Clinical guidelines and research papers help clinicians measure and understand the risk of falling in their older clients but very few provide the assessor with recommendations as to which interventions they can use to reduce the risk of a fall.



The Guide to Action for Falls Prevention tool (GtA) was developed to help professionals from a broad range of organisations to recognise factors that might increase falls risk and know which actions to take to lessen that risk.

  

Twenty four professionals tested the GtA in a clinical setting and found it quick (15 mins) and easy to complete. The GtA needs further evaluation to test whether it is a practical way of delivering a falls prevention intervention

Burn, Ann

Challands, Linda

Conroy, Simon P.

Dodds, Verity

Gordon, Adam L.

Humpage, Sally

Logan, Phillipa A.

Robertson, Kate

Smith, Sue

English

Clinical guidelines and research papers help clinicians measure and understand the risk of falling in their older clients but very few provide the assessor with recommendations as to which interventions they can use to reduce the risk of a fall.The Guide to Action for Falls Prevention tool (GtA) was developed to help professionals from a broad range of organisations to recognise factors that might increase falls risk and know which actions to take to lessen that risk.  Twenty four professionals tested the GtA in a clinical setting and found it quick (15 mins) and easy to complete. The GtA needs further evaluation to test whether it is a practical way of delivering a falls prevention intervention

