Caroline Helwick

October 14, 2014

NEW ORLEANS — The frequency of inpatient falls has doubled in recent years, but it is not the result of epidural analgesia, according to an analysis of data from the Nationwide Inpatient Sample.

"Our study shows a troubling increasing trend in inpatient accidents and falls during admissions for thoracic and major upper abdominal surgery, but there is no association with epidurals in these accidents," said Tiffany Williams, MD, from the University of Texas Southwestern Medical School in Dallas.

Epidurals are often considered risk factors for falls, possibly because of the potential for sensory, functional, and cognitive alterations associated with this form of pain relief.

"We showed that epidurals are not the troublemakers that many think they are, and because they have many benefits, perhaps we should incorporating them more into our practice," Dr Williams said in an interview with Medscape Medical News.

She presented the study results here at Anesthesiology 2014.

To identify the risks associated with epidurals, Dr Williams and her colleagues searched the Nationwide Inpatient Sample for adults who underwent elective thoracic or major upper abdominal surgery from 2007 to 2011. They excluded procedures involving cardiac surgery, transplants, trauma, laparoscopic surgery, emergent surgery, and robot assistance.

Cases selected for this study were divided into two categories — epidural and mixed (both epidural and nonepidural cases) — because the National Inpatient Sample uses ICD-9 CM codes for procedures, so some of the postoperative epidural analgesia data using CPT codes are not reported.

"Given the manner in which our dataset was collected, we felt it prudent to assume that some individuals may have had epidurals for postop analgesia, even though they weren't appropriately identified," Dr Williams explained. "Our dataset is based on discharge and billing coding, which can be incomplete. Our nonepidural group was treated as a mixed group to control for this data limitation."

It could be that this is not an anesthesia issue but a money issue.

Multiple logistic regression analyses were conducted to investigate the independent association between falls and epidurals. The model was adjusted for patient demographics, comorbidities, and hospital characteristics.

The team identified 36,595 cases of thoracic surgery and 25,537 cases of major upper abdominal surgical.

In the thoracic group, the overall incidence of inpatient accidents and falls was 6.6%, but there was an increasing trend from 4.8% in 2007 to 8.5% in 2011 (P < .0001).

Similarly, in the abdominal group, the overall incidence of accidents and falls was 6.3%, with an increasing trend from 4.5% in 2007 to 8.1% in 2011 (P < .0001).

On logistic regression analysis, the incidence of accidents and falls was not significantly different between the epidural and mixed categories in the thoracic group (odds ratio [OR], 0.96; P = .68) or in the abdominal group (OR, 1.11; P = .34).

It is hard to interpret the increasing trends of inpatient accidents and falls, the investigators report. They speculate that one factor might be increased reporting by hospitals as a result of pressure from the Centers for Medicare and Medicaid. Another factor might be the greater willingness of providers to operate on elderly patients, Dr Williams added.

"There are many possible reasons. We can pull data out from this study to see if falls are mainly increased in a certain age group or are associated with certain procedures or time after surgery," she said. "But here, we just wanted to get our feet wet on this topic."

Physicians Should Be Concerned

"I think that what's happening is that we are very sensitive to falls," said Jonathan Kay, MD, from Aurora St. Luke's Medical Center and the Medical College of Wisconsin in Milwaukee.

"Falls in the hospital are not a very desirable thing and are considered by national health regulators to be preventable," he told Medscape Medical News.

Noting that preventable factors have become part of quality metrics, Dr Kay said he predicts that "we are all going to be in the same boat when it comes to falls. Now that we are not looking closely at epidurals as the problem, we need to drill down and find the real cause."

He suggested that staff shortages could be a factor. "We have been cutting back on nurses and nurses' aides, so now we have more people in the hospital and fewer people taking care of them. It could be that this is not an anesthesia issue but a money issue."

Dr Williams and Dr Kay have disclosed no relevant financial relationships.

Anesthesiology 2014 from the American Society of Anesthesiologists (ASA): Abstract A2137. Presented October 12, 2014.


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