FALLS PREVENTION MANAGEMENT IN SWANSEA NHS TRUST CONTENTS 1. Outline of Falls Prevention Management in Swansea NHS Trust 2. Nursing Procedure for Reducing Patient Falls 3. Flow Chart, Reducing Patient Falls - On Admission 4. Flow Chart, If a Patient Falls Post Admission 5. Patient Falls Risk Assessment Tool 6. Morse Falls Risk Assessment 7. Patient Care Management Plan a. Low Risk b. Medium risk c. High Risk 8. Patient Care Management Plan -Falls Care Plan 9. Falls Diary 10. Guidelines For The Use Of Side Rails 11. Risk Assessment Tool For The Use Of Side Rails 12. Audit of Bed Rails Falls Prevention Management in Swansea NHS Trust 1
1. FALLS PREVENTION AND MANAGEMENT - Swansea NHS Trust Swansea NHS Trust was established on 1 April 1999. It provides a comprehensive range of hospital and community health services for the Swansea population of approximately 250,000. The Trust also provides many specialist services for the people across south and mid Wales and some specialist services for the whole of Wales. Services are provided from 9 hospitals with over 1,800 beds and in a range of community premises. Hospitals Morriston Hospital Singleton Hospital Cefn Coed Hospital Gorseinon Hospital Hill House Hospital Fairwood Hospital Clydach Hospital Gellinudd Hospital Garngoch Hospital These include psychiatric day centres and resource centres, health centres, health clinics, hired premises, GP surgeries and patients' homes. The Trust is one of the largest in Wales with an annual income in excess of 240 million. The number of staff employed by the Trust is approximately 7,000 Background The most common cause of death in adults over 75 is falls, as well as being a significant cause of injury and disability (DTI 1999, Smith 2000). Over 14,000 older adults die each year following osteoporotic hip fractures (DoH 2001). The Department of Health has addressed falls prevention in standard six of the National Service Framework for The Older Adult (DoH 2001). This Standard is aimed at reducing the incidence of serious fall-related injuries whilst promoting the effective treatment and rehabilitation of the victims. In June of 2003 Swansea NHS Trust undertook a pilot project to introduce a Falls Prevention and Management resource pack into 9 of its sites. This Initiative was supported by the Foundation of Nursing Studies (www.fons.org). A Falls resource pack was developed by reviewing some of the highly successful innovations to prevent falls throughout the country and in particular work previously undertaken by Barnett (2002). The pack was piloted in the identified areas throughout the Trust. Post Falls Pilot A trend analysis shows the incidence of falls pre and post the pilot period A decrease can be seen in falls during the pilot phase of the project. Falls Prevention Management in Swansea NHS Trust 2
Progress to Date Resource pack Falls Log Book Since the introduction of the Datix Incident Recording System there is no longer a need for a Falls Log Book. Falls data can be requested and returned electronically, as required, by each unit. Visual Cues Visual cues are no longer used due to the fact that many of the patients often leave the bed side, where the visual cue would be displayed, and sit in the ward day room. There was no suitable place by each patient s chair in the day room to display the patient s visual cue. Side Rails A local audit of 8 Elderly Care Wards identified side rails that required attention, the need for more cot bumpers and extra height side rails. The Trust is currently looking at a bed management system which will take into consideration all of the issues discussed in the Audit of Detachable Side Rails. Patient Falls Audit A random selection of 10 patients nursing records including care-planning documentation was audited. It highlighted the need for further training in 3 of the 9 pilot areas. Falls Prevention Management in Swansea NHS Trust 3
The Way Forward The falls Prevention and Management Group disbanded in November 2003 due to Management Restructuring throughout the Trust. However the Resource Pack continued to be used within the 9 identified areas. The group reconvened in June 2004 to discuss the development of a Falls Prevention and Management Integrated Care Pathway which would incorporate the existing Resource Pack. The group is multi-agency with representatives from all areas within the Trust and Local Health Board. Process Mapping will be undertaken by the group in October 2004. This will assist in identifying the existing Falls Prevention services within Swansea NHS Trust, whilst enabling the recognition of services that will