Leeds Teaching Hospitals has been working on reducing falls across the organisation for some years. As one of the biggest teaching hospitals in Europe and spread over five sites across Leeds, this has been hugely challenging. As the population ages, providing high-quality care to our older, frail patients is of paramount importance, evidence tells us that nationally 10% patients suffer harm in hospital and the risks are higher in older people.
We wanted to refresh our falls QI work, reignite enthusiasm and ensure our most vulnerable older patients are cared for appropriately to reduce their risk of falls. A QI approach using a breakthrough series collaborative model with pilot wards testing PDSA cycles has led to a 26% reduction in falls across our organisation, this equates to approximately 65 falls per month and 780 falls per year.
We have been on a journey fraught with both failure and success and through this work, we have learnt a huge amount. Our success has been due to adopting a multi-disciplinary approach, sharing good practice, positive culture change, access to improved data and celebrating success.
We noted that on falls SPC charts we had a data point above the control limit and 7 points above the mean, we were worried about falls increasing especially in our elderly, more vulnerable population. As a multi-disciplinary faculty team, we came together and devised a driver diagram which outlined our aim which is to reduce inpatient falls by 40% on pilot wards by October 2019. Our four primary drivers are:
• Leaders take action
• Excellent team working
• Creating a safe environment
• Patient empowerment/education
Our pilot wards tested interventions using PDSA cycles to address each of the primary drivers. We were then able to create a bundle of interventions that were tried and tested on our wards and had led to a reduction in falls and therefore were evidence based.
The interventions could then be scaled up in the form of a bundle across the organisation. Our faculty continues to mentor wards to embed the bundle. Our measures are falls (crude number trustwide, by department and by ward) falls per 1000 bed days to factor in acuity and our balance measure is pressure ulcers (if more people are kept in bed there will be less falls but more pressure ulcers).
Across LTHT we have reduced falls per 1000 bed days by 26 % (seen on SPC chart). This is a reduction in falls per 1000 bed days from 4.8 to 3.6 and equates to approximately 65 falls per month since 2014 and 780 per year.
We are proud of this achievement, demonstrating this initiative has improved the care of elderly patients - not just on elderly medicine wards but across our large organisation. The main difficulties we came up against have been how to maintain the focus on falls amid all other clinical priorities.
Key enablers have been better access to improvement data for frontline teams and celebrating success. We have also disproved the myth that you cannot improve in winter! In addition, falls with harm has consistently been below 0.9% as seen on safety thermometer data.
Furthermore, since April 2017 falls with harm have seen a statistically significant reduction of 62% with the mean recalculated from 0.39% to 0.15%. We are passionate about re-iterating to staff that each of these numbers represents a patient with a story. We regularly share patient stories and are currently filming a falls video to highlight the impact of falls from a patient perspective.
A key part of this work was scale up/spread: across our organisation we have 18,000 staff and >100 inpatient wards. We chose pilot wards that represented a range of specialties, not just elderly medicine, to ensure that the interventions would be generalisable/replicable in a range of environments.
The bundle was scaled up across the organisation department to department over ~1 year. Over time we then observed falls start to increase – this was excellent learning for us, we needed to ensure that the QI work was seen as ‘normal practice’ and cultural changes were embedded.
We therefore re-launched this work and maintained a ‘QI coaching’ model that enables a faculty member to coach teams, ensure the bundle has been embedded and highlighting achievements to the faculty team.
Another factor that has facilitated sustainability/spread has been celebrating success. We award certificates to teams that have gone a significant period without a fall. This helps to foster healthy competition between wards, reinforce good practice and boost morale. This work has been presented at national conferences–the bundle can be adapted to context and given its extensive use in LTHT we have proven it can work in a variety of environments to reduce falls.
Our work to reduce falls has demonstrated positive value and outcomes in a qualitative and quantitative sense. Falls have reduced by 26% per 1000 bed days (see supporting evidence) trust wide. Furthermore, since April 17 falls with harm have had a statistically significant reduction.
Falls with harm have a huge financial cost across the NHS (>£2.3 billon/year) but many have a psychological cost i.e. fear of falling leading to social isolation. Our patient/carer team member hat has been profoundly affected by falls during her life and she said ‘ The organisation has transformed’ she is proud to be part of our falls QI team and this feeling is reciprocated.
Another major factor in the value of this work has been better collaboration between wards across our organisation regarding how all specialities can care better for older people, learn from each other and share good practice. Our bundle of successful interventions includes; safety huddles (a brief multidisciplinary catch up focusing on testing ideas to reduce falls, patients wearing appropriate footwear, cohorting high-risk patients, intentional rounding and post falls review and sharing learning and data real time. All of these interventions can be scaled up across differing wards, the organisation and beyond.
This work has helped to shift culture and the belief that falls are a problem for ‘nurses’ or ‘geriatricians’; to a culture where falls are seen as everyone’s responsibility to prevent.
Our key stakeholders have been our frontline teams that have embraced this QI work and tested interventions enabling the development of the bundle. It was key that our pilot wards included both elderly medicine wards and other specialties such as orthopaedics, general surgery, oncology etc.
This was to enable cross-learning and sharing of good practice, improving the care of older people and reducing falls in patients outside the elderly medicine bed base. Engaging patients in this work has also been a key factor, as an adjunct to this work LTHT has been successful in securing a grant from NHS Citizen (£10,000) to further our work in involving patients/carers in QI to enable truly patient-centered improvements.
As part of this we have one of our ‘Quality partners’ involved in our collaborative as a key member of the faculty team. She underwent QI training alongside staff and brings the care/patient voice into all of our decision making, she is a huge asset to our team