Fall Prevention Without Restraints: A Project.

Adapted from a 1999 OPTIMA Awards Entry

Although our facility's Restraint Reduction Project was initiated on April 1, 1994, it is an ongoing project because the need to balance freedom and safety is ongoing. After a great deal of teamwork and staff education, the level of restraint use was dramatically reduced without compromising safety. This has meant more freedom and autonomy for patients and an improved quality of life, because we are using the least restrictive means to keep them safe.

Eastern State Hospital Hancock Geriatric Treatment Center is the largest psychogeriatrics facility in the state of Virginia, with a bed capacity of approximately 250 patients. The facility was similar to others in terms of overutilization of restraints. There were blanket restraint policies, as well as widespread use of unapproved or inappropriate restraints rather than individualized plans. A total of 101 patients, or 44% of the total patient population, were in restraints, with a total of 285 restraints in use. The project's goal was to significantly reduce the number of patients in restraint and the number of restraints used per patient. In addition, using an appropriate restraint and compiling an interdisciplinary assessment were encouraged.

As of March 1999, a total of 25 restraints were in use for 9% of the population. The original goal of the program was to reduce restraint usage, but no one imagined that it would be reduced to such a level as to be almost nonexistent in some areas of the facility. This dramatic reduction was accomplished through a comprehensive interdisciplinary process that makes the program unique.

At the outset of the project, a Restraint Committee was established with the goal of reducing both the number of patients in restraints and the use of multiple restraints. (We define a restraint as a device that restricts the patient's ability to move freely.) Our plan included the following steps:

* Research of the literature

* Educating staff and families

* Using the term "restraint-appropriate" versus "restraint-free"

* Identifying restraint high-usage areas as target areas

* Implementing the program in these high-usage areas

* Establishing a support team to work with the nursing staff

* Developing and implementating an interdisciplinary restraint assessment form

* Accepting the fact that this needed to be implemented slowly

The interdisciplinary treatment team consisted of a physician (either a psychiatrist or general practitioner), social worker, occupational therapist and/ or activity therapist, dietitian, nurse and nursing aide, as well as at the administrative or management level, a licensed nursing home administrator. The heads of each appropriate clinical discipline conducted the senior clinical review sessions.

All patients in restraints and others who were potential candidates for restraints were assessed, including special populations, such as those at risk for falls. The interdisciplinary treatment team assessed the patients' need for restraint usage. Originally there was an informal or preliminary assessment, not a formal assessment tool. Within a short time, staff began to realize that they needed a more formal physical assessment tool.

At this point, the team initiated restraint rounds that involved observation of the patients; the team was able to determine the appropriateness of restraint usage and begin to determine alternatives. The data were analyzed through a flow chart by ward and by building, with different codes to identify specific restraints. These were tallied at the end of each month. These aggregate numbers were presented in senior clinical staff meetings and at the Geriatric Restraint Committee to assess the progress of the program and identify alternatives to various restraints.

Some restraints were seen as totally inappropriate; for example, pelvic restraint and 4-point restraints were eventually eliminated. Programs such as wheelchair positioning and mobility and strength enhancement were increased. Medication reduction was implemented to assist in the restraint reduction as well.

The program has a very strong component in terms of involving families and authorized representatives, as well as residents, if they are capable. There also had to be a lot of education for staff and families. One important result of this was that staff felt invested in the restraint reduction program. One of the initial major obstacles had been staff resistance. This was addressed by having the interdisciplinary team hold meetings in each building to hear staff concerns. This was particularly important for direct care staff, including nursing aides, who are called Human Service Care Workers, and for nurses who are trained to make safety primary and to be concerned about liability, as opposed to looking at innovative ways to improve the lives of patients. This education included reassuring staff, making them a part of the decision making process, and explaining that there would be no personal liability if the appropriate documentation was present. It was emphasized that the final decision in all cases would be that of the interdisciplinary treatment team and not that of an individual staff member.

Family education was done on an individual basis. The clinical social work staff provided family members with an explanation and rationale for restraint usage, including any changes, and addressed their questions and concerns about restraint reduction. As a result, the families grew to trust and rely on the clinical decision making of the treatment team.

