Fall prevention and bathroom safety in the epilepsy monitoring unit

Highlights

• Over thirteen years, there were 2.81 falls per 1000 patient days in the epilepsy monitoring unit.

• Seizures and psychogenic events occurring in the bathroom were more likely to result in falls.

• Multiple prevention initiatives resulted in a downward trend in fall rates over time.

• Installation of a ceiling lift system reduced the frequency of falls in and out of the bathroom.

Abstract

Falls are one of the most common adverse events occurring in the epilepsy monitoring unit (EMU) and can result in significant injury. Protocols and procedures to reduce falls vary significantly between institutions as it is not yet known what interventions are effective in the EMU setting. This study retrospectively examined the frequency of falls and the impact of serial changes in fall prevention strategies utilized in the EMU between 2001 and 2014 at a single institution. Overall fall rate was 2.81 per 1000 patient days and varied annually from 0 to 9.02 per 1000 patient days. Both seizures and psychogenic nonepileptic events occurring in the bathroom were more likely to result in falls compared with events occurring elsewhere in the room. With initiation of increased patient education, hourly nurse rounding, nocturnal bed alarms, having two persons assisting for high fall risk patients when out of bed, and immediate postfall team review between 2001 and 2013, there was a trend of decreasing fall frequency; however, no specific intervention could be identified as having a particular high impact. In late 2013, a ceiling lift system extending into the bathroom was put in place for use in all EMU patients when out of bed. In the subsequent 15 months, there have been zero falls. The results reinforce both the need for diligent safety standards to prevent falls in the EMU as well as the challenges in identifying the most effective practices to achieve this goal.

Introduction

Falls are a significant cause of morbidity in hospitalized patients. It has been estimated that 2–12% of hospitalized patients will fall during their admission and that almost 1:4 will suffer an associated injury [1], [2], [3]. Hospitals participating in the National Database of Nursing Quality Indicators (NDNQI) safety initiative reported an overall inpatient fall rate of 3.44 per 1000 patient days and 3.82 falls per 1000 patient days in medical units [1]. Compared with patients admitted to other inpatient areas, patients admitted to epilepsy monitoring units (EMUs) may be at particularly high risk of falling due to spontaneous and provoked seizures. Retrospective single-center studies of safety during video-EEG monitoring have reported 2.3–8 falls per 1000 patient days [4], [5], [6]. In retrospective studies of safety events occurring in the EMU, falls account for over 1/3 of adverse events during video-EEG monitoring and caused both minor and major injuries such as fracture and epidural hematoma [4], [5], [7].

Although most epilepsy centers employ various strategies to reduce falls, practices vary widely, and there is little evidence to guide which strategies are effective [8], [9]. For example, some centers may allow patients unlimited ambulation without supervision, while others may allow patients out of bed only with close supervision, and others may restrict activity to the bed. The bathroom area is of particular concern as patient safety must be balanced with a desire for privacy. In the bathroom, lack of direct nursing supervision and video monitoring can compromise the ability of the EMU staff to recognize and respond to events. Furthermore, the presence of hard surfaces, including the toilet and sink, and limited space can magnify the risk of injury if a fall occurs. A 2009 survey of practice in U.S. EMUs found that 69% allowed unsupervised time in the bathroom, 28% supervised patients in the bathroom at all times, 23% used a bedside commode with supervision, 5% allowed ad lib use of bedside commode, and 3% used a bedpan only [8]. Despite reasonable concerns, little is known about the actual risk of falls and injury in the bathroom area. While the National Association of Epilepsy Centers presented new guidelines in 2012 [10], the recommendations concerning safety are, for the most part, nonspecific as little data exist to guide an evidence-based approach. Recent consensus-based guidelines on safety in EMUs state that the environment in the patient room and bathroom facility should be assessed to optimize patient safety but did not provide specific safety strategies again due to lack of data [9]. To date, there has been only one evidenced-based report examining the effectiveness of specific safety practices for fall prevention in the EMU by Spanaki et al. at the Henry Ford Hospital [6]. In 2009, they instituted full-time observation of patients by EEG technologists, hourly nurse rounding, improved staff and patient education, use of a fall prevention contract signed by the patient, and immediate team review of all falls. Reviewing two years before and after these changes, they saw a nonstatistically significant reduction of 15% in falls (2.7 to 2.3 falls per 1000 patient days). Therefore, it remains uncertain what strategies are and are not effective in minimizing falls in the EMU. In the last decade at our institution, we have made multiple changes in nursing protocols, patient education, and infrastructure in the EMU in a process of continuous quality improvement aimed at reducing falls (Table 1). In this study, we retrospectively analyzed the effectiveness of these changes in reducing the incidence of falls over time.