vulnerable patient policy based on NABH guidelines.

1. By
A.DEEPARANI.,RNRM.
DEPUTY NURSING SUPERINTENDENT
VULNERABLE POLICY

2. objectives
At the end of the session staff nurses shall,
 define vulnerable patients.
 list identified vulnerable patients in prashanth
hospitals.
 knows fall risk assessment tools.
 explains policy on vulnerable patients.
 enemurate and practice patient education and
implement.
interventions based on fall risk assessment.

3. DEFINITION OF VULNERABLE PATIENT
A patient who is or may be for any reason
unable to protect and take care of him or herself,
against significant harm or exploitation.

4. Assessment of Vulnerable Elderly:
Neurological status
Psychological and mental status
 Ability to meet Activities of Daily Living
General physical assessment
 Assessment for suspected nutritional and functional risks
Assessment for the risk of fall injury
 Skin integrity assessment
 Assessment of Vulnerable Young Children:
 General conditions
 Medical or surgical conditions
 Assessment for a suspected abuse or maltreatment

5. Following type of patients can be
identified as vulnerable patients
 Below 12 years.
 Above 65 years.
 Terminally ill patients.
 Patient with intense and chronic pain(Pain more
than 6).
 Women experiencing terminations and
pregnancy.
 Patients with emotional psychiatric disorders.
 Patients receiving Chemotherapy.
 Patient whose immune systems are
compromised.
 Patient Suspected of Drug and alcohol
dependency.

6. Fall risk assessment tools
 Morse fall risk assessment
 Humpty dumpty scale for paediatrics
 Obestetric fall risk assessment

7. Policy on Vulnerable patients
 Staff nurse shall assess Fall risk assessment for all
patients, twice a day(Morning and Night) initiate
appropriate interventions and ensure these are
documented.
 Fall risk assessment need to be reassessed on internal
transfer of patient from one unit to another& in case
of patients’ clinical condition alters(e.g.Surgical
intervention, clinical deterioration).
 Assess the patient condition and provide care according to
their condition
 Provide education on safety first programme and same
need to be documented.

8. Vulnerable patients are prone to face
following problems during their stay in the
hospital
1. Fall from bed or in washroom or while
transporting from one place to another. The physical
and mental limitation makes it difficult for these
patients to avoid falls
2. Harms due to medical errors such as wrong
medication, wrong diet etc., as they are unable to be
watchful about the care being given to them
3. Neglect, abuse (verbal or physical) and similar
other behaviours by some staff
4. Infringement of their rights, such as privacy,
informed consent, confidentiality, respect etc.
5. Acquiring of healthcare-associated infections, as
these patients may not be observant about infection
prevention practices

9. How to take appropriate care of vulnerable patients
It is evident that vulnerable patients require special
care and attention to prevent them from likely
harms. Following things can be done in this
regard
1. Identifying vulnerable patients – The
first step is to identify the vulnerable patient who
may require special attention. The list of
conditions under which a patient should be
considered ‘Vulnerable’ (as the one, given above)
can be used for quick identification of such
patients..

10. Contd….
Vulnerable patients so identified can be given a
patient ID band of a Orange colour, or a safety
first labelled on their medical file for the
information of healthcare staff. Fall leaf is
displayed on patient cot.
2. Fall risk assessment - One of the
prevalent risk, all vulnerable patients face is the
risk of fall. Hence, as a prevention measure, all
patients identified as vulnerable must be
assessed for risk of fall. ‘Morse fall scale’ can be
used for this purpose, which gives a risk score.
Necessary measures can be taken for a patient

11. 3. Safety of vulnerable patient – As vulnerable patients are susceptible
to certain harms, following safety practices must be followed for each
vulnerable patient. While this list is generic and can apply to all types
of vulnerable patients, inclusion, exclusion and modifications can be
done in the list depending upon the type and level of vulnerability
assessed.
 Hospitals must have disabled friendly environment as
many patients categorized as vulnerable will be disabled.
 Such patients should be monitored more frequently for
ensuring that they are safe.

