Download Fall Prevention - Intervention Guidance

Falls Prevention Toolkit- Section 4 – INTERVENTION GUIDANCE
3rd edition – September 2015
Review: September 2017
Principal Authors:
Rob Morris
Karen King
Ellen McMahon
Beverley Brady
Pathway Lead Clinician for Older people
Practice Development Matron
Practice Development Matron
Matron
Additional contributors:
Fiona Branch
Emma Grace
Faye O’Callaghan
Kathryn Draper
Keith Knox
James Saxton
Dave Allen
Nicola Fountain
Nicky Lindley
Abbie Betts
Consultant Nurse, Nursing Documentation Group
Senior Pharmacist
Practice Development Matron
Practice Development Matron
Practice Development Matron
Datix manager
Information Support Officer
Patient Safety Administrator
Matron, Patient Safety
Medstrom Clinical Nurse Specialist
Section
Section 4
Intervention
Guidance
Content
Page

Guidance for the use of Cohort Bays
2

Cohort Nursing Poster
3

The use of 1:1 supervision to prevent falls
4

Side-Rooms
5

Mental capacity
5

Patient Placement
5

Advice Sheet (Guidance) for the use of Bed Rails
6

Toileting & Continence Management
7

Footwear Assessment Guidance
9

Information Sheet – Footwear
9

Visual Assessment Guidance
10

Lying and Standing (Orthostatic) Blood Pressure Measurement
11

Guidance for the use of Ultra Low Beds
13

Guidelines for Physiotherapists in Falls Risk Assessment
18

Handy Hints on the management of delirium
19
Falls Prevention Toolkit 3rd Edition September 2015- Section 4- INTERVENTION GUIDANCE
Page 1
The use of a “Cohort Nursing Bay” to Prevent Falls
Definition:
Cohort nursing refers to the practice of grouping together patients with intensive nursing needs
or those at a high risk of an untoward event to enable you to manage their needs more
effectively. This may include particular patient groups e.g. patients returning from the operating
theatre or patients who are at a high risk of falling.
Cohort nursing allows patients at risk of falling to be nursed in one area (usually a bay) in order
that we can provide active supervision at all times to the area. This can be particularly effective
for managing patients whose behaviour is challenging (e.g. wandering, agitation or confusion).
To Provide Cohort Nursing, this means:
To “free up” nursing staff to provide continual observation of the Cohort Nursing Bay, you will
need to reconfigure the allocated workload of all ward staff on each shift (including the night
shift).
If you are providing observation for a Cohort Nursing Bay you should NOT carry out any other
duties. Your sole responsibility is to observe and supervise the patients being co-horted in the
bay. If a patient requires care, you will need to ask another member of staff to either replace you
or carry out that care themselves. You should not be answering call bells.
Cohort supervision should NOT be provided by the nurse allocated to the bay to provide general
nursing care – Cohort nursing is provided by an additional nurse (at least one). Therefore –
there will be more than 1 nurse allocated to that bay (1 to cohort, and 1 registered to provide
general care for those patients).
The Cohort Nursing bay should NEVER be left unattended. If the Cohort nurse needs to leave
the bay then they must ensure there is another nurse or ward team member to take over the
role of co-horting.
The cohort nurse may need to move position within the cohort bay to provide supervision to
patients at all time. This may happen if personal care is being carried out to a patient behind
curtains by another member of staff. Curtains can often obscure the view of one of the patients
within the bay, and to enable the observation of all patients within the cohort bay the nurse will
need to move position.
Very occasionally, it may be necessary to co-opt the support of other ward team members
(e.g. physiotherapists, occupational therapists, domestic and reception staff) in providing “an
extra pair of eyes” whilst nursing staff are temporarily unable to maintain observation (This is
not a request to provide nursing care but is merely a means of maintaining observation of those
patients at risk of falling).
Co-horting should not be carried out by any member of staff that has not been trained in falls
prevention - this is particularly important with regard to “bank” and agency staff. Staff must not
be expected to provide cohort supervision if they are not absolutely clear about what is required
of them. Student nurses should not be expected to provide cohort supervision routinely - they
have not received specific training and it cannot be regarded as a good learning experience for
them. It is good practice to rotate the member of staff providing cohort supervision regularly
over the course of a shift as it can be a very challenging role.
Falls Prevention Toolkit 3rd Edition September 2015- Section 4- INTERVENTION GUIDANCE
Page 2
Falls Prevention Toolkit 3rd Edition September 2015- Section 4- INTERVENTION GUIDANCE
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The use of 1:1 supervision to prevent falls
1:1 supervision can be provided by any nurse – registered or non-registered
1:1 supervision can be used to care for patients who are at risk of falling when the patient’s
behaviour is particularly challenging. This could include:




