Safe Operation and Care of Individuals with Assistive Device

Objectives

By the end of this activity, the learner will be able to:

1. Identify at-risk patients
2. List the six domains of healthcare quality
3. Differentiate the levels of risk identified in the Morse Fall Scale
4. Recognize the ten items assessed on the Oasis form of a home health assessment
5. Identify five types of assistive devices
6. Describe safe use of three assistive devices
7. Identify five assistive tools for the blind or visually impaired patient
8. Identify three common assistive tools for the hearing-impaired patient

Patient Safety

Patient safety is the prevention of harm to patients in every health care setting. While health care has become more effective, it has also become more complex with greater use of new technologies, medicines and treatments.¹ The largest number of patients in the health care system are the elderly, with more complex problems and a high incidence of falls.

An estimated 25,500 Americans died from falls in health care and community settings in 2013. Countless more suffered life-changing injuries, such as fractures, internal injuries, and traumatic brain injury. Experts estimate that more than 84% of adverse events in hospital patients are related to falls, which can prolong or complicate recovery.⁵

Safety is everyone’s responsibility, not only in hospitals and nursing homes but the home setting as well. It does not matter what position a person holds. Everyone on staff is responsible for working to uphold patient safety. Safety is part of the quality agenda; therefore, a dimension of the quality culture, requiring broad commitment from both the organization and the community.¹

Education is a part of the safety process, including staff, volunteers, and families. Once they are educated, they are committed to ensuring good safety practices.

Quality Care

Quality is an optimal balance between possibilities realized and a framework of norms and values.² Quality of care looks for ways to improve patient outcomes by using quality indicators. Most health care facilities utilize patient surveys to augment their policies on patient safety.

The six domains of health care quality include:

• Safe: No harm to patients
• Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit.³
• Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs and values.³
• Timely: All treatments provided without long waits
• Efficient: Avoiding waste, including waste of equipment, supplies, ideas and energy.³
• Equitable: Providing the same level of care to all patients

Providing information to understand better the six domains of health care quality helps with the use of these indicators and gives the staff and families a framework to keep patients safe.

Falls

A fall can be defined as a position change from one plane to a lower one. The prevention of falls and injury from falls in patients who are hospitalized are indicators of high-quality bedside health care professional care given to a particular unit or at a hospital. Falls are the leading cause of fatal and non-fatal injuries for older Americans. Falls threaten seniors’ safety and independence and generate enormous economic and personal costs.⁴ Falls can happen to anyone, not just the elderly. In the health care setting, falls may be attributed to many conditions including seriously ill patients, patients taking narcotics, and patients with decreased vision. Health care professionals must always be alert to these conditions and have an obligation to check on at-risk patients frequently. Assessments can help health care professionals to identify patients at risk for falls, and these assessments are required in all health care settings on admission, change in level of care and after a fall.

There are three types of falls; Unwitnessed fall, patient states there was fall, but no one saw it happen. Witnessed fall, the patient is seen falling. Assisted fall, the staff or caregiver eases the patient to the floor without injury.

Falls are most likely to happen:

• Environment- wet floors, cluttered room
• Lack of footwear
• Poor lighting
• Low toilet seat
• Use of restraints
• Unsafe equipment
• Incontinence
• Generalized weakness
• Dizziness/vertigo
• Poor judgement
• Orthostatic hypotension

Falls with injuries are considered a sentinel event per Joint Commission. Falls with serious injury are consistently among the Top 10 sentinel events reported to The Joint Commission’s Sentinel Event database which has 465 reports of falls with injuries since 2009, with the majority of these falls occurring in hospitals. Approximately 63 percent of these falls resulted in death while the remaining patients sustained injuries.⁶

There are interventions to facilitate the job of trying to prevent falls. The most common assessment is the Morse Fall Scale used in acute care settings, nursing homes, and home care.

Morse Fall Scale

The Morse Fall Scale (MFS) is a rapid and simple method for assessing a resident’s likelihood of falling. This scale is easy to use and understand:

Morse Fall Scale 0-49 No/Low risk

• Eliminate clutter in room/house
• Call light in reach
• Maintain personal items in reach at all times
• Educate patient on use of assistive devices
• Place bed in low position with brakes locked
• Use night lights
• Ensure patient has proper footwear (shoes, non-skid socks)
• Assess for mental changes

Morse Fall Scale 50-79, Moderate risk:

Examples of moderate fall risk patients are: Change in mental status, sundowning, confused patients, lack of safety awareness. Preventions include:

• Frequent rounds for toileting
• Offer fluids or snacks every 2-3 hours
• Apply bed/chair alarms
• Use hip protectors
• Consider diversional activities such as music, TV, relaxation tapes

Morse Fall Scale greater than 80, High Risk

Examples of high-risk patients include: a history of falls, severe confusion, acute disease process, depression. Preventions included:

• Close observation is needed. If in the hospital, move close to nurses’ station
• Consult with physician and pharmacy for medications that may exacerbate confusion
• One-on-one if needed

Home Health Fall Risk

In home health care, healthcare professionals use the Oasis form (CMS) for fall risk. This form is similar to the Morse Fall Scale but more involved. This form is completed on admission, just as the Morse Fall Scale is. This assessment examines ten items:

1. Age 65+
2. Diagnosis (3 or more co-existing)- Includes only documented medical diagnoses.
3. Prior history of falls within three months-An unintentional change in position resulting in coming to rest on the ground or at a lower level.
4. Incontinence- Inability to make it to the bathroom or commode in a timely manner, includes frequency, urgency, and/or nocturia.
5. Visual impairment- Includes but not limited to, macular degeneration, diabetic retinopathies, visual field loss, age-related changes, decline in visual acuity, accommodation, glare tolerance, depth perception, and night vision or not wearing prescribed glasses or having the correct prescription.
6. Impaired functional mobility- May include patients who need help with IADLs or ADLs or have gait or transfer problems, arthritis, pain, fear of falling, foot problems, impaired sensation, impaired coordination, or improper use of assistive devices.
7. Environmental hazards- May include but limited to, poor illumination, equipment tubing, inappropriate footwear, pets, hard to reach items, floor surfaces that are uneven or cluttered or outdoor entry and exits.
8. Polypharmacy (4 or more prescriptions-any type)-All PRESCRIPTIONS including prescriptions for OTC meds. Drugs highly associated with fall risk include but not limited to, sedatives, anti-depressants, tranquilizers, narcotics, antihypertensives, cardiac meds, corticosteroids, anti-anxiety drugs, anticholinergic drugs, and hypoglycemic drugs.
9. Pain affecting the level of function- Pain often affects an individual’s desire or ability to move, or pain can be a factor in depression or compliance with safety recommendations.
10. Cognitive impairment- Could include patients with dementia, Alzheimer’s or stroke patients.

Each area is worth one point:

0-3 points-Patient education on fall prevention and home safety

4-5 points- Consider for interdisciplinary referrals as indicated. Patient education on fall prevention and home safety.

6-10 points- Contact physician to request PT evaluation or possibly OT evaluation. Patient education on fall prevention and home safety. (CMS)

All of these areas assist the home health professional to complete a more comprehensive evaluation and to make the necessary recommendations. Patient education is emphasized in every aspect of fall prevention, and education is mandatory at each visit.

Case Study

Cindy, a home health nurse, was called to a home where the patient had several falls over the last week. While doing the admission assessment, Cindy noticed how agitated Mrs. Graham became when she tried to stand up and kept falling back into the chair. The family stated that Mrs. Graham has severe arthritis and has trouble standing up and walking, and she shuffles her feet. Cindy gently asked Mrs. Graham to stand and walk with her for a small distance. Cindy noted that there were throw rugs in several places and that there were no grab bars in the bathroom. Cindy also found that one of the patient’s medications could affect her walking. After educating the family on the importance of picking up the rugs and installing grab bars, she made referrals to Physical Therapy and Occupational Therapy. As a team, they will work with the patient and her family on safety issues. The physician was notified about the referrals and the medication issue. Cindy took the necessary steps to help keep the patient safe within the home setting.

Assistive Devices

Using assistive devices safely is not only the nurse’s role but that of a physical therapist, occupational therapist, and athletic trainer as well. Again, the entire team is responsible for patient safety.

How many people use assistive devices? According to The Centers for Disease Control (CDC), one in five Americans, about 53 million people, has a disability of some kind. 2.2 million people in the United States depend on a wheelchair for mobility, and 6.5 million people use a cane, a walker, crutches or prosthetic limbs to assist with mobility.⁷

People with physical disabilities can benefit from mobility aids. There are many situations that compromise safety including, barriers in community buildings, classrooms and even in the home. For example, ADL’s in the kitchen, in the bathroom, and going outdoors. There are many barriers in the home setting including throw rugs, electrical cords and food spills.¹¹

Walker

A walker may be needed if the cane does not afford safety for the patient and may have wheels or no wheels. There are five types of walkers including:

• Standard walker.  This walker has four nonskid, rubber-tipped legs to provide stability. You must pick it up to move.
• Two-wheel walker.  This walker, which has wheels on the two front legs, is helpful if you need some, but not constant, weight-bearing help.
• Three-wheel walker. This walker provides balance support like a four-wheel walker, but it is lighter weight and more maneuverable. 
• Four-wheel walker. This walker is for people who don't need to lean on the walker for balance
• Knee walker. This walker is similar to a foot-propelled scooter, but it has a platform for resting your knee.⁹

The walker provides the patient a wide base of support and is the most stable assistive device. Two disadvantages of the walker include difficulty fitting through doorways due to its width and it cannot be used on stairs. A walker must be the appropriate size for each patient; to ensure proper fit, measure from the floor to the wrist. 

