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Nurses' Experiences with Bed Exit Alarms May Lead to Ambivalence About Their Effectiveness

Beth Hubbartt, MSN RN CRRN · Sarah G. Davis, BSN RN · Donald D. Kautz, PhD RN CRRN CNE

The literature reports conflicting evidence regarding the effectiveness of any single intervention, including bed exit alarms, in preventing falls.Yet bed exit alarms are widely used in healthcare settings as part of comprehensive fall-prevention programs even though no large-scale randomized controlled trials have demonstrated their effectiveness. As a part of a quality improvement project, bed alarms were piloted on two nursing units in a Level I trauma center. Nurses' patterns of use, their experiences and beliefs about bed alarms, and the literature regarding bed exit alarms were explored. Alarms were used with confused and agitated patients who did not fall. Nurses said that bed alarms may have helped prevent falls, but, even with bed alarms in use, nurses still needed to monitor their patients hourly. The conflicting experiences of nurses using the alarms, combined with nurses' comments and literature both supporting and not supporting bed alarms, shed light on the dilemma nurses face when prioritizing safe patient care and the ambivalence some nurses experience regarding bed alarms. Bed alarms, which are designed to signal nursing staff when a patient is getting out of bed, have been advocated as a tool for preventing falls since a randomized clinical trial conducted by Tideiksaar, Feiner, and Maby (1993) reported that bed alarms were acceptable to patients, families, and nurses as a way to prevent falls. This study found no significant differences between the control and treatment groups; however, it often is cited as providing evidence that the use of bed alarms helps prevent falls. Today the Joint Commission requires all healthcare facilities to have a fall-prevention program in place and to conduct ongoing evaluations of that program. Bed alarms often are one component of fall-prevention programs, especially for patients who have cognitive impairments. This article reviews the current level of evidence for the use of bed alarms and discusses our hospital's use of portable bed alarms on two hospital units. A more recent study (Cummings et al., 2008) and systematic reviews and meta-analyses of strategies to prevent falls (Coussement et al., 2008; Oliver et al., 2006) concluded that no single intervention, including bed alarms, has been shown to be effective in preventing high-risk patients from falling. In addition, consistent use of bed alarms by nursing staff is questionable; this may be related to excessive false alarms and the need to turn off alarms when attending to patients (Kwok, Mok, Chien, & Tam, 2006). On the other hand, another study (Rabadi, Rabadi, & Peterson, 2008) found that bed and chair alarms, enclosed beds, placement close to the nursing station, wheelchair lap belts, and bed rails decreased the numbers of falls and fall-related injuries among stroke patients in a rehabilitation unit. Despite conflicting evidence in the literature, bed alarms are thought to be a reasonable strategy to prevent falls and many different systems are available. Bed-alarm types include systems built into hospital beds, standalone technology, or portable systems that consist of a sensor pad and a monitor alarm, voice alarms, and seat belt alarms for wheelchairs. Criteria for use of bed alarms have not been clearly established, and it often is difficult for nurses to predict who will attempt to get out of bed unassisted. Fall risk assessment tools identify risk but may not effectively help nurses determine who can benefit from a bed alarm. The literature recommends use of alarms with patients who cannot be constantly supervised and need frequent reminders (Kelly, Phillips, Cain, Polissar, & Kelly, 2002). Two studies (Cumming, 2002; Cumming et al., 2008; Vassallo et al., 2004) recommended using alarms with patients who have delirium and cognitive impairment, cannot safely walk unsupported, or have unsafe gait. Since 1998 our facility has had a comprehensive fall-prevention program that includes an electronic fall risk assessment that nurses complete on every shift and standard interventions that nurses implement to ensure patient safety. We evaluate our program quarterly, and all units receive reports of falls and benchmarking data. Our program is proven to be effective; our institution's fall rate at the time of this quality improvement project was 3.8 falls per 1,000 patient days, which is within the control range set by the facility.


Rehabilitation Nursing · Vol. 36, No. 5 · September/October

The use of bed alarms at our facility was suggested when, during safety rounds, nurses said that patient falls were among their greatest safety concerns. Some nurses reported that other hospitals had alarm systems that alerted staff members when an at-risk patient had gotten out of bed. Hospital administrators heard the nurses' concerns and inquired about the value of making the bed-alarm system available to enhance patient safety. One nurse on the unit had used a portable bed alarm at another facility and believed that bed alarms were an effective intervention. A decision was made to pilot alarms on two units to determine whether they should be part of a reasonable fall-prevention strategy. Because many of the current hospital beds did not have a working bed-alarm system, a portable alarm with sensor pad and monitor alarm was used. The clinical nurse specialist (CNS) assumed responsibility for educating nursing staff about the alarms. Education included a review of the fall-prevention program already in place, appropriate patient interventions, the use of the bed-alarm system, and criteria for using a bed alarm with specific patients. Educational sessions were conducted on all shifts on both units piloting the alarms to encourage nurses to use the bed alarms as a fall-prevention intervention. Even though ours was not a research project, approval was obtained from the medical center's institutional review board to report patient safety data and the results of a focus group meeting with nurses. Informed consent was obtained from all staff members who attended the focus group. Participants were assured that their participation was voluntary and would not reflect on job performance. Alarm Use We monitored the pattern and frequency of alarm use and the fall rate on the two units to evaluate bed alarm effectiveness. One goal was to determine whether nurses would use an alarm if it were readily accessible. To provide staff with easy access to the alarms, they were stored on the unit in a cabinet. Periodic checks were made by key resource people to encourage use of the alarms for patients who might benefit from them. The unit-based educator and CNS made rounds and asked if staff were using the alarms. The staff always responded that they were aware the alarms were available. Often staff members commented, "We just don't have anyone who needs an alarm now." Some staff said, "You can put it on the patient." The unit was busy and some nurses viewed the alarms as one more distraction, particularly because putting on an alarm meant monitoring its use. If a patient had not attempted to get out of bed and had not already fallen, nurses did not see the need for an alarm. Nevertheless, the alarms were used with some patients.

