Intended for healthcare professionals

CCBYNC Open access
Research

Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4185 (Published 17 July 2019) Cite this as: BMJ 2019;366:l4185

Linked editorial

Preventable harm: getting the measure right

Re: Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis

Dear Editors,

Panagioti et al have done a detailed analysis and have presented interesting findings. It is extremely important that healthcare associated harms are recognized and reduced to the minimum possible.

We would like to draw readers' attention to an under-recognized, under-reported and under-treated challenge which has not been documented enough in the scientific literature and hence has not been appropriately represented in various databases.

Prevalence estimates report older hospitalized patients can spend anything up to 95% of their time in bed or chair, during their hospitalization. The physiological effects of bed rest start to take place with-in the first 24 hours whilst some patients may still be in a trolley in the emergency department. Interventions such as intravenous infusion, catheterisation, bedrails, naso-gastric tube, etc. can further reduce mobility and progressively worsen the physiological deterioration. Data from the Acute Frailty Network suggests that impact of bed rest in first 24 hours includes reduced muscle power by 2-5% and reduced circulatory volume by up to 5%. Impact in the first 7 days includes reduced circulatory volume by up to 25%, reduced VO2 max by upto 8-15%, reduced muscle strength by up to 5-10%, reduced Functional Residual Capacity (FRC) by up to 15-30%, reduced skin integrity, reduced dignity, self-confidence, independence, choice and quality.

There is thus substantial evidence that prolonged bed rest in older people can be harmful.

Additional under-reported harms could include increased incidence of delirium, immobility, incontinence, loss of self-esteem, poorly planned discharge, delayed care transitions/co-ordination/communication, leading to premature decisions about future care needs in the wrong setting and worse outcomes, and premature institutionalisation.

It is in this context that the term ‘deconditioning syndrome’ has been increasingly used and understood in recent years. We define ‘deconditioning syndrome’ as the syndrome of physical, psychological and functional decline that occurs as a result of prolonged bed rest and associated loss of muscle strength, commonly experienced through hospitalisation. Though it can affect people of any age, the effect on older people can be more rapid, severe, and can often be irreversible.

The Oxford dictionary defines the term deconditioning as 'Cause to lose fitness or muscle tone, especially through lack of exercise’ and ‘sedentary lifestyles that decondition their bodies’. (1)

There is also enough evidence that activity and exercise help in recovery and therefore can contribute to reduced length of stay in hospitals and improve fitness therefore potentially impacting on self-care, independence and care needs. (2) The evidence around strategies for mass implementation has been relatively less. The current work by the authors provide some of this much required evidence.

The ‘National Deconditioning Awareness and Prevention Campaign (UK) -Get Up, Get Dressed Get Moving’ (3) and #EndPJParalysis (4) have generated widespread support nationally (5,6) and internationally as an approach to generate awareness and understanding and to prevent the detrimental effects caused by deconditioning in hospitals, care homes and those living alone. Whilst understanding the pitfalls and qualms about use of social media, the huge popularity of endpjparalysis on social media (and beyond) for this work has demonstrated how this concept of getting patients dressed and moving connects usefully with healthcare staff and patients/families alike.

What can be done to prevent deconditioning at scale?

Methods to prevent deconditioning could involve multiple approaches. These could include creating individualized care plans for activity and exercise based on individuals’ abilities, group exercise and self-care tasks, deconditioning ‘care bundles’, incorporating deconditioning in all root cause analysis (aka DATIX), prescribing personalized exercises depending upon individuals’ abilities, educating staff and public, busting myths and highlighting facts; common dining and activities. Some of these have been tried with varying successes in various settings but equally one needs to be careful of not under-mining those who may feel less able to participate than others at a certain time in their illness.

To further raise awareness, it is essential that education on physical activity, exercise and deconditioning syndrome is implemented into all health care professionals’ curricula, and supported by charities and patient groups. A move to include the importance of physical activity is currently under way with all UK medical, nursing and pharmacy schools. It remains to be seen how the prevention of deconditioning work may be better integrated nationally and despite staffing shortages, whether adequate training and deconditioning awareness will be enough to tackle this important challenge.

With a rapidly shifting population demographic deconditioning syndrome must be addressed more robustly across the board. It has significant implications not least on quality of life, dignity and mortality but also in the number of occupied hospital beds and in reducing health care associated unintended harms. All groups of staff--namely, receptionists, therapists, porters, healthcare assistants, nurses, therapists, doctors and others--have an important role in patient care and therefore in preventing deconditioning. The current challenge lies in developing and implementing effective strategies to prevent deconditioning in hospitals and care homes. Reporting and measuring such harm will be the first step in this journey. Older people deserve no less.

Ref:

1. Oxford Dictionaries. Oxford Dictionary of English. 7th Revised Edition. Oxford. Oxford University Press. 2012
2. Getting hospital patients up and moving shortens stay and improves fitness. Published on 16 April 2019. doi: 10.3310/signal-000759
3. Arora A. Blog – Time to move: Get up, get dressed and keep moving. [Internet] 2017 [Cited 2017 November 22] Available from: https://www.england.nhs.uk/blog/amit-arora/
4. O’Hanlan S. Editorial – British Geriatrics Society. [Internet] 2017 [Cited 2017 November 22] Available from: http://www.bgs.org.uk/nursepublications/newsletter/jun17-news/jun17-edit...
5. https://www.economist.com/britain/2018/06/14/why-britains-hospitals-are-... (accessed 18.08.2019)
6. Jane Cummings. Blog- We should all support #EndPJparalysis [Internet] 2017 [Cited 2017 February 23] Available from: https://www.england.nhs.uk/blog/jane-cummings-32/

Competing interests: Working with colleagues, I created the 'National Deconditioning Awareness and Prevention Campaign: Get Up Get Dressed Get Moving' and work closely with endPJparalysis campaign to generate awareness about harms associated with inappropriately prolonged bed rest in NHS. The work is supported by NHS England/NHS Improvement and British Geriatrics Society and has been shortlisted for a BMJ award previously. There are no financial or pharmaceutical gains or payments. The resources produced are freely available on internet for patient benefit.

18 August 2019
Amit Arora
Consultant geriatrician
West Building, University Hospital of North Midlands, Stoke on Trent