Essential Falls Management

Insomnia and Risk of Falls

Dr. Rein — Fri, 13 Apr 2012 19:07:00 +0000

For nursing home and hospital patients, insomnia is an important risk factor for falls and injury. Sedative-hypnotic medication, often used to treat insomnia, is a leading cause of falling. Sleep medications produce significant balance and cognitive impairments upon awakening from sleep. While drugs can impair balance and contribute to falls, untreated sleep problems are also a risk factor for falls. In fact, patients with untreated or inadequately treated insomnia may have a higher risk for falls than those who use hypnotics. Lastly, there are multiple mental and physical factors that, when combined with insomnia, can lead to falls. Consequently, managing fall risk in patients with insomnia can be challenging. Aside from, designing behavioral approaches to treat insomnia (such as, regular exercise, exposure to light during the day, an environment that is conducive to sleep, avoidance of caffeine, etc.), the use of a fall alarm or monitor (FALLGUARD® SAFETY AUTO-RESET™ FALL PROTECTION & MOBILITY MONITOR) to detect and alert staff of unsafe mobility in patients with insomnia can be beneficial.

Osteoarthritis and Fracture Risk

Dr. Rein — Wed, 16 Nov 2011 22:06:41 +0000

Elderly women with osteoarthritis (OA) have a 20% higher risk of bone fractures and experience 30% more falls than those without arthritis. OA results in changes that include bony overgrowth, fluid accumulation, and loosening and weakness of muscles and tendons; all of which may cause pain/swelling, limit movement, and increased fall risk. An increase in the number of falls is the cause of a higher number of fractures (i.e., the more falls one has, the greater the likelihood of a fracture). To guard against fractures, patients with OA should be:

Properly assessed for both fall and fracture risk.
Provided with a hip protector to guard against hip fractures.
Provided with a bedside floor mat to prevent injurious bed falls.

Patient Activity and Fall Risk

Dr. Rein — Fri, 11 Nov 2011 17:49:26 +0000

It’s often assumed that restricting patient activity can reduce the risk of falling. This, however, is a mistaken belief. According to recent research (*), hospital patients who fall do not walk around anymore than patients who don’t fall. In fact, keeping patients immobile can backfire; not moving enough can lead to poor muscle tone/decreased balance and increased fall risk.

To examine the incidence of falls among ambulatory and non-ambulatory elderly patients, researchers equipped 35 elderly patients with small electronic devices that recorded every step they took. They determined that there was no difference in the amount of walking between the two groups.

Nevertheless, they did find that falls were associated with delirium and/or poor cognitive function. Additionally, all of the falls took place at night, with 60% of falls related to trips to the bathroom.

Using a fall alarm is a good way to reduce the risk of ‘toileting falls’ at night. Nurses often rely on toileting rounds to detect patients needing to use the toilet. This strategy, however, is not very effective at night (no one wants to wake a sleeping patient and ask them if they need to use the bathroom) or in patients with poor cognition who may not be able to communicate their needs.

(*) Fisher SR, Galloway RV, Kuo YF, et al. Pilot study examining the association between ambulatory activity and falls among hospitalized older adults. Archives of Physical Medicine and Rehabilitation, 2011.

Nursing Shift Changes and Falls

Dr. Rein — Fri, 04 Nov 2011 20:23:39 +0000

In hospitals and nursing homes across the country, many falls occur during nursing shift changes. The majority of falls occur to patients who are already identified as being at fall risk; those with poor mobility (e.g., gait/balance impairment) and cognitive impairment. The reason for falling? During shift changes, patients are generally left alone and without the supervision, monitoring and care they need. These mishaps create a tremendous liability for management. Key strategies to eliminate falls during shift changes include:

Provide nurse rounding of high-risk patients during shift changes.
Discussing high fall risk patients during shift change handoffs.
Promoting communication between nursing staff, which includes addressing the patient’s:
Identified fall risk factors
Current risk condition /fall precautions
Current fall management care plan

Utilizing fall alarms during shift changes as a safety measure; alarms detect unsafe patient activity/send a signal to nurses that patient’s are engaging in unsafe behavior.

