FallSafe: Cognitively impaired and delirious patients - a pragmatic response to the gaps in the evidence

Dr Frances HealeyAssociate Director of Patient Safety

RGN, RMN, PhD

FallSafe Quality Improvement Project

• Led by the Royal College of Physicians

• Funded by the Health Foundation

• Supported & promoted by:

The FallSafe team

“Can a ward-based nurse influence all disciplines to embed evidence-based falls prevention care bundles into regular ward practice using a quality improvement approach?”

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Reported falls rate per 1000 bed days + rolling 12 month average

Reported injurious falls rate per 1000 bed days + rolling 12 month average

Falls rate ratio 12 months before full bundle v.12 months after 0.75 (0.68-0.84), p<0.001

Injurious falls rate ratio 12 months before full bundle v.12 months after 0.86 (0.71-1.03), P=0.11

60% certain last fall was

reported

77% certain last fall was

reported

www.rcplondon.ac.uk/resources/falls-prevention-resources/

High levels of dementia and delirium in inpatient fallers

• 88% had mobility problems

• 65% were cognitively impaired • 65% had bone health problems

• 58% had continence problems/urgency

• 49% culprit medication

• 42% had orthostatic �BP/cardiovascular

• 37% impaired vision

• 36% had delirium

Royal College of Physicians 2012 Clinical Effectiveness and Evaluation Unit Report of the 2011 inpatient falls pilot audit www.rcplondon.ac.uk based on case note review of 447 patients in 46 hospitals who fell in September 2011 – data drawn from those where assessment was not omitted, so potentially skewed

Identifying patients with dementia

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“ Oh yes, the Occupational Therapists always do MMSE – they’ll be in the OT notes in their office somewhere”

“That’s a doctors’ job”

“We would do an AMTS when we notice that a patient’s confused…..”

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Starting point for some FallSafe units

Under-recognised in previous surveys

Patients nurses

know are forgetful or confused

Patients with AMTS

<6/10

AMTS 0/10

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Do doctors do AMTS well?

• 105 doctors (geritricians/psychiatrists, consultant/junior)

• 1 unaware of AMTS

• 82 used incomplete/wrong set of questions

• 103 scored incorrectly

• 78 incorrectly used half marks

• 1 doctor scored correctly

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Holmes & Gilbody Differences in use of abbreviated mental test score by geriatricians and psychiatrists BMJ 1996;313:465

If they do it at all……..

“………many doctors do not administer the full 10 questions, preferring to estimate the patient's score instead. We asked doctors to predict the patient's AMTS during the admission interview. A true AMTS was then recorded.”

13Burleigh et al. Can doctors predict patients' abbreviated mental test scores? Age & Ageing 2002 31 (4): 303-306.

• 69% of the predicted AMTS incorrect

• 32% of the predicted AMTS very incorrect:

• 13% were underdiagnosed (cognitive impairment missed)

• 19% were overdiagnosed (not actually cognitively impaired)

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FALLSAFE

EXTENDED EVALUATION

Baseline +12 months +18 months

1 Call Bell in reach 95% 100% 99%

2 Cognitive screen 60% 82% 70%

3 Asked about fear of falling 31% 76% 78%

4 History of falls taken 85% 99% 97%

5 Lying Standing BP 30% 70% 52%

6 Medication review 49% 75% 82%

7 Night sedation not given 66% 87% 90%

8 Safe footwear on feet 93% 98% 99%

9 Urine dip-test 55% 84% 83%

Cognitive assessment: in summary

• Competency-based training for all disciplines

• Case note box for cognitive status

• Routinely measure compliance

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Identifying patients with delirium

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Differences between delirium & dementia

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Confusion assessment Method (CAM)?

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Key thinking 1. Are they confused?

• using an objective assessment like AMTS

2. Is the confusion new/different? • talk to their family & friends

• listen to the last shift each handover

• notice changes since your days off

3. Think of apathetic delirium • Remember they can be delirious without being agitated

“Could this be delirium?” 20

Managing falls prevention in patients with delirium and/or cognitive impairment:

Tackling associated risk factors

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Systematic reviews of in-hospital prevention Reference Title Details /link NICE 2013 Falls in older people clinical guideline update

Appendix E Evidence tables http://www.nice.org.uk

Myakie-Lye et al. 2013

Inpatient Fall Prevention Programs as a Patient Safety Strategy: A Systematic Review

http://annals.org/article.aspx?articleid=1656443

Cameron et al. 2012

Interventions for preventing falls in older people in care facilities and hospitals.

doi: 10.1002/14651858.CD005465.pub3

DiBardio et al. 2012

Meta-analysis: multidisciplinary fall prevention strategies in the acute care inpatient population

J Hosp Med. 2012;7:497-503

Spoelstra et al. 2012

Falls prevention in hospitals: an integrative review

Clin Nursing research 21 (1) 92-112

Oliver, Healey & Haines 2010

Preventing falls and fall-related injuries in hospitals (narrative update of Oliver et al. 2007)

Clin Geriatr Med. 2010;26:645-9

Oliver et al. 2007

Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses.

