Patients in the acute rehabilitation phase of recovery from a brain injury are at a high risk of falls, largely because of physical limitations and cognitive impairments.
But some prevention strategies implemented at Shepherd Center have proven successful in reducing fall rates significantly in this setting.
Falls among these patients can occur because patients experience weakness, confusion, impulsivity, impaired safety awareness, and poor judgment and reasoning.
They may also have uncontrollable spasms or movements that increase the risk of sliding out of a bed or a chair. Also, assisted falls may occur when a patient with limitations is learning new ways of moving and attempting to rebuild strength and endurance.
Strategies to prevent falls among these patients can be simple, but effective.
Shepherd Center uses bed alarms on all brain-injured patients, seatbelt alarms, one-on-one attendants and frequent rounding on patients.
Also, leadership engages staff members in maintaining a culture that recognizes the high risk of falls requires a high sense of urgency in responding to alarms, and that safety has to be more important than privacy for the brain-injured patient.
Shepherd Center Brain Injury Unit nursing manager Gail Greene, RN, is here to explain how Shepherd Center uses an interdisciplinary, collaborative approach to teaching and reinforcing the use of these strategies.
Selected Podcast
Fall Prevention in the Acute Rehabilitation Setting
Featured Speaker:
Because brain injury patients are at an especially high risk of falls due to physical and cognitive impairments, Gail has leading Shepherd Center’s Fall Prevention and Restraint Work Group since 2007. It is an interdisciplinary group whose work has significantly decreased the incidence of falls and, therefore, the risk of injury to patients at Shepherd Center.
Learn more about Gail Greene, RN
Gail Greene, RN
Gail Greene, RN, BSN, CRRN has been the nursing unit manager of the Acquired Brain Injury Program at the Shepherd Center since 2007. Gail has practiced nursing for 39 years and has been a rehabilitation nurse since 1994 and a nursing manager since 2000. She is a graduate of the University of Pittsburgh, School of Nursing and earned her Certification in Rehabilitation Nursing (CRN) in 1998.Because brain injury patients are at an especially high risk of falls due to physical and cognitive impairments, Gail has leading Shepherd Center’s Fall Prevention and Restraint Work Group since 2007. It is an interdisciplinary group whose work has significantly decreased the incidence of falls and, therefore, the risk of injury to patients at Shepherd Center.
Learn more about Gail Greene, RN
Transcription:
Fall Prevention in the Acute Rehabilitation Setting
Melanie Cole (Host): Having an unexpected fall can be a very scary experience, not only for the person who fell but also for the caregiver or the family. Prevention strategies implemented at Shepherd Center have proven successful in reducing fall rates significantly in the rehab setting. My guest today is Gail Greene. She’s the Nursing Unit Manager of the Acquired Brain Injury Program at Shepherd Center. Welcome to the show, Gail. Tell us what’s going on and what is the risk of falls when they’re in the rehab setting.
Gail Greene (Guest): Our patients are at an especially high risk, especially given the nature of the types of patients that we have—primarily brain injury patients and spinal cord patients. Their risk tends to be related to either their impaired functional status or their cognitive impairments that lead them to either be confused or impulsive or have poor safety awareness, where they just aren’t aware that they have some kind of a deficit or some kind of a functional impairment that they can’t do what they used to be able to do.
Melanie: People tend to think of the rehab setting as lots of physical therapists and occupational therapists all around. So, are the patients on their own at some points or are there generally people around and sometimes the falls just happen?
Gail: Well, that’s a good question. Generally, our staffing ratios are quite good for the nursing department, so there are nursing staff around at any given point but most patients are not necessarily, attended one on one throughout their stay. So, there are periods of time where they may be alone, perhaps, in their room or in the hallway or that sort of thing. They do have some freedom of movement and are not being watched over literally every second.
Melanie: So, watching over and privacy--I mean, they go to the bathroom; they get up and go change what they’re doing. So, how is that something that might be a little interactive where maybe they want to go to the bathroom by themselves but the risk of falling might be greater if they do?
