Pulling together for restraint reduction: submitted by Botsford Continuing Care Corporation.

Comment from the Beverly Foundation:

Two medical directors and a psychologist wrote recently that "with common expectations, support and guidance, the talent in a facility can be focused on understanding behavior and responding to it in productive ways."(*) Here is a wonderful case in point. The facility made a direct link between restraint reduction and a corporate philosophy that promises the best possible care in a supportive and comfortable environment. It then developed a comprehensive, flexible approach that integrated multiple sources of input. Even staff resistance and the uneasiness of family members were transformed into opportunities for education, greater understanding and, ultimately, a more effective caregiving team.

Many facilities these days have attempted restraint reduction, but few have known at the outset the effort involved. In our Optima Awards submission describing our own experience, we have chosen to follow the outline developed by the co-sponsoring Beverly Foundation. Therefore:

I. Problem

What were the circumstances before the program commenced and what led you to focus on this need or problem? What convinced you that a change was necessary or desirable?

Even though OBRA requires facilities to achieve 0% physical restraint usage and a reduction in medications at least twice yearly, we were not yet in compliance with these mandates. For instance our 1995 survey referred to residents on our dementia unit exhibiting episodes of extreme agitation and, as of March 1995, 19% of those residents were receiving psychotropic meds without close supervision for reduction of medications.

With the onset of OBRA, we had been faced suddenly with the challenge of removing physical restraints and with the fear that residents would sustain injuries because, we felt, we would no longer be able to protect them. Interviews with residents and their families brought to light the human dignity side of the question, however. One female resident, when asked why she wore a restraint, responded, "I don't know, but I must have been bad." This was only the first of many eye-opening and poignant statements we heard from our restrained residents as we began to include them in the process of change...hopefully, to 0% restraint usage in our 179-bed facility.

As for those residents who were chemically restrained without a reduction in medication over a period of time, the facility did not have on staff a board-certified psychiatrist available for follow-up with these residents. We had a psychiatrist who was affiliated with our organization, but who was very inaccessible. Mental health screenings were very difficult to arrange in a timely fashion.

Use of psychotropic drugs, both in quantity and number of residents, actually increased from March to July 1995. Further investigation of these residents' history indicated psychotropic drug use dating back to 1993 without reduction.

What resources initiated, were consulted, or helped in definition of the problem?

Staff assisted in counting and identifying numbers and types of physical restraints. We considered a variety of assessment tools, finally deciding on merging the "best" of each into a comprehensive initial assessment and quarterly review plan. Staff also developed a checklist of environmental and physical factors that could affect residents' behavior.

To address use of chemical restraints, we turned to the community at-large. Though we encountered little enthusiasm from advocate agencies for assisting nursing home residents suffering from dementia, we interviewed psychiatrists who expressed an interest in working with our population. We searched specifically for an individual or individuals who shared our commitment to finding alternative methods to manage resident behavior so that it would be less disruptive to other residents and more supportive of the resident's quality of life. The psychiatrist whom we subsequently engaged was affiliated with an academic setting, and was well-known and respected nationally in the geriatric psychiatry field.

II. Objectives

What led you to choose the approach you selected?

Having learned that restraints of a physical and chemical nature were used for many reasons, we believed an interdisciplinary team approach would put us in the best possible position to identify the core reason that a restraint was being used, and then address that reason specifically. On this team we included representatives from occupational and physical therapy, nursing and social work, with other departments included as needed. Prior to beginning the program, we decided how the resident would be assessed, and how we would evaluate the resident's progress in order to identify possible strategies to eliminate or reduce problem behaviors.

What did you expect to accomplish?

Our corporate philosophy states, "...we will provide an environment in which clients will receive personal attention by health care professionals dedicated to maintaining their health, safety, independence, comfort and dignity during their residence through state-of-the-art medical, nursing, dietary, therapeutic, recreational, spiritual and quality of life programs within aesthetically pleasing facilities and grounds." In line with this, we hoped to create a calmer living environment for our residents. We desired to reduce, and eliminate over time, physical restraint usage and to have medications, particularly psychotropic drugs, monitored for utilization, with a goal of reduction/elimination as early as feasible.

We wanted to provide on-site psychiatric services for our residents. The availability of a medical professional whose specialty was psychiatry with an emphasis in geriatric medicine was paramount to our achieving success in our efforts.

