Introduction and Contents

Falls are a leading concern in acute care or long-term care facilities. The majority of falls take place in the bedroom during transfers from bed. As a result, there is an urgent need to address the issue of bed safety. This CD-ROM is designed to provide staff members with an increased knowledge of why falls from bed occur and what factors are associated with a risk of falling from bed; with this information, staff will be able to more easily explore appropriate solutions aimed at reducing clients risk of falling. Several agencies have focused on bed safety, including the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Patient Safety Foundation (NPSF), and the U.S. Department of Veterans Affairs (VA). Some of the patient safety issues identified concern the hospital bed, including side rail and entrapment injuries and falls. This CD-ROM provides an understanding of the potential for bed falls and how to prevent them. Although various approaches to fall prevention exist, best practice suggests that a program of prevention is most effective when organizations have a formal strategy to prevent bed falls and staff have an increased awareness of risk factors and potential preventive strategies as well as knowledge of which clients are at risk for falling.

ABOUT THIS CD-ROM

This CD-ROM contains a Microsoft PowerPoint presentation, Bed Safety, that provides in-service educators with an off-the-rack lecture to use as part of ongoing inservice staff education on fall prevention or in the orientation of new staff members. The presentation slides can be printed as handouts to accompany a lecture or be printed along with explanatory notes to be used as a self-instruction program. (A self-instruction program may be especially helpful in accommodating the educational needs of volunteers and part-time staff.) For those users without access to Microsofts PowerPoint software, simply log onto http://www.microsoft.com and download the free PowerPoint Viewer 2003. This allows any user to view and print the presentations. In addition, the CD-ROM contains all of the decision-making guidelines and assessment tools that the staff members need to ensure bed safety for all clients. These documents are presented in PDF format and can be viewed using Adobe Reader, which is included on this CD-ROM. All documents on this CD-ROM can be accessed from the current document. Links embedded in the Table of Contents below will take users directly to the section or form indicated.

Essential Falls Management Series: Guide to Bed Safety. by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.

TABLE OF CONTENTS
Bed Safety Overview An overview about the importance and consequences of bed falls, the causes of bed falls, and strategies aimed at reducing bed falls Bed Safety A PowerPoint presentation, with notes, designed for staff education; reviews the extent and complications of bed falls, the causes and risk factors for bed falls, and strategies aimed at reducing risk, including an approach to preventing bed falls Bed System Entrapment Guidelines A handout that describes the hazards of and modifications to prevent entrapment injuries Performance-Oriented Bed Mobility Screening Tool A screening tool to assess risk for bed falls Bed Safety Checklist A checklist to help nursing staff spot and correct common bed hazards Bed Safety Protocol A protocol that describes a step-by-step approach to reducing bed falls, including a risk screening and intervention tool Sitter Guidelines Guidelines for implementing a sitter program Client Education Plan: Bed Safety An educational handout designed to inform clients and families about bed fall risk and preventive interventions Side Rail Guidelines Guidelines for the appropriate use of side rails Bed Alarm Purchase Guidelines Guidelines for purchasing bed alarms Bed Alarm Criteria Criteria for the appropriate use of bed alarms

Essential Falls Management Series: Guide to Bed Safety. by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.

Introduction and Contents

Bed Safety Consent Form A consent form for clients or families that allows use of bed safety equipment; it helps to protect staff members and the facility against the risk of legal liability in the event of injurious falls Bed Safety Audit Guidelines Guidelines for conducting a bed safety audit Bed Safety: Steps to Success A list of the major educational, process, equipment, and organizational factors needed to achieve a successful bed safety program. Fall Prevention Program Guidelines Guidelines that provide an overview of the fall prevention process Components of a Successful Fall Prevention Program A list of the major clinical and organizational factors needed to achieve a successful fall prevention program This practical guide includes all the information needed to implement a successful bed safety program. Although all of the materials, including the PowerPoint presentation, can be used as is, it is recommended that each facility adapt the materials to meet its individual needs.

Essential Falls Management Series: Guide to Bed Safety. by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.

Introduction and Contents

Bed Safety Overview

LEARNING OBJECTIVES
To understand the Scope of the problem and complications of bed falls Causes of bed falls Causes of bed-fallrelated injuries Risk assessment for bed falls Strategies aimed at reducing bed falls

SCOPE OF THE PROBLEM AND COMPLICATIONS

There are approximately 3 million acute care hospital and long-term care (i.e., nursing facility and assisted living facility) beds in use in the United States. It is estimated that as many as 50% of clients residing in an acute care or long-term care facility experience one or more falls annually. Anywhere from one third to one half of falls take place in the bedroom and occur when clients are getting up from bed. Falls from bed are associated with significant physical and psychological complications, including injury (e.g., hip and other fractures); immobility resulting in muscle weakness and/or functional disabilities, which can increase the risk of further falls; and psychological distress (e.g., depression, fear of falling). Client falls are equally distressing for caregivers (e.g., nurses, nursing aides) and administrators, often leading to concerns about client safety and risk of legal liability. In addition, family members may become troubled when their loved one falls and may question the quality of care provided by the facility, especially if the fall resulted in injuries.

