- Email: [email protected]
When the falls expert becomes the fall risk patient: Through the looking-glass
Geriatric Nursing 37 (2016) 311e312
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Acute Care of the Elderly Column
Elizabeth Capezuti, PhD, RN, FAAN
Sarah Hope Kagan, PhD, RN, FAAN
Mary Beth Happ, PhD, RN, FAAN
Lorraine C. Mion, PhD, RN, FAAN
When the falls expert becomes the fall risk patient: Through the looking-glass Lorraine C. Mion, PhD, RN, FAAN * Vanderbilt School of Nursing, 421 21st Avenue South, Nashville, TN 37204, USA
Lewis Carroll: Alice in Wonderland and Through the Looking-Glass “when she thought it over afterwards it occurred to her that she ought to have wondered at this, but at the time it all seemed quite natural”
For many years (more than I care to admit), I have concentrated on the provision of nursing care to older adults in hospital settings. Early in my practice as a geriatric clinical nurse specialist, I was challenged by a British physician of ‘why do American nurses tether their patients.’ It was as if blinders came off my eyes and I could see the madness of involuntary immobilization when tying patients to the bed or chair, many of them in tears or angst, while at the same time encouraging early mobility and ambulation. Thus began my journey over the ensuing decades to reduce our reliance on the use of physical restraints in the care of older patients who were delirious or with dementia, who were at risk for falls or who were likely to disrupt or terminate their medical devices, e.g., intravenous lines, indwelling bladder catheters (treatment disruption). With colleagues, I have conducted quality improvement and clinical studies testing non-restraint strategies to prevent patient falls or treatment disruption in the hospital setting. Some strategies have helped in reducing fall rates1; some not so much.2 I have actively participated on several hospital falls committees, even serving as chair. Yet, none of my clinical, administrative or research
* Tel.: þ1 615 343 7098. E-mail address: [email protected]. 0197-4572/$ e see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2016.06.006
experiences helped in the least when it was I who became the fall risk patient. Last year I underwent major abdominal surgery that required a 5-day hospital stay. Besides the general anesthesia for the procedure, the anesthetist placed an epidural line for dilaudid infusion, which stayed in until post-operative day two. After surgery, I also received Neurontin for nerve pain due to the abdominal surgical procedure. At 60 years of age, I developed post-operative delirium. Take pity on the nurses. They all knew I was a professor at the university. My surgeon was the Chair of the department and made sure they all knew who I was. I had high ranking nurse and physician visitors during my stay. My position may have placed them in an awkward situation when it came to patient education and patient safety. Much of what occurred, I have little memory. But some memories are still quite vivid. Post-operative day 1: I look at my feet and see I am wearing yellow, non-skid socks. I say to the nurse, “Look at this. I’m wearing the ‘fall risk’ socks”! I was really quite amused. She replied, “yes.” My interpretation: Isn’t that cute, she is agreeing with me that the socks I’m wearing are the ones used for fall risk patients. I did not interpret this to mean that I was at falls risk. Post-operative days 2 and 3: As typical for many delirious patients, I was quite awake during the nights. I remember getting up from the bed to chair. Or going to the bathroom and returning to bed or chair. And the night aide coming in, stating, “You got up by yourself again, didn’t you?” I remember being somewhat surprised that he seemed annoyed. My reply was always, ‘yes,’ but without understanding why he was annoyed. I wanted to ask him, but then thought ‘perhaps he’s just really busy.’
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L.C. Mion / Geriatric Nursing 37 (2016) 311e312
On POD 2, I remember I didn’t like how the furniture was arranged in the room and decided to rearrange it. With the IV pump in hand, I was pushing the recliner chair to another part of the room when the night nurse came in and said, “You know, I don’t think you are supposed to be doing that with the type of surgery you had.” I was so surprised and remember stating, “Really!?” (or something to that effect). When she assured me I shouldn’t be doing that, I just said “OK” and stopped doing it. The following day, when the surgeon came in and instructed me I was not to bend, push, pull, lift, twist, and so on, my thought was, “The night nurse ratted on me.” I certainly was not grasping the potential consequences of such actions. The day shift nurse (I was fortunate I had her several days in a row) kept asking me to watch the falls prevention video on the patient education TV channel. One of the nights while awake, I decided to view it. I remember thinking I should call and ask for pen and paper so I could critique the video. I had many thoughts on how it could be improved! However, it never dawned on me that she was requesting I view it because I was considered a falls risk patient.
