How To Improve Falls And Bone Health

Transcription

1 National Audit of the Organisation of Services for Falls and Bone Health of Older People Commissioned by: Healthcare Quality Improvement Partnership Conducted by: The Clinical Effectiveness and Evaluation Unit, Clinical Standards Department, Royal College of Physicians, London Advised and approved by: The Falls and Bone Health Steering Group Generic Site Report March 2009 England, Wales and rthern Ireland

2 CONTENTS Page 2 Contents 3 List of tables 4 List of figures 5 Report authors 6 Introduction 7 Executive summary 17 Background and Method Results 24 Presentation of results 26 Domain 1: Local strategies and commissioning 30 Domain 2: Case finding and referral 32 Domain 3: Structure and staffing of the falls and bone health service 37 Domain 4: Specialist falls management 44 Domain 5: Service settings 60 Domain 6: Training and audit 64 Organisation of care index 67 Public indicators 69 Comparison of bone health to falls Appendices 1 References 2 Scoring system 3 Comparison Falls and Bone Health 4 Full data collection form 5 Participants and non participants 6 National Falls and Bone Health Audit Steering Group Falls and Bone Health Organisational Audit Generic Site Report. March

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4 LIST OF TABLES Page Title Background 1 24 Domains and applicable healthcare settings 2 25 Recruitment and numbers submitting data Domain 1: Local strategies and commissioning 3 27 Commissioning strategy 4 28 Service lead 5 28 Reporting 6 29 Service level agreement or contract 7 29 NICE Guidance 8 29 Care Homes Domain 2: Case finding and referral 9 31 First level screening Domain 3: Structure and staffing of the falls and bone health service Falls service Clinics with trained medical staff Clinics without trained medical staff All clinics Staffing Domain 4: Specialist falls management Multi-factorial falls risk assessment: clinical note proforma or similar tool Multi-factorial falls risk assessment: components Multi-factorial falls risk assessment: home hazards Exclusions Intervention plan Exercise training Individualised programmes Interventions for osteoporosis Syncope Domain 5: Service settings Care Home: number and type of beds Care Home: NHS continuing healthcare Care Home: falls prevention reduction policy or procedures Care Home: services provided to residents Provision of training to care homes from falls service Provision of assessments and interventions from falls service to care homes Community mental health services provided to care homes Community physiotherapy service Inpatient or resident falls prevention policy Inpatient or resident falls: systems to record, gather together and analyse Inpatient or resident falls: assessment documentation A&E or MIU Ambulance services Fracture service: hip fractures Fracture unit/clinic: fragility fractures Fracture unit/clinic: staffing and provision of care Fracture unit/clinic: older people admitted with fractures

5 Domain 6: Training and audit Training for staff Audit programme Patient views Organisation of Care Index Organisation of Care Index - PCOs Organisation of Care Index - HSCTs Organisation of Care Index - acute trusts Organisation of Care Index - MHTs Public Indicators Falls score scaled to maximum of Bone health score scaled to maximum of 100 LIST OF FIGURES Page Title 1 64 Organisation of Care Index - PCOs Organisation of Care Index - acute trusts Organisation of Care Index - MHTs Average score across the Falls indicators - PCOs 5 70 Average score across the Falls indicators - acute trusts 6 70 Average score across the Falls indicators - MHTs 7 71 Average score across the Bone indicators - PCOs 8 71 Average score across the Bone indicators - acute trusts

6 Report Authors Report prepared by Dr Finbarr C Martin, MD MSc FRCP Consultant Geriatrician, Guys and St Thomas NHS Foundation Trust Associate Director for Falls and Bone Health, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians Dr Jonathan Treml, BA, MBBS, FRCP Consultant Geriatrician, University Hospitals Birmingham NHS Foundation Trust Associate Director for Falls and Bone Health, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians Mrs Janet Husk, RGN, MSc, Dip Project Manager, National Falls and Bone Health Audit, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians Mr Robert Grant, BSc, Dip Stat Medical Statistician Clinical Effectiveness and Evaluation Unit, Royal College of Physicians Ms Michelle Spencer-Williams, BA Project Co-ordinator, National Falls and Bone Health Audit, Clinical Effectiveness and Evaluation Unit, Royal College of Physicians Report approved by the National Falls and Bone Health Audit Steering Group

