Derek Lowe

Finbarr C Martin

Janet Husk

Jay Banerjee

Jonathan Benger

Jonathan Potter

Jonathan Treml

Rob Grant

CiteSeerX

The National Falls and Bone Health Audit: implications
for UK emergency care
Jay Banerjee,1 Jonathan Benger,1 Jonathan Treml,2 Finbarr C Martin,2 Rob Grant,2
Derek Lowe,2 Jonathan Potter,2 Janet Husk2
ABSTRACT
Introduction The National Clinical Audit of Falls and Bone
Health, coordinated by the Royal College of Physicians,
assesses progress in implementing integrated falls
services across the UK against national standards and
enables benchmarking between service providers.
Nationally, falls are a leading contributor towards
mortality and morbidity in older people and account for
700 000 visits to emergency departments and 4 million
annual bed days in England alone.
Methods Two rounds of national organisational audit in
2005 and 2008 and one national clinical audit in 2006
were carried out based on indicators developed by
a multidisciplinary group.
Results These showed that management of falls and
bone health in older people remains suboptimal in
emergency departments and minor injury units and
opportunities are being missed in carrying out evidence-
based risk assessment and management.
Conclusions Older people attending emergency
departments in the UK following a fall are receiving
a poor deal. There is an urgent need to ensure more
effective assessment and management to prevent
further falls and fractures.
INTRODUCTION
Each year, over 700 000 older people in the UK
attend emergency departments (EDs) after a fall and
many more attend minor injury units (MIUs), or
call for ambulance assistance. Injurious falls,
including over 60 000 hip fractures annually, are the
leading cause of accident-related mortality in older
people. The National Service Framework for Older
People1 emphasises that “preventing falls in older
people depends on identifying those most at risk of
falling and coordinating appropriate preventative
action. Older people who attend accident and
emergency departments having fallen should, with
their consent, be referred to a specialist falls service.”
The National Audit of Falls and Bone Health in
the UK, is commissioned by the Healthcare Quality
Improvement Partnership (HQIP, formerly Health-
care Commission), and is conducted by the Clinical
Effectiveness and Evaluation Unit (CEEU) of the
Royal College of Physicians, London. It is facilitated
by a multidisciplinary steering committee repre-
senting the many different stakeholders involved in
the care of older people after falls. The CEEU
conducted an organisational audit in 2005 and then
a patient-level clinical audit in 2006 before re-
auditing changes in the organisation of care in 2008.
The objectives of the national audit are to assess
progress across the UK in the implementation of
integrated falls services against national standards
and to enable benchmarked comparisons of the
organisations and provision of falls and bone health
services. This paper describes findings from this
national audit that are relevant to EDs and MIUs.
METHODS
Indicators of the structure and process of high-
quality care were developed by a multidisciplinary
steering group representing professional and patient
organisations relevant to falls and bone health. The
original brief was to audit the extent to which
Trusts had met the requirements set out in the
National Service Framework for Older People,1 and
the group derived audit questions to match these
and other standards and guidelines.2e5
The organisational audit of November/December
2005 covered England only and all eligible acute
Trusts participated. The organisational audit of
November/December 2008 recruited 95% of eligible
healthcare Trusts in England, Wales and Northern
Ireland, and involved the acute hospital sector,
primary care, combined health and social care orga-
nisations, and mental care trusts. Direct comparison
between 2005 and 2008 is difficult because in 2005
acute Trusts provided overview information across
the local falls service as a whole, whereas 2008 data
were obtained separately from commissioning trusts,
community, acute and mental healthcare providers
about what specific services they themselves
provided (structure indicators).
The clinical audit of October/November 2006
recruited acute hospitals in England, Wales,
Northern Ireland and the Channel Islands, with
91% submitting data on process indicators for
individual patients. The audit covered two groups
of patients aged $65 years and presenting to the
ED or MIU, those with a hip fracture and those
with other fragility fractures (wrist, humeral, pelvic
or vertebral). The audit asked for data on 20
consecutive hip fracture and 40 consecutive other
fragility fracture cases, using a retrospective review
of case notes. Data were submitted to a secure
internet site with no transmission of personally
identifiable information.
Organisational data were also entered into web-
based data collection tools. Audit data were
exported to the CEEU for cleaning, analysis and
reporting. All audits were piloted for data proforma
and the web tool.
RESULTS
Results from the two organisational audits of
services for older people who fall and attend EDs are
shown in table 1. In 2005, only 29% of acute Trusts
1Clinical Effectiveness
Committee, College of
Emergency Medicine, London,
UK
2Clinical Standards Department,
Clinical Effectiveness and
Evaluation Unit, Royal College of
Physicians, London, UK
Correspondence to
Dr Jay Banerjee, Emergency
Department, University
Hospitals of Leicester NHS
Trust, Leicester Royal Infirmary,
Infirmary Square, Leicester LE1
5WW, UK;
jb234@le.ac.uk
Accepted 6 October 2011
Banerjee J, Benger J, Treml J, et al. Emerg Med J (2011). doi:10.1136/emermed-2011-200501 1 of 3
