Falls interventions procedure

1 Introduction

This procedure details specific interventions which can be applied to reduce the risks of falls and subsequent harm from falls. As with any clinical intervention, careful consideration is given to the risks versus benefits of each of the specific interventions to aid clinical decision making by the MDT.

2 Scope

This is a trust wide procedure which is applicable to all patients under our care. It focuses in particularly on the needs of those patients who are in the higher falls risk groups or who already have a history of falls (over 65’s and, or patients with pre-existing health conditions which means they are at a higher risk of falling).

3 Link to overarching policy, and or procedure

Patient falls manual (prevention and management)

4 Risk from falls

4.1 Risk factors for harm from falls are

Have had a previous fragility fracture.
Are currently using steroid tablets or injections or have used them frequently.
Have a history of falling have a family member who has had a hip fracture.
Have another condition known to cause osteoporosis.
Have a low body mass index.
Smoke, and drink more than 14 units of alcohol a week for women and 21 units a week for men.
Low levels of the sex hormone oestrogen in women as a result of early menopause, having a hysterectomy with removal of ovaries (before the age of 45), anorexia nervosa or Turners syndrome.
Low levels of the sex hormone, testosterone, in men following surgery for some cancers.
Hyperthyroidism when levels of thyroid hormone are abnormally high.
Conditions that cause long periods of immobility.

5 Use of bed rails and bed bumpers

Please refer to the MHRA bed rails, management and safe use guidance on managing and using bed rails safely for management:

5.1 Assessment procedures

There are different types of beds, mattresses, and bed rails available and each patient is an individual with different needs. Most decisions about bed rails are a balance between competing risks. Colleagues should use professional judgement and clinical reasoning to consider the risks and make decisions for individual patients.

A baseline assessment of the patient’s ability to maintain a safe environment should be made and documented immediately on admission to the clinical area. This should be reviewed as indicated in the patients care plan after 2 weeks or if the patient’s condition changes.
For patients identified as potentially at risk of rolling or falling out of bed, a ‘bedrails risk balance assessment checklist’ shall be completed on SystmOne or an equivalent clinical process followed. Note risk balance tools are an aid to making professional judgements but not a substitute for them.
The bedrails risk balance assessment checklist must be completed on SystmOne prior to bed rail usage with any patient.
If the patient has the potential to fall from the bed consideration must be given to the causes of risk and ways these may be minimised, for example, different position in the ward, regular toileting, observing patient regularly, night lights, medication review with medical colleagues (such as reducing diuretics).
Any decision to implement or not implement the use of bed rails will be discussed with the patient, relative or carer (if appropriate) and multi-disciplinary team (MDT). If an immediate decision is required and MDT members are not available (for example, at night; at weekends) then the nurse in charge or senior nurse will make the decision at that time. This must be communicated effectively for colleagues involved in that patients care.
Consider mental capacity and best interest decision making in accordance with the Mental Capacity Act 2005. Consent should be sought for the use of any restrictive equipment. Where there are concerns about the person ability to consent colleagues should assess mental capacity and where the patient lacks capacity to make a decision in their best interests as to whether they should be used.
Information about bed rails use and falls prevention should be routinely provided to patients and carers (for example, bed rails information leaflet).
If a patient or relative request the use of bed rails the same risk assessment and decision-making procedures should be followed.
Using bed alarms or nursing the patient on a low bed or ultra-low bed if available, may also be considered. The use of a “crash mat” at the side of the bed could also be considered but an assessment must take place due to the risk of a trip hazard.
Bed grab handles or bed lever or bed stick which fit under the mattress or clamp to the bed frame should not be confused with bed rails. These are designed to aid mobility in bed and whilst transferring to and from bed. They are not designed to prevent patients falling from their bed.
Consider any ligature risks, document clinical decision making.

