Rob Morris

Closed pelvic fractures : characteristics and outcomes in older patients admitted to medical and geriatric wards

OBJECTIVE To investigate the characteristics and outcomes of older patients with pelvic fracture admitted to medical and geriatric wards. METHODS All patients admitted to medical and geriatric wards with a pelvic fracture over a four year period were identified using the hospital clinical coding database. Data were collected from casenotes, hospital and Family Health Services Authority databases. Where available, pelvic radiographs were graded according to the Singh index. RESULTS The casenotes of 148 patients (126 women) were studied; 83% (n=123) of patients suffered a pelvic fracture in low energy trauma. Mean (SD) length of hospital stay was 21.3 (17.6) days. Single breaks of the pubic rami accounted for 47.2% (n=68) of all fractures. Inpatient mortality was 7.6% and at one year was 27%. There was a marked adverse effect on the mobility of survivors with all patients using at least a walking stick at discharge and 51.1% (n=70) needing assistance for mobility. Although 70.9% (n=83) of patients admitted from home (or warden aided accommodation) were able to return there, 84.3% (n=70) of them required extra community support. Rates of institutionalisation rose from 20.9% (n=31) at admission to 35.8% (49/137) of survivors at discharge. Altogether 93% (n=107) of 115 patients, in whom adequate quality pelvic radiographs were available, were assigned a Singh index grade of 4 or less indicating the presence of osteoporosis. CONCLUSIONS Pelvic fractures are often the result of low energy trauma. They are associated with appreciable inpatient and considerable one year mortality. They also have marked negative effects on mobility in the short term. They result in increased levels of dependency in terms of higher levels of community support and rates of institutionalisation. On the evidence of Singh index grading, pelvic fractures are associated with low bone density.

Multifactorial day hospital intervention to reduce falls in high risk older people in primary care: a multi-centre randomised controlled trial [ISRCTN46584556]

Falls in older people are a major public health concern in terms of morbidity, mortality and cost. Previous studies suggest that multifactorial interventions can reduce falls, and many geriatric day hospitals are now offering falls intervention programmes. However, no studies have investigated whether these programmes, based in the day hospital are effective, nor whether they can be successfully applied to high-risk older people screened in primary care.The hypothesis is that a multidisciplinary falls assessment and intervention at Day hospitals can reduce the incidence of falls in older people identified within primary care as being at high risk of falling. This will be tested by a pragmatic parallel-group randomised controlled trial in which the participants, identified as at high risk of falling, will be randomised into either the intervention Day hospital arm or to a control (current practice) arm. Those participants preferring not to enter the full randomised study will be offered the opportunity to complete brief diaries only at monthly intervals. This data will be used to validate the screening questionnaire. Three day hospitals (2 Nottingham, 1 Derby) will provide the interventions, and the University of Nottinghams Departments of Primary Care, the Division of Rehabilitation and Ageing Unit, and the Trent Institute for Health Service Research will provide the methodological and statistical expertise. Four hundred subjects will be randomised into the two arms. The primary outcome measure will be the rate of falls over one year. Secondary outcome measures will include the proportion of people experiencing at least one fall, the proportion of people experiencing recurrent falls (>1), injuries, fear of falling, quality of life, institutionalisation rates, and use of health services. Cost-effectiveness analyses will be performed to inform health commissioners about resource allocation issues. The importance of this trial is that the results may be applicable to any UK day hospital setting.SitesGeneral practices across Nottinghamshire and Derbyshire.Day hospitals:Derbyshire Royal Infirmary (Southern Derbyshire Acute Hospitals NHS Trust)Sherwood Day Service (Nottingham City Hospital Trust)Leengate Day Hospital (Queens Medical Centre Nottingham University Hospital NHS Trust)

Prevention of falls in hospital

ABSTRACT Falls among inpatients are the most frequently reported safety incident in NHS hospitals. 30–50% of falls result in some physical injury and fractures occur in 1–3%. No fall is harmless, with psychological sequelae leading to lost confidence, delays in functional recovery and prolonged hospitalisation. Yet falls are not true accidents and there is evidence that a coordinated multidisciplinary clinical team approach can reduce their incidence. Identification of multiple underlying risk factors coupled with clear interventions to ameliorate the impact of each has been shown to reduce the incidence of inpatient falls by 20–30%. The implementation of complex multiprofessional interventions is challenging and successful schemes seek to nurture a culture of vigilant safety consciousness in all staff at the clinical interface. Strong leadership and organisational oversight help to combine this cultural evolution with relevant evidence and rigorous measurement of performance in order to improve patient safety. The results of national audit suggest that NHS acute hospitals could do more to reduce the incidence of falls among inpatients.