Fall prevention strategies Which brings me back to the whole concept of falls prevention in hospital settings. We have patient education, patient reminders and signs, and for when patients won’t listen, we have strategies such as alarms, moving the patient closer to the nurses’ station, routine rounding, toileting schedules, and finally, use of sitters or restraints. We know that patient education can work, but studies have focused primarily on patients who are cognitively able to understand and participate in the patient education.3 What I can assure you, if the patient does not grasp the concept of being at risk for falls, patient education and patient reminders may not work. As with Alice in Wonderland, in looking back at my experiences, I should have wondered at all the clues and indices from the nurses that I was at fall risk. Yet, I didn’t. Would one say ‘impaired judgment’? Most likely. But at the time, I thought I was no different than before the surgery. Would one say, ‘impaired decision making’? Absolutely. I continue to ponder this. For you see, fall rates and fall injuries have not changed much over the years, even with the Centers for Medicare and Medicaid Services (CMS) dictating no payments for injuries which occur during hospitalization4 . because hospital injuries are considered by CMS as ‘never events.’ The assumption is our processes of care can prevent all injury. For some injuries, I do believe that processes of care can eliminate injuries, such as incorrect medication administration. If the nurse completes the safe medication administration behaviors prior to giving the medication to the patient rather than engaging in ‘work arounds,’ then adverse drug events from this error source should be greatly reduced. This is because it is the nurse’s behavior, not the patient’s
behavior, which determines whether the injury occurs in the first place. Not so with falls. It’s the patient’s behavior which determines the hospital fall event. It’s not only those with cognitive impairment that place themselves at risk for falls. Those with normal cognition place themselves at greater risk when refusing to call for assistance due to ‘not wanting to be a burden’ or misjudging the effect of acute illness on their physical capabilities.5 Thus, nurses and other health professionals must strategize on ways to circumvent the patient’s behavior. Sadly, I am hearing anecdotal stories from nurse colleagues across the country that physical restraint rates on general adult units are on the rise again. After several decades of minimizing restraint, promoting function and mobility, we are regressing. In the name of safety. In the name of reimbursement. It’s lunacy. Surely, we can do better. Recommendation for patient education and reminders Despite all the cues nursing staff were giving me, I could not grasp that I was at high falls risk. I suggest we need to be overly cautious and state with every encounter with the patient, “These yellow socks are for people who are at risk for falling. You, [name of patient] are at risk for falling and this is why [short rationale]. You MUST call for help before getting out of the bed (chair).” I doubt I would have grasped it the first or even the fifth time, but perhaps by the sixth time, I would have responded with “Really!?” and then “OK.” The surgeon’s lecture on my activity restriction made an impact. Thus, not only nursing personnel, but anyone entering the room, including the patient’s visitors and families, could deliver the same message before leaving the room. I’m writing this column during the basketball playoffs and the “All In” slogan is indeed fitting. But for some patients, such as those with organic functional impairment from dementia or stroke, the ability to grasp the message may never occur. Nevertheless, I believe it is a work habit that can be easily incorporated within our normal work flow processes. Try it. We have nothing to lose. Our patients have everything to gain. References 1. Mion LC, Fogel J, Sandhu S, et al. Targeted restraint reduction programs in the acute care hospital: outcomes of a two-site quality improvement initiative. Jt Comm J Qual Improv. 2001;27(11):605e618. 2. Shorr RI, Chandler AM, Mion LC, et al. Increasing bed alarm use to prevent falls in hospitalized patients: a cluster-randomized trial. Ann Intern Med. 2012;157(10): 692e699. 3. Hill Am, McPhail SM, Waldron N, et al. Fall rates in hospital rehabilitation units after individualized patient and staff education programmes: a pragmatic, stepped-wedge, cluster randomized trial. Lancet. 2015;385(9987):2592e2599. 4. Bouldin ED, Andresen DM, Dunton NE, et al. Falls among adult patients hospitalized in the United States: prevalence and trends. J Patient Saf. 2013;9(1): 13e17. 5. Haines TP, Lee D-CA, O’Connell B, McDermott F, Hoffmann T. Why do hospitalized older adults take risks that may lead to falls? Health Expect. 2012;18: 233e249.