Repository@Nottingham

Guide to Action paper resubmission 30.6.10 1Thinking Falls- Taking Action: development of a Guide to Action for Falls PreventionTool (GtA)Kate Robertson1*, Phillipa A Logan2, Simon Conroy3, Verity Dods4, Adam Gordon2, LindaChallands1, Sue Smith5, Sally Humpage6, Ann Burn7 on behalf of the Rushcliffe FallsPrevention and Research Group1Nottinghamshire Community Health2Division of Rehabilitation and Ageing, University of Nottingham3University of Leicester School of Medicine4Surrey Community Health5Nottingham CitiHealth6Charter Housing Association*Address for CorrespondenceKate Robertson, Falls Clinical Specialist, Nottingham Community Health, Lings Bar Hospital,Nottingham. NG2 6PR. UK. Email: kate.robertson@nottscommunityhealth.nhs.ukThis paper has been accepted for publication and will appear in a revised form,subsequent to layout and copy editing by MA Healthcare Ltd, in the British Journalof Community Nursing. MA Healthcare Ltd hold the copyright.Guide to Action paper resubmission 30.6.10 2AbstractClinical guidelines and research papers help clinicians measure and understand the risk offalling in their older clients but very few provide the assessor with recommendations as towhich interventions they can use to reduce the risk of a fall.The Guide to Action for Falls Prevention tool (GtA) was developed to help professionals from abroad range of organisations to recognise factors that might increase falls risk and knowwhich actions to take to lessen that risk.Twenty four professionals tested the GtA in a clinical setting and found it quick (15 mins) andeasy to complete. The GtA needs further evaluation to test whether it is a practical way ofdelivering a falls prevention intervention.Word Count: 117Key words:Falls, older people, risk factors, checklist, implementationGuide to Action paper resubmission 30.6.10 3Key Points: Falls in older people are due to an interaction of multiple risk factors and events Identifying risk factors significant for an individual older person, and taking action toreduce or reverse those risk factors, can reduce falls Many opportunities to reduce falls are overlooked A quick and simple checklist of risk factors known to contribute to falls in older people,with suggested actions to take to reduce those factors, has been shown to be useableacross health, social care and partner organisationsBackgroundFalls are a major cause of disability and mortality in people over 75 (Scuffham P, Chaplin S etal. 2003). They are a consequence of multiple and diverse risk factors, many of which can beprevented and corrected (National Institute for Health and Clinical Excellence 2004). Yetfrequently older people are not aware of their risk of falling and opportunities to intervene toprevent falls are overlooked, with risk factors only becoming evident after an injury hasoccurred (American Geriatrics Society, British Geriatrics Society et al. 2010).Multi–agency, multi-factorial interventions have been shown to be most effective in reducingthe incidence of falls in older people (Gillespie LD, Robertson MC et al. 2009) and theprovision of fall prevention interventions has been recommended by the National Institute forHealth and Clinical Excellence (NICE) (National Institute for Health and Clinical Excellence2004) and in the National Service Framework for Older People (Department of Health 2001).Although there is research evidence and clinical guidelines to help clinicians deliver theappropriate treatments, there are concerns that the time and energy has not beenforthcoming to embed the evidence in clinical practice (Close 2005). This is made morechallenging by clinicians not knowing who to target with the interventions.Predictive risk assessment tools have been developed to try and address this problem, whichgrade a person’s level of risk of falling (Oliver, Daly et al. 2004). The Falls Risk AssessmentTool (FRAT) (Nandy, Parsons et al. 2004) is one of the most widely used risk tools in the UK,Guide to Action paper resubmission 30.6.10 4although there are concerns about the impact in clinical practice (Oliver 2008). Using a riskfactor check list to identify an individual’s risk factors for falling and then taking targetedaction to reduce or reverse those risk factors is key (Oliver and Healey 2009).The Rushcliffe Falls Prevention and Research Group is a multi-agency inter-professionalforum working within South Nottinghamshire, UK that shares and disseminates good practiceand develops initiatives to raise awareness of falls. There are 24 members including healthcare professionals, a carers support worker, representatives from social services, the fireservice, the voluntary sector, University of Nottingham, the borough council, home alarmservice, preventative adaptation service, housing agencies and a local forum of older peoplewho act as service user representatives. One aim of the group was to develop a community-based risk factor checklist that could be used across various disciplines and clinical settings asa guide to implementing proven falls prevention techniques. This paper describes how thistool was developed.Development of the Guide to Action for Falls Prevention Tool (GtA)Medline, Pubmed and Cinahl databases and the Department of Health and ProFanE websiteswere searched for evidence regarding risk factors significant to falling in older adults andinterventions shown to reduce the rate of falls in the community. The falls research groupappraised the research literature and clinical guidelines and listed the assessments andevidence-based interventions suitable for implementation in a primary care setting. The listwas presented to a group of medical, pharmacy, nursing, social care, therapy and researchprofessionals. An iterative process was used to agree which of the evidence based itemsshould be included in the check list. A final two page document called the Guide to Action forFalls Prevention Tool (GtA) was produced (Figure 1). On the first page, 34 risk factors werepresented as a table under the headings history, movement, environment and personal.Shaded boxes indicated areas where published research has shown these factors aresignificantly associated with a higher risk of falling. The second page (Figure 2) mirrored thefirst with recommended actions to be taken for each risk factor. An information pack withadvice sheets was written to support the areas highlighted for action. For example if a clientGuide to Action paper resubmission 30.6.10 5reported that they were missing two meals a day on page 1, then on page 2 the suggestedinterventions would be: ‘Provide advice re importance of healthy eating, encourage client toeat