RISK FACTORS FOR BED FALLS

Bed falls (i.e., falls occurring from bed or shortly after exiting the bed) are not accidental, random events but are, to a large degree, predictable and, therefore, amenable to preventive interventions. The risk of falling from bed is due to a combination of internal, or client-related, factors and external, or hazardous environmental, factors.

Internal Factors
Bed falls occur most often in those clients who have medical conditions (e.g., muscle weakness, arthritis, sensory loss) and/or cognitive impairments (e.g., depression, delirium, dementia) or who are taking certain medications (e.g., diuretics, sedatives, psychotropics) that may affect their ability to maintain safe transfer activity. Several
Essential Falls Management Series: Guide to Bed Safety. by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.

other factors also may increase the risk of bed falls. For example, one of the strongest predictors of bed falls is having a prior history of falls from bed. The onset of bladder dysfunction (e.g., frequency, incontinence, nocturia) may lead to frequent bed transfers (i.e., need to toilet) and fall risk; traveling to the bathroom immediately after leaving the bed is one of the most frequently reported activities associated with falls. In addition, clients with untreated or partially treated sleeplessness and insomnia (e.g., trouble falling asleep, trouble staying asleep, frequent nighttime waking, early waking) have a much higher risk of bed falls.

External Factors
Several environmental factors may contribute to the risk of bed falls. These include bed heights that are either too high or too low; overly soft mattresses, resulting in poor sitting/transfer balance; waxed floor surfaces; slippery footwear, resulting in unstable transfers; and beds equipped with wheels that roll away during transfers. Low staff visibility of client bedrooms, which may be located down long hallways or a distance from nursing stations, is a risk factor for bed falls as well. Last, recently admitted clients may be at unusually high risk for bed falls because of their unfamiliarity with beds (i.e., beds of varying height and width, equipped with wheels and side rails). Institutional bed heights are usually 68 inches higher than standard home beds.

CAUSES OF BED-RELATED INJURIES

Bed side rails are used extensively in hospitals, nursing facilities, and residential facilities to prevent clients from falling from their beds. Interestingly, side rails, rather than being protective against falls, actually can increase the risk of bed falls and injury. Up to 40% of falls out of bed involve clients whose side rails are up. Not only do the number of falls increase but the number of fall injuries also increase when side rails are raised. When side rails are up, clients may risk falling by trying to climb over the top of the rail or by circumventing the rail by exiting the bed over the footboard. Climbing out of bed with the rails raised also can lead to side rail entrapment injuries. Entrapment injuries occur when clients become caught between two half-rails; between the slats of a rail; between the rail and the mattress; or between the head- or footboard, rail, and mattress (for more information, see Bed System Entrapment Guidelines). Side rails are divided with either horizontal or vertical slats spaced about 6 or more inches apart. This space can trap an elderly clients head, causing him or her to be strangled, or may allow a thin client to squeeze between the slats and fall to the floor. Entrapment between the side rail and the side of the mattress occurs when the mattress does not fit flush against the side rail. Mattresses that fit loosely in the frame, leaving gaps large enough to trap the client between the mattress and side rail, may lead to suffocation.

Essential Falls Management Series: Guide to Bed Safety. by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.

Bed Safety Overview

The use of physical restraints to keep clients in bed also can lead to numerous harmful consequences, such as strangulation or disorientation and agitation, which can increase the risk of injury. Clients with the highest risk of bed-related injuries are those who have moderate to severe cognitive impairment who demonstrate poor judgment and are unable to walk without assistance; they also are the most likely to attempt to get out of bed despite a raised side rail and get injured doing so. There is no evidence that side rails or physical restraints reduce falls or injury risk; conversely, both can increase the risk of falls and injury.

RISK ASSESSMENT
The goal of risk assessment is to identify clients who are at risk for bed falls and the factors that place them at risk. In addition to a history of prior bed falls, those factors that are most likely to be associated with bed fall risk include confusion or altered mental status, increased toileting needs (urinary incontinence and/or frequency), altered mobility, and use of psychotropic medications. Although these factors by themselves increase a clients susceptibility to bed falls, their relationship as a true measure of risk is more accurately reflected by their effect on the clients ability to transfer safely and independently from bed. A simple performance-based screen can be helpful in quickly assessing a clients bed mobility (see Performance-Oriented Bed Mobility Screening Tool). Clients who are able to complete the maneuvers in the Performance-Oriented Bed Mobility Screening Tool independently and safely without a loss of balance generally are at low risk for bed falls. Conversely, clients who demonstrate poor bed mobilitybecause of internal factors, external factors, or bothare at high risk. Because fall risk is a dynamic, or ongoing and changing, process (i.e., one that is dependent on the clients medical and functional status, medications, and/or environmental conditions), it is important to assess risk on a regular basis. If the client experiences a fall from bed, a history of the circumstances surrounding the fall should be obtained (i.e., inquire about any physical symptoms prior to the fall and about the activity being performed at the time of the fall). A pattern may emerge that can point the way to fall prevention. For example, if the client complains of feeling dizzy, the possibility of orthostatic hypotension must be considered. Conversely, if the client states that he or she slipped on the floor while getting out of bed, an environmental hazard may be responsible.

