The Washington Post wrote an article titled, “Overzealous in preventing falls, hospitals are producing an ‘epidemic of immobility’ in elderly patients“. The content highlighted exactly what has been occurring in my hospital.
In just a few days at the Ohio hospital, where she had no occupational or physical therapy, Twigg grew so weak that it took three months of rehab to regain the ability to walk and take care of herself.
As many may or may not know, this phenomenon can be attributed to Medicare and Medicaid.
“Congress introduced stiffer penalties with the Affordable Care Act, and CMS began to reduce federal payments by 1 percent for the quartile of hospitals with the highest rates of falls and other hospital-acquired conditions.”
Running hospitals is business. As practitioners, we may face pressures such as meeting daily productivity quota in acute care. We may have large caseloads, and many patients likely have been discharged or do not have orders for treatment with us.
I’d like to format this post from the perspective of the important players. This is from my personal experience, and not their actual perspective, but I hope it helps to gain perspective into how complicated the situation is, and how important a team approach is to solve this problem of patients not getting up in the hospital.
“This patient should not get up without a therapist.”
“This patient should walk X times a day with staff.”
- RN/CNAs/Care Partners
“I do not have enough time to mobilize this patient, I am already behind on X, Y, X.”
“This patient is a high fall risk, if they fall on my watch, I will get in trouble.”
“Alarms go off when I try to get up.”
“I get in trouble when I try and get up.”
“No one comes by to help me get up.”
“I feel more comfortable waiting for a therapist to come and get them up.”
“I am too weak and in too much pain to get up.”
(Patient, e.g. dementia, does not have the cognitive capacity to think about getting up)
- Family member
“Why is my family member not getting up X times a day?
“Patient needs to get up X times a day with nursing”
“I already/will ordered/will order more PT.”
Currently, my hospital is piloting a program to promote increased or early mobilization with nurses. While I think this is a step in the right direction, the underlying penalties should be addressed from a policy or financial level. Nurses may already have a dangerous amount of responsibilities. Thankfully, their unions keeping patient ratios low. Another problem I see is the system that calls off CNAs/Care partners off work when census drops. Simply having more support staff such as CNAs to walk patients can help reduce the burden on nurses.
I believe it is not only the responsibility of OTs/PTs to mobilize patients but the entire team. Of course, nurses or staff should not be penalized or get in trouble when a fall occurs on their watch. Even if they did not, psychologically, it can discourage them from mobilizing that same patient again. I like the idea of taking a team approach to tracking how many times a patient mobilizes each day, if appropriate. Nurses already track I&O’s, so this will add yet another form of documentation to nursing, but, as the article outlines, weakness can contribute to further falls and poorer health outcomes. Here is an example I drafted.
- Is the patient safe to ambulate? Yes / No
- If no, why not?
- Are they a high fall risk? – i see a potential issue with this question as patients are all high fall risks or perceived to be.
- Has the patient been evaluated by OT/PT to ambulate?
- How many times has the patient ambulated today?
- With whom? 1)RN 2)CNA 3)Alone or family member 4)OT/PT 5)Other