25 The Post Fall Review- An Opportunity to Intervene for Bone Health

Abstract

Abstract Background Falls are a common occurrence in Irish hospitals and can result in much morbidity and mortality for our patients. According to NICE guidelines, a multi-factorial falls risk assessment should be carried out for those patients at risk of falling, including assessment of osteoporosis risk and medication review. In practice, the post falls assessment is a golden opportunity to assess Osteoporosis risk and adequate bone protection. Methods We compiled a list of patient falls registered on the Datix incident reporting system for our five wards over a three-month period from 13/10/18-15/1/19. We looked at the note post fall from the reviewing doctor and documented whether bone protection was addressed and also whether a known history of osteoporosis was documented. This was done on our electronic patient record system. Results A total of 106 falls were recorded during this time period. 87% of falls had a documented review post fall. 83 reviews were by the intern on call and team reviewed in 54 cases, often after the intern. 2 of the notes documented whether or not the patient had a known history of Osteoporosis. There was no mention about the presence or absence of bone protection in any of the notes. 14%(15) patients were on bone protection. 37%(40) were on vitamin D or calcium. 2 patients sustained a fracture in their fall. Conclusion This audit highlights that bone protection and osteoporosis risk are rarely being addressed post fall. To improve this we are going to give education on post falls assessment (including evaluating osteoporosis risk and assessing current bone protection or need for bone protection) to incoming intern groups and doctors on teams assessing falls. We will reaudit 3 months after this education to evaluate whether there has been an improvement.