BMJ. 2007;334:82

Coussement et al. 2008

Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta-analysis.

J Am Geriatr Soc. 2008;56:29-36

Dementia & delirium almost always combined with multiple physical risk factors for falls

• 88% had mobility problems • 65% were cognitively impaired

• 65% had bone health problems • 58% had continence problems/urgency • 49% culprit medication• 42% had orthostatic�BP/cardiovascular• 37% impaired vision • 36% had deliriumRoyal College of Physicians 2012 Clinical Effectiveness and Evaluation Unit Report of the 2011 inpatient falls pilot audit www.rcplondon.ac.uk based on case note review of 447 patients in 46 hospitals who fell in September 2011 – data drawn from those where assessment was not omitted, so potentially skewed

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Reported falls rate per 1000 bed days + rolling 12 month average

Reported injurious falls rate per 1000 bed days + rolling 12 month average

Falls rate ratio 12 months before full bundle v.12 months after 0.75 (0.68-0.84), p<0.001

Injurious falls rate ratio 12 months before full bundle v.12 months after 0.86 (0.71-1.03), P=0.11

Mental health units falls rate ratio12 months befor e full bundle v.12 months after 0.54

60% certain last fall was

reported

77% certain last fall was

reported

Even if you can’t make anything better, don’t make anything worse

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Risk factors for falling in hospital

Hospital inpatients Odds Ratio (95% CI)

History of falls 2.85 (1.14–7.15)

Sedatives 1.89 (1.37–2.60)

Antidepressants (yes vs. no) 1.98 (1.00–3.94)

Cognitive impairment 1.52 (1.18–1.94)

Age (for 5 years increase) 1.04 (1.01–1.06)

Deandra S, Bravi F, Lucenteforte E et al. Risk factors for falls in older people in nursing homes and hospitals; a systematic review and meta-analysis Arch Gerontol Geriatr 56 (2013) 407–415

Risk factors for being injured in a fall in hospital

Hospital inpatients Odds Ratio (95% CI)

SRRIs (yes vs. no) 1.84 (1.04-2.67)

2+ antipsychotic 3.26 (1.20-8.90)

Opiate 1.59 (1.14-2.20)

Diuretic 1.53 (1.03-2.26)

Mion et al. Is it possible to identify risks for injurious falls in hospitalized patients? Jt Comm J Qual Patient Saf; 2012 Sep;38(9):408-13

One of the best in-hospital falls prevention studies

• Large (N= 3718) time-interrupted series

• Computer-based system to advise doctors on contraindications and reduced doses in older patients if they tried to prescribe neuroleptics or sedatives

• Significant reductions in prescriptions

• Fall rates in the intervention group were significantly lower (2.8 vs 6.4 falls per 1000 OBDs, P<.001)

Peterson et al. 2005. Guided prescription of psychotropic medications for geriatric inpatients. Archives of internal medicine, 165, (7) 802-807

EXTENDED EVALUATION Baseline +12 months +18 months

1 Call Bell in reach 95% 100% 99%

2 Cognitive screen 60% 82% 70%

3 Asked about fear of falling 31% 76% 78%

4 History of falls taken 85% 99% 97%

5 Lying Standing BP 30% 70% 52%

6 Medication review 49% 75% 82%

7 Night sedation not given 66% 87% 90%

8 Safe footwear on feet 93% 98% 99%

9 Urine dip-test 55% 84% 83%

EXTENDED EVALUATION Baseline +12 months +18 months

1 Call Bell in reach 95% 100% 99%

2 Cognitive screen 60% 82% 70%

3 Asked about fear of falling 31% 76% 78%

4 History of falls taken 85% 99% 97%

5 Lying Standing BP 30% 70% 52%

6 Medication review 49% 75% 82%

7 Night sedation not given 66% 87% 90%

8 Safe footwear on feet 93% 98% 99%

9 Urine dip-test 55% 84% 83%

EXTENDED EVALUATION Baseline +12 months +18 months

1 Call Bell in reach 95% 100% 99%

2 Cognitive screen 60% 82% 70%

3 Asked about fear of falling 31% 76% 78%

4 History of falls taken 85% 99% 97%

5 Lying Standing BP 30% 70% 52%

6 Medication review 49% 75% 82%

7 Night sedation not given 66% 87% 90%

8 Safe footwear on feet 93% 98% 99%

9 Urine dip-test 55% 84% 83%

Managing falls prevention in patients with delirium and/or dementia:

