Download Enhanced Observation and Support Policy

Enhanced Observation and Support
Policy
Type: Clinical Guideline
Register No: 15031
Status: Public
Developed in response to:
Contributes to CQC Regulation
Trust requirements Best Practice
9,11
Consulted With
Lyn Hinton
Rabina Tindale
Lee Dodge
Clive Gibson
Hilary Bowring
Helen Clarke
Ryan Curtis
Doug Smale
Sandra Morton Nance
Professionally Approved By
Post/Committee/Group
Deputy Chief Nurse
Associate Chief Nurse
Alcohol Liaison Nurse
Adult Safeguarding Named Nurse
Associate Chief Nurse
Clinical audit/NHSLA Lead
Health, Safety and Security manager
Local Security Specialist Manager
Learning Disabilities Specialist
Cathy Geddes, Chief Nurse
Version Number
Issuing Directorate
Ratified by:
Ratified on:
Executive Management Board Sign Off Date
Implementation Date
Next Review Date
Author/Contact for Information
Policy to be followed by (target staff)
Distribution Method
Related Trust Policies (to be read in conjunction with)
Date
14/09/2015
14/09/2015
14/09/2015
14/09/2015
14/09/2015
14/09/2015
14/09/2015
14/09/2015
14/09/2015
14/09/2015
1.0
Corporate
Documentation Ratification Group
th
27 January 2016
February 2016
th
5 February 2016
February 2019
Carrie Tyler Falls Practitioner
Julie Green Dementia Specialist
Fran Hodby Elderly Assessment Team
All healthcare professionals working on adult inpatient wards
Intranet and Website
Safeguarding Vulnerable Adults Policy
Mental Capacity Act Policy
Deprivation of Liberty Safeguards Policy
Restrictive Interventions Policy
Consent to treatment and examination
Safer restraint policy
Care of patients with Dementia policy
Management of Delirium in Older Adults Policy
Adult in-patient Falls Prevention and Safe Use of
Bed rails
Detoxification policy
Learning Disabilities & Autism Policy
Document Review History
Version Number
(published versions only
1.0
Authored/Reviewed by
Active Date
Julie Green, Carrie Tyler
Fran Hodby
5 February 2016
th
INDEX
1.
Purpose
2.
Background
3.
Scope
4.
Definitions
5.
Enhanced Observation and Support
6.
Staffing and Management Responsibilities
7.
Staff Training
8.
Incident Reporting
9.
Communication of Risk
10.
Support for Staff following an event
11.
Equality and Diversity
12.
Audit and Monitoring
13.
Review
14.
Communication and Implementation
15.
References and Further Reading
16.
Embedded documents and appendices
A.
B.
C.
D.
E.
F.
G.
H.
I.
Enhanced Observation Intervention Table
Communication Assessment Tool
Delirium Pathway
Dementia Pathway
Clinical Alcohol Withdrawal Assessment Chart
ABBEY Pain Assessment Scale
Post Falls Flow Chart
Criteria for use of Bed and Chair Alarms
Criteria for use of low rise beds
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1.0
Purpose
1.1
The purpose of this policy is to provide information and guidance to Registered Nurses,
Healthcare Assistants, Medical staff, Allied Health Professionals, Matrons, Assistant
Chief Nurses, Clinical Operations Managers and Security staff (henceforth known as
staff) who work in adult in-patient wards to ensure a consistent and safe approach
across Mid Essex Hospital Services Trust (henceforth known as the Trust) to the
assessment of patients requiring an Enhanced Observation Assessment and guidance
for the 4 levels of observation.
1.2
The policy aims to raise awareness amongst staff about the correct identification of
patients requiring an Enhanced Observation and Support Assessment and the
appropriate management of .the assessment including the risk assessment process and
to facilitate the implementation of best practice.
1.3
Specifically the policy provides guidance on:
•
•
•
1.4
Enhanced Observation and Support Assessment and Plans
Responsibilities of staff
Meaningful Activity Plans
It is essential that this policy is read in conjunction with related policies where specific
guidance will be available on:
•
•
•
•
•
•
•
•
•
•
•
Delirium Pathway
Dementia Pathway
Alcohol Detoxification Pathway
Security
Use of assistive technology as part of falls prevention
Falls Assessment for adult in-patient
Behaviour = Communication charts
Safer Restraint
Mental Capacity Act
Deprivation of Liberty Safeguards
Life History (e.g. "This Is Me" or Hospital Passport)
1.4
The Trust aims to take all reasonable steps to ensure the safety and independence of
its patients and to respect the rights of patients to make their own decisions about their
care.
2.0
Background
2.1
Some patients require more than a general level of observation, often with the primary
aim of reducing risk and protecting the patient (e.g. they have increased confusion or
are at risk of failing and sustaining injury). This activity is often referred to as
‘specialling’ or ‘one to one’ care however it is important to recognise that ‘specialling’ is
only one method of enhancing the level of observation.
2.2
There are many reasons why a patient may require an enhanced level of observation.
The most common factors are high risk of falls and/or cognitive impairment secondary
to delirium and/or dementia.
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2.3
Falls
Each year over 250,000 patient falls are reported to the National Reporting and
Learning service (NRLS) from acute hospitals every year. A significant number of these
falls result in death, severe or moderate injury. It should be noted that even for the less
serious falls, the human cost may include distress, pain, injury, loss of confidence and
loss of independence, as well as anxiety caused to patients, relatives and hospital staff.
2.4
Risk of falls increases with age, with those aged over 65 years. Specific factors
contributing to higher risk of falling and injury amongst the elderly include a decrease in
bone density and reduced levels of regular exercise leading to poor muscle tone,
decreasing strength, loss of bone mass and flexibility resulting in fragility fractures.
There is also a higher risk of a patient over the age of 65 suffering a sub dural
haematoma post fall.
2.5
Delirium
Delirium (sometimes called 'acute confusional state') is a common clinical syndrome
characterised by disturbed consciousness, cognitive function or perception, which has
an acute onset and fluctuating course. It is a serious condition that may be associated
with poor outcomes. However, it can be prevented and symptoms treated if dealt with
urgently. People with hyperactive delirium have heightened arousal and can be restless,
agitated and aggressive.
2.6
NICE identify that about 20–30% of people on medical wards in hospital have delirium,
and between 10% and 50% of people who have surgery develop delirium.
2.7
In order to comply with NICE (QS63) Quality Standard 3: “Adults in hospital …who have
delirium are not given antipsychotic medication … unless they are very distressed or are
thought to be a risk to themselves or others, and if other ways of calming them down
have not worked or are not suitable”, it is essential that non-pharmacological measures
such as Enhanced Observation and Support are provided.
