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  • JAMA Viewpoint: The 'False Dichotomy' of Hospital Falls Prevention vs Mobility Promotion

    Hospitals that keep patients immobile as a way of preventing falls are engaging in a "false dichotomy" that can be damaging in the long-term, argue authors of a "Viewpoint" article published recently in JAMA Internal Medicine (preview only available for free). In fact, they write, programs that promote mobility with supervision "may actually help to prevent injurious falls" more effectively than those that encourage patients to stay in bed.

    Current federal payment policies penalize hospitals for certain hospital-acquired conditions, including falls resulting in injuries. While well-intended, these policies have had "unintended consequences" for patient mobility, function, and quality of life, according to authors Matthew E. Growdon, MD, MPH; Ronald I. Shorr, MD, MS; and Sharon K. Inouye, MD, MPH. Patient immobility contributes greatly to "post-hospital syndrome," in which patients are at risk for functional decline, adverse events, and readmission to the hospital.

    Instead, the authors advocate for the Centers for Medicare and Medicaid Services (CMS) to "develop quality measures that promote mobility as part of routine clinical care"—including early mobilization protocols, documenting how often patients are out of bed, and use of patient accelerometers instead of bed or chair alarms to monitor patient movement.

    Despite widespread implementation of hospital falls-prevention efforts over the past 20 years, authors write, evidence shows the rate of "injurious falls" has not declined significantly in the United States. Research has found this to be true in Australia, as well.

    According to the authors, the problem with current falls prevention efforts lies in their "troubling assumption that keeping patients from moving can stop such falls." "Falls prevention teams could be transformed into mobility teams" to enhance patient outcomes, they write.

    Authors cite recent studies of combined assisted walking and mobility initiatives, such as the Hospital Elder Life Program (HELP), designed by coauthor Inouye, that may be more effective at preventing falls than current falls prevention programs that result in keeping patients immobile much of the time. Other promising programs included supervised walking combined with a balance assessment or a behavioral intervention to promote mobility after leaving the hospital.

    While noting that data collection will be the key to assessing effectiveness of such efforts, the authors argue that making changes now will "shine a bright light on the false dichotomy between fall prevention and the promotion of mobility."

    APTA offers a variety of resources on falls prevention, including a practice guideline on the assessment and prevention of fallstests and measures related to falls, a Physical Therapy-published clinical guidance statement from the Academy of Geriatric Physical Therapy, an online community for PTs and physical therapist assistants interested in falls prevention, and a balance and falls webpage.

    Comments

    • Early mobility is crucial to the health of patients. There still exists that never ending battle between nursing and rehab professionals of getting patients out of bed. Many nurses request PT evaluations because they do not want to get their patients out of bed or they don't want the responsibility of a fall occurring during their shift. Also, it is common to be told by a nurse to leave the patient in bed, because they want to prevent a fall. I am tired of evaluating patients who came in walking to the hospital and leave having to go to a SNF for rehab because the only time they got out of bed during their hospital stay was with a therapist. We need to work together for the good of the patient!

      Posted by Maria T. on 6/15/2017 8:33 PM

    • Can we not move away from the misleading and grossly inaccurate term "early mobility". As noted by this article and most other articles discussing mobility in the acute care setting, they are discussing appropriately or correctly timed mobility. The term early suggests premature, poor timed and with increased risk for adverse outcomes.

      Posted by Steve Morris on 6/22/2017 12:35 PM

    • Team work and education are the key for early, safe, and consistent mobilization. We as PTs and other health care professionals also need to look within and challenge some recent pushes towards using mechanical lifts with patients who are heavy assist. I have had patients come to SNF level care who have never attempted a transfer and are a hoyer lift even with therapy. This may certainly be appropriate in some cases, but it should be rare. Although these lifts are great safety devices, I have noticed a trend in them being used by therapists rather than challenging patients whose transfers are difficult or require two persons. The answer is usually that their facility does not allow two person transfers, but that should be reserved for staff who don't have the time, training, and equipment to move the patient safely. If we as PTs don't challenge these patients in a safe manner who will?

      Posted by Lisa Doyle on 7/7/2017 11:28 AM

    • Amen sister! In response to Maria T's comment. It seems like a universal problem. I don't know how we are going to be successful in getting nurses to get the patients up as a normal, routine standard of care. I've tried so many ways and still haven't made much headway!

      Posted by D Waggoner on 7/7/2017 1:51 PM

    • I agree with the first comment. Nurses want a PT evaluation but when mobility recommendations are given they are not followed and often times the therapists have to constantly remind and encourage nursing staff to follow the recommendations. Often times we go to supervisor to complain that 4 days go by before nursing is forced to comply with PT recommendations

      Posted by Daniela Kowal PT on 7/7/2017 3:28 PM

    • Steve, I understand your point about the word "early" and agree with the concept of "correctly timed mobility". I think the problem is that "early" has different meanings to different people. The ICU literature defines early as the point of physiological stability (neurologic; cardiovascular; pulmonary) and should trigger greater "mobility" (We can discuss mobility versus rehabilitation at a later date!). In the ICU, we know that once physiological stability is attained, most patients remain on bed rest. So the term "early mobility" is accurate - I would also agree with your point that once physiological stability is achieved, greater mobility is also "correctly timed mobility"!

      Posted by Daniel Malone on 7/7/2017 6:59 PM

    • I have been working at a SNF for the past 10 years and I have noticed an increase in fall occurance at different facilities. I am interested in studies that prove that Increasing mobility in dementia and stroke patient decrease fall frequency. I have not done any research on the topic myself I just observed that when I teach patients to walk they are more stable and perform better on BERG tests. However when those patients don't have s family support when discharged they are at higher risk for falls

      Posted by Edith Mankiewicz on 7/8/2017 9:15 AM

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