Some clinical conditions can mean that patients are at greater risk of injury or entrapment, for example those with:

acute or chronic confusion showing signs of agitation or challenging behaviours. They are unaware of the risks and limitations imposed by their disabilities
involuntary movements or muscle spasms
patients with atypical anatomy are at greater risk of entrapment. Patients under 40kg in weight or under 146cm in height are particularly at risk. A recent NPSA recommends that children and adults with this atypical anatomy should be using beds or cots (and their recommended bedrails) compliant with BS EN 50637:2017 unless there is a clinical reason for using a non-compliant bed, which should be documented, including any steps which need to be taken to reduce risk
micro-or hydrocephalus presenting a particular risk of entrapment
sensory impairment who may not be aware of trapped limbs
learning disabilities affecting their ability to understand safety issues
communication difficulties; unable to understand safety issues or alert others when in danger
people who may self-harm with the help of electric beds or bed rails. Consider any ligature risks, document clinical decision making

Risk assessment is intended to highlight the potential risks but does not replace clinical reasoning or judgment. The decision to provide or not provide remains that of the clinician after careful consideration of the risks and benefits to the patient and wherever possible a multidisciplinary approach should be taken.

The following should be documented in the care plan or electronic patient record:

rationale for use of bed rails or for not using bed rails. Where restrictions are used there should be evidence that they are necessary and a proportionate response to the likelihood of the person coming to harm
plans for review
whether bed rail bumpers are required
discussion with patient (and, or relative as appropriate)
decisions about bed rails should be reviewed immediately whenever a patient’s condition or wishes change. If they are removed, details of this decision shall be documented
bed rails should not be used in place of supervision, and consideration must be given to the patient’s need for observations with relation to their continued safety and needs, particularly for patients’ who are agitated or unsettled
if a patient is found in positions which could lead to entrapment (for example, limbs through gaps in rails or between split rails or between mattress and bedrails) or is attempting to climb over the rail this is a clear indication that they may be at risk of injury from entrapment or falling. Immediate changes must therefore be made to the care plan, for example, possibly a change to a different type of bedrail, or decision made not to use bed rails as risks may now outweigh benefits
safety of patients using bed rails is enhanced by frequent checking that they are safe and comfortable and that they have everything they need, including toilet needs. The safety needs of patients who are vulnerable to falls without bed rails are very similar. Observing patients with bed rails (for example, for pain, discomfort, anxiety, breathlessness, medical needs) should therefore be part of routine good practice on the ward. Standard practices and policies for observation and observation levels should be followed
in some situations bedrail use is standard (for example, when transporting patients, when patient is unconscious, after anaesthetic)

Please see bedrails risk balance assessment checklist’ in SystmOne.

5.2 Safe operation of bed rails

All colleagues should ensure that they are aware of how to use a piece of equipment prior to caring for the patient.
Detachable bed rails must not be used.
All colleagues using bed rails should be competent in their use to minimise any risks of injury to the patient such as trapping or falls.
If the patient is an unusual body size , for example, emaciated, hydrocephalic, micro cephalic, small, check for any bedrail gaps which would allow head, body, or neck to become entrapped.
All colleagues must inspect each bed rail for defects before use to ensure that it is in safe working order, each colleague has a responsibility to remove and report unsafe equipment.
Colleagues must ensure that bed rails are compatible to the bed they are used with.
Care must be taken to ensure that anything such as bed clothes, giving sets, catheter tubes, cables or mattress covers are not trapped in the bed rails. Things trapped in the rails or hinges can prevent bed rails from safely locking.
Once raised and clicked into place the security of the bed rail must be double-checked.
Beds should usually be kept at the lowest possible height to reduce the likelihood of injury in the event of a fall, whether or not bed rails are used. The exception to this is where patients are independently mobile and the bed needs to be at a certain height for safe transfers or standing.
Beds need to be raised when direct care is being provided. Patients who are on bed rest and receiving frequent interventions may prefer their bed to be left raised, rather than it being constantly raised, and lowered.
Colleagues must ensure that the mattress is correct for the bedframe they are used with.

6 The use of hip protectors

Hip protectors are not used routinely within the trust in any of the inpatient areas. However they do have their place, but not as a first line of approach, other risk factors identified in the MFRA are to be mitigated as a priority. They can be provided on an individual patient basis based on presenting needs, risks and associated medical conditions. This will be a decision for the MDT caring for that individual patient.