Original article
 EMJ Online First, published on November 1, 2011 as 10.1136/emermed-2011-200501
Copyright Article author (or their employer) 2011. Produced by BMJ Publishing Group Ltd under licence. 
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used a member of a specialist falls service to assess such patients,
and only 14% of these had a 24 h service. This, despite 74% of
Trusts claiming they had a coordinated multiprofessional
specialist falls service in their ED for the care of older people with
osteoporotic fractures. Services were available to assess osteopo-
rosis risk after falling in 41% of Trusts. In 2005, 54% of services
had a falls coordinator and 34% had a fracture liaison nurse.
The 2008 audit asked about services provided by acute hospitals,
primary care, combined health and social care organisations, and
mental care providers. Half (51%, 148/289) of those with EDs or
MIUs routinely screened older people after falls for risk of future
falls. For commissioning providers (primary care, health and social
care) with written commissioning strategies for falls prevention,
59% (43/73) routinely screened for future risk, compared with 39%
(13/33) without written strategies. Routine screening was mostly
done on site and available 7 days a week. Systems allowing staff to
arrange direct referral for further assessment and treatment were
available in 77% of providers with an ED or MIU (222/289). Only
19% (56/289) of providers with an ED/MIU routinely assessed
older people for risk of osteoporosis after a fall. Among acute trusts
and combined health and social care trusts, 91% (176/193) had
audited the quality of the falls and bone health service in the
previous 12 months but only 27% of these (47/176) had audited on
the screening of older patients in A&E for falls and osteoporosis
risk. In acute Trusts, 29% (51/175) had a fracture liaison nurse and
31% (55/175) had a falls coordinator.
The 2006 clinical audit of patients presenting to emergency
care with fractures after a fall gave results for separate aspects of
multifactorial falls risk assessment (table 2). Often, considerably
fewer than half the relevant number of patients with non-hip
fragility fracture were being assessed: medication review 31%,
cardiovascular examination 40%, vision 10%, continence 21%,
mobility and balance 28%. Only 22% were referred for exercise
training to reduce falls and only 20% were receiving appropriate
treatment by 12 weeks for osteoporosis. Whereas almost all
(99.8%) of patients with hip fracture were admitted to hospital,
66% (3700/5642) of patients with a non-hip fragility fracture
were not admitted.
DISCUSSION
This is the most comprehensive audit cycle of UK falls and bone
healthcare ever conducted and provides as true to life a picture of
Table 1 Results from the 2005 and 2008 organisational audits of emergency departments
2008 Audit question 2008 Audit result 2005 Audit question 2005 Audit result
Are older people who fall and
attend A&E departments or MIUs
routinely screened for risk of future falls?
For those with A&E or MIU: e e
Acute: 50% (92/183)
PCOs: 55% (53/96)
HSCTs: 30% (3/10)
Is (routine) screening performed on site
in A&E?
Acute: 88% (81/92) e e
PCOs: 81% (43/53)
HSCTs: 67% (2/3)
Is this available 7 days a week? Acute: 80% (65/81) e e
PCOs: 84% (36/43)
HSCTs: 100% (2/2)
Within A&E/MIUs are there systems for
providing onward direct referral for falls
and bone health assessments/treatment?
For those with A&E or MIU: e e
Acute: 75% (138/183)
PCOs: 80% (77/96)
HSCTs: 70% (7/10)
Are older people who attend A&E/MIUs after
a fall routinely assessed for osteoporosis risk?
For sites with A&E or MIU: Are older people who attend hospital following a
fall assessed for osteoporosis risk?
41% (61/149)
Acute: 15% (28/183)
PCOs: 29% (28/96)
HSCTs: 0% (0/10)
Between September 2007 and August 2008
have there been any local audits performed to
assess any aspects of the falls and bone health
service?
Acute: 91% (167/183) Is there a regular audit programme to assess
some aspects of the falls service?
62% (92/149)
PCOs: 67% (106/159)
HSCTs: 90% (9/10)
Has an audit been performed on the screening
of all older people attending A&E for falls and
osteoporosis risk?
Acute: 28% (46/167) e e
PCOs: NA
HSCTs: 11% (1/9)
e e Are older people who fall and attend A&E assessed
by a member of the specialist falls service?
29% (44/150)
e e Is this a 24 h service? 14% (6/44)
Is there a local coordinated, integrated,
multiprofessional and multiagency falls service?
Acute: 70% (128/183) Is there a coordinated multiprofessional specialist falls
service?
74% (111/151)
PCOs: 75% (120/159)
HSCTs: 50% (5/10)
e e Has the specialist falls service agreed protocols for the
care of older people with osteoporotic hip fracture with
the A&E department[s]?
44% (67/151)
Do you have a falls service coordinator(s)? Acute: 31% (55/175) Which of the following professionals have within their job
description/job plan a commitment to the specialist falls
service: Falls coordinator?
54% (81/150)
PCOs 71% (111/157)
HSCTs: 40% (4/10)
Do you have a fracture liaison nurse (s)
or similar designated person(s)?
Acute: 29% (51/175) Is there a fracture liaison nurse or similar designated person
who performs a falls and osteoporosis assessment on older
people that have a fragility fracture?
34% (51/150)
PCOs 15% (24/157)
HSCTs: 60% (6/10)
Acute, acute hospital sector; MIU, minor injury unit; PCO, primary care organisation; HSCT, health and social care trusts.
2 of 3 Banerjee J, Benger J, Treml J, et al. Emerg Med J (2011). doi:10.1136/emermed-2011-200501
Original article
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actual clinical practice as is possible with large-scale audit. It
