How to prevent falls

Specialties Orthopaedic

Published

I work on a busy ortho unit. Our recent problem is increased number of falls. Especially lower extremity joint replacement patient falls while getting them up and ambulating. Although we stay with the patient, use gait belt, bed and chair alarms, fall risk signs, yellow socks... We still end up with patient's knee buckling and falling. How do you prevent falls???

Good luck refusing the bed alarm. I had a hysterectomy last year, and they put a bed alarm on me. I was AOx3. I told them I wanted the alarm removed. They refused to disable it. I told them that as a competent adult that I had the legal right to refuse any drug, test, procedure, or intervention and that I was refusing the bed alarm. They refused to disable it. I told them that by using an alarm against my wishes they were committing medical battery and false imprisonment. They refused to disable it. After 2 hours of arguing I gave up.

Actually it's not that tough. If the staff won't listen, don't waste your time and theirs arguing - go over their head.

You pick up the phone and call the patient advocate and find out who is the hospital CMS compliance person. You then call that person and inform them that the purpose of your call is to file a formal grievance for violation of your patient rights under 42CFR482.13, and if the situation is not immediately resolved to your satisfaction you will be filing followup written complaints directly with both CMS and your state agency that regulates hospital licensing and operations.

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Actually it's not that tough. If the staff won't listen, don't waste your time and theirs arguing - go over their head.

You pick up the phone and call the patient advocate and find out who is the hospital CMS compliance person. You then call that person and inform them that the purpose of your call is to file a formal grievance for violation of your patient rights under 42CFR482.13, and if the situation is not immediately resolved to your satisfaction you will be filing followup written complaints directly with both CMS and your state agency that regulates hospital licensing and operations.

Thanks for that information. I will file that away for future use!

I did try the patient advocate, but they only work 8 :30 am - 5 pm and it was outside those hours (6 pm). They decided by 9 am that I was not a fall risk and turned it off.

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Specializes in orthopedic/trauma, Informatics, diabetes.

I still don't understand why someone would go through all of that to refuse something that was for your own safety? The next thing you know, the person that refuses and falls and injures themselves-they sue the hospital for injuries. Why is out of the realm of possibility that an otherwise alert and oriented person would become altered after sx and be a danger to themselves? I would refuse to assume care of a pt that would go through patient relations to allow themselves to be put at risk. Sorry, not risking my license for that kind of pt.

I just read that. You can't make informed consent to use or refuse a bed alarm if you are under the influence of narcotics. Filing a grievance does not supersede safety. For example, if a pt will not comply with staying on unit with their PCA, they risk it being d/c'd.

I just don't understand why it is an issue? Where are you going with BIL knees done w/o help?

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Specializes in Public Health.

I think it's more the problem of the sound it makes in the room. It's loud. If someone refuses, they should sign a waiver so that they can't sue when they fall. But I'm not sure if the regulatory bodies still count that as compliant with fall precaution protocols.

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I still don't understand why someone would go through all of that to refuse something that was for your own safety? The next thing you know, the person that refuses and falls and injures themselves-they sue the hospital for injuries. Why is out of the realm of possibility that an otherwise alert and oriented person would become altered after sx and be a danger to themselves? I would refuse to assume care of a pt that would go through patient relations to allow themselves to be put at risk. Sorry, not risking my license for that kind of pt.

I just read that. You can't make informed consent to use or refuse a bed alarm if you are under the influence of narcotics. Filing a grievance does not supersede safety. For example, if a pt will not comply with staying on unit with their PCA, they risk it being d/c'd.

I just don't understand why it is an issue? Where are you going with BIL knees done w/o help?

