David Oliver: Do bed and chair sensors really stop falls in hospital?BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k433 (Published 06 February 2018) Cite this as: BMJ 2018;360:k433
All rapid responses
We agree with David Oliver’s reflections (1) on the controversial opinion expressed by the coroner on the clinical story of Ken Swift, an 80-year-old woman who was hospitalized for pneumonia and died due to the consequences of a fall from a hospital bed.
Oliver emphasizes the extreme uncertainty in the scientific literature regarding the effectiveness of specific technical and organizational measures to prevent the falls of frail patients. In fact, at best, only 20% of such falls would be preventable by adopting multi-pronged approaches (1).
After all, the great poet Dante also states “And fell, even as a dead body falls” (2). Falls can happen so suddenly, and in so many different ways, that even the presence a rescuer with feline reflections, such as those of goalkeepers David De Gea, Thibaut Courtois or Fraser Forster, could not prevent them from happening.
However, in this case, the most controversial aspect of the coroner’s opinion is the economic evaluation, one that supports the alleged efficiency of a simple remedy: on one side, an alarm bell worth £90; on the other, the deceased patient’s human capital, priceless by definition.
At first glance, this solution seems inarguable. Such an evaluation suggests a willingness to sacrifice a human life to save £90, hence presenting an unconscionable moral decision, even more so when the life is question has already been made frail by disease.
But, even following the coroner’s utilitarian economic analysis, we must ask ourselves: are only £90 at stake?
Those who judge health systems and organizations using mere accounting are limited by the fact that such accounting does not take into consideration the invaluable contribution of the human resources employed to make such organizations effective.
If somewhere an alarm bell rings, it is necessary for a health care worker to promptly assist the potential victim. Furthermore, if an alarm bell exists, it is necessary that a health care worker informs the patient of the meaning of the bell and of its functioning.
Assuming that the number of health care workers employed on a ward does not change, the time spent informing and helping frail patients at risk of falling is inevitably subtracted from the time devoted to the care of other frail patients on the ward, such as those with cardiovascular, respiratory and hypoglycemic risks. In other words, tools assumed to be supportive in fact often increase the need for supervision and protection and, consequently, assistance.
Therefore, the cost of an alarm system in the form of a bell to prevent falls is more than £90. We must also recognize that monitoring such a system inevitably requires the expansion of the staff dedicated to assistance or increases in the number of hours worked by the health care workers already employed.
Otherwise, the patient would fall anyway, despite the sound of the bell.
Oliver D. Do bed and chair sensor really stop falls in hospital? BMJ 2018; 360:k433;
Dante Alighieri. The Divine Comedy. Inferno, V, 142.
Competing interests: No competing interests
Falls in the frail, elderly population continue to be one of the most important risks for in-hospital morbidity and mortality. Numerous interventions to try and reduce both the frequency and severity of falls have not been consistently effective in these settings to reduce this risk. Even where predictive instruments such as falls risk assessment tools are used to determine the likelihood of events in individuals, there is a lack of effective strategies to mitigate this risk. Complicating this is the complexity of intersecting variables that result in a heightened and dynamically evolving risk of falls in hospital patients.
As highlighted by Oliver, acute delirium is one such variable that is intimately related to falls risk. Acute illness superimposed on age, comorbidities and medications and polypharmacy are important factors that steeply increase falls and delirium risk. Sleep-wake cycle disturbances, noise and lighting are all important environmental variables in hospital settings that are difficult to adequately control. We agree that there is lack of evidence supporting the effectiveness of sensors but would caution against complete cessation of their use for all patients and in all settings, at least until we have adequate alternatives. Meanwhile, it is essential that we continue to seek and research new and innovative technologies such as motion sensors and combine these with staff and patient education, family and volunteer supervision and an unrelenting focus on judicious deprescribing to help us in managing this risk.
Competing interests: No competing interests