2.8
Dementia
Dementia is a clinical syndrome evidenced through a set of symptoms, which classically
include a decline in memory and thinking, present for six months or more, and of a
degree sufficient to impair functioning in daily living, World Health Organisation (2012).
2.9
Being in hospital can be an unsettling and disorientating experience for anyone. For a
person with dementia the effects may be much worse. There is growing evidence that
when compared to patients without dementia, patients with dementia in hospital are
more likely to:
•
•
•
•
•
experience poor nutrition and poor hydration
develop delirium
receive inadequate pain control
experience extended hospital stays
move from hospital into long term care
2.10 Approximately 25% of people occupying general hospital beds have dementia (DoH,
2012). People with dementia are usually dependant on staff having the skills and
knowledge to meet their needs effectively and ensure the patient’s experience is less
stressful and no longer than necessary.
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Please refer to Dementia Policy (10081) for further advice on management of patients in
alcohol withdrawal.
2.11 Learning Disabilities (LD)
2.11.1 The DoH (2001) defines a ‘learning disability’ as a:
•
•
•
significantly reduced ability to understand new or complex information, to learn
new skills (impaired IQ)
reduced ability to cope independently (impaired social functioning)
which starts before adulthood with lasting effects on development.
2.11.2 Evidence Based Facts:
•
14% of the general population are admitted to hospital each year BUT with
people with learning disabilities/autism this figure rises to 26%.
• People with learning disability/autism stay in hospital longer than other patients.
• People with learning disability/autism have a higher readmission rate than other
patients.
• People with learning disability/autism are more likely to suffer adverse events
during their hospital stay due to:
o Poor understanding of the physical risks associated with levels of cognitive
impairment.
o Poor understanding of the individuals increased support/observational
needs.
o Assumptions made on the individual’s quality of life; value of treatment
and ability to co-operate with treatment.
2.11.3 Coming into hospital can be a very frightening experience for people with Learning
Disability / Autistic Spectrum Disorder (LD/ASD) . So many barriers are known to exist
which puts them at a disadvantage in comparison to the general population in accessing
the health care they need which results in poor health outcomes. People with LD/ASD
are generally dependant on others and need reasonable adjustments to be made in the
hospital setting for efficient, effective and equitable care to be delivered.
2.12
Alcohol
2.12.1 Delirium tremens (DTs) is the most severe form of alcohol withdrawal manifested by
altered mental status (global confusion) and sympathetic overdrive (autonomic
hyperactivity), which can progress to cardiovascular collapse. DTs occur in about 5% of
patients during withdrawal, usually 2-5 days after alcohol cessation or reduced alcohol
intake and are fatal in 15-20% of inappropriately managed patients. Symptoms and
signs include agitation, fever, hallucinations, confusion and seizures.
2.12.2 Wernicke’s Encephalopathy refers to the presence of neurological symptoms caused by
biochemical lesions of the central nervous system, after exhaustion of B vitamin
reserves, in particular thiamine. It classically presents with the triad of confusion, ataxia
and ophthalmoplegia, but only 10% of patients present with all three features.
2.12.3 It may develop rapidly or over a number of days. Inappropriately managed, it is the
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primary (or a contributory) cause of death in up to 20% of patients and results in
permanent brain damage (Korsakoff’s psychosis) in 85% of survivors.
Please refer to Acute Alcohol Withdrawal Management for Adult Inpatients for further
advice on management of patients in alcohol withdrawal.
3.0
Scope
3.1
This policy applies to all patients over the age of 18 years.
3.2
All staff working within the Trust's adult in-patient wards are expected to adhere to this
policy.
4.0
Definitions
4.1
Enhanced Observation and Support Levels: When a patient is identified as being at
risk of harm to themselves, to others and/or the environment and therefore requires an
increased level of observation (i.e. beyond Level 1).
4.2
Restraint: the intentional restriction of a person’s voluntary movement or behaviour.
This includes physical, environmental and chemical measures such as sedation.
4.3
Risk: the term ‘risk’ is determined to mean ‘the likelihood of harm or injury arising from
a hazard’
4.4
‘One to One’ Care: Also often referred to as ‘specialling’, this means that the patient
requires a healthcare worker to provide a constant level of observation and support to
minimise the patient coming to avoidable harm.
4.5
‘Cohort’ Nursing: This is a term used to describe the identification of two or more
patients on the same ward, who have been assessed to require a Level 3 Enhanced
Observation and Support Plan and are therefore positioned in the same area of the bay
where increased staffing resource can be directed. A member of staff will remain within
eyesight of these patients at all times. Please note that for the purposes of this policy
the term ‘cohort’ is not being used in relation to nursing patients with infection).
4.6
‘TAG’: This is a term used to describe how the staff member undertaking Cohort
Nursing leaves the cohort bay. The staff member physically touches the hand of the
replacing staff member, avoiding a mistake being made whereby there is not a staff
member in the cohort bay.
4.7
‘Enhanced Support Assistant’: This is the title of staff who have been employed
specifically to deliver therapeutic and supportive one to one care for patients who
require Level 4 Enhanced Observation and Support and have received the relevant
training.
4.8
‘Well-being’: this term describes a state of mind which indicates a person with
dementia physical, emotional, spiritual needs are being effectively met. The expectation
is that people with dementia (regardless of the stage of disease) are in well-being.
4.9
‘Ill-being’: this term describes a state of mind which indicates a person with dementia
physical, emotional, spiritual needs are not being effectively met. Most of the time, illbeing is not an inevitable symptom of dementia. Anyone in a state of ill-being needs
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special attention to identify their unmet needs as a state of ill-being is usually a result of
a person’s physical or psychological needs not being met (Bradford Dementia Group,
2008).
4.10 ‘Unmet Needs’: Many patients with a cognitive impairment are unable to identify for
themselves or communicate verbally their physical, emotional and spiritual needs and
are dependent on practitioners to anticipate and address these. Common examples of
‘unmet needs’ include: hunger, thirst, boredom, pain, need to use toilet, constipation,
desire to be heard, need for change of environment/outdoor space, need to mobilise,
need to see family/friends.
4.11 ‘Meaningful Activity Plan’: Meaningful activity plans are individualised plans for
occupation and activities as prescribed by an occupational therapist. Plans are devised
based on a review of life history, evaluation of personal interests and clinical
assessments. Plans are graded and prescribed dependent on a person’s abilities.
