Track patient falls, but beware restraints
Track patient falls, but beware restraints
Are patient falls tripping you up?
It’s gotten harder to prevent patient falls now that the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, is hammering away at the issue of restraints. Facilities nationwide are scrambling to deal with the issue, but it often comes down to "damned if you do, damned if you don’t."In the geriatric psychiatry unit of Gratiot Community Hospital in Alma, MI, staff have increased the use of "pillow buddies" to help stabilize patients so they don’t lean forward and fall or slip out of their chairs. Pillow buddies are heavy pillows that sit on patients’ laps while they’re in a wheelchair. Most patients can lift the pillows out of the way when they choose, but they serve as reminders not to get up without asking for help.
Carole H. Patterson, RN, deputy director of the department of standards at the Joint Commission, says emphatically that pillow buddies are not restraints under the Joint Commission standards. In addition, she says, "Hospitals do not have to document wheelchair seat belts as restraints as long as the patient can undo the seat belt, just as one does in a car. If the belt is locked behind the patient where he cannot reach, however, he is considered to be tied in the chair and restrained."
Surveyors see it differently
But quality managers on the front lines see mixed reactions from individual surveyors on pillow buddies. "The Joint Commission is working on revisions to its definition of restraints and is trying to clarify the issue," explains Jill Goodell, MS, CPHQ, quality and risk manager at Gratiot. "It’s very murky right now. No one here is certain where the Joint Commission stands on pillow buddies."Clearly, according to the Joint Commission definition, the pillow buddy would not be considered a restraint. "But from our experience," continues Goodell, "surveyors are inconsistent on how they use the definition. There’s no clear answer at the moment."
Gratiot developed a system for tracking patient falls, and two years later the rates are down. In addition to possibly getting unwanted attention from the Joint Commission, falls can result in lawsuits and costly extended lengths of stay. (See related article on JCAHO restraint policy, p. 34.) Although there is no specific mention of patient falls in the Joint Commission’s standards, the occurrences come under the category of risk management.
"The Joint Commission’s interest in falls is based on the assessed needs of a patient population," says Ann Kobs, associate director of the Joint Commission. "We don’t track them, but if you find you have a population that’s prone to falls, we want to know what you’re doing about it. It’s all driven by patient needs and what’s going on in the organization. In the same way, we don’t say you must track needlesticks, but that’s part of a good employee health program."
The problem is especially acute on units with elderly patients. Pinpointing causes and correcting them can be a challenge. Goodell noticed an overall increase in the number of patient falls while monitoring the hospital’s occurrence reporting process two years ago. Something had to be done. Since there was no easy way to determine what was causing the increase, Goodell gathered all the recent fall reports and divided them according to which nursing units they involved. That analysis showed the highest number of falls were occurring on the geriatric psychiatry unit and the medical rehabilitation unit.
"That wasn’t a real surprise, but we weren’t sure how much to attribute the falls to those units until we actually analyzed the reports," Goodell recalls. "Then it was clear that those two units needed a lot of our attention."
After conducting a literature review on patient falls and how to prevent them, Goodell met with the managers of the two units to review the cases and find ways to improve the situation. A key part of their analysis was examining each fall and looking for information such as where it happened, what time of day it occurred, and what category of staff were present. Patients were not injured in most cases, but Goodell points out that the risk of serious injury is high with any patient fall. And a patient fall can be difficult to defend in case of a lawsuit, especially if serious injury results.
Goodell’s research showed patient falls often can be traced to problems unique to the particular nursing unit where they happen. She devised separate solutions for the geriatric psychiatry and medical rehabilitation units.
In the geriatric psychiatry unit, many of the falls happen because patients there are more disoriented than patients on other units and often are unaware of what they are doing. With that in mind, Goodell worked with the unit manager to adjust staffing so more staff were available at the times of day when most falls occurred. The mix of nurses and assistants can make a substantial difference in whether staff have enough time to properly aid patients at risk. Staff stretched too thin can find it impossible to devote enough attention to individual patients and leave them unattended.
In the medical rehab unit, Goodell and the unit manager had to find a way to decrease falls without hindering patients’ independence — finding a compromise between leaving patients alone and at risk of falling, and taking away all independence. The solution was educating staff and family members, not the patients.
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