Basic Method

The Restraint Assessment we developed is divided into 10 sections, with each section assigned to a respective discipline for completion using an interdisciplinary approach. The Restraint Assessment is completed on each patient being considered for restraints and for all patients who are currently using restraints. Once a patient's need for restraint is identified, the team completes the assessment within 10 days. An Interdisciplinary Treatment Planning Conference is then held to discuss recommendations and consults. In addition, Restraint Rounds, scheduled within one to two weeks prior to scheduled Team Planning Conferences, are instituted.

The committee developed a quarterly review follow-up form. The team completes these reviews at least quarterly, but can do so more frequently if the patient's condition changes.

Also, in an attempt to provide guidelines for usage of restraints, a Program Standard Operating Procedure (291-0) was developed.

Incorporated into the restraint reduction initiative was a Continuous Quality Improvement Monitor, used both when there is a restraint change and at least quarterly for all patients. The CQI Monitor is used to ensure proper usage of restraints and appropriate supporting documentation, as well as to assist in maintaining compliance with OBRA and JCAHO Long-Term Care Standards.

Interdisciplinary Perspectives

Medical (Physician) Services. Serving as head of the treatment team, one of the physician's major roles is to ensure that restraint usage is appropriate for the patient's medical needs. Each patient is screened by the interdisciplinary treatment team and assessed by the occupational therapist or physical therapist, with physician orders made for medical reasons only.

Nursing Services. Staff is asked to identify patients currently in restraints who they feel could have them removed. When staff expressed concern about patient injuries as a result of restraint reduction, the committee members identified their role as one of support and stated "We are all in this together." The staff was educated in use of the new wheelchairs and the Ambi-Walker. Meanwhile, members of the Restraint Reduction Committee were on the wards and in building meetings to collaborate with staff. All of this was of basic importance. Our success in reducing restraints was possible because of the front-line staffs involvement in decision making and the support from the Restraint Reduction Committee members.

All levels of nursing participate in the documentation sheet approved by Nursing Service. The form identifies the range of restraints available and the policy guidelines for monitoring their use. The RNs are accountable for assessment and reevaluation, summarizing all nursing input on the forms used.

Rehabilitation Services. Preliminary steps to reduce restraints had actually been taken in May 1993, with the request to include in the budget funds for 20 custom wheelchairs, as well as additional needed rehabilitative equipment. From that point, a wheelchair clinic was conducted twice monthly in which the Occupational Therapy Staff evaluated patients and made recommendations to the physician for the proper fit of appropriate positioning devices. This in itself resulted in a decrease of the numbers and type of restraints needed and used by several patients.

In March 1994, the Occupational Therapy Staff provided in-service training on all three shifts regarding positioning, transfer techniques and the new wheelchairs.

In May 1994, the occupational therapists worked on enhancing the functional mobility programs within the building by incorporating the use of a device known as the Ambi-Walker. This device provides a safe situation for staff and patient during ambulation and decreases the number of staff needed to ambulate each patient.

Since July 1994, the Occupational and Activities Therapy Department (currently known as the Rehabilitation Services Department) has developed and implemented a Fitness Group in each geriatric ward, which meets on an average of three times weekly. The patients are scheduled for these groups based on their functional, as well as physical, abilities.

Additional restraint alternatives implemented have been seatbed alarms for monitoring patient activity, pommel cushions for augmenting posture and wedge cushions to optimize positioning in bed. In-service training was provided to instruct staff in the proper usage of these devices.

With these programs--the Wheelchair Clinic, Positioning Program, Fitness Track, Functional Mobility and Restraint Alternatives--emphasis has been placed on improving the patient's motor functioning and coordination, strengthening muscle groups and improving physical health. This led to a natural progression to reducing restraints and reaching the goal of a restraint-appropriate environment for all patients.

Clinical Social Work Services. From its inception, social work services has been represented on the Restraint Team by a clinical social work supervisor. The major role of the social worker has been and continues to be to serve as a liaison between the family and the team regarding restraint reduction efforts. Whenever changes are made to the patient's restraint plan, the social worker contacts the family to supply an explanation and rationale for restraint changes, to address family questions and concerns and to help alleviate fears the family might have about reducing restraints. We found that concentrating on the concepts of "restraint-appropriate" and "least restrictive measures" served as major tools in keeping families informed.

Overall Evaluation

A summary of the five-year results of the Restraint Reduction Project can be found in the figure.

            Number of Patients in Restraints April '94-March '99
April 1994     101
March 1998      26
June 1998       28
September 1998  27
December 1998   24
March 1999      23