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8 Introduction We present the results of the second national audit which examines the organisation of services provided to older people for falls prevention and bone health. Falls and fractures are a common and serious problem affecting older people, with high levels of personal and financial cost. National guidelines, supported by the research evidence, require the provision of integrated services for falls and fracture prevention and treatment. Effective commissioning is needed to produce such high quality services. This audit was commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the second cycle of audits on services for the prevention of falls and fractures in older people. It follows the first organisational audit, performed in 2005, and the clinical audit of All were audited against specific standards from the National Service Framework for Older People (NSF) and guidance from the National Institute for Health and Clinical Excellence (NICE). Since the first audit, indicators have been added or updated in line with new guidance including that on falls prevention of inpatients following the National Patient Safety Agency (NPSA) report on slips, trips and falls in hospital (2007). For the first time, the audit also looks specifically at falls and fracture prevention in mental healthcare and a sample of care homes. We are grateful for the hard work of many NHS professionals, who have contributed to a very high return rate 93% (315/337) of acute trusts, primary care organisations and health and social care trusts in England, Wales and rthern Ireland. We are confident that we have produced a reliable and comprehensive picture of services across these three home nations. The results show that, despite modest improvements since the first audit, major variation between trusts persist, and deficiencies in care remain widespread. We make recommendations that will lead to better falls and bone health services, and which can be implemented cost-effectively by the NHS. We urge you to consider the key messages and recommendations in the report. There is much that can be done, and must be done, to reduce injury, disability and preventable death from falls and fractures. Finally we would like to thank everyone who helped in the design, performance and analysis of this audit. Janet Husk Dr Finbarr Martin Dr Jonathan Treml Dr Jonathan Potter Project Manager Associate Director Associate Director Director, CEEU

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10 Executive Summary Each year, over 700,000 older people in the United Kingdom (UK) attend hospital accident and emergency departments (A&E) following a fall and many more attend minor injury units (MIUs), or call for ambulance assistance. Falls and resultant fractures in people aged 65 and over account for over 4 million bed days each year in England alone. Injurious falls, including over 60,000 hip fractures annually, are the leading cause of accident-related mortality in older people. Falls may also result in loss of confidence, activity restriction, reduced functional ability and thus increased dependency on carers and services. Well organised services, based on national standards and evidence-based guidelines can prevent future falls and reduce death and disability from fractures. As judged against these standards, this audit shows that the large variation in the quality of services observed in the 2005 audit were still evident in Some services are doing well but there are important deficiencies in commissioning and in the provision of care. The high rate of participation in this audit, however, demonstrates strong commitment in the NHS to monitoring quality and we believe there is an appetite to do better. These results deserve serious local scrutiny to develop the improvements needed. Headline findings 1. Opportunities to prevent recurrent falls and fractures are being missed: a. Risk assessments in A&E departments and Fracture services are inadequate. b. Services with Falls Coordinators and Fracture Liaison Nurses have better case finding systems in place to identify high risk fallers. c. Most trusts have developed inpatient falls policies, but only a third know their inpatient falls rates. 2. Commissioning is patchy, rarely providing a coordinated falls and fracture strategy: a. Important public health information on fracture rates is inadequate or not collated. b. Only 39% (67/171) of commissioning trusts report being compliant with the NICE technology appraisal on secondary prevention of osteoporotic fragility fractures. This figure contrasts with the results of 2007/8 Healthcare Commission annual health check on NHS trusts, for which the great majority of PCOs in England selfreported as compliant as reflected in Core Standard 5a. This public reassurance about fracture prevention services turns out to be misleading since only 24% (40/169) have audited bone health prescribing in their local primary care and only 9 know their local fragility fracture rates. 3. Many clinical services are not adhering to the NICE CG21 and TAG 87 guideline-based treatments to prevent falls and fractures: a. Patients with first fractures are not flagged up for secondary prevention. b. Many of the exercise programmes being provided are not evidence based. c. Too few services used patient-agreed treatment plans. d. Assessments for safety at home using a validated approach could be better. Recommendations Primary care organisations (PCOs) should develop commissioning strategies that include: o Case finding systems in hospital and community settings to identify high risk fallers o Adherence to NICE treatment guidelines with monitoring by local audit o Clinical leaders including a consultant with job plan commitment o A fracture liaison service o Widespread and accessible evidence-based exercise programmes o Targeted use of validated home safety assessments. The Department of Health should review how it can best support these developments by: o Provision of advice on commissioning o Strengthening incentives o Provision of useful metrics for falls prevention, fractures and osteoporosis treatments. Falls and Bone Health Organisational Audit Generic Site Report. March