require development. In August 2004 the existing work was presented to Swansea NHS Trust Innovations in Care Board, where the need for resources was identified to enable the existing work to continue and services to be developed. References: Barnett, K. (2002) Reducing patient falls in an acute general hospital. In Shaw, T. and Sanders, K. (Eds) Foundation of Nursing Studies Dissemination Series. Vol. 1, No, 1. Department of Trade and Industry (1999) Accidental Falls: Fatalities and Injuries. An Examination of the Data Sources And Review of the Literature on Preventative Strategies. Newcastle: University of Newcastle Upon Tyne. Department of Health (2001) National Service Framework for Older People. London: The Stationary Office. Morse, J. (1997) Preventing Patients Falls. Sage Publications. Morse, J. M., Morse, R. and Tylko, S. (1989) Development of a scale to identify the fall prone patient. Canadian Journal on Ageing. Vol. 8. No. 4. pp 366-377. Smith, S. (2000) Catch-all Solution. Nursing Times. Vol. 96. No. 3. pp 22-23. This project received professional support and a grant of 2000 from the Foundation of Nursing Studies. Falls Prevention Management in Swansea NHS Trust 4
2. NURSING PROCEDURE FOR FALL RISK PREVENTION - Swansea NHS Trust Falls are the most common injury sustained by hospitalized patients. They are a major cause of injury and death among the elderly and debilitated patients. Environmental, physical, and psychological factors contribute to patient falls and the ensuing injuries. Falls are preventable occurrences that injure patients, prolong hospitalizations, and significantly increase healthcare costs. The implementation and adherence to an effective fall prevention program negates many of these incidences of injury and additional costs. The goal of the fall prevention program is to identify the patient who is at risk to fall, institute proactive efforts to reduce the occurrence of fall- related incidents, and provide a safe environment. Definition Any untoward event in which the patient comes to rest unintentionally on the floor. Professional and clinical judgement is needed to capture the full range of possibilities. Implementation Procedure All patients, over the age of 50, will be assessed for potential to fall using the Patients Falls Risk Assessment tool. The tool must be completed within 24 hours following admission. Further assessments will be completed according to the patient/clients level of risk.. Based on the assessment, the nursing staff will assign the appropriate fall risk level and institute a fall prevention management plan. Additionally, patients will be re-evaluated for fall potential whenever there is a change in status, a transfer to another unit, or as necessary. If a patient/client falls an incident report must be completed, the details must also be recorded in the patient/client s fall diary. If side rails are to be considered, please refer to the Guidelines For The Use Of Side Rails. It is advisable that the unit undertakes an environmental risk assessment annually. This will assist in identifying any hazards/risks that could be the cause of a fall. Action can then be taken to eliminate or reduce the hazards/risks. Falls Prevention Management in Swansea NHS Trust 5
3. REDUCING PATIENT FALLS ON ADMISSION - Swansea NHS Trust Patient admitted to hospital Morse falls risk assessment completed within 24 hours Manual handling risk assessment completed within 24 hrs Low risk of falling Good basic nursing care provided Bed on lowest appropriate setting Ensure patient has necessary items in easy reach Assess environment Encourage regular toileting Morse falls reassessment every week Refer to appropriate members of multidisciplinary team Medium risk of falling Additional strategies considered: Re-orientate confused patients Assess patient with regard to use of side rails Educate patients in safe practices Morse falls reassessment every 4 days High risk of falling Additional strategies considered: Position patient in easily observable area Consider using sensor alarms Consider one-to-one nursing Arrange care management meeting to discuss alternative strategies Morse falls reassessment alternate days Patient reassessed using Morse falls assessment tool Falls Prevention Management in Swansea NHS Trust 6
