By Melissa Bailey Oct. 13, 2019 at 7:30 a.m. CDT
Dorothy Twigg was
living on her own, cooking and walking without help until a dizzy spell landed
her in the emergency room. She spent three days confined to a hospital bed,
allowed to get up only to use a bedside commode. Twigg, who was in her 80s, was
livid about being stuck in a bed with side rails and a motion sensor alarm,
said Melissa Rowley, her cousin and caretaker.
“They’re not letting
me get up out of bed,” Twigg protested in phone calls, Rowley recalled.
In just a few days at
the Ohio hospital, where she had no occupational or physical therapy, Twigg
grew so weak that it took three months of rehab to regain the ability to walk
and take care of herself, Rowley said. Twigg repeated the same pattern — three
days in bed in a hospital, three months of rehab — at least five times in two
years.
Falls remain
the leading cause of
fatal and nonfatal injuries for older Americans. Hospitals face financial
penalties when they occur. Nurses and aides get blamed or reprimanded if a
patient under their supervision hits the ground.
But hospitals have
become so overzealous in fall prevention that they are producing an “epidemic
of immobility,” experts say. To ensure that patients will never fall,
hospitalized patients who could benefit from activity are told not to get up on
their own — their bedbound state reinforced by bed alarms and a lack of staff
to help them move.
That’s especially
dangerous for older patients, often weak to begin with. After just a few days
of bed rest, their muscles can deteriorate enough to bring severe long-term
consequences.
“Older patients face
staggering rates of disability after hospitalizations,” said Kenneth Covinsky,
a geriatrician and researcher at the University of California at San Francisco.
His research found that one-third of patients 70 and older leave the
hospital more disabled than when
they arrived.
The first penalties
took effect in 2008, when the Centers for Medicare and Medicaid Services declared
that falls in hospitals should never happen. Those penalties are not severe: If
a patient gets hurt in a hospital fall, CMS still pays for the patient’s care
but no longer bumps up payment to a higher tier to cover treatment of
fall-related conditions.
Still, Covinsky said
that policy has created “a climate of fear of falling,” where nurses “feel that
if somebody falls on their watch, they’ll be blamed for it.” The result, he
said, is “patients are told not to move,” and they don’t get the help they need.
To make matters worse, he added, when patients grow weaker, they are more
likely to get hurt if they fall.
Congress introduced
stiffer penalties with the Affordable Care Act, and CMS began to reduce federal payments by
1 percent for the quartile of hospitals with the highest rates of falls and
other hospital-acquired conditions. That’s substantial because nearly a third
of U.S. hospitals have negative operating margins, according to the American
Hospital Association.
Nancy Foster, the
AHA’s vice president of quality and patient safety policy, said these policy
changes sent “a strong signal to the hospital field about things CMS expected
us to be paying attention to.” Limiting patient mobility “certainly is a
potential unintended consequence,” she said. “It might have happened, but it’s
not what I’m hearing on the front line. They’re getting people up and moving.”
While hospitals are
required to report falls, they don’t typically track how often patients get up
or move. One study conducted in 2006-2007 of patients 65 and older who did not
have dementia or delirium and were able to walk in the two weeks before admission found they
spent, on average, 83 percent of their hospital stay lying in bed.
While lying there,
older patients often find themselves tracked by alarms that bleep or shriek
when they try to get up or move. These alarms are designed to alert nurses so
they can supervise the patient to safely walk — but research has shown that
the alarms don’t prevent falls. Often stretched thin, nurses are deluged by
many types of alarms and can’t always dash to the bedside before a patient hits
the ground.
Cynthia J. Brown, a
professor at the University of Alabama at Birmingham, has identified common
reasons older patients stay in bed: They feel too much pain, fatigue or
weakness. They have IV lines or catheters that make it more difficult to walk.
There’s not enough staff to help them, or they feel they’re burdening nurses if
they ask for help. And walking down the hallway in flimsy gowns with messy hair
can be embarrassing, she added.
Yet walking even a
little can pay off. Older patients who walk just 275 steps a day in the
hospital show lower rates of readmission after 30 days, research has found.
Across the country,
efforts are underfoot to encourage hospital patients to get up
and move, often inside special wings called Acute Care for Elders
that aim to maintain the independence of seniors and prevent hospital-acquired
disabilities.
Another initiative,
called the Hospital
Elder Life Program, which is designed to reduce hospital-acquired
delirium, also promotes mobility and
has shown an added benefit of curtailing falls.
In a study of HELP sites, there were no reported falls while staff or volunteers
were helping patients move or walk.
Barbara King, an
associate professor at the University of Wisconsin-Madison School of
Nursing, studied how
nurses responded to “intense messaging” from hospitals about preventing falls
after the 2008 CMS policy change. She found that pressure to have zero patient
falls made some nurses fearful. After a fall happened, some nurses adjusted
their behavior and wouldn’t let patients move on their own.
CMS declined a
request for an interview and did not directly answer a written question about
whether its falls policy has limited patient mobility.
In 2015, King studied
a nurse-driven effort to
get more patients walking on a 26-bed hospital unit in the Midwest. The
initiative, in which nurses encouraged patients to get out of bed and
documented how often and how far they walked, boosted ambulation.
Hospitals still face
barriers, such as the shortage of staff time, walking equipment and ways to
record ambulation in electronic medical records, King said.
Getting more patients
out of bed will also take a significant change in mind-set, she said.
“If we think that a
patient walking is a patient who will fall,” King said, “we have to shift that
culture.”
— Kaiser Health News
Kaiser Health News is
a nonprofit news service and an editorially independent program of the Kaiser
Family Foundation that is not affiliated with Kaiser Permanente.
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