11 The NSF, 2001 set out the standards and actions needed to address a range of common health problems in older people. Standard 6 was devoted to falls. Subsequently the National Institute for Health and Clinical Excellence, NICE, produced guidance on the clinical practice needed (2004). This set out a strategy for case finding and clinical treatments to reduce the risk of falls and injuries. In 2005, NICE described cost-effective treatments for improving bone health for the secondary prevention of fragility fractures. Previous audits The major finding from the first Organisational Audit in 2005 audit was that, whilst 74% of falls services stated they had established an integrated and comprehensive falls service, the details in the audit showed that this was far from the case. Case finding was poorly developed; numbers of patients seen in specialised clinics and for investigations were low; and there was little evidence of effective collaboration between primary and community care, social services and hospital services; or falls prevention and osteoporosis pathways. This was followed in 2007 by a clinical audit of the care actually received by patients attending hospital with a fragility fracture. This had wide coverage of the NHS (over 90% of trusts) and gave a genuine indication of what care was being received. The findings suggested that there were serious gaps in the provision of secondary prevention for falls and fractures, particularly following non-hip fractures. Changes since 2005 Following each of the previous audits, the Clinical Effectiveness and Evaluation Unit (CEEU) at the Royal College of Physicians, along with other professional groups have promoted improvements in falls and fracture services in many ways, including a series of regional workshops which were followed by action plans being prepared by trusts and collected by the CEEU on behalf of the Healthcare Commission. There have of course been competing priorities influencing developments in commissioning and in the services developed by PCOs and acute trusts. In contrast to other clinical areas, there have been no direct incentives, such as exist in the Quality and Outcomes Framework for Primary Care. The 2005 organisational audit was based on data collected from acute trusts only although it included information they had obtained from local primary care trusts (England). This audit sought to obtain a wider picture across the whole health economy, including acute trusts, PCOs (Local Health Boards and Primary Care Trusts), mental healthcare trusts/services and a sample of care homes. This is the most definitive examination of falls and bone health services ever conducted, in the UK or elsewhere. Audit standards and indicators The audit questions have been derived from the following sources: National Service Framework for Older People (NSF) Chapter 6 Falls, 2001 National Service Framework for Older People in Wales (NSF Wales) Standard 8 Falls and Fractures, 2006 National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 21 Falls: The assessment and prevention of falls in older people, 2004 (NICE CG 21) NICE Technology Appraisal Guidance 87, Bisphosphonates (alendronate, etidonate or risedronate), selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fractures in post menopausal women, 2005 (NICE TAG 87) British Orthopaedic Association (BOA), The Care of Fragility Fracture Patients (Blue book), 2007 Department of Health (DH) Urgent Care Pathways for Older People with Complex Needs, 2007 NHS National Patient Safety Agency (NPSA), Slips trips and falls in hospital, *Subsequently superseded by the equivalent updated TAG 161 on secondary prevention, but TAG 87 was the relevant guideline at the time of the audit. Falls and Bone Health Organisational Audit Generic Site Report. March

12 Questions were arranged in the following domains. Depending on the nature of the trust undertaking the audit, some domains applied, some did not: Table 1: Domains and applicable healthcare settings Domains Healthcare settings 1. Local strategies and commissioning PCOs and health and social care trusts (HSCTs) 2. Case finding and referral PCOs, HSCTs and mental healthcare trusts (MHTs) 3. Structures and staffing PCOs as providers, HSCTs and acute trusts 4. Specialist falls management PCOs as providers, HSCTs and acute trusts 5. Service settings All, for various aspects Sections 5.1 and 5.3 completed by care homes 6. Training and audit All, for various aspects Participation rates (as % of eligible NHS organisations) Primary Care Organisations 88% (150/171) Combined Health and Social Care Trusts 88% (7/8) Acute trusts 100% (158/158) Mental Healthcare trusts 76% (44/58) Care homes 73 homes, drawn from 2 national providers Scoring systems The scoring system was devised so that each site could benchmark their performance for the relevant domains (Table 1) and organisation of care index (which is the weighted average of the domain scores) in comparison with other sites in their healthcare sector (acute, primary care or mental healthcare trusts). The individual site results by domains and index are not identified to the public. Results within the report also provide the national picture for each healthcare setting. For the first time, the results of some selected audit items have been collected together as Public Indicators. These were developed by the full multi-professional steering group who included representatives such as clinicians, managers and commissioners from all the different types of healthcare settings. The public indicators that have been selected are those which are most important, generally relating directly to the national guidance, and for which we believe the evidence base is most reliable. In addition, the indicators were kept to a manageable number, so as to make presentation user-friendly. The public indicators will be presented in a separate report as non-anonymised information where sites will be identified by name within their strategic health authorities. Understanding the Results In this 2008 audit, we are therefore assessing who provides what services, as well as how well organised they are. Direct comparison between settings is generally not possible as different audit questions applied to the various settings, depending on their role. Only local scrutiny of these results by multi-agency partnerships will clarify where gaps are. For example, an acute trust cannot achieve full marks if the local arrangements are that certain services are provided only by the PCO community services. Sharing reports will promote discussion locally. Comparisons with First Round Audit (2005) The results from this audit cannot be directly compared with that from The 2005 organisational audit was answered by acute trusts in England. Each provided information about the organisation of care across their local falls service as a whole. So, if their patients received a falls risk in the community, this was entered on their behalf by the acute trust. This more ambitious 2008 audit obtained data separately from commissioning trusts, community, acute and mental healthcare service providers, providing a much fuller picture and a more informative baseline for future comparisons. Falls and Bone Health Organisational Audit Generic Site Report. March