Avoiding Risk of Skin Trauma

Dr. Rein — Mon, 19 Sep 2011 11:40:48 +0000

The risk of skin trauma (bruises, abrasions and tears) is great in patients with sensitive skin. Skin trauma frequently occurs during:

A fall against or bump into furnishings with sharp edges, such as dressers, tabletops, chair frames, wheelchairs, unpadded side rails, and other objects.
Caregiver assistance with mobility (lifting, turning, positioning and transferring techniques).

Injured Body Part

The upper extremities (forearm and hand) are most frequently the site of injury, followed by the leg.

Identified Risks

Advanced age
High fall risk status
Sensory loss
Compromised nutrition
History of previous skin trauma
Cognitive impairment
Dependency
Poor mobility
Polypharmacy
Use of an assistive device
Decreased vision

Prevention

Patients should be encouraged to wear long arm sleeves or pants for protection against injury.
Educate staff on the importance of carefully handling elderly patients with frail skin.
Encourage proper positioning, turning, lifting, and transferring techniques.
Provide padding to bed rails, wheelchair arm and leg supports, and any other equipment that may be utilized to protect the patient from accidentally bumping into a hard surface.
Provide a well-lit environment to minimize the risk of patients/residents bumping into equipment or furniture.

Do you have a problem with skin tears in your fall risk patients? What methods do you use to reduce the risk of skin tears? Your comments are most welcome.

Nursing Strategies to Reduce Fall Risk: Impaired Mobility

Dr. Rein — Mon, 19 Sep 2011 11:33:59 +0000

Mobility Problems

Impaired mobility (i.e., an inability to ambulate and transfer safely and independently) is a major fall risk factor.
Diseases directly affecting mobility (i.e., strength, flexibility and balance) include acute and chronic conditions that affect the muscular, skeletal or neurological systems and limit a patient’s ability to move about safely.
Disorders such as stroke, arthritis, diabetes, and Parkinson’s disease may affect a resident’s muscle strength and reaction time. As a result, walking becomes more difficult and balance control and coordination are affected.
Any weakness or impairment of the legs and/or arms (e.g., from arthritis, muscular weakness, stroke, etc) can inhibit safe transfers, ambulation and balance. Diseases such as arthritis, diabetes, and stroke can alter muscle strength in the legs and arms. As a result, using leg and arm strength while getting out of a bed or up from a chair or toilet becomes much more difficult. This can easily lead to balance loss and increased fall risk.

Risk Reduction Strategies

Anticipatory care (anticipate patient’s toileting needs, hunger, thirst, etc. and meet those needs, as appropriate)
Supervision/observation (monitor at-risk patients and provide assistance with ambulation/transfers when necessary). Consider use of fall alarm to assist with monitoring.
Continuously assess for environmental hazards interfering with safe mobility/eliminate as appropriate
Beds (adjust to a height that allows patients to transfer easily)
Chairs (seat height should allow patient to sit and rise easily)
Bathrooms (install handrails around the toilet for safe transfers)
A gait belt should be used whenever possible, especially when assisting a patient during transfers/ambulation
Instruct patients on the proper use of the nurse call bell, including when and how to call for assistance. Consider the use of a fall alarm for those patients non-compliant with use of call bell
Teach safe transfer techniques from bed, chairs, toilet, and wheelchairs.
Make sure that canes, walkers, and wheelchairs are in good condition
Arrange furniture to allow for wide walking/wheeling spaces.

Add to the discussion. What strategies do you use to prevent falls in patients with impaired mobility? Your comments are most welcome.

How To Use Fall Alarms

Dr. Rein — Wed, 15 Jun 2011 11:50:51 +0000

Fall alarms are devices designed to assist nurses in their fall prevention efforts. Alarms have several functions, which include:

Warning Alert (Staff)

Warn staff that the patient has changed position and is about to leave their bed, chair, wheelchair or toilet. This may give staff enough time to assist the patient.
Warn staff that the patient has shortly left the bed, chair, wheelchair or toilet. This may give staff enough time to intercept the patient before a fall
Promote speedy assistance to patients who have already fallen in order to promptly provide care. This can help reduce fall complications, such as the amount of time that a patient lies unaided.

Warning Alert (Patient)

Alarm, in some cases, can warn patients themselves. When a patient attempts to leave their bed, the alarm can activate a verbal reminder through speakers/intercoms reminding the patient to wait for staff. In some cases the sound of the alarm may prompt the patient to sit back in bed, chair, wheelchair or toilet (i.e., the alarm warns the patient that they are “doing something that they shouldn’t be doing”) and/or remind the patient to call for assistance.

