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Guidelines for assessing use of position change.

Position or pressure change alarms have been used in many nursing facilities as part of a safety plan to decrease or eliminate physical restraints. These types of device sound an alarm when the resident changes position, lifts his or her weight off a bed or chair, or exceeds the limits of a cord attached to the resident's chair or bed. One way these devices have been used at the Benedictine Nursing Center is as a substitute call light for residents who are unsafely mobile and cognitively unable to use the call light. When staff hear the alarm, it is a message to assist the resident, rather than to simply tell the resident to sit down -- a command that may have the effect of reducing, rather than enhancing, the resident's mobility.

Position or pressure change alarms may be used routinely for specified times during the day, or until balance or endurance improve. Residents and families need to be clearly informed that these devices in no way can assure safety, but are merely one part of a safety plan, and there may be times when the alarm will not work (the resident removes it, the alarm fails to sound or is slow to do so). It is not fail-safe, but merely a tool intended to increase the resident's safety. Position change alarms can restrict freedom and privacy, to a degree, so ethically must be used only after careful assessment and discussions with the resident and/or family.

These devices have been found to be particularly useful for the types of person listed below and for those with combinations of these problems:

1. Persons with mild forgetfulness or impaired judgment who are on restricted weight-bearing status following orthopedic surgery.

2. Persons with impaired mobility, judgment and balance following a stroke.

3. Persons with dementia who have an unreliable or unsteady gait.

4. Persons who ambulate to the bathroom at night by themselves, but may experience incontinence along the way or periods of transient dizziness.

5. Persons with poor balance or unsteady gait who attempt to get out of bed without assistance.

6. Persons with a history of frequent falls.

Before initiating use of a position or pressure change alarm, it is helpful to take the following steps:

1. Conduct a mobility assessment.

2. If they pass such an assessment, it is probably not appropriate to use a position change alarm.

3. If mobility problems are found to exist, administer a more detailed gait evaluation. An example is the Tinetti Balance and Gait Evaluation. Contact the resident's physician to share the results of the evaluation and explore the possibility of seeking an underlying cause or requesting a Physical Therapy consult for gait and/or balance training.

4. Discuss the use of the device with the resident and/or family.

After initiating use of the device, consider:

1. If the resident removes it frequently, or tries to, it may not be the best intervention, and a different safety plan should be developed. Frequent attempts at removal may indicate that the device is a burden to them.

2. Use of the device should be continually re-evaluated (at least every three months). If indicated, and following discussion with resident and/or family, conduct a three-day trial without the device, evaluating the results from the resident's perspective. During those trial days, each shift should document the resident's responses.

3. If the resident is no longer mobile or has ceased attempting to stand, and the situation seems likely to remain unchanged, the device should be removed.

Costs of position change alarms vary greatly. Alarms designed specifically for resident use may cost up to $150 to $200 apiece. Some facilities have adapted window and burglar alarms for this purpose by attaching the cord-pull alarms in various ways to wheelchairs or beds; the cost of these devices is in the $10 to $30 range.

Finally, there are as yet no studies that alarm devices alone prevent falls or injury. Since our culture tends to be over-protective of the elderly and seek solutions in technology, it is easy to over-rely on these devices instead of seeking the underlying causes of falls and instability. When considering use of a device it is important to ask, "Is this to increase the resident's safety, or to make the staff feel more secure?"

Adapted from Magic, Mystery, Modification & Mirth: The Joyful Road to Restraint-Free Care, by Joanne Rader, RN, MN. Ms. Rader, a recognized pioneer in restraint reduction, is on the staff of the Benedictine Institute for Long Term Care, Mt. Angel, OR, and is an assistant professor at the Oregon Health Science University School of Nursing.
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Author:Rader, Joanne
Publication:Nursing Homes
Date:May 1, 1993
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