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Physical Restraint
Reduction
Beth Hercher
Tiresa Parker
Learning Session 1
October 2008
Why Are We Here?
Prevalence of Physical Restraints
National Rate
45
40
35
30
25
20
15
10
5
0
1988
1996
1998
2004
2005
2006
2007
Prevalence of Physical Restraints
Tennessee Statewide Rate
45
40
35
30
25
20
15
10
5
0
2004
2005
2006
2007
Physical Restraints: 9 SoW Participating Nursing Homes - East TN
30%
Baseline
(Q1 & Q2 Y07)
Q1Y08
25%
Improvement
20%
15%
NH Compare:
Q1Y08 Rates
10%
TN: 7.45%
National: 5.48%
5%
0%
E1
-5%
-10%
E2
E3
E4
E5
E6
E7
E8
E9
E10
E11
E12
Physical Restraints: 9 SoW Participating Nursing Homes - Middle TN
Physical Restraints: 9 SoW Participating Nursing Homes - East TN
25%
Baseline
Baseline
(Q1
& Q2 Y07)
(Q1 & Q2 Y07)
Q1Y08
Q1Y08
30%
20%
25%
Improvement
Improvement
20%
15%
15%
10%
NH Compare:
Q1Y08 Rates
10%
NH Compare:
TN:
7.45%
Q1Y08
Rates
National:
5.48%
5%
TN: 7.45%
National: 5.48%
5%
0%
M1
M2
M3
M4
M5
M6
M7
M8
M9
0%
E1
-5%
-5%
-10%
-10%
E2
E3
E4
E5
E6
E7
E8
E9
E10
E11
E12
Physical
PhysicalRestraints:
Restraints:99SoW
SoWParticipating
ParticipatingNursing
NursingHomes
Homes- -Middle
West TN
TN
Physical Restraints: 9 SoW Participating Nursing Homes - East TN
25%
25%
30%
Baseline
Baseline
(Q1
& Q2 Y07)
(Q1 & Q2 Y07)
Q1Y08
Q1Y08
Q1Y08
20%
25%
20%
Improvement
Improvement
Improvement
20%
15%
15%
15%
NH Compare:
Q1Y08 Rates
10%
10%
10%
NH Compare:
Compare:
TN:
7.45%
NH
Q1Y08
Rates
National:
5.48%
Q1Y08
Rates
5%
TN:
TN: 7.45%
7.45%
National: 5.48%
5.48%
National:
5%
5%
0%
M1
M2
M3
M4
M5
M6
M7
M8
M9
0%
E1
E2
E3
E4
E5
E6
E7
E8
E9
E10
E11
E12
0%
-5%
-5%
-10%
-5%
-10%
W1
W2
W3
W4
W5
W6
W7
OBRA ’87
“Residents have the right to be
free from restraints imposed
for discipline or convenience,
and not required to treat
medical symptoms”
Tennessee Pilot
Restraint Collaborative
• Nine month pilot that took place between
April 2005 and January 2006
• 15 facilities participated statewide
• Reduced physical restraints from 13.75%
to 3.50%
Pilot Collaborative Goals for
Reducing Restraints
• Utilize change package to reduce
restraint use
• Test, refine and spread “Best Practices”
• Reduce restraint rate in Tennessee
nursing facilities to 2% or less
• Culture change within facilities
• Patient centered care
It is Unclear Why…
• Restraint rates vary nationwide
• Restraint reduction and restraint
free environment varies between
states and facilities
What is a Restraint?
CMS Definition
“Any manual method, physical or
mechanical device, material or equipment
attached or adjacent to the resident’s body that
the individual cannot remove easily which
restricts freedom of movement or
normal access to one’s body”
Why do we use physical restraints?
•
•
•
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•
•
History of restraint use in psychiatric facilities
Troublesome behaviors
Families
Fear of lawsuits
Medical model
What we have learned
Why do we use physical restraints?
• Research shows physical restraints
do not make people safer
• Restraints are often harmful
• New practices are replacing restraint use
except in emergency situations
Why do we use physical restraints?
• Evidence show restraints do not assure
safety
– Falls that occur with out restraint have less
serious injury
– Falls that occur with a restraint may result
in more serious injury
Who is most likely to be restrained?
•
•
•
•
Oldest residents
Those who are physically frail and may fall
Alzheimer’s, dementia, confusion
Treatment Interference
Restraint Myths
•
•
•
•
•
•
•
Prevent falls and injury
Safeguard residents
Failure to restrain increases legal risk
Residents do not mind, they feel secure
Inadequate staffing
Family is always right
Do not know what else to do
Negative Effects of Restraints
• Physical consequences of immobility
– PU, incontinence, muscle atrophy, bone loss…..