Wandering patients
Confused patients
Highly agitated patients
Delirious patients (including those with hypoactive delirium)
When carrying out 1:1 supervision you are expected to supervise that patient and that patient
alone. You are not expected to provide care to other patients within the bay or be the person
responsible for cohort nursing.
This patient may also be in the cohort bay but, due to their challenging behaviour, they require
additional supervision. In this instance there will be a nurse providing patient care, a cohort
nurse for the bay and a third nurse providing the 1:1 supervision.
DO:







Complete an ‘About Me’ document (Click Here) to establish the patients normal behaviours,
habits, likes and dislikes etc. as this information will prove useful and beneficial when caring
for the patient
Accompany a wandering patient at all times (including going to the toilet)
Consider using books, games, photographs, newspapers etc. to engage your patient
Take into account the individual needs of the patient with regard to ‘invading their personal
space’ as this can cause additional agitation
Rotate the nurse providing the 1:1 supervision regularly. It is widely acknowledged that
providing this level of supervision is challenging and tiring. However, assess this based on
the individual needs of your patient as some patients will respond better to consistent care
from a preferred member of the ward team.
When you are unable to provide 1:1 supervision, for whatever reason, escalate the need to
your Matron and the Site Matron.
Assess the patient acuity/dependency against the number of staff on duty. You may need to
re-allocate the workload across a group of wards to accommodate 1:1 supervision. Liaise
with similar wards within specialties or book additional staff.
DON’T


Leave the patient unattended
Allocate any member of staff to provide this level of supervision unless they:
o Have a full understanding of what is required by the role
o The nurse in charge has clarified their understanding of supervision – This is particularly
important when “bank” or agency staff members are involved and it is likely to be better
that additional staff “backfill” the role of regular members of the ward team in order to
permit their allocation to 1:1 supervision.
Falls Prevention Toolkit 3rd Edition September 2015- Section 4- INTERVENTION GUIDANCE
Page 4
Additional Notes – Supervision and Observation of Patients at risk of falling
Patients in side rooms
Confused and agitated patients who require a side room for either infection control reasons or
other care complications will need 1:1 supervision.
Reassess the need for 1:1 supervision
1:1 supervision can be discontinued:


If the patient’s condition changes so they are no longer wandering (now nursed in bed). Cohorting would be more appropriate in this instance
If the patient’s condition is treated and their confusion has subsided as a result of this, then
reassess on an individual basis
Mental Capacity
Patients considered to be confused (syn. agitated or delirious) must have a 2-stage Mental
Capacity Assessment Test (Click Here) performed on admission and at any point that their
condition changes during their stay. If a patient is found not to have capacity then staff will be
able to provide the appropriate level of supervision in the patients best interests.
A prolonged need for co-horting and/or 1:1 supervision will require referral to the Safeguarding
Team (Click Here) for consideration of applying for a “Deprivation of Liberty” authorisation.
All of this assessment process must be documented in the nursing record/evaluation
Patient Placement on the Ward
Please think very carefully about where in the ward your patients are placed:
There is always more than one bed to choose from when placing patients. Simply because the
side-room is empty does NOT mean that a newly admitted patient should be placed there.
Consider the remaining patients on the ward and decide who would be most suitably nursed in
a side-room and where on the ward your new patient should be. It may be preferable to place
new admissions in your cohort bay for better observation until you are confident that you
understand their needs properly. This guidance can also be used for supervising your other ‘at
risk patient’s’ for example, patients who are septic, patients who are returning from ITU etc.
Although this means moving patients around the ward, the safety of those in our care is
paramount. If there is a compelling reason to isolate a patient in a side-room (infection
prevention and control most likely), carefully consider the level of supervision required to
maintain their safety – This may mean providing 1:1 Supervision for the patient in the sideroom.
To quickly move patients around the ward as quickly as possible, it will be necessary to engage
all available staff in the bed moves. Make the changes as soon as the risk has been recognised
and effect all the bed moves required in “one go”. Delay will add to the risk and increase the
likelihood of a fall or other adverse event.
Falls Prevention Toolkit 3rd Edition September 2015- Section 4- INTERVENTION GUIDANCE
Page 5
Bed Rails Advice Sheet
Bed rails are sometimes referred to as side rails, cot sides or safety rails. The term bed rail is
preferred for general use and does not refer to rails used on trolleys or children’s cots.
They must not be used if broken or incorrectly fitted as they could cause serious harm
even death.
Default position– Do not use:
 On a patient who is confused and/or agitated – the patient will climb over them
 On an ultra-low bed in the low position
 To keep someone in bed - Bed rails are not to be used as any form of restraint (defined as
‘the intentional restriction of a person’s voluntary movement or behaviour’)
 If a patient is found trying to climb over the bed rail or out from the bottom of the bed,
 If a patient is found in positions which could lead to entrapment e.g. feet or arms through
rails. They are at risk of serious risk injury and urgent changes must be made in their care.
 If the bed rails are incorrectly fitted or broken
Do use in the following circumstances:
 When transferring patients between wards and departments (under constant supervision)
 To aid positioning of a patient (when a patient has capacity) temporarily. For example, patient
may hold onto the bed rails during a wash. During such activities your patient must be
supervised at all times and the bed rails removed when the intervention is complete
 When specifically requested by the patient (when a patient has capacity) – the reason for this
should be clearly documented in the patients evaluation.
The use of bed rails must be reviewed in accordance with the falls prevention checklist
(medium risk). If the patient’s condition changes, the use of bed rails must be reviewed in
line with this change using the adult In Patient Falls Flow Chart.
The decision to use bed rails must be recorded in the nursing notes and communicated to all
members of the ward (multidisciplinary) team. Bed rail use should be reviewed whenever there
is a change in the patient’s condition. The patient’s family and/or carers should also be involved
if possible and kept fully informed of the rationale employed.
Consider the following if you are going to use bedrails:




Make sure you follow the bed manufacturer’s instructions and guidance
Patient must have capacity
The patient does not fulfil any of the criteria in the ‘Do not use’ section
Consider if your patient’s head, neck, chest or any part of their body could become trapped
between the bars of the bed rails or any other gaps created by the bed, rail, and mattress and
head/footboard combination?
 Bariatric beds must be used with an appropriate extra wide mattress and bed rails that are
safe to use with the bed. These are usually supplied by the manufacturer as a complete unit.
 If you have a bed with Split bedrails they should either be “all up” or “all down”.
Falls Prevention Toolkit 3rd Edition September 2015- Section 4- INTERVENTION GUIDANCE
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Toileting & Continence Management
Almost half of the falls amongst in-patients at NUH are associated with toileting - patients falling
on the way to, from or in the toilet itself.
Toileting can be a particularly dangerous activity for patients who are at risk of falls. For
example, patients who rely on mobility aids are unable to use them correctly as they open or
close doors and manipulate clothes. Toilets and bathrooms can be challenging and confined
spaces to move around in, which further increases the risk of a patient falling. In addition, falls
in toilets are more often associated with severe injuries and head injuries in particular than falls
which occur elsewhere.
Patient safety must always be our priority, even though sometimes we may have to
compromise their privacy and dignity in order to do so.
Handy Hints on Toileting
DO:
 Assess the patient individually using the Elimination questions in the ‘NUH Inpatient
Admission and Discharge Booklet’.
 Escalate any ‘yes’ scores that are new to the patient to the medical team for further
investigation or perform a more detailed continence assessment (Frequency/Volume
Documentation Chart, Post-Void Residual Volume Bladder Scan, Urinalysis and Digital
Rectal Examination – Nursing Guideline).
 Use the ‘About me’ document to establish the patient’s normal toileting regime/needs, bowel
and urinary habits. Encourage family or carers to complete these sections in detail.
 Establish a toileting regime for the patient if appropriate. Patients may require prompting to
go to the toilet. The frequency of prompting is individual to the patient but 2-4 hourly is the
general norm for most patients.
 Ensure you stay with the patient whilst they are on the commode if they are being nursed in a
cohort bay. This may mean observing the patient through curtains or discretely remaining
behind curtains in order to be able to respond to the patient’s attempts to mobilise unsafely.
 Ensure you use an appropriate catheter fixator device - patients who are mobile should have
a leg-bag in place, secured with a sleeve/strap. Urometer bags attached to bed frames or
other furniture effectively become one-point restraints and can be dangerous.
 Consider any additional equipment that the patient needs to manoeuvre whilst in the toilet,
e.g. A Zimmer frame or a drip stand. These additional factors can prove a falls hazard or risk
to even the most mobile patients and need to be considered when patients are manoeuvring
in or moving to/from the toilet.
 Be prepared - use the handover to ensure that you understand the continence/elimination
needs of your patients so that if they need pads, net knickers or 'Cavalon', you are able to
take it into the toilet with you. This will reduce the risk of leaving the patient unsupervised.
 Position a patient with continence needs near to the toilet wherever possible so that they
have less distance to walk.
 Use a bowel chart to record when your patient has had their bowels open. Use the Bristol
Stool Chart to document the consistency and quantity of their stool so that you are aware of
the need to provide any further intervention(s) if required (enemas and/or laxatives).
Falls Prevention Toolkit 3rd Edition September 2015- Section 4- INTERVENTION GUIDANCE
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 Perform a digital rectal examination (DRE or PR) for patients who you think might be
constipated ( if not contradicted) - guidance on how to perform a DRE is on the nursing
website CLICK HERE
 Closely monitor laxative usage and consider other drugs that could affect a patient’s toileting
needs e.g. opiates (morphine, codeine, tramadol etc.) and diuretics.
 Keep the toilet door open when not in use so patients can see that it is a toilet.
 Use an enlarged photograph (not a cartoon) on the door of toilets to aid patient’s navigation.
 Ensure that bathrooms and toilets are clutter free at all times.
 Attempt to answer the nurse call buzzer promptly - this will lessen the risk of a patient
attempting to get up by themselves. Make toilet buzzers a priority.
 Use a bladder scan (if competent to do so) when you find your patient is making frequent
trips to the toilet and passing only small amounts of urine - discuss results with the medical
team. Perform urinalysis and ask about symptoms indicative of infection (dysuria, frequency
or new incontinence etc.).
DON’T:
 Don’t leave commodes by the bedside at night - this encourages the patient to use them
without necessarily requesting help.
 Don’t encourage the use of a commode - patients should be walking to the toilet when able to
do so and with appropriate supervision.
 Don’t wake up a patient at night to prompt them to use the toilet - if they are awake they can
be offered/ prompted to use the toilet.
 Don’t use urethral catheters purely for convenient management of incontinence needs.
Falls Prevention Toolkit 3rd Edition September 2015- Section 4- INTERVENTION GUIDANCE
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Guidance for assessing in-patient footwear
Take into account the following when assessing foot wear:
 Does the patient have their own slippers/shoes?
 If they do not have their own slippers/shoes we need to attempt to obtain them from family
members
 If they have their own footwear, is it well fitting?
 Can the patient fasten their own footwear
 If the patients footwear is damaged, worn or has been altered in any way do not use and
provide or seek an alternative
 Does oedema prevent them from wearing commercially available slippers / shoes
 Does the sole of the slipper grip?
 In your opinion, does the patient’s footwear contribute to their instability?
 Have they had a physiotherapist mobility assessment?
Patients, who have no means of obtaining or don’t have their own footwear, should be supplied
with Trust issued ‘Gripper Socks’. This is NOT an alternative to using a patient’s own foot wear
(if it is appropriate and safe), nor are Gripper Socks to be seen as an alternative to relatives
bringing in safe appropriate foot wear.
The Gripper Socks used on the wards should be those with gripping surface on both sides
(order codes are available via falls champions). Gripper socks must be removed at least daily
and skin integrity checked.
The orthotic department can provide specialist footwear for patients under the following
circumstances:
 For patients with dressings and/ or oedema which prevents them from safely wearing ‘off the
shelf foot wear’, Patients with long term medical foot problems, which cannot be
accommodated by ‘off the shelf’ footwear.
 Patients who are temporarily unable to wear appropriate footwear.
Remember patients should always be encouraged to bring in suitable footwear or have
shoes brought in from home
More Information is provided in this leaflet – Click Here
Falls Prevention Toolkit 3rd Edition September 2015- Section 4- INTERVENTION GUIDANCE
Page 9
Keeping an Eye on Visual Problems to Reduce Falls

