Cautious hospitals keep the elderly in bed
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.”
- - -
Produced by Kaiser Health News, a nonprofit news service and an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.