Fall prevention falls short on evidence base

Fall prevention is not usually considered a controversial issue in hospital medicine. It's conventional wisdom—and a component of Medicare payment policy—that hospitals need to take action to prevent their patients from falling.

When orthopedic surgeon Terry A. Clyburn, MD, began an evidence review of fall prevention measures, he was trying to determine which actions orthopedists and their hospitals should take to reduce falls. Should they focus on technologies like bed alarms, identification of at-risk patients with wristbands, or perhaps changes in hospital flooring?

Photo courtesy of Terry A Clyburn
Photo courtesy of Terry A. Clyburn.

But what he found was a surprising dearth of evidence for any of these interventions, leading him to conclude “that there is no conclusive medical evidence that any [existing fall prevention technique] qualifies as an evidence-based guideline or is even effective, with the exception of addressing delirium.” The review found correlations between delirium and falls, and some support for outpatient fall prevention efforts, but no convincing evidence that modifications to medications, nutrition, vision care or hospital facilities reduced inpatient falls.

Dr. Clyburn, who practices at the University of Texas Medical School in Houston, published the review and conclusions in the Journal of the American Academy of Orthopaedic Surgeons in July with coauthor John A. Heydemann, MD. Dr. Clyburn recently spoke to ACP Hospitalist about the significance of his findings for inpatient practice, future research and Medicare payment policies.

Q: What led you to conduct this review?

A: I, for many years, was a member of the patient safety committee of the American Academy of Orthopaedic Surgeons. Fall prevention is one of the issues of interest to the Academy. I was tasked with doing a review and making a report to our committee, with regard to what orthopedists can do to assist in fall prevention.

Q: Were you surprised by the findings?

A: I was surprised to find that the incidence of falls in the hospital is only minimally greater than the risk of falling at home. You have patients who are in the hospital for a reason—some are in for surgery, some are in for medical reasons. If they've had surgery, they're on pain medicine and sleeping tablets and other pharmaceutical agents, which might cause them to be drowsy, delirious, or lose their balance. They're in an environment that they're not accustomed to. They may wake up in the night and think they're at home and want to get up and go to the bathroom.

For these reasons I would have predicted that the fall rate in the hospital would be a lot higher than at home. Thus, the efforts that the hospital takes to prevent falls must be effective, [but] when you actually look at the literature, all of the methods—bed rails, alarming beds, fall risk bands on the wrist—in the studies simply have not been found in the acute care setting to be effective at all. That's very surprising.

Q: What's the practical import of these findings? Should hospitals give up current fall prevention techniques?

A: Absolutely not. What I really think it means is that the techniques probably do have some effectiveness, but the studies that have been done to date have not been large enough. Most of the data that we have is not bad data, but it's not strong evidence-based medicine data.

Putting the fall bracelet on, alerting everybody that's with the patient, keeping the bed down, keeping the bedrails up, trying to minimize narcotics and other medicines that induce delirium—we all believe that these are probably effective. There's just no data to prove that. The fact that the risk of falling in the hospital is not significantly higher than at home is in my opinion indirect evidence that what we're doing is effective.

Q: Are there any potential risks to using these unproven interventions?

A: None of these interventions have any risk at all. What I don't want to see happen is because of the punitive financial situation that exists [Medicare non-payment for inpatient falls], the hospitals may take measures such as increasing use of restraints, which obviously will help to reduce the risk of falls, but that intervention has known risks. Wristbands, being careful with IV lines and things like that, keeping the bed at a lower height, keeping the bedrails up—all of these may or may not be effective. None of them cause harm; none of them have ill effects, so why not use them?

Q: Are there any particular interventions that you would like to see studied more intensively?

A: What I would like to look at is whether the patient has a family member staying with them. It's my impression, having practiced orthopedic surgery for 26 years, that the people who fall tend to be alone. We could do this in a retrospective, possibly in a prospective way, to go back and look at falls in the hospital and see how many of those are witnessed, how many of them occur unwitnessed, how many of them occurred when there was a family member in the room. I tell my patients that at least the first night or two, it would be a very good idea for a family member to stay with you. But I don't have the data to show that that's an effective tool. The issue you have with this kind of study is it has to be very large. It might take several thousand patients to come up with statistical significance.

Q: You mentioned the Medicare policy of not paying for consequences of inpatient falls. What do you think about that rule in light of your findings?

A: I'll have to get on my political soapbox. We know that Medicare funding is a problem; we know that it's gradually going broke. Legislators are trying to find a way to not spend the money. Falls are extremely costly. Basically, what CMS has done is say falls are preventable, so we're not going to pay for them. The problem with that is it makes financial sense for them, but falls aren't preventable. There's nothing a hospital can do to completely, totally 100% prevent falls. People fall.