From our earliest columns on falls we’ve pointed out that we always have two goals that may seem to be somewhat contradictory: (1) preventing injuries related to falls and (2) promoting mobility and its positive consequences. Notice that we put the emphasis not on preventing falls but rather preventing injuries that occur related to falls. Perhaps because of our background in neurology we’ve been sensitive to the need to encourage mobility in many of our patients who have neurologic impairments.
A recent “Viewpoint” in JAMA Internal Medicine (Growdon 2017) eloquently expresses this tension between promoting mobility and preventing falls in the hospital. The authors emphasize some of the problems engendered by immobility, including contribution to the “post-hospital syndrome” (see our February 17, 2015 Patient Safety Tip of the Week “Functional Impairment and Hospital Readmission, Surgical Outcomes”). They note that, in our zeal to prevent falls, we do things that restrict mobility (eg. bed and chair alarms, etc.). They also discuss that many fall prevention interventions have failed to impact fall-related injury rates.
They go on to point out that strategies that promote mobility may actually help prevent falls. Note that in another of this month’s What's New in the Patient Safety World columns “” we discussed the Hospital Elder Life Program (HELP program). While one of the primary goals of HELP is prevention of delirium and its consequences, it has also been shown that the HELP program actually prevents falls. A meta-analysis of multicomponent nonpharmacological interventions for delirium prevention (Hshieh 2015) confirmed that multicomponent nonpharmacological interventions are effective in decreasing delirium incidence and preventing falls. It estimated that potential savings in the US from such programs might be more than $16 billion annually. The meta-analysis included over 4000 patients from 14 studies. Most used HELP or a modified HELP program. Some used volunteers, family, or nurses in their interventions. Overall, the odds of delirium were 53% lower in patients receiving these interventions and the NNT (number needed to treat) was 14.3. In addition, the odds of falling were 62% lower among patients with such interventions (delirium is a risk factor for falls). While there were trends favoring those in the intervention group for length of stay, institutionalization, and changes in functional or cognitive status, these trends did not reach statistical significance.
Growdon and colleagues attribute the limitation on promoting mobility, in part, to the risk of lawsuits and to institutional cultures driven to avoid any financial penalties. Specifically, they note that hospitals are penalized financially only for falls that result in
injuries, so they do not always collect data that can prospectively separate injurious from noninjurious falls.
We’ve always advocated use of “ambulation teams” that can help promote mobility in a safe manner and relieve some of the pressure on nursing staff. Growdon et al. also advocate transforming fall prevention teams into “mobility teams”. Further they suggest we need to add measures of mobility promotion to our measures of quality and safety. They suggest that, rather than using bed and chair alarms, we should be using accelerometers to assess how many steps our patients are actually taking and use these as measures of progress during hospital stays. They note that the “dichotomy” between fall prevention and mobility promotion is really a false one.
Further, they call for adjustment of current fall prevention metrics to reflect the counterbalancing benefits of increased mobility. We wholeheartedly agree.
Some of our prior columns related to falls:
Some of our previous columns on falls after correction of vision:
June 2010 “Seeing Clearly a Common Sense Intervention”
June 2014 “New Glasses and Fall Risk”
August 2014 “Cataract Surgery and Falls”
Growdon ME, Shorr RI, Inouye SK. The Tension Between Promoting Mobility and Preventing Falls in the Hospital. JAMA Intern Med 2017; 177(6): 759-760
Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med 2015; 175(4): 512-520