The disproportionate use of emergency ambulance services in relation to patient falls in the UK independent care sector is at an unprecedented level (Jennings and Matheson-Monnet, 2017; Pope et al, 2017). The existing literature demonstrates how the likelihood of inappropriate and frequent use of unnecessary ambulance services can be demographically predicted. Patterns are characterised by lower socioeconomic status, chronic disease status, and low perceptions of health-care accessibility in practice (Scapinello, 2016; Hudon et al, 2016). Notably, there is minimal mention of the accountability of independent care sector staff in requesting emergency services, nor of the relevant contexts, but which may both be attributed to people in these groups.
Raising awareness of the implications of the unnecessary use of emergency services is pivotal if it is to be prevented. If organisations recognise the fiscal expense and potential human cost of wasted time for paramedics, a mechanism of public education is warranted.
The current paper provides descriptive statistics to illustrate this issue. The authors' findings reveal that calling emergency services has become the norm when people are found on the floor and are unable to independently mobilise.
Methodology
Through the current study, the authors aim to illustrate the first-line response to patient falls that is operational in the independent care sector in a specific region of North East England. This was conducted specifically in nursing and residential care homes, which is largely representative of the practice in the independent care sector. The study used a basic survey questionnaire, via Survey Monkey, taken in March and April 2016. A convenience sample of 32 (100%) care-home managers in South Tyneside was targeted, with a total of 24 (75%) agreeing to take part in the study. This response rate mirrored the completion rate as the non-response rate was 25% (n=8).
Formal ethical approval for the present study was granted by South Tyneside NHS Foundation Trust and the University of Sunderland.
The online questionnaire survey posed questions about the following points, and each of these will be discussed individually:
Policy
When questioned if they had a policy in relation to the management of falls, ‘yes’ was the unanimous answer. With a response rate of 96%, and a total survey response count of 23 organisations, only 4% reported that they had no policy in relation to the management of falls.
Staff awareness and appropriate action
Further questioning revealed how organisations ensured that staff were aware of the policy and acted on it appropriately. Of the responses, 87% reported that their policy had specific guidance on what to do if a resident falls and is on the floor, while 13% had none. As an adjunct to this question, the 87% of organisations with a positive response to this question were asked to provide information on the guidance given to staff. This revealed a diverse array of actions with common themes, when subjected to basic qualitative framework analysis (Ritchie and Spencer, 2004). The five most salient themes were:
Residents who are immobilised
This question had a response of 75%. The most common feedback was that staff were required to call for an ambulance. In these homes, there was an institutional policy that staff were not to move clients if they had fallen to the floor. A minority of organisations reported that staff were expected to use hoists to move patients from the floor.
Some organisations reported having an individualised care plan for each patient and that carers had to use this in instances where patients fell, regardless of the circumstances. Registered general nurses (RGNs) were used to check for head injuries and broken bones in some organisations, and some reported only calling an ambulance if there were signs of ‘visual injuries’.
It was further reported in one organisation that if it was suspected that a patient had a spinal or hip injury, an ambulance must be called. One organisation reported that there was nothing in the policy about what to do in the instance that a client had a fall.
Exact responses from each responding organisation are outlined below:
‘After someone has fallen it is suggested that a Post Falls Assessment is carried out, this will then be specific to the individual within the home.’
‘Ring for wardens/ambulance.’
‘No policy in place due to clients living in their own homes.’
‘If appropriate use hoist.’
‘They phone an ambulance and make no attempt at all to move the service user.’
‘Staff follow each residents moving and handling document this is in each resident's care plan.’
‘All customers are assessed by our mobility co, we must follow the correct procedure in plan. Provided there are no injuries.’
‘Call for medical help.’
‘Always hoisted. RGN to check for immediate signs of injury, accident form, report, 12-hour, 24-hour and 36-hour check. Head injuries 111 or 999.’
‘Registered nurse completes a full body assessment to assess for any broken bones.’
‘To check for any visual injuries to contact emergency services if resident is complaining of any pain or unable to get up off the floor and to look at the capacity of the resident if they're able to state they are in pain.’
‘Not in policy.’
‘Carry out a full body check to identify for injuries, if no injuries are identified and the person is unable to say we would contact healthcare professional for advice. And carry out observation for any side effects or more discomfort.’
‘Use hoist.’
‘Would contact healthcare professional, if unable to get up, unaided, if fall was not witnessed, and no visible injuries identified and person was unable to say how they were on the floor.’
