The purpose of this course is to provide healthcare professionals with a synopsis of falls, fall assessments, and safety with the use of assistive devices in all arenas of health care.
By the end of this activity, the learner will be able to:
Patient safety is the prevention of harm to patients in every health care setting. While health care has become more effective, it has also become more complex with greater use of new technologies, medicines and treatments.1 The largest number of patients in the health care system are the elderly, with more complex problems and a high incidence of falls.
An estimated 25,500 Americans died from falls in health care and community settings in 2013. Countless more suffered life-changing injuries, such as fractures, internal injuries, and traumatic brain injury. Experts estimate that more than 84% of adverse events in hospital patients are related to falls, which can prolong or complicate recovery.5
Safety is everyone’s responsibility, not only in hospitals and nursing homes but the home setting as well. It does not matter what position a person holds. Everyone on staff is responsible for working to uphold patient safety. Safety is part of the quality agenda; therefore, a dimension of the quality culture, requiring broad commitment from both the organization and the community.1
Education is a part of the safety process, including staff, volunteers, and families. Once they are educated, they are committed to ensuring good safety practices.
Quality is an optimal balance between possibilities realized and a framework of norms and values.2 Quality of care looks for ways to improve patient outcomes by using quality indicators. Most health care facilities utilize patient surveys to augment their policies on patient safety.
The six domains of health care quality include:
Providing information to understand better the six domains of health care quality helps with the use of these indicators and gives the staff and families a framework to keep patients safe.
A fall can be defined as a position change from one plane to a lower one. The prevention of falls and injury from falls in patients who are hospitalized are indicators of high-quality bedside health care professional care given to a particular unit or at a hospital. Falls are the leading cause of fatal and non-fatal injuries for older Americans. Falls threaten seniors’ safety and independence and generate enormous economic and personal costs.4 Falls can happen to anyone, not just the elderly. In the health care setting, falls may be attributed to many conditions including seriously ill patients, patients taking narcotics, and patients with decreased vision. Health care professionals must always be alert to these conditions and have an obligation to check on at-risk patients frequently. Assessments can help health care professionals to identify patients at risk for falls, and these assessments are required in all health care settings on admission, change in level of care and after a fall.
There are three types of falls; Unwitnessed fall, patient states there was fall, but no one saw it happen. Witnessed fall, the patient is seen falling. Assisted fall, the staff or caregiver eases the patient to the floor without injury.
Falls are most likely to happen:
Falls with injuries are considered a sentinel event per Joint Commission. Falls with serious injury are consistently among the Top 10 sentinel events reported to The Joint Commission’s Sentinel Event database which has 465 reports of falls with injuries since 2009, with the majority of these falls occurring in hospitals. Approximately 63 percent of these falls resulted in death while the remaining patients sustained injuries.6
There are interventions to facilitate the job of trying to prevent falls. The most common assessment is the Morse Fall Scale used in acute care settings, nursing homes, and home care.
The Morse Fall Scale (MFS) is a rapid and simple method for assessing a resident’s likelihood of falling. This scale is easy to use and understand:
Morse Fall Scale 0-49 No/Low risk
Morse Fall Scale 50-79, Moderate risk:
Examples of moderate fall risk patients are: Change in mental status, sundowning, confused patients, lack of safety awareness. Preventions include:
Morse Fall Scale greater than 80, High Risk
Examples of high-risk patients include: a history of falls, severe confusion, acute disease process, depression. Preventions included:
In home health care, healthcare professionals use the Oasis form (CMS) for fall risk. This form is similar to the Morse Fall Scale but more involved. This form is completed on admission, just as the Morse Fall Scale is. This assessment examines ten items:
Each area is worth one point:
0-3 points-Patient education on fall prevention and home safety
4-5 points- Consider for interdisciplinary referrals as indicated. Patient education on fall prevention and home safety.
6-10 points- Contact physician to request PT evaluation or possibly OT evaluation. Patient education on fall prevention and home safety. (CMS)
All of these areas assist the home health professional to complete a more comprehensive evaluation and to make the necessary recommendations. Patient education is emphasized in every aspect of fall prevention, and education is mandatory at each visit.
Cindy, a home health nurse, was called to a home where the patient had several falls over the last week. While doing the admission assessment, Cindy noticed how agitated Mrs. Graham became when she tried to stand up and kept falling back into the chair. The family stated that Mrs. Graham has severe arthritis and has trouble standing up and walking, and she shuffles her feet. Cindy gently asked Mrs. Graham to stand and walk with her for a small distance. Cindy noted that there were throw rugs in several places and that there were no grab bars in the bathroom. Cindy also found that one of the patient’s medications could affect her walking. After educating the family on the importance of picking up the rugs and installing grab bars, she made referrals to Physical Therapy and Occupational Therapy. As a team, they will work with the patient and her family on safety issues. The physician was notified about the referrals and the medication issue. Cindy took the necessary steps to help keep the patient safe within the home setting.
Using assistive devices safely is not only the nurse’s role but that of a physical therapist, occupational therapist, and athletic trainer as well. Again, the entire team is responsible for patient safety.
