• Always follow Standard Precautions, including thorough hand washing. Refer to Table 13-3 for a summary of infection-prevention precautions, including airborne, droplet, and contact precautions.

• Be familiar with the different alarm systems, including how and when to use such equipment as code call buttons, staff assist buttons, and bathroom call lights.

• Know the facility’s policy for accidental chemical, waste, or sharps exposure, as well as emergency procedures for evacuation, fire, internal situation, and natural disaster. Know how to contact the employee health service and hospital security.

• Confirm that you are with the correct patient before initiating physical therapy intervention according to the facility’s policy. Most acute care hospitals require two patient identifiers (by patient report or on an identification bracelet), such as name and hospital identification (ID) number or another patient-specific number. A patient’s room number or physical location may not be used as an identifier.¹ Notify the nurse if a patient is missing an ID bracelet.

• Elevate the height of the bed as needed to ensure your use of proper body mechanics when performing a bedside intervention (e.g., stretching or bed mobility training).

• Leave the bed or chair (e.g., stretcher chair) in the lowest position with wheels locked after physical therapy intervention is complete. Leave the top bed rails up for all patients.

• Use only equipment (e.g., assistive devices, recliner chairs, wheelchairs) that is in good working condition. If equipment is unsafe, then label it as such and contact the appropriate personnel to repair or discard it.

• Keep the patient’s room as neat and clutter free as possible to minimize the risk of trips and falls. Pick up objects that have fallen on the floor. Secure electrical cords (i.e., for the bed or intravenous pumps) out of the way. Keep small equipment used for physical therapy intervention (e.g., cuff weights) in a drawer or closet. Do not block the doorway or pathway to and from the patient’s bed.

• Store assistive devices at the perimeter of the room when not in use. However, when patients are allowed to ambulate independently in their rooms with an assistive device, the device should be in safe proximity to the patient.

• Provide enough light for the patient to move about the room or read educational materials.

• Reorient a patient who is confused or disoriented. In general, patients who are confused are assigned rooms closer to the nursing station.

• Always leave the patient with the call bell or other communication devices within close reach. These include eyeglasses and hearing aids.

• Make recommendations to nursing staff members for the use of bathroom equipment (e.g., tub bench or raised toilet seat) if the patient has functional limitations that may pose a safety risk.

• Dispose of linens, dressings, sharps, and garbage according to the policies of the facility.

Fall Risk

A fall is defined as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.”² A fall by this definition applies to the conscious or unconscious patient. For hospitalized patients, a fall is one of the most common adverse events and accounts for increased hospital personnel needs, length of stay, cost, and morbidity and mortality, especially among older adults.³ Fall prevention during hospitalization includes a fall risk assessment performed on admission by the nurse. Further prevention of falls involves a multitude of strategies and safety initiatives to prevent falls, including personal alarms, proper footwear, medication review, frequent toileting, adequate room lighting, and routine mobilization. The standardized fall risk assessment performed on admission varies from hospital to hospital; however, common components include prior falls, age, polypharmacy, the use of diuretics or antihypertensive agents, bowel and bladder incontinence, visual acuity, presence of lines and tubes, medical conditions associated with falls, and a history of dementia or impaired short-term memory.⁴ Depending on the fall risk score and the subsequent designation of increased fall risk, a patient is identified as such (depending on hospital policy) by a specialized wristband, on a sign at the doorway to the room, and in the medical record.

