Study Warns New Government Regulations Could Lead to Overuse of Restraints

A new congressional mandate changing hospital reimbursement made by the U.S. Centers for Medicare and Medicaid Services (CMS) could inadvertently reverse tremendous progress in reducing the use of physical restraints among hospitalized elderly patients, according to Beth Israel Deaconess Medical Center (BIDMC) gerontologist Sharon Inouye, MD, MPH, writing in the latest issue of The New England Journal of Medicine (NEJM).

Inouye, a professor of medicine at Harvard Medical School and director of the Aging Brain Center at Hebrew Senior Life, points out in a "Perspective" editorial, that in an attempt to keep patients safe from falls, the CMC's good intentions may have adverse consequences.

"In 2005, in response to disturbing and widely cited findings by the Institute of Medicine about the prevalence of life-threatening conditions acquired by patients in U.S. hospitals, Congress authorized the CMS to implement payment changes designed to encourage the prevention of such conditions," wrote Inouye and coauthors Cynthia Brown, MD, of the University of Alabama and Mary Tinetti, MD, of Yale University. As such, according to the report, Medicare will reduce reimbursement rates to hospitals if one of eight hospital-acquired conditions develops during the patient's stay; hospital falls and trauma were included as one of these eight.

"Our greatest concern is that the heightened focus on fall prevention will have unintended consequences," noted Inouye, adding these are likely to include a decrease in mobility and a resurgence in the use of physical restraints and other restraining devices, such as bed alarms, in what she called "a misguided effort to prevent fall-related injuries."

Physical restraints have long been used because they are believed to prevent falls, but the study contends that not only are restraints ineffective in reducing the risk of falls and related injuries, they are actually associated with increased rates of medical complications, including immobility, functional loss, delirium, agitation, pressure sores (which are themselves one of the non-reimburseable hospital-acquired conditions), asphyxiation, and death. Moreover, accumulating evidence suggests that restraints may actually increase the risk of falling or sustaining an injury from a fall.

"At present, there are no proven strategies that are documented to be effective in preventing falls in the hospital setting," explained Inouye. However, she added, because previous studies have indicated that a change in mental status is the leading risk factor for falls in the hospital, strategies that incorporate multiple components may prove beneficial.

For more information, visit www.bidmc.org.

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