Restraint reduction.

Springfield Health & Rehab Center undertook the initiative of becoming a restraint-free facility, or as close to it as possible, as a way of allowing residents to achieve their highest practicable level of independence. Our goal was to eliminate restraint or reduce its use to the least restrictive device for each individual resident. We felt this initiative was very relevant, as many of our residents are admitted with some type of restraint.

When we began our restraint reduction initiative January 1995, 50% of our residents were in some type of restraint. Today, only 2.5% of our residents are restrained. In the same time period, 100% of our residents were evaluated for side rail use, and 82% of them have had a reduction in side raft usage, either by using only one raft, going to half-rails or eliminating side rails entirely.

Besides reducing the use of restraints, the initiative also was aimed at educating the public, residents, family members, physicians and staff about what restraints are and the positive and negative outcomes of using them. Restraints potentially can cause a negative outcome, such as skin breakdown, agitation, weakness, incontinence, depression, social isolation, stiffness and a decrease in self-esteem.

Because these potential side effects affect the total resident, the restraint reduction initiative became an interdisciplinary issue. The restraint reduction committee consists of the administrator, physical therapist, occupational therapist, recreational therapist, social services, environmental services, director of nursing and assistant director of nursing, other nurses, licensed nursing assistants, physicians, a psychiatrist, and the patient/family and staff in-service educator.

Our first step toward restraint reduction was to develop policies and procedures for restraint and side rail use. We evaluated restraint devices, such as side rails; pelvic, vest and belt restraints; cardiac chairs with trays; Omni belts; and Merry Walkers.

We had to assess every resident inhouse as to the need for side rail or other restraint use. For instance, we asked whether the restraint was actually used as a restraint or to assist the resident with sitting balance. Physician orders were checked regarding when the restraint was to be used and under what particular circumstances. Restraints used as enablers for sitting balance or positioning were not included in the reduction initiative. Once we determined which restraints were used to restrain and not enable, the quality improvement initiative began.

Reducing the use of side rails was an especially time-consuming venture. It has always seemed to be an inborn "instinct" for healthcare staff to protect the resident. After all, the last thing they are taught to do is pull up the side rails on the resident's bed before leaving the room. We finally decided that under the new initiative, residents who do not move voluntarily or purposefully by themselves should have the rails left down.

We started the reduction of side rails on the night shift, whose staff monitored the residents and did checklists every half-hour, or more often if needed, to determine whether the resident moved independently in bed. When we determined that it was safe for the resident, the side rails were discontinued or reduced to half-rails or one rail. We even purchased special beds to allow residents to be restraint- and side-rail-free.

Side rail reduction assessments continued for several days, as did the other restraint reduction or elimination assessments. These included mental status evaluations, ambulation, vision and other considerations, such as histories of falls and the resident's own safety awareness. Sources used for assessments included interviews with residents and family members, medical record reviews, physician interviews, physical therapy and nursing assessments, social service and recreational therapy assessments, assessments regarding past life experiences and history, resident and family psychosocial assessments and spiritual needs assessments. After analyzing the potential benefits and consequences of restraint reduction, we determined whether to reduce, eliminate or to make no changes in the type of restraint or side rail utilization.

All departments had to get involved in making the restraint reduction successful. Social Services and Recreational Therapy got involved by working to increase awareness and activities for those residents who had had restraint reductions or elimination. We realized that we needed to budget for more recreational therapy and activities assistants to provide enhanced activities for those residents who were no longer restrained or who were in a reduced restraint. Maintenance and Housekeeping had to make changes in the physical environment to ensure a safe environment for those residents who were no longer restrained. Organizational leaders played a large role in this initiative, first by supporting it, then by providing the tools and resources necessary to make it a success.

The initiative also necessitated increased concentration on our fall prevention program and monitoring of falls to determine whether they increased. We also stepped up monitoring the use of psychoactive medications and antidepressants and felt the need to reduce dosages. To do this, we needed the expertise of a psychiatrist, so we found one to serve on our advisory committee and evaluate each resident taking a psychoactive, psychotropic or antidepressant medication.

