Keywords: Falls prevention/Patient
safety/Care bundles/Quality
improvement/Leadership
●This article has been double-blind
peer reviewed
Using a regional initiative to improve falls prevention resulted in the development
of champions who ensure falls avoidance is a priority on wards
A care bundle approach
to falls prevention
In this article...
 hy FallSafe works
W
The contents of a falls prevention care bundle
What falls champions do
Authors Debbie Sutton is FallSafe project
coordinator; Julie Windsor is falls lead
specialist nurse; both at Queen Alexandra
Hospital, Portsmouth Hospitals Trust;
Janet Husk is patient safety and quality
improvement programme manager at the
Royal College of Physicians, London.
Abstract Sutton D et al (2014) A care
bundle approach to falls prevention.
Nursing Times; 110, 20, 21-23.
Falls cause harm and distress to NHS
inpatients every year. One hospital’s
implementation of a regional FallSafe
project has increased the use of evidence-
based measures to prevent falls. The
project relied on a network of falls
champions, who were nurses or healthcare
assistants who taught and inspired their
colleagues to implement care bundles.
M
ore than 200,000 patient falls
are reported annually in acute
hospitals (National Patient
Safety Agency, 2010). Between
2008-09, 777 falls in NHS settings caused
severe harm, and 68 contributed directly to
patient death (NPSA, 2010).
As well as the distress and anger experi-
enced by patients and their families, there
is a huge financial cost associated with
unplanned care and treatment necessi-
tated by falls. The social and psychological
costs associated with loss of confidence,
fear of falling and consequent social
isolation are also significant (Salkeld et
al, 2000).
The FallSafe project
Our aim was to introduce FallSafe, an ini-
tiative in which falls prevention interven-
tions are rigorously applied in care bun-
dles, into a an acute hospital across several
Nursing Practice
Innovation
Patient safety
5 key
points
1 Over 200,000
falls are
reported annually
in acute NHS trusts
wards and specialties. The original FallSafe
project was run at 16 sites in the south cen-
2 The Royal
College of
Physicians has
tral region in 2010-2012, funded by the reduced falls by
Health Foundation and delivered by the 25% in 16 hospitals
Royal College of Physicians. through its FallSafe
FallSafe lead nurses were supported to project
inspire ward colleagues and multidiscipli-
nary teams to introduce and sustain an
evidence-based falls prevention care
3 FallSafe
involves simple
interventions
bundle. The project resulted in a measur- rigorously applied
able improvement in falls-related care and in a care bundle to
suggested a 25% reduction in falls (Royal reduce the
College of Physicians, 2012). incidence and
severity of falls
Introducing FallSafe in the trust
Effective change management is essential
to organisational development. Teasdale
4 Portsmouth
Hospitals Trust
has improved
(1992) suggests six strategies to embody implementation of
into planning change: falls prevention
» Create ownership and involvement; measures in 14
» Create a positive environment; wards through
» Identify the need for change with staff; FallSafe
» Work with staff on an action plan;
» Communicate the changes;
» Anticipate conflicts and resistance.
5 After
introducing
FallSafe more
All these strategies were used. patients at risk had
As part of Portsmouth’s falls strategy a cognitive
implementation and in the light of assessment
emerging FallSafe project results, many of
the care bundle elements had already been
introduced and were included in the trust’s
falls prevention and care plan (Portsmouth
Hospitals Trust, 2012). This plan is
expected to be used routinely for all inpa-
tients identified as being at risk of falling
on admission or during their stay.
Before starting work on wards, the falls
specialist nurse met senior management
and news of the project was disseminated
via the local falls network. A project coordi-
nator was appointed to drive the implemen-
Alamy
tation and a band 5 clinical educator was All call bells had to be within patients’ reach
www.nursingtimes.net / Vol 110 No 20 / Nursing Times 14.05.14 21
 Nursing Practice
Innovation
seconded for two days a week to support
training in care bundle elements.
Fourteen wards were chosen, with spe-
cialties, including trauma and orthopae-
dics, medicine, surgery, oncology, medicine
for older people, rehabilitation and stroke.
Each ward identified a FallSafe cham-
pion nurse or healthcare assistant to lead
the work, plus a deputy where possible to
provide support. All champions were
expected to complete the falls prevention
e-learning materials produced for the orig-
inal FallSafe project, and to encourage
their ward colleagues to do so as well.
