# Presentation: 662822

## Spotlight Case April 2003

**Coagulopathic Patient ****with Subdural Hematomas Falls out of Bed**

**webmm.ahrq.gov**

## Source and Credits

- This presentation is based on the April 2003 Medicine Spotlight Case
- See the full article at http://webmm.ahrq.gov
- CME credit is available through the Web site
- Commentary by: **Sidney T. Bogardus**, **MD**; Yale University School of Medicine
- Sidebar by: **Brian Liang, MD, JD, PhD**
- Editor, AHRQ WebM&M: Robert Wachter, MD
- Spotlight Case Editor: Tracy Minichiello, MD
- Managing Editor: Erin Hartman, MS

## Objectives

*At the conclusion of this educational activity, participants should be able to:*
- List risk factors for falls in hospitalized patients
- Understand appropriate use of restraints
- Identify system issues contributing to falls in hospitalized patients

## Case: Patient Falls out of Bed

*A 42-year-old man with alcoholic cirrhosis, coagulopathy, thrombocytopenia, and history of subdural hematomas from falls was admitted with new bilateral subdural hematomas. Neurosurgery service drained these via burr holes.** **In first week of hospitalization, patient received 45 units of fresh frozen plasma to keep INR below 1.5 and to minimize chances of expansion of his subdural hematomas. The patient improved and was transferred from the ICU to the step-down unit.*

## Subdural Hematoma 

## Epidemiology of Falls

- Common in elderly patients
- 35%-45% of people >65 fall each year
- Increased risk in nursing home residents
- >50% of residents fall annually
- Higher injury rate in institutionalized patients
- Up to 25% result in need for hospital care

*Anon. J Am Geriatr Soc. 2001;49:664-672.*

**Notes:**
Anon. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001; 49:664-672. 

## Risk Factors for Falls

- Intrinsic
- History of falls
- Mobility impairment
- Muscle weakness
- Visual deficits
- Cognitive impairment
- Postural hypotension

- Agitation
- Urinary frequency
- Depression
- Arthritis
- Age>80

*Anon. J Am Geriatr Soc. 2001;49:664-672; Tinetti MA, et al. NEJM. 1988;319:1701-1707. Nevitt MC, et al. JAMA. 1989;261:2663-2668; Oliver D, et al. BMJ. 1997; 315:1049-1053. *

## Risk Factors for Falls (cont.)

- Extrinsic/Environmental
- Medications
- Poor lighting
- Loose carpets
- Agitation
- Urinary frequency

*Anon. J Am Geriatr Soc. 2001;49:664-672; Tinetti MA, et al. NEJM. 1988;319:1701-1707. Nevitt MC, et al. JAMA. 1989;261:2663-2668; Oliver D, et al. BMJ. 1997; 315:1049-1053. *

## Case (cont.): Patient Falls out of Bed

*The patient was identified as being a fall risk.*
*The following precautions were taken: *
*Bed rails up*
*Bed in lowest possible position*
*Call light immediately accessible*
*Patient told explicitly: “Call nurse if you need anything”*
*Patient placed in area with many nurses nearby*
*Bed alarm activated*

## Case (cont.): Patient Falls out of Bed

*The patient stated he did not want to be restrained. The next evening, the patient attempted to climb out of bed by squeezing between his bed rails, and fell to the ground.*

## A Patient Caught in Bedrails

## Strategies for Fall Prevention

- Multifactorial interventions
- Education of staff
- Review and modification of medications
- Exercise and balance training
- Modification of environmental hazards

## Strategies for Fall Prevention (cont.)

- Specific interventions
- Bed alarms
- Moving patient to room near RN station
- Sitter for agitated patient
- Placing patient’s mattress on the floor
- Chemical restraints
- Physical restraints

## Use of Physical Restraints

- Substantial evidence indicates that restraint use can harm patients
- Use of physical restraints does not stop injury
- Use of restraints may increase injury
- Bed rails may be hazardous

## Case (cont.): Patient Falls out of Bed

*The patient was found on the floor with no sign of injury. He agreed to be placed in a Posey overnight. Two days later, he was transferred to the medical ward. The nurses identified him as being at “very high risk” for falls and thought he should be placed in restraints, but he adamantly refused. Because the staff believed the patient to be competent, they did not feel they could restrain him against his will. No psychiatric evaluation was requested.*

## Medicolegal Issues in the Use of Physical Restraints 

- Most accreditation groups strongly recommend against use of restraints
- Physical restraints that result in injury may lead to law suit
- Standard malpractice negligence rule
- General negligence rule

***Sidebar: Bryan A. Liang, MD, PhD, JD***

**Notes:**
The standard medical malpractice negligence rule: This rule generally requires a patient-plaintiff to show a breach of the relevant standard of care. If the standard (as usually determined by expert testimony) is that the patient, when taking into account all relevant clinical and sociomedical circumstances, was a risk to himself or others in the hospital, restraints may be deemed justified. 

The general negligence rule: This latter circumstance would not require a professional standard of care to define what is acceptable. Rather it would rely on a layperson determination of whether use of restraints in the specific circumstance was “reasonable.” Since use of restraints is a very emotional issue and would be evaluated in hindsight, providers may risk significant liability under this kind of general negligence suit.

## Medicolegal Issues in the Use of Physical Restraints (cont.)

- Restraint use against a patient’s wishes
- Professional assessment deems patient a risk to himself and/or others
- Consider psychiatric evaluation for competency
- Document all findings and assessments clearly

***Sidebar: Bryan A. Liang, MD, PhD, JD***

*Sheline Y, et al.  Bull Am Acad Psychiatry Law 1993;21:321-9.*

**Notes:**
Sarno GG. Civil liability for physical measures undertaken in connection with treatment of mentally disordered patient. In: American Law Reports. 4th ed. Rochester, NY: Lawyers Co-op Pub. Co.; 1981:464-509.
Sheline Y, Nelson T. Patient choice: Deciding between psychotropic medication and physical restraints in an emergency. Bull Am Acad Psychiatry Law. 1993;21:321-9. 

## Case (cont.): Patient Falls out of Bed

*That evening, the patient fell for a second time while trying to get out of bed. He was found on the floor, bleeding from his mouth. There were no new neurological findings. A repeat head CT showed no increase in the size of the subdural hematomas. The lip laceration was stitched and the patient was placed in restraints, over his objection.*

## Root Cause Analysis

- Floor nurses not aware of patient’s previous fall in the step-down unit
- Efforts to put the patient closer to RNs failed due to a lack of bed availability
- No high volume bed alarms available
- Bed alarms in use inaudible at RN station
- Sitters not available due to budget restrictions

## Cost per Intervention

- Forty-five units of FFP —$5,085
- Repeat head CT —$1,150
- Physical restraints —$2.50-$10.75
- Loud bed alarm—$270 each, 1-time cost
- Sitter/day—$360
- Relocation of patient —$0

## System Improvements

- Enhance communication
- Bracelets to identify patients at high fall risk
- Checklist—risk factors reviewed on sign out
- Maintain mobility
- Balance risk of falling with benefits of activity
- Avoid cascade of functional decline
- Seek financially feasible alternatives
- Sitters—solicit family members
- Reserve beds near RN station for at-risk patients

## Take-Home Points

- Falls are common in hospitalized patients
- Patients should be screened by assessing  intrinsic and extrinsic fall-related risk factors
- Communication of fall risk between providers is critical to prevent falls

## Take-Home Points (cont.)

- Other fall prevention strategies include:
- Medication review
- Relocation of patient
- Sitters
- Bed alarms
- Mobility preservation
- Bed rails should be used with caution
- Physical restraints should be a last resort