Spotlight Case April 2003

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Spotlight Case April 2003

• Coagulopathic Patient with Subdural Hematomas
  Falls out of Bed

webmm.ahrq.gov
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Source and Credits

• This presentation is based on the April 2003
  Medicine Spotlight Case
• See the full article at http//webmm.ahrq.gov
• CME credit is available through the Web site
• Commentary by Sidney T. Bogardus, MD Yale
  University School of Medicine
• Sidebar by Brian Liang, MD, JD, PhD
• Editor, AHRQ WebMM Robert Wachter, MD
• Spotlight Case Editor Tracy Minichiello, MD
• Managing Editor Erin Hartman, MS

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Objectives

• At the conclusion of this educational activity,
  participants should be able to
• List risk factors for falls in hospitalized
  patients
• Understand appropriate use of restraints
• Identify system issues contributing to falls in
  hospitalized patients

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Case Patient Falls out of Bed

• A 42-year-old man with alcoholic cirrhosis,
  coagulopathy, thrombocytopenia, and history of
  subdural hematomas from falls was admitted with
  new bilateral subdural hematomas. Neurosurgery
  service drained these via burr holes. In first
  week of hospitalization, patient received 45
  units of fresh frozen plasma to keep INR below
  1.5 and to minimize chances of expansion of his
  subdural hematomas. The patient improved and was
  transferred from the ICU to the step-down unit.

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Subdural Hematoma
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Epidemiology of Falls

• Common in elderly patients
• 35-45 of people 65 fall each year
• Increased risk in nursing home residents
• 50 of residents fall annually
• Higher injury rate in institutionalized patients
• Up to 25 result in need for hospital care

Anon. J Am Geriatr Soc. 200149664-672.
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Risk Factors for Falls

• Intrinsic
• History of falls
• Mobility impairment
• Muscle weakness
• Visual deficits
• Cognitive impairment
• Postural hypotension

• Agitation
• Urinary frequency
• Depression
• Arthritis
• Age80

Anon. J Am Geriatr Soc. 200149664-672 Tinetti
MA, et al. NEJM. 19883191701-1707. Nevitt MC,
et al. JAMA. 19892612663-2668 Oliver D, et al.
BMJ. 1997 3151049-1053.
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Risk Factors for Falls (cont.)

• Extrinsic/Environmental
• Medications
• Poor lighting
• Loose carpets
• Agitation
• Urinary frequency

Anon. J Am Geriatr Soc. 200149664-672 Tinetti
MA, et al. NEJM. 19883191701-1707. Nevitt MC,
et al. JAMA. 19892612663-2668 Oliver D, et al.
BMJ. 1997 3151049-1053.
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Case (cont.) Patient Falls out of Bed

• The patient was identified as being a fall risk.
• The following precautions were taken
• Bed rails up
• Bed in lowest possible position
• Call light immediately accessible
• Patient told explicitly Call nurse if you need
  anything
• Patient placed in area with many nurses nearby
• Bed alarm activated

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Case (cont.) Patient Falls out of Bed

• The patient stated he did not want to be
  restrained. The next evening, the patient
  attempted to climb out of bed by squeezing
  between his bed rails, and fell to the ground.

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A Patient Caught in Bedrails
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Strategies for Fall Prevention

• Multifactorial interventions
• Education of staff
• Review and modification of medications
• Exercise and balance training
• Modification of environmental hazards

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Strategies for Fall Prevention (cont.)

• Specific interventions
• Bed alarms
• Moving patient to room near RN station
• Sitter for agitated patient
• Placing patients mattress on the floor
• Chemical restraints
• Physical restraints

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Use of Physical Restraints

• Substantial evidence indicates that restraint use
  can harm patients
• Use of physical restraints does not stop injury
• Use of restraints may increase injury
• Bed rails may be hazardous

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Case (cont.) Patient Falls out of Bed

• The patient was found on the floor with no sign
  of injury. He agreed to be placed in a Posey
  overnight. Two days later, he was transferred to
  the medical ward. The nurses identified him as
  being at very high risk for falls and thought
  he should be placed in restraints, but he
  adamantly refused. Because the staff believed the
  patient to be competent, they did not feel they
  could restrain him against his will. No
  psychiatric evaluation was requested.

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Medicolegal Issues in the Use of Physical
Restraints

• Most accreditation groups strongly recommend
  against use of restraints
• Physical restraints that result in injury may
  lead to law suit
• Standard malpractice negligence rule
• General negligence rule

Sidebar Bryan A. Liang, MD, PhD, JD
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Medicolegal Issues in the Use of Physical
Restraints (cont.)

• Restraint use against a patients wishes
• Professional assessment deems patient a risk to
  himself and/or others
• Consider psychiatric evaluation for competency
• Document all findings and assessments clearly

Sheline Y, et al. Bull Am Acad Psychiatry Law
199321321-9.
Sidebar Bryan A. Liang, MD, PhD, JD
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Case (cont.) Patient Falls out of Bed

• That evening, the patient fell for a second time
  while trying to get out of bed. He was found on
  the floor, bleeding from his mouth. There were no
  new neurological findings. A repeat head CT
  showed no increase in the size of the subdural
  hematomas. The lip laceration was stitched and
  the patient was placed in restraints, over his
  objection.

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Root Cause Analysis

• Floor nurses not aware of patients previous fall
  in the step-down unit
• Efforts to put the patient closer to RNs failed
  due to a lack of bed availability
• No high volume bed alarms available
• Bed alarms in use inaudible at RN station
• Sitters not available due to budget restrictions

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Cost per Intervention

• Forty-five units of FFP 5,085
• Repeat head CT 1,150
• Physical restraints 2.50-10.75
• Loud bed alarm270 each, 1-time cost
• Sitter/day360
• Relocation of patient 0

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System Improvements

• Enhance communication
• Bracelets to identify patients at high fall risk
• Checklistrisk factors reviewed on sign out
• Maintain mobility
• Balance risk of falling with benefits of activity
  
• Avoid cascade of functional decline
• Seek financially feasible alternatives
• Sitterssolicit family members
• Reserve beds near RN station for at-risk patients

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Take-Home Points

• Falls are common in hospitalized patients
• Patients should be screened by assessing
  intrinsic and extrinsic fall-related risk factors
• Communication of fall risk between providers is
  critical to prevent falls

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Take-Home Points (cont.)

• Other fall prevention strategies include
• Medication review
• Relocation of patient
• Sitters
• Bed alarms
• Mobility preservation
• Bed rails should be used with caution
• Physical restraints should be a last resort