Contents lists available at ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
Acute Care of the Elderly Column
Elizabeth Capezuti, PhD, RN, FAAN
Sarah Hope Kagan, PhD, RN, FAAN
Mary Beth Happ, PhD, RN, FAAN
Lorraine C. Mion, PhD, RN, FAAN
When the falls expert becomes the fall risk patient: Through the looking-glass Lorraine C. Mion, PhD, RN, FAAN * Vanderbilt School of Nursing, 421 21st Avenue South, Nashville, TN 37204, USA
Lewis Carroll: Alice in Wonderland and Through the Looking-Glass “when she thought it over afterwards it occurred to her that she ought to have wondered at this, but at the time it all seemed quite natural”
For many years (more than I care to admit), I have concentrated on the provision of nursing care to older adults in hospital settings. Early in my practice as a geriatric clinical nurse specialist, I was challenged by a British physician of ‘why do American nurses tether their patients.’ It was as if blinders came off my eyes and I could see the madness of involuntary immobilization when tying patients to the bed or chair, many of them in tears or angst, while at the same time encouraging early mobility and ambulation. Thus began my journey over the ensuing decades to reduce our reliance on the use of physical restraints in the care of older patients who were delirious or with dementia, who were at risk for falls or who were likely to disrupt or terminate their medical devices, e.g., intravenous lines, indwelling bladder catheters (treatment disruption). With colleagues, I have conducted quality improvement and clinical studies testing non-restraint strategies to prevent patient falls or treatment disruption in the hospital setting. Some strategies have helped in reducing fall rates1; some not so much.2 I have actively participated on several hospital falls committees, even serving as chair. Yet, none of my clinical, administrative or research
* Tel.: þ1 615 343 7098. E-mail address: [email protected]. 0197-4572/$ e see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2016.06.006
experiences helped in the least when it was I who became the fall risk patient. Last year I underwent major abdominal surgery that required a 5-day hospital stay. Besides the general anesthesia for the procedure, the anesthetist placed an epidural line for dilaudid infusion, which stayed in until post-operative day two. After surgery, I also received Neurontin for nerve pain due to the abdominal surgical procedure. At 60 years of age, I developed post-operative delirium. Take pity on the nurses. They all knew I was a professor at the university. My surgeon was the Chair of the department and made sure they all knew who I was. I had high ranking nurse and physician visitors during my stay. My position may have placed them in an awkward situation when it came to patient education and patient safety. Much of what occurred, I have little memory. But some memories are still quite vivid. Post-operative day 1: I look at my feet and see I am wearing yellow, non-skid socks. I say to the nurse, “Look at this. I’m wearing the ‘fall risk’ socks”! I was really quite amused. She replied, “yes.” My interpretation: Isn’t that cute, she is agreeing with me that the socks I’m wearing are the ones used for fall risk patients. I did not interpret this to mean that I was at falls risk. Post-operative days 2 and 3: As typical for many delirious patients, I was quite awake during the nights. I remember getting up from the bed to chair. Or going to the bathroom and returning to bed or chair. And the night aide coming in, stating, “You got up by yourself again, didn’t you?” I remember being somewhat surprised that he seemed annoyed. My reply was always, ‘yes,’ but without understanding why he was annoyed. I wanted to ask him, but then thought ‘perhaps he’s just really busy.’
312
L.C. Mion / Geriatric Nursing 37 (2016) 311e312
On POD 2, I remember I didn’t like how the furniture was arranged in the room and decided to rearrange it. With the IV pump in hand, I was pushing the recliner chair to another part of the room when the night nurse came in and said, “You know, I don’t think you are supposed to be doing that with the type of surgery you had.” I was so surprised and remember stating, “Really!?” (or something to that effect). When she assured me I shouldn’t be doing that, I just said “OK” and stopped doing it. The following day, when the surgeon came in and instructed me I was not to bend, push, pull, lift, twist, and so on, my thought was, “The night nurse ratted on me.” I certainly was not grasping the potential consequences of such actions. The day shift nurse (I was fortunate I had her several days in a row) kept asking me to watch the falls prevention video on the patient education TV channel. One of the nights while awake, I decided to view it. I remember thinking I should call and ask for pen and paper so I could critique the video. I had many thoughts on how it could be improved! However, it never dawned on me that she was requesting I view it because I was considered a falls risk patient.