We also wanted to utilize our staff as a better/more immediate resource for the psychiatrist, to be able to assess changes in resident behavior and request a psychiatric follow-up for determination of therapy. We desired more active input from family members to assist nursing and medical staff in identifying changes in residents' behavior patterns.

We hoped to achieve full compliance with OBRA mandates concerning use of psychotropic drugs. Using a team approach, the physicians, the pharmacist, social worker, clinical nurse specialist, competency-evaluated nursing assistant, and any other staff member who came in regular contact with the resident (such as recreational, physical, speech and occupational therapists) were encouraged and trained to share information with one another concerning residents' behavioral changes.

The team would therefore, upon admission, evaluate the resident's need for medication and determine appropriateness of dosage. Labs were ordered and monitored for therapeutic levels, and we monitored for signs and symptoms of toxicity.

The team charted on monthly "behavior sheets" residents' behavior changes as they arose. This enabled us to determine any trend in behavior patterns or causal incidents for possible response (e.g., trend or causal incident: combative behavior during care occurring on midnight shift during checks; response: provide medications, verbally assure resident of care activity, have resident participate in recreation programs during the day). The pharmacy consultant, a team member, noted in the resident's chart any change or stoppage in dosage of medication. Through this process, more individualized care plans were developed for residents with behavior problems.

Were your objectives quantified and, if so, how?

For reduction of physical restraints, objectives included:

* Reduction in use of restraints from 30% to 0% within 12 months.

* No increase in rate of injury from falls due to lack of restraints.

For reduction of chemical restraints, they included:

* Decreased response time to requests for psychiatric evaluation, from two to four months to approximately seven to fourteen days.

* Shortened time frames between psychotropic medication evaluations, from two months to now having phone contact with immediate intervention within 24 hours, with a follow-up evaluation in seven days.

* Increased number of persons able to report behavior changes from 15% to 90% of staff, using one-on-one instruction and role modeling within housewide continuing education classes.

* Psychiatrist to review the behavior change sheet on a weekly basis. Clinical nurse specialists to review behavior sheets between psychiatric visits to evaluate effect of treatment.

III. Methods

Describe how you planned and carried out the program. How did you select the population?

The population selected for reduction of physical restraints included residents whose gait was unsteady or who were confused and could fall and injure themselves. Staff selected a resident they felt would have a successful outcome. Why look for a "success story?" Because companies involved in quality improvement efforts have learned the benefits of selecting smaller projects with a high potential for successful outcomes - outcomes that will build support among staff and momentum for future improvements.

The first resident we chose for physical restraint evaluation was a gentleman who required some assistance with ADLs, had some level of confusion, was nonambulatory/wheelchair bound, and was wearing a waist restraint. We chose him because we noticed that, wherever the staff placed him in his wheelchair, that was the place he stayed until they moved him in his chair again.

The population selected for reduction of chemical restraints included residents of our Alzheimer's unit, as well as residents from other nursing units with diagnoses of dementia. The clinical nurse specialist assigned to the dementia unit was very knowledgeable about changing behaviors, and provided invaluable input in choosing individuals from that population.

Residents with behavior problems, as identified by the interdisciplinary team, were the first to receive a psychiatric evaluation. Residents on more than one psychotropic medication were included in this first group.

What information did you look for?

With the waist-restrained gentleman, we examined his ability to feed himself and participate in basic grooming and hygiene tasks. We discussed what time of day the waist restraint was used, and the resident's functional capacity.

Labs were drawn on all these individuals to provide a baseline for evaluation. On an ongoing basis, labs were reviewed for therapeutic range and signs and symptoms of toxicity. The psychiatrist reviewed on a monthly basis the pharmacy consultant's Drug Report for information regarding toxic or subnormal levels of various medications, side effects, or abnormal lab values indicating negative effects of therapy or drug interaction. Following this review, the psychiatrist adapted medications and monitored them on a weekly basis until stabilization was obtained. Behavior was monitored for number and severity of disruptive episodes.

How did you obtain other information?

We met with the resident, the nurse and the CNA who was the direct caregiver to learn specifics of the resident's day-to-day functionality with and without the restraint.

The psychiatrist, along with a clinical nurse specialist and the Director of Social Services, visited these residents weekly. The psychiatrist was informed of any behavior patterns identified by staff or family members, and reviewed the resident's current medications.

How was the information analyzed?

The psychiatrist and medical director are primarily responsible for analyzing the information obtained during evaluation, as well as the medical record and behavior record. The interdisciplinary team, including the nurse and CNA/direct caregiver, also discussed the information received to examine trends and make conclusions.