4.12 ‘Behaviour = Communication Assessment Tool’: This is a tool that assists
practitioners to explore themes and trends of patients behaviour to assist them to
identify what it is the patient is attempting to communicate through their behaviour. The
tool supports practitioners to identify ‘triggers’ to behaviour and identify unmet needs as
well as appropriate de-escalation solutions.
4.13 Alcohol Detoxification: Also known as medically assisted alcohol withdrawal and
normally indicated in patients regularly drinking between 60 to100+ units of alcohol per
week. This is usually implemented using a reducing dose of the benzodiazepine
chlordiazepoxide and supported with regular I.V pabrinex and the Clinical Institute
Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale which is used regularly to
help inform the need for medication. The aim of the treatment being to keep the patient
comfortable and safe, preventing progression to states of agitation, seizures and DTs.
For further information please refer to the guidelines set out in Acute Alcohol Withdrawal
Management for Adult Inpatients which can be found on the intranet.
Fall: An unexpected event in which a person comes to the ground or other lower level
with or without loss of consciousness
Falls Alarms: an early alert device to notify staff a patient is mobilising from their bed,
chair, toilet or commode; whereby there is a risk a patient may fall if unaccompanied or
without use of specialist equipment. Restraint free, discreet placement monitor to
promote dignity and privacy. These should be assessed prior to use to ensure
appropriate for the patient and not likely to cause distress. The falls alarms can also be
used with pagers to create a silent alert.
5.0
Enhanced Observation and Support
5.1
The 4 Levels of Observation are:
5.1.1 Level 1 - The patient displays predictable and safe behaviour. No concerns regarding
risk to well-being.
Enhanced Observation and Support Plan not required:
• Routine observations and two hourly care rounding required.
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•
•
Routine contact with staff for planned drug rounds, meal times and tea rounds.
No additional measures required.
5.1.2 Level 2 - The patient displays mainly predictable behaviour with occasional unsafe
behaviour (which is not expected to result in serious harm) or is at avoidable risk of mild
levels of ill-being.
Level 2 Enhanced Observation and Support Intervention Plan:
• Obtain consent or mental capacity assessment (including involvement of family).
• Increased care rounding and patient contact from staff to 1 hourly.
• Commence pathways such as dementia, delirium or alcohol detoxification if
relevant.
• Ensure open visiting is encouraged.
• Consider use of volunteers.
• Consider DoLS if appropriate.
• Multifactorial Falls assessment and consideration of falls alarms.
• Behaviour = Communication Chart and identify ‘triggers’ to behaviour.
• Identify unmet needs.
• Obtain Life History (e.g. This Is Me or Hospital Passport).
5.1.3 Level 3 – The patient displays infrequent, unpredictable, unsafe behaviour towards self,
others and/or the environment (not expected to result in serious harm) or is at avoidable
risk of moderate levels of ill-being.
Level 3 Enhanced Observation and Support Intervention Plan:
• All interventions recommended for Level 2 Plan.
• Consider ‘Cohort’ nursing with ‘TAG’.
• Consider one to one care (from existing ward skill mix) during periods of
unpredictable, unsafe behaviour.
• Implementation of Meaningful Activity Plan.
• Consider use of a low-rise bed.
• Consider referral to relevant specialist service (e.g. Falls Practitioner, Alcohol
Liaison Nurse, Learning Disabilities Specialist Nurse, Dementia Specialist,
Elderly Assessment Specialist, Local Security Specialist Manager, Health and
Safety Manager, Mental Health).
5.1.4 Level 4 – The patient displays frequent, unpredictable, unsafe behaviour towards self,
others and /or the environment or infrequent, unpredictable, unsafe behaviour towards
self, others and/or the environment (which it is expected may result in serious harm) or
is at avoidable risk of significant levels ill-being.
Level 4 Enhanced Observation and Support Intervention Plan:
• All interventions recommended for Level 2 Plan.
• Consider constant ‘One to one’ care rather than ‘Cohort’ nursing.
• Make referral to relevant specialist service (e.g. Falls Practitioner, Alcohol Liaison
Nurse, Learning Disabilities Specialist Nurse, Dementia Specialist, Elderly
Assessment Specialist, Local Security Specialist Manager, Health and Safety
Manager, Mental Health).
• Ensure Ward Sister/Matron/Clinical Operations Manager are aware of
assessment
8
•
Reassessment of continued requirement for Level 4 at least every 24 hours (or
more frequently if condition changes) which must be reported to the COM team ,
to ascertain if the level 4 enhanced observation is still required
5.2
Providing Enhanced Observation and Support can be complex, particularly when
behaviours that may be perceived as challenging increase. Assignment of staff to
deliver this care must be based on the skills and experience of staff available to meet
patient needs. It is recommended that inexperienced staff are encouraged to shadow
more experienced colleagues.
5.3
Regular ward staff will be expected to undertake Enhanced Observation and Support. If
Level 4 is required an Enhanced Support Assistant should be allocated to care for the
patient during early and late shifts.
5.4
It is expected that many patients who receive appropriate occupation and stimulation
during the day will have an appropriate sleep/wake cycle and therefore may not require
one to one care overnight. However, there will be exceptions where overnight one to
one care is required. In these circumstances (and if an Enhanced Support Assistant is
not available during daytime) an additional member of staff may be required based on
the risk assessment if authorised by the Deputy Chief Nurse or Chief Nurse or (Clinical
Operations Team out of hours) . The nurse in charge should ensure that additional staff
are used to release ward staff to deliver the Enhanced Observation and Support.
5.5
Providing Enhanced Observation and Support is a skilled nursing intervention and
therefore it is appropriate that all levels could be delivered by a nursing student under
the guidance and supervision of a Registered Nurse.
6.0
Staffing and Management Responsibilities
(Staff responsibilities following an incident can be found in section 11.)
6.1
The Chief Nurse and Chief Medical Officer
6.1.1 The Chief Nurse and Chief Medical Officer are the nominated Executive Directors with
responsibility for patient safety and will act on behalf of the Chief Executive to ensure
processes are in place to manage the Enhanced Observation Assessment and the
placement of the Enhanced Support Assistants including implementing and monitoring
this policy.
6.2
Clinical Operation Managers Responsibilities
6.2.1 The Clinical Operations Managers will be responsible for ensuring the Enhanced
Support Assistants attend their designated ward.
6.2.2 The Clinical Operations Managers will reallocate Enhanced Support Assistants based
on clinical need.
6.3
Matrons Responsibilities
6.3.1 The matron is responsible for ensuring that staff are familiar with and adhere to this
policy and are responsible for monitoring its implementation
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6.4
Ward Managers responsibilities
6.4.1 To ensure all Registered Nurses are competent to undertake responsibilities identified
below.