How many people use assistive devices? According to The Centers for Disease Control (CDC), one in five Americans, about 53 million people, has a disability of some kind. 2.2 million people in the United States depend on a wheelchair for mobility, and 6.5 million people use a cane, a walker, crutches or prosthetic limbs to assist with mobility.7
People with physical disabilities can benefit from mobility aids. There are many situations that compromise safety including, barriers in community buildings, classrooms and even in the home. For example, ADL’s in the kitchen, in the bathroom, and going outdoors. There are many barriers in the home setting including throw rugs, electrical cords and food spills.11
A walker may be needed if the cane does not afford safety for the patient and may have wheels or no wheels. There are five types of walkers including:
The walker provides the patient a wide base of support and is the most stable assistive device. Two disadvantages of the walker include difficulty fitting through doorways due to its width and it cannot be used on stairs. A walker must be the appropriate size for each patient; to ensure proper fit, measure from the floor to the wrist.
After the Walker is ready to use, patient education is the next important step and may take the entire team working together to safeguard patient safety. The following information and chart are helpful when working with patients with a walker:
A knee walker is used as an alternative to crutches or a traditional walker.
There are pros and cons to using the knee walker, as with any assistive device. The pros to using a knee walker include:
The cons are as follows:
Using a knee walker safely requires practice. First and foremost is to ensure the patient understands that he/she cannot start “zooming” without starting slowly! Always wear a non-slip shoe on non-injured foot as that foot is the “propeller.” Make certain the brake is on before placing knee in walker.
Canes are used to help the patient with balance and mobility, but the patient must be cognitively aware. There are different types of canes, including a standard one foot cane, a tripod cane with three feet, and the quad cane which has four feet. Some canes like a wooden cane are not adjustable to the client's height, and others can be adjusted to meet the height needs of the client.8
The first step to using a cane safely is to make certain it fits the patient. The top of the cane should reach the crease in the wrist, and the elbow should be slightly bent. Education should include: look straight ahead, not down at the feet, avoid slick conditions such as wet floors and snowy or icy driveways, always using the strong or uninjured leg to take the first step going up stairs and curbs. Remind the patient to hold the cane close to the body on the uninjured or strong side.12
Using crutches is not easy and takes practice. First, they must be fitted to make sure they are comfortable and safe. Fitting includes:
Once the patient is ready to use the crutches, the next step is accident proofing the environment either in the hospital or the home. Pick up scatter rugs, make sure the floors are clutter free, and place items the patient will need within reach.
Tips for walking with crutches:
Going down stairs can be dangerous, and the patient will need someone to stay close while learning to use the crutches. There are a few tips for safely going up and down stairs:
Going down the stairs:
Patients use wheelchairs for many reasons. Wheelchairs may afford the patient independence by allowing the patient the ability to wheel him/herself without assistance. First, and foremost, the wheelchair must be fit to the patient for safety and comfort. Guidelines include:
Once the wheelchair is deemed safe and fits the patient, the team, including nursing and therapy, steps in for patient education. The patient and caregivers (family) are actively involved in the education process. There are many safety tips for safe wheelchair use:
Severe vision loss is a significant problem affecting millions of older Americans. According to the Family Caregivers Alliance, “Nearly 3.5 million Americans over 40 have some degree of vision loss.17” There are several medical conditions that can cause low vision/blindness including Glaucoma, Macular Degeneration, Diabetes, and Cataracts.
The healthcare professionals assessment includes asking the patient if he/she wears glasses, or if he has cataracts or a prosthesis. The patient can demonstrate the ability to see by reading newsprint or count fingers at arm's length.
There are four levels of visual function:
Learning to cope with the challenges that come with low vision/blindness can be overwhelming.
While surgery can help with Glaucoma and Cataracts, most seniors must learn to live with these debilitating diseases. There are many assistive devices available on the market today.
There are some important steps to help cope with vision loss:
Some interventions to help with low vision/blindness in any healthcare setting are:
Because the patient will not be able to drive, the health care professional should help him/her to formulate a new plan. Perhaps family and friends can help, but the patient may be able to learn to use public transportation to gain more independence.
There are many tools for the blind and visually impaired. The white cane is a recognized tool and makes other aware of the person’s blindness. It can be a signal for others to help if needed. A guide dog is a good choice if available. These dogs are highly trained to help the person navigate the world.18 Other tools include talking watches, braille phones and books, doorbells with flashing lights, magnifiers for low vision and audio books. All of these tools can help a blind/low vision person lead a reasonably normal life.
Hearing loss affects approximately 20 percent of Americans, and after the age of 65, one out of three people have a hearing loss. Communication is the most difficult aspect of caring for deaf patients. Communication strategies include:
Hearing aids are the most common assistive devices used today, but there are numerous other devices available. There are telephones with amplifiers, notification signalers for doors, windows, babies crying and doorbells. There are even amplified stethoscopes for medical personnel. Families and caregivers can learn sign language, and there are programs online to help.
The professional assessment is basic for hearing loss. Speak to the patient in your normal voice to see if he can understand your words without difficulty. Does the patient use hearing aids? Can patient hear in a noisy environment?
Patient safety is everyone’s responsibility in all health care settings. Falls are the leading cause of injury in the older Americans, with the majority of falls happening in the hospital. Education is an important part of the safety process, including staff, volunteers, patients and families. Health care professional’s assessments play an important role in falls prevention in all arenas of healthcare. The Morse Fall Scale is a comprehensive assessment that is simple to use and is used in all health care settings.
Patient education regarding the use of all assistive devices is significant in fall prevention techniques. Walkers, canes, knee walkers, crutches and wheelchairs all come with their own set of educational needs. Assistive devices for the blind and hearing impaired are available, and these devices need extra education. It takes the entire team working together is help prevent or reduce the number of falls with serious injuries. Although all falls and injuries cannot be prevented, the incidence can be reduced with excellent assessments and education.
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