Hip protectors are not routinely assessed for or supplied in RDaSH services. Instead the focus is on the prevention of falls in terms of risk assessment and care planning. Hip protectors reduce the risk of fracture but don’t prevent the fall happening in the first place.

NICE did not recommend hip protectors in their 2013 guidance (opens in new window) (due to insufficient evidence that hip protectors are effective in preventing hip fractures in people in the community and in care homes but did support some consideration for their use on an individual basis in extended stay settings.

6.1 What are hip protectors

A hip protector is a specialised form of pants or underwear containing pads (either hard or soft) along the outside of each hip or leg, designed to prevent hip fractures following a fall. Most hip fractures follow an impact due to a lateral fall. The pads are located over the trochanters, the bony extrusions of the hip region. Hip protectors are either of the “crash helmet type” or “energy-absorbing type”. The “crash helmet type” distributes impacts into the surrounding soft tissue, while the “energy-absorbing type” is made of a compressible material and diminishes the force of impact.

6.2 How might hip protectors prevent hip fractures?

The use of hip protectors to reduce the risk of hip fracture following a fall is an option to consider which needs clear clinical reasoning. The evidence in support of their use is limited but they have been shown to have a slight reduction on hip fracture rates in residential care settings (Cochrane Review, 2022).

Evidence also suggests that they are not tolerated well by patients who often stop using them due to discomfort or skin irritation. They can also be an incumbency to toileting. (Cochrane Review, 2022).

There are some individuals who may not be suitable to wear hip protectors.

People who have had bilateral hip replacements do not benefit as a future fracture is extremely unlikely. Those either at high risk of pressure ulcers or with existing pressure ulcers, should not wear hip protectors. All wearers must have their skin integrity monitored, while extra care should be taken with people wearing hip protectors during the night, who are incontinent or are physically unwell. Chairs should be wide enough for older and, or people who spend long periods of time sitting, to avoid increasing pressure on the hips.

6.2.1 Guidance for use

Hip protectors must be considered as a part of the falls management plan or Intervention, and must not be seen as a standalone solution. All other aspects of falls prevention, other risks identified must be addressed in addition to the provision of the hip protectors.
If hip protectors are likely to limit independence in toileting, self-care or well-being then discussion about their appropriateness and the balance of overall risks should occur, involving other members of the MDT as appropriate. These discussions and decisions made must be clearly documented.
It is important to include the patient in the decision-making process if possible and consent obtained and documented in notes. Carers or family may also be consulted especially if the patient is unable to provide consent.
Hip protectors should not be provided unless a falls risk assessment and care plan has been completed.
For patients suffering from pressure sores, or who have other tissue viability problems, then further advice should be sought from the tissue viability nurse before the use of hip protectors. Advice should also be sought and multi-disciplinary discussion occur if the patient is confined to bed for 24 hours or more.
Some wards may keep limited stock to ensure that all identified patients receive the hip protectors immediately. Measurements must be taken and care to ensure the correct size hip protectors are issued.
Once the hip protectors have been given to the patient they are deemed to belong to that patient. Care must be taken that they are washed and dried in line with manufacturer’s instructions. Patient’s name clearly marked inside the hip protectors.
Once out of the care of the ward future use of hip protectors and issues related to this becomes the responsibility of the general practitioner (GP), (and the care home). If the patient is discharged to a care home, a copy of the falls risk assessment and associated care plan should be sent with the patient to ensure continuity of care and to alert the home to potential falls risks, and also the use of hip protectors.

7 Use of sensors

Falls sensors do not prevent falls but they do act as “an early warning system”, alerting colleagues when a patient attempts to leave their bed or chair unassisted. Falls sensors should be used alongside other interventions such as Oxevision where available.

Falls sensors should be part of a multifactorial falls care plan.

Following initial assessment and completion of the MFRA the decision to use falls sensors is made. Also at the point of handover from the referring service the use of falls sensors may be highlighted due to the falls risk. The decision to use or remove the of use bed sensors should be clearly documented in the patient’s clinical record.