Special equipment

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Alarms: the evidence • Tideiksaar et al. 1993 – null (but small size and old technology) • Sahota 2009 – pilot for Kendrick et al., single unit, ambiguous findings • Kendrick et al. 2012

• RCT 1839 participants (intervention=921; control=918) acute• Mean age 85 years, 55% were female and 65% had a MMSE<23• 85 bedside falls intervention/ 83 in the control arm (8.71 vs 9.84/1000

bed days) No significant differences in any measures • Shorr et al. 2012

• Cluster RCT 27 672 inpatients in acute hospital• No significant difference in in fall rates per 1000 patient-days (risk

ratio, 1.09 [95% CI, 0.85 to 1.53] or any other measures

Alarms: the frontline

“The alarm has been an absolute godsend …..”FallSafe lead, FallSafe spread project

“ ....... the alarm was brilliant – after we’d been using it for a few days he didn’t even try to stand up any more.”

Ward sister, overheard at a conference

Alarms: if you do use

Ensure you have the staff to respond • Right numbers• Right location

Select equipment carefully:• Integral buzzers?• Pocket-located bleeps? • Nurses’ station buzzers?

Have clear criteria for patient selection:• Could they & would they use a call bell?• Will they fall immediately? • Will the noise agitate them?

Too much of a good thing? • “…. the decision to go alarm-free was prompted, in part, by an

incident in which multiple alarms were sounding simultaneously, and we were all running around, colliding with each other

• ……the nurses' aides [were] afraid they were going to get in trouble if a patient fell, it took us almost a year to remove 33 alarms…

• [Patients with] dementia who were agitated and restless are much calmer since the alarms were removed……and falls fell by 15%”

http://www.courant.com/health/connecticut/hc-alarm-free-nursing-homes-

20130320,0,4359903.story

Ultralow beds

Haines et al. 2010• 10,937 admissions to 18 public hospital wards.• Provision of one low-low bed for every 12 on a hospital ward• No significant differences between intervention & control

Barker et al. 2013 • 9-year single hospital evaluation • “When there was one low-low bed to nine or more standard

beds there was no statistically significant decrease in serious fall-related injuries. An important reduction only occurred when there was one low-low bed to three standard beds.”

Ultralow beds: a note of caution

NPSA 2010• Trips over crash mats • Beds left at height• Injury from floor level fittings• Used inappropriately to

restrict mobile patients

http://www.nrls.npsa.nhs.uk/resources/?EntryId45=94850

“The relative dearth of evidence on the relationship between falls and restraint use in hospital settings is probably academic, given the wider harms and the ethical and legal concerns [about their use]” Oliver et al. 2010

Are bedrails restraint?

‘the intentional restriction of a person’s voluntary movement or behaviour ….’

Queensland government, 2003

‘Stopping them from doing something they appear to want to do’

Counsel and Care, 2002

Do bedrails increase the risk of falls & injury?

AFTER REDUCTION:

Falls (% change)

Injuries (% change)

Serious inj. (number)

Statistically significant?

Si,1999 +61% No change +1 Yes (falls ����)

Hoffman, 2003

-7% -2% +1 No

Capezuti, 2007

���� 46% int.���� 38% cont.

~~

2 �17 �4

No sig difs

Brown,1997 +118% ~ ~ Yes (falls ����)

Hanger, 1999 +25% +3% +1* Yes (falls ����)

Healey et al. The effect of bedrails on falls and injury: a systematic review of clinical studies 2008 Age and Ageing 33(4) 390-394

Technical bedrail safety

Managing falls prevention in patients with delirium and/or dementia:

Making best use of staff

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Special observation

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Specialling(one-to-one observation)

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Special observation

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Intentional rounding

“Position, Possessions, Pain, Potty” [aarrrggggh]

Snelling 2013 ‘Ethical and professional concerns in research utilisation: Intentional rounding’ Nursing Ethics 1–14

Intentional rounding: if you do use

• Don’t standardise, individualise

• Minimise documentation

• Remember:

• Communication skills in dementia

• An hour is a long time

Managing falls prevention in patients with delirium and/or dementia:

The hospital environment

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Kings Fund: Enhancing the Healing Environment

54http://www.kingsfund.org.uk/projects/enhancing-healing-environment/ehe-in-dementia-care

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One critical environmental facilitythat most hospitals lack

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High levels of dementia and delirium in inpatient fallers

• 88% had mobility problems

• 65% were cognitively impaired • 65% had bone health problems

• 58% had continence problems/urgency

• 49% culprit medication

• 42% had orthostatic �BP/cardiovascular

• 37% impaired vision

• 36% had delirium

Royal College of Physicians 2012 Clinical Effectiveness and Evaluation Unit Report of the 2011 inpatient falls pilot audit www.rcplondon.ac.uk based on case note review of 447 patients in 46 hospitals who fell in September 2011 – data drawn from those where assessment was not omitted, so potentially skewed