After the assessments were completed by the physical therapist, occupational therapist, nursing departments and, when indicated, a physician, the restraint review committee did an interdisciplinary review of the assessments. Appropriate changes were then made in the resident's plan of care.

We next summarized the collected data to show the number of residents assessed and the number of resident restraints eliminated, reduced or kept the same. In addition, we considered comparative studies done at like-sized facilities and with similar populations. External databases were used, such as state quality indicators that showed minimum data set reports, so that we could compare our facility's restraint percentages with those across the state.

These performance measurement data were disseminated in the form of a storyboard to our advisory board - including physicians, a pharmacist, rehab staff, nursing personnel and administrators - at the monthly quality assurance meeting. Information about our progress was also disseminated to general staff on a monthly basis. At these meetings, residents were presented anonymously. Individualized performance measures on specific residents were also given to these individuals, their family members and private physicians.

The results of this initiative and what we learned from them were also shared with members of the community and resident/family councils as part of our community education and awareness programs. In fact, education is a major component of this initiative. While its short-term goals involved improved resident care, long-term goals were to change the attitudes and thoughts that caregivers historically applied to restraint use. With our current mindset, we try alternatives first and view restraints as a last resort.

We spent many hours educating the community, staff, family, residents and physicians on how to reduce or eliminate the use of restraints and to properly use the ones that were truly needed. We devoted resources to getting expert guest speakers and to creating a patient/family/staff resource center where educational materials, including handouts and a video library, would be available. Educational materials were provided to staff at in-services and to residents, family members, community members and physicians. We voluntarily participated in a HCFA Quality Improvement Program regarding restraint reduction. All department heads and general staff were retrained in the use of restraints. Educational programs were followed by question-and-answer sessions and discussions.

Often at the start, family members would not consent to attempted restraint reduction for fear their loved ones would fall or wander and be injured. After we increased family education, however, we were able to accomplish our goals. We find it more productive now to send a restraint reduction notification to family members informing them that the restraint has been reduced. A booklet, Restraints: What You and Your Family Need to Know, was developed to explain to residents and family members the issues regarding restraints. It has had an extremely positive impact on our ability to work cooperatively with family members.

This initiative has not only helped residents achieve the highest practicable level of independence and improve their mobility, but it has also directly affected outcomes of direct resident care. We noted a major decrease in negative skin conditions (we currently have no facility-acquired skin breakdowns), a decrease in agitation in many residents, and more time spent by residents in recreational therapy. We now see less incontinence and fewer contractures, as well as increased resident/family satisfaction and improved patient and family self-esteem.

Another positive is that the program has improved community and public awareness about the type of care provided in our facility and has promoted positive relations with physicians, family members, hospital discharge planners and community members. It has enhanced the facility's image in both the lay and medical communities. Frequently we are called upon as a resource by other facilities.

The experience has also been good for staff morale and, in general, we believe this initiative helped our facility to achieve JCAHO accreditation and a deficiency-free survey.

The initiative continues, with no plans for termination, and we have put mechanisms in place to sustain the improvements we have made. We continue to assess each resident quarterly or when a change in condition (positive or negative) indicates. We continue to update our staff and educate new staff on the restraint reduction initiative, and we continue to involve all staff in the improvement actions. The interdisciplinary planning and managing of this initiative - and others like it - have allowed us to provide quality care and to become a facility that the staff, residents, family members and community can be proud of.

Program Staff

Claire Merchant Director of Nurses

Audrey Kerin Assistant Director of Nurses

Karen Carboneau, RPT Rehab Director

Tammy Lumbra, PTA/COTA

Elaine Amsden Activity Director of Social Services

Dennis Sousa Maintenance Director

Mark Hamilton, MD Medical Director

Tony Petrillo, PAC

Cheryl Lawrence Patient and Family Education

Also acknowledged are the individual nurses and licensed nursing assistants on all shifts who were assigned to specific patients.