4. IF A PATIENT FALLS POST ADMISSION - Swansea NHS Trust Patient admitted to hospital Medical staff Low risk identified Near Miss Patient Falls Patient is physically examined to determine if an injury has occurred Incident report completed Circumstances surrounding fall documented in care plan. Details for incident report: Time of incident Where incident occurred Circumstances surrounding incident If Fall Fall score prior to fall Strategies in place prior to fall Staffing levels at time of fall Strategies to be put in place to prevent further falls occurring Medium risk identified High risk identified Patient s reassessed using Morse falls assessment tool Details of fall documented in patient s fall diary in patients Kardex. Care plan reviewed and alternative strategies deployed if appropriate Patient s next of kin informed Falls Prevention Management in Swansea NHS Trust 7
5. PATIENT FALLS RISK ASSESSMENT TOOL - Swansea NHS Trust Patients Name Unit Number Ward Named Nurse CATEGORY SCORE SCORE SCORE SCORE SCORE SCORE 1. History of falling Score 25 if the patient has fallen during the present hospital admission or if there was an immediate history of physiological falls, such as from seizures or an impaired gait prior to admission. If the patient has not fallen score 0 2. Secondary Diagnosis If more than one medical diagnosis is listed in the patients notes 3. Mobility Aids None/bed rest/nurse assist Crutches/stick/walker Furniture 4. Attachment is equipment If the patient is attached to IV, monitoring equipment or has a catheter stand If not score 5. Gait Normal Weak Impaired 6. Mental Status Orientated to own ability Overestimates/forget limitations ins cms Patients hip measurement.. Patients waist measurement.. Score = Low, 0-25 Medium, 30-55 High, 60-125 YES NO YES NO YES NO 25 0 15 0 0 15 30 20 0 0 10 20 0 15 TOTAL SCORE DATE/TIME SIGNATURE FULL TITLE Falls Prevention Management in Swansea NHS Trust 8
6. MORSE FALLS RISK ASSESSMENT - Swansea NHS Trust 1.1 The risk falls assessment tool must be completed within 24 hours of admission 1.2 The six categories of assessment are: History of falling Secondary diagnosis Mobility Aids Attachment to equipment Gait Mental status 1.3 History of Falling If the patient has fallen immediately prior to admission or during the present hospital admission, score 25 If no history of falling score 0 1.3.1 If the patient has fallen immediately prior to admission or during the admission, even if the admission was some time ago, it is still necessary to score 25 1.3.2 If the patient suffered a physiological fall, such as a stroke, epilepsy or from impaired gait, immediately prior to admission, this will score 25 1.4 Secondary Diagnosis If the patient has more than one diagnosis in their records, score 15 1.4.1 The diagnosis needs to be relevant and causing ongoing problems in order to be included in the score. For example, if a patient has hysterectomy indicated in their documentation it may be relevant if it is less than a year since the surgery and recovery is still occurring. However, if the surgery occurred 10 years ago and the patient is fully recovered then it is not a relevant diagnosis for this assessment 1.4.2 The diagnosis would be relevant if the patient is taking prescribed medication for the condition, even if they appear to be stable on the medication e.g. Diuretics Benzodiazapines Psychoactive Antihypertensives Antidiabetic drugs Corticosteroids Polypharmacy Falls Prevention Management in Swansea NHS Trust 9
1.5 Mobility Aids 1.5.1 If the patient walks without walking aids, walks with assistance of a physiotherapist, occupational therapist or nurse, is on bed rest or completely wheelchair dependent then 0 is scored. 1.5.2 If the patient uses walking aids, such as a stick, frame, crutches, then 15 is score. 1.5.3 If the patient does not use walking aids but grasps for furniture during ambulation, then score 30 1.6 Attachment to equipment 1.6.1 If patient attached is to IV fluids or syringe driver, score 20 1.6.2 If a patient has a catheter and uses a stand rather than a leg bag, score 20 1.6.3 If not attached to equipment, score 0 1.7 Gait Assessment of gait uses the terminology normal, weak, impaired gait 1.7.1. Normal Gait (score 0) Patient walks with head erect, arms swinging freely at the side, striding unhesitantly 1.7.2. Weak Gait (score 10) Patient is stooped but able to lift head while walking without losing balance. If support from the furniture is required, it is for reassurance only, rather than grabbing to remain upright. 1.7.3. Impaired Gait (score 20) Patient may have difficulty rising from a chair, attempting to get up by pushing on the arms of the chair and/or bouncing. Patient s head is down and they watch the ground. The patient takes short steps and shuffles. Because balance is poor, they are unable to mobilise without the support of a mobility aid, another person or furniture 1.8 Mental status This relates to the patient s ability to determine his or her own ability in mobilising 1.8.1 Ask the patient Are you able to go to the bathroom alone or do you need assistance? If the patient can answer consistently with your assessment of mobility then they are rated as normal (score 0) If they are inconsistent or unrealistic then they are considered to overestimate his/her abilities and be forgetful of limitations (score 15) 1.8.2 The scores must be added together to produce a total score 1.8.3 The total score will relate to a high/medium/low risk of falling, calibrated to Falls Prevention Management in Swansea NHS Trust 10
