Patient Falls Initiative - Impact of Medications on Patient Falls

There is good data in the literature to suggest that sedative-hypnotics increase the risk for in-hospital falls. The ‘sleeping aid protocol’ was designed to increase the use of non-pharmacological interventions to promote sleep and reduce the use of sleeping aid medications which can cause confusion and impair judgment and mobility, thereby increasing the risk for falls. 

The protocol proceeds step-wise through non-pharmacological interventions such as

• massages
• warm blankets
• tea
• backrubs
• relaxation tapes
• low dose of acetaminophen to relieve any general discomfort that may be preventing sleep
• low dose of a pre-selected sleeper as a last resort

 The purpose of this is to discourage inappropriate high dosage prescriptions with other sleeping medications since increased dose of a sleeping aid carries an increased risk for falls.

Secondly, we wished to discourage the use of diphenhydramine (Benadryl), which has been associated with delirium.

Patients on the protocol at one hospital received “Sleep Kits,” which included tea bags, face masks, a tape player & relaxation tape, batteries, and earplugs. Anecdotal reports indicated that patients enjoyed the non-pharmacological approach very much, especially the backrubs and tea!

A snapshot obtained from collection of protocol documentation sheets showed that when using the protocol- 88% were able to stop at the non-pharmaceutical interventions or just acetaminophen and 61% of the patients were asleep after this step. Of the patients who did require the sleeping aid, none needed the higher dose.

Implementation of the protocol entailed great education to physicians, nurses, patients and other staff. Notably, considerable face-to-face education was needed for physicians, as most were actually not aware of the untoward effects of sleeping aids. As well, hospitals had to remove the administration of sleepers from many standing orders and guidelines. In one hospital, the sleep protocol was incorporated into computerized order entry.

Related to the sleeper protocol, challenges that were revealed included reclaiming the sleeper protocol documentation sheets from patients’ charts in order to assess at which point the protocol was stopped and even getting the nurses to use the sheet and document how the protocol was used, i.e. provided tea & massage and then patient fell asleep or proceeded up until giving ibuprofen. Tracking the sheets down and getting the steps documented required many visits and reminders to the units and medical records areas and a number of protocol sheets were never retrieved.

Through the focus on reducing sleeping aids, it was also revealed that many of the hospitals’ standing orders and guidelines included orders for sleeping aids to be given to patients, making it a challenge initially to reduce their usage. Teams had to spend considerable time to obtain approval to purge these standing orders and guidelines of the promotion of sleeper use.

Results

• Sleeping aid (“Sleeper”) use is down to around 4% from around 24%.
  It is felt that a good portion of the remaining sleeper usage is patients that come in to the hospital already on a prescribed sleeping medication.
• Standardized the type and dosage of sleepers when given: went from multiple sleepers, many of which were associated with falls and/or fractures, down to a very low dose of one that, to date, has not been associated with falls and/or fractures in the literature. Please note: no sleeper is a safe sleeper!
• Falls in patients having had a sleeper within 12 hours are down, with 0 falls w/ sleepers in Q4.
• Since the protocol start, there have been 0 falls with a patient having received a sleeper at any of the 3 hospitals (prior ranged from 0%-60% of falls having had sleeper).
• No adverse events or complaints associated with protocol use were received.
• Several patients have sought out individuals to report that the protocol is “fantastic” patient care.
• Interestingly, Hospital B was able to arrange a target and control population on the unit piloting the sleeper protocol. The target population, which received the protocol, had zero falls with a sleeper once the protocol was in use. In the control population that did not receive the protocol, the percentage of fallers that had received a sleeper within 12 hours ranged from 0-50%, with an average of 22%.

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