13 Key messages from the audit For most domains the median scores for individual trusts indicated adherence to about half the audit standards but the scores were highly variable, showing that high quality strategic commissioning and comprehensive and well integrated service provision is possible. Identifying the high risk patients Just over half (51%, 148/289) of providers with an A&E or MIU routinely screen older people attending with falls for risk of future falls. In 2005, 29% (44/150) of falls services reported that such patients would be assessed by the specialist falls service during office hours. There has probably been some improvement but it should be universally done, as the evidence for secondary prevention of falls is strongest for those who attend urgent care. Only in 44% (85/193) of sites are older people admitted to hospital with a fracture routinely screened for osteoporosis risk. Perhaps this explains why only 28% (2339/8341) of fragility fracture patients in the 2007 clinical audit had been started on the relevant medication for bone protection by 12 weeks after fracture. Since 50% of patients with a hip fracture have previously had a fragility fracture of another bone, this shows that opportunities for secondary prevention (as set out by NICE) are being missed. Patients who are admitted with a fracture are more likely to receive an assessment for osteoporosis than patients attending fracture clinic. This lack of arrangements to promote secondary prevention for fragility fractures is particularly disappointing. Half of hip fracture patients have had a previous fragility fracture. This is an opportunity to act and the treatments available can reduce subsequent fractures by up to 50% over the following years. What could be conceptually more convincing than applying a treatment with up to 50% efficacy in the prevention of a major injury, after an initial warning event? Neurovascular services are being established from all PCOs based on a similar approach to secondary stroke prevention after transient ischaemic attacks. A service model to bridge this gap, the Fracture Liaison Service, has existed for over a decade and numerous research evaluations have confirmed its effectiveness in ensuring better rates of secondary prevention. Fracture Liaison Services have yet to become universally commissioned or provided. Doing the right things with patients at risk 50% (151/302) of sites do not employ a proforma to prompt standardised visual acuity assessment and 48% (70/146) of PCOs do not assess cardiac status including a basic ECG. The most effective component of multiple component falls risk reduction programmes is evidence based individually-prescribed and supervised strength and balance training programmes of sufficient duration to produce significant change. Only 38% (108/286) of services provide a programme which meet our fairly strict criteria for effectiveness based on research evidence. Home hazard assessment along with advice on safe and effective performance of activities of daily living is a proven component of falls reduction programmes, particularly if patients have experienced a recent change in health such as a hospital admission or injurious fall. But only 41% (123/303) of sites include a validated approach to this aspect of falls prevention. Patient uptake and adherence to active interventions that include changes in health related behaviour does depend on information and explanation for patients. This is highlighted in the NSF, but only 35% (122/351) of sites provide a written agreed intervention plan for their patients after an assessment. Falls and Bone Health Organisational Audit Generic Site Report. March

14 Supporting services to get it right for their inpatients and residents Half of trusts (52%, 183/353) providing falls services did not provide any training to care homes or guidance on when residents should be referred to falls services; indeed a quarter (24%, 85/352) provided no access to these services for care home residents. Although most trusts with inpatients (83%, 314/379) had policies or procedures to minimise falls and injuries, primary care providers [with community hospitals or intermediate care beds] and mental healthcare trusts were more likely NOT to have them (29%, 41/140 and 17%, 8/46 respectively) than acute trusts (5%, 10/183). Raising quality now and in the future The PCOs with a written commissioning strategy for falls prevention (Domain 1) were more likely (59% (43/73) v 39% (13/33)) to have implemented routine screening for falls risk for patients who attend A&E (or MIU). Every PCO should develop a strategy to address routine case finding for high risk patients. One out of 4 (25%, 88/352) falls services have no agreed referral criteria for DXA scanning, a role for which is clearly indicated in NICE guidance on secondary prevention after fractures. The NICE technology appraisal requires PCOs to make funding available for the approved medication for osteoporosis. It does not require commissioners or providers to ensure that it is actually prescribed. New incentives or other methods must be used to solve this problem. One in 8 acute trusts (12%, 21/175) do not have a geriatrician with any commitment to falls services. This was an essential component of a falls service in the NSF. Medicine is part of the service and every service needs a champion. Still too few services use patient s views (51%, 179/353) to support and guide service improvement. The CEEU, in collaboration with Help the Aged, has piloted a patient experience questionnaire suitable for use, which will soon be available for any trust to use. Falls and Bone Health Organisational Audit Generic Site Report. March

15 Organisation of care index and domain scores, nationally and for your site The maximum and weighted score for a domain can vary between domains and between care settings (for a more detailed explanation of the scoring see Appendix 2). Table 44 PCOs 2008 Maximum One quarter of sites had a score equal to or less than One half of sites had a score within One quarter of sites had a score equal to or more than Domain 1 Local strategies (D1) & commissioning to Domain 2 Case finding and (D2) referral to Domain 3 Structure and (D3) staffing to Domain 4 Specialist falls (D4) management 100* to Domain 5 (D5) Service settings to Domain 6 Training and (D6) audit to Index (D1+D2+D3+ D4+D5+D6) to * - (scaled to take into account those with / without A&E / MIU facilities) Your site Number of sites Total organisation of care index 2008: PCOs Figure 1 the maximum index was Falls and Bone Health Organisational Audit Generic Site Report. March