How were the results used to formulate interventions?

The team involved in the physical restraint reduction pilot program had to be very cautious in their next steps, as failure could bring the loss of staff support. They placed the waist-restrained resident in a self-releasing waist restraint and taught him how to release the restraint at his own choosing. Staff directly involved with the resident carefully monitored him during the initial phase for attempts to ambulate alone, thus creating a risk for fall and/or injury.

They met with the resident after one week to review his progress, both from the staff's and the resident's perspective. The staff felt his behavior had been appropriate and decided to take "the big step" and remove the restraint entirely.

To their surprise the resident, who had always sat in the hallway waiting for staff to take him to activities or meals, became mobile. When it was time for meals, he would propel his wheelchair to the dining room. If there was a program in which he wished to participate, he propelled his wheelchair there. We discovered in follow-up discussions with the resident that he had believed that, when he wore the restraint, he couldn't move the wheelchair!

For our residents who were chemically restrained, the psychiatrist recommended changes in any aspect of the residents' environment that might impact a negative behavior pattern. These included, in part, changes in medication type or dose, room changes, and provision of one-on-one therapy. Staff and family were informed of the psychiatrist's intentions with regard to resident care throughout the individualized care plan process.

The charge nurse also monitored the lab results and behavior changes as documented on the behavior report, notifying the psychiatrist as needed for medical intervention. This nurse served as a liaison between the psychiatrist and nursing staff.

As the psychiatrist's caseload increased, he hired a clinical nurse specialist to provide one-on-one and group therapy during the week, thus allowing the psychiatrist the time for evaluations. This also permitted time for the psychiatrist to conduct 14-day evaluations for newly admitted residents.

Meanwhile, the psychiatrist inserviced the interdisciplinary team on psychiatric drug signs and symptoms and on treating the elderly depressed resident.

What findings or conclusions emerged?

The team working with the waist-restrained resident learned how important it was to talk with the resident and staff, and truly understand their fears and frustrations. Based on this experience, we decided to roll-out the program to the entire facility, utilizing the motto, "Retrain, Don't Restrain" (the title of an American Health Care Association program that our facility purchased for inservice use).

For our chemically restrained residents, the need for interaction with a psychiatrist was confirmed through his caseload increase; this reinforced our intent to conform with the OBRA mandate concerning reduction of psychotropic medications.

Our staff is noticeably more competent in caring for residents admitted with major psychiatric symptoms, and is able to keep them stabilized through alternate methods (although recently we have noticed a few admitted residents with histories of alcoholism, which has resulted in more difficulty in refining a treatment plan).

Lastly, our residents have benefited from in-house psychiatric care. We have been able to minimize the incidence of transfer of residents to the hospital for psychiatric care. Conversely, when hospitalization is required, it is facilitated by collaborative efforts spearheaded by our psychiatrist and his psychiatric team.

IV. Obstacles

Describe major, persistent or highly frustrating obstacles you experienced in implementation, and indicate how you coped with the difficulties.

With physical restraints, staff attendance at initial restraint reduction meetings was intermittent at best. Staff buy-in to the program was a slow, tedious process. Some staff refused to attend the initial restraint reduction meetings, even though they were notified of them. It was difficult to convene a multidisciplinary team on a regular basis, as well as on an as-needed basis. This was further hampered by staff failing to have residents ready for restraint reduction committee evaluation at their scheduled times. Some staff threatened to call residents' families, believing that we were endangering resident safety. This fed on families' fears, many having authorized restraints for their loved ones sight-unseen. Even some of the facility's upper management expressed doubts about resident safety in our moving to become a 0% restraint facility.

With our chemical restraint reduction efforts, once the psychiatrist was on staff, we found staff expected the psychiatrist to "cure" these residents. When they learned the residents' problems were not of a curable nature, they perceived the psychiatrist to be ineffective. It took time for the staff to learn to accept dementia as an incurable disease needing lifestyle and medical management.

When the intervention program was in place, it became a challenge for the staff to implement it consistently. Staff did not always follow the plan, creating delay in monitoring the success of various interventions. The staff also failed in some instances to notify the psychiatrist when major changes were noted in resident behavior.

There were also instances when the medical director, involved with every admission, would write an order for a psychiatric evaluation before the interdisciplinary team had evaluated the newly admitted resident, thus bypassing their data gathering. This was corrected through the intervention of the Administrator of Nursing Services to ensure that the interdisciplinary protocol was followed.