your particular clinical area 2. Care Planning and Nursing Documentation 2.1 A relevant care plan relating to the patient s level of risk must be placed in the nursing documentation 2.2 Any care relating to preventing falls must be entered into the care plan so that there is clear communication to all concerned about the strategies in place aimed at reducing the risk of falling 2.3 The patient must be informed at all times if any strategies for fall prevention are to be used 2.4 Reassessment of fall score must be performed as indicated on the care planning documentation 2.5 If the named nurse can justify altering the reassessment timetable then this must be clearly documented in the care plans 2.6 Reasons stating why the reassessment timetable is altered and the next formal reassessment due date must be documented 3. Intervention following a fall 3.1 The circumstances surrounding the fall must be documented in the care plan 3.2 The patient must be reassessed in light of the changing circumstances 3.3 Physical examination of the patient must take place, with the results documented in the care plan 3.4 If no extrinsic factors can be associated with the fall, medical advice must be sought in order to rule out pathophysiological factors 3.5 The incident report forms must be completed, by the appropriate member of staff, as soon as possible after the incident. Information should include :- Time of incident Place of incident Circumstances surrounding the fall Staffing levels at time of fall Fall score prior to fall Strategies in place prior to fall Strategies to be put in place following the fall to reduce the chance of a further fall occurring Non compliance to strategies already in place 3.6 The care plan must be reviewed and alternative strategies deployed if appropriate Falls Prevention Management in Swansea NHS Trust 11
3.7 The patient s next of kin should be informed that a fall has occurred 3.8 Details of the fall must be documented in patient s fall diary Falls Prevention Management in Swansea NHS Trust 12
7. PATIENT CARE MANAGEMENT PLAN Low risk - Swansea NHS Trust Patient is at risk of falling NEED: To maintain the safety of the patient, and maintain a safe environment Name Hospital No Ward Named Nurse LOW RISK 0-25 1. If the patient has fallen prior to admission, document the circumstances surrounding the fall, if known, in the care plan 2. If the patient has fallen or had a near miss whilst in hospital, document the circumstances surrounding the fall and action taken to prevent recurrence in the care plan 3. Document patient risk assessment score in care plan 4. Communicate risk assessment score to other members of the multidisciplinary team 5. Keep bed on lowest appropriate setting, except when giving nurse care. Ensure brakes are locked 6. Ensure patient has appropriate seating 7. Ensure patient has all necessary items within reach 8. Provide patient/carer with leaflet regarding falls prevention. 9. Check patient s footwear, refer to Podiatrist/Chiropodist if required (place a red sticker on the referral form to identify the patient as being at risk of falls). Advise patient/carer on appropriate footwear if necessary. Document any action in care plan 10. Assess patient s environment for safety hazards and remove clutter. Ensure spillages are wiped up immediately 11. Assist with regular toileting 12. Refer to appropriate Multi-disciplinary Team Member if assessment of function is required. Document referral in care plan Falls Prevention Management in Swansea NHS Trust 13