On the first pilot unit the alarms were available in a cabinet for a 5-month period and were used with eight patients. On the second pilot unit, the alarms were used with seven patients over a 2-month period. None of these patients fell. The alarms appeared to be helpful when they were used. The nurses used the alarms on patients who had a psychiatric diagnosis or experienced confusion, dementia, or alcohol or substance withdrawal. The reasons nurses gave for using the alarms were consistent with literature indicating that patients most likely to benefit from alarms are those with mobility impairment or dementia (Kwok et al., 2006). For example, a patient may be dizzy or unstable or have other risk factors for falls, and a bed alarm may be useful to signal a nurse that a patient is getting out of bed without assistance. Patients with loss of cognitive function are more likely to make judgment errors about their ability to walk safely and have misperceptions about intravenous (IV) lines, other tubes, and dressings. A bed alarm was installed for a patient on a pilot unit because he was trying to get out of bed. Another patient was not at risk of falling but would wander, and the nurses wanted to monitor her wandering. Some ambulatory but unsteady patients were restless and trying to get out of bed, one of whom was a war veteran with dementia. The alarm caused him to panic when he got out of bed. He tried to get away from the alarm, ran out of the room, and was already down the hall before the staff heard the alarm. In this instance, the alarm was appropriately used on a disoriented patient with an unsteady gait. The possibility that a bed alarm can increase agitation and fall risk may be an unforeseen consequence of this technology. A similar experience could lead a nurse to avoid using an alarm on a future patient with comparable characteristics. Ambivalence About Bed Alarms To obtain feedback about the pilot program and nurses' experience with and beliefs about using bed alarms for fall prevention, an informal focus group session was conducted during working hours with a convenience sample of day-shift RNs and nursing assistants. The focus group was held in a conference room on the nursing unit at the end of the regular monthly unit-based, self-governance meeting. All staff members attending the meeting were invited to participate. Fifteen staff members were present and all had worked on the unit during the time when bed alarms were available. Eight short questions were used to encourage discussion and obtain general information about the use of bed alarms. These nurses' statements describe the rationale behind their practice. However, these comments need to be validated through formal research and it is not possible to predict how many nurses share these same beliefs.

Rehabilitation Nursing · Vol. 36, No. 5 · September/October 197

Nurses' Experiences with Bed Exit Alarms May Lead to Ambivalence About Their Effectiveness

Key Practice Points

1. The literature reports conflicting evidence that bed exit alarms are effective in preventing falls, yet bed exit alarms are widely used in healthcare settings as a part of comprehensive programs to prevent falls. 2. Nurses' use of bed alarms for fall prevention demonstrates the dilemma nurses face when prioritizing safe patient care and the ambivalence some nurses experience about using bed exit alarms. 3. There are no established criteria for determining which patients will benefit from a bed exit alarm, even though fall risk assessment tools identify level of risk for a fall. 4. The patients who appear to benefit from a bed exit alarm are those who have delirium and cognitive impairment and cannot walk unsupported or have unsafe gait.

Staff members were given the option to participate in the focus group and everyone present elected to stay for the discussion. The unit educator remained on the unit to assist patients and reduce interruptions. Nurses were asked, "If you know your patients are on a bed alarm, are you more likely to go check on them?" and "Do you believe your patients are safer with the alarm?" The discussion lasted approximately 30 minutes and responses were captured using a voice-activated recorder. Several nurses were more verbal than others, but most staff responded to questions or acknowledged agreement with other comments. The focus group discussion was transcribed and the transcript read through to obtain a general sense of the information and reflect on its overall meaning. Content then was analyzed to identify participants' ideas related to their experience and views of bed alarms. Nurses' comments revealed ambivalence about the effectiveness of the alarms. Some said, "Why use the alarms? You have to make routine rounds anyway." One nurse explained that she could not hear the alarm, while others said bed alarms represented only one type of alarm to which nurses must respond (alarms are now associated with feeding pumps, sequential compression devices, IV pumps, and bathroom call lights). Alarm overload, they said, has the potential not only to make bed alarms ineffective but also to sensitize nurses against responding to the alarm. One nurse said, "Sometimes you just hear another beeping, and you don't know which alarm is going off." The nursing staff also reported excessive false alarms, which have been noted in the literature (Murray, Cammeron, & Cumming, 2007). The nurses believed that there were times when the alarms were effective, however. One nurse said