Sensors are made in many forms:

a common form is a pressure-sensitive pad that is placed beneath the patient whilst in bed or in a chair, usually in the shoulder area (in bed) or in the area of the buttocks (in bed or chair). The pad is attached to a control unit. Other forms of sensors include:
- floor mats are pressure-sensitive mats placed alongside the bed
- infrared beam sensors are typically set up next to the bed or on the wall to send a beam over the top or alongside the bed, they are activated when the patient breaks the beam

7.1 Criteria for use

Pressure sensors are to be considered for patients who are at risk of falling especially through the night.
For patients under 38.1kg in weight pressure sensors are ineffective, as they do not activate. They are also unsuitable for patients who are using a pressure relief overlay mattress.
If bed pressure sensors are thought to be reducing the amount of quality sleep that a patient has, alternatives will need to be considered.

7.1.1 Who may benefit from this additional safety intervention?

Based on an individual falls risk assessment, if a patient has been identified as at high risk of falling, this intervention may be considered useful.
Some patients who have cognitive impairment and do not know that they need help will not be able to use the call bell.
Patients who do not want to ask for help, do not use the call bell and try to mobilise Independently.
Patients may choose not to use sensors, if they have capacity to make this decision they would need to sign an informed refusal form.

7.2 Key points

The falls risk assessment and care planning procedures must have been followed and the use of a bed alarm must be part of a falls management plan.

When portable bed sensors are used consideration should also be given to the location of the patients’ bedroom. The patient should be allocated a room as close to the main observation area of the ward as possible.

Any shortage of sensors to meet patient needs must be reported to the ward manager. An assessment should be made if the patient has capacity to agree to sensor use. If not, a best interest decision should be agreed following discussions with the MDT and family or carers.

7.3 Caution and advice

Pressure sensors may not prevent a fall but they alert colleagues to a potential risk so they can respond quickly to a patient who may be at risk of falling.
Some patients may become more agitated with the noise emitted from the pressure sensor alarm.
Pressure sensors may or may not work under certain cushions or pressure relieving equipment.
The use of pressure sensor equipment does not mean that a patient does not need to be observed frequently.
If a patient falls, despite the use of this equipment, review the risk assessment.
The effectiveness of the sensors is dependent on colleagues being able to respond in time to prevent the fall.
Bed sensors should not be confused with the use of Oxevision. Oxevision is an additional system that can be used along with the sensors.
All colleagues must ensure that they are familiar with the sound made by the respective sensors or alarms.
A chair sensor will need to be moved with the patient if they change seats, for example, move from sitting at the bedside to sitting in the day room.

7.4 Useful Information

Always read manufacturer’s instructions for relevant pressure sensor equipment.

Maintenance and checking:

device instruction manuals should be consulted for guidance on care and maintenance
all identified faults must be reported as agreed locally
senior colleagues nurse to monitor and report when integrated sensors fail to function

8 Use of ultra-low beds

Ultra-low beds can help to prevent harm from falls particularly for patients who are at risk of falling out of bed.

Some patients are at risk of falls from their bed. Risk factors include:

dementia
delirium
agitation
disorientation
limited mobility and acute illness

To prevent injuries to such patients when the use of bed rails is deemed inappropriate, consideration should be given to the use of ultra-low beds. A low bed should not be a standalone falls prevention solution, and if provided inappropriately for mobile patients could be deemed as restraint. It is important to consider that even when the bed is in its lowest position some patients may still sustain serious injuries such as a fractured hip or head injury. Patients must be assessed individually to ensure that this is the most appropriate method of preventing potential falls from bed.

A search of the National Reporting and Learning System (NRLS) database of all incidents reported from 1 November 2003 to 24 June 2010 identified a series of patient safety incidents related to the use of ultra-low beds. These included:

injuries from floor-level furniture or fittings such as radiators, pipes, or lockers
ultra-low beds placed close to a wall but not flush with it, creating potential for asphyxia entrapment if the patient slipped between the side of the mattress and the wall (see MHRA bedrail guidance)
ultra-low beds left at working height in error, leading to falls from height
patients who appeared to have tripped over crash mats used beside the ultra-low bed