7. PATIENT CARE MANAGEMENT PLAN Medium risk - Swansea NHS Trust Patient is at risk of falling NEED: To maintain the safety of the patient, and maintain a safe environment Name Hospital No Ward Named Nurse MEDIUM RISK 20-55 1. If the patient has fallen prior to admission, document the circumstances surrounding the fall, if known, in the care plan 2. If the patient has fallen or had a near miss whilst in hospital, document the circumstances surrounding the fall and action taken to prevent recurrence in the care plan 3. Document patient risk assessment score in care plan 4. Communicate risk assessment score to other members of the multidisciplinary team 5. Keep bed on lowest appropriate setting, except when giving nurse care. Ensure brakes are locked 6. Ensure patient has appropriate seating 7. Ensure patient has all necessary items within reach 8. Provide patient/carer with leaflet regarding falls prevention. 9. Check patient s footwear, refer to Podiatrist/Chiropodist if required (place a red sticker on the referral form to identify the patient as being at risk of falls). Advise patient/carer on appropriate footwear if necessary. Document any action in care plan 10. Assess patient s environment for safety hazards and remove clutter. Ensure spillages are wiped up immediately. 11. Assist with regular toileting Falls Prevention Management in Swansea NHS Trust 14
12. Refer to appropriate Multi-disciplinary Team Member if assessment is required. 13. Frequently re-orientate confused patients to location of facilities 14. Assess patient regarding the use of bed rails. If bed rails are used, document in care plan 15. Educate patients/carers in safe practices. 16. Place slip mat in chair if appropriate Falls Prevention Management in Swansea NHS Trust 15
7. PATIENT CARE MANAGEMENT PLAN High risk - Swansea NHS Trust Patient is at risk of falling NEED: To maintain the safety of the patient, and maintain a safe environment Name Hospital No Ward Named Nurse HIGH RISK 60-125 1. If the patient has fallen prior to admission, document the circumstances surrounding the fall, if known, in the care plan 2. If the patient has fallen whilst in hospital, document the circumstances surrounding the fall and action taken to prevent recurrence in the care plan 3. Document patient risk assessment score in care plan 4. Communicate risk assessment score to other members of the multidisciplinary team 5. Keep bed on lowest appropriate setting except when giving nurse care. Ensure brakes are locked 6. Ensure patient has appropriate seating 7. Ensure patient has all necessary items within reach 8. Provide patient/carer with leaflet regarding falls prevention. 9. Check patient s footwear, refer to Podiatrist/Chiropodist if required (place a red sticker on the referral form to identify the patient as being at risk of falls. Advise patient/carer on appropriate footwear if necessary. Document any action in care plan 10. Assess patients environment for safety hazards and remove clutter or wipe up spillages 11. Assist with regular toileting 12. Frequently re-orientate confused patients to location of facilities Falls Prevention Management in Swansea NHS Trust 16
13. Assess patient regarding the use of bed rails. If bed rails are used, document in care plan 15. Educate patients/carers in safe practices. 16. Place slip mat in chair if appropriate 17. Position patient in easily observable area if possible 18.Consider one to one nursing, if possible. Review on a shift by shift basis 19. Discuss patient s management with multidisciplinary team. Document outcome in care plan. 20. Consider using sensor alarm, if available. If sensor alarms used, document in care plan Falls Prevention Management in Swansea NHS Trust 17
8. PATIENT CARE MANAGEMENT PLAN FALLS CARE PLAN - Swansea NHS Trust Name Hospital No Ward Sign: PRINT: Title: Date: Reassessment strategy: Low, 0-25: Weekly Medium, 30-55: Every Four Days High, 60-125: Alternate Days Or at named nurses discretion. If different please document reasons for altering reassessment strategy If there is a non compliance with advice or aids given to the patient, please document in the care plan Date and Time Relevant Information Related to Patient Needs/Score/Level of Risk Signature and Full Title Falls Prevention Management in Swansea NHS Trust 18
Patients Name Date and Time Relevant Information Related to Patient Needs/Score/Level of Risk Unit No Signature and Full Title Falls Prevention Management in Swansea NHS Trust 19
9. FALLS DIARY - Swansea NHS Trust PATIENTS NAME HOSPITAL NO. WARD WALKING AIDS USED? WALKING STICK ZIMMER FRAME OTHER (please state) FALLS LEAFLET GIVEN TO: DATE GIVEN: DATE TIME PRECISE LOCATION INJURY DESCRIPTION OF FALL EVALUATION/PREVENTATIVE MEASURES SIGNATURE Falls Prevention Management in Swansea NHS Trust 20
