With each of these podcasts we will also publish a GeriPal post with citations of the articles we mentioned during the discussion. For this episode, we discussed the following articles:
- Barker Anna L, Morello Renata T, Wolfe Rory, Brand Caroline A, Haines Terry P, Hill Keith D et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial BMJ 2016; 352 :h6781
- Shorr RI, Chandler AM, Mion LC, Waters TM, Liu M, Daniels MJ, et al. Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients: A Cluster Randomized Trial. Ann Intern Med. 2012;157:692-699.
- Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-Associated Disability“She Was Probably Able to Ambulate, but I’m Not Sure”. JAMA. 2011;306(16):1782-1793
- Zisberg, A., Shadmi, E., Sinoff, G., Gur-Yaish, N., Srulovici, E. and Admi, H. (2011), Low Mobility During Hospitalization and Functional Decline in Older Adults. Journal of the American Geriatrics Society, 59: 266–273
by: Eric Widera (@ewidera), Alex Smith (@alexsmithmd), and Ken Covinsky (@geri_doc)
produced by: Sean Lang-Brown (linkedin.com/in/seanlangbrown)
Note: GeriPal Podcasts can be found on:
Transcript of the Podcast:
Eric: Okay. We're live. Welcome to the very first GeriPal podcast! This is Eric Widera.
Alex: This is Alex Smith.
Ken: Ken Covinsky.
Alex: Shall we begin with a song?
Eric: Let's begin with a song, Alex. What have you got for us?
Alex: I think we should start with “Sweet Home Chicago”.
Ken: Go Cubs!
Alex: In honor of the playoff series between our San Francisco Giants ...
Ken: And my Chicago Cubs.
Alex: ... and Ken's Chicago Cubs.
Alex plays “Sweet Home Chicago” by Robert Johnson
Eric: Ken, the last time we had a journal club we discussed a pretty interesting article from the BMJ. The title of the article is 6-PACK Program to Decrease Fall Injuries in Acute Hospitals: A Cluster Randomized Control Trial. I'm pretty sure this wasn't about 6-packs of beer. You had some pretty interesting stuff to say about it.
Ken: Yeah. This is sort of, of course, a worthy initiative because it's not good when patients in the hospital. Sometimes even after a fall in the hospital, a patient can break their hip. They try to do all these things. That's why it's called a 6-PACK. This included things like doing a fall risk assessment and making sure patients got help before they got out of bed. The problem was it didn't help. No improvement in fall rates with this study. Why do you think that was?
Eric: I'm guess that many of the things that they did in the 6-PACK intervention don't actually work. I think the most likely thing that they used was a sign that told people that person is at risk for falls. Then there were a fair amount of, I guess, five other interventions that also have very limited evidence to prevent falls in the hospital.
Ken: Yeah. What do you think about this bed alarm thing? Patients lying in bed and they try to get out of bed and then it goes bzzz to try to remind them not to get out of bed.
Eric: Yeah. I tried putting one on Alex's chair, but he still comes over to my office all the time! We have two randomized control trials on bed alarms. The last one was in Annals of Internal Medicine which basically showed that bed alarm use, at least in an urban hospital, had no effect on fall-related events or physical restraint use. They just don't work despite that nearly everyone is on one if they're over age seventy-five here in this hospital.
Alex: Why is that? Is that because they get out of bed, the alarm goes off, and by the time the nurse gets there they've fallen?
Eric: There could be two potentials. It's too late by the time the bed alarm goes off to prevent the fall in that person who was going to fall. The second thing, and this is what I hear from Ken all the time, is you have these devices that restrain people to their bed, including bed alarms, people get weaker because they’re not walking. The second we encourage them to walk, now we have somebody who's weaker and who's more prone to fall.
