For the purpose of this assignment I have chosen to analyse and review the fall’s pathway that is used by an ambulance service in the North of England. The aim of any care pathway is to enhance the quality of care by the improvement of patient outcomes, promoting patient safety, increasing patient satisfaction, and by optimizing the use of resources available at that present time. (Zander K.2002). I will look at the referral process of a patient that has fallen in their home wither it be their first fall or have a history of multiple falls with the multiagency falls team which are available to the ambulance service.
In February 2006, the National Patient Safety Agency (NPSA) published a report entitled ‘SLIPS, TRIPS AND FALLS IN HOSPITAL’. This report recommended ways of identifying and acting on reversible risk factors that may cause a person to fall, from this research there is clear evidence that the number of falls and the negative impact of their consequences can be reduced by 30% if health and social care communities work together effectively to address falls and their impact on elderly people.
It also suggested ways of improving the care of patients that are vulnerable to falls and evidence on preventing falls, such as practical ways of implementing effective interventions that could reduce the risk of repeated falls. This was done by reviewing medication associated with falls detecting and treating eyesight problems physiotherapy access to walking aids and providing safer footwear.
A fall may be defined as an event whereby an individual comes to rest on the ground or another lower level with or without consciousness (British Geriatric Society 2001)
Falls can have a serious impact on both the quality of life of older people and on health and social care costs. Age UK (2010), states up to one in three people over 65 have a fall each year in the UK, which is around 3.4million adults. New research and calculations puts the daily cost to the health service at more than ?4.6 million and the cost of treating osteoporotic fractures in the UK is ?1.8 billion of which ?1.5 million is estimated per PCT (Torgerson 2000)
Falls can cause distress, pain, injury and loss of confidence and independence of older people, which causes multiple A&E attendances, inpatient stays and increase the level and cost, of social care services provided. Ambulance services are often called as an emergency to assist older people who have fallen (Mark P.et al 2002). The after effects of even the most minor falls can be catastrophic for an older person’s physical and mental health. Falls may be caused by the person’s poor health or frailty, or by environmental factors, such as trip hazards inside and outside their home
Elderly fallers account for approx 10% of all 999 calls to the Ambulance Service and more than 60,000 people fell and fractured their hip in England in 2007/8. In the England upto 14,000 people die a year as a result of an osteoporotic hip fracture. Falls pathways have been developed to improve the treatment of people over 65 years old who have fallen within their home and to prevent unnecessary admissions to hospitals. Almost half of the fallers can be safely treated at home by the attending ambulance crew. According to NICE recommendations, people at risk who require referral to a falls service include all those who have received medical attention for a fall or have fallen more than once in a year. The development of a falls prevention pathway is a requirement of both the National Service Framework (Standard Six) for Older People and NICE clinical guideline on the assessment and prevention of falls. (DoH 2003)
The falls pathway aim to reduce harm to elderly people who have fallen by putting measures in place to reduce the risk of further falls and their admittance to hospital. The pathways are also aimed at improving communication between health professionals such as ambulance staffs, GP’s and falls teams.
Falls in older people is a significant health and social care issue and fall prevention services are being implemented across the north of England, local fast response teams have worked to make service improvement across health and social care.
Services are based around comprehensive falls pathways, which proactively identify those at highest risk of falling and carry out an assessment of internal health and social care and external environmental risk factors. The service is supported by dedicated falls practitioners, who ensure an individual care plan is in place and manage risk through onward referral, including for strength and balance training, home hazard intervention, physiotherapy therapy, visual or hearing specialist and medication review
When the ambulance service are called to a patient who has fallen within their home the call is often put through to NHS direct for assessment by doing this they try to assess the patient over the telephone by asking a number of question. This can result in patients being left on the floor for a number of hours if in their opinion the patient does not have any injuries an ambulance will not be sent straight away which can cause distress to the patient. Over 1 in 5 people were not confident at all about getting up from the floor and or to summoning help. This is important given the well documented evidence of the risks associated with a ‘long lie’ (being on the floor longer than 1 hour). (The Royal College of Physicians 2009)
As the patient cannot get themselves up off the floor the ambulance crew is still called to help the patient up off the floor. In this case if there are no injuries a full set of baseline observation including an Electrocardiograph (ECG) are taken on the patient and again a number of question asked to why the patient has fallen. A full medical history and a list of medication are also needed. This information is then placed onto a patient report form and a non transport form is completed and signed by the patient this is time consuming and prevents the ambulance from attending other more serious incidents. If the patient has injuries then between the patient and the ambulance crew a decision on which is the best treatment and actions for the patient will take place this could be that the injuries could be treated in the home by an emergency care practitioner or a district nurse for wound care.
