Fall prevention expert Dr Patricia Quigley offers her opinion on maximizing safe bed exits and preventing falls from beds in senior care settings.
Dr Quigley has vast experience in patient safety, both in practice in acute, post-acute and rehab situations and as a clinical scientist and researcher. Her renowned clinical research into the biomechanics of bed falls is nationally recognized and her passion for preventing falls and injuries is unparalleled. So here are 10 of Dr Pat's top tips to help caregivers maximize bed exit safety for older adults.
If we want to secure better clinical outcomes for our residents and patients then we need to come with an attitude that's open to change and be unafraid to challenge our own understanding of what is universal best practice and what actually works in practice.
Dr Pat says that if we are to achieve better outcomes then we must change our practice "beyond over-reliance on universal approaches that are not working and a fall-risk score that is not working for safe bed-mobility and exits."
Falls from beds happen. We know that not all falls are preventable but it's always good to remind ourselves as caregivers that people do and will make their own choices but it's wise to try to understand the motivations that lead them to make the decision to attempt to exit the bed unassisted without calling for help.
"People are going to get up without you. My legacy is in the Department of Veterans Affairs - Those who've born the battle for us and others to be free - and I always tell people 'You should have learned a long time ago with our Veterans who've jumped out of planes into battlefields that they're not all going to call you for help.' So you know that people are going to get out of bed without you so you have to anticipate and plan for that." - Pat Quigley
According to Dr Pat, screening is not necessarily enough to identify specific risks for a resident. "Colleagues, you have to appreciate that for the patient, screening is not the same as assessment and many of the tools that you are using are not assessment tools. [...] You have to consider cognitive and mobility function and the environment."
Dr Quigley suggests assessing risk for the following factors:
• Individual bed mobility
• Bed and mattress - and reassess if either change
• An appropriate safe exit side
• Individual bed height
• Assisted transfer technology
• Assess for position change alarms
So if screening doesn't cut it, then what can we use to thoroughly assess for fall risk? Dr Quigley states, "Actually the best fall risk assessment tool that's out there is the HD Nursing one. It's called the Hester Davis [...] but it is a whole program."
As part of a study that was funded by the VA, Dr Quigley offers valuable insights on the implications of certain types of falls from beds with a view to understanding, anticipating and potentially preventing injuries.
"If you fall onto padded carpet, the trauma that you sustain is very different to if you fall onto hard concrete sidewalk. So, padding makes a difference in terms of trauma that makes it to the bone but so does distance."
Dr Pat comments, "This is simulation but it is evidence. [...] We want to be protecting the head and torso when people fall, whether it's high distance or low distance. I want us to all realize that for older people, just the velocity of a fall without a head strike can result in micro-tears around the brain and you can still have a delayed onset subdural."
Understanding the biomechanical nature of different falls may be able to help healthcare professionals to implement more effective fall prevention programs for high-risk individuals.
Bed exit alarms (or nuisance alarms as they are sometimes known) are no longer considered to be a best practice fall intervention. Healthcare professionals have long debated bed-exit alarm effectiveness at preventing falls but Dr Pat suggests repurposing those bed alarms to become "position change alarms". So the goal here is not necessarily to be alerted when the resident is falling or about to fall, but when they are changing position. That way nursing staff can be alerted to their movements via the bed sensor pad or similar device but it must alert the nurses, rather than make a noise in the resident's room which can cause disturbance and alarm.
Pat Quigley suggests that especially for Alzheimer's patients "you should still have some motion sensors - you don't want to have bed alarms on them. Take some of those bed alarms and make sure they are connected to the nurse call system so they're not making noise in the room. You don't want to be scaring people."
The National Council on Aging recommends utilizing walls to reduce the likelihood of bed falls in home settings for older adults, so in long-term care, why do we assume the bed has to have the headboard against the wall like in a hospital ward? By putting one side of the bed against the wall you may be able to cut the possibility of that person falling from the bed by half. Dr pat says you may even be able to use the bed rail on that side since there's no risk of that person climbing over it with the wall there. So first assess if it's appropriate for that person to place their bed against the wall and then choose the best wall to still provide a safe bed exit side.
Safe transfers rely on having the bed height at the correct level for each individual resident or patient. So, it's vital that we make note of the individual heights that each person needs to be able to have their feet flat on the floor by the safe exit side and hold a 90-degree angle between their thigh and shin bones.
Less than a 90-degree angle will significantly increase the effort required to stand from this position and much more than this and they may not feel as secure to weight-bear through their feet.
"I'm encouraging all of you to have an individual adjusted bed height program so that when you come in to take care of me, and I'm almost 6 foot tall, that you know what height my bed should be at for me to safely stand up." Dr Patricia Quigley.
This might be a bit of a knowledge-bomb for some but you CAN move the bed in the room. It does not have to stay where it is. We've talked about the fact that it does not have to protrude into the room but before furniture starts moving there are key some considerations:
• Which side of the bed needs to be the side they get out of? You might need to think about which side of the body is stronger due to a history of strokes.
