Mitigating fall risk in hospital, after a traumatic brain injury

[ScottishJD]

Hi folks.

My dad has a traumatic brain injury 4 weeks ago and is currently in hospital in Scotland. He's in a rehabilitation ward.

Unfortunately, he's unable to walk and is unable to retain information in short-term memory. One of the effects is that he keeps trying to get out of bed, then falling. That's now happened 7 times while he's been in hospital.

He's in a room across from the nurses station, has the bedrails up and has a pressure mat with an alarm. Unfortunately, he is still getting up through the night and falling over because he's forgotten that he cannot walk, that he shouldn't get up and that he should press the buzzer to call a nurse.

At 75 and with a traumatic brain injury already, he's at high risk of injury if he keeps falling.

I've been told that there's nothing more the nursing team or doctor can do, but I don't consider that acceptable. Does anyone have experience in this area, who could advise on any additional action to protect a patient in this condition.

I've suggested the following (hospital is still considering them) - some of which are problematic when he's still considered to have good mental capacity and capable of making decisions about his own care:

- Putting a sign at the end of his bed, that tells him he shouldn't get up - which is lit at night so he can read it

- Putting some visible indicator on his leg(s), so that he remembers he can't get up (e.g. a knee brace, etc - which might be considered a 'restraint' and therefore not permitted)

- Putting a skull cap or some other protective device on his head at night to minimise further impact on his existing brain injury (which might be uncomfortable)

- More impediments to getting out of bed e.g. full length bed rails, or something he needs to remove/move in order to stand up (might pose a higher risk if he tries to overcome obstacles, and might make it more difficult for clinicians to reach him in an emergency)

- Ensuring there is always somebody at the nursing station (which might be challenging, given other duties in the ward)

- Using a mobile monitoring device e.g camera in the room, that can be constantly viewed using a phone or mobile device regardless of where the nurses are (nurses may not have time to check this when they are tending to somebody else)

- Improved alarm system - that instead of making a noise and flashing a light in the corridor, actually sets off an alarm that the nurse carries, with an indication of which patient so that they know my dad is at risk of falling (nursing staff may not want this, they might genuinely be unable to help because of a higher priority patient, such a device may not be available, etc.)

- 1:1 nursing care (which might be challenging due to cost and staffing shortages)

- Using some sort of volunteer service so that he has somebody in the room with him 24 hours a day (may irritate him, he may not want them, and it may be difficult to arrange - or not exist at all)

- Mild sedation at night (problematic from a human rights perspective, and not 'clinically' necessary)

- Catheterisation (since he's trying to go to the toilet) - but there's a risk he gets up anyway and rips out the catheter; also the usual risk of infection, etc.

- Moving him into a higher dependency unit with a higher staff-to-patient ratio (problematic as there are likely to be people who need that service because they are clinically acute)

- Moving him to a specialist unit with experience of people with very high fall risk (if such a thing exists)

Any assistance or ideas that can limit his fall risk would be greatly appreciated and accepted.

Thanks.

[Pairofboots]

Hi. This is a difficult problem to mitigate. As you are aware, some interventions maybe regarded as excessive. The important thing is that a risk assessment is carried out, is a live document. This can then be used to justify any actions taken to mitigate. This would give evidence to base interventions on. Not having staff/time/funding is never acceptable and cannot be used in order to ignore the fact that a risk is present.

The whole idea of a risk assessment is to identify and then take reasonable steps to mitigate that risk.

Capacity cannot also be used to justify not acting in the best interest. Capacity can be a vague measure. It could be argued that if a person keeps presenting the same risk behaviour, that they do not have capacity to understand and manage that particular risk regardless of capacity to make other choices.

I don't have any advice as to what steps you can suggest, but the management of the risk is squarely with the hospital trust in charge of his care.

The are some differences between English and Scottish laws regarding capacity and what may or may not constitute restraint or excessive force.

[paxo05]

Hi, Like has Been said it's a tricky situation. In an ideal world he would be personally monitored to have someone on hand to stop him getting out of bed.

Apparently I kept trying this then finding out I couldn't walk. The hospital felt there were two solutions , to knock me out with drugs or the one they chose which was the get me to discharge myself .

