Published in the June 2011 issue of Today’s Hospitalist
As hospitals feel financial pressure to prevent inpatient falls, hospitalists everywhere are being asked to play a much more active role. But not everyone in the specialty thinks that preventing falls is the best use of their time.
The debate over the role that hospitalists should play in preventing and treating falls is heating up in part because of financial considerations. In 2008, Medicare stopped paying to treat hospital-acquired conditions like falls that it says are preventable. And data have shown that patients who fall cost hospitals much more in resources, in part because they have longer hospital stays.
As a result, hospitals have started asking their hospitalists to get more involved. In some hospitals, for example, nursing directors are looking to hospitalists to treat falls like codes and to evaluate all patients who fall. Other facilities are bringing physicians into prevention efforts and “post-fall huddles” to prevent repeat incidents.
How do those efforts sit with hospitalists? Some welcome the opportunity to prevent falls through initiatives that focus on medications, tethers, pain and comfort measures, but the feeling is far from universal. While no one debates the seriousness of inpatient falls, some hospitalists say there simply are too many unanswered questions about what they are being asked to do “and not enough evidence to guide their actions.
There are also concerns about how to best use hospitalists’ limited resources and ensure that hospitals aren’t simply “dumping” more patients on hospitalist programs.
But despite some resistance, hospitals are moving ahead and creating new initiatives to reduce falls. And many of those efforts tap into hospitalist expertise.
Better quality care?
Scott W. Tongen, MD, former director of the hospitalist program at United Hospital in St. Paul, Minn., thinks back to one patient whose fall in the hospital several years ago contributed to that patient’s death. In part because of that experience, Dr. Tongen wholeheartedly endorses the idea of hospitalists staffing falls services. In fact, hospitalists at United have been providing face-to-face evaluations for patients who fall since 2003.
Dr. Tongen, who serves as medical director for clinical documentation, quality and care coordination, thinks that physicians can bring not only their clinical expertise but their experience in quality improvement to fall evaluation and prevention.
“You start to see patterns, like this floor has an issue or these meds are always involved,” he says. “Physician involvement has resulted in more creative use of alarms, the implementation of hourly nurse rounding, being vigilant around shift change, and trying not to use medications that contribute to falls.”
A question of autonomy and guidance
At the other end of the spectrum, Brian D. Schroeder, MD, MBA, medical director of the 26-provider hospital medicine group at Covenant HealthCare in Saginaw, Mich., is wary of hospitals that want physicians to see all patients who fall. Some hospitals argue that preventing and treating falls is covered by contract language that refers to “other duties as assigned.”
“From an administrator’s perspective,” Dr. Schroeder says, “if I was paying huge amounts of money to my hospitalists, I would want the hospitalists to do this. But I see it as an erosion of our professional autonomy. Hospitals are looking at their employed physicians with an emphasis on the ’employed’ as opposed to on the ‘physician.'”
At his hospital, preventing and assessing falls is the purview of nurses who began a new rounding program to prevent falls about a year ago. Nurses now check in with patients every hour during the day “and every two hours at night “to ask about “the three Ps: pain, position and potty,” says Dr. Schroeder.
While the program has reduced fall rates and improved patient satisfaction scores, Dr. Schroeder doesn’t think that bringing in hospitalists to evaluate all patients will make it any more effective.
He’s quick to add that the hospitalists are available 24/7 to respond to codes or to assist with rapid response teams for any patient who needs to be evaluated or treated. “However, I’m reluctant to volunteer “or be volunteered by an administrator “to assume the care of patients without a clear, standardized approach or guide- lines,” Dr. Schroeder says.
Where’s the evidence?
Mitchell Wilson, MD, a hospitalist and chief medical officer for Eagle Hospital Physicians in Atlanta, sees both sides of the debate. Hospitalist-led falls services may make sense, says Dr. Wilson, “given the expanding scope of practice that we as hospitalists are being called on to deliver.” Hospitalists at one hospital that Eagle serves, in fact, are considering a request from the director of nursing to see all patients who fall.
But Dr. Wilson sees resources (or the lack thereof ) as a big challenge to getting a falls service off the ground. While his group wants to add value, “We don’t want to add on yet another service with existing staff who are already functioning at capacity.”
Another problem is the lack of evidence on how hospitalists should evaluate falls “and prevent future ones. Because of the paucity of that evidence, he points out, most hospitalists don’t know how to begin to staff and run a fall-evaluation service.
“This is cutting-edge stuff,” says Dr. Wilson. “That’s curious, because people have been falling forever. Gravity is not a new phenomenon.”
Screening and evaluation tools
Hospitalist J. Rush Pierce Jr., MD, associate professor of internal medicine and geriatrics at the University of New Mexico Hospital in Albuquerque, agrees that the literature gives little in the way of guidance. The typical scenario in most hospitals, he says, is as follows: “The nurse calls the doctor and says, ‘Hey, your patient fell. You need to come see him.’ And the doctor says, ‘Well, what am I supposed to do? Why do I need to come see him?'”