Ensure patients who need spectacles to see are wearing them and they are clean!

Spectacles can go missing in hospital, particularly when people are ill and confused. You
can use a patient id label to make them identifiable

Make sure patients with poor vision who need help mobilising can easily call for help using
the call bell system or a viable alternative.

Keep all doors to toilets/bathrooms fully open or fully closed - never ajar.

You might want to consider putting a picture of a toilet on the toilet door.

Make sure the ward team are aware of patients who have poor eyesight. This should be
done via the handover.

Keep bed spaces and walkways clear of obstacles and clutter – Remember that glaucoma
causes visual field loss (poor peripheral vision) putting patients more at risk of bumping into
things around them or managing stairs or steps.

Always ask your patients about problems with their eyesight and if their vision causes
problems with any normal functional activities.

Cataracts, macular degeneration, glaucoma, and diabetic eye problems are the commonest
causes of poor eyesight amongst older people.

Ask patients when they last had an eyesight check – this should be done at least once a
year if patient is aged over 70yrs or living with diabetes. Eyesight should be checked
annually over 40 years if there is a family history of glaucoma. Otherwise eyesight should
be examined every 2 years.

Bi-focal and Vari-focal lenses in spectacles can cause problems judging distances and
changes in the floor surface (particularly on steps and stairs).

Strokes can cause a person to lose vision on one side (Hemianopia) – keep in mind on
which side their vision is poor when you consider their position in the ward/bay and the side
to which their locker and tray table are placed.

If a patient has severely reduced vision, let them know you’re approaching or passing them
(they may jump or lose their balance if they haven’t realised you are nearby).
Falls Prevention Toolkit 3rd Edition September 2015- Section 4- INTERVENTION GUIDANCE
Page 10
Lying and Standing Blood Pressure Measurement
Why is this Important?
Orthostatic or postural hypotension is defined as an excessive fall in blood pressure that occurs
when a person stands up or is in an upright position .It is common amongst many groups of
patients. The drop in blood pressure is often greater when:
 Patients are taking drugs which lower blood pressure – Antihypertensive drugs and diuretics
 Patients are ill – particularly with infections and a fever
 Patients are dehydrated – up to half of older patients admitted as an emergency are
dehydrated
All three of these added risk factors can be treated and the risk of falls lessened as a result.
Causes and risk factors
Postural hypotension can occur in any patient. However, older patients are particularly
vulnerable. This is due to additional risk factors such as:
It can be caused by:



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


Hypovolaemia
Diabetes
Peripheral neuropathy
Parkinson's disease
Anaemia
Adrenal insufficiency
Prolonged bedrest.
Who should have their Lying and Standing Blood Pressure Measured?
 All adult patients admitted to hospital
 And repeated on the following:




All patients who fall whilst in hospital
All patients that have a change in clinical condition ( if patient can tolerate)
All patients who appear unsteady on mobilising
All patients who report feeling dizzy (particularly if occurs on rising from bed or chair)
When Should Lying and Standing Blood Pressure be Measured?
A decrease in blood pressure can occur early in the morning and /or following meals therefore
readings should ideally be taken at different times to take this into account dependent upon the
patient’s medical history. Lying and standing blood pressure should be measured at least twice
in the first two days of admission.
Falls Prevention Toolkit 3rd Edition September 2015- Section 4- INTERVENTION GUIDANCE
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How is Lying and Standing Blood Pressure Measured?
Automated equipment can be used but where measurements are difficult it will be necessary to
use a manual sphygmomanometer. Ascertain if the patient is able safe to stand. Illness may
impair their ability to bear weight and severe symptoms resulting from a profound fall in blood
pressure on standing could lead to a fall. Sitting blood pressure can be taken however this can
reduce the sensitivity of the test
1.
2.
3.
4.
5.
Ask the patient to lie on the bed.
Wait at least 5 minutes.
Apply the cuff securely such that its position will be unchanged when the patient stands up.
Take Blood Pressure lying down.
Ask or assist the patient to stand up or sit on the edge of the bed if the patient is unable to
stand.
6. Take BP immediately AND repeat after 3 minutes of standing/sitting on edge of bed.


Stop if the patient is unable to stand/sit unsupported or is at risk of falling
Keep the patient standing/sitting for the full 3 minutes.
What is Abnormal?
Postural hypotension is said to be present if:


Systolic Blood Pressure falls by > 20mmHg on standing
Diastolic Blood Pressure falls by >10mmHg on standing
OR
Nursing management and lifestyle advice
For patients with symptomatic postural hypotension, it is important to alleviate the symptoms
and prevent them from recurring so as to minimize the risk of injury and maintain the patient's
quality of life.
 Inform the medical team and ask them to review medications urgently.
 Make sure your patient is well hydrated (by mouth if possible)
 Ensure your patient has easy access to the call button and advise them not to mobilise
without assistance.
It is of primary importance to provide patient education before discharge. Advice to the patient
should include, for example, taking care when changing from a sitting to a standing position and
when taking medication that could precipitate postural hypotension.
Medical management
In patients with chronic postural hypotension the aim is to ensure appropriate mobility and
function, prevent falls and provide low-risk treatment while maintaining a suitable quality of life.
If possible, the cause should be thoroughly treated. When non-pharmacological treatment
measures are not wholly successful, drugs that help to raise the blood pressure may be
considered: for example fludrocortisone (although fludrocortisone is not licensed for the
treatment of postural hypotension it is usually the drug of choice). Its actions include volume
expansion and the promotion of arteriolar vasoconstriction.
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Guidance on the Use of Ultra-Low Beds

Ultra-low beds can help to reduce the HARM our patients may suffer as a result of a fall
from a bed. This is particularly so for patients with delirium who are at risk of falling out of
bed and may attempt to try to climb over the bed rails.

An ultra-low bed is NOT a fall prevention measure.

An ultra-low bed should be selected using the In-patients falls flow chart. If a patient scores
high risk on the care checklist and shows clinical signs of CONFUSION, AGITATION and
NURSED IN BED consider the use of an ultra-low bed.

BUT if a patient is confused, agitated and “WANDERING” then the use of an ultra-low bed
is NOT appropriate. This is due to the patient being at risk of attempting to mobilise at an
incorrect height. This could lead to a fall. Consider 1:1 supervision and a standard bed
frame.

For High risk patients that fluctuate between “wandering” and “bedbound” with confusion
and agitation ensure that the height of an ultra-low bed is adjusted accordingly and the
correct level of supervision is in place to maintain safety.
How to use an ultra-low bed

All patients must be assessed individually using the Adult Falls Flow Chart to ensure that
the most appropriate method of preventing potential harm is employed

An ultra-low bed must ALWAYS be used in an allocated cohort bay. If the patient is nursed
in a side-room on an ultra-low bed they must be subject to 1:1 supervision.

NEVER have the bed rails up when the bed is in the ultra-low position, unless the patient is
receiving STRICT 1:1 supervision.

If the patient is being transported to a new area then the ultra-low bed frame should be
elevated to the standard height, and bed rails should be upright. This is ONLY for the
duration of transportation.