For the following reasons:

1. There have been 0 well designed studies that show bed alarms decrease the number of falls or the severity of falls in the acute care environment. There have been studies that show that they do NOT decrease the number of falls or severity of falls. The largest such study (27,672 patients) is here:

Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients

2. Bed alarms operate at a dB level that can cause hearing damage in as little as 15 seconds.

3. There have been studies that show that noise in the hospital increases heart rate and bp, negatively affects immune function, and results in poorer outcomes. Here's one:

Associations of exposure to noise with physiological and psychological outcomes among post‐cardiac surgery patients in ICUs

4. There are studies that show that all noise negatively affects patients, but the most damaging to patients is from alarms.

5. Bed alarms prevent the patient from moving around in the bed. They can't roll over or sit up or move in any way without an alarm sounding. Being unable to move increases the risk of skin break down and DVT. Being unable to reposition increases the use of narcotics for pain.

6. It is psychologically damaging. You feel like you are a prisoner.

7. It is a dignity issue.

You assume care all the time of patients that put themselves at risk. You have patients who don't use their incentive spirometer and who take off their SCD/PAS. You have diabetics that don't follow their prescribed diet. You have patients that refuse their stool softener and other prescribed medications. When this happens you document and move on.

Adults have the right to make health care decisions that they feel are best for them based on their values and goals.

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I think it's more the problem of the sound it makes in the room. It's loud. If someone refuses, they should sign a waiver so that they can't sue when they fall. But I'm not sure if the regulatory bodies still count that as compliant with fall precaution protocols.

The regulatory bodies do not require the use of a bed alarm. All they require is that you have a fall prevention plan for the patient and that the plan was followed. The plan could be instucting the patient to call for assistance before getting OOB, and offering toileting Q2 hours.

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I'm not against ALL use of bed alarms. I'm saying that bed alarms should not be applied to every patient. Just like everything in the care plan the patient's goals and values should be taken into consideration.

My 83 yo mother was in the hospital recently. Her nurse enabled her bed alarm. I didn't object because

1. My 115 lb mother required assist x 2 just to stand. She couldn't take a step even with assist.

2. She was very confused. She did try to get OOB w/o assistance repeatedly.

3. The alarm did not go off in her room. The alarm went to the nurse call only. Alarms were not going off in her room and increasing her agitation or causing delirium. Alarms were not going off in other patients' rooms causing anxiety in her. Alarms were not causing hearing damage.

4. The alarm was implemented with the patient's consent or the POA's consent (me).

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Specializes in orthopedic/trauma, Informatics, diabetes.

We are able to adjust volume and sensitivity of alarms. They are also hooked up to call light system so light outside door lights up and HUC is aware. Every policy in my hospital is EBP. I will try and find the literature.

I am not trying to be so contrary, but I did not expect such a violent response to something I use EVERY day in my practice. I have never had a pt refuse or complain (not the ones w/o AMS) other than the ones that really need it. I don't love having to drop everything and run into a room to see what is going on, but my colleagues and I follow the policy and whoever is closest to alarming bed goes and tends to it. It works for us and we have a pretty decent (low) fall rate. Right now, most of the falls are with PT/OT and hypotension issues.

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Specializes in PACU, pre/postoperative, ortho.

Also, our managers randomly check that alarms are set & PT will write up nurses who don't have alarms set if pt hasn't passed goals. Sucks, but it makes everyone a bit more diligent about keeping alarms on.

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We are able to adjust volume and sensitivity of alarms. They are also hooked up to call light system so light outside door lights up and HUC is aware. Every policy in my hospital is EBP. I will try and find the literature.

I am not trying to be so contrary, but I did not expect such a violent response to something I use EVERY day in my practice. I have never had a pt refuse or complain (not the ones w/o AMS) other than the ones that really need it. I don't love having to drop everything and run into a room to see what is going on, but my colleagues and I follow the policy and whoever is closest to alarming bed goes and tends to it. It works for us and we have a pretty decent (low) fall rate. Right now, most of the falls are with PT/OT and hypotension issues.

Thank you. I would be very interested in seeing the literature your hospital used in developing this policy.

I do NOT think you are trying to be contrary. I'm sure you are a conscientious nurse/employee who is trying to do the right thing for their patient and who is trying to follow their employer's policies. I also appreciate your willingness to listen to another viewpoint.

