Care And Prevention Of Falls 'Inadequate And Unacceptable'

Main Category: Bones / Orthopaedics
Article Date: 08 Nov 2007 - 5:00 PDT

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The first national clinical audit to investigate the care received by patients who have fallen and fractured bones (hip, wrist, arm, pelvis or spine) shows that an inadequate service is being provided by most local health services, and that there are unacceptable variations of care across PCTs and Trusts in England, Northern Ireland and Wales.

The audit, commissioned by the Healthcare Commission and carried out by the Royal College Of Physicians' Clinical Effectiveness and Evaluation Unit (CEEu), shows that most PCTs and Trusts were nowhere near meeting national standards and guidelines from NICE, SIGN and the National Service Framework for Older People on the care and prevention of falls.*

Results from 157 Trusts were included in the audit. Significant findings include:

- 80% of people with hip fractures spent over 2 hours in A&E before transfer to a suitable ward, in contrast to accepted best practice

- Less than a third had a pre-operative medical review by a suitably trained physician, despite the high rates of co-morbidity in this patient group

- 31% of operations for hip fracture were delayed beyond the 48 hours target, and it is known that delay is associated with increased mortality

- 29% of hip operations were delayed due to organisational issues, which suggests that many trusts have yet to optimise the capacity and logistics necessary so as to provide prompt surgery.

- Most patients returning home from A&E after a fragility fracture were not offered a falls risk assessment and only 22% were referred for exercise training to reduce future falls.

- 3 months after sustaining the fracture, only a fifth of these patients were on appropriate treatment for osteoporosis

- Even after surgery for the most severe fragility fracture, the hip, less than 50% were on appropriate osteoporosis treatment

- In only one in ten cases did the patient's notes document that they had been given information on how to prevent further falls

- For the minority of patients who attended a falls clinic, the falls and fracture risk assessments and treatment offered were better. Primary Care Trusts should consider commissioning specialist services, for example falls clinics, to improve the care of their patients

These results are very worrying as good clinical practice can reduce death and disability from hip fractures, and prevent future falls and fragility fractures. In 2005 the RCP CEEu audit on the organisation of health services for falls showed widespread gaps in services for the identification, referral, assessment and treatment of patients, and two years later the consequences of these failings are now evident in the individual patient results. Prevention of falls has been identified as a priority area by Professor Ian Philp, National Director for Older People's Services, in a 2007 report where he emphasises the importance of putting in place fully integrated falls prevention services.

Dr Finbarr Martin, Associate Director at the RCP CEEu and lead author of the report, said:

"Despite several years of national policy and clear evidence based guidelines, local health services have much more progress to make in this vital clinical area for older people. The wide variation between the sites in this audit does show however what can be done, and it is up to local NHS commissioners, managers and clinicians to work together to provide for their local populations what only a few are currently achieving."

Main recommendations of the report

PCTs should commission a patient care pathway for the secondary prevention of falls and fractures that includes a fracture liaison service that targets the high risk group of patients presenting with a first fragility fracture

- Acute hospital trusts should review their capacity and operational systems to ensure that prompt surgery can be offered for patients with hip fractures. They should consider applying the approach developed by the NHS Institute for Innovation and Improvement - Delivering Quality and Value - Focus on: Fractured Neck of Femur (2006). (http://www.institute.nhs.uk)

- PCTs should commission community or hospital based clinics which can perform the range of risk factor assessments necessary to offer an individual targeted treatment plan to reduce falls and fractures

- PCTs should review the range of therapeutic exercise options available locally and promote evidence based programmes in collaboration with local authorities

- The Department of Health should consider supporting inclusion of osteoporosis treatment in the Quality and Outcomes framework for primary care

- Acute and community trusts should review their procedures to share clinical information such as clinic letters and hospital discharge reports with patients receiving falls and fracture care.

- PCTs and local providers should review their information sharing agreements and practice so as to promote coordinated clinical governance and audit of patient care pathways.

* Audit standards and indicators were taken from:

- National Service Framework for Older People (NSF) Chapter 6 "Falls", 2001

- British Orthopaedic Association (BOA), "The Care of Fragility Fracture Patients", (Blue book) 2003

- Scottish Intercollegiate Guideline Network (SIGN) Number 56 - Hip Fracture Management, 2002

- National Institute for Health and Clinical Excellence (NICE) - CG21 Falls: The assessment and prevention of falls in older people, (2004),

- NICE Technology Appraisal (TA) 87, Bisphosphonates (alendronate, etidonate, risedronate), selective oestrogen receptor modulators (raloxifene) and parathyroid hormone (teriparatide) for the secondary prevention of osteoporotic fragility fractures in post menopausal women, 2005.

Royal College of Physicians