Fall Prevention – Who is Ultimately Responsible?

It seems that as of October 1, 2008, Medicare will no longer be reimbursing hospitals for eight conditions that befall patients who are hospitalized, and that might have been reasonably prevented using certain evidence-based measures.

These eight conditions include:

* Pressure ulcers (bed sores)
* Objects left in patients during surgical procedures
* Falls suffered by patients while in hospital
* Blood incompatibility
* Air embolism
* Mediastinitis (infection of the area between the lungs)
* Urinary tract infections (UTIs) associated with indwelling catheters
* Sepsis that is central venous catheter-related

While some of these conditions appear reasonable (surgeons should not leave instruments in patients during surgery!), I have mixed emotions about the “falls” category.

While it is true that many falls can be prevented, some cannot. Sometimes patients do not follow the advice of their caregivers and persist in attempting to get out of bed on their own. This happens despite all side rails being up, a call bell situated within easy reach (sometimes pinned to their gown), and admonishment from staff not to attempt to get up by themselves. So who is to blame when patients fall, despite several safety measures in place?

The right to self-determination is a basic human right, and caregivers are sometimes placed in an awkward position, stuck between the proverbial rock and a hard place. Patients have the right to make decisions for themselves, don’t they?

Patients who are confused or who suffer from cognitive disorders may not have the ability to make wise decisions for themselves. These patients are often the ones who fall despite nursing staff’s best efforts. These patients often end up restrained, either physically, with the use of mechanical restraints, or chemically restrained using medications to calm them when they become agitated (meaning they are unwilling or unable to follow instructions not to get out of bed). This is done in an effort to prevent the patient from doing something that may result in an injury to themselves.

It seems that Medicare is placing the onus squarely on hospital personnel to prevent falls. At the very least, they won’t be paying the costs associated with falls suffered by patients in hospitals. My concern is that this policy will lead to an increase in the use of physical and chemical restraint in an effort to reduce the number of falls that hospitals will now be required to cover themselves.

While I agree that every effort should be made to prevent patients from falling while in hospital, I do not believe that falls can be prevented in every instance. Further, I do not believe that hospitals should be “punished” in those cases where falls occur despite the use of fall prevention strategies.