8.1 Use of an ultra-low bed

Consider risk of injuries to the patient from:

floor level furniture or fittings
risk of burns from being near to radiator
risk of entrapment and asphyxia if bed placed close to but not flush with wall
physical illness, some essential medical and nursing interventions may be difficult or impractical when using an ultra-low bed
psychological illness or distress, the unusual position may aggravate distress, confusion and, or agitation
discomfort or pain, any unsettling stimuli such as pain can aggravate confusion and, or agitation
disabilities or capabilities, the use of an ultra-low bed may affect the patients capabilities, for example, transfers and mobility
the wishes of patients and, or relatives or carers
previous accidents or injuries
tissue viability and whether the low bed is compatible with any air flow mattresses
any patients identified as requiring a pressure mattress must be reviewed by the MDT team as to whether they require a full profiling bed
whether the patient requires a bed table and whether the item is compatible for the bed
any variation in status over a 24-hour period, for example, nocturnal confusion
consider mental capacity and best interest decision making in accordance with the Mental Capacity Act 2005. This must be documented in the clinical record
check weight limit for bed is compatible with patient’s weight
the decision to use an ultra-low bed must be recorded in the nursing notes and discussed with and communicated to all members of the ward MDT
the patient’s family and, or carers should also be informed of the decision
the use of ultra-low beds must be reviewed and documented as part of care planning review process. The timeframe for review must be documented

8.2 Key points when using low bed

Care must be taken to ensure beds are not near to floor level furniture or fittings such as radiators, pipes or lockers due to the risk of injury to the patient.
Check that there are no items that may fall on the patient or cause injury.
Consider risk of potential asphyxia entrapment if patient slipped between side of mattress and wall if bed placed against the wall. Ensure bed is flush to the wall or has a large enough gap to ensure no entrapment.
Crash mats are to be used with caution. These can in themselves cause a trip hazard for both patients and colleagues. When the patient is not using the bed the crash mat must be removed and stored safely.
Consider any risk of the patient tripping over the crash mat placed next to bed when mobilising.
Care must be taken when positioning legs of a hoist under a low bed as limitations from the bed may cause manual handling difficulties. Manual handling risk assessment should be completed.

8.3 Ultra low bed assessment guide

If an ultra-low bed is not used how likely is it that the patient will come to harm?

Ask the following questions:

how likely is it that the patient will roll out of bed?
how likely is it that the patient would be injured if they rolled out of bed?
will the patient feel anxious if they are not near the floor?
will an ultra-low bed stop the patient from being independent?
could the patient stand up unaided from an ultra-low bed?
could the patient become trapped under the carriage of an ultra-low bed?
could using an ultra-low bed cause the patient distress?

Consider using ultra low bed if bed rails are not suitable and benefits outweigh the risks.

Ultra-low beds can be used alone of in conjunction with other falls prevention measures.

The above can be used as a checklist for decision making and included in the electronic patient record.

NPSA (2011) signal, the safe use of ultra-low beds.

8.4 The use of floor mats

8.4.1 Issues to consider before using floor mats

Before using Impact mats the following prompts must be considered as a risk versus benefit to the patient, and others:

will the mat create a hazard to patients colleagues and others contributing towards trips and falls?
will the mat impose space restrictions to the environment?
will the use of the mat impose moving and handling issues?
where will the mat be stored if not in use?

When using a mat care must be taken:

ensure mat is secure and does not slip or slide
ensure that patient cannot trip over edge of mat
when not in use mats should be collected and stored
need to have a robust cleaning plan for mats used
consider patients falls risk and mobility
if the decision is made to use floor mats, a care plan is to be developed to outline their use

9 Use of restrictive interventions (lap belts, nursing on the floor, head protectors)

Respecting people’s basic human rights to dignity, freedom, choice and respect underpins good quality care. Whilst some people may need support in making choices and decisions, they have the right to make choices about their lives and to take risks.

It is important for colleagues to understand their role within ‘duty of care’. It distinguishes between putting people at risk and enabling them to choose to (if they have capacity) to take reasonable risks, duty of care does not mean people have to be kept safe from every eventual risk. No environment is entirely risk-free.