10. GUIDELINES FOR THE USE OF SIDE RAILS (June 2003) - Swansea NHS Trust 1. Purpose Side rails are used extensively in hospitals and community to prevent patients falling out of their beds. However, there have been a number of adverse incidents involving side rails that have led to injury and in some cases death. These guidelines have been developed to support staff to identify patients/clients who require side rails, which side rails should be used, the correct fitting and positioning and the maintenance of side rails. These guidelines are based on advice given by the Medical Devices Agency (MDA) DB2001 (04) July 2001 2. Target group All nurses and midwives and health visitors working within Swansea NHS Trust. 3. Definitions For the purpose of these guidelines the term side rails will be used, although other names are often used e.g. bed side rails, cot sides and bed guards. MDA - Medical Devices Agency 4. Risk assessment There are many types, designs and sizes of side rails, all with a variety of fitting and operation methods. That together with a range of mattresses means that careful assessment is necessary if serious incidents are to be avoided. A detailed documented risk assessment should be carried out before side rails are fitted. 4.1 Are side rails actually required? This question should be asked before fitting side rails. The MDA suggest that: Often bed rails are used not because the individual needs them, but because of association with the environment, their condition or their age. Other questions that need to be considered include: Is the person likely to fall out of bed? If so, are side rails the most appropriate solution? Can an alternative method be used? If a disabled person requires some sort of body positioning device can this be used instead? Could the use of side rails increase the risk e.g. could a confused patient try to climb over them? 4.2 Use of side rails Side rails are used to prevent patients/clients from falling and sustaining injury. They are not designed or intended to limit the freedom of people by preventing them from leaving their beds voluntarily; nor are they intended to restrain people whose condition disposes them to erratic or violent movement. SIDE RAILS ARE NOT TO BE USED AS A RESTRAINT. Falls Prevention Management in Swansea NHS Trust 22
Side rails are not to be designed to function as grab handles, which are aids for getting in and out of bed and moving around when in bed. Nursing staff should explain the importance of this to patients/clients and their next of kin. Using them in this way may make them unsafe. Side rails should be used with care and only after a full, documented risk assessment has been carried out for each patient /client (see Appendix 1) This will determine if their use is the most appropriate method of bed management in each case. 4.3 Assessing the patient Before fitting side rails a full assessment of the patient should be carried out. Areas that need to be considered include: Is their head or body small enough to pass between the side rail s bars? Is their head or body small enough to pass through the gap between the lower bed rail and the mattress? Is their head or body small enough to pass through the gap between the bed rail and the side of the mattress? Are they agitated or confused? This may mean they might try to climb over the side rails. Will they need to get out of bed when they are not directly observed e.g. at night? How high is the risk that they will fall out of bed without side rails being fitted? Risk assessments should be reviewed after each significant change in the patient s/client s condition, or as a minimum of every two weeks. The continued use (or not) of the side rail should then be recorded in the care plan and appropriate documentation. 5. Selecting the side rail The following should be ensured before making a multidisciplinary team decision upon the choice of side rail: That the supplier or manufacturer has provided enough information for its use and advise on contra-indications? That the side rails are suitable for the bed/mattress to which it will be fitted? That there are no large spacings which may lead to entrapment? 6. Selecting side rails for use with in a community setting In community care environments it is common for bed and side rails to have been acquired from different sources. Side rails that have been designed to be used with for example, a divan bed will be a fairly universal design. They are not necessarily tailored for a specific divan bed with exact base and mattress dimensions or a specific density. Therefore the MDA recommend that the following are avoided: Poor side rails designs, with a very large space between the bars which could allow the patient/client to slip through. Gaps between the end of the side rails and the head/footboard which could be sufficient to cause entrapment. Falls Prevention Management in Swansea NHS Trust 23
