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When restraints are not an option

April 1, 2008
by root
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Staff accomplishes seemingly insurmountable goal of no restraints—physical or medicinal

Editor's note: Since 1996, Nursing Homes/Long Term Care Management has been honor-ing long-term care facilities that are proactive with programs that go “above and beyond” routine care for their residents with our OPTIMA Award. It is conferred by a jury of long-term care peers from submitted entries. This month, we feature the 2007 runner-up,* Edgemoor Hospital, Santee, California. It provides long-term, 24-hour skilled nursing care for patients unable to be cared for by the private sector. Edgemoor residents require more specialized interventions and a more highly trained staff than other local facilities can provide. Over three years, the staff transformed their hospital into a restraint-free facility with teamwork and a systematic implementation plan.

The first place OPTIMA winner, Ballard Healthcare, was featured in the September 2007 issue of Nursing Homes/Long Term Care Management.

Like many facilities in 2004, Edge-moor Hospital was using restraints on patients. The restraints used included seat belts, Y-leg restraints on chairs, occasional vest or pelvic restraints, and side rails. We also used some higher doses of sedating medications to reduce negative behaviors. The use of these restraints was justified based on medical conditions such as fall risk or aggression. In accordance with regulations, the nursing staff carefully documented failed attempts to reduce these risks. Restraints were viewed as a necessary part of care for challenging residents. Although staff had heard about restraint reduction, it did not apply to our facility—in our eyes, our patients were different, more challenging, younger, more violent—and we saw restraints as our only option.

Through the efforts of our medical director, Rebecca Ferrini, MD, and involvement of a subcommittee of our Quality Council, the use of restraints was reviewed in 2005-2006. In examining restraint use, Edgemoor conducted a review of existing restraints and identified (1) restraints that could be eliminated through the application of medical and behavioral interventions or other means; (2) a significant number of devices had been miscoded as restraints; and (3) medication use should be reviewed to ensure that none were serving as chemical restraints. From this, our facility began a process of staff education regarding restraints and enablers, alternatives to restraint, the risks of using restraints and the impact on the patient of being restrained, and revised the restraint policy and procedure more than once to reflect this. (Our latest revision explicitly states the goal to remain restraint-free.) Additionally, through efforts of the medical director working directly with facility physicians, the physicians took a more active role in restraint reduction by becoming more hesitant to write an order for a restraint.

Rebecca ferrini, md

Rebecca Ferrini, MD

Before 2006, Edgemoor did not explicitly set a goal to be restraint-free, but promoted a vague goal of reducing restraints “as much as possible.” Restraint use was tracked by our Quality Council and was discussed in interdisciplinary teams. At the beginning of our efforts, we had little hope of eliminating restraints.

Impetus for change

The first inkling that restraints may not provide the most desirable protection for patients and may be harmful, occurred when Dr. Ferrini attended an American Medical Director's Association conference on the hazards of side rails and heard about the dangers of this seemingly innocuous intervention. Established in 1923, Edgemoor Hospital had very old beds (some with cranks!). Most beds could only lower to 21" from the ground. Long rails (full side rails) were present on most patient beds. Our facility thought it needed those side rails to protect the patients, but an inspection of the side rails led to concerns about entrapment. To protect patients, Edgemoor devised wonderful vinyl slings to cover the gaps in the side rails, and embarked on purchasing new beds with short rails only.

In 2002, Edgemoor initiated a bed replacement program. This was a process of negotiation. Nursing feared eliminating long rails was risky. As a result, 150 beds with short rails were purchased and only 50 with long rails. These new beds would lower to 15" off the ground and had mattresses that were curved up on the sides to prevent falling. Additional floor mats were also ordered. In making this purchasing decision, Edgemoor began the process of culture change: Restraints would no longer be an option for the majority of our patients in beds that had no rails. When the new beds were deployed to the nursing units, there was a resistance to using them—the nursing staff were frightened about patients falling. There were, in fact, attempts to retrofit the beds with long rails. Suddenly, the older beds were appealing. Staff could not imagine Mr. Smith or Ms. Harm without side rails.

To overcome the resistance, old beds were gradually replaced with new models. Staff were forced to experience the new beds. To much surprise, they learned that immobile patients did not fall out of the beds and that patients who were more mobile did not try to get up and hurt themselves. Keeping the beds in a low position also needed constant reinforcement.