The project was launched with a study
day, and study days took place at monthly
intervals over the six-month implementa-
tion period. Each included an opportunity
for the falls champions to share experi-
ences, successes, challenges and the many
inventive ideas they developed to over-
come barriers. There was also teaching
from consultants and therapists who were
an important part of the wider falls team.
At each study day, the FallSafe cham-
pions were given a pack containing a sum-
mary of the work needed over the next
month plus data collection sheets. They
then introduced the bundle elements to
their ward, ensured colleagues were compe-
tent to carry them out then audited each ele-
ment to test the extent to which it was being
implemented. This was achieved using a
plan, do, study, act (PDSA) approach.
Champions undertook a range of initia-
tives that included, putting prompt sheets
into nursing notes, creating posters and
asking for a column for mobility status to
be added to handover sheets, as well as
using ward meetings.
One study day included a session on
personality types. This had a terrific
impact on all participants, who engaged
well with the session. Beginning to under-
stand how personality influences the
ability to communicate with others and
how their personality governed their
response helped staff see how they might
vary their approach. This was particularly
valuable to champions who were finding it
difficult to persuade others to engage.
Comments received included:
“The session was enlightening – made me
evaluate what type of learner I am and, by
doing that, it made me rethink how I get
messages across to people.”
Data collection
There were two groups of care bundle ele-
ments. Bundle A (Box 1) was applied to all
inpatients and bundle B (Box 2) to those
identified as being at risk of falling.
Before the bundles were introduced,
22 Nursing Times 14.05.14 / Vol 110 No 20 / www.nursingtimes.net
Box 1. Care Bundle A –
for all inpatients
● Call bell within reach
● Falls history taken
● Fear of falling discussed
● New night sedation avoided
● Appropriate footwear available
● Timely provision of walking aids
● Mobility status communicated
● Personal items within reach
● No trip or slip hazards
● Urinalysis undertaken
falls champions were asked to collect base-
line data for bundle A for 20 patients on
their ward. Sets of three bundle elements
were introduced over periods of between
two weeks and one month, after which
data on the newly introduced elements
was collected. After all of bundle A had
been introduced, baseline data for
bundle B was collected. Elements from the
bundle were then introduced and data col-
lected in the same way as for bundle A.
Results
Quantitative results from the measured
audit of care bundle elements are shown in
Tables 1 and 2. Data was collected between
1 January and 31 May 2013. Overall, there
was an improvement in implementation.
Qualitative outcomes
The falls champions developed innovative
ideas to improve ward culture around falls
prevention among all staff:
» Wards developed laminated sheets or
used whiteboards to show individual
patients’ mobility requirements so all
those caring for them could see at a
glance what help might be needed.
Some wards used the purple colour
scheme from the FallSafe resource pack
(RCP, 2012) in poster information for
patients and visitors.
» One champion drafted a traffic light
guide for medications that increase fall
risk. After consultation with the
pharmacy department, this was
developed into a chart that could go in
the drug trolley.
» Another champion designed a guide
sheet to be kept within the cover of the
nursing notes folder to prompt and
guide to the relevant pages of the
nursing care booklet.
» One ward negotiated the provision of
two walking frames that patients could
use out of hours when there is no
physiotherapy cover.
Box 2. Care Bundle B
– for patients at risk
from falling
● Cognitive assessment
● Bedrail assessment
● Appropriate bed in use and in
appropriate place
● Visual assessment
● Lying and standing blood pressure
● Manual pulse check
● Medication review
● Medical review of bone health
● Toileting plan in place
» Another ward held a productive
discussion with the ward pharmacist
and medical team, which resulted in
night sedation being dispensed earlier
in the evening to identified at risk
patients so its effects would have worn
off by the morning.
» An initiative between ward and
catering staff improved the supply of
milky drinks and biscuits to prepare
patients for sleep.
Challenges for champions
Some significant issues made it chal-
lenging for some wards to implement the
care bundles.
Several champions found that the
timing of drug rounds, the frequency
of ward rounds and the ability to identify
the therapists and junior doctors attached
to their wards affected how successful
they were in communicating on intro-
ducing bundle elements. This was particu-
larly an issue when action from the team
was needed with, for example, medication
reviews, avoiding night sedation and
communicating the results of lying
and standing blood pressure. This problem
was particularly acute if the falls cham-
pion nurse worked mainly nights or
the ward duty system was based on
12-hour shifts.
The striking improvement in cognitive
screening reflects the concurrent hospital-
wide introduction of a Commissioning for
Quality and Innovation target for
dementia. This illustrates the benefits of
identifying and carrying out actions that
will draw attention to aspects of care that
are relevant to a patient group, in this case
those with dementia. Tackling all issues
relating to dementia through the CQUIN
automatically included specific falls issues.
