By Greg Freeman
EXECUTIVE SUMMARY
Wheelchair falls are common and may not receive enough attention in safety improvement programs. Some populations are at much higher risk.
- Patients with dementia or other cognitive disabilities are at high risk of wheelchair falls.
- Safety devices and alarms can reduce the risk of falls.
- Healthcare providers should provide training for patients, especially for long-term wheelchair users.
Falls from wheelchairs are a serious patient safety risk but may not receive enough attention in the overall effort to prevent falls. A focus on reducing wheelchair falls can substantially affect overall fall reduction.
Any patient using a wheelchair is at risk of falls, but the risk is greater with the elderly because they are more often in wheelchairs and may be weaker overall, says Marco Aguiluz, director of home care for Parentis Health in Laguna Hills, CA.
“The reason these falls happen in healthcare facilities usually comes down to a shortage of staff members. Particularly with memory care and assisted living facilities, they can have a large number of clients, and there typically are not enough staff members to monitor and watch all of them,” Aguiluz says.
The risk of wheelchair falls is especially high in memory care facilities because patients with dementia or other cognitive disabilities may not remember how to be safe when using a wheelchair. They try to get up from the wheelchair when no staff member is present, and may fall.
“These patients can get confused easily and may not even realize they are unable to safely stand and walk, so they need to be monitored closely,” Aguiluz says. “When patients decline, staff members may not always recognize the increased risk of falling. Staff may previously have been confident they could leave this patient without monitoring, but then the condition can change very quickly, and the patient falls.”
These falls often are not witnessed. Aguiluz says the typical scenario occurs when the patient tries to stand up on his or her own when the wheelchair is locked. This may occur when staff have transferred the patient to the wheelchair and locked it in place, thinking that is sufficient to keep the patient safe, and then leaves the area.
Insufficient staff training can increase the risk of wheelchair falls. Optimal staff training emphasizes anticipating challenges with wheelchairs and communicating with patients and family members to better understand the patient’s limitations.
Assess Risk for Wheelchair Users
Proper intake also is important to identify which patients are at high risk for falls. “If they are in a wheelchair, that is automatically on our minds as a risk for falls, regardless of whether they have had a previous fall,” Aguiluz says. “Staff awareness and good monitoring are key. It is important not to leave some patients unattended, especially if it is a client with cognitive disabilities, because they are the ones we end up seeing having these falls.”
Patients who are new to using a wheelchair, regardless of age, also are at high risk. They are unfamiliar with the mechanics of entering and exiting the wheelchair and may underestimate how challenging it can be when they are ill or injured.
For instance, poorly trained staff may adjust wheelchair settings incorrectly. Brakes and rollback prevention devices must be set properly. A rollback prevention device on the chair usually consists of a stopper that prevents the chair from moving backward when the patient sits in the chair, a common scenario in which falls occur.
“Sometimes, the wheelchair was not locked into place, or the patient may unlock it to move about the area. Then, the patient tries to stand up and the wheelchair moves backward, causing the fall,” Aguiluz says. “The anti-rollback device attaches the wheelchair and prevents it from rolling back and having a really bad fall.”
Other wheelchair safety devices include alarms and drop seats. An alarm can be used to notify staff when the patient tries to get out of the wheelchair without assistance. Drop seats lower the seating height, which can allow the patient’s feet to reach the floor or foot supports. That can make transfers safer and promote independent wheelchair mobility.
Transferring to or from the wheelchair poses a high risk for falls, Aguiluz notes. A fall can occur when the patient tries to transfer without assistance, or when a staff member or family member is not properly trained in how to assist the transfer. A patient’s condition may render him or her combative when being assisted with the transfer.
Range of Injuries, Few Deaths
The healthcare community is creating fall prevention methods, says R. Lee Kirby, MD, FRCPC, professor in the Division of Physical Medicine & Rehabilitation in the Department of Medicine at Dalhousie University in Halifax, Nova Scotia. The injuries from a wheelchair fall can range from minor to severe.
“There have been many studies, and they all seem to be pointing in the same direction — which is that there is a relatively small number of people who end up dying from their injuries,” Kirby says.
When powered scooters became a popular alternative to traditional wheelchairs, injuries from tip-over accidents spiked. These were quickly traced to the three-wheel design of early scooters. Manufacturers responded by switching to a four-wheel design for some models, or by moving the rear axle back to make it more stable.
“The biggest takeaway for me from those studies is that the majority of wheelchair injuries and deaths were related to tips and falls. The second most frequent was related to transfers, people getting in and out of their wheelchairs,” Kirby says. “The risk of injury from tip-overs still exists because there is no perfect solution. There is a tradeoff between safety and performance.”
No One Solution for All
Efforts to reduce the risk of wheelchair falls need to be tailored to the individual patient, Kirby says. What might be best for an elderly dementia patient might not be appropriate for a younger, healthier patient who is comfortable manipulating a wheelchair and making transfers.
One challenge in addressing wheelchair falls involves the differences in the use of a wheelchair in the healthcare institution vs. its use in everyday life outside the facility, Kirby notes. For some patients who will use a wheelchair long term or permanently, the precautions and devices to reduce risk in the facility will be impractical after discharge.
“We all accept a certain amount of risk in our lives, and I think healthcare institutions are going to have to do some of that to allow people to use wheelchairs for the purpose they are intended, which is to allow people to get around easily,” Kirby says. “Improved wheelchair design is one goal, and chairs are getting better. Some of the tipping problems are being solved, and making the world more accessible is a big improvement, with the United States leading the way on that with the Americans with Disabilities Act.”
Training wheelchair users also is key. This has been a primary focus of Kirby’s research for the past 20 years. Even when wheelchair training is provided, it often is minimal, Kirby says. He urges healthcare providers to ensure patients provided with wheelchairs are trained on how to use them both effectively and safely.
“This is about teaching not only wheelchair users, but their caregivers, so they can get over obstacles effectively but also safely — how and when to lean in what direction, and those sorts of skills,” Kirby says. “The effectiveness of wheelchair skills training has been proven in studies using meta-analysis. There also are studies — and we’ve done a couple of them in recent years — showing that wheelchair training isn’t being done nearly as often as it ought to be by wheelchair service providers.”
In 2019, the Canadian Agency for Drugs and Technologies in Health released guidelines that can help reduce the risk of wheelchair falls. The recommendations include supervised exercise, assessment of a patient’s ability to use his or her wheelchair, assessing whether the wheelchair is appropriate for the patient, and ensuring the wheelchair is in good condition.1
REFERENCE
- Sutton D, McCormack S. Fall Prevention Guidelines for Patients in Wheelchairs or Patients with Delirium: A Review of Evidence-Based Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; July 19, 2019.
SOURCES
- Marco Aguiluz, Director of Home Care, Parentis Health, Laguna Hills, CA. Phone: (949) 603-0833. Email: [email protected].
- R. Lee Kirby, MD, Professor, Division of Physical Medicine & Rehabilitation, Department of Medicine, Dalhousie University, Halifax, Nova Scotia. Email: [email protected].
Falls from wheelchairs are a serious patient safety risk but may not receive enough attention in the overall effort to prevent falls. A focus on reducing wheelchair falls can substantially affect overall fall reduction.
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