Older people attending A&E after a fall are not all routinely screened for risk of future fractures. What should be looked for, and why? Ingrid Torjesen reports
Every year 700,000 older people in the UK attend accident and emergency after a fall. Many more will present to minor injury units and other services.
Fractures in people aged 65 and over are responsible for more than four million bed days each year in England.
The Department of Health estimates that if every strategic health authority in England invested £2m in falls and bone health early intervention services they could each save £5m (net £3m) each year through reduced NHS costs, such as 400 fewer hip factures.
The national service framework for older people sets out standards and actions for preventing falls, and the National Institute for Health and Clinical Excellence has published a strategy for case finding and treatments and recommended cost-effective drugs for the secondary prevention of osteoporotic fractures.
However, according to the second national audit of the organisation of services for falls and bone health of older people, conducted by the Royal College of Physicians, many trusts are not following this guidance.
The audit found only half of providers with an A&E or minor injury unit are routinely screening older people attending with falls for risk of future fractures. The two thirds of primary care trusts with a written commissioning strategy for falls prevention are most likely to do this.
Although research has shown fracture liaison services ensure better rates of secondary prevention, these services are not universally provided.
Royal College of Physicians associate director for falls and bone health Jonathan Treml emphasises it is vital to have someone whose job it is to take the lead on falls: a dedicated falls co-ordinator or falls nurse specialist and a dedicated fracture liaison nurse - who is backed up by a geriatrician with an interest in falls prevention. Data from the audit shows services with falls co-ordinators and fracture liaison nurses have better case finding systems in place. Not every trust needs these personnel, but rather every locality.
“We can’t expect the falls co-ordinator to be there round the clock but there needs to be a system in place where all fallers get a basic assessment, some screening and identified to be further assessed, particularly those that are discharged, as the majority will be,” Dr Treml says.
Assessment should determine the likely cause of the fall, such as osteoporosis, unexplained loss of consciousness (syncope) or visual disturbances, so further falls and potential fractures can be prevented through effective management. Half of sites do not conduct a standardised visual acuity assessment and 48 per cent do not assess cardiac status, including a basic ECG, as recommended by NICE guidelines for loss of consciousness.
Only 44 per cent routinely screen for osteoporosis in older people admitted with a fracture, and this is much higher than the figure for patients attending fracture clinics.
Dr Treml admits many admissions are unnecessary and simply to ensure patients get the investigations they need for osteoporosis or syncope because the treating clinicians have little confidence of this being done once the patient is discharged.
Many trusts do not have an adequate falls register, so do not know which fallers have been assessed or what management (if any) they are receiving. The most appropriate management is usually an exercise programme and perhaps drugs to maintain bone density.
Just 39 per cent of commissioning trusts reported being compliant with NICE guidance on secondary prevention for osteoporotic fracture in the audit. However, most trusts self-reported as compliant in the 2007-08 Healthcare Commission annual health check. Only 24 per cent had audited prescribing of drugs for bones by GPs and only nine PCTs knew their local fragility fracture rates.
Only 28 per cent of fragility fracture patients had been started on medication for bone protection 12 weeks after the fracture. As half of hip patients have previously fractured another bone this is a missed opportunity - treatment against osteoporosis can reduce the risk of more fractures by 50 per cent.
Although many trusts provide exercise programmes, only 38 per cent provide ones that meet the criteria of the two that have been validated for use in falls, FaME and Otago.
Dr Treml says almost no one who does a modified version does it often enough or long enough. He says programmes need to be followed three times a week for at least 12 weeks for improvement to be sustained.
Falls and fractures are due to be included in NHS metrics and Dr Treml hopes this will help commissioners do things better. The Department of Health is to launch a toolkit to help them.
“At the very least commissioners should be commissioning proper case finding systems, a fracture liaison service and a falls service that includes a falls co-ordinator and a consultant with dedicated sessions related to falls,” Dr Treml says.
“If you want one simple solution it has got to be exercise for falls prevention and drugs for osteoporosis.”
He says initiatives such as the Sloppy Slippers footwear exchange got falls talked about but distracted from the need to be “a bit more detailed than just giving someone new shoes.
“For every complex problem there is a solution that is simple, neat and wrong,” he says.
Preventing further falls: good practice
Rather than being conducted in a falls clinic, multidisciplinary assessments are conducted for as many people as possible in their own homes.
Health professionals in the falls team visit the patient at home sequentially and use a standardised tool for documenting the visit.
A medical falls prevention clinic, small specialist falls team and day rehab facilities are also available. An extensive exercise continuum has been developed across health and leisure services with nationally validated joint training for healthcare and exercise professionals. This has enabled the provision of sustainable, safe and effective local exercise opportunities for reducing risk of falls.
Newcastle upon Tyne Hospitals foundation trust
The falls and syncope service is the largest unit of its kind in Europe for investigating syncope and has successfully reduced admissions for “collapse query cause”.
The area has established a local falls network where health, social care, voluntary sector and ambulance services meet regularly to keep each other informed and smooth out any problem areas.
FIND OUT MORE
Royal College of Physicians www.rcplondon.ac.uk
The national service framework for older people www.dh.gov.uk/en/Healthcare/NationalServiceFrameworks