www.nursingmanagement.com36 December 2009 Nursing Management

2010Guide to

Fa l ls /wander ingPatient Safety Technology

atient falls are a leadingcause of adverse events andinjury in hospitals. Approx-

imately 42% of falls result in someform of injury, and 8% result in serious injury.1 Falls can result inincreased length of hospital stay, dis-charge to a long-term care facility,hospital litigation, and increasedhealthcare costs.1 By 2020, the cost offall injuries is expected to reach $43.8billion.2 While falls are most preva-lent in patients age 65 or older, it’simperative that fall assessment andprevention strategies account for allpopulations serviced by the hospital.

Setting strategiesThe Agency for Healthcare Researchand Quality and the Institute forHealthcare Improvement (IHI) rec-ommend the assessment of patients’fall risk as an initial fall preventionstrategy in the hospital setting.Specifically, patients should bescreened for falls on admissionusing a standardized assessmentinstrument followed by a repeatassessment at regular intervals andwith change in clinical status.3 TheIHI recommends the following fallprevention strategies:1. Assess risk of falling and risk fora serious or major injury from a fall.2. Communicate and educate aboutpatients’ fall risk.

3. Standardize interventions forpatients at risk for falling.4. Customize interventions forpatients at highest risk for a seriousor major fall-related injury.3

Due to the complex nature ofpatients in the hospital setting,nursing leaders should determinehow nurses will meet the aforemen-tioned fall prevention strategies andconsider what interventions bestmeet their patients’ needs.

Patient safety specialists andnurse managers are finding thatenvironmental hazards in the hospi-tal setting have significant impacton patient safety. Environmentalconsiderations include lighting;pathways; floor surfaces; placementand stability of room furnishings,location of patient’s call light, tele-phone, and personal belongings;and position and functionality ofhospital equipment. The equipmentdevice most commonly used byhospitalized patients is the hospitalbed. Believed by many healthcareproviders to protect patients fromfalls and injury, bedside rails areused extensively throughout hospi-tals and residential care environ-ments as a safety device. However,numerous adverse incidents involv-ing body entrapment have beenlinked to the use of bedrails, whichhave resulted in serious injury to

the bed occupants and, in moreextreme cases, fatalities.4 Inresponse to continued reports ofpatient entrapment, the U.S.Department of Health and HumanServices, the FDA, and the Centerfor Devices and Radiological Healthissued recommendations related tohospital beds and hospital bedaccessories. The published reportidentifies body parts at risk forentrapment and locations of hospi-tal bed openings that are potentialentrapment areas, and recommendsdimensional criteria for thesedevices.5

ConsiderationsThorough patient assessment andidentification of fall risk factors arecritical elements of fall prevention.Patients identified as a fall risk benefit from patient- and condition-specific initiatives. Careful consider-ation must be given to the selectionof safety measures for patients withaltered self-awareness due to med-ication or illnesses, impaired alert-ness or balance, and visual orperipheral neuropathies. Commonfall prevention strategies includeenvironmental modifications, height-adjustable beds, alarm devices, medication adjustments, increasedmonitoring, and restr aint alterna-tives such as jackets and belts.

Bed enclosures: Suitable safety net?

Healthcare personnel with the authority to set patient safety initiatives should consider this technology as a strategy to

enhance clinical outcomes.By Tonya Haynes, ANP-C, MSN, and Elizabeth S. Pratt, ACNS-BC, MSN

P

A safe alternative for patients withaltered self-awareness and/or neuro-logic impairments is bed enclosuretechnology. Bed enclosure involvesthe use of a canopy attached to aheight-adjustable bed to promotepatient safety. The canopy has zip-pered panels for patient access andports for I.V. lines, drainage lines,and the nurse call button. Thoughclassified as a restraint, bed enclo-sure is less restrictive than otherrestraint options.

Benefits of the use of bed enclo-sure include freedom of movement,fall risk reduction, and eliminationof the need for side rails when thepatient is unattended, which avoidsthe risk of the patient being trappedin side rails, or between the mat-tress and side rails. As with all

restraints, use of bed enclosuretechnology requires a physician’sorder and assessment of the patientand equipment at regular intervals.

Indications for bed enclosure tech-nology include cognitive impairmentand severe risk of falls due to clinicalconditions. Contraindicationsinclude violent or self-destructivebehaviors and claustrophobia.Review the warnings and precau-tions listed by the manufacturer.

The decision to utilize bed enclo-sure as a patient safety initiativeshould be based on thoroughpatient assessment and considera-tion of indications and contraindi-cations. Though not appropriate forevery patient at high risk for falls,bed enclosure offers a safe solutionto specific patient populations in

the hospital setting. Healthcare per-sonnel who have the authority toselect patient safety initiativesshould consider bed enclosure tech-nology as a strategy to enhanceclinical outcomes.

Patient-centered careThe Institute of Medicine has setsix aims for improvement inhealthcare: safe, effective, patient-centered, timely, efficient, andequitable.6 In the acute care setting,the focus should be to ensurepatient safety and to respect thepatient and family’s needs. Patient-centered care emphasizes that sys-tems work if care encompassescompassion, empathy towardneeds, and recognition of patient’spreference. Staff must provide evi-dence-based nursing, including thebest clinical expertise and circum-stance, research, patient prefer-ences, and healthcare resources.7

In our case study, the bed enclo-sure device meets the qualificationsfor evidence-based practice. Directphysical restraints are more restric-tive and may limit the patient’sphysical ability. The patient is athigh risk for injury to himself andothers. To support the best practiceof using the least restrictive device,the interdisciplinary team felt thatthe bed enclosure device was thebest choice for Mr. Jones. Because ofhis restless and impulsive behavior,the bed alarm could be an alertthat’s too late to prevent injury. Thenursing staff frequently found thepatient far from the bed by the timethey reached his room. The bedenclosure device provided a safeplace for the patient to rest andcould be opened for meals andphysical and occupational therapy.