To combat that lack of evidence, Dr. Pierce and his colleagues have created a post-fall interdisciplinary checklist for evaluating inpatient falls. The checklist, which is being piloted at his hospital, is divided into three parts.
The first part gives nurses seven yes/no questions for their initial assessment. The questions get to whether the patient hit his or her head, experienced a loss of consciousness or is experiencing pain.
If patients answer “yes” to any of the questions, a physician is called for an urgent exam within 30 minutes. Even if the initial screening doesn’t turn up any problems, physicians are expected to assess those patients for their fall during the doctors’ next visit.
The second part of the checklist prompts physicians to look for five things during their patient assessment, from examining the back of the patient’s neck to performing a sternal compression test.
And because the most important modifiable risk factor to prevent falls is whether the patient has fallen recently, the third part of the checklist reviews items that doctors and nurses can consider changing to make it less likely that patients will fall again. (See “Preventing a second fall.”)
According to Dr. Pierce, the items on the checklist aren’t necessarily based on evidence about how to examine patients who have fallen. The items were, however, derived from discussions with emergency physicians about how they examine trauma cases that come into the ER.
Easy injuries to miss
Checklists are important because they ensure that clinicians don’t miss occult injuries that are particularly worrisome in elderly patients.
“I don’t worry about the injuries that are obvious. A scalp laceration does not go unnoticed,” explains Ethan Cumbler, MD, director of the acute care for the elderly service at the University of Colorado Hospital in Aurora, Colo. “I worry about the injury that could be missed.”
Dr. Cumbler, who is also a hospitalist and associate professor of medicine, says that those injuries can include an unstable cervical neck injury, which could cause paralysis, or an unrecognized hip fracture that could worsen when a patient attempts to bear weight unassisted, or an undetected subdural hematoma. If doctors and nurses don’t take a systematic approach, he explains, those injuries can go undetected. Dr. Cumbler’s hospital has started tracking falls and conducting post-fall huddles to assess patients who have fallen.
Other hospitals have likewise moved to create proto- cols. At Hillcrest Baptist Medical Center in Waco, Texas, nurses began running a falls protocol a year or two ago. Debbie Ucci, DNP, a hospitalist NP at the hospital, says that the centerpiece of the protocol is a falls huddle guided by a checklist in the hospital’s computer system.
The idea, she says, is to evaluate why patients have fallen and whether the fall could have been prevented. (Hospitalists, who care for the vast majority of the medical inpatients, are not involved in the falls protocol, be- yond being notified at the time of the fall if they are the attending for that patient.)
“We depend on the fall team’s evaluation as to whether I need to rush up and order an X-ray or see if the patient is all right,” Dr. Ucci says, “and that seems to be working well. Eventually, we are going to see the patient.”
Finding triggers
One of challenges of fall-prevention protocols like the one being used at Hillcrest Baptist is proving that they work. Falls are caused by so many factors that it’s often difficult to identify specific triggers that can be managed.
“I don’t think we’ve seen a pattern,” says Dr. Ucci. “It seems like every time I have been called to see a patient who has fallen, it’s been for a different reason, like there was water in the bathroom or the patient had a seizure. We have not identified that most people have fallen because they are getting Ambien at night or because they got a narcotic.” She also says that it’s hard to see how adding hospitalists to the falls-huddle program would help.
But Dr. Cumbler at the University of Colorado is beginning to wonder if part of the reason why falls prevention programs are not having more of an impact is because doctors aren’t included either in planning or implementing those programs.
Dr. Cumbler points to a study on fall prevention published in the Nov. 3, 2010, Journal of the American Medical Association. In that study, researchers were able to reduce inpatient falls by identifying patients most at risk of falling. They then posted signs above those patients’ beds that stressed the actions that should be taken to address patients’ particular fall risks.
That study is important for hospitalists, says Dr. Cumbler, because it shows the value of identifying specific risk factors. That allows hospitalists to focus on risks that are “modifiable,” as opposed to factors like age that they can do nothing about.
Modifiable risks
A good example of a modifiable risk factor that physicians can address is patients’ need to use the bathroom.
One solution, says Dr. Cumbler, is to increase how often nurses do a toileting prompt. Another is to change how physicians order medications so patients aren’t taking diuretics late in the evening, only to have those kick in right at nursing shift changes and in the middle of the night.
“That would be driven by the hospitalist,” Dr. Cumbler says. “This gets at the complex interplay between the risk factor in the host, the hospital macro environment and the way in which individual provider behavior can decrease risk.”
His program is trying to “change our focus from risk stratification” “merely identifying which patients are at highest risk for falling “”to identifying and modifying risk factors that can be changed,” a task that he believes is best done with hospitalist involvement.
“Because hospitalists control with their pen some of the things that increase the risk for falls,” Dr. Cumbler says, “we should be part of the process.”
Deborah Gesensway is a freelance writer who covers U. S. health care from Toronto.