Gail: Well, one of the things about the culture here at the Shepherd Center is we are very focused on patient safety and, as a result, we have implemented some cultural expectations of our staff where safety, as I mentioned, is our utmost concern. So, we even have a little mantra that we have to concern ourselves with safety before privacy. It’s not to say that we’re not concerned about patient’s privacy, it’s simply that we know that if most of our patients are left alone, they may end up on the floor which may lead to them having further injury and may put them in a worse situation than they are already in. So, we’ve just prioritize that, for many of our patients, privacy just has to come after our concerns about their safety. So, in those situations the staff member would stay with them in the bathroom. Perhaps they would put the hand on the shoulder and turn their back. What that does is, it gives us that physical feedback that the patient is moving but it allows us to turn our backs so they at least feel we’re not standing there gawking at them which I can certainly understand would be uncomfortable.
Melanie: Gail, give us some more strategies to prevent the falls among these patients.
Gail: Well, the other part of our culture is that, for the brain-injured patients especially, we use bed alarms any time they are in the bed. Then, we also have seatbelts alarms that we use on many of our patients when they’re in a wheelchair, although for some patients, that is not sufficient and we may need to use restraints either in the bed or the wheelchair. However, one of the things about the culture that we’ve instilled in the staff is that when we hear an alarm going off, it is dangerous. That means that there’s the potential for danger to the patient. We end up feeling the need to run towards that alarm--in other words, not being casual about our response to that alarm. I see my staff running and that makes all the difference in getting to that patient quickly to ensure that they’re not going to fall. The alarm doesn’t stop them from falling but it simply alerts us that the patient is moving in a way that may be unsafe and may lead to a fall.
Melanie: What about assisted devices? Wheelchairs, walkers, canes? Do these things really help to prevent the falls or sometimes can a cane be something they get tangled up in?
Gail: In fact, part of the reason why some of our patients at Shepherd fall, and this may be especially true in the spinal cord population, their bodies aren’t working the way they had been working in the past and so, while they’re learning new skills such as using a sliding board to transfer from a wheelchair to the bed, or vice versa, or perhaps, using a walker but, in the meantime, their legs are very weak, their arms are weak because of the injury that they’ve had and their having to rebuild their strength throughout the therapy. In the process of learning these new skills and rebuilding their strengths, sometimes they have what we refer to as an “assisted fall” where there’s somebody with them. This new skill is something that they’re not proficient at yet and so, they end up having an assisted fall where somebody’s with them and helps to safely lower them to the ground. That can be one way that people fall. The other way is, we have stroke patients and sometimes they can stand on one strong side because the nature of the stroke is that you’ll be weaker or have impaired function on one entire side of your body but the other side, generally, is strong and capable. We may do what is called a “stand pivot transfer” or a “squat transfer” from, say, the bed to the wheelchair. Sometimes, in the course of those where the caregiver is helping to transfer the patient, there is a loss of balance. Maybe the patient shifts before the caregiver is expecting them to and there’s a loss of balance and they might both go down. In those cases, again, usually it’s easing them on down but that’s a result of their impairment and occurs during the transfer.
Melanie: What about footwear? Is this something that can impede their balance or help it? What do you recommend patients wear?
Gail: They, generally, are recommended to wear a good supportive shoe--something that might be rather easy to get on an off. I think some popular shoes for them to wear are some form of athletic shoe, what I would have called a “sneaker” growing up, with Velcro, perhaps, to make it easier to get it on and off but something that has enough support that their foot is not going to roll around much and also that isn’t going to fall off their foot while they’re moving. So, a slip-in shoe might not be recommended in that setting.
Melanie: For caregivers and even at home, Gail, what do you recommend if somebody does fall? Should they help that person up and how do they do that without throwing out their own back?
Gail: One of the things we do here at Shepherd is, we have quite extensive family and caregiver training and that extends even to our website. We have a link called “MyShepherdConnection.org” and we encourage our families and caregivers to communicate that we have this link to everyone that they know and anyone they might be cross-training to help them in the home and also to go to that site themselves to review it. We have therapists that have done some really wonderful instructional videos that review safe transfers of all different types: from the bed to the chair, from the chair to the bed, from the car to the wheelchair, etc. and that sort of thing. We also have other videos at MyShepherdConnection.org that review home safety, home modifications, and it goes room by room in a former patient’s house giving some suggestions on some things that they did in his home to help keep him safe and improve his independence and allow him to be more self-sufficient, while, again, at the same time, keeping him safer because he has the proper handholds to support himself with and that sort of thing. So, MyShepherdConnection.org is a wonderful resource for anybody to use that is an enhancement to what we provide for education while the patient and family or caregivers are still here.