Following criticism of services in the wake of a number of patient safety tragedies, the Department of Health’s, Positive and Proactive Care, reducing the need for restrictive interventions (April 2014), is part of a wider programme ‘positive and safe’ to make sure restrictive interventions is reduced across all health and social care. A restrictive intervention occurs when you stop someone from doing what they want to do. One type is mechanical, when something is used (for example, arm gaiter) to prevent the free movement of a part of the person’s body protecting them and others from harm.

MCA Section 6(4) of the act states that someone is using restraint if they:

use force, or threaten to use force, to make someone do something that they are resisting
Mental Capacity Act Code of Practice, restrict a person’s freedom of movement, whether they are resisting or not. You may need to put protective measures in place to which the person can consent to. The MCA would only be used where there are concerns about the person ability to consent

Where there are concerns about the person ability to consent, colleagues should carry out an assessment of capacity. Where the person lacks capacity colleagues must make a decision as to whether or not it is in the persons best interests in line with the trusts MCA Mental Capacity Act 2005 policy.

The MCA would only be used where there are concerns about the person ability to consent.

The person taking action must reasonably believe that restraint is necessary to prevent harm to the person who lacks capacity. The amount or type of restraint used and the amount of time it lasts must be a proportionate response to the likelihood and seriousness of harm.

The Mental Capacity Act 2005 states “restraint may only be used for a person who lacks capacity where it is evidenced that it necessary to protect the person from harm and is proportionate to the risk of harm”.

Mental health units (use of force) policy.

Restrictive intervention could also be: Limiting independence for safety. Restrictions should only be used when deemed absolutely necessary. When they are applied it must be conducted in a safe and effective manner by trained professionals. A care plan must be completed to ensure personalised care is delivered and alternatives to restriction have been implemented. Where possible the persons consent to the restrictive interventions in the care plan should be obtained and recorded in the electronic patient record. When restrictions are necessary, they should be used for the shortest possible time, be recorded, monitored, and reviewed in line with trust policy and procedure.

9.1 Decision making process

Decisions to use a restraint should be made within the MDT with the responsible clinician leading the process. Expert advice of other professionals should also be sought if necessary, for example, safeguarding leads, moving and handling key trainers.

In exceptional or emergency situations where immediate action is needed, agreement or concurrence by the MDT to the decision, may occur retrospectively.

The following documentation must be entered into SystmOne:

risk assessments and care planning completed
reasoning for action to be documented
wishes of the patient sought and recorded
families or carers wishes sought and documented
when a decision is made that using restraint is necessary, consent must be obtained and recorded

Consent:

consent must be informed, for example, steps must be taken to ensure that the patient has understood the pros and cons of the restraint, and considered other options (see consent to care and treatment policy)
colleagues need to take into account how the person can themselves end the restraint if they wish to withdraw consent
where the patient lacks capacity the Mental Capacity Act 2005 must be followed (see MCA Mental Capacity Act 2005 policy)
the decisions should justify that any restraint used is the least restrictive method, and that it is in line with the level of risk

Care planning and actions:

care plans should specify what is to be done and include time limits for use of restraint and frequency of reviews. (Decisions must be reviewed frequently)
care plans must also specify any actions required to comply with tissue viability and with any other care needs arising from the use of restraint
if mobility or movement is restricted by the restraint, then the care plan must also include actions to provide adequate range of motion interventions to maintain health, independence and well-being
these care plans and records related to them should be subject to regular review by ward managers

9.2 Physical restraint

Physical restraint: a physical restriction to moving around as one wishes. This might be by using belts or cords, sheets or blankets to tie or secure someone to a place such as a chair or a bed; chairs or beds from which someone is unable to move; bed or side rails; or chair or lap tables.

9.2.1 When it is appropriate to use restraint

The purpose of restraint in relation to falls is to prevent harm and maintain patient safety.
The measures used are necessary to prevent the person coming to harm and a proportionate response to the likelihood and seriousness of harm.
Should only be used with the persons consent or in the persons best interests under the Mental Capacity Act 2005.

