Impact of the Hospital-Acquired Conditions Initiative on Falls and Physical Restraints: A Longitudinal Study
BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) implemented the Hospital-Acquired Conditions (HACs) Initiative in October 2008; the CMS no longer reimbursed hospitals for fall injury. The effects of this payment change on fall and fall injury rates are not well described, nor its effect on physical restraint use.
OBJECTIVE: The aim of this study was to examine the effects of the 2008 HACs Initiative on the rates of falls, injurious falls, and physical restraint use.
DESIGN/SETTING: This was a nine-year retrospective cohort study (July 2006-December 2015) involving 2,862 adult medical, medical-surgical, and surgical nursing units from 734 hospitals.
MEASUREMENTS: Annual rates of change in falls, injurious falls, and physical restraint use during the two years before the payment rule went into effect were compared with one-, four-, and seven-year rates of annual change after implementation, adjusting for unit- and facility-level covariates. Stratified analyses were conducted according to bed size and teaching status.
RESULTS: Compared with prior to the payment change, there was stable acceleration in the one-, four-, and seven-year annual rates of decline in falls as follows: -2.1% (-3.3%, -0.9%), -2.2% (-3.2%, -1.1%), and -2.2% (-3.4%, -1.0%) respectively. For injurious falls, there was an increasing acceleration in the annual declines, achieving statistical significance only at seven years post CMS change as follows: -3.2% (-5.5%, -1.0%). Physical restraint use prevalence decreased from 1.6% to 0.6%. Changes in the rates of falls, injurious falls, and restraint use varied according to hospital bed size and teaching status.
CONCLUSIONS AND RELEVANCE: Since the HACs Initiative, there was at best a modest decline in the rates of falls and injurious falls observed primarily in larger, major teaching hospitals. An increase in restraint use was not observed. Falls remain a difficult patient safety problem for hospitals, and further research is required to develop cost-effective, generalizable strategies for their prevention.
© 2019 Society of Hospital Medicine
We examined the data collected from adult medical, medical-surgical, and surgical units in United States acute care hospitals that elected to participate in the fall and physical restraint use data collection within the NDNQI for the 27 months before and the 87 months after the implementation of the CMS rule change. Eligible units contributed at least one fall and physical restraint use data point during both the 27 months preceding October 1, 2008, and the 87 months immediately after. The Institutional Review Board at the University of Kansas Medical Center reviewed and approved the study before its implementation.
Endpoints
Fall Events
The NDNQI defines a patient fall as an unplanned descent to the floor, regardless of whether the fall results in injury and regardless of whether the patient was assisted to the floor by a member of the hospital staff. Events in which a patient lands on a surface where one would not expect to find a patient (eg, on a mat next to a low bed) are also counted as falls.
Using internal data sources (eg, medical records, incident reports), participating hospitals report the number of inpatient falls each month to the NDNQI. We analyzed the falls data for the period July 1, 2006, through December 31, 2015. Thus, each unit could contribute 114 months (27 months before the rule change and 87 months after the rule change) of falls data.
Hospitals classify the injury level of each fall as none, minor (resulting in bruise, pain, abrasion, wound cleaning, or limb elevation, or in the use of ice, dressing, or topical medication), moderate (resulting in suturing, splinting, muscle or joint strain, or application of steri-strips or skin glue), major (resulting in surgery, casting, traction, any type of fracture, consultation for neurological or internal injury, or receipt of blood products for patients with coagulopathy), or death (resulting from injuries sustained from falling). For this study, a fall resulting in any injury (including minor) was considered as an injurious fall. The NDNQI data have been validated for falls and fall injury.23,24
Based on patient counts from unit censuses and/or internal data on actual patient hours on the unit, hospitals also report to the NDNQI the monthly number of patient days for each unit for which falls data are reported. The NDNQI uses these data to calculate each unit’s total and injurious fall rate per 1,000 patient days.
Physical Restraint Use
The NDNQI follows the CMS definition of restraint, which is “any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely”.13 The NDNQI restraint use data are collected quarterly. Participating hospitals choose one day each quarter to conduct a restraint use prevalence survey on participating units. On the selected day, designated RNs within these hospitals visually assess each patient on the unit for restraint use. Based on this survey, hospitals report to the NDNQI the total count of patients surveyed and whether each was restrained. For restrained patients, hospitals also report the type of restraint as limb, vest, or other (eg, four side rails, net beds, mitts not attached to the bed).