16 Table 45 Domain 1 (D1) Domain 2 (D2) Domain 3 (D3) Domain 4 (D4) Domain 5 (D5) Domain 6 (D6) Index HSCTs 2008 Local strategies & commissioning Case finding and referral Structure and staffing Specialist falls management Maximum One quarter of sites had a score equal to or less than One half of sites had a score within One quarter of sites had a score equal to or more than to to to to Service settings to Training and audit (D1+D2+D3+D4 +D5+D6) to to There are too few HSCTs to allow useful histograms to be drawn without identifying individual site results. Table 46 Domain 3 (D3) Domain 4 (D4) Domain 5 (D5) Domain 6 (D6) Index Acute trusts 2008 Structure and staffing Specialist falls management Maximum One quarter of sites had a score equal to or less than One half of sites had a score within One quarter of sites had a score equal to or more than to to Service settings to Training and audit (D3+D4+D5 +D6) to to Your site Your site Number of sites Total organisation of care index 2008: Acute trusts Figure 2 the maximum index was Falls and Bone Health Organisational Audit Generic Site Report. March

17 Table 47 Domain 2 (D2) Domain 5 (D5) Domain 6 (D6) MHTs 2008 Case finding and referral Maximum One quarter of sites had a score equal to or less than One half of sites had a score within One quarter of sites had a score equal to or more than to Service settings to Training and audit to Index (D2+D5+D6) to Your site Number of sites Total organisation of care index 2008: MHTs Figure 3 maximum index was 100 Falls and Bone Health Organisational Audit Generic Site Report. March

18 Public Indicators Public identification of results by individual audit site is limited to those sectors who participated last time (e.g. primary care organisations and acute trusts). Mental healthcare trusts participated for the first time and this audit should build sufficient confidence in the data so that results can go public for them next time. Each site s public indicator results for primary care organisations, health and social care trusts and acute trusts are marked with a darker border within their individual site reports. The public indicators will also be presented in a separate report as non-anonymised information where all applicable sites will be identified by name within their strategic health authorities. Table 48: Public Indicators PCOs HSCTs Acute Domain 1 Local strategies & commissioning Is there a written local commissioning strategy which covers issues pertaining to falls prevention? Is there a written local commissioning strategy for bone health? Is there a local population based report on health needs and outcomes relevant to falls and bone health services including hip fracture rates? Is there a mechanism at PCO level for assessing whether primary care treatment for people who have a fragility fracture is provided in accordance with TAG 87? Domain 2 Case finding and referral Is a first level screening tool in use, including people who have fallen within a defined time period? Does the screening tool trigger and direct further assessments according to a locally agreed falls pathway? Domain 3 Structure and staffing Is there a local coordinated, integrated, multiprofessional and multi-agency falls service? te: The Audit team feel that this indicator should be interpreted with caution as some trusts that have answered '' to this indicator do not, in fact, demonstrate evidence of a fully integrated service in view of their responses to other indicators - e.g , Does your trust provide a clinic(s) or equivalent facility where individual patients attend for assessment and interventions related to falls prevention with direct clinical involvement of consultant grade or other trained medical staff? Do you have a Consultant(s) in geriatric medicine with a commitment to the falls service within their job description / job plan? Do you have a Fracture Liaison Nurse(s) or similar designated person(s)? 66% (107/161) 22% (36/161) 83% (75/90) 41% (66/161) 94% (145/154) 91% (140/154) 75% (120/159) 54% (85/157) 41% (64/157) 15% (24/157) 30% (3/10) 30% (3/10) 100% (3/3) 10% (1/10) 100% (5/5) 80% (4/5) 50% (5/10) 90% (9/10) 50% (5/10) 60% (6/10) N/A N/A N/A N/A N/A N/A 70% (128/183) 81% (141/175) 75% (132/175) 29% (51/175) Falls and Bone Health Organisational Audit Generic Site Report. March

19 PCOs HSCTs Acute Domain 4 Specialist falls management For all patients considered locally to need a multifactorial falls risk assessment is this undertaken by your trust using a clinical note proforma or similar tool which specifies the individual components? Does the tool include assessment for fracture risk or osteoporosis risk factors? Is a validated home hazard assessment used for assessment of potential hazards within the home? Does the service provide written, agreed intervention plans which are given to patients? Does the intervention include a validated exercise programme delivered by appropriately trained healthcare professionals and/or exercise specialists: FaME and/or Otago Is there an agreed process/pathway to access syncope services for patients who have unexplained falls / blackouts? Domain 5 Service settings Is there an inpatient or resident falls prevention/reduction policy? Has the trust calculated its overall inpatient falls rate against activity (e.g. per admission or occupied bed day)? Has the trust calculated its injurious inpatient falls rate against activity (e.g. per admission or occupied bed day)? Is there provision for all patients who need walking aids to be able to routinely access these within 24 hours of admission? Are older people who fall and attend A&E departments or MIUs routinely screened for risk of future falls? (This may not apply to your site and will need to be interpreted locally) Are there arrangements for routine pre-operative medical assessment and treatment on the orthopaedic ward by a senior physician with relevant training? Domain 6 Training and audit Combined and Is there a mechanism to record patients views of the falls and bone health service using questionnaires and/or interviews? These two questions have been combined into one indicator. It will count if your trust answered to either or both of the questions. 59% (94/160) 88% (129/147) 49% (67/138) 44% (70/159) 50% (66/134) 72% (115/159) 62% (99/160) 24% (33/139) 19% (27/139) 76% (106/140) 33% (53/159) N/A 58% (63/108) 50% (5/10) 100% (7/7) 71% (5/7) 10% (1/10) 29% (2/7) 80% (8/10) 40% (4/10) 30% (3/10) 20% (2/10) 30% (3/10) 30% (3/10) 100% (4/4) 30% (3/10) 43% (78/183) 78% (116/149) 44% (51/117) 28% (51/183) 36% (40/110) 73% (134/183) 95% (173/183) 45% (83/183) 34% (63/183) 67% (123/183) 50% (92/183) 50% (75/151) 50% (61/122) Falls and Bone Health Organisational Audit Generic Site Report. March