demonstrates quite clearly that the management of falls and
bone health in older people is suboptimal. This is especially
important given the nature and size of the problem and future
projections within an ageing population. Given that emergency
care departments are often the first port of call for many older
fallers, the relevance of the roles played by clinicians at this
interface between secondary and primary care and the need for
surveillance, assessment and management cannot be overstated.
Opportunities to prevent recurrent falls and fractures are
being missed. Services with falls coordinators and fracture
liaison nurses probably have better case-finding systems in place
to identify high-risk fallers than services that do not.6 Assess-
ment rates for secondary prevention are so low that many
clinical services clearly do not adhere to NICE guidelines on
preventing falls and fractures. Half of the patients with hip
fractures have previously had a fragility fracture of another
bone,7 and hence there are missed opportunities to reduce the
incidence of subsequent hip fractures in this group by using
osteoporosis treatment and falls risk reduction. The clinical
audit indicated that two-thirds of patients presenting with
a non-hip fragility fracture were not admitted to hospital. This
means that the majority of high-risk patients miss the best or
only opportunity for their falls and fracture risk to be identified
in the majority of hospitals. Local strategies are needed to enable
the case-finding opportunity at the point of presentation to be
coordinated with subsequent primary and community health-
care responses. In addition, every primary care organisation
needs a strategy to for case finding other patients at high risk.
An audit8 showed that in managing older patients after a fall,
the ED focused on injuries sustained but little effort was made
to establish and manage risk factors to prevent recurrent falls.
Furthermore, falls are a geriatrics syndrome, which indicates
that the individual is also at higher risk of adverse outcomes.
The DEED II trial9 and the PROFET study10 demonstrated that
comprehensive geriatric assessment and multidisciplinary inter-
vention can improve health outcomes of older people at risk of
deteriorating health and admission to hospital.
More research is needed, however, into the management of
older people presenting with falls in EDs and into the reasons for
non-concordance with evidence-based practice which are
multifactorial. The acute care setting, targets and consequent
influence on patient investigation and shared decision-making
may alter the focus on different aspects of patient management,
resulting in less time being spent on risk assessment for future
falls or fragility fractures than managing the immediate conse-
quent injuries. Attitudes towards, and knowledge and uptake of,
evidence-based management may also affect management of
these patients. Lack of knowledge on older peoples’ issues,
ageism, sociocultural and communication barriers and health
beliefs of patients may all influence elements of care delivery.
In summary, older people attending EDs in the UK after a fall
are ‘receiving a poor deal’. There is an urgent need to ensure more
effective assessment and management to prevent further falls
and fractures. Ideally, all elderly patients attending EDs should
be asked about their history of falls in the previous 12 months
and assessed for mobility and balance problems. Patients iden-
tified as being at risk of falling should receive assessment for
fracture risk and should be referred for appropriate falls and/or
osteoporosis assessment and treatment.
Competing interests None.
Contributors All authors contributed to developing the manuscript.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES
1. Department of Health. National Service Framework for Older People. 2001,
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@dh/@en/documents/digitalasset/dh_4071283.pdf (accessed 24 Mar 2011).
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(2004). Falls: the assessment and prevention of falls in older people. http://www.
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Table 2 Results from the 2006 clinical audit in relation to secondary prevention intervention within
12 weeks of falling
Question Non-hips (5642) Hips (3184)
Was there evidence of a medication review? 31% (1773/5642) 52% (1654/3184)
Performance of a cardiovascular examination? 40% (2240/5642) 89% (2827/3184)
Did the patient have an assessment for visual
impairment?
10% (573/5642) 19% (595/3184)
Did the patient have an assessment of urinary
function including continence status?
21% (1187/5642) 63% (2009/3184)
Do the clinical records indicate that a gait,
balance and mobility assessment was performed?
28% (1421/5086) 68% (2018/2952)
Has patient attended any form of exercise? 22% (1108/4933) 44% (1224/2764)
Was patient prescribed a bisphosphonate or other
appropriate treatment for osteoporosis?
20% (1038/5311) 43% (1301/3030)
PAGE fraction trail=3
Banerjee J, Benger J, Treml J, et al. Emerg Med J (2011). doi:10.1136/emermed-2011-200501 3 of 3
Original article
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doi: 10.1136/emermed-2011-200501
 published online November 1, 2011Emerg Med J
 
Jay Banerjee, Jonathan Benger, Jonathan Treml, et al.
 
implications for UK emergency care
The National Falls and Bone Health Audit:
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The National Falls and Bone Health Audit: implications for UK emergency care

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The National Falls and Bone Health Audit: implications for UK emergency care

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