meals, review reasons for poor appetite, discuss with GP’. The advice sheet would advisethe client or carer about the use of small meals, nutritious snacks, supplementary foods, easymenus and local meal delivery services, potentially reducing the need to refer on to morespecialist services for those at less risk. The tool delivers immediate and targeted informationto older people at risk of falls, as recommended by the NICE (2004) in the Falls ClinicalGuidelines (National Institute for Health and Clinical Excellence 2004).Figure 1: Guide to Action for Falls Prevention (GtA) page 1Guide to Action paper resubmission 30.6.10 6Figure 2: Guide to Action for Falls Prevention (GtA) page 2HISTORY MOVEMENT ENVIRONMENT PERSONALHistory of FallsReview incidents, advise onprevention ,refer tocommunity Nurse for BPreview, refer to OT and PT,inform GPBalanceAdvice re stabilising before walkingAccessAdvise re hazards, refer to OTNutritionAdvice re importance ofhealthy eatingRefer to Physiotherapist TelephoneAdvice e.g. phone extension, cordlessphone, ansaphoneReview reasons, offeralternatives e.g. Meals atHome, inform GPStumbles or tripsReview incidents, advise onprevention, refer OT andPTMobilityRefer to Physiotherapist, assist incompleting exercise programme, advisere safe use of aid, replace walking aidor ferrulesDisrepairAdvise Environmental Health at local CouncilFluidAdvice re importance ofadequate fluid for continenceand healthPrevious FractureConsider osteoporosis /refer to GPFear of FallingRefer OT and PTTransfersRefer to OT and PTFlooringAdvice re rugs, surfacesAlcoholRefer to GP if concerned /Advice re effects of alcoholCoping strategiesRefer OT and PT, Refer forAlert AlarmExerciseRefer to Physiotherapist, assist incompleting home based exercisesThresholds & DoorsAdvise re hazards, refer to OTVisionExplain risks, advise against bior varifocal glasses, advisesight test every 2 yearsMedicationAdvise review with GP ifreports any concerns remedication or on 4+prescribed medicationsReachingAdvise on lifestyle, give “Slips andTrips” leaflet, refer to OTStairsAdvise, Refer to Physiotherapist / OT /Preventative Adaptation SchemeContinenceDistrict Nurse re urgency /frequency; OT for accessdifficultiesMedical HistoryRefer to GP if medicalreview requiredCarryingReview equipment in home, advise safepractice, refer to OTHeatingAdvise, refer to Healthy Housing / AffordableWarmth / Social ServicesFootwear & ClothingAdvice on suitable footwear,check footcare, considerpodiatryMental StateRefer to GP if medicalreview requiredBendingAdvise safe practice, refer to OTLightingAdvise, refer to Preventative AdaptationScheme / HousingPetsAdviceSleepRefer to GP and / orgeneral advicePainRefer to GP if medical review requiredGardenAdvice, Preventative Adaptation Scheme,Voluntary Sector or OTSocial ContactAdvice / Social Services re DayCare Give Information re localVoluntary GroupsAGREED ACTION PLANDATE ACTION SIGNEDThe GtA tool and information pack were checked for clarity by the Nottinghamshire OlderPerson’s Forum and the Plain English Group. To support implementation a training packagewas developed and delivered, attended by staff from a range of organizations concerned withthe care and support of older people and who would use the GtA in everyday practice -including therapists, community nurses, social workers, supported housing staff,environmental health officers and care assistants. The package lasted three hours, wasdelivered by the falls clinical specialist using a small group format and included informationabout the importance of preventing falls and case-based discussion about its application.Follow-up support was provided in the form of telephone consultations with the trainer todiscuss the first few GTA assessments undertaken.Guide to Action paper resubmission 30.6.10 7Piloting the GtA ToolMembers of the falls research group piloted the GtA tool in their respective workplaces forease of use and face validity. They reported their experiences back to the group and foundthe tool easy to use, taking approximately 15 minutes to complete with each client and thenan additional 15 minutes to discuss each action. The group felt that the tool’s content wasappropriate for their clients and that the suggested interventions were acceptable within theirlocal environments. The GtA was then presented to local NHS organisations and ratifiedthrough Clinical Governance for use across South Nottinghamshire with a population of660,000. Over a period of 12 months in 2006, 186 people from 12 different organisationsundertook the training.Audit of the GtA ToolAt the end of 2006, the NHS Clinical Audit Service completed an audit of the GtA. The auditquestionnaire was sent to nurses, therapists or managers of older people’s services in healthand social services, Rushclifffe Borough Council and Sheltered Housing complexes.Respondents were asked to complete the audit if they had day to day contact with olderpeople as clients. A stamped addressed envelope was included for return of the anonymisedreplies.The aims of the audit were: to establish whether the GtA was being used in practice to understand barriers to using the GtAResultsSeventy four percent (112/150) of participants returned questionnaires. The professions ofrespondents are summarised in Table 1.Profession Number (%) replies received n=112Community Nursing (Matron, District Nurse, StaffNurse, Healthcare assistants)68 (60.7%)Therapy (Physiotherapist, Occupational Therapist,Assistant Practitioner, Rehabilitation Support Worker)25 (22.3%)Practice Nurse 10 (8.9%)Guide to Action paper resubmission 30.6.10 8Pharmacist 4 (3.6%)Other (e.g. Dietician, Care Assistant) 5 (4.5%)Table 1 Profession of participantsOne hundred and six (95%) of the respondents were aware of the GtA tool. Eighty four(75%) were aware that GtA training was available, of whom 63/84 (75%) had attended thetraining. Reasons for non-attendance were lack of time and staff shortages. Although 71/112(63%) people reported that they felt the GtA could be useful, only 62/112 (55%) hadcompleted the assessment with an older person. Table 2 shows why people did not use thetool.Reason 43 repondersDid not think about it 5 (11.6%)Didn’t have the GtA paper work with me at the time 15 (34.9%)Confident in assessing falls without the GtA 5 (11.6%)GtA already completed by another professional 11 (25.6%)No response 7 (16.3%)Table 2 Reasons for not using the GtANine out of sixty two (14%) respondents reported using the tool with every older person,11/62 (18%) used it with those in whom they were unsure of the reason for falling and 17(27%) used it with clients deemed to be at risk of falling. Fifty four out of