6.4.2 To ensure all staff receive training in falls prevention, safe use of bed rails, dementia,
adult safeguarding, mental capacity act and deprivation of liberty safeguards in
accordance with the Trust’s Training Needs Analysis and in the use of any equipment
required to comply with this policy.
6.5
Registered Nurse Responsibilities
6.5.1 It is the Registered Nurse’s responsibility to identify patients who may require an
Enhanced Observation and Support Assessment and that an Enhanced Observation
and Support Intervention Plan is implemented accordingly and shared with all ward
staff, patient and family (if relevant).
6.5.2 The Registered Nurse should ensure any unmet needs that may reduce the need for
Enhanced Observation and Support have been addressed to ensure all measures
implemented are least restrictive.
6.5.3 The Registered Nurse should identify patients who would benefit from either the
dementia or delirium pathway and initiate relevant actions.
6.5.4 The nurse in charge must ensure that it is documented that consent to the Enhanced
Observation and Support Intervention Plan has been obtained from the patient.
6.5.5 If the patient is unable to consent the nurse in charge must ensure a mental capacity
assessment has been completed confirming that the Enhanced Observation and
Support Intervention Plan is in the patients best interests.
6.5.6 If the patient lacks capacity in regard to this decision the nurse in charge is responsible
for liaising with the Elderly Assessment Team / Adult Safeguarding Team to determine
whether this constitutes a Deprivation of Liberty and a DoLS should be applied for.
6.5.7 For patients who require Level 4 Enhanced Observation and Support and one to one
cannot be provided within existing staffing the nurse in charge must ensure the Risk
Assessment and Decision Algorithm is authorised by the Matron or Clinical Operations
Manager.
6.5.8 The Registered Nurse must adhere to the ‘Safer Restraint’ policy if the Enhanced
Observation and Support Plan includes any type of chemical, physical and/or chemical
restraint.
6.5.9 The Registered Nurse must ensure that all staff involved in the delivery of this Enhanced
Observation and Support plan receive a handover of necessary information including
key concerns for the patient, the Meaningful Activity Plan and individualised nursing care
plan.
6.5.10 Delivering Enhanced Observation and Support can be an emotionally demanding
activity particularly when high levels of risk are identified. To ensure the quality of
therapeutic observations and interactions remain high, periods of meaningful activity
should not exceed 2 hours and periods of rest and relaxation is actively facilitated.
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6.5.11 After two hours (or sooner if needed) the member of staff providing the Enhanced
Observation and Support should be offered an opportunity to backfill another member of
staff for a short period of time (i.e. fifteen minutes) however in order to avoid
unnecessary distress to the patient continuity of care is paramount unless the member
of staff feels unable to continue providing the support. Therefore a nominated member
of staff should provide the majority of the care throughout a shift.
6.5.12 The Registered Nurse must regularly review the care of the patient during the shift and
adjust the Enhanced Observation and Support Plan as required.
6.5.13 To ensure that steps are taken to implement the requirements of Trust policies and
management guidelines.
6.5.14 The Registered Nurse is responsible for ensuring that all forms of restraint (chemical,
environmental and/or physical) are only used as a last resort. If chemical restraint needs
to be considered this should be escalated to medical team. Patients can only be
restrained if they either give consent or the mental capacity assessment confirms that
they lack capacity and evidences that it is in their best interests. The Registered Nurse
must refer to the Safer Restraint policy and datix all incidents where restraint is used
(which includes escalation to medical team if chemical restraint may need to be).
6.5.15 In situations where a patient is escalating through the levels rapidly or have reached
level 3 or 4 the Registered Nurse is responsible for escalating to medical team for a
timely review.
6.6
Enhanced Support Assistant and staff delivering Enhanced Observation and
Support Responsibilities
6.6.1 Staff must ensure the following:
• Receipt of an adequate handover of information from the Registered Nurse.
• Familiarisation of all relevant documentation (e.g. Behaviour = Communication
Chart, This Is Me/ Hospital Passport, Meaningful Activity Plan, Nursing Care Plan)
• Establish a therapeutic relationship with patient and initiate person centred care
• Ensure all documentation of interventions are completed
• Provide all basic nursing interventions; nutrition, hydration, skin care, personal
hygiene, observations. This list is not exhaustive.
• Report identified ‘triggers’ to behaviour, concerns, positive and negative interventions
to Registered Nurse and Occupational Therapist
6.7
All Employees
6.7.1 All Employees have an individual responsibility and accountability for the provision of
safe and competent practice and are expected to adhere to Trust policies and follow the
guidelines to prevent risks to themselves and others.
7.0
Staff Training
7.1
Nurses, Enhanced Support Assistants, Healthcare Assistants, Occupational Therapists
and Physiotherapists who work in adult in-patient areas are identified to be job mapped
to undertake Falls Prevention & Safe Use of Bedrails training available as e-learning or
planned sessions. This is to be undertaken every 2 years.
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7.2
Nurses, Enhanced Support Assistants, Healthcare Assistants, Occupational Therapists
and Physiotherapists who work in adult in-patient areas are identified to be job mapped
to undertake Dementia Training in line with Trust Training needs Analysis.
7.3
Understanding & Supporting people with LD/ASD within the hospital setting is now
mandatory for all nursing and front line staff. A rolling training programme runs monthly.
7.4
All staff involved with patients who display challenging behaviour due to reduced
capacity, particularly involving violence and or aggression if not specifically trained,
should seek the advice of trained staff in the management of such patients, such as
EAT team, Dementia / LD specialists, Local Security Management Specialist and mental
health team staff. Should patients recently or currently display or develop challenging
behaviour, particularly involving violence and or aggression staff should ensure their
own safety and that of others through communication of predictabilities, behaviours or
triggers and subsequent documentation and seek trained advice.
8.0
Incident Reporting – Serious Incident Reporting
8.1
Where a fall occurs, the incident must be reported in accordance with the Incident
Policy.
8.2
If the fall results in a serious injury. The Falls Practitioner, the ward Sister and the must
be alerted and the incident discussed to ascertain if the injury is to be reported as a
Serious Incident.
8.3
Further details are available in the Serious Incidents Requiring Investigation Policy.
Root cause analysis will be undertaken in accordance with the required timescales and
the learning points identified and acted upon. Out of Hours, the Clinical Operations
Managers must also be informed. For guidance on risk ratings please see: http://mehtintranet/clinical-pages/incidents-and-risks/ and open risk rating guidance.
