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Restraint reduction: A success story

September 1, 2007
by Deborah Taube
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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.”