Journal of Nursing Administration:
Departments: Spotlight On[horizontal ellipsis]
Authors' Affiliations: Associate Professor (Dr Tzeng), Division of Nursing Business and Health Systems, School of Nursing, The University of Michigan, Ann Arbor, Michigan; Professor (Mr Yin), Chinese Culture University, Department of History, Taipei, Taiwan.
Corresponding author: Dr Tzeng, Division of Nursing Business and Health Systems, School of Nursing, The University of Michigan, 400 North Ingalls, Room 4156, Ann Arbor, MI 48109-0482 (firstname.lastname@example.org, email@example.com).
The Joint Commission emphasizes the need for healthcare institutions to reduce the risk of patient harm resulting from falls.1 Individual risk factors for falls include (1)intrinsic risk factors (eg, reduced vision and unsteady gait) and (2) extrinsic risk factors (eg, medications, height of bed, bedside rails, lack of support equipment in bathtubs and toilets, poor illumination, and inadequate assistive devices).2
In a continuing effort to promote patient safety and reduce falls, the Joint Commission2 suggested several environmental strategies related to bed height, such as the use of adjustable-height high-low beds or fixed low-deck-height beds where applicable and keeping beds in the lowest position when feasible. Hospitals should use adjustable beds that can be raised and lowered to enable patients to easily get in and out of beds and for staff to assist in this process.
Falls From Beds
The Joint Commission2 recognizes the height of occupied patient beds as an overlooked contributor to inpatient falls. However, nurses seldom recognize or discuss this risk factor.
When a patient falls from a higher bed, the gravitational potential energy (also called the downward pull of gravity) will be greater. When a patient's weight is kept constant, if the height of the bed is greater, the downward pull of gravity will be greater. Consequently, in comparison with the lower height of beds, the impact of the fall-related injury will be more severe. We are concerned about the fall rates and about the severity of fall-related injuries!
A Patient Safety-Driven Facility Design Is a Must
Hignett and Masud3 took an ergonomic system perspective and applied Maslow's hierarchy of needs to analyzing inpatient falls. They claimed that fulfilling patients' physiological and safety needs is the highest priority and must be addressed first. From a patient-centered perspective, the first hazard interaction is the bed. A safety-driven, patient-centered facility design should be based on evidence to promote quality care and patient safety. After all, the design of a hospital facility and the design of work processes should work for the most vulnerable patients.4
How low does the hospital bed need to be in the low position? Alexander et al5 found in their study that all the seniors with a mean age of 82 years could rise from sitting to standing from a seat of 100% knee height with hand use only. This finding suggests that the height of the hospital bed from the floor to the top of the bed surface in the horizontal position should be adjustable to the patients' knee height (about 21 in. for men and 19 in. for women).
New Bed Features to Prevent Patient Falls
Some hospitals are using low beds (approximately 6 in. from the floor to the mattress surface) with patients who are at high risk for falls, particularly geriatric patients.6 Nursing homes often purchase low-height beds and used them for residents who are at high risk of falling. This has not been done in hospitals.
Some hospital bed styles have features that allow them to be placed in the "chair" position. This enables the patient to be passively moved into a sitting position. This type of bed has been adopted in some medical centers and used in medical and surgical wards. However, we found that only a few nurses use the chair function. Nurses should be familiar with the new features of patient beds to help move patients and prevent occupational back injuries.
Lowering the Bed Height After Completing Healthcare Treatments
We have observed that many patients, across different age groups, do not even try to adjust the height of bed before getting out of bed. These patients usually say that they did not feel comfortable adjusting the height of bed after staff left their rooms. These patients thought that their nurse or physician might get angry if they changed the height of bed. The patients' rationale was that staff would be inconvenienced by having to adjust the height of bed again to an ergonomic working height before giving care.
This suggests that staff should lower manual or automatic adjustable beds to their lowest position after completing medical treatments or tasks. This after-procedure task will help decrease patient fears as they get in and out of bed and prevent patient falls. In acute care settings, this action should be enforced and monitored regularly as part of a hospital's patient fall prevention program.
Future Patient Bed Purchases
Nursing executives and hospital administrators need to keep in mind that when purchasing new patient beds for acute care settings, the height of bed frames in the low position should be specified to be as low as possible. As long as these are automatic, adjustable patient beds, this design specification will respond to patient safety concerns as well as worker ergonomics.
If purchasing new patient beds is not imminently feasible, some other innovative approaches may address the bed height issue. For example, a new task designed to help patients get out of hospital beds safely by using the prone position instead of the traditional sitting-standing position can be adopted.7
Patient falls still consistently comprise the largest single category of reported safety incidents in hospitals.2 Studies provide data indicating that the design-regulation height and the staff-working height for patient beds may be linked to fall-related injury severity in inpatient settings.7-9 Given that the height of occupied patient beds can be an overlooked contributor to inpatient falls, strategies to address the height of patient beds are imperative.
2. The Joint Commission. Defining the problem of falls. In: Smith IJ, ed. Reducing the Risk of Falls in Your Health Care Organization
. Oakbrook Terrace, IL: The Joint Commission; 2005:13-27.
3. Hignett S, Masud T. A review of environmental hazards associated with in-patient falls. Ergonomics
4. The Joint Commission. Joint Commission consideration for planning and design. In: Miller KM, ed. Planning, Design, and Construction of Health Care Facilities
. Oakbrook Terrace, IL: The Joint Commission; 2006:47-95.
5. Alexander NB, Galecki AT, Nyquist LV, et alet al. Chair and bed rise performance in ADL-impaired congregate housing residents. J Am Geriatr Soc
6. Fonda D, Cook J, Sandler V, Bailey M. Sustained reduction in serious fall-related injuries in older people in hospital. Med J Aust
7. Tzeng HM, Yin CY. Innovation in patient safety: a new task design in reducing patient falls. J Nurs Care Qual
. In press.
8. Tzeng HM, Yin CY. The staff-working height and the designing-regulation height for patient beds as possible causes of patient falls. Nurs Econ
9. Belechri M, Petridou E, Trichopoulos D. Bunk versus conventional beds: a comparative assessment of fall injury risk. J Epidemiol Community Health
© 2007 Lippincott Williams & Wilkins, Inc.