Use of Restraints

The use of a restraint may be indicated for the patient who is at risk of self-harm or harm to others, including health care providers, or is so active or agitated that essential medical-surgical care cannot be completed.⁵ A restraint is defined as “any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely; or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.”⁶

The most common types of physical restraints in the acute care setting are wrist or ankle restraints, mitt restraints, or a vest restraint. Side rails on a bed are considered a restraint when all four are raised.⁷ The use of restraint requires an order from a licensed independent practitioner that must be updated approximately every 24 hours.⁸ A patient must be monitored on a frequent basis, either continuously, hourly, or every 4 to 8 hours, depending on the type of restraint used or according to facility policy and procedure.⁸

Although restraints are used with the intent to prevent injury, morbidity and mortality risks are associated with physical restraint use.⁷ Most notably, the presence of the restraint and the resultant limitation of patient mobility can increase agitation. New-onset pressure ulcers or alterations in skin integrity, urinary incontinence, constipation, pneumonia, and physical deconditioning also can occur.⁹ Musculoskeletal or nerve injury from prolonged positioning or from pushing or pulling on the restraint or strangulation/asphyxiation from the restraint as a result of entrapment can occur if the patient is not monitored closely.⁹ Many hospital care plans and policies reflect the trend of minimizing restraint use and using alternatives to restraints, including scheduled toileting, food and fluids, sleep, and walking; diversions such as reading material or activity kits; recruitment of help from family or other patient care companions; relaxation techniques; camouflaging medical devices; and adequate pain management.⁹ Nonrestraint strategies for minimizing fall risk include bed and chair alarms that alert staff when a patient has moved from a bed or chair unassisted.

General guidelines most applicable to the physical therapist for the use of restraints include the following:

Medication Reconciliation

Medication reconciliation is the process of comparing a list of the medication(s) a patient is taking to that which is ordered on admission, on transfer between areas of the hospital, and on discharge for the purpose of ensuring an up-to-date medication list.¹⁰ Medication reconciliation has become an important safety initiative in hospitals to prevent medication errors such as inadvertent omission or duplication of a medication, incorrect dosing, and drug interactions and to ensure that all health care providers can access a similar and complete medication list.¹¹

Latex Allergy

A latex allergy is a hypersensitivity to the proteins in natural rubber latex. If the reaction is immediate, then it is IgE-mediated with systemic symptoms resulting from histamine release.¹² If the reaction is delayed, typically 48 to 96 hours after exposure, then it is T cell–mediated with symptoms at the area of contact and related to the processing chemicals used in the production of natural rubber latex.¹² Signs and symptoms of an allergic reaction to latex may include urticaria, contact dermatitis, rhinitis, asthma, or even anaphylaxis.¹³

Natural rubber latex can be found in a multitude of products and equipment found in the acute care setting. The products most commonly used in the hospital setting include gloves, stethoscopes, blood pressure cuffs, Ambu bags, adhesive tape, electrode pads, catheters, tubes, and hand grips on assistive devices. Many hospitals have minimized or eliminated latex products, particularly powdered latex gloves; they have been replaced with vinyl products for the benefit of the patient and health care provider.

Between 5% and 10% of the general population has a sensitization to latex; health care workers have a greater incidence.¹³ Persons with spina bifida, congenital or urogenital defects, indwelling urinary catheters or condom catheters, multiple childhood surgeries, occupational exposures to latex, or food allergies are at increased risk for latex allergy.¹⁴ An association exists between latex sensitivity and food allergy, in which a person can have a cross-reactive protein allergy to a food (often a fruit) that is linked allergenically to natural rubber latex.¹⁵ This cross-reactivity is known as latex-fruit syndrome; those fruits most strongly identified with a reaction include banana, kiwi, avocado, and chestnuts.¹⁵ Although not all people with latex sensitivity will also be allergic to certain foods, awareness of the possibility is important.

If a patient has an allergy or hypersensitivity to latex, then it is documented in the medical record and at the patient’s bedside. Hospitals will provide a special “latex-free kit,” which consists of latex-free products for use with the patient. Health care providers may be at risk for developing latex allergy from increased exposure to latex in the work setting primarily from repeated latex glove use. The allergen is leached directly from the glove by skin moisture or from the powder in the glove or is inhaled when the allergen becomes airborne with glove use.¹³ If you suspect a latex hypersensitivity or allergy, seek assistance from the employee health office or a primary care physician.