20 Background We can only be sure to improve what we can actually measure" (Lord Darzi, High Quality Care for All, June 2008) In the United Kingdom (UK), approximately one in three older people will fall each year and two-thirds of them will fall more than once (Masud T and Morris RO, Age and Ageing 2001) Falls lead to physical injury, loss of function, loss of independence and increased mortality. They are the leading cause of mortality due to injury in older people aged over 75 in the UK. Over 400,000 older people in England attend accident and emergency departments (A&E) following an accident and up to 14,000 people a year dies in the UK as a result of an osteoporotic hip fracture. (National Service Framework for Older People, 2001 (NSF) Coding and other difficulties make accurate estimates problematic but hospital bed days used in 2006/7 in England for fractures in over 60 year olds and frailty-related falls in over 75 year olds is estimated to be about 4 million. (Available from: The combined cost of social and hospital care for patients with fragility fractures has been reported as more than 1.8 billion per year in the UK (.Burge RT, Worley D, Johansen A, Bhattacharyya S, Bose U,. Journal of Drug Assessment 2001) though this might be an underestimate. Of total costs, about 45% is for acute care, 50% for social care and long term hospitalisation and 5% for drugs and follow up. (QRESEARCH report to the NHS Information Centre on: Evaluation of standards of care for osteoporosis and falls in primary care, 2007). The most common serious consequence of falling is hip fracture. This occurs in approximately 86,000 people per year in the UK (Torgerson D, Iglesias C, Reid D. The economics of fracture prevention : in "The effective management of osteoporosis". 2001). Half of people suffering a hip fracture never return to their previous level of independence. About 10% die within a month and about 20% enter a care home. Causes of falls in older people are complex and multiple multi-factorial risk factor assessment and modification is an essential part of a falls prevention service. Most fractures in older people occur in the context of increased bone fragility, osteopenia or osteoporosis. There is considerable evidence for interventions that reduce the risk of falling and for medications that reduce the risk of fracturing. If all clinicians and services implemented this evidence in a fully integrated falls and bone health service, it would lead to an estimated reduction of 400 hip fractures per SHA, with a net saving of 3 million per SHA (Philp I, Recipe for Care - t a Single Ingredient, Department of Health (DH), 2007). The NSF, published in 2001, set out a model for service provision for falls prevention and management in England, though less prominence was given to bone health. This was followed by National Institute for Health and Clinical Excellence (NICE) guidance on assessment and prevention of falls (NICE CG21, 2004) and secondary prevention of osteoporotic fractures (NICE TAG 87, 2005). Guidelines on the specific management of fragility fractures came from the British Orthopaedic Association in the blue book (Care of fragility fracture patients, BOA, 2003 and 2007) written in collaboration with the British Geriatrics Society. A Welsh NSF for Older People appeared in 2006, which made explicit the integration of services for falls and bone health. In 2006, the Clinical Effectiveness and Evaluation Unit (CEEU) of the Royal College of Physicians, London reported on the first national audit on the organisation of falls and bone Health services in older people. This audit was commissioned by the Healthcare Commission and performed in The scope was broad and covered commissioning and service provision, whether hospital or community-based. Falls and Bone Health Organisational Audit Generic Site Report. March