hundred and twelve(48%) respondents had used the information pack to accompany the tool.DiscussionWe have described the development and piloting of a Guide to Action for Falls Prevention tool(GtA) which can be used by professionals from a broad range of disciplines and organisations.This provides prompts toward evidenced-based action to prevent falls for services which maynot have access to any research articles or clinical guidelines. Oliver et al (2008) suggest thatfalls risk assessment tools can prompt good comprehensive geriatric assessment and careGuide to Action paper resubmission 30.6.10 9planning, yet it is not clear that simply stratifying risk provides a clear prompt to action andthat, when professionals do act, that they do so in line with best evidence The GtA maypotentially bridge this gap by connecting the falls risk assessment with evidence-basedpractice guidelines. It may also act as a resource for professionals not normally undertakingfalls risk assessment, such as wardens in supported housing schemes and social care staff,and may also augment assessments completed by health care staff including communitynurses.The GtA was developed in collaboration with staff from a wide range of agencies and serviceusers and accepted as useful by professionals across multiple disciplines and acceptable toolder people. The audit results provide evidence that the tool is easy and quick to complete, isperceived as relevant to the population and suitable for use in a community setting. We wereencouraged that a high proportion of respondents were aware of the GtA tool but wereconcerned that many did not have the paper work to hand to use the assessment and werenot aware of the supporting information. This problem has been addressed through a changeto the training programme which now uses case studies with which to practice completing thetool. In addition the tool is now included within the community nursing documentation. Sincethis work was completed the GtA has been included as a first line assessment within theNottinghamshire Falls Guidelines for use across health and social care and will be included inan analysis of performance data by NHS commissioners in 2010. This process will allow us tocontinue to appraise the GtA.There are a number of limitations to the GtA. The GtA is not a risk assessment that willproduce a score; it is essentially a clinical check list providing recommendations for action. Noformal reliability testing was completed on this Tool when first devised. However, we areintending to undertake test - retest reliability testing as part of a further research project. Wedo not know if completing the tool results in any change to clinical decision making. It isreasonable to hypothesise that encouraging the implementation of evidence based fallsprevention advice will reduce falls. However we have not formally evaluated the GtA andGuide to Action paper resubmission 30.6.10 10further research needs to be completed to assess whether the GtA is an effective way toimplement falls prevention interventions. The GtA has not been tested for use by familymembers, care homes or paramedics. These are areas that need exploring as, over time andin different settings, the actions that could be taken may be very different. We would suggestcaution is taken when using the GtA in these settings.ConclusionThe diversity and number of people and agencies involved in the development of the Guide toAction for Falls Prevention Tool has resulted in the production of a user friendly, quick,evidence based risk screening and action checklist, that can be used within health, social careand partner organizations.Copies of the GtA Tool are available upon request from Kate Robertson at:kate.robertson@nottscommunityhealth.nhs.ukWord count including abstract, key points 2,535Word count including abstract, key points, authors 2,745Word count including abstract, key points, authors, references 3,016Guide to Action paper resubmission 30.6.10 11ReferencesAmerican Geriatrics Society, British Geriatrics Society, et al. (2010). "Prevention Guideline for theprevention of falls in older persons." Journal of the American Geriatric Society 49: 664-672.Close, J. (2005). "Prevention of falls - time to put evidence into practice." Age and Ageing 34: 98-100.Department of Health (2001). National Service Framework for Older People. London, Department ofHealth.Gillespie LD, Robertson MC, et al. (2009). "Interventions for preventing falls in older people living in thecommunity. " Cochrane Database of Systematic Reviews (2): CD007146. DOI:10.1002/14651858.CD007146.pub2.Nandy, S., S. Parsons, et al. (2004). "Development and preliminary examination of the predictive validity ofthe Falls Risk Assessment Tool (FRAT) for use in primary care ." Journal of Public Health 26(2): 138-143.National Institute for Health and Clinical Excellence. (2004). "Clinical practice guideline for the assessmentand prevention of falls in older people." 2005.Oliver, D. (2008). "Falls risk-prediction tools for hospital inpatients. Time to put them to bed? ." Age andAgeing 37(3): 248-250.Oliver, D., F. Daly, et al. (2004). "Risk factors and risk assessment tools for falls in hospital in-patients: asystematic review." Age and Ageing 30(33): 122-1.Oliver, D. and F. Healey (2009). "Falls risk prediction tools for hospital inpatients: do they work? ." NursingTimes 105(7): 18-21.Scuffham P, Chaplin S, et al. (2003). "Incidence and costs of unintentional falls in older people in theUnited Kingdom. Journal of Epidemiology & Community Health 2003;57(9):740-4." Journal ofEpidemiology & Community Health 57(9): 740-4.

Thinking falls - taking action: development of a guide to action for falls prevention tool (GtA)

Nottingham eTheses

Clinical guidelines and research papers help clinicians measure and understand the risk of falling in their older clients but very few provide the assessor with recommendations as to which interventions they can use to reduce the risk of a fall.\ud
\ud
The Guide to Action for Falls Prevention tool (GtA) was developed to help professionals from a broad range of organisations to recognise factors that might increase falls risk and know which actions to take to lessen that risk.\ud
  \ud
Twenty four professionals tested the GtA in a clinical setting and found it quick (15 mins) and easy to complete. The GtA needs further evaluation to test whether it is a practical way of delivering a falls prevention intervention

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Thinking falls - taking action: development of a guide to action for falls prevention tool (GtA)

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