8.4
When any event of a restraint technique is used this should be documented in the
patient’s notes, giving specific reference to the technique and the rationalisation for the
method being used i.e. breakaway, deflection, de-escalation, physical, environmental,
chemical mechanical including whether this was planned or unplanned as well as the
name of the person this has been escalated to.
8.5
A clinical incident risk event form (datix) should be completed to report any incident of
physical and/or chemical restraint.
8.6
Any incident of violence and aggression towards another patient, staff member or
member of the public must have a clinical risk event form (datix) completed.
9.0 Communication of Risk
9.1
All risks identified within the Enhanced Observation and Support Plan (i.e. if patient
known to be at risk of falls) should be communicated with all relevant staff.
10.0
Support for Staff following an Event
10.1
Any member of staff involved in an event (fall, episode of violence, restraint or
emotionally challenging situation) can obtain immediate advice and support from their
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line manager or relevant specialist service. For further information on supporting staff
refer to the Supporting for Staff Involved in a Traumatic Incident, Complaint and Claim
Policy.
11.0
Equality and Diversity
11.1
The Trust is committed to the provision of a service that is fair, accessible and meets
the needs of all individuals.
12.0
Audit and Monitoring
12.1 Monitoring
12.1.1 The Associate Chief Nurse, Falls Practitioner and the Falls Steering Group will monitor
incident frequencies and near misses in relation to slips, trips and falls. Incident report
will be regularly reviewed by the Falls Steering Group, Clinical Governance Group
12.1.2 The Dementia Specialist/Elderly Assessment Team should be informed of all relevant
risk event forms who will raise concerns to the Trust Dementia MDT which meets
fortnightly. The Dementia MDT reports quarterly to the Patient, Safety Group.
13.0
Review
13.1 The policy will be reviewed on a two yearly basis unless earlier revision is required as
the result of any changes in legislation, the Trust’s assessment processes or
technological improvements.
14.0
Communication & Implementation
14.1
The policy will be made available on the Trust’s intranet and website. The Health and
Safety Team and Professional Development Team will be responsible for issuing copies
to all Directorate Leads and Ward Sisters for dissemination within their departments.
14.2
The approved policy will be notified in the Trust’s Staff Focus that is sent via e-mail to all
staff.
15.0
References and Further Reading
Department of Health (2005) Mental Capacity Act. Available at: www.doh.uk
Healey F, Oliver D (2006) Preventing falls and injury in hospitals where are efforts best
directed?. Health Care Risk Report. p 12 7 15-17
Health and Safety Executive: Health & Safety at Work Act 1974 Section 2, Section 3
and Section 7 - September 2006
MHRA Device Bulletin DB2006(06) The safe use of bedrails www.mhra.gov.uk
MHRA Device Alert 2007/009 Bed Rails and Grab Handles www.mhra.gov.uk
National Institute for Clinical Excellence (NICE) Clinical Guidance 161Falls: the
assessment and prevention of falls in older people, June 2013.
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National Patient Safety Agency (2007) Bedrails – Reviewing the evidence. Available at:
www.npsa.nhs.uk
National Health Service England, Serious Incident Framework, March 2015
NPSA 2007 Slips, trips and falls in hospitals www.npsa.nhs.uk
Patient Safety First. The 'How to' guide to reducing harm from falls. London: NPSA,
2009 www.patientsafetyfirst.nhs.uk/Content.aspx?path=/Campaignnews/current/Howtoguidefalls/
16. Appendices
A.
B.
C.
D.
E.
F.
G.
H.
I.
Enhanced Observation Intervention Table
Communication Assessment Tool
Delirium Pathway
Dementia Pathway
Clinical Alcohol Withdrawal Assessment Chart
ABBEY Pain Assessment Scale
Post Falls Flow Chart
Criteria for use of Bed and Chair Alarms
Criteria for use of low rise beds
14
Appendix A
Level of Enhanced Observation & Support Assessment & Decision Algorithm for Acute Adult Inpatient Areas
Section A: IMMEDIATE ACTIONS TO ASSESS AND REDUCE RISK- Please tick YES or NO
Immediate Actions
YES
NO
Subsequent Actions:
Recent medical/medication review
If NO - request review within 6 hours
Has ‘Behaviour = Communication Assessment Tool’ been
completed and ‘triggers’ for behaviour been explored?
If NO - commence chart and identify de-escalation solutions
Have ‘unmet needs’ been explored and addressed (e.g. pain,
thirst, hunger, boredom etc)?
If NO – explore all possible ‘unmet needs and address accordingly
If applicable has Life history been obtained (e.g. ‘This Is Me’ /
Hospital Passport)?
If NO – complete and use information to individualise care plan
Does patient require an Abbey Pain Assessment?
If NO – complete and administer analgesia accordingly
*have appropriate referrals been made to the MDT?*is there a
clear MDT management plan including risk assessment?
If NO-make referrals and use the behaviour chart &/or night time functional chart
to develop plan
Is there a current substance misuse problem?
If YES- refer to Psychiatric Liaison Nurse/Team
Have environmental concerns been considered or addressed?
If No- reduce environmental stimuli- noise etc./move to more observable position
Has the falls trigger questions been answered and subsequent
assessment completed?
If NO-complete and consider referral to falls team, ultralow bed/crash mats,
completed falls assessment and refer to falls team
Is a mental health assessment required or is the patient sectioned
under the Mental Health Act?
If YES- refer to Psychiatric liaison Team or call if urgent. Ensure response time
is documented
Is there concern about the patient’s capacity to make decision
about their care and treatment?
If NO - complete MCA2
Has intentional rounding been commenced?
If NO- complete and prescribe an individual plan for intentional rounding
Can the patient’s care be safely maintained within the usual
staffing levels?
If NO – proceed to section B and follow algorithm and clinical judgment to inform
your request for a special
Descriptor of patient’s
behaviour
Examples
Recommended Enhanced Observation and Support Plan
1
The patient has predictable
and safe behaviour towards
self, others and environment.
No concerns regarding risk
to well-being.
All patients
Enhanced Observation and Support Plan not required:
• Routine observations and two hourly care rounding required.
• Routine contact with staff for planned drug rounds, meal times and drinks
rounds.
• No additional measures required.
• Consider implementation of Meaningful Activity Plan if indicated and
resources allow.
2
The patient displays mainly
predictable behaviour with
occasional unsafe behaviour
(which is not expected to
result in serious harm) or is
at avoidable risk of mild
levels of ill-being.
Occasional unsafe behaviour such
as mobilising alone and unsafely.
Unknown behaviour, triggers
easily deescalated.