After the Walker is ready to use, patient education is the next important step and may take the entire team working together to safeguard patient safety. The following information and chart are helpful when working with patients with a walker:

1. Stand in the middle of the walker. (In the diagram below, the affected, or weaker, leg is represented by the white footstep and the unaffected, or stronger, leg is represented by the blue footstep.) 
2. Grasp the walker grips with our hands. Then move the walker forward at an arm's length that feels comfortable. The back legs of the walker should be even with your toes. 
3. Step forward with your affected (weaker) leg into the middle of the walker. Continue to grasp the walker grips with your hands.
4. Then step forward with your strong leg. As you do so, keep wight off your weaker leg by supporting some of your weight with your arms. 
5. Repeat steps 2,3, and 4 above - move the walker, then your weaker leg, and then your stronger leg. 

Safety Tips

• Do not take a step until all 4 legs of the walker are level on the ground.
• Do not place the walker too far ahead of you. Keep the walker’s back legs even with your toes.
• To get up from a seat, do not pull up on your walker. Push up from your seat.
• Do not lean forward over your walker. Work at keeping good posture.
• Be careful when you walk from a tile or hardwood floor to a carpeted floor.
• Be careful when you step into or out of an elevator.
• Do not use your walker on stairs or on an escalator.
• Check the rubber tips on the legs of your walker often. Replace the tips when they become worn. You can buy new tips from a drug store or medical supply dealer.

Knee Walker

A knee walker is used as an alternative to crutches or a traditional walker. 

There are pros and cons to using the knee walker, as with any assistive device. The pros to using a knee walker include:

• Low to floor and more stable
• Cushioned for comfort
• Patient can “zoom” around quickly
• Does not require upper body strength as crutches do

The cons are as follows:

• Can be unstable if patient leans too far back
• Cannot go up or down stairs
• May be too wide to go through narrow doorways¹³

Using a knee walker safely requires practice. First and foremost is to ensure the patient understands that he/she cannot start “zooming” without starting slowly! Always wear a non-slip shoe on non-injured foot as that foot is the “propeller.” Make certain the brake is on before placing knee in walker.

Cane

Canes are used to help the patient with balance and mobility, but the patient must be cognitively aware. There are different types of canes, including a standard one-foot cane, a tripod cane with three feet, and the quad cane which has four feet. Some canes like a wooden cane are not adjustable to the client's height, and others can be adjusted to meet the height needs of the client.⁸  

The first step to using a cane safely is to make certain it fits the patient. The top of the cane should reach the crease in the wrist, and the elbow should be slightly bent. Education should include look straight ahead, not down at the feet, avoid slick conditions such as wet floors and snowy or icy driveways, always using the strong or uninjured leg to take the first step going up stairs and curbs. Remind the patient to hold the cane close to the body on the uninjured or strong side.12

Crutches

Using crutches is not easy and takes practice. First, they must be fitted to make sure they are comfortable and safe. Fitting includes:

• Top of crutches should be about one to two inches below armpits
• Hand grips even with hip
• Elbows should bend a bit
• Shoulders should lean slightly forward¹⁴

Once the patient is ready to use the crutches, the next step is accident proofing the environment either in the hospital or the home. Pick up scatter rugs, make sure the floors are clutter free, and place items the patient will need within reach.

Tips for walking with crutches:

• Start by standing, lean forward slightly and move both crutches about one foot in front of you
• Shift weight to the crutches and sway forward with your hips
• Swing good leg forward between the crutches and place it on the ground in front of you
• Look ahead to where you are walking, don’t look at your feet
• Take short steps and rest often
• Keep most of your weight on your hands rather than your arm pits¹⁴

 Going downstairs can be dangerous, and the patient will need someone to stay close while learning to use the crutches. There are a few tips for safely going up and down stairs:

• If there is no handrail, use both crutches and lead with the good leg
• If there is a handrail, use it. Hold both crutches in one hand, hold the handrail with the other, and use all your weight on your arms

Going down the stairs:

• Take one step at a time holding your injured foot in front of you and hop down each stair on your good foot¹⁴

Wheelchair

Patients use wheelchairs for many reasons. Wheelchairs may afford the patient independence by allowing the patient the ability to wheel him/herself without assistance. First, and foremost, the wheelchair must be fit to the patient for safety and comfort. Guidelines include:

• Seat width: Usually the width of the user plus 1 inch
• Seat depth: Usually the seat depth of the user less 1-2 inches
• Seat height: Usually the height of the user where they can access tables and transfer without too much difficulty
• Footrest length: Should be the distance from the back of the knee to the bottom of the heel while wearing shoes the user usually wears
• Back height: Will vary from user to user but normally should be a little above the middle of the back around the bottom of the shoulder blades¹⁵