With staff better trained to identify potential behavior problems, and an increase in caseload, the psychiatrist increased the number and length of his weekly visits with our residents. The psychiatrist now attends the monthly quality assurance meeting to report on residents' progress.

To improve staff appreciation for psychiatric services and to improve their understanding of the reasons behind initiation of certain interventions, the psychiatrist conducted inservice sessions and began to "think aloud" during his evaluations. This helped the staff gain a more thorough understanding as to how they could impact the resident's environment and thereby his/her behavior.

An obstacle at the outset of this project was the lack of an assessment tool. The psychiatrist, clinical nurse specialist, Director of Social Services, and charge nurse developed an assessment tool for the staff to utilize to gather data prior to the first psychiatrist visit and, thereafter, during one-on-one visits.

V. Indicators of Success

Describe how the intervention contributed to the optimum well-being, function or autonomy of residents. The key is demonstrable success - evidence that the intervention achieved the objectives.

Our physical restraint reduction has made major strides since its inception. In the span of twelve months, we have progressed from having 51 residents in physical restraints to 8. There has been an increase in falls, as expected, but no correlating increase in injuries. All residents who fall with a subsequent Incident and Accident Report sent to Administration are referred to Rehabilitation Services for review and follow-up. We have seen a decline in falling incidents and believe that it may be attributable to this intervention.

Staff now questions as a matter of course any order for restraint that accompanies a resident's admission. Evaluation is begun immediately to initiate restraint reduction.

Staff now ambulates the resident who is becoming restless and agitated. If the resident is unable to ambulate, staff will encourage him or her to participate in recreational programs, or will just take time to sit and talk with the resident for a few minutes. Referrals are also encouraged, when appropriate, to our Restorative Nursing Program.

Some anecdotal evidence of success: Our facility partners with local colleges and universities to provide a site for students to complete their nursing clinicals. At one recent classroom session, a speaker from Citizens for Better Care, our state's ombudsman program, was commenting on the use of restraints in nursing homes and OBRA regulations against this practice. One of the students spoke up, sharing that her clinical experience at our facility indicated no restraints were used for newly admitted residents. The speaker didn't believe her until several other students confirmed her account. The ombudsman was speechless.

One particular success story involved the committee working with a very confused gentleman who, staff believed, would be prone to falls due to his confusion and agitation. The committee spent a great deal of time with this resident, his family members, and our own staff. We discovered that when the family came to visit, they always brought the resident his watch, which he had received when he retired. They knew how much he loved the watch and that he was always asking for it. The family had never informed the staff that they were bringing the watch during their visits and then taking it home, and the staff would find the resident mysteriously agitated after their departure. The committee suggested that the family find an inexpensive watch that closely resembled the resident's cherished watch and that they could leave with the resident. (The same situation was occurring with the resident's wallet!) We believed that the resident became agitated when the family left because he was frustrated looking for these treasured items which had "disappeared." Being able to "keep them" calmed him considerably.

To improve this resident's gait, staff worked closely with him, helping him ambulate more regularly. Therapy staff taught him how to use a rollator walker. After a period of time, staff and family agreed to removal of the "lap buddy" restraint he was using. Now the resident ambulates regularly, reserving wheelchair use for those occasions when he accompanies the family outside the facility.

We believe, through experience, that staff and family resistance were the most difficult barriers to our program's success. Future efforts will involve staff and family education as to a resident's functional potential. We also need to teach residents - who will fall - how to minimize injury, and continue to review protective measures that do not involve restraints.

In March 1995, we found only one resident of the 19% who were receiving psychotropic medications on a daily basis to be receiving psychiatric follow-up. Today, all of our residents who are receiving psychotropic medications are receiving psychiatric services. All medications are being evaluated on a regular basis, and psychotropic drug usage is falling within the OBRA mandates.

Today, we have calmer residents, happier family members, and more educated staff members, who are now confident in recognizing signs and symptoms of psychiatric disorders and are seeing the results of their education.

* Luxenberg JS, Stone DL, Wendland LV. Behavior Management in Geriatric Long-Term Care: Treatment of Choice Considerations for Medical Directors and Attending Physicians. Beverly Foundation 1995.

Linda S. Mlynarek, FACHCA, is President and Linda C. Mondoux, MS, RN, CS, is Administrator of Nursing Services, Botsford Continuing Care Corporation, Farmington Hills, MI.