Calling out & disturbing other
patients.
Level 2 Enhanced Observation and Support Intervention Plan:
• Obtain consent or mental capacity assessment (including involvement of
family).
• Increased care rounding and patient contact from staff to 1 hourly.
• Commence pathways such as dementia, delirium or alcohol detoxification if
relevant.
• Ensure open visiting is encouraged.
• Consider use of volunteers.
• Consider use of ‘TAG’ nursing.
• Consider DoLS if appropriate.
• Multifactorial Falls assessment and consideration of falls alarms.
• Behaviour = Communication Chart and identify ‘triggers’ to behaviour.
• Identify unmet needs.
• Obtain Life History (e.g. This Is me or Hospital Passport).
• Complete ‘Abbey’ Pain Assessment and administer analgesia accordingly.
Level
Low
Risk
Can slip/fall from bed.
Reduced mobility or bedbound and
attempting to mobilise
Low risk of pulling out any
indwelling devices.
Manage with current ward establishment.
3
Medium
Risk
The patient displays
infrequent, unpredictable,
unsafe behaviour towards
self, others and/or the
environment (not expected to
result in serious harm) or is
Cognitively impaired and unsafe
mobilising presenting risks to self
and others.
High risk of pulling out any
indwelling devices and therefore
Level 3 Enhanced Observation and Support Intervention Plan:
• All interventions recommended for Level 2 Plan.
• Consider ‘Cohort’ nursing.
• Consider one to one care (from existing ward skill mix) during periods of
unpredictable, unsafe behaviour.
• Implementation of Meaningful Activity Plan.
16
at avoidable risk of moderate
levels of ill-being.
requires mittens.
•
•
Agitation/Anxiety
Predictability unpredictable
can deescalate.
Impaired cognition/reduced insight
•
Consider use of a low-rise bed.
Consider referral to relevant specialist service (e.g. Falls Practitioner,
Alcohol Liaison Nurse, Learning Disabilities Specialist Nurse, Dementia
Specialist, Elderly Assessment Specialist, Local Security Specialist
Manager, Health and Safety Manager, Mental Health).
Medical review
Manage with current ward establishment - may need additional support from
Enhanced Support Assistant / Health Care Assistant
4
High
Risk
The patient displays
frequent, unpredictable,
unsafe behaviour towards
self, others and /or the
environment or infrequent,
unpredictable, unsafe
behaviour towards self,
others and/or the
environment (which it is
expected may result in
serious harm) or is at
avoidable risk of significant
levels ill-being.
Unpredictably
unpredicatable, can’t
deescalate.
Cognitively impaired and unsafe
mobilising presenting risks to self
and others.
Violent behaviour & aggression to
others and self.
Immediate risk to self/harm to
others.
Substantial & immediate risk of
absconding.
Expressing intent or recently
attempted to self-harm/suicidal
ideation.
Level 4 Enhanced Observation and Support Intervention Plan:
• All interventions recommended for Level 2 Plan.
• Make referral to relevant specialist service (e.g. Falls Practitioner, Alcohol
Liaison Nurse, Learning Disabilities Specialist Nurse, Dementia Specialist,
Elderly Assessment Specialist, Local Security Specialist Manager, Health
and Safety Manager, Mental Health).
• Ensure Ward Sister/Matron/Clinical Operations Manager are aware of
assessment
• Reassessment of continued requirement for Level 4 at least every 24 hours
(or more frequently if condition changes) which must be reported to the
COM team , to ascertain if the level 4 enhanced observation is still required
• Consider constant ‘One to one’ care rather than ‘Cohort’ or ‘TAG’ nursing.
Likely to require additional support from Enhanced Support Assistant / Health
Care Assistant / Security / RMN
Under mental health section
17
18
Appendix B
Communication Assessment Tool
For use with patients who have cognitive impairment
Summarise evidence of any unmet needs that the patient may have been trying to communicate through
their behaviour over the previous 24 hours.
Signature of RN
Date/Time
Description of behaviour and
situational triggers
What is the unmet need the patient is trying to
communicate?
Actions Taken, review of care and Outcomes
Care Plan(S) Updated
Date/Time
Signature/Role
Description of behaviour and
situational triggers
What is the unmet need the patient is trying to
communicate?
Actions Taken, review of care and Outcomes
Care Plan(S) Updated
Date/Time
Signature/Role
Description of behaviour and
situational triggers
Actions Taken, review of care and Outcomes
Care Plan(S) Updated
Signature/Role
What is the unmet need the patient is trying to
communicate?
Appendix C
20
Appendix D
DEMENTIA
CARE
PATHWAY
Part A: Admission
Decision made by medical/surgical team to admit
patient into hospital
Patient consent obtained to be admitted into hospital or admission evidenced to be
in the best interests if the patient lacks capacity and is resisting admission or
Bed allocated on EAU or relevant speciality
ward
Admit to ward
Identify type of
dementia and date of
formal diagnosis
Admission assessments
Assess Environment
Cognition
Complete Stage 1 of FAIR
Assessment and give patient
and their relative the ‘MEHT
Dementia Pack’
Pain
Nutrition
Consider if patient is reaching
the end stages of dementia
(NB – Delirium and
depression must be excluded
before this decision can be
arrived at)
Spiritual/emotional
needs
Part B: Inpatient Stay
UNMET
NEEDS
Constipation
Overstimulation
Spiritual needs
Nutritional
Pathway
COGNITION
ABC
Behaviour
chart
Nausea
Medication
Environment
Communication
Oral
hygiene
MCA /
DoLS
Delirium
pathway
Mealtimes
Medical/ surgical
treatment
Mental
Health
review
Medically/surgically
stable for discharge
Boredom
Too
hot /
cold
Meaningful
activities
Requires inpatient
treatment
Visiting
Lack of
exercise
Hunger /
thirst
‘This is
me’
Pain
Assess
delirium and
depression
Minimise distractions
Positioning
Dentures,
hearing
aids,
glasses
Fear &
anxiety
22
• Inform family that options that include alternatives to return to permanent address will
not be considered until all assessments are complete.
• Ensure patient is at the centre of all decision making.
• Ensure patient consents
to all C:
stages
of discharge plan. If there are reasons to
Part
Discharge
assume a lack of capacity and patient is not in agreement with plan, complete MCA2
and refer to EAT/Dementia Specialist. If the patient has capacity their choices must be
respected.
End of life diagnosis.
Complete MCA2
Discharge
Surgically/Medically stable
Y
Y
Is the patient back to cognitive/functional ability?