‘We have an accident policy and the staff have falls training, however, the policy does not state what to do in the event service user falling. The reporting of accident policy has guidelines on how to manage and report injury and accidents.’
‘Check for injuries. If concerned contact emergency services and if no injuries support resident or use hoist depending on their needs.’
‘Hoist.’
‘Call 999.’
‘To assess and utilise the appropriate equipment if injuries are not evident.’
‘If injuries are evident we are to make them comfortable and await emergency services.’
‘Check the resident for any injuries, and they are suspecting any fracture hip or spine—contact emergency ambulance services for further support.’
‘Press emergency buzzer for more senior staff to attend and assess situation.’
‘All falls by Service Users no matter how trivial are immediately recorded in care plan daily records also in accident book, nurses inform falls team for assessment.’
Assessing injury and guidelines
This survey question received a positive response, with 79% of organisations reporting that they did have an inclusion in their falls policy of assessments to check clients for sustained injury or harm as a consequence of a fall. Of the sample, 21% had no specific recommendations in their falls policy for how staff ought to assess the condition of the client who had fallen. Those 79% who reported having an inclusive policy of assessment of sustained injury or harm to residents responded that clear guidelines were available to follow in instances of there being no harm or injury apparent. The 21% reported clear guidelines for instances where there was concern that harm or injury had occurred; two organisations omitted to answer this question.
Ring an ambulance
All but one of the 23 organisations responded to this survey question. Specific responses are below:
‘If the individual is unable to mobilise normally, if they are expressing pain, if the individual is unconscious.’
‘If the service user is hurt or in pain’
‘Due to each client being in their own home, we would contact an ambulance if they were to sustain an injury. Otherwise we would contact GP/DN for advice.’
‘Suspicion of serious injury.’
‘With falls we ring ambulance immediately’
‘If the resident has a suspected injury fracture or bleeding, nasty bump.’
‘If head injury or suspected fracture.’
‘Head injury, fractures, resident shows clear signs of severe pain in limbs.’
‘From the assessment if there were any signs of broken bones or lacerations that won't stop bleeding.’
‘If service user has sustained injury if a service user is unable to move limbs, head injury, bleeding and if a resident is unable to state in pain due to capacity.’
‘Head injury, obvious injury.’
‘When injuries are identified or any distress.’
‘Serious Injury - Fractures – Cuts.’
‘If person was unable to get up themselves, if person has any identified injuries or signs of any discomfort or pain.’
‘If the person was non-responsive, hurt or injured and was unable to get up.’
‘If the client could not move, depending on the type of injury. Assess the situation at the time.’
‘Suspected/actual injury, any loss of consciousness, and evidence of sudden onset illness.’
‘Head injury suspected fracture.’
‘If injury was evident or head injury suspected.’
‘Any suspected fracture or head injury, heavy bleeding, large soft tissue or tendon injuries.’
‘Head injury, broken bones, unconsciousness, if the injury is causing pain or discomfort in any limbs, back or hip area or a severe head wound or blow to the head is present/suspected, then an ambulance must be called. Also, for any cut that is more than superficial to any area. If the service user has abnormal bruising to or is on blood thinning medication.’
‘Yes.’
If an ambulance is delayed
Of the total sample, 50% responded affirming the availability of guidance for staff if a resident is on the floor and an ambulance has been called but is delayed in responding due to high levels of activity. The remaining 50% or respondents said they had no availability of guidance in these circumstances.
Access to falls training
Staff reported having accessed staff development sessions, which were clearly divided into ‘in-house training’ and e-learning packages.
Discussion
The current study examined policies and guidelines for falls in 24 independent sector care homes. The survey findings highlight the disparate responses to falls in care-home settings. Despite 96% of homes having a policy on falls, only 80% included an assessment of possible injury or harm to residents, and 13% included no direct guidance for care staff where residents are on the floor.
For policies that did include direct guidance, there was a great disparity in available information. The most commonly recommended action was to call emergency services in order to move patients, even in the absence of physical injury. Findings were consistent with those outlined in the existing literature, which also highlighted the inappropriate use of accident and emergency (A&E) services (Chalk et al, 2016).
While the present research indicated use of ambulances as a common policy, the literature indicates that patterns may also exist between inappropriate ambulance use and minimal staffing in the independent care sector. An example of this would be during night shifts where often skeleton staffing is used to cover significant numbers of patients (Bruni et al, 2016).
It is relatively easy to be critical of 4% of the independent care sector having no policy on falls; however, if we account for the impossibility of standardising this in the overlap between accident policies, this could account for them being covered elsewhere. It is also arguable that not having overlapping policies and choosing to implement an accident policy only permits a less legalistic approach, and encourages proactive informed decision-making for individuals.