For an older person a fall can have serious effects on confidence and independence (Salkeld et al, 2000 Pg 341-346).
Where possible all elderly patients who fall at home with their consent should be referred to a specialist fall’s service team. The Ambulance Service has developed a pathway allowing a paramedic to make a clinical decision to directly refer the patient to the Fast Response Team for further management and then onto the falls prevention service.
On consent of the patient to be referred a phone call to the clinical hub is made information on the patient is provided including date of birth, GP details and patient baseline observations are past referral team also answers to parameters of assessment questions.
“Is there a history of falls in the previous yearHow many?
Is the person on four or more medications per day?
Does the person have fear of falling?
Does the person report any problems with gait and/or balance?
Does the person have dementia or confusion?
Do they have a long term medical diagnosis (e.g. Parkinson’s/arthritis/stroke?)” (Yorkshire Ambulance Service Jan 2010)
This information is then past onto the local Fast Response Team who will aim to contact the patient within 2 hours. However not all area have a 24/7 service so some patient may not be assessed straight away. All the paperwork for the patient including ECG strip should be left with the patient to that when the team arrives to assess the patient they will have all the information they need. Also with the consent of the patient they should be advised to contact their own GP for a medication review and follow up if any minor injuries are caused and to inform relatives of the fact they have had a fall and been seen by the ambulance service..
Critically analyse role of the multi disciplinary team
Multidisciplinary fall assessment teams are working to develop within the National Health Service (NHS). These teams make up the building blocks of health care and every team is composed of different professionals, such as Physiotherapists, Occupational Therapists, Podiatrist and Nurse Practitioners all of which provide assessment, treatment, and rehabilitation to patients who have fallen or who are at risk of falling.
Their work consists of environmental assessment, provision of equipment to maintain independence and safety in mobility and daily living skills, gait and balance work and advice on footwear and foot care. The overall aim of the falls teams are to provide a timely and responsive service to help maintain people in the community and help prevent avoidable hospital admissions and to identify patients at risk of falling and those who have fallen and to help prevent and reduce further falls.
By the reviewing and discussions with multidisciplinary teams their findings from the individual patient assessment can be used to develop an individual plan of care to prevent further falls (UIGN.2004).
Due to many falls fast response team not working 24/7 and only working weekdays many elderly people are left in their home over night or the weekend without being assessed. This could lead to further falls and injuries.
Falls Prevention Services should provide adequate verbal and written communication about treatment with both patients and their family where appropriate and healthcare and other professionals involved in their care. This includes following up the results of investigations this often does not happen as the ambulance service has no follow up in communication with the fast response fall teams this leads to poor communication between different healthcare professionals and between healthcare professionals and patient.
In the Department of Health Next Stage Review (2008), Lord Darzi announced the introduction of several new measures for improving quality such as “Quality Accounts” to include patients’ views on the quality of their experiences
Older people who have fallen currently receive crisis intervention to address immediate risks. The missing link is access to a coordinated integrated falls pathway that is consistent, effective, offers active rehabilitation and places an emphasis on falls prevention
Falls Prevention Services should recognise that effective communication takes time, but if achieved this is likely to increase satisfaction with the Service and improve compliance with any recommendations made for reducing the risk of falls and reducing injuries from falls. This is likely to reduce the number of patients seen in a busy clinic for example.
