Falls Collaborative
Caroline Humphreys, Senior Nurse, Cwm Taf Morgannwg University Health Board
Introduction
Older People's Mental Health wards in Cwm Taf Morgannwg University Health Board (CTMUHB) have high incidences of falls, with 58% of patients falling more than once, leading to significant harm and costs.
In 2023, 252 falls occurred, 12% resulting in moderate or severe harm. A collaborative project aimed to standardise falls prevention processes across five wards, focusing on new metrics like time between falls and falls rate per bed days. The goal is to reduce inpatient falls by 15% in five Mental Health wards by the end of 2024 through shared learning and standardised approaches.
Methods
The team initially focused on Angelton Clinic, recognising the need for a broader program across the Health Board to reduce falls. Using the Model for Improvement, they conducted a Fishbone analysis, which highlighted the necessity of an MDT approach, involving the Improvement team, senior nurses, patient safety leads, pharmacists, and physiotherapists. The project aimed to reduce falls through various PDSA cycles, addressing multifactorial issues identified via driver diagrams and Fishbone analyses.
Adopting a Collaborative approach based on the IHI's Breakthrough Series, the team organised four learning sessions and action periods. These sessions focused on standardising falls prevention measures across wards, simplifying Datix reporting, and involving additional teams like Catering and Community teams. The Driver Diagram based on NICE guidelines helped standardise falls prevention practices, ensuring consistent implementation across all wards.
Outcomes
- Implemented bed rate as a new outcome measure to account for bed occupancy and align with national targets (6% rate for medical wards, NHS England).
- Teams are reducing variability in falls rates since Nov 2023, likely due to standardised falls prevention and reporting practices.
Learnings
- Ensure sustainability of the new process by continued use of the bundle and audit tool for falls prevention.
- Teams showed strong engagement, shared learning, and contributed diverse perspectives, crucial for the project's success.
- SRO and clinical lead provided ongoing support and motivation to ensure team participation.
- Need to co-produce further ideas for change with patients and carers
- Barriers: tight timelines, multiple change ideas, manual data analysis due to unlinked DATIX systems, and potential financial challenges post-project.
What next?
- Spread and scale to district and community hospitals, leveraging Mental Health Liaison Teams.
- Integrate work into the health board's wider falls prevention initiative.
- Address gaps in physiotherapist provision and pharmacist availability
- Utilise ACB medication score to improve falls prevention.
- Recognise need for MDT participation in Falls Scrutiny Panels. Efforts are underway to establish a specialised Falls MDT Panel.