N
Consider referral to
intermediate care
(IMC), Drake House,
Non-weight bearing
pathway, POP
Is there potential for further improvement?
Y
N
Discharge home with
increased care
Y
Could the needs be met with increased care
N
Continuing
Healthcare process
DST
Consider Nursing Needs Checklist
Y
N
Following Decision Support
Tool (DST), has CHC
funding been agreed?
End of
Life, Fast
Track
process
Respect wishes
and plan
discharge
accordingly
Y
Y
Liaise with Social care
N
If concerns re: discharge home remain, complete risk
benefit analysis.
If patient is expressing a wish to return home or is
unlikely to respond well in placement, consider home
visit before any decisions are made about discharge
destination
Has patient got mental capacity to make the decision
about discharge?
N
Plan discharge
according to best
interests’ decision
MCA2 if risks identified at home, if 24hr care indicated or if change of accommodation
refer to EAT/Dementia Specialist for best interests’ collaboration
23
DEMENTIA PATHWAY: Additional Notes
Part A: Admission
Decision made by medical/surgical team to admit patient into hospital
•
•
•
•
Ensure the hospital admission is clinically indicated
Establish baseline cognition; does this impact on the decision to admit?
Are there any alternatives to hospital? Is treatment available in the community?
Is hospital the right environment?
Patient consent obtained to be admitted into hospital or admission evidenced to be in the
best interests if the patient lacks capacity and is resisting admission or treatment
•
•
•
Explain to the patient the purpose of admission and treatment
Complete MCA2 if indicated
Consider DoLS
Bed allocated on EAU or relevant speciality
ward
•
•
•
•
Avoid sending the patient to a medical outlier bed
Prioritise patient with dementia where possible
Prevent unnecessary bed moves
Minimise likelihood of bed moves later in hospital admission
Admit
• to ward
•
•
•
•
Take measures to welcome patient to the ward, reassure and orientate
Consider patient’s ill-being and well-being and spiritual needs
Consider cognition and mood in order to assess risks for patient health and safety
Consider a bed in a high observation area of the ward and/or close to a toilet
Assess environment
•
•
•
•
Encourage next of kin to bring in home comforts, e.g. blankets, photos, clothes,
toiletries, glasses, teeth, hearing aids etc.
Liaise with patient and next of kin
Encourage open visiting where possible
Orientate the patient to the toilets and consider a picture on the toilet door for clear
communication
Admission assessments
•
•
•
Complete all generic assessments
Liaise with next of kin for collateral history and baseline
Explain and encourage completion of ‘This is Me’ to patient and next of kin
24
•
•
Discuss next of kin concerns and offer support if needed; e.g. Action for Family Carers
(AFFC), counselling
Establish patients feelings and concerns and document
Cognition
•
•
•
•
•
•
•
MOCA/CAM
Consider the delirium pathway if indicated
Discuss cognition with the patient and next of kin
Are there any considerations that the patient may lack mental capacity? Consider MCA1
for day-to-day decisions or MCA2 for all significant decisions.
Consider DOLs (Refer to DOLs flowchart)
Are there concerns with behaviour? Consider behaviour chart to identify cause of
distress/agitation.
Refer to EAT/Dementia Specialist if specialist input is required
Pain
•
•
•
•
•
Commence Abbey Pain Scale assessment tool at least four times a day (QDS). This
should be assessed at rest and on movement.
Does the patient have a risk factor for pain?
Does the patient show signs of challenging behaviour on nurse interaction or
movement? Could this be associated with pain?
Was the patient taking analgesia prior to hospital admission?
Liaise with physiotherapists prior to exercise and nursing staff to consider analgesia
Nutrition
•
•
Refer to the Dementia Nutritional Pathway
Encourage relatives to become involved at mealtimes
Spiritual/emotional needs
•
•
It is important to be aware that many patients with dementia may not be able to
communicate their religious beliefs/needs to you but may display signs of ill-being until
these considerations are met
Ensure the patient has home comforts and items required to fulfil their religious needs,
e.g. a bible, rosemary beads etc.
Commence step 1&2 FAIR assessment and give MEHT Dementia Pack
•
•
•
Essential for those aged 75 and over but should be considered for anyone who meets
the criteria
Complete step 1 and confirm a diagnosis of dementia
Ensure Dementia pack is given appropriately and encourage completion of
questionnaire
25
Part B: Inpatient stay
Environment
•
•
•
•
•
•
History can be obtained from the patient, family and carers care home, GP, community
staff.
Encourage family involvement and reduce distractions in the environment
Encourage next of kin to bring in home comforts, e.g. blankets, photos, clothes, toiletries
etc.
Encourage open visiting where possible
Orientate the patient to their surroundings and for example consider a picture on the
toilet door for clear communication
Encourage small meals and drinks, finger foods and snacks frequently
Cognition
•
•
•
•
•
•
•
In patients with Dementia, functional status and cognition can deteriorate significantly if
they experience delirium. Ensure that a medical assessment of the symptoms is
performed.
Refer to the delirium pathway
Perform a delirium screen including urinalysis.
Commence and maintain the ABC behaviour chart to explore trigger factors
Refer to the Elderly Assessment Team/Dementia Specialist and if the medical team
decide that the patient is not experiencing delirium, consider a mental health referral.
Avoid prescribing medication as required and consider covert medication
Consider MCA2 and DOLs
Unmet needs
•
•
•
•
•
•
•
•
Use the ‘This is me’ and discuss the reactions with the patient and next of kin to explore
unmet needs and to ensure that the care is person-centred.
Discuss pain regularly with the patient and if the patient may have difficulty expressing
their needs, the Abbey pain scale should be used at least 4 times a day and more
frequently if the pain score is greater than 3.
Consider prescribing analgesia regularly rather than as required.
The patient may appear comfortable at rest, but consider that the individual might be
experiencing pain or discomfort when repositioned, during personal hygiene or during
therapy sessions. Therefore it may be necessary to give analgesia prior to these times.
Refer to the Nutritional Pathway
Ensure the patient is receiving adequate oral care and is clear from oral infection
Consider constipation, nausea and pain as causes for signs of distress
Ensure the patient has dentures, hearing aids and/or glasses and uses them when
required
26
•
Consider referral to Elderly Assessment Team/Dementia Specialist
Part C: Discharge
Is the patient back to cognitive/functional
•
Evidence clinical rationale why patient will not return to previous cognitive and functional
ability
• Is there potential for further improvement?
•
•
Explore patient views and establish goals
Therapists to establish achievable goals for the individual
Could the needs be met with increased care package?
