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
Accidental falls are among the most common incidents reported in hospitals, complicating approximately 2% of hospital stays.1-3 Approximately 25% of falls in hospitalized patients result in injury, and 2% involve fractures.4 Substantial costs are associated with falls, including patient care costs associated with increased length of stay and liability.5-7
Beginning October 1, 2008, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursing hospitals for the additional care associated with eight hospital-acquired conditions (HACs), including serious fall-related injury, which were believed to be “reasonably preventable.”8,9 Before this change, hospitals recovered the costs of these “never events” by assigning a higher level MS-DRG (Medicare Severity Diagnosis-Related Group) code for patients experiencing such an event. This is no longer allowed under the revised CMS Prospective Payment System rules.
Although the financial penalty for iatrogenic injury was modest, the payment change placed pressure on hospital staff to decrease falls, and some nurses reported changing practice to be more restrictive of patient mobility.10 Increased use of physical restraints is a potential unintended consequence of this rule change.11 Restraints are known to cause agitation, delirium, decubiti, deconditioning, strangulation, and death.12 Not surprisingly, use of restraints is discouraged in hospitals and is a CMS quality of care indicator.13,14 Although there is no evidence that restraint use prevents patients from falling,15,16 there is a perception among both health professionals and patients that restraints reduce the risk of falling, and they are often used as a “last resort” method of fall prevention.17-19
The aim of this longitudinal study was to determine whether this payment change was associated with changes in short-, intermediate-, and long-term rates of falls, injurious falls, and physical restraint use in acute care hospitals. The CMS has included fall-related hip fracture in newer value-based purchasing programs by adding Patient Safety Indictor (PSI) 90 to both the HACs Reduction Program (HACRP)20 and the Hospital Value-Based Purchasing (VBP)21 in FY2015. However, the HACs Initiative remains the only Medicare value program that directly penalizes all injurious inpatient falls.
METHODS
Study Units
As previously described,22 the National Database of Nursing Quality Indicators (NDNQI) is a data collection project initiated by the American Nurses Association (ANA). The NDNQI provides national comparative data at the unit and facility levels on nursing-sensitive indicators endorsed by the National Quality Forum. More than 2,000 hospitals voluntarily participate in the NDNQI, including virtually all ANA Magnet-recognized hospitals, and more than 90% of nursing units participate in the fall measures (NDNQI, personal communication). At the start of study data collection, the project was administered by the School of Nursing at the University of Kansas Medical Center. In 2014, the ownership of the NDNQI was transferred from the ANA to Press Ganey Associates, Inc. In addition to standardized data on unit, facility, and staffing characteristics, the NDNQI member hospitals can elect to submit monthly data on falls and quarterly data on physical restraint use prevalence.