Using side rails designed for divan beds on a wooden or metal bedstead. Using insecure fittings or designs, which allow the side rails to move away from the side of the bed or mattress. Using only one side of a pair of side rails when the other side of the bed is against a wall. Using a mattress overlay on top of an existing mattress where the height lessens the effectiveness of the side rails and allow the patient/client to roll over the top. Extra height side rails should be used when a mattress overlay is used. The above guidance may also be applied in a hospital setting. 7. Fitting side rails Fitting of side rails correctly is essential if accidents are to be avoided. When fitting side rails the following things need to be ensured: There is no gap between the lower bar of the side rails and the top of the mattress that could cause entrapment? That if the mattress compress s easily at the edge, that there is no risk of entrapment. That the gap at the end of the side rails and the headboard/foot of the bed will not allow entrapment? Staff should also take care to avoid entrapment of their hands whilst fitting the side rail. Once fitted, side rails should be checked to ensure that all locking mechanisms are properly engaged to secure the side rail to the bed frame, after each use. Side rails must not be used as hand-holds when moving beds. If a bed fitted with a side rail is moved, or the mattress is disturbed, the side rail fittings should be checked again (MDA SN 1999 (36). 7.1 Accessories Side rail bumpers, padding or padded enveloping covers, in some instances, can also be used to reduce the potential for entrapment. However we are reminded that their primary use is to prevent the patient/client from impact injuries, and that the risk of entrapment may still exist. (MDA 2001). 8. Using side rails with children A risk assessment should always be carried out and documented on the suitability of side rails for the child, as bar spacing may need to be smaller. 9. Using side rails with air mattress or overlays Special care should be taken when using side rails with the above mattress s because: The reduction in the effective height of the side rails relative to the top of the mattress may allow the patient/client to roll over the top of it. As the mattress edge is easily compressible the risk of entrapment is increased. Falls Prevention Management in Swansea NHS Trust 24
When beds are hired staff must ensure that the appropriate side rails are available for the bed. When side rails are no longer required by the patient/client they should be removed from the bed, if appropriate, cleaned in accordance with the Swansea NHS Trust Decontamination of Equipment Policy, and stored safely. Side rails that are defective should be removed from use and reported to the Estates Department. They will then be checked, repaired if possible, or condemned. 10. Alternatives to using side rails The use of selecting and fitting of side rails needs considerable care to ensure that the patient/client is not placed at risk. Alternative methods of risk management should be considered, such as; Beds with variable height used in the lowest position. Soft cushioning on the floor to break a patients/client s fall. Patient bed sensor alarms (to alert staff that a patient has moved from a bed or chair). Body positioning devices (used to position patients/clients with specific clinical conditions, such as cerebral palsy). Place the patient/client on special observations. 11. Audit of the use of side rail Auditing the condition and use of side rails is very important and should be carried out on an annual basis by each Division 12. References Medical Devices Agency DB2001(04) July 2001. Advice on the Safe Use of Bed Rails. Medical Devices Agency SN1999 (36) October 1999. Bed Side Rails (cotsides) Fitted with Telescoping Crossbars Risk of Movement and Subsequent Patient Injury (Appendix C) Medical Devices Agency SN2001(35) December 2001 Swansea NHS Trust (2002) Decontamination of Equipment Policy 13. Bibliography Barnett K (2002) Guidelines on the use of bedrails. Mid Yorkshire Hospitals NHS Trust. BS EN 716-1: 1996 Furniture Children s cots and folding cots for domestic use, Part 1 Safety Requirements. BS EN 747-1 Furniture Bunk beds for domestic use part 1. Safety Requirements BS 1694: 1990 Specification for Hospital ward cots for children. Falls Prevention Management in Swansea NHS Trust 25