9.2.2 Key points

Restraint should never be used unless no other options can be found and the practice is within the law.
Restraint should only be considered where there is an immediate risk of harm to the individual or others.
Other methods to control the situation have been tried, found to be unsuitable or failed.
Minimise the risk of harm by the use of other falls prevention methods such as increased colleagues support or supervision.

9.2.3 Legal implications

The inappropriate use of restraint is against the law. Restraint can constitute assault, battery or false imprisonment and can lead to criminal prosecution. Certain criteria need to be met for restraint to legally occur, if it is used in an inappropriate situation the restraint may constitute abuse and may be subject to safeguarding adults legislation.

9.3 Guidelines for the use of wheelchair lap-belts

There are a number of concerns regarding the use of wheelchair lap-belts, particularly with people who have been identified as having an increased risk of falls. These concerns relate to the difficult decisions that may have to be made regarding balancing risks with safe and lawful practice.

9.3.1 The use of wheelchair lap-belts

Wheelchair lap-belts are intended as a safety device to be used during transportation only.
Wheelchair lap-belts may also be used at the request of patients, occasionally patients themselves feel safer wearing them, for example, if they have some balance problems or are anxious about falling out of a chair.
Postural support or positioning.

9.3.2 Implementation

Decisions should be made within the MDT.
Rationale for use of lap-belts will be clearly documented within electronic patient record with evidence of MDT discussion, risk, clinical reasoning; least-restrictive methods; protection of the patient’s rights, dignity and well-being.
Decisions must be documented in the electronic patient record.
Advice or input from the safeguarding leads may be sought.
Decisions should be reviewed on every occasion that the lap-belt is used.
Measures in place to meet a patient’s needs (for example, toileting, nutrition) during use.
Patient to be reviewed in line with their personal care plan for signs of distress.

9.3.3 Key points

Patients should only be sitting in a wheelchair (with cushion) for short periods of time for transit purposes. The only exception to this is for patients who are long-term wheelchair users or dependent, these patients should be using their own bespoke chair complete with their own pressure care cushion or customised seating system or when a clinical need is identified.
Wheelchair lap-belts should never routinely be used as a falls prevention method, evidence suggests that restraining people in a wheelchair with a lap-belt can increase the risk of falls (for example, it leads to decreased mobility, a loss of muscle strength and increased distress or agitation).
Consent must be informed and steps must be taken to ensure that the patient has understood the pros and cons of using the lap-belt.
A patients’ capacity to consent will be assumed unless there is just cause to question this ability. In this instance, capacity will be assessed and if the person is found to be lacking in capacity, a decision will be made in their best interests.

9.4 Guidelines for nursing patients on the floor

Nursing patients on a mattress on the floor is occasionally used in the management of patients who are at risk of falling out of bed. Nursing patients on the floor should only be considered to reduce the risk of potential injury or distress as a result of current mental or physical condition; it should only be considered when other alternatives have been explored or tried and deemed unsuitable (for example, use of adjustable high or low bed). Colleagues are advised to use procedures for safeguarding (child and adult protection procedures) to help inform their decisions; direct advice and support in individual cases or situations can be sought from RDaSH ‘safeguarding leads or managers’.

9.4.1 Benefits

Minimise risks or potential injury associated with falling from a bed at height.
May minimise fear or distress related to feeling unsafe or at risk of falling out of bed.

9.4.2 Implementation

Decisions should be made within the MDT.
Rationale to nurse a patient on the floor will be clearly documented within electronic patient record with evidence of MDT discussion, risk, clinical reasoning; least-restrictive methods; protection of the patient’s rights, dignity and well-being and must only be considered when other alternatives have been tried and deemed unsuitable.
Patient consent must be obtained unless the patient lacks capacity. In the event of the patient not having capacity an MDT decision would be made based on the best interests of the patient.
Decisions should be reviewed, on every occasion care is delivered in this way.
Ensure changes of position and monitoring with regards to tissue viability in line with trust polices and guidance.
Advice or input from the safeguarding leads may be sought.
Measures in place to meet a patient’s needs (for example, toileting, nutrition) during use patient to be regularly monitored for signs of distress.

