Fragala G, Perry B, Fragala M. Examining bed width as a contributor to risk of falls from bed in long-term care. Annals of Long-Term Care: Clinical Care and Aging. 2012;20(6):35-38.
Falls pose a considerable problem in long-term care (LTC) facilities, increasing the risk of both morbidity and mortality among residents. While it is yet unclear whether all falls are preventable in this setting, many measures can be taken to curtail their incidence, including modifications to various environmental factors. Because a large number of falls in the LTC setting occur from beds, typically while residents reach for something by their bedside or reposition themselves on the mattress, the authors conducted a small pilot laboratory study that examined whether the short mattress width of 35 inches, which is the bed size generally used in LTC facilities, is also a contributor to falls risk. They found that the risk of an elder falling from a 35-inch mattress is 51%. They also found that this risk can be reduced by up to 36% when the mattress is changed to one with a 42-inch width. These data indicate that while more research is needed in this area, mattress width should be considered in falls prevention programs, especially if procurement of new bed systems is being contemplated.
Healthcare practitioners are discovering that the concepts of ergonomics can provide much value when used to create safer environments in healthcare facilities. Through the application of ergonomic principles, progress has been made in healthcare safety, benefitting both patients and caregivers; however, the long-term care (LTC) environment continues to expose residents to many hazards, despite striving to provide quality care to the aging population. One such hazard, especially among LTC residents with deteriorating functional abilities, is falls. Prevention of resident falls demands serious attention, and healthcare practitioners need to continue to seek effective solutions to reduce falls risk in this population.
This article examines the issue of falls from bed, a major contributor to the overall falls problem. Background information on the magnitude of the problem is provided and thoughts about causation are discussed. We also describe the results of our small pilot laboratory study, which was conducted to investigate how bed surface width might impact falls risk. This study sheds light on how equipment design improvements can reduce risk of falls among high-risk populations.
The Magnitude of Resident Falls
Residents’ high risk of falling and the frequent occurrence of falls in the LTC setting have been well documented. It has been estimated that 45% to 70% of residents fall each year, of whom 50% experience multiple falls.1,2 It has also been determined that older adults residing in LTC settings are two to three times more likely to experience multiple falls than their community-dwelling counterparts.2-6 Approximately 50% of the falls that occur in LTC settings involve falling from bed.7,8 Bedside falls are associated with significant physical and psychological complications, including hip injuries, fractures, immobility resulting in muscle weakness, functional disability, and psychological distress, such as depression and fear of falling.7 They are also associated with an increased risk of subsequent falls.
In addition to their serious health risks, falls pose a significant financial burden to healthcare delivery systems. Currently, containing the cost of healthcare is a major objective for society, and reducing falls among elders offers opportunities for cost savings. A study of people aged 72 years and older found that the average healthcare cost of a fall injury was $19,440, which included hospital, nursing home, emergency department, and home healthcare, but did not include physicians’ services.9 The total direct cost of all fall injuries for people 65 years and older in 2000 was slightly more than $19 billion: $0.2 billion ($179 million) for fatal falls and $19 billion for nonfatal falls.10 By 2020, the annual direct and indirect cost of fall injuries is expected to reach $43.8 billion (in current dollars).11,12
Falls sustained by residents in post-acute care facilities do not have a single cause, but result from the interaction of several risk factors. Bed falls are common among residents with lower extremity dysfunction, cognitive disorders, or on medications that impair their ability to rise up and move independently. Elevated bed heights and soft mattresses can contribute to falls when a resident is trying to get out of bed. Bladder dysfunction can lead to more frequent attempts to leave the bed, increasing falls risk.13 When new residents are placed in unfamiliar surroundings and in beds with casters that are set at a different height and width than what they are accustomed to, risk of falls increases.7 Studies involving the implementation of an interdisciplinary program that included staff education, environmental modification, exercise programs, provision of aids and free hip protectors, drug regimen reviews, and post-fall problem-solving conferences significantly decreased the risk of falls and hip fractures among institutionalized elders.6,8,14-17
Implementation of resident fall prevention programs has been on the safety agenda of many organizations over the years. Current programs are usually strong at identifying individuals at risk of falls, but improvements are often needed when it comes to finding and implementing effective solutions. Managing falls among a population with decreasing functional abilities is a complex and challenging endeavor, and one that requires a multifactorial approach. The first step in this approach is to identify the key individual components of the set of multifactorial solutions. The next step is to implement each of these individual components using an appropriate knowledge base and any available technology and expertise.
Considering both the extrinsic and intrinsic risk factors related to falls in LTC settings, applying the concepts of ergonomics to optimize furnishings in the physical care environment might be one of the most effective individual components in the multifactorial solution. The most important furnishing within the LTC care environment is the bed system provided for the resident. Understanding the needs of the resident through a proper assessment, and matching available bed system features to those needs, might be the most important individual solution component when devising a multifactorial solution to address the risk of resident falls.
