Doctor fears rise of restraint use to prevent falls in hospitals
By Elizabeth Cooney
Globe Correspondent
Patient falls and the injuries they cause are considered such a crisis that in October, the federal government stopped paying hospitals for extra care if a fall is deemed preventable. Now, a Boston doctor is warning that the pressure to keep patients from falling may lead to greater harm through the use of restraints, reversing a trend of greater mobility among hospitalized patients.
Writing intomorrow's New England Journal of Medicine, Dr. Sharon K. Inouye of Harvard Medical School and her co-authors argue that because falls have proved to be such an intractable problem despite broad efforts to reduce them, they should not be included on a list of avoidable medical errors that result in hospitals not being paid.
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."
Comment
Permalink
E-mail
I think it imperative that hospitals, nursing homes and other institutions caring for fragile patients not substitute chemical restraints, i.e psychotropic medications, for physical restraints. All too often patients who have not been taking such drugs before their admissions are placed on them, often with very detrimental results. Staff should be creative in devising ways to deal with the needs on an individual patient basis. I agree that more frequent checking on patients is important, as is keeping them walking. The argument that staff does not have time or are too poorly staffed is a poor excuse. There is always time for things that are so important.
Big brother knows best. This is just the beginning, As Washington gains more control over costs more rules will be in place to control EVERYTHING.
I agree with Dr. Inouye. Falls have been and continue to be an intractable problem in multiple patient care settings. Care givers at home, in nursing homes, rehab facilities and hospitals, all struggle with this very important but hard to prevent issue. As a physician who provides care to patients in multiple different settings and being very aware of the need to prevent falls given their associated morbidity, I have been constantly frustrated by the failure of interventions - from individualized to multi-disciplinary ones. This problem is not akin to infections etc. that CMS is trying to prevent by instituting penalties. There are no clear "best practices" that, if followed, will consistently decrease fall rates. I am afraid Dr. Valuck and CMS's agenda is driven more by cost-containment than any proof that the adoption of certain practices will in fact improve patient care. That is an important distinction to make when looking at why CMS does what it does.
The issue of physical restraints to prevent falls should always be the last resort to protect the patient from injury. It is an action that has serious potential for abuse.
However, there are circumstances which may necessitate such an intervention but only as a last resort and only for the briefest period possible. Restraints themselves create the potential for harm both physically and psychologically.
Of note to hospital administration, never use restraints as a means to save money.
If need be authorize OT or assign needed personel to protect the patient from injury whenever possible. Consult to see what combination of behavioral intervention and medication will insure the patients safety. Remember, restraints are used for the patients safety, not the staffs convenience !
Another reason restraints are used far less frequently than previously is that there is a whole lot of paperwork involved in thier use. Hospitals are required to have strict guidelines in place with frequent monitoring and daily or twice daily review by a prescriber. Documentation must specifically state why other methods are not being implemented. I doubt that restraints will make a comeback if for no other reason the liability issues. Staffing is the root of the problem - it's easy to say it's no excuse, but there is often just no way overworked and understaffed nurses and aides can physically do the work. You just can't be at eight patient's bedsides at the same time.
We have seen some incredible improvements here at The Methodist Hospital in Houston, Texas related to diminishing number of falls and falls with harm: most center around everyone's vigiliance to the issue: doctor, nurse, patient, family and all of our clinical and supprt staff. Though not zero, great strides have been achiefe3d when all individuals are engaged in the process. We as an industry have spent an inordinate amount of time on the development of assessment tools: though important, the key is consistent execution of the bundlte of interventions that are salient to the specific patient.
I have great hope that as teamwork evolves and everyone's awareness of the potential devastating effects that falls have both psychologically as well as physically will help us in finding even more novel ways to keep our patients safe.
This blogger might want to review your comment before posting it.
Contributors
blogger
Boston Globe Health and Science staff:
browse this blog
by categoryrelated links
INside Boston.com