Nurse Call Bell

Serve as an alternative to nurse call bells in patients who are noncompliant or unable to use their call bell because of cognitive and/or physical impairments. The nurse call bell is used immediately prior to the fall in only 3% of cases; up to 24% of individuals who do not use the call bell feel that they don’t need assistance.
Alarms, which do not require active participation by patients/residents to trigger, may be preferable to nurse call systems, which demand active participation by individuals to activate.

Assessment/Care Planning Tool

Serve as an assessment or planning tool by monitoring the frequency of attempts to leave the bed, chair or wheelchair, which can help identify emerging trends and interventions. Coupled with initial and ongoing risk assessments, fall alarms can inform staff about a patient’s habits. For example, a patient may consistently attempt to arise at a certain hour to go to the bathroom, while another patient may get up at nonspecific times, driven by an urge to wander. As a result of such a “history,” nurses can adjust their attention and care to each patient’s habits and needs.

Monitoring Assistance

Allow staff more freedom of time (avoiding constant supervision of patients at risk). This provides nurses more opportunity to work with patients as opposed to spending time on surveillance or being frequently interrupted to observe patients.
Allow staff to monitor patients post fall. Falls are the best predictor of future falls and up to 70% of repeat fallers engage in the same activity

Do you use fall alarms? What is your experience (both positive and negative) with fall alarms? Your comments are most welcome.

Indications for Fall Alarms

Dr. Rein — Wed, 15 Jun 2011 11:44:04 +0000

Fall alarms serve as an “early warning system”; they alert nursing staff when “at-risk” patients are engaging in activities that are likely to result in falls. The use of fall alarms is based on specific criteria and/or risk factors.

Criteria
Patient experiences:
•    Fall(s) from bed, chair, wheelchair or toilet.
•    Fall(s) shortly after leaving bed, chair, wheelchair, toilet or is found on floor after an unwitnessed fall.
•    Impaired mobility/ demonstrates unsafe bed, chair, wheelchair or toilet transfers.
•    Cognitive/communicative problems (e.g., forgets to use call bell or ask for assistance, can’t remember or follow instructions).
•    Nocturia (i.e., excessive urination at night).

Risk Factors
History of Falls
•    A history of falling is one of the most reliable predictors of future falls. Patients with recurrent falls may repeat the circumstance or characteristics of their falls, such as leaving their bed and toileting at night. Knowing the circumstances of a patient’s/ resident’s fall(s) can help design targeted interventions and the appropriate use of fall alarms.

Balance or Gait Problems
•    Patient has problems walking or standing without assistance from a walker or requires staff assistance.

4 or More Medications
•    Multiple medications can inhibit motor skills and/or personal safety awareness and increase fall risk. Common drugs include those that act on the central nervous system, such as sedatives and tranquilizers.

Muscle Weakness
•    Any weakness or impairment of the legs and/or arms (e.g., from arthritis, muscular weakness, stroke, etc) can inhibit safe transfers, ambulation and balance.

Newly Admitted
•    New admissions should be watched thoroughly until their condition is fully assessed. Many falls occur during the early period of institutionalization or the first 72 hours of stay.

Continence Problems
•    Patients with bladder problems are more inclined to get up without assistance to use the bathroom; individuals with nocturia, incontinence and those requiring toileting assistance are especially at high fall risk.

Cognitive Problems
•    Altered mental status (e.g., confusion, disorientation or impaired memory) is one of the most important risk factors for falling. Cognitive losses can cause errors in judgment (i.e., inability to recognize a difference between safe and hazardous transfers), forgetting to use the nurse call bell or not recognizing the purpose of the call bell (i.e., not making a connection between pushing a button and getting help), and not asking for assistance or not recognizing a need for assistance (i.e., overestimating the ability to transfer and walk safely or denying any mobility limitations).

Mobility Problems
•    Inability to ambulate and transfer safely and independently. Diseases directly affecting mobility (i.e., strength, flexibility and balance) include acute and chronic conditions that affect the muscular, skeletal or neurological systems and limit a patient’s ability to move about safely.
What risk factors do you use to determine the need for a fall alarm? Your comments are most welcome.