9.4.3 Key points

Ensure manual handling risk assessment completed, ensure environment risk assessment completed (of immediate environment where the bed is).
Ensure colleagues are trained and competent to ensure safe movement of patient from the floor or low level.
Ensure colleagues are trained and competent to use any equipment and that relevant manual handling equipment is available, for example, hoist.
Consider patient’s privacy and dignity needs.
Consider impact on mobility or physical health of the patient.
Consider emergency evacuation procedures.
Consider consent. Consent must be informed, take steps to ensure that the patient understands pros and cons of being nursed on the floor.
Patient consent must be obtained unless the patient lacks capacity. In the event of the patient not having capacity an MDT decision would be made based on the best interests of the patient.
Ensure area can be cleaned in line with infection control measures.
Ensure no hazards within reach, for example, things that may fall on top of the patient.

9.5 Guidelines for the use of patient head protection or helmets

Head protection is occasionally used in the management of patients who are at risk of falling, or occasionally chosen to be worn by the patient or patient to increase their confidence in their own safety.

Head protection may be used to reduce the risk of patient injury as result of current mental or physical condition; longer term use must always be justified in that the risks remain or are recurrent or ongoing. Colleagues are advised to use procedures for safeguarding (child and adult) to help inform their decisions; direct advice can be sought from ‘safeguarding leads or managers’.

The use of head protection may be part of a risk management plan whereby wearing the head protection enables the patient or patient to choose to participate in activities and routines which they otherwise may be unable to do as safely.

9.5.1 Implementation

Decisions should be made within the MDT.
Rationale to use head protection will be clearly documented within electronic patient record with evidence of MDT discussion, risk, clinical reasoning; least-restrictive methods:
- protection of the patient’s rights, dignity and well-being and must only be considered
- when other alternatives have been tried and deemed unsuitable

9.5.2 Documentation

Must include plans for review.
Patient consent must be obtained unless the patient lacks capacity. In the event of the patient not having capacity an MDT decision would be made based on the best interests of the patient.
Patient to be regularly monitored for signs of distress as a result of appearance and comfort.
Head protection or helmets must be individually prescribed or fitted for use, instructions for correct daily fitting and wearing should be followed.
All colleagues who fit or assist the patient or patient in the putting on of the head protection or helmet should ensure it is fitted correctly.

9.5.3 Key points

Consider that use of head protection may affect hair growth and cause hair loss.
Consider risk of scalp problems or rubbing to pressure areas or infection, particularly if not fitted correctly or not maintained properly.
Consider risk of stigma and patient’s privacy and dignity needs.
Monitor with regards to possible pressure areas in accordance with trust pressure ulcer procedure.
Ensure head protection can be cleaned in line with infection control measures.
Consider consent. Consent must be informed, take steps to ensure that the patient understands pros and cons of being nursed on the floor. In the event of the patient not having capacity an MDT decision would be made based on the best interests of the patient.

9.6 Checklist for the use of wheelchair lap-belts or head protection or nursing on the floor

This checklist provides a tool for clinical reasoning and decision making in relation to falls and the use of wheelchair lap belts, head protection and nursing on the floor as part of an overall falls management plan.

Has a falls risk assessment been carried within the previous 24 hours?
Is a falls prevention care plan in place?
Have all other alternatives for falls management been considered?
Has an MDT discussion taken place about the use of the item or procedure, potential risks or issues related to restraint?
Has a discussion taken place with the patient and, or family about the use of the item or procedure?
If restraint is a concern has safeguarding procedures been followed?
Have implications for manual handling been considered?
Has tissue viability and infection control been considered and any necessary actions taken to ensure that these are not compromised?
All discussions and decisions made must be fully documented in the patient’s clinical records.

10 References

Document control

Version: 1.2.
Unique reference number: 1048.
Approved by: Clinical policy review and approval group.
Date approved: 5 December 2023.
Name of originator or author: Clinical team leader, fall lead.
Name of responsible individual: Executive director of nursing and AHP’s.
Date issued: 12 January 2024 (amendment).
Review date: 31 August 2026.
Target audience: Clinical staff.

Page last reviewed: April 23, 2024
Next review due: April 23, 2025

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