•
•
•
•
•
Agitation
Confusion
Loss of dignity
Positional asphyxia/strangulation
Falls/falls related injuries
Practical Approaches to
Restraint Reduction
• Senior leader buy in
• Create plan of care to eliminate
restraint as quickly as possible
• Complete assessment of underlying
physical, mental, environmental, care
related and behavioral factors that
contribute to falls
Practical Approaches to
Restraint Reduction
• Planned and methodical way
• Staged substitution of alternative
less restrictive
• Ongoing monitoring and revision
of care plan
Practical Approaches to
Restraint Reduction
• Involve medical director and physicians
• Ultimate goal to eliminate device or
replace with least restrictive
• Successful elimination or reduction
programs require the involvement of
the entire nursing home staff
Safety Concerns of Families
• Legitimate desire for safety without
current and substantive information
about dangers of restraints
• May be open to other interventions if
their safety concerns are addressed
• Include families/decision makers in
assessment and careplanning
• Education
Categories to Consider
During Assessment
•
•
•
•
•
•
•
•
•
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Toileting
Monitoring
Protective clothing
Bed Safety
Individualized seating
Environment
Underlying medical conditions
Chronic conditions
Pain management
Behavior management
Toileting
• Evaluation – urgency, frequency,
residual urine, medications, UTI
• Individualized and more frequent
• Restorative care
• Lighting, clear pathway
• Bedside commode
• Signage
Monitoring
• Increased supervision
– Volunteer network
– Activities, activity boxes
– Exercise, ambulation
• Alarms
• Placement in facility
Protective Clothing
• Helmets
• Wrist guards
• Hip Protectors
Individualized Seating
• Wheelchair modifications
–
–
–
–
–
improve positioning
reduce pain
increase functional ability
participate in daily activities
reduce pressure to bony prominences
• Seating items to reduce sliding out,
leaning to one side and falling over
• Equipment added to prevent tipping over
and improve ease of locking brakes
Environment
• Reduce clutter, uneven flooring,
unstable furniture
• Improve lighting especially at night
• Ensure safe footwear and adequate foot
care
• Ensure easy access of personal items
Underlying Medical Conditions
•
•
•
•
•
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•
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Uncontrolled blood sugar
Acute infections
Medication side effects
Number of medications
Baseline function
Fluctuations in strength
Side effects of medications
Disease progression
Pain Management
• Careful assessment
• Routine scheduling
• Management of medication side
effects
• Careful titration
Behavior Management
• Comprehensive assessment
• Basic management skills
• Individualized strategies specific to
resident’s personal agenda and needs
Restraint Alternatives
Bed Related Falls and Injuries
• Nighttime or bed related falls
constitute 1/3 of all falls
• More than ½ of all fractures occur
in residents’ room
• Almost 1/3 of fractures occur at night
Bed Related Falls and Injuries
• Siderails are meant to deter residents from
getting out of bed unassisted or as
a reminder to call for assistance
• Most residents that use siderails are
cognitively impaired and view the rail as
a barrier/something to go over
• Increase chance of an injurious fall
(increase the height of the fall by 2 ft.
– Also can lead to entrapment)
Bed & Nighttime Safety
•
•
•
•
•
•
•
•
Low bed, mat
Alarms
Sleep hygiene measures
Cradle mattress, perimeter reminders
Elimination of entrapment zones
Pain management
Food, drink or activity when awake
Sleep hygiene (caffeine intake, routine,
meds, daytime napping, pain, noise, etc.)
Potential Bed Entrapment Zones
Tennessee Pilot Collaborative
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•
•
•
•
New admissions
Falls and serious injuries
Frequent fallers
Re-evaluations to reduce restraints
Family education at admission and
consideration of restraint
Tennessee Pilot Collaborative
• Non-restraint interventions tried
prior to restraint
• Intervention within 24 hrs. and
Care Plan revised within 48 hrs. of fall
• Direct care staff educated
• Psychotropic medication
Tennessee Pilot Collaborative
• Resident centered care
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–
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Individualized assessment and care plans
Use of least restrictive device
Positioning device vs. restraint
Individualized seating
Equipment
Increased activities
Staff and family education
When You Get Back Home…
• Assess your current restraint program
• Review currently restrained elders
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Assessment
Medical diagnosis
MD order
Family notification/education
Recommendation
Documentation
When You Get Back Home…
• Individual assessments
– Basic data from assessments, evaluations
and referrals
• Test and implement changes
– Known effective and ineffective strategies*
• Details from direct care staff
• Knowledge of available resources
and equipment
*Some things are worth trying again.
Our Goals for Reducing Restraints
• Utilize change package to reduce
restraint use
• Test, refine and spread “Best
Practices”
• Reduce restraint rate in Tennessee
nursing facilities to 2% or less
• Culture change within facilities
• Patient centered care