Restraint reduction: a success story; Considered on a case-by-case basis, residents are freed from restraints by the nursing staff at St. Barnabas Senior Living Services.

Nationwide, nursing home facilities are striving to comply with federally mandated restraint reductions. Brigetta Nethery, nursing home administrator of St. Barnabas Senior Living Services in downtown Chattanooga, Tennessee, describes how her organization attained a 2006 zero-restraints rating, exceeding the government's goal by 7.8%. "In 2006, Tennessee ranked near the top nationally in terms of the number of restraints used in its 325 nursing homes," says Nethery. Until recently, lower restraint use was considered nearly impossible to achieve. Last year, however, St. Barnabas used no restraints, with the exception of a mitten for a resident whose movements would dislodge his tracheostomy tube.

Eric Boston, St. Barnabas president and CEO, is pleased with the outcome. "Zero is the best you can do," he says. "Our goal has always been to keep patients happy and safe, and to provide the highest quality of care. The nursing home staff has made that mission evident throughout all of our clinical and lifestyle interventions."

St. Barnabas, like many nursing facilities across the country, has confronted significant operational challenges in complying with the standards of the Omnibus Budget Reconciliation Act of 1987. By law, residents have the right to be free from all unnecessary physical restraints beyond the treatment program prescribed by physicians or unless their physical safety is in jeopardy. The Centers for Medicare & Medicaid Services defines a physical restraint as "any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he or she cannot remove easily that restricts freedom of movement or normal access to one's body."

In fall 2005, Nethery and Director of Nursing Donna Rutherford began to examine how best to implement restraint reduction in their facility. They realized immediately that they would need to address reductions on a case-by-case basis, and they presented their plan to Medical Director Bruce Pendley, MD. "My first reaction was, 'It won't work!'" laughs Dr. Pendley. "I'd never known a nursing home that actually achieved zero restraints. With 87 skilled beds in this facility, it was reasonable to assume some residents might become restraint-free, but not an entire facility." However, Dr. Pendley was pleasantly surprised when the nursing staff reached its objective. After two short months of intensive patient evaluation and rethinking nursing procedures, all patient restraints were removed. "I credit the nursing staff members for the success of the program," Dr. Pendley says. "They initiated the concept and did the follow-through. My contribution was to not stand in their way."

Today, St. Barnabas staff thoroughly evaluates all pertinent safety issues for each incoming resident and removes restraints from those wearing them who arrive from hospitals. The ongoing evaluation program targets root problems related to restraint use, just as medications treat symptoms of an underlying cause. Behaviors are analyzed to determine whether restraints should be used or if alternative measures can eliminate the need.

Nursing staff members often feel compelled to administer restraints to prevent residents from falling or wandering, and Nethery says reeducating staff is the first place to start. "We can definitely think outside the box," she says. "At St. Barnabas, we have made it more difficult to use restraints than not." To illustrate, Nethery notes that new research is being used to reevaluate common practices. "In the past, if a patient fell out of bed, the staff's first concern was whether the siderails were positioned," she says, speaking from 25 years in the nursing profession. Documented neglect to use siderails would negatively affect a facility's survey ratings. Recent research indicates, however, that siderails and other restraints can actually increase the risk or seriousness of injury.

"It's very important to get a resident's family involved early in the decision-making process," says Nethery. "They are naturally concerned about their loved one falling, but when we describe our philosophy and strategies, and explain the dangers of using restraints, they no longer insist on them." In fact, since implementing restraint reduction measures, St. Barnabas has had no increase in falls.

Nethery, who joined St. Barnabas as nursing home administrator nearly three years ago, attributes the facility's extraordinary achievement to adequate staffing and policies that require both physician and administrator approval for restraint use. "The Freedom Committee," an interdisciplinary restraint reduction team, has met weekly since its inception more than a year ago. When an infrequent fall does occur, Nethery and her team immediately audit the incident to determine the cause. The next morning the committee meets to evaluate future interventions on an individual basis depending on the resident's cognitive status, physical functions, or limitations. In-service training keeps staff current with St. Barnabas's new policies, which may include placement of a 24-hour sitter as a last resort rather than applying restraints.

"Sometimes just moving residents closer to the nurses' station eliminates the need for a restraint," notes Rutherford. "We also evaluate each person to determine proper seat cushions and how high to position a bed, and we place cushioning mats on the floor--whatever it takes to keep residents functioning at the highest possible level."

In lieu of physical restraints, alarms notify staff when residents leave their bed or chair; even so, staff must exercise constant vigilance over some particularly clever residents--one correctly inferred that placing heavy books on her bed would prevent the alarm from sounding. In addition, the need for monitoring escalates once physical conditions improve through therapy, since more mobility may mean an increased likelihood of falling.

Early this year, news of St. Barnabas's successful restraint reduction efforts reached the state level, and Nethery was invited to present to colleagues at a best practices panel at the annual Tennessee Health Care Association Medical/Legal Summit on April 5 in Nashville. At the time of the invitation, Tennessee's best restraint reduction record was above the acceptable number. Nethery, together with Rutherford, Pendley, and Boston, explained how St. Barnabas's focus on quality care directed the nonprofit's innovative strategies. For example, knowing how important staff consistency is to its comprehensive program, the facility chose to secure a consistent workforce rather than use staffing agencies. St. Barnabas has nearly doubled payroll, more than doubling the minimum number of hours nursing staff members are required to spend with residents while still retaining earnings. This strategy in turn directly contributed to the success of the restraint reduction program.

"The key to quality improvement is knowing your residents personally--having a consistent staff that stays long enough to become familiar with each resident's habits," says Rutherford. Today, St. Barnabas's day shift provides a nurse-to-resident ratio of approximately 1:12, and a CNA ratio of 1:6-8, about half the average resident load found in similar facilities. Night nurses never have to care for more than 29 residents.

Following April's panel presentation, Nethery participated as expert speaker for the Advancing Excellence in America's Nursing Homes campaign from QSource, Tennessee's Medicare quality improvement organization. "It's a very time-consuming process to maintain our zero-restraints position," she says. "But our program has paid off tremendously." For Nethery, enhancing residents' quality of life means evaluating all areas of risk and refusing to be content with a good rating. "If you achieve a 90% restraint reduction," she says, "you need to look at the 10% remaining and ask yourself, 'Why do we have to use restraints for these cases?'"

St. Barnabas continues its tradition of clinical excellence with the opening of a new, state-of-the-art nursing home in July 2007, on the campus of Siskin Hospital for Physical Rehabilitation.

Deborah Taube is Director of Public Relations and Marketing for St. Barnabas Senior Living Services. For more information, visit www.st-barnabas.com. To send your comments to the author and editors, e-mail [e-mail].