Consider alcohol, sedatives when assessing fall risk
Consider alcohol, sedatives when assessing fall risk
Otherwise, patients may be missed
If you are relying solely on the Hendrich Fall Risk Model to identify patients at high risk for falls in your ED, you might be overlooking patients at risk. When researchers looked at 57 falls that occurred in the ED at Methodist Hospital of Indiana in Indianapolis over a two-year period, they found that the tool would have predicted only one-third of those falls. Of the patients who fell but weren't identified as being at risk, 11 were intoxicated with alcohol, and 11 received a potentially sedating medication.1
"We feel it is important to get the message out to ED nurses that they must recognize the unique characteristics in the ED patient that can predispose them to a fall," says Mary Ross, RN, BSN, CEN, one of the study's authors and an ED nurse at Methodist.
Currently, an ED-specific screen for falls to be done electronically at triage is being developed at Methodist. "If positive, it will launch a tracking board icon to alert all staff to the potential fall risk," says Ross.
Diana Tarone, RN, BSN, clinical coordinator for the ED at St. Luke's Hospital — Bethlehem (PA) campus, says to look for these risk factors: Recent falls, history of falls, patient age, difficulty with ambulation, use of assistive devices, weakness, dizziness, lightheadedness, mental status, confusion, disorientation, extremity injury, head injury, impaired eyesight or hearing, drug or alcohol impairment, medication side effects, and presence of intravenous access if arriving via emergency medical services.
At Saint Margaret Mercy's Hammond Campus Emergency Department in Dyer, IN, the ED "has a very low fall population," says Sheree Tylicki, RN, ED nurse manager. "To some degree, we treat all patients as though they may be a fall risk." To reduce risks:
• Alert inpatient nurses.
Miriam Chapman, RN, nurse manager of the ED at Long Island College Hospital of Brooklyn (NY), says that the ED's faxed reports to the floors for admitted patients include falls awareness. "This helps with appropriate bed assignment. A patient at risk for falls is placed closer to the nurse's station," she explains.
• Make at-risk patients visible.
St. Luke's ED nurses apply yellow bracelets to patients deemed to be at high risk for falls and give them yellow blankets and yellow nonskid slipper socks.
"These items discreetly allow caregivers to quickly identify a patient at high risk for a fall," says Tarone.
Reference
- Terrell KM, Weaver CS, Giles BK, et al. ED patient falls and resulting injuries. J Emerg Nurs 2009; 35:89-92.
Give your patient some company to stop fall risk Restraints are last resort A confused elderly woman with a history of frequent falls was waiting for transport after being discharged from the ED at St. Luke's Hospital — Bethlehem (PA) campus, and ED nurses took many precautions. The stretcher was in the lowest position, the side rails were up, the call light was in reach and clipped to the blanket next to her, and the television was on for diversion. Despite all this, the patient still appeared anxious and continued to attempt to climb off of the stretcher. She probably would have fallen, if not for another action taken by the ED charge nurse, says Diana Tarone, RN, BSN, clinical coordinator for the ED. "She assisted the patient into a wheelchair and brought her out to the charge desk for close observation, next to herself and the unit clerk," says Tarone. "The brakes were set on the wheelchair, and the patient was content sitting there in the company of staff, shuffling through some papers, and occasionally conversing with passersby. She no longer appeared anxious and was no longer trying to get up." Brian Silvas, RN, an ED nurse at Saint Margaret Mercy's Hammond Campus in Dyer, IN, says he likes to move the patient near the nurses' station for closer observation. "If family is present, we ask for their assistance with patient care observance," says Silvas. "For those patients who have no family or visitors to assist, we provide 1-to-1 supervision. Sometimes restraints are necessary to keep the patient safe, but that is a last resort." Pam Hric, RN, another ED nurse at Saint Margaret Mercy, recalls a non-English-speaking patient who kept getting out of bed every time Hric left the room. "I think she was frightened by being in an unfamiliar environment and by not being able to communicate with staff," she says. "We had a tech sit in the room with the patient to help her feel safer. She stayed in the bed and eventually fell asleep." |
Create a chalkboard to prevent falls "We are really looking at falls in our ED right now," says Joan Somes, PhD, MSN, RN, CEN, FAEN, ED educator at St. Joseph's Hospital in St. Paul, MN. "Many falls are related to the need to go to the bathroom and/or confusion." To address this, maintenance used chalk board paint to create a permanent chalkboard measuring 12 x 18 inches, on the wall by the patient's bed. "We went with this kind of paint vs. a grease board because we did not figure it would 'walk' like most of the stuff hanging on our walls," says Somes. The ED nurse writes the name of the patient, nurse, tech, and physician on the chalkboard. A daisy sticker purchased at a discount store was put on the bottom of the chalkboard. If the daisy is circled, this means the ED nurse has assessed that the patient can get up to go to the bathroom. If there is an "X" though the daisy, the patient is to stay in bed. "If there is no mark, the patient is not to be ambulated until the nurse has made an assessment that it is appropriate for this patient to be up and about," says Somes. "Staff are instructed to assess and mark the board for all patients, but it seems to be done more consistently when the patient is a fall risk." She also recommends "shaking the bed rail twice. We jiggle the railing back and forth to make sure it is secured." |
Do these interventions for patients at risk At St. Luke's Hospital — Bethlehem (PA) campus, ED triage nurses complete a fall risk assessment and identify every patient as being low, moderate, or high risk for falls. Here are interventions for each category: • Low risk: — Orient patients to their surroundings and the location of the bathroom. — Maintain the stretcher in the lowest position, and adjust the side rails as appropriate. — Ensure that wheelchair brakes are on. — Place the call bell and personal items within reach. — Remove room clutter, unnecessary equipment, and furniture. — Perform hourly patient rounding. — Use properly fitting nonskid, nonslip footwear. — Encourage use of assistive devices, such as hearing aids or glasses. • Additional interventions for moderate risk: — Instruct patient to call for assistance before getting out of bed. — Do not leave the patient unattended in the bathroom. — Use a gait belt or other assistive devices as needed for patient transfer and ambulation. • Additional interventions for high risk: — Encourage family members to stay with the patient. — Evaluate the need for constant supervision. — Consider placement in a room or area of high visibility. — Consider the use of a recliner for comfort. — Provide diversional activities. — Apply yellow identification bracelet. — Apply yellow slippers and/or yellow blanket for fall risk identification. — Perform more frequent patient rounding. — Do not leave patient unattended in patient testing areas. |
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