21 The first audit sought to assess compliance with the key NSF milestone for falls that all local health and social services systems should have established by April 2005 an integrated falls service to provide the standards and actions set out in the NSF. Of the 90% of acute trusts that submitted data in the organisational audit, 74% reported having an integrated falls and bone health service. However, prevention of falls and fractures is a complex matter and the devil was in the detail: Systems to screen older A&E attendees for falls risk was provided in only 26% of departments and only 27% of fracture services had a fracture liaison nurse. Numbers of patients attending falls clinics were low relative to the expected numbers of older people needing assessment and interventions. Public health information about services or outcomes was rarely collected. There was wide variation in performance between the 151 trusts that contributed to the audit. In essence, whilst most services had created a service framework that might suggest an integrated service, the identification, referral, assessment and treatment of suitable patients was often less than adequate. In 2006, the Healthcare Commission commissioned the CEEU to perform a national clinical audit to investigate the quality of clinical care received by individual patients at high risk of falls and fractures. This was an opportunity to drill down into the care pathway at patient level and to examine in detail the discrepancies and weaknesses identified in the organisational audit. This audit was performed on patients presenting with fragility fractures between October 2006 and January 2007 and included 16 weeks follow up. The findings were published in vember The audit covered secondary falls prevention and bone health assessment and treatment in older people that had presented acutely with a fragility fracture, as well as the acute management of patients who were admitted for treatment of a hip fracture. Again the results showed wide variation in the care provided between localities. In particular, most services performed less well with regard to provision of bone protection compared to falls prevention. This clinical audit report made a number of recommendations, including: Primary care organisations (PCOs) should commission a patient care pathway for the secondary prevention of falls and fractures that includes a fracture liaison service PCOs should commission clinics which can perform effective assessments PCOs should review local therapeutic exercise options and promote evidence-based programmes in collaboration with councils DH should consider supporting inclusion of osteoporosis treatment in the Quality and Outcomes framework for primary care Acute trusts should review their capacity and operational systems to ensure prompt surgery and consider applying the approach developed by the NHS Institute for Innovation and Improvement (Delivering Quality and Value - Focus on: Fractured Neck of Femur 2006.) Acute trusts and PCOs should review procedures to share clinical information and develop joint clinical governance for the falls/fracture pathways. Since the first audit, the evidence base for falls prevention and bone protection has become consolidated, though there has not been any new evidence of sufficient weight to merit a paradigm shift in clinical practice. However, there is no room for complacency. The five-year review of the NSF (A New Ambition for Old Age Next steps in Implementing the NSF for Older People, DH, 2006) provided a timely reminder that many falls services were yet to achieve the standards required by the original framework and emphasised the need for bone protection to be fully integrated with falls prevention. At the time of the second organisational audit, NICE had not revised its guidelines on falls or osteoporosis, though it has subsequently published new Technology Appraisals on primary and secondary prevention of osteoporotic fractures (TAG 160 and TAG 161, 2008). A further development has been the establishment of the National Hip Fracture Database. This offers trusts continuous monitoring of a small number of core process and outcome quality indicators for hip fracture care. This complements the work of the national audits, which provide far greater detail in a periodic, rather than continuous, fashion. Falls and Bone Health Organisational Audit Generic Site Report. March

22 The Healthcare Quality Improvement Partnership (HQIP) commissioned the CEEU to perform a national falls and bone health audit programme from 2008 to The National Falls and Bone Health Audit Steering Group (see appendix 6) recognised that this was an opportunity to look further than the indicators from the first organisational audit in 2005 and to assess any impact of the recommendations from the 2007 clinical audit. Falls and fracture prevention fits well within the stated aim of World Class Commissioning (DH 2007) to add life to years and years to life. In addition, since April 2008, PCOs and local authorities have been mandated to produce joint strategic needs assessments* (JSNAs), which should include commissioning falls services as part of injury prevention. The section of the audit dealing with commissioning has been enlarged and updated to reflect these changes. There have also been changes in the governance structure of the NHS. The Healthcare Commission s functions have been divided between the newly-formed Healthcare Quality Improvement Partnership (HQIP) and Care Quality Commission (CQC). HQIP have become the new commissioners of the national audit programme and CQC will take on much of the statutory monitoring duties previously held by the Healthcare Commission and the Commission for Social Care Inspection (CSCI). For the first time, this second national falls and bone health organisational audit includes data from a sample of care homes, on a pilot basis, and hopes to extend this to a larger and more representative sample of homes in the future. Mental healthcare trusts are also included in the audit for the first time. As a result, this report seeks to provide a picture of falls services in England, Wales and rthern Ireland that is both broader and deeper than before. *Joint Strategic Needs Assessment is a systematic method for reviewing the health and wellbeing needs of a population, leading to agreed commissioning priorities that will improve health and wellbeing outcomes and reduce inequalities, DH Guidance on Joint Strategic Needs Assessment, 2007 The Scope and Purpose of the Audit The purposes of this audit were: (i) to assess the quality of services nationally for older people who fall or who are at risk of a fall or fracture, against explicit standards, (ii) to enable comparisons between services, benchmarking, using numerical scores derived from the audit results, and (iii) to enable a comparison at the national and local levels with the results of the equivalent Organisational Audit performed in Winter Methods The following documents were used as the sources of audit standards: National Service Framework for Older People (NSF) Chapter 6 Falls, 2001 National Service Framework for Older People in Wales (NSF Wales) Standard 8 Falls and Fractures, 2006 National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 21 Falls: The assessment and prevention of falls in older people, 2004 (NICE CG 21) NICE Technology Appraisal Guidance 87, Bisphosphonates (alendronate, etidonate or risedronate), selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fractures in post menopausal women, 2005 (NICE TAG 87)* British Orthopaedic Association (BOA), The Care of Fragility Fracture Patients (Blue book), 2007 DH Urgent Care Pathways for Older People with Complex Needs, 2007 NHS National Patient Safety Agency (NPSA), Slips trips and falls in hospital, * Subsequently superseded by the equivalent updated TAG 161 on secondary prevention, but TAG 87 was the relevant guideline at the time of the audit. Falls and Bone Health Organisational Audit Generic Site Report. March