After a patient has be transported to or from a new area – ENSURE the correct care is in
place and the ultra-low bed is at its lowest position and bed rails are placed back down.
Unless, as previously stated, the patient is subject to STRICT 1:1 SUPERVISION.

Never leave a falls patient without care on an ultra-low bed e.g. in a waiting area or X-RAY.

An ultra-low bed should NEVER be used as a form of restraint
Safety Tips When Using an Ultra-Low Bed

There is specific competency-based training in the use of ultra-low beds. The ward Falls
Champions will have attended this training and will provide training for ward staff. Contact
your ward Falls Champion to receive this training.
Falls Prevention Toolkit 3rd Edition September 2015- Section 4- INTERVENTION GUIDANCE
Page 13

An ultra-low bed cannot be used with specialized mattresses (e.g. Primo or Duo AIR). If
your patient has SIGNIFICANT pressure damage and there is a valid reason for using tan
ultra-low bed then contact the Clinical Nurse Advisor at Medstrom or the Tissue Viability to
seek further advice.

BEFORE lowering the ultra-low bed to the low position ensure there are no bedside tables
or other objects underneath the bed frame.

Ensure the brakes are engaged BEFORE lowering the ultra-low bed to the low position.

Ensure the bed control functions are “LOCKED OUT” if the patient is likely to attempt to
use the controls inappropriately.

Ensure the patients weight is not exceeding 30 stone / 190kg
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Ultra-Low Bed Decision-Making Tool
Is your patient
Confused and/or agitated and displaying unpredictable
behaviours whilst nursed in bed?
AND
At risk of falling from or rolling out of a standard bed?
Yes
Patient should be placed
on an ultra-low bed in
the Cohort Bay or under
1:1 supervision
No
Patient should NOT be
placed on an ultra-low
bed
Please Note:
•
Bed Rails must NOT be used when the ultra-low bed is in the low position
unless the patient is subject to strict 1:1 supervision.
•
If using an ultra-low bed to transport a patient to another clinical area, the bed
must be elevated to standard height, the bed rails should be deployed and the
patient should be supervised at all times during transportation (including those
times where patients may be waiting for an investigation e.g. whilst in x-ray).
•
Ultra-low beds are NOT a form of restraint – if your patient is confused and
agitated but mobile and “wandering”, then an ultra-low bed is not appropriate
(consider1:1 supervision.
Falls Prevention Toolkit 3rd Edition September 2015- Section 4- INTERVENTION GUIDANCE
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How to Obtain an Ultra-Low Bed
STEP 1 - Please re-assess all patients currently nursed on ultra-low beds on your ward. Is it
possible to nurse any of these patients on a standard bed? If not go to STEP 2
STEP 2 - Refer to the “Ultra-low Bed Allocation Plan” and check if nearby wards with ultralow beds are able to loan one for your patient. MESU will replace ultra-low beds loaned in
this way within 4 hours of the request. If there are no ultra-low beds available for loan from
other wards go to STEP 3
STEP 3 - Request an Equipment Library Ultra-Low Bed from MESU
All patients nursed on an ultra-low bed according to the High Risk Falls Prevention
Care Checklist outside of a cohort bay MUST be considered for 1:1 supervision.
Normal Working Hours
Monday to Friday 08:30 – 17:00
Contact MESU and order an Ultra-Low Bed.
The bed should be delivered within 4 hours
of the request and the standard bed frame
will be removed by the MESU Team
MESU = Clinical Engineering Response
Centre ext. 64287
Outside Normal Working Hours
Monday to Friday - 17:00 - 08:30
Weekends and Bank Holidays
Contact Logistics and order an Ultra-Low
Bed. The bed should be delivered within 4
hours of the request and the standard bed
frame left outside the ward (the bed will be
removed by the MESU Team in normal
working hours)
Logistics = QMC ext. 62389 (Cisco
70522)
City 07976 190145 or Bleep 780
7816
All ultra-low beds labelled “Equipment Library Low Bed MUST be returned to MESU as soon
as possible when they are no longer required. Contact the Clinical Engineering Response
Centre on 64287 to arrange collection.
In an emergency out of normal hours contact your site matron who will be able to call the
Clinical Nurse Advisor “on-call” to authorise the delivery of an Equipment Library Ultra-Low
Bed directly from Medstrom (lines open 24/7 - 0845 3711717)
This is only necessary if there is no Equipment Library Ultra-Low Bed available on site.
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Ultra-low Bed Allocation Plan
Use the Table below to determine which wards near to you carry a sock of ultra-low beds.
Ask if all available ultra-low beds are appropriately in use and request that any unused ultralow bed be made available on loan to your ward.
The ward loaning out an ultra-low bed should then request an “Equipment Library Low
Bed” to be delivered as a replacement (see “How to Obtain an Ultra-Low Bed”).
QMC
Cohort Bay UltraLow Beds
City
Cohort Bay UltraLow Beds
B47
10
Beeston
2
B48
3
Berman 1
2
B49
3
Linden Lodge
1
C4/C5/C6
1 each
Hayward House
1
C51
3
Newell
4
C52
3
Seacole
4
C54
3
Fleming
1
D10
3
Southwell
1
D11
3
Toghill
1
D58
3
F18
3
F19
3
F20
3
F21
3
Total QMC
49
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Physiotherapy Management Guidelines for Inpatients at Risk of Falls
Aim:
To ensure that patients at risk of falling receive a physiotherapy assessment and an appropriate
intervention to ensure that transfer of care is as safe as possible.
Referral Process
Patients at risk of falling will be referred to physiotherapy by nursing staff completing the Falls
Care Plan.
Physiotherapy Assessment and Intervention
The Physiotherapy assessment and subsequent intervention may vary according to where and
when a patient is assessed. However, there are certain standards within the procedure that
must be met and completed by time of discharge.
Minimum Standards for Physiotherapy Assessment
All patients who have been admitted to NUH having had a fall, or with a history of falls or
sustaining a fall on the ward, can expect a physiotherapy assessment which includes as a
minimum



