Doctor fears rise of restraint use to prevent falls in hospitals

As many as one of five patients fall at least once during their time in the hospital, leading to injuries, longer stays, lawsuits, and hospital bills higher by about $4,000, according to previous research cited in the opinion piece. Falls are often caused by the illnesses or impairments patients have and the medications and other treatments they receive to treat them, Inouye said, meaning falls can happen despite the best hospital care.

Without well-established guidelines on preventing falls, Inouye said she fears restraints will be used.

"We have to do something to counteract what may be people's natural tendency to think to stop falls, we've got to tie everyone up," Inouye said in an interview. "We want to open people's eyes to the fact that restraints are actually associated with lots of complications."

Patients who are in restraints can become agitated or delirious, both of which can lead to falls. They also are more likely to develop bed sores, breathing problems, or die, research has shown.

A hospital-group representative said measures designed to keep a closer watch on patients and to keep them moving are more likely to be used than restraints.

"People never talk about restraints. We're always trying to prevent that," said Patricia Noga, senior director of clinical affairs at the Massachusetts Hospital Association and a member of a statewide coalition to prevent falls. "We are always looking at other ways to keep the patients moving and as free and functional as possible."

As director of the Aging Brain Center at the Institute for Aging Research at Hebrew Senior Life, Inouye has spent more than 20 years studying ways to prevent delirium, a state of acute confusion common among the hospitalized elderly. Her research has shown that efforts to prevent delirium, minimize certain medications, and maintain mobility, combined with lowered beds and scheduled trips to the toilet, reduce falls. She has watched the use of restraints -- straps to confine patients to beds or chairs -- decline by two-thirds over those two decades, but now she fears their use will return.

"We don't want to give the message at all that falls are fine to occur in the hospitals," Inouye said. "We just feel this is a very blunt instrument in making them a no-payment condition."

Dr. Thomas Valuck, medical officer and senior adviser in the Center for Medicare Management at the Centers for Medicare & Medicaid Services, disagreed, saying the policy encourages alternatives to restraints.

"I think it's totally appropriate to use the Medicare payment incentive to encourage adherence to those best practices," he said.

The Mass. Hospital Association's Patients First initiative posts on its website tallies of falls and the number of resulting injuries at the state's acute care hospitals. Some hospitals have care teams visit vulnerable patients more frequently -- as often as once an hour -- to check on them, helping them use the toilet more often, or checking on other needs, Noga said.

Patricia Rutherford, vice president of the Institute for Healthcare Improvement in Cambridge, also said such measures are working.

"Falls and patient injury from falls are a significant problem," she said. "We do need to catalyze action around it. There are a few simple interventions starting to show promise that help to reduce patient injuries from falls."