198 Rehabilitation Nursing · Vol. 36, No. 5 · September/October

that with a "patient undergoing alcohol withdrawal, the alarm was effective and we didn't need a oneon-one sitter." Some nurses said the alarms worked best with "patients who are more restless, seem to magically move quickly (Houdini characteristics), and might be all the way to California before you get to them." In many cases they said patients were confused and categorized as at high risk for falls, but unless the patient attempted to get up the bed alarm was not used. In fact, bed alarms often were not used until a patient demonstrated a need by attempting to get out of bed without assistance. At the same time, some nurses said patients who were agitated and constantly attempting to get out of bed required closer observation than a bed alarm could provide. The comments of the nurse participants in the focus group and the inconsistent use of the alarms on the pilot units suggest that nurses experience ambivalence about what really keeps a patient safe. The nurses noted that when a fall occurred, a risk management investigator would automatically ask, "Was a bed alarm in use?" Risk management's goal was to gather information, but asking the question implied that nurses should use alarms even when they believed they might not be the best option for a particular patient. This may have contributed to nurse ambivalence. More systematic research is needed to evaluate the effectiveness of bed alarms as a component of a comprehensive fallprevention safety program. It is important to note that fall rates in hospitals are extremely low. The standard method to measure fall rates is to calculate the number of falls per 1,000 patient days. At the time the bed alarms were instituted, our overall hospital fall rate was 3.8 falls per 1,000 patient days; 99.6% of the time, our patients did not fall. Consequently, the nurses' experiences led them to believe the alarms would not improve patient safety. The nurses' view that alarms are not needed was enhanced by their knowledge that they still needed to check regularly on patients with an alarm. One nurse said, "You go put the alarm on." This nurse was saying that the alarm was a good idea but not a priority, and she was unwilling to "give up" another aspect of care for her patients to put on the bed alarm. Implications for Research and Practice It is not easy to identify patients who might benefit from a bed alarm. There are no clear policies or procedures to identify who will get out of bed. Also, with shorter patient lengths of stay, there is less time to evaluate a patient's potential for getting out of bed or the usefulness of an alarm in preventing falls. Sometimes a patient's confusion may resolve before his or her nurse is able to evaluate the effectiveness of a bed alarm in preventing falls. In addition, applying a bed alarm will not help to resolve a

patient's underlying problem, and resolving the underlying problem is the priority, not applying the bed alarm. The authors believe that nurses choose whether to use alarms because they are thinking through complex issues. Nurses on the pilot units appeared ambivalent about using alarms for fall prevention. However, this project's outcome cannot allow us to generalize the claim that all nurses are ambivalent about using bed alarms to prevent falls. In fact, we often hear nurses suggest the use of bed alarms for confused and agitated patients. Questions about the effectiveness of bed alarms for fall prevention can be answered only through multisite, long-term randomized clinical trials. When only three or four falls occur in 1,000 patient days, it is difficult to determine whether improvements have been made with the use of bed alarms, without such large studies. Trials tell us which patients are more likely to benefit from bed alarms or which criteria nurses should use to decide on the use of a bed alarm. The University HealthSystem Consortium (UHC) Patient Safety Net aggregated falls data for 2008 examined more than 20,000 submitted fall reports that occurred in 2008 in 39 organizations. The data showed that bed exit alarms were one of the fall-prevention strategies in place at the time of the fall on more than 3,000 fallers, and the UHC did not find any evidence supporting the use of monitoring devices (bed/chair or exit alarms) in preventing falls. However, the UHC also noted that "alarms on" were associated with a slightly lower percentage of harmful events (11.4%­12%) among those who fell (University HealthSystem Consortium, 2009). Despite conflicting evidence regarding the effectiveness of bed alarms in preventing falls, there is a pressing need to prevent falls and injuries in hospitals. Research is needed to establish the effectiveness of bed alarms in fall prevention. Use of bed alarms (or lack of use) is not yet an indicator of quality care. Acknowledgment The authors gratefully acknowledge the support of nursing administration at Wake Forest University Baptist Medical Center, the editorial assistance of Elizabeth Tornquist, and the assistance of Mrs. Dawn Wyrick with this manuscript. About the Authors

Beth Hubbartt, MSN RN CRRN, is a clinical nurse specialist at Wake Forest Baptist Medical Center in Winston-Salem, NC. Sarah G. Davis, BSN RN, is a staff nurse at Wake Forest Baptist Medical Center in Winston-Salem, NC. Donald D. Kautz, PhD RN CRRN CNE, is an assistant professor of nursing at the University of North Carolina at Greensboro in Greensboro, NC. Address correspondence to him at [email protected]


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