23 Development of Audit Indicators The steering group refined indicators derived from the evidence based guidance, the standards listed overleaf, the previous 2005 national organisational audit (which was reported upon in 2006). The key considerations were the strength of recommendations in the standards sources, the feasibility of collection, and the face validity to the participants. To emphasise the source of the audit indicator, the relevant standards were identified by bold text in the help notes above each of the indicators. Governance of the Audit Performance was accountable to HQIP. It was managed by the CEEU and supported by a multi-disciplinary and multi-agency advisory steering group. Membership of this group reflected the breadth of clinical and service expertise needed to represent the different perspectives of hospital and community healthcare, social care, and older persons advocacy. An associate director was appointed to provide clinical leadership. (See appendix 6 for membership). Recruitment of sites Primary Care Organisations (PCO) Recruitment letters were written to Primary Care Trust (PCT) and Local Health Board (LHB) chief executives, previous falls audit leads and clinical audit / effectiveness managers. They were asked to support the audit, provide details of a contact for the audit within their organisation and identify the acute trust(s) from which their local population received falls services. The PCT or LHB details were then sent to the corresponding acute trust lead and vice versa. Acute Trusts and Health and Social Care Trusts (HSCT) Acute trusts were recruited via letters to their chief executive, previous falls audit lead, and clinical audit or effectiveness managers. They were asked to support the audit, to provide details of a contact for the audit within their organisation and to identify the main PCO responsible for commissioning the falls services they provided. Mental Healthcare Trusts (MHT) Mental healthcare trusts were also recruited via their chief executives and clinical audit or effectiveness managers and were asked to support the audit, by providing contact details. Care Homes A meeting took place in July 2008 with representatives from two care home providers, the Commission for Social Care Inspection (CSCI) and steering group to discuss the involvement of care homes in this and future falls and bone health audits. As a result, care home audit items were developed, these items concentrate on the services available and provided to their residents by the local NHS. Furthermore the method used to recruit a sample of care homes and to check the feasibility of care homes taking part in the audit, was agreed. Consequently, the English Community Care Association (ECCA), a representative body for independent care homes, was approached to assist with recruitment. Using their network ECCA contacted 10 large care home provider organisations, which cover a wide geographical area, asking if they would be interested in taking part. Two care home provider organisations (Care UK and MHA Care Group) agreed and they contacted their care homes to get them on board. Contact details and the name of the care home manager were provided for each care home. Falls and Bone Health Organisational Audit Generic Site Report. March

24 Pilot 17 sites (3 care homes, 1 mental healthcare trust (2 additional mental healthcare trusts provided their comments on the audit indicators), 7 PCOs, 1 HSCT and 5 acute trusts) undertook a pilot of the web based data collection tool, hard copy tools and support information from 12th to 30th September The pilot was evaluated by the project team, resulting in changes to the audit indicators and support information which were signed-off by the steering group in October Support and Information for participating sites As soon as sites were recruited and had provided their contact details they were kept up to date with monthly newsletters or by . The audit web tool home page was regularly updated and included a link to a frequently asked question sheet. Sites were provided with guidance on how to undertake the audit based on previous experience and feedback from the pilot sites. To capture the full range of relevant clinical activity sites were advised to set up a multi-disciplinary team combining PCO and acute trust participants to plan how and by whom information was best collected from both a commissioning and hospital and community provider perspective. Support information was provided for auditors, giving definitions and guidance on how to answer each audit question for the patient groups. They were advised to gather data initially on the paper copy of the data collection tool and to enter this onto the web tool once data collection from various sources was complete. All sites were fully prepared for the audit by the 31 st October 2008 in readiness to begin data collection on 3 rd vember Data collection continued into the first week of December Web tool design The web tool was designed so that each healthcare setting s representative logged on with an individual password and site code and only saw the sections (Domains) that they needed to complete rather than the whole web tool. This was especially pertinent to care homes and mental healthcare trusts as they had less to complete. Data entry to the web tool Web tool help notes were provided and a help desk team was available to sites during data collection by and phone. Sites were asked to refer to the web tool user notes to aid data entry and the support information to clarify any of their answers. Many data entry items required a simple YES or NO response but sometimes other options were possible, e.g. that a tool was, fully used,, partially used or, not at all. To improve quality of data entry, the web tool had routing and consistency checking built-in to it which meant in particular that if the answer to a stem question was then the relevant sub section questions were not presented on screen; conversely if the answer to the stem question was then an answer to any sub section question was required in order to progress further with data entry. Post export quality checks After all data had been entered by a site they were asked to lock their form and to export their data to a spreadsheet. They were asked to quality check their exported data against their hard copy data collection form. If there were errors caused by transcribing these were amended. This also enabled sites to do local analyses on their own data. Falls and Bone Health Organisational Audit Generic Site Report. March