and blackouts (syncope syndrome). When older patients are in hospital they have a higher chance of a drop in blood pressure on standing and simple interventions such as encouraging fluid intake and stopping some medications can reduce this[1]. The audit’s MAG, which includes patient representation, identified this as a key indicator on the basis that it is indicative of good practice and is an achievable aim for quality improvement[2].[1] Jevon P (2001) Postural hypotension: symptoms and management. Nursing Times; 97:3, p39[2] Inpatient Falls Audit 2015, p16
  • Guidelines/mapping:This metric maps approximately to NICE CG 161[1], relating to individual risk factors for falling in hospital that can be treated, improved or managed during their expected stay, which may include syncope syndrome. Trusts are rated according to the percentage of patients who received the assessment.Red/poor: 0-49%
    Amber/fair: 50-79%
    Green/good: 80-100%[1] NICE CG161, section 1.2.2.3
  • Quality improvement prompt question: The audit recommends that if the trust’s rates of lying and standing blood pressure are low, they should consider using the Royal College of Physicians’ clinical practice tools to standardise practice.[1] KLOE – S2[1] Inpatient Falls Audit 2017, p8

4. Crude proportion of patients assessed for the presence or absence of delirium (if applicable)

  • Rationale: Delirium (sometimes called ‘acute confusional state’) is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course. It usually develops over 1–2 days. It is a serious condition that is associated with poor outcomes, including falls. The audit’s MAG, which includes patient representation, identified this as a key indicator on the basis that it is indicative of good practice and is an achievable aim for quality improvement[1].[1]Inpatient Falls Audit 2015, p16
  • Guidelines/mapping: NICE CG 103 recommends that people at risk of delirium should be assessed for delirium within 24 hours of admission[1]. Trusts are rated according to the percentage of patients who received the assessment.Red/poor: 0-49%
    Amber/fair: 50-79%
    Green/good: 80-100%[1] NICE CG103, section 1.3.2
  • Quality improvement prompt question: The audit recommends that all trust review their dementia and delirium policies to embed the use of standardised tools and documented relevant care plans. Falls teams should work closely with dementia and delirium teams (if present) to ensure team working for these high risk patients[1].  KLOE – S2[1] Inpatient Falls Audit 2017, p8

5. Crude proportion of patients with a call bell in reach (if applicable)

  • Rationale: The Patient Safety First ‘How to’ Guide for Reducing harm from falls stipulates that having call bells visible and in reach is an important environmental factor that may impact on the risk of falls[1].[1] Patient Safety First; The ‘How to’ Guide for Reducing harm from falls’, p21
  • Guidelines/mapping: Trusts are rated according to the percentage of patients who received the intervention.Red/poor: 0-49%
    Amber/fair: 50-79%
    Green/good: 80-100%
  • Quality improvement prompt question: The audit found a highly variable rate for patients having easy access to call bells and as such suggests a hospital-wide approach to address this[1].[1] Inpatient Falls Audit 2017, p9

 

CG: Clinical Guideline

NICE: National Institute for Health and Care Excellence

MAG: Multidisciplinary Advisory Group

NAIF: National Audit Inpatient Falls

 

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