The Patient and Public Engagement Support Programme (DH, 2009) plan to use patient experience to improve service quality by engaging and empowering users of services
Early intervention and preventative advice can delay reliance on more intense interventions at a later stage. If staff groups are working effectively together and follow a common pathway. This should raise standards and promote more effective use of resources.
Raising public awareness and highlighting falls prevention can help to reduce or delay the consequences of a fall.
Preventing falls in older people will save lives and decrease disability and by using a fall pathways this will achieve the following outcomes, it will help to reduce repeated falls and associated injuries and fractures it will also make a reduction in the number of falls related admissions into accident and emergency departments and calls made to the ambulance service. The widespread use of an effective falls risk assessment tool with better standards for effective prevention and rehabilitation services increased patient satisfaction and wellbeing for patients with a reduction in acute, community, rehabilitation and social care costs.
The uses of risk assessment tools are important but equally having identified contributing risk factors does not in itself lead to interventions (Oliver, D., et al (2004). Preventing falls in older people depends on identifying those most at risk of falling but many old people who fall do not seek medical help, but can be identified as being at risk by being identified as having a history of falls by family members or carers. This is an effective integrated care pathway which is universally adopted between health care professional which improved partnership working between multiagency teams. Help to maintain the person independence and to prevent further falls and injuries from falls. Using patients’ experiences can help to develop such services (Kings Fund, 2009, NHSI 2009).
Age UK (2010) Falls in the over 65s http://www.ageuk.org.uk/latest-news/archive/cost-of-falls.(Accessed DATE HERE)
British Geriatric Society and American Academy of Orthopaedic Surgeons Panel on Falls Prevention (2001). Guidance for the Prevention of Falls in Older persons, Journal of the American Geriatrics Society, Volume 49 pg 664 – 672.
Clinical practice guideline for the assessment and prevention of falls in older people NICE clinical guideline http://www.nice.org.uk (accessed DATE HERE)
Department of Health. National Service Framework for Older People. 2001. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance (Accessed DATE HERE)
Department of Health. High Quality Care for All: NHS Next Stage Review final report, 2008. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH (Accessed DATE HERE)
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National Patient Safety Agency (2006) slips, trips and falls in hospital http://www.npsa.nhs.uk (Accessed DATE HERE)
Oliver, D., et al (2004). Risk factors and risk assessment tools for falls in hospital inpatients: a systematic review. Age and Aging Volume 33 pg 122-130.
Salkeld, G., Cameron, I D., Cumming, R G., Easter, S., Seymour, J., Kurrle, S E., Qunie, S., Ameratunga, S N., and Brown, P M. Quality of life related to fear of falling and hip fracture in older women: a time trade off study. British Medical Journal. 2000; 320: Pg 341-346.
The Kings Fund Point of Care Programme. Measures of patients experience in hospital: purpose, methods and uses. (Coulter, A., Fitzpatrick, R., and Cornwell, J.) 2009.
The Royal College of Physicians National Audit of Services for Falls and Bone Health of Older People (2009) http://www.rcplondon.ac.uk/resources/national-audit-falls-and-bone-health-older-people (accessed DATE HERE)
Torgerson D. J. and P. Dolan, ‘The Cost of Treating Osteoporotic Fractures in the United Kingdom Female Population’ (letter), Osteoporosis International (2000) Volume 11 pg 551
University of Iowa Gerontological Nursing Interventions Research Center (UIGN). (2004). Fall prevention for older adults. University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core. http://www.nursing.uiowa.edu/consumerspatients/evidencebased.htm.(Accessed DATE HERE)
Yorkshire Ambulance Service (Jan 2010) Referral of Patients Fast Response Pathway York and North Yorkshire Primary Care Trust area Attachment 3
Zander K. Integrated Care Pathways: eleven international trends. Journal of Integrated Care Pathways 2002 Volume 6 pg 101-107