•
Relevant professionals to reach agreement on level of care required. This must include
agreement between social workers, therapists and nursing staff
Consider Nursing Needs Checklist
•
Liaise with ward based discharge co-ordinator
If concerns re: discharge home remain, complete risk benefit analysis
•
•
•
•
•
•
If patient is expressing a wish to return home or is unlikely to respond well in placement,
consider home visit before any decisions are made about discharge destination
Risk/benefit analysis must include risk of psychological harm as well as physical harm
Explore least restrictive option as a priority and therefore evidence attempts made to
mitigate risks
If fire risk identified refer to Home Fire Safety Manager ([email protected]/ 01376 576226)
Therapists, Dementia Specialist /Elderly Assessment Team and Social Workers to
decide whether a discharge home visit is indicated
Refer to Elderly Assessment Team/Dementia Specialist
MCA2 if risks identified at home, if 24hr care indicated or if change of accommodation
- refer to EAT/Dementia Specialist for best interests’ collaboration
•
Ensure relevant professionals (e.g. GP, community staff), patient and family are
provided with a copy of the MCA2 as indicated
Review Date: 31 October 2015
27
Appendix E
29
Appendix F
30
Appendix G
Post Falls Flow Chart Mid Essex Healthcare Trust
ABCDE assessment
Baseline Observations & NEWS
AVPU
Blood sugar
Falls Practitioner ext 6731, 24/7 voicemail. Bleep #6555 1496
Signs of life
FALL
No Signs
of life
Call cardiac
arrest team
and follow
cardiac arrest
policy
Suspected head
Injury
Suspected C
Spine Injury
Check before moving patient from floor for:
No/Low harm
Injury
Suspected Upper
Limb Injury
Suspected Hip Injury
Suspected Lower
limb Injury
Request urgent
medical review
<30 minutes.
Reassure patient
Request medical
review.
Document
incident.
Datix incident.
Inform family.
Repeat
observations,
include blood
sugar.
Complete
Care plan 10 +
10a.
Ensure the MDT
team are aware of
fall.
Follow all actions
as no/ low harm
injury
Keep injured limb
close to body
when retrieving
from the floor
Request medical
review>30
minutes. .
Telephone
radiology
department to
make aware of inpatient fall, x-ray
within 4 hours
Follow all actions as
no/ low harm injury
Follow all actions as
no/ low harm injury
Follow all actions as
no/ low harm injury
Straight lift from
the floor, use
stretcher hoist
only.
Request medical
review <30 minutes.
Request urgent
medical review <30
minutes.
Start neurological
observations.
Request urgent
medical review>30
minutes. .
Telephone radiology
department to make
aware of in-patient
fall, x-ray within 1
hour
Telephone radiology
department to make
aware of in-patient
fall, x-ray within 4
hour
½ hrly – 2 hours
1 hrly – 4 hours
2 hourly –
thereafter
If GCS falls by 2,
urgently contact Dr.
Do not move
patient until head
and neck are
immobilised
Start neurological
observations.
Use scoop
stretcher & head
immobiliser to
retrieve patient
from the floor.
Ensure imaging
in 1 hour of
request, contact
radiology
Appendix H
Criteria for use of Falls Alarms
Falls Alarms are to be treated as an automatic call bell, to alert staff that a patient who has been identified as at
risk of falling, with poor or absent insight to the risks of standing and mobilising alone.
The longer mutlifactorial falls assessment includes an abbreviated mental test score and a physiotherapy
assessment. Both of these will be able to provide the evidence required to use a falls alarm from the equipment
library. To assess whether the patient has the capacity to assess their own risk of falling, a mental capacity
assessment may be required.
If a falls alarm is used for a patient sitting on a chair or lying in a bed the alarms are constantly monitoring the
patients physical position. The alarm will be triggered when the patient stands up, or if using the cord and clip
instead of a pad, the intent to stand up, bringing staff to monitor the patients mobilisation. This means that the
patent will require a Deprivation of Liberty order. Falls alarms are a Level 2, Enhanced Observation.
Falls alarms are suitable for patients who:
• Are unsafe to mobilise independently and have a lack of insight to the danger which mobilising
independently could be to them
• Temporary use for a patient who will stand up without seeking assistance from the toilet or commode ,
in this instance a DOLS is not required
Falls Alarms are not suitable for patients who:
• Can override the alarm, or reset the alarm
• When a patient is fully mobile with a lack of capacity and is seeking to leave the ward, the falls alarm
must not be used. It is not a security device or restraint device
• If the alarm distresses the patient, it can heighten their fear and anxiety
Silent alarm facility
• This feature using a pager is for night time allowing other patients to achieve sleep in a quiet
environment
• To use with a patient who will be distressed at the sound of an alarm, increasing their fear and anxiety
Verbal message Facility
• This feature is to be used with caution and rarely. It is designed for a relative to request the patient to sit
down and call for a nurse, the familiarity of the relatives voice can reassure a patient. However if the
patient has short term memory loss, a disembodied voice giving a command is frightening and
overbearing, it is not conducive to enhance a healing environment for the patient
Cord and Clip attachment
• The cord and clip attachment is an alternative to the bed and chair mats
• The cord and clip are to be used when the patient is using a commode , promoting dignity as well as
safety
• If a falls alarm wall plate has been mounted in the toilet, the patient can also be monitored in the toilet
Bedrail and Falls Alarm Incompatibility
• Bedrails are only to be used to prevent a patient slipping, sliding or rolling from their bed. Bedrails are
potentially very dangerous and can entrap patients, causing limb damage or asphyxiation and increase
the height of a fall from the bed.
• If a patient is active enough to require a falls alarm, then the patient is unsuitable for bed rails
Appendix I
Criteria for the use of a low rise bed
•
Low rise beds are to be used in the circumstance that a patient is assessed to be unsafe for bed rails, by
climbing or pulling self over the top of the rails, but the risk of slipping, sliding, rolling and climbing from
the bed is still present.
Should a patient slip, slide or roll from the bed, the fall is reduced to a height that should not create a serious
harm injury.
Patients suitable for placement on a low rise bed:
• Lack of insight to maintain own safety should bedrails be used, Risk of sliding, rolling or slipping from the
bed remains
• Be unable to walk
Patients unsuitable for placement on a low rise bed:
• Mobile patients
• patients with full insight who can maintain their own safety
Low rise bed and bed rails
• The purpose of a low rise bed is to reduce the risk of injury from bed rails or falling from a bed at normal
height
• Therefore the bed rails must remain down and the bed at the lowest height setting when the patient is
left unattended
Low rise bed and falls alarms
• Falls alarms are compatible with a low rise bed
33