Ken: Actually, there was a report in JAMA Internal Medicine recently where they quoted a patient who had a bed alarm who said they felt they were in prison. We've moved away from physical restraints in the hospital. This is almost like you have an electronic monitoring bracelet on you. It's almost like you're in prison when you have a bed alarm. Part of the problem is there's this underlying philosophy that we'll stop falls by having patients not move. That actually makes the problem worse. We're going to just have everybody leave the hospital weak. What's so great about having patients not fall in the hospital if we send them home so weak that they fall when they get home?
Eric: Is that really a common problem?
Ken: It does turn out that hospitals are really bad for older people. There's a number of studies that show that when patients have been in the hospital, they often leave the hospital a lot weaker, more disabled, poorer mobility, when they go home. This only makes it worse.
Alex: On the other hand, it's kind of sad that it's a negative study because falls in the hospital are a big deal. These interventions seemed relatively low cost. Although, as they point out in the article, there's an opportunity cost in doing any of this stuff. What kind of things could we do to prevent falls in the hospital?
Eric: I guess from the BMJ article, not the randomized control article on bed alarms, but from the BMJ article on 6-PACK, it's unclear whether or not those interventions had no effect. For most patients all they got was a sign. Isn't that right, Ken?
Ken: That seemed to be what most of them got. Most of them just got an assessment which, a lot of times, people don't even read and just a sign on their door.
Alex: Oh, so they got a 1-PACK.
Ken: Yeah, that may be the problem.
Alex: They didn't get the 6-PACK. We haven't actually tested the full intervention?
Eric: No. With that said, if you go to any hospital in the US, they're doing these fall assessments, or at least risk scores, on everybody who comes into the hospital. It does beg the question. I think this article helps us answer it. Do those fall assessments change anything? The one thought reading this article is, even with the best idea of how to decrease falls using the 6-PACK, that had no effect on fall rates. Why do fall risk scores if we have no mechanism to decrease the risk of falls?
Ken: Yeah. Just feeding information without knowing what to do about it, that just doesn't help. You also wonder, are we going about this all wrong? This concept of we're going to prevent falls by not having patients move in the hospital, or tell them they have to get help whenever they move. Actually, there's no one there to help them so that means they don't move. Is that really the right way to go? Should the approach be actually let's let patients move all they want? Actually, maybe encourage them to move and encourage them to mobilize and have the staff on the floor to help them when they're trying to be mobile. That staff can't be nurses because the nurses are too busy.
Eric: How about this, Ken? How about instead of bed alarm, we at GeriPal make the anti-bed alarm? If somebody is in bed during daylight, the alarm goes off to tell them to get out of bed.
Ken: That is a great idea. You need an alarm that tells you you're not moving enough. We're joking, but this is actually really serious. The problem is actually just the opposite of the way we're going. Patients are not moving enough in the hospital. Maybe what we need to do is leverage family members. We can just train family members to help patients mobilize and mobilize safety. This would be a great thing for volunteers in the hospitals. Right now, when we're on the medical service we're often writing orders to mobilize the patients three times a day. How can nurses who have so much to do and are so overworked to begin with do that? We need somebody else who can do that.
Alex: It seems like you don't need a nurse level of professional care in order to help a patient to walk safety. You should be able to train family members or nurse's assistants to do that same sort of work.
Ken: Yeah. Do you think we're over-medicalizing walking?
Alex: I think so. I'm sure that the lawyers would have a different opinion about risk. What are the barriers to this happening? Nursing assistants aren't cheap in and of themselves. Family members may or may not be available. It would require a rethinking of the whole approach towards family members visiting patients. Right now, we restrict their activity and their visitation hours. We would want to encourage them.
Eric: I think the other thing to consider is that all financial incentives, really all incentives, are about reducing the risk of fall during the hospital stay with no follow-up to what happens to the patient after the hospital stay. Keeping a person bed-bound in their bed, not getting up and walking, is a good way to stop them from falling during the hospital stay. But it sounds like it's going to increase potentially their risk the second they leave the hospital.
