How to prevent falls

[Karolyte]

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???

[ComeTogether, LPN]

We had alarms on all of our patients, but we were acute rehab. No patients were permitted to get up unassisted unless they were cleared by PT. The rational being, if you can get up unassisted, you don't need to be here. They didn't go off unless the patient actually got out of the bed.

On a regular floor, we'd never be permitted to put an alarm on a patient who was A&O x3, If I were the patient I'd be turning that crap off myself!

[fromtheseaRN, BSN, RN]

All of our ortho patients have bed alarms on at all times. Our beds allow you to set the alarm to 3 different levels of movement sensitivity, and ours are set to only alarm if the patient actually gets up. It is the hospital policy, and it has prevented many, many falls on our unit (which funny enough, are mostly the young, fully A&O patients who underestimate how much the surgery and meds affect their ability to safely ambulate, and roll their eyes when we educate them about it). If a patient wants to be on our ortho unit with our staff specifically trained for orthopedics, they have to follow our rules. We are more than happy to find another room to accommodate the patient on another unit if they don't want a bed alarm... and each time we have the patient has requested a transfer back in order to be cared for by our ortho team.

[mmc51264, BSN, MSN, RN]

If a bed alarm is a traumatic sound, what about our code/emergency RRT alarms? that scares the crap outta me and it doesn't happen very often on my floor (Thank God, that's one of the reasons I like ortho!).

Everything in a hospital is loud. Getting woken up at 0400 for blood draws is stressful, but we have to do them. VS and blood sugar checks are stressful and all raises BP and HR. So does the screaming that the psych pt in the next room. That is why we try to get pts d/c as fast as is safe. Hospitals are not hotels.

If I were to tell risk management that a fall was d/t a bed alarm on, I would be liable in a lawsuit and they would distance me as far as they could. That is why we should all carry our own liability ins. Like I said, I would not accept the care of a pt who refused a bed alarm,

[cjcalimer]

Just to add to the general consensus....

As far as the OP goes...I have no idea! Sure, we have a few patients who buckle. Luckily, PT generally works with our patients post-op afternoon/evening so generally you have a heads up that this has been occuring. If it was really bad, we'd probably use a ceiling lift to the commode or an increased amount of assistance to the commode. Our patients don't generally have femoral blocks (just spinal with bupivicain) but sometimes might have a continuous peripheral femoral/adductor canal/sciatic block or something like an On-Q or Go pump. These are by nature adjustable, so if someone was having huge issues with buckling, it could easily be turned down. We also don't use knee immobilzers on primary TKAs. Revisions sometimes depending on the patient and physcian and if so, then these are worn at all times or very occasionally taken off only for ROM with PT.

As far as bed alarms go it is absolutely hospital policy that ALL patients (Ortho or non-Ortho, cleared by PT or not) have a bed alarm set to level 2 from 10pm until 6am. We do have refusal forms that patients can sign, however, we are strongly encouraged to only use this option if absolutely necessary because it really has no legal standing and would not hold up in court to absolve anyone from legal responsibilty if a patient fell. Patients are often frustrated with the bed alarms. A level 2 alarm really shouldn't go off unless your shoulders are off the bed. That being said, I frequently set mine to level 1 if it becomes an issue if someone is a frequent mover etc.. Because they are based on weight, it's helpful to make sure the patient is positioned in the center of the bed and that the bed scale is zeroed. If I have a patient that refuses the alarm, it makes me very nervous because now I automatically assume they are going to try to get up without me. So I don't shut their door unless they demand it and perform frequent checks and if I hear a peep from their room I'm high tailing it in there. So you might want to consider giving the alarm a fair chance before you refuse it. For your safety and your sanity and your sleep.

[RedSoxFan84]

We use a fall risk score and most of our total joints come up with a high fall risk score and require a bed alarm. We actually had an alert and oriented patient fall and fracture their wrist on POD 0 because they didn't want to call anyone and ended up falling. We have had patients sign a refusal for the alarm and we put it in the chart. I use my nursing judgement and will often not utilize the alarm because I encourage the use of the trapeze but I always take that on a case by case basis.

With regard to TKR, we always use a knee immobilizer and I haven't experienced any falls when ambulating as you've described.

[NurseLatteDNP, MSN, DNP, RN]

We have to score every patient for a fall risk and implement precautions based on their score. Bed alarms are used on everyone above a score 50. We also have low beds and a ceiling tile that says "call don't fall". Patients are most likely to fall when trying to use the bathroom on their own. Our aides help the nurses with hourly rounds. We used to have about 10 falls per month, but since implementation of the fall policy, we are down to about 2.

[outsidethebox]

We also have had a higher number of falls, especially related to nerve blocks. We have been working on this for a while now, but there is something you can do to help. We do not use immobilizer or bed alarms. We do hourly rounding during the day and every two hours at night. We also do not leave men or women alone if their feet are on the floor. We found that most of our falls had nothing to do with walking, but rather toileting. We also were made more conscientious about what we were asking of patients, such as handing them a roll of toilet paper and walking out of the room. Of course, this was when they fell trying to wipe. Also, setting them up for a bath and having clothes nearby, made them think they were capable of dressing themselves and down they went. The staff had to be fully trained and involved, but without immobilizers and alarms, we did it. It is just a matter of making clear what you actually think the patient is capable of. Men cannot re position themselves to the edge of the chair to use the urinal. Women cannot wipe themselves. No one can actually pull their pants up. We used to tell patients not to get up alone, but these are not people that got up alone. They did ask for help. They were not noncompliant. We just did not fully recognize their needs. Also, on bed alarms. Get rid of them. They are demeaning not only to patients, but to staff. It is like being whistled at. There is no place in a hospital for another way to call staff. You have call lights, zone phones, pagers, tele alarms, BP alarms, and pulse ox alarms. Please tell me how this prevents falls. If anything this awful noise triggers fight or flight and only increases falls.

[mmc51264, BSN, MSN, RN]

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:

Tell Duke University that. Everything we do is EBP. We have 100s of people on the IRB. If I get time, I will see if our Falls Champions (we have nurses that extra training in different areas, I am diabetes) can get me the info.