12.  They shall be accompanied by an attendant
while going to washroom or any other area.
 The washroom that they use must have grab
bars, anti-skid mats and call alarm system
 While they are on bed safety railings should be
put up in place to prevent fall from bed
 While being transported on wheelchairs or
stretchers, safety belt shall be put up

13.  Within the hospital the all vulnerable elderly and children will be
given all-necessary care needed with consideration.
 If the patient’s condition demands further care which is not
available in our hospital , patient will be transferred to the
other hospitals/facilities.
 While transferring the patients a staff nurse will be accompany
the patient along with the caregiver.
 If the patient’s condition is critical , will be escorted by a doctor
 and a nurse while transferring them form hospital to hospital.
Staff taking care of high risk patients must have adequate
training and skills.
 The identified vulnerable patients will be under close monitoring
at all times during their hospitalization to minimize risks of health
care services.

14.  All healthcare providers will maintain a safe environment, related but not limited
to: equipment, wheelchairs, bed rails, mobility needs, fall precautions .
 All healthcare providers will encourage family involvement and support in care
delivery, education and decisions as appropriate.
 Special consent considerations will be taken when needed for each individual case
following the hospital approved consenting policies
 Once the patient is stabilized with the disease process, they will be fit for the
discharge.
 The discharge patient will be discharged with follow-up advise.
 All documentation required for the team to work and communicate effectively in the
care of high risk patients must be maintained as per hospital documentation policy.

15. Maintaining a safe environment
for all patients
 Patients are nursed in an appropriate bed
 Orientate all patients, parents/carers to room and ward
 Keep beds in low position with brakes on and bed ends
in place
 Side rails and cot sides are raised for appropriate age and
patient groups
 Appropriate non slip footwear for ambulating patients
 Nurse call within reach; educate patients and families on
its functionality
 Maintain adequate lighting in patient’s room; low level
lighting at night.

16. Conti…..,
 Keep floors clear of clutter including equipment and toys incase
of paediatrics.
 Secure and supervise all patient with a safety belt or harness in
wheelchairs,stretchers
 Hourly rounding will support the provision of proactive care
such as the need for assistance to the bathroom
 Assist unsteady patients with ambulation; refer to physiotherapy
notes where available
 Place necessary items a patient may need within reach (drinking
water, phone, etc)
 Patients who have received sedation or general anaesthetic may
be unsteady and require supervision
 Ensure equipment is well maintained and serviced appropriately
(such as wheelchairs and commodes)

17. Documentation of a fall event
 Record the incident including: description of event
(location, activity occurring, time, who was present),
assessment findings, interventions and patient outcomes,
notification of the incident to the relatives.
 Report the incident through the hospital incident reporting
system, All falls, including near misses should be reported.
The information from reported falls is used to gain insight
of the causes of falls for patients at the prashanth hospitals
and continuously improve the local falls prevention
program.
A fall has occurred
 What factors contributed to the fall.
 Outcome of post-fall assessment.
 What additional protective measures have been put in place.

18. Who can give consent?
 The consent shall be taken from the patient in all cases when the patient
is capable of giving consent and above the legal age for giving consent.
 In case the patient is independent of decision making, this would
include the next of kin.
 The order of preference for next of kin/legal guardian is
 Spouse
 Son/daughter/Parents
 Brothers/Sisters
 For life threatening situations, when a patient is incapable and next of
kin is unavailable, in the interest of time, the treating doctor and
another clinician can take a decision to safeguard the patient’s life.
 For Adult patients: His/her signature or thumb impression is obtained
in the consent form along with the witness signature, name and contact
details.
 For Paediatric cases: The signature is obtained from the parents.

19.  For unknown patients: Consent shall be given by the Medical Director along with
witness signature and are marked as MLC in the patient case sheet and the police is
intimated about the same.
 For unconscious patients: consent shall be given by the attendant with the reason for
why the patient could not give the consent has to be documented by the consultant.
 On life saving conditions: treating Doctor shall be authorized for decision making.
 Consent for surgery and other related procedure shall be obtained by the surgeon
prior to surgery explaining about the procedure, outcome and expected duration of
recovery and the consent is obtained from patient / attending relative.
 Consent for anaesthesia is obtained from patients after explaining the risks, benefits and
alternatives, person performing the procedure by the anaesthetist.
 All patients those who undergo plastic surgery at Prashanth hospital, consent will be
obtained from the patient for taking photographs(before and after surgery) by the
surgeon.
 For blood transfusion consent shall be obtained from patient by staff nurse and the
same will be verified and counter signed by the ordering consultant/ Doctor on duty.
 For all invasive procedures consent will be obtained from the patients / attending
relative.

