Break the "ill-fated trio": falls-immobility-delirium, an outstanding issue in the quality of hospitals

Marco Inzitari

The pressure on the safety of patients and medical errors to which we are all subject, together with the fear of professionals for possible complaints resulting from adverse events within the hospital (Hospital Acquired Conditions - HAC, for Americans), are changing the hospital culture, prioritizing the prevention of falls, in many cases, on top of mobility, functionality and, finally, the well-being of patients.

This is what happened in the US from 2007-2008, when the Centre for Medicaid and Medicare Services decided to penalize the billing of episodes of patients affected by different HAC, including falls with injury, to the Affordable Care Act (Obamacare), which penalizes hospitals with worse results in this sense. In our context, in recent years some care areas have also been rewarded or penalized, at the contract level, according to an indicator of intra-hospital falls.

A recent editorial in JAMA Internal Medicine, signed by ME Growdon et al, puts the prevention of falls and the risk-benefit relationship with the possible restriction of mobility that this may entail at the centre of the debate on clinical management and general management of hospitals. In summary, he argues, with evidence, that the current efforts to reduce intra-hospital falls are based on an erroneous assumption: that reducing the mobility of patients would prevent falls. In fact, that has practically caused an "epidemic of immobility."

Some of the supporting arguments of this thesis:

• In US acute care hospitals patients spend more than 95% of their time in bed.
• Immobility in the hospital is one of the main factors behind the "post-hospitalization syndrome", a transitory state of vulnerability that follows hospitalization, and which determines more risk of functional decline, adverse events and readmissions. It’s well known that, in elderly people, immobility very quickly causes skin wounds, disorientation and loss of muscle mass. Even in experiments on voluntary healthy adults, after 10 days of immobility in bed, despite following a proper diet, muscle strength is reduced by up to 14%. The relationship between loss of strength, difficulty walking and falls is intuitive.
• Despite the fall prevention measures promoted in hospitals, in the US, between 2007 and 2010, falls have not been reduced.
• Evidence about the effectiveness of interventions aimed at preventing falls in hospitals is limited, even more than in the community. It’s a fact that programs that include elements such as the identification of patients at risk (including through "labelling"), the review of risk factors, especially extrinsic (of the environment), education of patients and caregivers, accompaniment in the bathroom and the use of sensors and alarms, have given insufficient results. In our context, still too often this can even be associated with the use of physical restraints, from bed rails to other means of restraint in the chair or in the bed. Why don’t they work? One of the reasons is that our hospitals concentrate high risk patients, usually elderly, often with co-morbidity and some degree of functional limitation and disability. Others may be the methodological limitations of the evaluation of these complex interventions. And it would not rule out the same adverse effects on the mobility of these prevention programs. 

On the other hand, mobility programs in hospitals have shown an impact in reducing falls with injuries. Perhaps the most complete is the Elder Life Program Hospital (HELP), well known and promoted by Dr. Sharon Inouye, co-author of the editorial; It’s a multi-component intervention to prevent delirium (formerly, "confusion syndrome"), one of the main risk factors for falls: one of the pillars of the program are the activities of promotion of ambulation and mobility based on the support of volunteers. The program, implemented in 200 hospitals in 11 countries, although the majority are in the US, has been effective for many years in the reduction of delirium, cognitive and functional decline, stays and hospital costs and the use of post-acute resources and institutionalization. The editorial also cites other programs to promote in-hospital mobility (for example, by means of ambulation assisted by auxiliaries or socio-cultural animators, up to 2 times a day, with behavioural strategies to promote mobility) that have shown an impact on maintaining the functions of the inpatient and reducing falls. 

The promotion of mobility in the hospital has finally proved to fulfill the "triple goal", mission of contemporary health services: better health, person-centred care and reduced costs. 

Which are the quality measures that we could implement in our hospitals? 

• Protocols for early patient mobilization. I confess that, as director of a geriatric hospital, one of the greatest joys is to walk the floors and see the empty beds at first hour.
• Adjusted mobility promotion plans based on the investigation of patients' personal history (habits, preferences), especially in patients with dementia.
• Support from staff and trained volunteers. 
• Availability of mobility support products. 
• Reconversion of fall prevention teams or falls commissions (how many do you have?) in "mobility promotion teams". If you don’t have them, build them already with this vision, I add. 
• At the level of indicators, clearly separate incidence of falls and falls with injuries. 
• Associate, to the indicators of fall prevention, indicators of mobility promotion or immobility avoidance (number of times the patient is lifted out of bed or number of ambulances per nursing shift, for example). 
• Avoid a punitive culture towards falls, including at the level of the administration, and promote a reward for the promotion of mobility and the prevention of falls with injuries.

Obviously nobody, even less the author, claims it’s best to forget about the prevention of falls in hospitals. But if we complement it with the promotion of mobility, breaking this false dichotomy we will have an explosive mix of quality improvement which will surely also benefit the prevention of delirium and the reduction of mechanical and pharmacological constraints. In fact, some of the highlighted elements match perfectly with containment removal programs. Without forgetting that, whenever we talk about clinical management in elderly people, we must take into account the complexity at the global level and the person, and design models of adapted interventions and precision, based on logic and science rather than on fear.