Melanie: That’s MyShepherdConnection.org. In just the last few minutes, Gail, it’s such great information, give your best advice to the listeners with loved ones in the rehab setting for prevention of falls and why they should come to Shepherd for their care.
Gail: I believe that a rehab environment such as Shepherd is going to focus a lot on training and instruction so that people leave here prepared for the care that they’re going to be providing at home and the challenges that they’re going to have. We feel strongly that that gives them a good foundation for taking on the next challenge after their inpatient stay in our rehab setting. I would say that if they were to take advantage of the training that they have, be prepared to really embrace it, think about who are the extended folks in their community or home or family who can be supplemental help to them because nobody can do a 24/7 job by themselves. Many of our patients do leave still needing pretty constant supervision or assistance. If not literally 24/7, very close to that. So, they are going to need support from their family, friends and neighbors. The more prepared they are to go home, then the more prepared they will be to help those extended folks learn how to be assistive to them as well.
Melanie: Thank you so much. You’re listening to Shepherd Center Radio. For more information you can go shepherd.org. That’s Shepherd.org. This is Melanie Cole. Thanks so much for listening.
Fall Prevention in the Acute Rehabilitation Setting
Melanie Cole (Host): Having an unexpected fall can be a very scary experience, not only for the person who fell but also for the caregiver or the family. Prevention strategies implemented at Shepherd Center have proven successful in reducing fall rates significantly in the rehab setting. My guest today is Gail Greene. She’s the Nursing Unit Manager of the Acquired Brain Injury Program at Shepherd Center. Welcome to the show, Gail. Tell us what’s going on and what is the risk of falls when they’re in the rehab setting.
Gail Greene (Guest): Our patients are at an especially high risk, especially given the nature of the types of patients that we have—primarily brain injury patients and spinal cord patients. Their risk tends to be related to either their impaired functional status or their cognitive impairments that lead them to either be confused or impulsive or have poor safety awareness, where they just aren’t aware that they have some kind of a deficit or some kind of a functional impairment that they can’t do what they used to be able to do.
Melanie: People tend to think of the rehab setting as lots of physical therapists and occupational therapists all around. So, are the patients on their own at some points or are there generally people around and sometimes the falls just happen?
Gail: Well, that’s a good question. Generally, our staffing ratios are quite good for the nursing department, so there are nursing staff around at any given point but most patients are not necessarily, attended one on one throughout their stay. So, there are periods of time where they may be alone, perhaps, in their room or in the hallway or that sort of thing. They do have some freedom of movement and are not being watched over literally every second.
Melanie: So, watching over and privacy--I mean, they go to the bathroom; they get up and go change what they’re doing. So, how is that something that might be a little interactive where maybe they want to go to the bathroom by themselves but the risk of falling might be greater if they do?
Gail: Well, one of the things about the culture here at the Shepherd Center is we are very focused on patient safety and, as a result, we have implemented some cultural expectations of our staff where safety, as I mentioned, is our utmost concern. So, we even have a little mantra that we have to concern ourselves with safety before privacy. It’s not to say that we’re not concerned about patient’s privacy, it’s simply that we know that if most of our patients are left alone, they may end up on the floor which may lead to them having further injury and may put them in a worse situation than they are already in. So, we’ve just prioritize that, for many of our patients, privacy just has to come after our concerns about their safety. So, in those situations the staff member would stay with them in the bathroom. Perhaps they would put the hand on the shoulder and turn their back. What that does is, it gives us that physical feedback that the patient is moving but it allows us to turn our backs so they at least feel we’re not standing there gawking at them which I can certainly understand would be uncomfortable.
Melanie: Gail, give us some more strategies to prevent the falls among these patients.
Gail: Well, the other part of our culture is that, for the brain-injured patients especially, we use bed alarms any time they are in the bed. Then, we also have seatbelts alarms that we use on many of our patients when they’re in a wheelchair, although for some patients, that is not sufficient and we may need to use restraints either in the bed or the wheelchair. However, one of the things about the culture that we’ve instilled in the staff is that when we hear an alarm going off, it is dangerous. That means that there’s the potential for danger to the patient. We end up feeling the need to run towards that alarm--in other words, not being casual about our response to that alarm. I see my staff running and that makes all the difference in getting to that patient quickly to ensure that they’re not going to fall. The alarm doesn’t stop them from falling but it simply alerts us that the patient is moving in a way that may be unsafe and may lead to a fall.