Ken: Yeah. In theory, if you could actually force a patient to stay in bed their whole hospitalization - Of course, it's hard to do that because a normal person doesn't want to do that - you, in theory, could stop falls in the hospital. Then patients will collapse when they get home.
Alex: I wonder if there are always ways of redesigning the structure of hospital wards so that they're more conducive and encouraging of walking.
Eric: I was thinking about when you had a treadmill desk, Alex. During your normal work hours you could actually use the treadmill. Imagine if, in these rooms, that there were treadmills patients could use.
Alex: Treadmills or some way of getting the patients together routinely even for meals, so that they weren't cloistered in their rooms and their beds.
Ken: Yeah. This is something that acute care for elder units try to do, ACE units, which is really trying to redesign this hospital care. Another approach that has shown some success is by our friend, Cynthia Brown, in Alabama, who found just by training volunteers, people with no clinical training, she could get volunteers to mobilize patients and markedly increase the amount of mobility in the hospital.
Alex: That's great and it's free.
Ken: That's right.
Alex: Just the cost of training. Why aren't we doing this? Why aren't these interventions ... Why isn't there uptake for these? Is it because they haven't been well studied? Is it because training people is hard and getting the people resources is a lot harder than bed alarm resources?
Ken: That's a puzzling question, Alex. We've done this. It has been shown over and over that some of these things actually do work. It's not the way hospitals are structured or incentivized. Hospitals are trained to take care of diseases, not functioning. No one goes into the hospital because a mobility diagnosis or they rarely do. It's usually because they have pneumonia or heart failure and we ignore that they stop walking while they're in the hospital.
Eric: During the average, or any, hospital stay, do we even have any data on functional status for anybody who gets admitted? We're capturing vital signs. I guess we're capturing falls. What about function?
Ken: It's interesting. This is sort of a worldwide phenomenon because Cynthia Brown in Alabama has shown that the average patient in the hospital is in bed twenty-three out of twenty-four hours a day. In Israel a researcher by the name of Anna Zisberg has found the same thing. These patients don't walk when they're in the hospital. They spend all day in bed. Zisberg and her colleagues actually showed that the amount of time in the bed is directly correlated with the risk of getting new disabilities.
Eric: A lot of patients feel like they're supposed to be bed because the hospital is a time to rest.
Ken: What do you think about that Alex?
Alex: Hospital is a time to rest? No, I don't think so.
Ken: Yeah. I think we need to get away from that belief. I do think it's a common belief, but we're really learning it's dead wrong.
Alex: I think part of it has to do with the “sick role”. We sort of have this notion that's been built up over time and history of what the sick patient is supposed to be like. That sick patient is supposed to be in bed. We need to re-conceptualize as a society, culture, as a world, what it means to be sick. Being an active sick older adult is healthier than being in bed. That takes culture change as well as resources as we were talking about.
Ken: Yeah. One thing that I often think about is when you have a patient in the hospital, no matter where they are, try to notch up the mobility one notch. If they're lying flat in bed, have them sit up in bed. If they're sitting up in bed, try to move them to a chair. If they're in a chair, have then try to walk the room. If they're walking the room, have them walk the hall. Just try to push things up one notch beyond whatever is going on right now.
Alex: That's great. That's almost like a Prochaska kind of model. Take them to the next stage of mobility.
Ken: Yeah. Exactly. Exactly.
Eric: That said, Alex, I think this is the end of our first podcast. Do you want to maybe end us with a little tune?
Alex: Let's see.
Ken: How about something San Francisco-ish to complement our Chicago ballad and to mollify the feelings of my fellow San Francisco citizens who will feel great pain as the Cubs massacre the Giants. How about “I Left My Heart in San Francisco” to complement “Sweet Home Chicago”?
Alex: Oh, yeah. That's good. We should do something San Francisco-ish. Right? Let's see. We'll see. Even year. It's the Giant's year. The Cubs are the best team in baseball, so we'll see what happens. Okay…
Alex plays “(Sittin’ on) The Dock of the Bay” by Otis Redding