20. EXCLUSIONS OF INFORMED
CONSENT
 A. Medical Emergency:
 A procedure which may otherwise require informed
consent may be performed without obtaining prior
informed consent in an emergency when the patient is
incapable and cannot make an informed decision, and
the patient has a life-threatening situation requiring
immediate treatment such that any delay in treatment
would likely result in death, deterioration, or serious
permanent impairment. In such circumstances
treating doctor shall consent the patient, with proper
reasoning and the same shall be documented in the
patient case sheet.
 If the patient is unconscious or not in a state to give
consent, the treating physician shall seek the consent
from attending relative or next of kin.

21.  B.Minor:
 If the patient is under 18 years of age, consent
should be obtained from legal guardian with the
specific facts and reasons the exception applies
must be documented in detail in the medical
record.

22.  C.Emergencies in unconscious patients:
 If an emergency arises in an unconscious patient
the practitioner should, if time permits, endeavor
to obtain the consent of the next of kin, but if
urgent treatment or investigation is essential the
doctor should have no hesitation in proceeding to
do what is necessary.
 A written opinion of a professional colleague that
an emergency operation is absolutely necessary
can be obtained.

23. Patient and family education
 Educational activities will be part of the fall prevention program and will
be as follows
 Staff training to increase awareness of high risk patients and prevention
strategies
 All nurses will be familiarized with the fall prevention program and
evaluated
 Educating the patient and family about the risk of falls, safety issues and
their mobility limitations. The same will be documented in patient
records.
 Teaching patients to make position changes slowly.
 Orienting all patients to their bed area, ward facilities and how to get
assistance.
 Explaining the use of grab bars in toilets to all patients
 Reinforcing education to all high risk patients on a regular basis (every
shift) and on transfer between two wards
 Side rails to be kept raised at all times for all high risk patients.
 Place call bell & other necessary items like spectacles, drinking water
etc. within patients reach
 Hourly visit to all patients to ensure all basic needs are met & all
necessary items & call bell is kept with the patients reach.

24. ENVIRONMENTAL ISSUES
 Activities that aim to reduce environmental risks
include:

 Decreasing obstacles and clutter
 Night lights at bedside and toilet
 Stabilizing beds and bed side furniture
 Having grab bar inside toilets
 All repairs to be attended without delay.
 If an equipment or furniture requires repair, patientis
admitted to the room only after the issue is fixed.
 Caution board stating “wet floor” must be placed in case
of wet floor or during routine mopping.

25. ELIMINATION NEEDS:
 Interventions to support the patient’s
elimination needs include:
 Placing patients with urgency near toilets
 Checking patients who are receiving laxatives and
diuretics
 Toileting at risk patients routinely (offering bed pan
and urinal at regular intervals)
 Instructing male patients prone to dizziness to sit
while urinatingIf need to stand, ensure someone is
there with the patient
 Emergency call bell must be placed inside toilets

26. MEDICATIONS & MOBILITY
MEDICATIONS
 Activities related to medication include:
 Assessing patients receiving laxatives, diuretics, anti-
hypertensives etc.
MOBILITY
Interventions related to mobility:
 Non-skid footwear
 Providing physiotherapy
 Instructing patients to rise slowly
 Assistance while walking for “PTF” patients
 Repeating activity limitation instruction to patient and family
 Assisting “PTF” patients during transfer
 Assisting “PTF” patients to increase mobility by walking
patients in corridor if there is no medical contraindication.

27. MENTAL STATE, BED REST
MENTAL STATE
 Altered mental status is one of the common identified risk
factor for falling and the intervention include:

 Reorienting confused patients regularly
 Orienting patients to the hospital environment
 Keeping confused patients near nurse’s station
 Using family members to be with confused patients at all times
BED REST
 Interventions that aim to reduce the risk of falling while
patient is on the bed include:
 Ensure bed is in “Low” position
 Ensure bed is locked.
 Ensure bed side-rails are in “UP” position
 Ensure patients can reach necessary items

28. WHEEL CHAIRS & CHAIRS
 To prevent fall involving wheel chairs
include:
 Use safety straps or seat belts in chairs
 Ensure support to prevent slipping from chairs
 Selecting suitable chairs for sitting.

29. Orange colour ID Band to identify
vulnerable patients

30. call bell

31. Foot stool Call in bath
room

32. Side rails and fall leaf

33. Grap bar Safety belt in
wheel chair

34.  Thank you…