Where I have a problem are facilities who say they respect patient's autonomy and their values when what they really mean is they respect them only when the patients don't disagree with the hospital/providers.

My experience with the bed alarm was terribly traumatic because they refused to respect my decision about my care and they used the alarm to hold me prisoner. I know that sounds melodramatic, but I'm not exagerating how it felt to me. If anything I'm understating the psychological damage they did.

I understand from your perspective that using the bed alarm is keeping your patient safe, but don't assume that a patient who refuses an alarm is not making an informed and rational choice.

From my perspective as a patient you are using an alarm because I MIGHT try to get OOB w/o assistance. If I do get OOB w/o assistance, I MIGHT fall. If I do fall, I MIGHT get hurt. If I get hurt, it MIGHT be a serious injury. I also know that bed alarms don't prevent falls. They just alert staff that they MIGHT have a patient on the floor.

The use of a bed alarm definitely causes me psychological trauma. It definitely caused my HR and BP to rise. Increased HR and BP definitely increases the risk of bleeding and hematomas following surgery especially in the 1st 24 hours. (During the time I was on a bed alarm I developed a hematoma that necessitated a 2nd surgery.) The bed alarms definitely cause me ear pain and cause hearing damage. The bed alarms definitely made it so I couldn't move at all. They definitely increased by anxiety and caused me to request more pain med.

From my perspective as patient I made a very reasonable and logical decision about what was best for me. That was to not have a bed alarm and instead I would call for assistance to get OOB.

I would be interested in knowing what your risk management would say to do if you have a patient who refuses a bed alarm. Would using an alarm on a patient who has refused it constitute medical battery? I know from talking with several lawyers that it would in my state.

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For the following reasons:

1. There have been 0 well designed studies that show bed alarms decrease the number of falls or the severity of falls in the acute care environment. There have been studies that show that they do NOT decrease the number of falls or severity of falls. The largest such study (27,672 patients) is here:

Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients

2. Bed alarms operate at a dB level that can cause hearing damage in as little as 15 seconds.

3. There have been studies that show that noise in the hospital increases heart rate and bp, negatively affects immune function, and results in poorer outcomes. Here's one:

Associations of exposure to noise with physiological and psychological outcomes among post‐cardiac surgery patients in ICUs

4. There are studies that show that all noise negatively affects patients, but the most damaging to patients is from alarms.

5. Bed alarms prevent the patient from moving around in the bed. They can't roll over or sit up or move in any way without an alarm sounding. Being unable to move increases the risk of skin break down and DVT. Being unable to reposition increases the use of narcotics for pain.

6. It is psychologically damaging. You feel like you are a prisoner.

7. It is a dignity issue.

You assume care all the time of patients that put themselves at risk. You have patients who don't use their incentive spirometer and who take off their SCD/PAS. You have diabetics that don't follow their prescribed diet. You have patients that refuse their stool softener and other prescribed medications. When this happens you document and move on.

Adults have the right to make health care decisions that they feel are best for them based on their values and goals.

All valid and excellent points.

A patient has the absolute legal right to refuse any test, treatment, medication or procedure without prejudice to any other needed care - hospital policy does not trump that. I would hope that the facility would listen to the patient and respect their rights. The bottom line is that the facility only has three options:

1. Comply with the patient's request

2. Discharge the patient if their condition permits

3. Transfer them to another facility that can comply if it doesn't

If they stonewall you, there's always the pseudo passive/aggressive option - move in such a way as to deliberately set the alarm off every 10 minutes or so. They'll get the message pretty quickly.

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Specializes in Transitional Nursing.

My first thought is something isn't right. The patient is being asked to walk too far, is too medicated or the staff isn't properly trained on how to instruct the patient/support the pt.

Are they actual falls, or are they assists to the floor? If they're being ambulated, someone should follow with a wheel chair. If they're going to the bathroom, perhaps a commode is in order until they are more steady.

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