February 2, 2017
by Judith Garber, MPP
What do you do when your patient’s well-being is threatened by rules beyond your control? St. Louis University School of Medicine resident Stephanie Cull, MD, faced this challenge when she realized that the guidelines for bed alarm placement were causing many of her patients to be unnecessarily trapped in their beds. Bed alarms are intended to prevent hospital falls, but can severely restrict patient mobility. The alarm is built into the hospital bed and beeps when the patient attempts to get out of bed.
One patient, a 67-year old woman in for a lung biopsy, suffered a pneumothorax and had to be admitted to the hospital. Although the patient was otherwise healthy, independent in her daily activities, and had no history of falls, she was at risk for falls according to the guidelines, and so the alarm was turned on. She wasn’t able to move around the hospital, or even go to the bathroom, without the alarm going off and nurses rushing to put her back in bed. She later told Cull that she “felt like she was in jail” and that she never wanted to come back to that hospital because of this experience. And this patient was not the only one. “I can think of three other patients off the top of my head who felt the same about the alarms,” said Cull. “I saw one patient doing pushups on top of his bed because he wanted to exercise but couldn’t leave his bed.”
The more Cull looked into bed alarms, the more she was convinced that the problem was systemic. “The checklist is arbitrary. Whether or not you get an alarm is based on how many medical conditions on the Morse Fall Scale you have, but most of the conditions aren’t even related to falling,” said Cull. The guidelines are strictly enforced because in-hospital falls are labeled a “Never Event,” but there isn’t evidence that having bed alarms actually reduces in-hospital falls. In fact, restricting patient mobility can have adverse effects, including blood clots and muscle atrophy.
Cull decided to raise awareness of this problem by using this case as an example of overuse for Right Care Rounds, and submitting the case as a vignette for the 2016 Right Care Vignette Competition. She was chosen as a finalist and her vignette was subsequently published in the JAMA Teachable Moments series. She also gave a presentation on the case at the 2016 Lown Institute Conference.
Talking with the patient, writing up the case, and preparing and giving a presentation has made Cull more aware of overuse in her daily patient interactions. “This experience has made me think about what I’m doing in every patient encounter,” said Cull. As a judge for this year’s vignette competition, Cull is excited to read the cases. “I think everyone should present an overuse case at least once in their training,” she said. “It would go a long way toward increasing awareness of overuse.”