Objective To identify good practices and highlight areas for improvement in the prevention and management of inpatient falls. Method Fifteen patients had serious inpatient falls between April and September 2023 within the hospital. Electronic notes and fall panel meeting minutes were used to provide an analysis of the ‘pre-fall’ and ‘post-fall’ assessments. Data was collected and analysed using AMaT and then compared to the standards set by RCP National Audit of Inpatient Falls (NAIF)—from KPI overview, 25% of patients had good quality Multi Factorial Risk Assessment (MFRA) in our Trust compared to National average of 33%. Results 70% of patients had been identified as high risk of falls at admission. Patients were prescribed a median of 10 medications, with a median of 3 falls-risk increasing drugs (FRID). Before the inpatient fall: the majority of patients received an ECG and mobility assessment early in admission. Only 40% of patients had a lying/standing blood pressure (LSBP) 100% of those that showed a deficit were acted on appropriately. Only 20% had a documented medication review. Following the inpatient fall: A LSBP was done in only 33% of patients. A medication review was completed in 53% yet the average patient was discharged with 3 more medications. 73% of patients suffered fragility fractures due to the fall however bone protection was only considered in 40%. Conclusion This audit highlights that there are areas of MFRA that require improvement, specifically LSBP, and a medication review. 33% of falls occurred in ‘medically-optimised’ patients—resulting in at least 60 additional inpatient days. The results have been discussed with the multi-disciplinary team—intervention to improve performance will be piloted in two areas with the highest incidence of inpatient falls, with continuous learning and sharing of lessons embedded into our Falls Collaborative Initiative.

中文翻译：

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2242 2023 年 4 月至 9 月住院跌倒导致患者伤害的回顾性研究。将我们的护理与 BSG 指南进行比较。


目的 确定良好做法并突出住院跌倒预防和管理需要改进的领域。方法 15 例患者在 2023 年 4 月至 2023 年 9 月期间在医院内发生严重住院跌倒。电子笔记和秋季小组会议记录用于提供对“跌倒前”和“跌倒后”评估的分析。使用 AMaT 收集和分析数据，然后将与 RCP 国家住院跌倒审计 （NAIF） 设定的标准进行比较——从 KPI 概述来看，25% 的患者在我们的信托基金中具有高质量的多因素风险评估 （MFRA），而全国平均水平为 33%。结果 70% 的患者在入院时被确定为跌倒的高风险。患者服用的药物中位数为 10 种，中位数为 3 种跌倒风险增加药物 （FRID）。住院跌倒前：大多数患者在入院早期接受了心电图和活动能力评估。只有 40% 的患者有躺卧/站立血压 （LSBP），100% 的患者显示有缺陷，并采取了适当的措施。只有 20% 的患者有记录在案的药物审查。住院跌倒后：只有 33% 的患者进行了 LSBP。53% 的患者完成了药物审查，但平均患者出院时又服用了 3 种药物。73% 的患者因跌倒而遭受脆性骨折，但只有 40% 的患者考虑了骨骼保护。总结这项审计强调了 MFRA 的某些领域需要改进，特别是 LSBP 和药物审查。33% 的跌倒发生在“医学优化”的患者中，导致至少增加 60 天的住院时间。 已与多学科团队讨论了结果——将在住院跌倒发生率最高的两个领域试行提高绩效的干预措施，并将持续学习和分享经验教训嵌入到我们的跌倒协作计划中。