• Access to other areas. If the resident is likely to be trying to get to the bathroom or hallway by themselves because of a personal need then they need to have a line of sight and clear walkway to that.
• Consider individual needs. How you lay a room out for types of populations and acuity levels will and should differ. So, take into account their physical needs and cognitive abilities to make the best environment for each individual.
• Involve the team. Dr Pat recommends involving the Occupational Therapists and the Physical Therapists in decisions regarding room layout because they'll be able to advise.
If the bed is up against the wall then you only have one bedside from which to perform care tasks, keep their personal items and for the individual to exit the bed, hopefully assisted by care staff. However, if you choose not to place the bed against a wall as previously mentioned, then Dr Pat advises you designate a working side and a bed exit side.
"The side of the bed where the patient can get out of it is the safe exit side. The other side of the bed is going to be the working side." In acute care, medical and surgical equipment would go on the working side and in any care setting the personal items that the resident/patient might be reaching for from their bed would also go on the working side. That should leave the bed exit side clear of obstacles or items that can cause injury if a bed fall does occur such as a nightstand.
As you saw from the images of different types of bed falls earlier, your placement of the fall mat is intrinsically connected to the success of protecting the head and torso if falls do happen. Often what happens is that the mat is laid from the bedside table down the length of the bed but as we saw before, most bed falls are likely to see the resident land nearer the headboard than the footboard. This puts residents at risk of significant harm if there are furniture or other solid objects in that area where impact is likely to occur for them to strike their heads against. Even if the exit side is obstacle and furniture-free, if the mat is not right up to the headboard there is still a significant risk of them experiencing impact on the floor rather than the mat, especially for their head.
Dr Pat recollects "I've had cases where we've had people who have fallen out of the bed, hit the furniture on the way down before they make it to the floor and we've had people who've ended up with cervical fractures. This is what we want, to make sure that we place it (high) enough so that you're protecting the head and the torso."
Senior care professionals know that the bedroom is an area of particular risk for falls to occur and also that falls in the bedroom are often related to the bed in some way. As caregivers, it's our responsibility to create a care environment with an excellent level of safety for our residents and to be as consistent with supporting bed mobility and transfer safety as possible.
For residents that are assessed to be appropriate for a FloorBed such as the Empresa by Accora, this is a great way to reduce the severity of injuries from bed falls. Lowering to just 3.9 inches, it decreases the distance the resident has to fall which significantly reduces impact. Also with the level-plane safety mat that is the same height as the bed with a mattress and the same length as the bed, in the case of accidental or unobserved bed exits, falls become rolls. No fall and no injury.
We know of one Quality of Care professional who utilizes the position change bed sensor pads on the adjacent safety mat to alert nurses to assist the resident back into bed if they have rolled off the FloorBed onto the level-plane safety mat. This supports the utmost safety of the resident and protects the nurses' time.
Sources
1 - Quigley, P., Accora., (2024). Strategies to Maximize Safe and Assisted Bed Exits [Webinar]. Retrieved from https://us.accora.care/webinars/strategies-to-maximize-safe-and-assisted-bed-exits
Bed exit alarms alert those nearby to a fall event or an unassisted bed exit. the aim of this is to reduce bed-related falls but they are no longer typically considered best practices because of the disturbance and distress they cause in a care community and also because of the limited evidence that they succeed in preventing falls or aiding in root cause analysis.
Bed-exit alarms are often referred to as "nuisance alarms" because they create at least as many problems as they can solve. Falls are a huge consideration in post-acute and acute care facilities, especially those that are responsible for older adults in their care. Bed alarms monitor and alert those nearby to potential fall events from the bed. There are two main downfalls to this approach in nursing homes.
1. Firstly, that caregivers are likely to only be alerted once a fall event has occurred. This may expedite the care the injured person receives but is hardly an example of effective and sustainable fall prevention.
2. Secondly, that the unexpected noise is alarming for the resident or patient, especially if they suffer from cognitive impairment of any sort.
Dr Quigley suggests repurposing bed alarm monitors as position change alarms for improved safety during night shifts. This should be connected to the nurse call system so it does not wake or disturb the resident but does indicate to nursing staff that a fall risk may be present and that the person may require assistance.
Bed sensors or position change sensor mats are tools that professional care facilities often use to help predict and prevent falls for fall-risk residents. Picking up the movement of the individual can alert nurses via the nurse call system that a particular person may be moving in bed. This could mean they are attempting to exit the bed without assistance or are no longer centered in their bed which can be dangerous and result in a fall.
Alerting nurses via silent alarms will prevent unnecessarily disturbing the resident while allowing care nurses to arrive in time to prevent harm and support safe mobility from the bed. This is an intervention that is ideal in combination with other protections against falls like automatic night lights, a floor-level bed and correctly placed safety mats.
