Indications for use of Hi-Lo bed

[Eve Wilson]

Q. I am wondering in what situations you would direct for a Hi-Lo bed to be put in its lowest position overnight?  My concern with this position is that a resident who can get out of bed may still be able to get up with it in its lowest position but it may put them at increased risk of falls. Then again, with a resident who can't get out of bed themselves, I am concerned that putting the hi-lo bed in the lowest position is still too high in the event they roll out of bed. So I am just wondering when this would be indicated?

[Eve Wilson]

The ‘low-low’ bed question… a great one, and one that is also difficult to answer. There are many facets that need consideration here…

1. Why are we advising or wanting to implement it in the first place?
2. What is the cognitive status of the resident?
3. What is the physical capacity of the resident?
4. Are there other ways to get around the risk at hand prior to implementing this bed?
5. Can staff be educated on better management strategies for this resident?
6. What is the staffing level like and their urgency in dealing with falls risk situation?

Low-low beds should be implemented in the instances of a resident whose ‘high falls risk’ or ‘falls incidents’ are mainly overnight – i.e. falling out of bed. They may be a wanderer, or a frequent over-night toileter who has poor insight into their physical capacity/safety, and who is unable to understand the use of the call bell. Alternatively they may use the call bell but the response time from staff is poor and hence the resident gets out on their own anyway as toilet urge is too great.

For a resident who is safely ambulant and cognitively ok a low-low bed is not suitable. A high low-bed set at a normal height to allow the resident to sit-stand with ease and safety is recommended. By making the bed too low to get up from we are increasing the resident’s risk of falling, needless to say we are insulting a person who ‘understands’ by informally restraining them. If they ‘can’, make the task as safe and easy as possible.

For a resident who is poorly cognitively able and/or non-compliant with use of a call bell or seeking assistance, and whose mobility is average, then a normal bed put into the low position is best recommended, with a sensor mat at the bedside (preferably stuck to the ground so it can’t slip). The lower height of the bed will obviously increase the time it takes the resident to get to standing, and therefore allow staff time to attend to the sensor alarm. In this instance it is imperative the night staff have this resident’s needs at highest priority. It is usually the resident’s in that middle stage of mobility who are greatest at risk, so sensor alarms need to be attended to promptly. If you don’t feel this can happen at the site/staff level, then it would be best to leave the bed at a normal height: ‘yes’, we are making the risk greater by allowing them to struggle to stand from a low bed height and then also not attend to them once they are up (they are fatigued from the stand and by this stage probably busting for the toilet- massive risk of falling). If neither of these avenues are considered ok by you and the staff, or falls continue to happen, then a low-low bed set at ground level overnight would be best.

For a resident who is poorly cognitively able and whose mobility is average to poor a low-low bed is always recommended. I would first assess the resident trying to get out of a low chair, and providing this is difficult or not possible with out assistance, then a low-low bed will be impossible and hence safe for falls prevention. At worst, a low-low bed will greatly slow them down, allowing staff time to attend from the alarm.

It is important to consider the room set-up when implementing the low-low bed: the space around the bed should be free of furniture that the resident could use to pull themselves up on or hit their head/body on if a fall does occur – bedside tables are the worst with their sharp edges.

If the resident tends to roll out of bed as their mechanism of falling, then a low-low bed with a crash mat bedside as well as a sensor mat should be used. Unless your site has super-brilliant night staff who check their residents less frequently than hourly over night then a sensor mat should always be used with a low-low bed. If a low-low bed is not available then the bed at its lowest height is next best. The extra option here is a concave mattress to provide that proprioceptive boundary to the bed dimensions – usually a very effective option, however due to it being a formal restraint sites can be hesitant to use. (Formal restraint; needs GP, facility and family written consent).

Secondly to this point, if you have a resident who rolls out of bed, but who is also ambulant then be careful what you recommend. Is falling out of bed less risky and less frequent for them to them than falling whilst walking to the toilet overnight? Do they suffer nocturia? I would be more comfortable leaving the set up as normal high-low bed in the low position, and no crash mat in place as it is a tripping hazard overnight. Leave their gait aide in reach, call bell and night light available. Ensure hip protectors be worn overnight. A low height normal bed is not a long way to fall, and less likely to break a bone than a fall from standing position. They will also still be able to get up form bed with relative safety.

Placing the bed against a wall is a restraint that is not viewed as formal by the sites, but which is viewed poorly by the accreditors, so it is important to encourage low-low beds to be away from the walls. If you are dealing with a resident who is poorly cognitively able and who has poor mobility then wall-side beds can cause the same entrapment and asphyxiation risk that a bed pole can so please be careful with prescription here.

 

Other possible strategies – half hourly visual checks (whilst it is a great idea, some facilities have poor overnight staffing and this never happens… seek info first from management or the team leaders before being reliant on this method); overnight toileting regime to prevent the resident having the urge to get out of bed on own; bedside commode so resident doesn’t have to walk anywhere and can simply transfer on and off the commode form bed; night light/touch lamp availability; pain management and sleeping pattern review… are they getting up due to reasons of discomfort or insomnia; room close to the nurses station; hip protectors (can create increased risk for some resident’s as they are difficult to get off – ensure staff are alerted to resident being on their feet through sensor alarm or checks); gait aid in reach for residents who are in a normal height bed to ensure they are as safe as they can be when on feet; non-slip tape on floor at bedside; bed socks with non-slip sole, mattress or laser beam alarm (better than sensor mat).

Remember that once a resident is on the floor they are essentially in the safest position the can be… unable to fall further, or put themselves at risk of falling again. It may not be comfortable for them, and it certainly feels morally inappropriate to not assist them off the floor as quickly as possible, but it is ok to leave them for a little while. Make them comfortable with a pillow and blanket if necessary, and ensure obs are done by the nurse. It is also a great opportunity to up-skill staff in not panicking, and using the sling hoist appropriately to get the resident up. Take your time. Most elderly people, short of those who are physically exceptional, are unable to get themselves to standing from the supine position – they can’t comprehend what to do, or they simply don’t have the strength to get up from kneeling without help… weird I know!

Low-low beds are expensive to buy and hire, so some sites will not have this as an option initially, especially if they were designed as a low-care facility. Always good to check with management.

Also, remember that once a low-low bed is in place it is a risk to that resident to remove it again, so it is usually a permanent change.

If facility managers or staff ask about what style of new beds to order in regards to getting new equipment, always opt for the low-low bed. It can be used for any function and so its versatility is paramount. I believe in time to come all facilities will only have low-low beds in all rooms.

Do also remember that once we implement low-low beds we are yet again restricting mobility, and hence mobility is likely to further decline… regular reviews/checks will need to be done in this time to ensure the resident remains safe with the current recommendations of assistance and gait aide type/use.

All situations are unique. Be comfortable with understanding the risk with each factor of your recommendation, and the risks put together with the final set up you choose. What is the biggest risk with possible worst outcome – address this as your priority, even if it does create other smaller risks in doing so. We can’t make every set-up completely risk free.

Formal restraints need written consent as I alluded to above, and these include: lap belts, Pelican belts, chemical restraint (medication), concave mattress, bed rails (not allowed usually).

Informal restraints (no written consent required but do understand the risk they involve); low-low beds, Princess chairs, locked doors (usually to bedrooms during day), beds against walls (becoming controversial – will be a management decision); bedside tables wrapped under chair legs such that the resident cannot push them away.

I hope this provides some insight for everyone. It is a very tricky question to answer in general terms, and so do feel free to contact me to talk out your unique situation if need be… only too happy to help.