Everitt V, Bridel Nixon J (1997) The use of bed rails: principles of patient assessment. Nursing Standrd.12, 6, 44-47. Govier I, Kingdom A (2000) The rise and fall of cot sides. Nursing Standard. 14, 31, 40-41. Royal College of Nursing (1987). Focus on Restraint Guidelines on the use and restraint in elderly people. 14. Ratificaton Lead Authors: Falls Prevention Steering Group Reviewed/updated: June 2003 Ratification Body: PNF Policy & Procedure Group Date for Review: June 2006 By Whom: PNF Nursing Policy & Procedure Group Falls Prevention Management in Swansea NHS Trust 26
11. RISK ASSESSMENT TOOL FOR THE USE OF SIDE RAILS - Swansea NHS Trust Patients Name Hospital No. Ward Date This tool should be used in conjunction with the Guidelines For The Use of Side Rails and the nurses/therapists own professional and clinical judgement. Assessing the patient Before fitting side rails a full assessment of the patient should be carried out. Areas that need to be considered include: Is their head or body small enough to pass between the side rail s bars? Is their head or body small enough to pass through the gap between the lower bed rail and the mattress? Is their head or body small enough to pass through the gap between the bed rail and the side of the mattress? Are they are agitated or confused? This may mean they might try to climb over the side rails. Will they need to get out of bed when they are not directly observed e.g. at night? How high is the risk that they will fall out of bed without side rails being fitted. Risk assessments should be reviewed after each significant change in the patient s/client s condition, or as a minimum of every two weeks. The continued use (or not) of the side rail should then be recorded in the care plan and appropriate documentation. 1. Does the patient have dementia, confusion, a learning disability, micro or hydrocephalus? Yes Consider using alternative methods. No Continue assessment 2. Will the patient need to get out of bed unsupervised? Yes Consider using alternative methods. Ensure a call bell is within reach. No Continue assessment 3. Does the patient need alternating pressure mattress or dynamic bed? Yes Ensure side rails are compatible with the mattress/bed and are the correct height Falls Prevention Management in Swansea NHS Trust 27
No Continue assessment 4. Are there gaps between the rails & foot of the bed where patient/client entrapment could occur? Yes Use alternative methods No Continue assessment 5. Are there gaps between the rails and mattress, including when the mattress is compressed where patient/client entrapment could occur? Yes Use alternative methods. No Continue assessment 6. Does the patient/client or next of kin insist on side rails being used? Yes Record in patients/clients records stating the use of side rails against advice No Continue assessment 7. Is the patient at risk of falling if side rails are used? Yes Justify and record in the patients records if side rails are used No Continue assessment 8. Does the patient/client or next of kin refuse the use of side rails? Yes Record in patient/clients records No Continue assessment 9. Is the patient considered at risk of falling if side rails are not used? Yes Justify and record in patient/clients records. No Continue assessment 10. Has the assessment been discussed with the patient/client or next of kin and alternative methods been discussed? Yes Record in patients/clients records. No Complete and discuss with patient/client or next of kin. 11. Does the patient/client or next of kin agree with assessment? Yes Record in patients/clients records. No Record in patients/clients records. Discuss alternative methods. Signature of named/team nurse Falls Prevention Management in Swansea NHS Trust 28
Date Falls Prevention Management in Swansea NHS Trust 29
12. AUDIT OF DETACHABLE SIDE RAILS (COT SIDES) - Swansea NHS Trust Hospital: Ward: Date: Person Undertaking Audit: N.B. Please use attached guidelines for undertaking bed rail audit Please number each individual bed rail whilst undertaking audit ** IF A BED RAIL IS FOUND TO BE FAULTY IT SHOULD BE REMOVED FROM USE IMMEDIATELY, CLEARLY MARKED TO INDICATE THAT IT SHOULD NOT BE USED AND THE MAINTENANCE DEPARTMENT MUST BE INFORMED IMMEDIATELY. Bed No. Comments Action Taken Has bed rail been fitted to Yes No bed correctly? Is there evidence of Yes No maintenance of bed rail? Is there a gap between the Yes No lower bar of the bed rail and the top of the mattress that could cause entrapment? Does the mattress compress Yes No easily at the edge, creating an entrapment hazard? Will the gap between the end of the bed rail and the headboard, or wall allow entrapment? Yes No Falls Prevention Management in Swansea NHS Trust 30
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