STRATEGIES
The goal of fall prevention is to maximize bed mobility, reduce the threat of injury, and maintain autonomy. Strategies designed to accomplish these goals encompass medical, rehabilitative, environmental, and nursing strategies, including the appropriate use of equipment intended to reduce falls or injury.
Essential Falls Management Series: Guide to Bed Safety. by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.

Bed Safety Overview

Medical Strategies
The presence of any internal risk factors or actual falls from bed should trigger a medical investigation aimed at evaluating the contributing factors. The medical investigation should rule out contributing acute and chronic conditions (e.g., altered cognition, lower extremity dysfunction, bladder dysfunction) and adverse effects associated with certain medications (e.g., sedatives, diuretics, hypnotics) and treat conditions or adverse effects accordingly. In addition, those clients who have osteoporosis (i.e., loss of bone strength) and fracture risk should be evaluated and treated.

Rehabilitative Strategies
For clients with impaired transfers, a focused program of muscle strengthening and flexibility exercises aimed at improving balance and bed transfers may be beneficial in reducing fall risk. As well, clients should be taught how to transfer safely from their beds.

Environmental Strategies
For clients with diminished bed mobility skills, modification of the bed and its surrounding area can be used to support safe mobility. A checklist can be used by nursing staff during client safety rounds to ensure that the bed and surrounding area is safe (see Bed Safety Checklist).

Bed Height
The height of the bed is essential to achieve safe transfers out of bed. Bed height is appropriate when the client can sit on the edge of the mattress with knees flexed at 90 and both feet can be planted firmly on the floor; this height promotes optimal sitting and transfer balance. Appropriate bed height is best achieved by observing the clients sitting balance and transfers and adjusting the bed to the correct height.

Safety Tips Keeping beds at their lowest height is a common fall preventive strategy. Maintaining beds in this position, however, may actually increase fall risk in certain clients. For example, clients with arthritis of the knees or Parkinsons disease generally require slightly elevated bed heights to achieve safe transfers. It is important to remember that client needs and not nursing needs should always dictate bed height. In general, clients should transfer out of bed toward their strongest side and back into bed toward their weakest side so that, if they fall toward their weakest side, they will land on the bed and not the floor. For facilities that use nonadjustable beds, a change in mattress depth (i.e., replacing the mattress with one that is thinner or thicker) may be used to achieve the desired bed height.

Essential Falls Management Series: Guide to Bed Safety. by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.

Bed Safety Overview

Conventional hospital beds may not be able to be lowered enough to achieve an appropriate height for clients who are less than 5 feet tall; for these clients, the use of height-adjustable low beds, which can be positioned as low as 8 inches from the floor, will promote safer transfers.

Bed Supports
Headboards and footboards should be attached firmly to the bed frame because clients may use them to support themselves as they stand up. As well, these surfaces should be slip resistant and easy to grasp. The application of nonslip adhesive tape along the top length of the headboard and footboard will help prevent clients hands from slipping during transfers.

Mattresses
Mattress edges should be firm, not saggy. The mattress should support the client securely when he or she is seated or transferring from the bed. Mattress edges that are raised or rolled provide a good grasping surface, which can help maintain stability during transfers.

Bed Wheels
Beds equipped with wheels that may roll away during transfers are a particular hazard. It is important to make sure that bed wheels always are locked. This information needs to be communicated to clinical staff as well as to nonclinical staff, such as custodial workers, who may disengage the wheel locks to clean underneath beds. Most beds with wheels, even those with adequate wheel-locking systems, show some degree of unsteadinessa combination swivel and wheel brake provides the most stability. Even properly locked wheels, however, may slide on slippery linoleum or tiled floors. Nonslip adhesive strips or decals placed beneath the wheels can minimize sliding. Beds equipped with immobilizer legs (i.e., wheels recess when legs are on the floor) provide the highest level of stability. When purchasing a height-adjustable bed with immobilizer legs, make certain that the model is user-friendly. Some designsfor example, those in which the immobilizer legs are only effective when the bed is in the lowest positioncan actually increase the risk of falls. This design flaw results from the bed manufacturers mistaken belief that all clients require the bed to be in the lowest possible position, a notion that is far from the truth.

Floor Surfaces
Slippery linoleum and wooden floor surfaces can interfere with stable foot placement during transfers. Floors can be made slip resistant with nonskid finishes. In addition, the application of nonslip adhesive strips placed on the floor along the length of the bed can help to maintain a slip-resistant and stable surface. The color of the nonslip strips should blend with the color of the floor, or the nonslip strips should be clear, so that clients with altered depth perception do not misjudge the strips as hazards and attempt to step over or avoid them.

Essential Falls Management Series: Guide to Bed Safety. by Rein Tideiksaar. 2006 Health Professions Press, Inc., Baltimore. All rights reserved.

Bed Safety Overview