Once the wheelchair is deemed safe and fits the patient, the team, including nursing and therapy, steps in for patient education. The patient and caregivers (family) are actively involved in the education process. There are many safety tips for safe wheelchair use:

• Be aware of your center of gravity- be careful when trying to reach, bend and transfer in and out of the wheelchair. These movements cause a change in balance and weight distribution 

• Bending backwards-when reaching for something by bending backward, position the wheelchair as close to object as possible. The casters must extend away from the drive wheels
• Bending forward- Very dangerous, never position yourself forward on the seat. Engage the wheel locks before reaching forward
• Tipping the wheelchair-Caregiver should grasp the back of the chair, let the wheelchair user know before you tip the chair back
• Moving through curbs- Always try to find curb cuts or ramps, never try to do without assistance from caregiver
• Preventing accidents- Tipping and falling are the most common accidents. Always engage the brake before rising or sitting down in the chair. Try to avoid slippery surfaces
• Lift up the foot and arm rests before transferring
• If using a wheelchair for long periods, be sure to have the chair serviced at least once every year¹⁶

Vision Loss

Severe vision loss is a significant problem affecting millions of older Americans. According to the Family Caregivers Alliance, “Nearly 3.5 million Americans over 40 have some degree of vision loss.¹⁷” There are several medical conditions that can cause low vision/blindness including Glaucoma, Macular Degeneration, Diabetes, and Cataracts.

The healthcare professional’s assessment includes asking the patient if he/she wears glasses, or if he has cataracts or a prosthesis. The patient can demonstrate the ability to see by reading newsprint or count fingers at arm's length.

There are four levels of visual function:

1. Normal vision
2. Moderate visual impairment
3. Severe visual impairment
4. Blindness²¹

Learning to cope with the challenges that come with low vision/blindness can be overwhelming.

While surgery can help with Glaucoma and Cataracts, most seniors must learn to live with these debilitating diseases. There are many assistive devices available on the market today.

There are some important steps to help cope with vision loss:

• Developing a new attitude- you can still live a pretty normal life after adjustments are made. You will need training and encouragement.
• Learn about the use of alternative methods that employ your other senses including touch and smell¹⁷

Some interventions to help with low vision/blindness in any healthcare setting are:

• Arrange furniture to make clear pathways
• Keep home, or room in facility free of clutter
• Use a night light
• Call light in reach in facilities
• Bell to ring at home
• Orient patient to surroundings
• Place food on plate using “clockwise” description

Because the patient will not be able to drive, the health care professional should help him/her to formulate a new plan. Perhaps family and friends can help, but the patient may be able to learn to use public transportation to gain more independence.

Tools for the blind and visually impaired

There are many tools for the blind and visually impaired. The white cane is a recognized tool and makes other aware of the person’s blindness. It can be a signal for others to help if needed. A guide dog is a good choice if available. These dogs are highly trained to help the person navigate the world.¹⁸ Other tools include talking watches, braille phones and books, doorbells with flashing lights, magnifiers for low vision and audio books. All of these tools can help a blind/low vision person lead a reasonably normal life.

Hearing Loss

Hearing loss affects approximately 20 percent of Americans, and after the age of 65, one out of three people have a hearing loss. Communication is the most difficult aspect of caring for deaf patients. Communication strategies include:

• Face the person directly
• Do not talk from a different room
• Speak clearly, slowly, distinctly
• Try to minimize background noise
• When possible, give the patient written instructions to help avoid mistakes¹⁹
• Watch your body language!

Hearing aids are the most common assistive devices used today, but there are numerous other devices available. There are telephones with amplifiers, notification signalers for doors, windows, babies crying and doorbells. There are even amplified stethoscopes for medical personnel. Families and caregivers can learn sign language, and there are programs online to help.

The professional assessment is basic for hearing loss. Speak to the patient in your normal voice to see if he can understand your words without difficulty. Does the patient use hearing aids? Can patient hear in a noisy environment?

Conclusion

Patient safety is everyone’s responsibility in all health care settings. Falls are the leading cause of injury in the older Americans, with the majority of falls happening in the hospital. Education is an important part of the safety process, including staff, volunteers, patients and families. Health care professional’s assessments play an important role in falls prevention in all arenas of healthcare. The Morse Fall Scale is a comprehensive assessment that is simple to use and is used in all health care settings.

Patient education regarding the use of all assistive devices is significant in fall prevention techniques. Walkers, canes, knee walkers, crutches and wheelchairs all come with their own set of educational needs. Assistive devices for the blind and hearing impaired are available, and these devices need extra education. It takes the entire team working together is help prevent or reduce the number of falls with serious injuries. Although all falls and injuries cannot be prevented, the incidence can be reduced with excellent assessments and education.