The Long Lies Study

When a person is unable to get up off the floor for a prolonged period of time after a fall, this is referred to as a ‘long lie’. Around 1 in 3 adults over 65 have at least one fall a year and around one in 5 of these will be a long lie (over 1 hour). People who have a long lie may suffer a number of complications, including dehydration, pressure injuries, muscle and tissue damage and psychological harm. Longer ambulance response times due to growing pressure on ambulance services means that people are being left on the floor for increasing periods of time. The problem of long lies may therefore be leading to worse health outcomes for an increasing number of people.

Whilst there has been a lot of research to understand how to prevent people falling, there is currently little information about how to manage people once they have fallen. Existing advice given to patients who have fallen assumes that an ambulance will arrive quickly. It is also based around concerns that the patient may have a hip fracture and need surgery. However, most people who fall do not have a fractured hip, and current advice that people should not be moved or should restrict fluids may be more dangerous for people who have a long lie.

We propose to do some research to understand more about what happens when people have a long lie and how people can be helped whilst waiting for an ambulance. We will work with patients and the public as well as relevant health and social care organisations. We will do this using the following research activities:

1. We will analyse an anonymised dataset of linked ambulance, emergency department and hospital patient records to understand which patients have a long lie and what happens to them after they have fallen. We will look at what health and social care services patients used during the 12 months after their fall and whether this is different for people who had a long lie. We will also use this data to understand the length of lie where the risk of long-term damage is increased. This will help ambulance services when deciding how to prioritise calls in future.
2. We will apply standard NHS and social care costs to the linked dataset to estimate the cost of care for people following their fall. We will compare costs of people who have a short lie with those who have a longer lie. We will look in detail at hospital notes for a subset of 200 patients. This will help us understand exactly how the long lie affected their health and care required after their fall (e.g. whether longer hospital stays are due to kidney injury).
3. We will understand how health and social care organisations currently manage patients after a fall to reduce the harm from a long lie. We will do this using a telephone survey of ambulance services and a survey of residential or care home staff.

Research Question

What is the scale, impact and care trajectory for patients who have a long lie after a fall and what interventions might mitigate the impact of a long lie?

Background

Falls are a significant public health problem, costing an estimated £2.3 billion p.a. in the UK.  Falling risk increases significantly with age, with around a third of adults over 65 having at least one fall a year. Many older people who cannot get up off the floor with help are likely to be triaged as a low priority call by the ambulance service in the absence of any apparent life-threatening signs or symptoms, and experience a long lie as a result. Patients who are unable to get up off the floor after a fall for over an hour may suffer a number of complications including hypothermia and secondary hypothermia, dehydration, pressure injuries, muscle and tissue damage and delayed medical treatment, as well as significant psychological damage.Incidence of long lies is increasing, in part due to increasing ambulance response times. Current guidance for treatment of patients with a long lie is inconsistent and little is known about the characteristics of patients who have a long lie, the social, health and economic impact of these long lies and whether any potential interventions may mitigate the impact of a long lie.

Aims and Objectives

Aim: This study aims to understand the characteristics of patients who have a long lie, their care trajectory and the health, psychological and economic impact of the long lie, as well as understand potential interventions to mitigate the impact of a long lie.

Objectives:

• To characterise the frequency and duration of long lies in ambulance patients using data from one UK region held within the CUREd+ routine linked dataset;
• To understand the care trajectory, health outcomes, and health resource use of patients after a long lie using the CUREd+ linked dataset;
• To understand the mechanisms by which a long lie impacts care trajectories using hospital notes review for a subset of 200 patients identified from ambulance service data;
• To identify interventions used to mitigate the impact of long lies before arrival at hospital using a survey of ambulance services and social care providers;
• To understand how key stakeholders mitigate long lies using staff interviews;
• To understand the impact of long lies on patient and carers using interviews with patient and carers;
• To refine the definition of a long lie that is likely to cause harm and identify actions to reduce their consequences for patients.

Methods

To address our objectives we will undertake a mixed methods study with seven inter-related work packages. We will use a linked dataset of routine emergency care data in the Yorkshire & Humber region (the CUREd+ dataset) to explore the demographic and clinical characteristics of patients experiencing a long lie and understand trends in the frequency and duration of long lies. We will also utilise this dataset to understand the care trajectory of long lie patients and model their healthcare resource use to understand the economic impact of long lies. Through detailed review of hospital notes for a sample of 200 patients, we will explore the mechanisms by which a long lie impacts the patient care trajectory and key health outcomes for the patient.  This qualitative and quantitative work will allow us to refine and improve the understanding of the length of lie likely to result in harm. We will identify existing interventions used in health and social care settings, and understand strategies used by key stakeholders to manage patients who are at risk of a long lie and  avoid harm by conducting semi-structured interviews and surveys with13 ambulance service clinical leads and up to 26 ambulance, hospital and social care staff across 3 ambulance service areas. We will interview a diverse group of up to 24 patients who have experienced a long lie after a fall and their carers, in order to understand the impact of a long lie on issues important to patients.

Recruitment and interview design will be conducted with guidance of PPI experts to ensure relevance and sensitivity.  Findings from multiple workstreams will be integrated, and working with diverse key stakeholders across the identified care trajectory  we will co-produce guidance for hospitals, ambulance services, and patients/carers, as well as recommendations for service policy to reduce risk to patients and avoid unnecessary healthcare resource use.

Timelines for delivery

The project will take place over 27 months, including 6 months for project set up and NHS ethics, CAG, HRA and data approvals. WP1 and WP2: Understanding characteristics and care trajectory of ambulance service patients who have been unable to get up after a fall, and understanding healthcare resource use by patients after their fall, will take place during months 7-18. WP3:  Understanding the mechanisms for impact of a long lie, will build on early work from WP1 and take place in months 13-21.WP4: Identifying how health and social care organisations manage and mitigate for long lies will take place in months 7-12. WP5 and WP6: Understanding how key stakeholders mitigate for long lies, and exploring the impact of long lies on patients and carers, will run concurrently during months 9-16. Data analysis and integration will take place over months 18-24. WP7: Co-production of guidance and recommendations, and dissemination of findings will take place in months 24-27.
 

The Team

Name	Organisation	Email address
Dr. Fiona Sampson (Chief Investigator)	The University of Sheffield	f.c.sampson@sheffield.ac.uk
Dr. Fiona Bell	Yorkshire Ambulance Service NHS Trust	fiona.bell7@nhs.net
Dr. Jen Lewis	The University of Sheffield	jen.lewis@sheffield.ac.uk
Dr. Joanne Coster	The University of Sheffield	j.e.coster@sheffield.ac.uk
Dr. Valentine Ngwa	Mid Yorkshire NHS Teaching trust
Miss Shannen Beadle	Mid Yorkshire NHS Teaching trust
Mr Richard Pilbery	Yorkshire Ambulance Service NHS Trust
Mrs Lyn Wilson	Mid Yorkshire NHS Teaching trust
Mrs Maxine Kuczawski	The University of Sheffield	m.kuczawski@sheffield.ac.uk
Ms Liz Jones	National Care Forum
Professor Simon Dixon	The University of Sheffield	s.dixon@sheffield.ac.uk
Professor Suzanne Mason	The University of Sheffield	s.mason@sheffield.ac.uk

Funding

This study is funded by the NIHR Health Services and Delivery Research.  For more information, see here.