Melanie: What about assisted devices? Wheelchairs, walkers, canes? Do these things really help to prevent the falls or sometimes can a cane be something they get tangled up in?
Gail: In fact, part of the reason why some of our patients at Shepherd fall, and this may be especially true in the spinal cord population, their bodies aren’t working the way they had been working in the past and so, while they’re learning new skills such as using a sliding board to transfer from a wheelchair to the bed, or vice versa, or perhaps, using a walker but, in the meantime, their legs are very weak, their arms are weak because of the injury that they’ve had and their having to rebuild their strength throughout the therapy. In the process of learning these new skills and rebuilding their strengths, sometimes they have what we refer to as an “assisted fall” where there’s somebody with them. This new skill is something that they’re not proficient at yet and so, they end up having an assisted fall where somebody’s with them and helps to safely lower them to the ground. That can be one way that people fall. The other way is, we have stroke patients and sometimes they can stand on one strong side because the nature of the stroke is that you’ll be weaker or have impaired function on one entire side of your body but the other side, generally, is strong and capable. We may do what is called a “stand pivot transfer” or a “squat transfer” from, say, the bed to the wheelchair. Sometimes, in the course of those where the caregiver is helping to transfer the patient, there is a loss of balance. Maybe the patient shifts before the caregiver is expecting them to and there’s a loss of balance and they might both go down. In those cases, again, usually it’s easing them on down but that’s a result of their impairment and occurs during the transfer.
Melanie: What about footwear? Is this something that can impede their balance or help it? What do you recommend patients wear?
Gail: They, generally, are recommended to wear a good supportive shoe--something that might be rather easy to get on an off. I think some popular shoes for them to wear are some form of athletic shoe, what I would have called a “sneaker” growing up, with Velcro, perhaps, to make it easier to get it on and off but something that has enough support that their foot is not going to roll around much and also that isn’t going to fall off their foot while they’re moving. So, a slip-in shoe might not be recommended in that setting.
Melanie: For caregivers and even at home, Gail, what do you recommend if somebody does fall? Should they help that person up and how do they do that without throwing out their own back?
Gail: One of the things we do here at Shepherd is, we have quite extensive family and caregiver training and that extends even to our website. We have a link called “MyShepherdConnection.org” and we encourage our families and caregivers to communicate that we have this link to everyone that they know and anyone they might be cross-training to help them in the home and also to go to that site themselves to review it. We have therapists that have done some really wonderful instructional videos that review safe transfers of all different types: from the bed to the chair, from the chair to the bed, from the car to the wheelchair, etc. and that sort of thing. We also have other videos at MyShepherdConnection.org that review home safety, home modifications, and it goes room by room in a former patient’s house giving some suggestions on some things that they did in his home to help keep him safe and improve his independence and allow him to be more self-sufficient, while, again, at the same time, keeping him safer because he has the proper handholds to support himself with and that sort of thing. So, MyShepherdConnection.org is a wonderful resource for anybody to use that is an enhancement to what we provide for education while the patient and family or caregivers are still here.
Melanie: That’s MyShepherdConnection.org. In just the last few minutes, Gail, it’s such great information, give your best advice to the listeners with loved ones in the rehab setting for prevention of falls and why they should come to Shepherd for their care.
Gail: I believe that a rehab environment such as Shepherd is going to focus a lot on training and instruction so that people leave here prepared for the care that they’re going to be providing at home and the challenges that they’re going to have. We feel strongly that that gives them a good foundation for taking on the next challenge after their inpatient stay in our rehab setting. I would say that if they were to take advantage of the training that they have, be prepared to really embrace it, think about who are the extended folks in their community or home or family who can be supplemental help to them because nobody can do a 24/7 job by themselves. Many of our patients do leave still needing pretty constant supervision or assistance. If not literally 24/7, very close to that. So, they are going to need support from their family, friends and neighbors. The more prepared they are to go home, then the more prepared they will be to help those extended folks learn how to be assistive to them as well.
Melanie: Thank you so much. You’re listening to Shepherd Center Radio. For more information you can go shepherd.org. That’s Shepherd.org. This is Melanie Cole. Thanks so much for listening.