These statistics can be used to raise awareness to reduce ambivalent ‘mind-sets’ around falls by independent care sector staff. This is apparent in the management of elderly patients, for whom the following issues gradually limit proprioception, mobility and visual senses (Zia et al, 2017):
For these physically vulnerable patients, annual screening is needed as an integral part of a comprehensive care package, which can recognise the need for healthcare interventions to minimise the risk of falls. Such screening can potentially serve as a prognostic indicator of the likelihood of vulnerable patients requiring hospitalisation or emergency admission (McCusker et al, 2012). The need to highlight organisational predictors of frequent and inappropriate use of emergency ambulance services also impacts how patients can potentially be perceived by paramedic staff (Chapman and Turnbull, 2016).
From an educational perspective, results show how independent care sector staff in residential care homes are directed and made accountable for how they deal with falls, which is notable. This almost always involves a focus on legalism, with staff signing to say they have gained an insight into falls, and are aware of how to deal with them. There is minimum evidence to suggest a robust and transferable training and development programme for all independent care sector workers in the context of the current research, despite several being established in recent years (Richardson et al, 2015; McKenzie et al, 2017).
The choice of whether or not to use emergency services is similar in terms of behavioural norms when discerning the residents' needs (Coster et al, 2017). In instances of emergency care, where patients have sustained injuries warranting hospital attention, the assessment of a qualified paramedic is invaluable (Halter et al, 2017; Snooks et al, 2017).
However, inappropriate use of emergency services causes a degree of frustration for paramedics in terms of how they perceive those they need to assess, diagnose, and manage in an emergency response (Dejean et al, 2016), and whether this is related to ambulance use or hospital treatment (Dawoud et al, 2016; Cardona-Morrell et al, 2017; Franchi et al, 2017).
In the context of residential care home settings, there was a high degree of ambiguity around the assessment of sustained injuries and whose responsibility this was; particularly where non-visible injuries were sustained and where patients were moved via hoists. There was also reported ambiguity in relation to the management of falls, where there was overlap between accident and falls policies.
Limitations
It is significant that the authors do not distinguish the qualifications of staff working with patients. Nursing homes usually have a registered nurse present, but in residential care homes, it is the norm for social care officers to be present instead. This distinction is important as the person who has fallen may not initially be assessed by a registered nurse. The authors therefore do not seek to make a generalisability about which professions can best assess injurious falls correctly, but to provide an insight into the evidence of outcomes in the context of everyday healthcare provision.
The authors acknowledge that this survey does not ascertain whether a GP was contacted first to assess the need to call ambulance, nor the implications of this in current policies and practice. The authors recommend the need for an adjunct piece of research examining whether delays in patients being assessed by GPs could also potentially be creating a behavioural response towards calling an ambulance.
While not within the scope of the current article, another possible avenue for exploration is the extent to which educational curricula for care staff is fit-for-purpose, which may reveal what is adverse behaviour in ringing an ambulance.
Conclusion
The current research reveals the variation and potential for ambivalence around awareness, staff development, and accountability in relation to falls in everyday practice in residential care homes. This is characterised by the majority of the independent care sector acknowledging the need for institutional policies. However, the implementation of these policies is treated as a legalistic process rather than being focused on the individual care needs of clients—specifically in their capacity for mobilisation following a fall.
In the majority of falls, the overall organisational response in the independent care sector surveyed is to call emergency services via 999 for an ambulance, regardless of the injury or harm a patient has sustained as a consequence of falling. The present research also reveals a paucity of available information, where policy implementation is not always adopted. Perhaps of greatest concern, 21% of organisations in the current research reported having no specific recommendations in their falls policy of how staff ought to assess the condition of the client who has fallen.
Aside from the fiscal implications and physical burden of the deployment of the paramedic workforce, a secondary concern is how the wider population is being impacted by this inappropriate use of emergency resources.
There is a clear need for the provision of definitive training of care staff in emergency first aid; particularly in the re-mobilisation of clients, and the circumstances where it is wholly appropriate for them to request emergency care provision from paramedic practice. This raises issues of discernment and critical decision-making for the paramedics, in order to establish how they might best change first-line response to falls.
The authors have drawn attention to the potential for interventions in terms of education and training packages. They have also highlighted the need for representation in the paramedic profession at committees, where responses to care in the independent sector are being formalised and sanctioned for operationalisation in practice.