Accepting that bed systems are important in the environment of care, consider some of the history that has dictated traditional healthcare bed design, specifically healthcare bed width. Traditionally, beds placed in post-acute and LTC facilities have surfaces that are 35 inches wide. This seems to have originated from the need to use beds as a transport device, which requires that they fit through a standard 36-inch wide doorway. Users of these beds are moving around on and repositioning themselves on a surface that is significantly narrower than common consumer products, which range from 39 inches for twin beds to up to 60 inches for queen-sized beds. According to an article by Banks,18 patients often fall from bed while repositioning or reaching for an object placed on a side table. The large difference of bed width noted between consumer and healthcare products may directly contribute to the risk of falling from bed, as the traditional LTC products provide less surface area for movement and repositioning.
When considering the ergonomics of well-designed healthcare bed systems, there are many design characteristics to consider, including bed surface height for egress, ambulatory assist handles for egress, bed exit alarms, bed surface options, and many other frame and surface characteristics. Although all of these design features are important to consider, a detailed discussion of each of them is beyond the scope of this article. Our report hones in on the specific design criteria of bed surface width, which we assessed in a small study.
Pilot Study Investigating Bed Width
To investigate the hypothesis that bed width is related to risk of falling, we conducted a small pilot study that included male and female LTC residents who were between 70 and 79 years old. These patients’ repositioning movement on a bed surface was observed and recorded, as patient falls from beds are often the result of a repositioning maneuver or occur when reaching for an object. The assumption was made that falls from bed result when patients are unable to arrest momentum once they are too far over the edge of the bed. To study this movement on the bed surface, each resident’s center of gravity was tracked using XSensor pressure mapping technology during a reposition from a supine position in the center of the bed to a side-lying position on three mattress widths: 35 inch, 39 inch, and 42 inch. The measured center of gravity for each resident was then extrapolated to estimate its position if he or she continued moving from a side-lying to a prone position, which was recorded in inches from the mattress edge.
For the purpose of this study, risk of falling from a bed was defined as a function of the position of the resident’s center of gravity and hip width. The center of gravity, as illustrated in Figure 1, is a critical point, as it is defined as the point around which a body is balanced and through which gravity acts. If the mattress did not support a resident’s center of gravity when he or she was in the prone position, it was surmised that a fall from bed would occur. Our observations indicated that almost all residents were at risk of falling from a 35-inch mattress.
The position of the center of gravity is a clear indication of risk; however, a patient’s hip width also contributes to whether he or she will fall from bed during a repositioning event. Although a patient’s center of gravity may be supported by a mattress, there may be some portion of the patient that is not. As a patient’s hip width increases, more of his or her body will be unsupported by the mattress as the center of gravity moves closer to the edge of the mattress during a reposition from the supine-lying position to the prone position. This lack of support from the mattress introduces the risk of falling, which is further increased when an extremity slides off the mattress. The risk contributed by hip width for all target populations was averaged for each mattress size and is presented in Figure 2.
Currently, there is little information available that defines an acceptable level of risk to a patient or resident related to falls from bed; however, making bed system design changes might improve safety. A previous but related example involves bed height and injury severity, which were assessed in a study that showed that increasing bed height has a direct correlation to severity of injuries associated with falls from bed.19 Improving patient safety can be accomplished not only through decreasing severity of injuries, but also by decreasing the frequency of falls from bed. As shown in Figure 2, the approach used in our study demonstrates that a patient has an approximately 51% chance of falling from a 35-inch wide mattress during a repositioning event. Testing and observations indicate that this risk is reduced exponentially as bed width is increased to 39 inches and 42 inches. Although an acceptable level of risk has not yet been defined, a patient’s risk of falling from his or her bed can be reduced by 36% simply by replacing 35-inch wide mattresses with those that have a width of 42 inches. The frequency of falling from bed and the severity of injuries associated with those falls contribute to the overall issue of patient safety. Implementing height-adjustable beds, which can be placed in a low position, has become an acceptable practice for intervention in falls management programs. Wider mattresses may be another effective equipment intervention for populations at risk of bed falls.
We acknowledge that the results of our pilot study must be interpreted cautiously because many factors put a resident at risk of falling in the LTC setting. A good resident assessment that considers intrinsic risk factors, such as cognitive ability, remains important. Still, the results of our pilot study strongly suggest that controllable extrinsic risk factors related to bed system design can be effective at reducing the overall level of falls risk.
Bed systems are an important consideration in healthcare environments, including LTC settings, and proper thought should be given to selecting appropriate beds for a post-acute facility. Input should be sought from various disciplines within the facility, including clinical, rehabilitation, risk management, engineering, and purchasing personnel. Good planning when making new bed acquisitions can pay big dividends for a minimal investment. If a wider surface can prevent a resident from falling out of bed and if a lower bed height can reduce injury severity when a fall occurs, many negative potential outcomes can be avoided. While it may seem impractical or expensive to obtain wider beds, options are currently available to increase bed width with little added cost. For example, bed frame extension kits can be purchased for some bed frame models, necessitating that only the mattresses are changed. When making bed system selections, facilities should make the effort to seriously consider how to best match bed system design and function to the needs of their resident population, as having proper bed systems can help LTC facilities meet the objective of maintaining a safer environment while fostering high-quality care.
Dr. Guy Fragala reports having served as a consultant or paid advisory board member of Joerns Healthcare; Ms. Perry reports being employed by Joerns Healthcare. Joerns Healthcare is a business that sells wound, safety, and design solutions to medical providers. Dr. Maren Fragala reports no relevant financial relationships.
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