OK I was disruptive trying to shout and managing the odd offensive remark. Add to this constantly trying to get out of be and removing monitors etc.

I can remember none of this just one day being in hospital the next being at home. I still tried getting up and fell constantly.

Believe it or not I don't sort of blame them it's more of a reflection of the times we were in . ...and still seem to be.

[MimiSpree]

I didn't want to call a nurse to go to the bathroom, even though my mobility was bad. However, I kept doing it which was incredibly stupid in hind-sight, but I was in great denial of my new limitations and focused on not making it my reality.

The rails were challenging, but when the nurses simply added one strap across the rails with a knot below my bed that I couldn't reach, that was just one more challenge that put a stop to my stubborn independence. The strap was inches above me and didn't touch me. It took only seconds for the nurses to release it, so I never felt constrained or unsafe.

[Juniorbhoy]

Hi there

Sorry to hear about your dad. We are from Glasgow and I had exact same situation as yourself. My husband Kevin was assaulted which led to bleeds in the brain. He needed acraniotomy, he would not keep bandage on wound and fell numerous times eventually re-opening the wound! He had a protection order against him as he had no capacity. I found him out of the ward down at the exit one day on arrival, the ward staff were unaware he was off ward! Eventually they placed someone outside his bedroom door in order to prevent further falls. This was no use whatsoever as he still tried to leave bed at every opportunity. We had to finally call a meeting with staff nurse and consultant as we suggested every safety gaurd u suggested especially the head protection. Unfortunately everything we suggested was denied due to protocol or human rights! Eventually I had to spend every day morning and night up by his side. This did not stophim trying to get out of bed during the night when I was home.

I am sorry I can't offer any advice to you but just to say you are not alone. I hope your father has a good recovery xx

[Leaf100]

They must be able to do something because getting up is typical behavior and I am sure he isnt the only one - maybe an OT or someone like that could be consulted?

When my Dad was in hospital they tied a sheet to the railings- it was just above the guy but he couldn't get out with it there.

MimiSpree's strap idea seems easier for the staff.

Keep us posed.

Leaf

[sashaming1]

I was a Fall Risk in a hospital and they put an alarm in my bed to sound if I got out of it.

[skydivesurvivor]

when I was in intensive care they tied my hands to the bed to prevent me, as I was coming out of my coma from pulling my tubes from my tracheotomy!! Rehab taught me to walk again. 20 years later am still falling over!! Unfortunate result of brain injury am afraid, good luck for the future though!! Trying time for all to cme. SMILE to spite the infuriating times to come!! Hope u get support from this site!

[Hidden in reply to skydivesurvivor]

I had the mitts as well as like you when coming out of the coma I was determined to pull out the trach

[scottishbluebell]

Hey, my son kept trying to get out of his hospital bed when he came out of his coma following his tbi. The nurses had big cot sides that they'd put on his bed, and he had his hands bandaged like boxing gloves so he was unable to grasp anything to aid his escape attempts. Through time they were going to move him into a side room with a mattress on the floor for his own safety which upset me but I could understand the reason behind it. He bypassed that phase as he caught covid and was transferred to covid icu and had 1:1 care. He was then moved to a side room with 1:1 care and less stimulation which kept him more settled. When he started physio to build his strength and learn to walk again that tired him out and his escape attempts stopped happening.

[skydivesurvivor in reply to scottishbluebell]

sounds like he’s a fighter!! Good luck to him!!! £ to you for the coming years!!! If like my recovery, will be a trying time for you. Good luck, parental love will be appreciated even though he may not show a lot of appreciation so beware! He doesn’t mean it honest!!!

[ftt1960]

The first night I was in hospital (in Scotland) after my accident when it was thought I had a fractured disc in my neck I was doped upon morphine. I got out of bed when I was supposed to be lying flat on my back, got out of bed and removed my neck brace. The joy of drugs. The following night an agency nurse was brought in to ensure I remained lying flat on my back. Clearly it can be done despite the cost. As it turned out what was seen in my neck was old arthritis rather than a fractured disc.

[skydivesurvivor in reply to ftt1960]

trying times ahead! Hope u get the support u need, oh & thank the giver!!!