Past history of falls and near misses.
Mobility to include strength, gait and balance compared with current and pre-admission
levels
Foot wear assessment
Minimum Standards for Physiotherapy Intervention
The advice and intervention may vary dependent upon where and when a patient is assessed.
The physiotherapist will make recommendations for how the patient is best to be managed on
the ward, with regard to mobilising with nursing staff, to facilitate the maximum safe mobility for
that patient whilst still enabling progression of mobility.




Provide appropriate walking aids as required
Give advice to the patients on appropriate footwear to use
Completion of appropriate stair assessments if necessary
Ensure the patients have been provide with the appropriate falls prevention
leaflet/information
Minimum Standards for Transfer of Care to Community Teams
Where physical deficits (gait, range of movement, strength, and balance) have been identified
and the individual risk of falling persists, then the physiotherapist should make arrangements for
further assessment and follow-up at transfer of care through the Community
Falls Prevention Teams:
Where appropriate, the physiotherapist may make a recommendation as to the most suitable
venue for further rehabilitation.
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Handy hints on the management of delirium
NB: for more go to Delirium tool kit which can be found on the falls prevention website or refer
to the guidelines on Emergency Control of the Acutely Disturbed Adult: Understanding
challenging behaviour
Complete the “About Me” document – this can give you invaluable information of the
patient’s usual behaviour, their likes and dislikes. The “About Me” document can be found here.
Communication






Address the patient by their name
Try to minimise distractions when communicating with patients
Maintain eye contact
Keep conversation simple
Don’t argue, patronise, contradict or ignore
Listen carefully
Continence





Remind the patient regularly about going to the toilet- the patient may need an
individual toileting regime
Watch for signs that the patient needs the toilet- e.g. fidgeting, pulling at their
clothes, getting up and down
Ensure the path to the toilet if free from clutter
Keep the toilet door open when not in use
Ensure plenty of drinks during the day and limit night drinks if continence issues
are a night time occurrence
Moving and walking


Constantly walking may be a sign your patient is bored- keep an activity box on
the ward for them to use (see below for what to put in it)
Walking could be a sign your pain is in pain – perform a pain assessment and
administer appropriate analgesia
Orientation

Encourage family members to visits to alleviate anxiety
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