Use of the bed enclosure device atthis hospital has resulted in positive

www.nursingmanagement.com38 December 2009 Nursing Management

2010Guide to

Fa l ls /wander ingPatient Safety Technology

Case studyWalter Jones* was admitted to an acute medicine nursing division for metabolicencephalopathy and diabetic ketoacidosis. He had a history of labile blood glucoselevels with insulin resistance and poor nutrition in addition to heart failure and renalinsufficiency. Mr. Jones had fallen at home. He presented with a loss of cognitivefunction, personality changes per family report, inability to concentrate, and impulsivebehavior. Mr. Jones’ family reported that prior to admission, he was running into furni-ture in the house and couldn’t follow directions. Upon arrival to the medicine division,Mr. Jones’ BP was 160/90. His blood glucose was elevated at 345, and the insulin pro-tocol was initiated with basal, bolus, and correction doses. Positive ketones indicatedthat the patient was in ketoacidosis. Normal saline was initiated in the ED and contin-ued on the medicine division. Haldol by mouth was administered for the treatment ofacute delirium and metoprolol and amlodipine for his hypertension and heart failure.Mr. Jones’s head was wrapped with gauze from several skin tears on his scalp fromfalling. His head computed tomography was negative for an acute bleed.

The nursing staff initiated the Fall Protocol, placing the patient on a low bed andbed alarm and a room close to the nurses’ station due to the patient’s history of fallsand climbing out of bed even after direction. Communication among the caregiversincluded that all staff should respond immediately to the bed alarm to prevent injury tothe patient. The nursing staff had difficulty managing the patient who was consistentlyclimbing out of bed around the room with the I.V. pole. Fluids were discontinued after2 L. The patient was agitated and had impulsive behavior, which was difficult for thenursing staff to redirect. The patient had severe cognitive impairment and was foundwandering into another patient’s room on the nursing division. After the initial day, aninterdisciplinary meeting was held with nursing staff, the physician, social worker, andthe clinical nurse specialist. It was determined that a bed enclosure device would besafest for the patient. The physician spoke with the family about the patient’s safetyand the decision to use a bed enclosure.

*patient’s name and other details changed for confidentiality.

outcomes, specifically, the prevention of falls and injuryin patients who meet the qualifications for the device.The bed enclosure device is available by an outsidevendor, which arrives within 4 hours of the order. Thebed provides a calm environment, reducing light and

external stimuli. Patients may have a more restful sleepwhen the device is employed.

Interdisciplinary care ensures communication amongcaregivers and transparency of the care plan with thefamily. Coordination of care is particularly important forpatients, such as Mr. Jones, due to the complex nature ofthe case and the physical and emotional support neededfor the patient and family. After learning of the clinical-safety issues and functionality of the bed enclosuredevice, the family supported the decision to utilize thebed. Mr. Jones’ family members were included in histransfer to the enclosed bed that evening.

Mr. Jones had an extended length of stay in the hospital due to the complex nature of metabolicenceph alopathy and insulin resistance. The patient wasplaced in a chair at the nurses’ station for each mealand worked with physical therapy routinely for exer-cise. While the patient was in his room, the bed enclo-sure device was employed. Mr. Jones never fell or expe-rienced a physical injury during his admission. He wasdischarged safely to a skilled nursing facility. The inter-disciplinary team celebrated the prevention of harmwith this patient and shared the success of the enclo-sure device with the hospital leaders and the manufac-turer. Using the bed enclosure for the appropriatepatient who meets the criteria can be a life-savingmeasure. NM

REFERENCES1. Krauss MJ, Nguyen SL, Dunagan WC, et al.. Circumstances of

patient falls and injuries in 9 hospitals in a midwestern healthcaresystem. Infect Control Hosp Epidemiol. 2007; 28(7):544-550.

2. Institute for Healthcare Improvement. Transforming care at thebedside how-to guide: Reducing patient injuries from falls. http://

www.ihi.org/IHI/Topics/PatientSafety/ReducingHarmfromFalls/Tools/TCABHowToGuideReducingPatientInjuriesfromFalls.htm.

3. Currie L. Fall and injury prevention. In: R. Hughes, ed. Patientsafety and quality: An Evidence-Based Handbook for Nurses.Rockville, MD: Agency for Healthcare Research and Quality;2008.

4. Boocock MG, Weyman AK, McIlroy R. Bedside safety rails:assessment of strength requirements and the appropriateness ofcurrent designs. Ergonomics. 2006;49(7):631-650.

5. United States Department of Health and Human Services, Foodand Drug Administration, & Center for Devices and RadiologicalHealth. Hospital bed system dimensional and assessment guid-ance to reduce entrapment. http://www.fda.gov/cdrh/beds.

6. Institute of Medicine. Crossing the quality chasm: A new healthsystem for the 21st century. http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.ashx

7. DiCenso A, Guyatt G, & Ciliska D. Evidence-Based Nursing: AGuide to Clinical Practice. St. Louis, MO: Mosby; 2005.

At Barnes-Jewish Hospital, St. Louis, Mo., Tonya Haynes is a nursepractitioner and Elizabeth S. Pratt is a clinical nurse specialist.

Nursing Management December 2009 39www.nursingmanagement.com

2010Guide to

Fa l ls /wander ingPatient Safety Technology

Use of bed enclosuretechnology requires a physi-

cian’s order and assessment ofthe patient and equipment at

regular intervals.

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