Fall prevention strategies Which brings me back to the whole concept of falls prevention in hospital settings. We have patient education, patient reminders and signs, and for when patients won’t listen, we have strategies such as alarms, moving the patient closer to the nurses’ station, routine rounding, toileting schedules, and finally, use of sitters or restraints. We know that patient education can work, but studies have focused primarily on patients who are cognitively able to understand and participate in the patient education.3 What I can assure you, if the patient does not grasp the concept of being at risk for falls, patient education and patient reminders may not work. As with Alice in Wonderland, in looking back at my experiences, I should have wondered at all the clues and indices from the nurses that I was at fall risk. Yet, I didn’t. Would one say ‘impaired judgment’? Most likely. But at the time, I thought I was no different than before the surgery. Would one say, ‘impaired decision making’? Absolutely. I continue to ponder this. For you see, fall rates and fall injuries have not changed much over the years, even with the Centers for Medicare and Medicaid Services (CMS) dictating no payments for injuries which occur during hospitalization4 . because hospital injuries are considered by CMS as ‘never events.’ The assumption is our processes of care can prevent all injury. For some injuries, I do believe that processes of care can eliminate injuries, such as incorrect medication administration. If the nurse completes the safe medication administration behaviors prior to giving the medication to the patient rather than engaging in ‘work arounds,’ then adverse drug events from this error source should be greatly reduced. This is because it is the nurse’s behavior, not the patient’s
behavior, which determines whether the injury occurs in the first place. Not so with falls. It’s the patient’s behavior which determines the hospital fall event. It’s not only those with cognitive impairment that place themselves at risk for falls. Those with normal cognition place themselves at greater risk when refusing to call for assistance due to ‘not wanting to be a burden’ or misjudging the effect of acute illness on their physical capabilities.5 Thus, nurses and other health professionals must strategize on ways to circumvent the patient’s behavior. Sadly, I am hearing anecdotal stories from nurse colleagues across the country that physical restraint rates on general adult units are on the rise again. After several decades of minimizing restraint, promoting function and mobility, we are regressing. In the name of safety. In the name of reimbursement. It’s lunacy. Surely, we can do better. Recommendation for patient education and reminders Despite all the cues nursing staff were giving me, I could not grasp that I was at high falls risk. I suggest we need to be overly cautious and state with every encounter with the patient, “These yellow socks are for people who are at risk for falling. You, [name of patient] are at risk for falling and this is why [short rationale]. You MUST call for help before getting out of the bed (chair).” I doubt I would have grasped it the first or even the fifth time, but perhaps by the sixth time, I would have responded with “Really!?” and then “OK.” The surgeon’s lecture on my activity restriction made an impact. Thus, not only nursing personnel, but anyone entering the room, including the patient’s visitors and families, could deliver the same message before leaving the room. I’m writing this column during the basketball playoffs and the “All In” slogan is indeed fitting. But for some patients, such as those with organic functional impairment from dementia or stroke, the ability to grasp the message may never occur. Nevertheless, I believe it is a work habit that can be easily incorporated within our normal work flow processes. Try it. We have nothing to lose. Our patients have everything to gain. References 1. Mion LC, Fogel J, Sandhu S, et al. Targeted restraint reduction programs in the acute care hospital: outcomes of a two-site quality improvement initiative. Jt Comm J Qual Improv. 2001;27(11):605e618. 2. Shorr RI, Chandler AM, Mion LC, et al. Increasing bed alarm use to prevent falls in hospitalized patients: a cluster-randomized trial. Ann Intern Med. 2012;157(10): 692e699. 3. Hill Am, McPhail SM, Waldron N, et al. Fall rates in hospital rehabilitation units after individualized patient and staff education programmes: a pragmatic, stepped-wedge, cluster randomized trial. Lancet. 2015;385(9987):2592e2599. 4. Bouldin ED, Andresen DM, Dunton NE, et al. Falls among adult patients hospitalized in the United States: prevalence and trends. J Patient Saf. 2013;9(1): 13e17. 5. Haines TP, Lee D-CA, O’Connell B, McDermott F, Hoffmann T. Why do hospitalized older adults take risks that may lead to falls? Health Expect. 2012;18: 233e249.