Question

Accidental Fall in a Hospital

The Story of Colin Lake (Australia)

After completing this case study, you will be able to:

List patient factors that contribute to falls in the hospital setting.

Discuss hospital environmental and human factors that may contribute to falls (e.g., poor lighting).

Discuss the effectiveness of risk assessment tools for falls.

Consider other factors for falls that could be included in standard risk assessment tools.

Develop strategies for ensuring all staff are aware of the risk status for patient falls.

Background

Colin Lake was a 53-year-old business man who presented to a Sydney hospital emergency department one Friday evening with a unilateral, painful red eye. Colin used daily disposable contact lenses and reported that his right eye had been sore for 2 days. He had not removed his lens periodically as required throughout this time, thinking that taking his lenses off and on might make it worse. He presented with a bad headache and was unable to focus on his computer screen. Both contact lenses were removed and sent for culture and sensitivity.

On examination, his affected right eye appeared injected (bloodshot) and his cornea was cloudy with a central corneal ulcer that measured 2 mm by 3 mm. The visual acuity in his unaffected left eye was 6/60, but he was unable to see the chart with his right eye and was scored as “can count fingers at 1 meter.” Colin admitted that he was not as careful with his contact lenses as he knew he should be, often neglecting to wash his hands before inserting them and exceeding the recommended usage time. Colin had no previous medical history but was overweight and admitted to feeling stressed after a recent acrimonious divorce.

Colin’s Hospital Stay

Colin was admitted to the eye ward and was placed in a single-bed room. He was given 1 gram of Paracetamol for analgesia and commenced on a regime of intensive topical therapy consisting of Gentamicin 1% eye drops every hour, Cephalothin 1% eye drops every hour, and Homatropine 2% eye drops four times a day. Because Gentamicin and Cephalothin are known to form a precipitate in the eye if mixed together, the drops were given 30 minutes apart. Eye drops were continued at this half hourly frequency throughout Friday night, Saturday, and Saturday night. Colin was told that the ulcer needed to be treated intensively to prevent any further scarring, because the ulcer was right in the center of his cornea. Corneal damage that penetrates deeper than the superficial epithelial layer of cells, which was the case with the ulcer, results in a milky opacity that it is not possible to see through.

Colin was significantly myopic (short-sighted) but had left his prescription eyeglasses at home. However, he could see well enough to shower and eat his meals. The rest of the time he rested or listened to the radio. The nurses dimmed the lights and pulled the blinds down over the window during the day to ease his sensitivity to light (photophobia).

On Sunday morning his eye was reassessed by the ophthalmic medical resident and the drops reduced in frequency to hourly from 6:00 a.m. to 10:00 p.m. only. In spite of this improvement and an easing of the regime, Colin became increasingly annoyed and irritable with the nurses and kitchen staff, complaining about the constant interruptions of his rest, the “terrible food,” and that he “couldn’t get a decent coffee.” One of the nurses suggested he ask his family to bring him some food more to his liking but Colin replied angrily, “I don’t have any friends or family left after the divorce.” He went on to say that he “felt like a leper” stuck in the side room. The nurse explained that Colin was not in isolation from the world but only from other vulnerable patients who had recently undergone eye surgery. There was no reason why he could not go downstairs to the foyer where there was a news kiosk and a coffee shop. He politely asked the nurse if she would go down and buy him a cappuccino, but she was unable to go due to work demands. So, in spite of his extreme fatigue, Colin decided that he would go and buy a coffee himself. He accepted a pair of sunglasses that the nurse offered to protect his sensitive eyes and set off for the elevator.

Colin purchased his coffee and then walked out the main entrance, intending to sit on a seat on the other side of the access road. He caught his foot on the curb and fell hard onto his outstretched right hand, injuring his right wrist, bruising both knees, and jarring his spine. He said later that he had not seen the curb at all. An x-ray of his right wrist showed a scaphoid fracture, and his hand was immobilized in a short arm thumb spica cast. The soft tissue damage to his back was treated with ice packs and topical Diclonfenac gel.

Conclusion

Colin’s corneal ulcer resolved fully over the next 3 days, and the ophthalmic specialist was happy for him to continue the eye drop therapy at home; however, he was not able to self-administer his eye drops due to the plaster cast on his dominant hand. After a delay of an extra day in hospital, Colin arranged to stay with a work colleague who was able to instill the drops.

Questions

1. Keeping people safe from falls and allowing patients to be independent and self-reliant are sometimes conflicting goals. Should all patients be accompanied when leaving the ward?

2. The level of falls risk is usually documented in the medical record or may come up as an alert on electronic medical records. Some wards consider this inadequate and instead have a system of coloured bracelets flagging risk to all staff members. Do you think this is appropriate? Under what conditions might this be useful? When might it be considered intrusive?

3. Intensive eye drop therapy is always reviewed daily and dosage frequency decreased as soon as the threat to vision has been controlled, but it remains a demanding regime for the patients and staff constantly having their sleep and rest interrupted. Cases of extreme confusion and even psychosis have been reported by patients in high-dependency units where noise, bright lights, and around-the-clock and frequent interventions can severely impact patients. The eye ward now considers this a flag for increased falls risk. Are there other types of treatment regimes that should be considered in a falls risk assessment?

4. Poor vision is considered an invisible condition as the extent of impairment is not immediately obvious. Colin’s ability to navigate safely around his room and attend to his activities of daily living (ADLs) may have misled the nurses forgetting his uncorrected myopia and overestimating his ability to go safely unaccompanied downstairs. What strategies could ensure prescription glasses are worn, if needed?

5. Some wards have implemented a very successful program of patient “watchers”; volunteers who provide extra supervision for confused patients at high risk of falling. They do not take part in actual patient care but can alert staff to the patient’s increased agitation or attempts at unassisted walking or getting out of bed. This approach replaces the former reliance on keeping bed rails up and physical or chemical restraints, which can actually increase the risk of injury. What other ideas for increasing supervision and assistance could be implemented on a ward?

6. Which of the core competencies for health professions are most relevant for this case? Why?

Answer 1

1. People who have difficulties in seeing doesn't need to be always isolated and prevented to move around. Instead the hospital can have some protocols for these patients. They can be given some assistive measures like guiding stick or provide someone to walk along with the patient. But this is not necessary for all the patients. It depends on what and how the visual acuity of the patient is.

2. I feel that flagging the high risk patients with different coloured flags is appropriate, because it not only gives awareness for the particular ward staffs but also it can notify the other health care workers regarding the patient's risk for fall. It can be useful especially when there is shortage of staffs or if the risk for falls is not noted in the health record or if the electronic devices are shut down or in circumstances when the nurse cannot verify the patient's risk for fall status.

3. The frequency of the eye medication should be reduced whenever possible. It is recommended to finish off the required dosage before bedtime so that it will not disturb the patient. The stimulus for disturbed sleep like noise, lighting, frequent interventions should be reduced. The patient should also be assessed for any other risk factors of falls like taking sedatives or anti psychotic medications.

4. Colin had visual disturbances. He was photosensitive and was prescribed protective glasses. He should have been explained by the nurse that the glass should be worn when he was exposed to light and other times he can remove it.

5. Other ideas are: the patients should always have a family member or significant other along with him, there should be cameras placed and should be watched always by a staff, a call bell should be available so the nurse can reach the patient.

6. The core competency for this case is responsiblity. The nurse has to be responsible of the patient. After knowing that the patient has visual disturbances the nurse should not have sent the patient alone without assistance.