It is pleasing to see that many of the
interventions that rely on good essential
nursing care scored highly. However, there
 Table 1. Care bundle A: change from baseline motivated people to behave differently. For
after implementation FallSafe to work in any setting, staff needs
to understand that implementation will be
Total number of patients audited: 280 (14 wards, 20 patients each time) time well spent. Fewer falls means less
Bundle element question % yes at % yes when % change unplanned work and fewer procedures – a
baseline in place good outcome for both patients and staff.
Call bell in sight/reach? 90 92 2.0
Recommendations
Safe footwear available? 87 92 6.4 The quality of falls prevention initiatives
Falls history taken? 67 80 19.4 in hospital wards could be improved if a
rolling programme of auditing the care
Asked about fear of falling? 47 59 25.8
bundle elements could be incorporated
Urinalysis performed? 44 55 25.3 into routine patient safety audits. Nursing
Night sedation avoided? 86 92 7.4 documentation could be reviewed to
streamline the recording of falls-related
Assessed for walking aids? 83 91 9.1
information.
Mobility status communicated? 82 89 9 Encouraging falls champions to share
Walking aids available? 76 83 9 information from falls reporting with
Personal items in reach? 95 96 1.5
ward managers and the rest of the ward
team might raise awareness of times of day
No visible slip or trip hazards? 95 95 0.1 or places where falls are frequent.
The mean relative change was 10.4%.
Conclusion
A care bundle approach to falls prevention
Table 2. Care Bundle B: Change from baseline can be implemented with sustained effort
after implementation and commitment from multidisciplinary
ward teams that include nurses, doctors,
Total number of patients audited for baseline bundle B was 280 (14 wards with 20
therapist, pharmacists, catering and
patients). During implementation, numbers varied since only patients at risk were
domestic staff.
included. On average there were 120 patients, within a range of 90–130.
It is best driven by a nominated member
Bundle element question % yes at % yes when % change of the nursing team with a strong person-
baseline in place ality and leadership attributes who is able
Cognitive assessment completed? 46 76 64.8 to inspire and motivate others, and who
recognises several teaching and communi-
Bedrail assessment completed? 94 100 6.1
cation styles will be required. Service
Appropriate bed? 97 100 6.1 development, however patient focused,
Basic visual assessment completed? 90 93 3.3 can fail without effective leadership.
Attention must be paid to how people
Lying and standing BP recorded? 41 52 26.5
are treated and motivated (McClenahan,
Pulse checked manually? 60 50 -16.6 1999) because “the strength of the NHS lies
Medication reviewed? 76 85 11.8 within its staff , whose skills, expertise and
dedication underpins all that it does”
Medical review of falls risk factors/ 68 58 -15.6
(Department of Health, 2000). NT
osteoporosis?
Toileting assessment/plan? 95 96 1.7 References
Department of Health (2000) The NHS Plan: a
Appropriate bed position? 97 98 0.2 Plan for Investment, a Plan for Reform. London:
Stationery Office.
The mean relative change was 8.5%. McClenahan J (1999) Emerging problems with
merger policy. In: Appleby J, Harrison A (eds)
Health Care UK 1999/2000: the King’s Fund
should be no complacency: on a 36-bed Many ward managers were sympathetic Review of Health Policy. London: King’s Fund.
ward, even a success rate of 92% leaves two and imaginative in supporting falls cham- National Patient Safety Agency (2010) Slips, Trips
or three patients unprotected. pions, rostering so they could attend study and Falls Data Update June 2010. tinyurl.com/
NPSA-Falls-2010
There were differences between wards days and encouraging them to use ward Portsmouth Hospitals Trust (2012) Policy for the
when it came to their ability to introduce meetings and handovers to communicate Prevention and Management of Adult in-patients
and implement the care bundle elements FallSafe information. Making time to do at Risk of Falling or Who Have Already Fallen.
tinyurl.com/porthosp-falls
and to share the work among colleagues. It the FallSafe work, which involved data col- Royal College of Physicians (2012) Implementing
is worth reflecting on the extent to which lection as well as designing communica- FallSafe: Care Bundles to Reduce Inpatient Falls.
the lack of tangible resources affected the tions materials for staff and patients, www.rcplondon.ac.uk/resources/falls-prevention-
resources
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nor could protected time be offered. dence that more money would have

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