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.

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.

After some time, Dr. Ferrini decided that it was time to finally get rid of all old beds. She worked directly with the nursing staff and management on a patient-by-patient basis to eliminate the older equipment. Over a 30-day period, the number of patients in long rail beds plummeted and now included mainly immobile patients whose families insisted on the long rails, a few patients with seizures, and some quadriplegics on air mattresses who felt more comfortable with long rails and used them to position themselves.

A new problem arose: Edgemoor needed more short rail beds!

Phase two

By 2005, clinical staff efforts were focused on the other patient restraints such as seat belts, other lap restraints, pelvic restraints, Y-leg restraints on chairs, and occasional vest restraints. Edgemoor chose to eliminate the use of pelvic restraints, the most invasive and uncomfortable, and switched to the Y-leg restraint or discontinued the restraint altogether. One young man with a brain injury was extremely aggressive and violent, with an oral fixation and a tendency to reach out and grab or hit staff or lick or bite them. He even chewed on the toe of an immobile patient. As a result, he remained both chemically and physically restrained.

He was in a pelvic restraint in a chair which was tied to the floor on a fixed board and with full padded box-like side rails while in bed. Achieving a restraint-free care plan for him took many months and was accomplished in incremental steps. Success depended on consistent staffing who could use their knowledge of his habits to keep themselves safe. Staff used environmental manipulations (placing his strong side against the wall), medication reductions, and encouragement of positive behaviors. Although he remains a risk, he is restraint-free and on fewer psychoactive medications.

Final catalyst

Our facility’s involvement in the Lumetra Culture Change Initiative proved to be the final catalyst regarding restraint use. Lumetra is a collaborative effort to promote person-centered care in long-term care, funded by the Centers for Medicare & Medicaid Services. Due to questions raised at the Lumetra conferences, Director of Nursing Nancy Beecham; Assistant Director of Nursing Soon Chu, RN; Psychologist Robert Gibson, PhD; and Dr. Ferrini began making systematic efforts to become restraint-free. There had been significant leadership from Dr. Ferrini before 2005 to reduce restraints and, historically, significant resistance from the nursing staff. After attending the Lumetra conferences, Beecham and Chu took a leadership role in establishing a goal to become restraint-free.

Their efforts were assisted by Dr. Ferrini, who worked with the medical staff, teaching the doctors they needed to say “no” to restraints and offer other alternatives. Our facility is continuing the process of reorienting all our staff.

When a patient behavioral problem occurs, and the nurse or nursing assistant asks for medications or restraints, he or she quickly learns that restraint alternatives are now the rule.

Becoming restraint-free involved a thorough re-examination of the use of restraints, as well as reviewing what is being classified as a restraint in light of relevant legal standards and definitions. In this effort, coding errors were discovered, particularly over-coding interventions, such as side rails or seat belts in patients who were completely immobile. Our facility instituted a multidisciplinary approach to restraint education and changes in practice, making the restraint-free goal an integral component of the provision of daily care. Dr. Ferrini and members of the Quality of Life committee became intimately familiar with each patient who was restrained and worked directly with the interdisciplinary team on strategies to reduce or eliminate that restraint. As we got closer and closer to zero, the pressure increased and fewer rationales for use would be accepted. Through interdisciplinary team action, the use of a restraint became something that needed to be strongly justified following trial and failure of other options.

This was a striking contrast to a tendency to “routinely” use restraints common in many long-term care facilities. Essentially, the burden for justifying the use of a restraint had shifted from asking, “Is there any reason why we shouldn’t use this restraint?”, if this was asked at all, to vigorously questioning the use of a restraint and instead asking, “What haven’t we tried yet; isn’t there any other option?”

One consequence of restraint reduction was that some patients required a higher level of staffing, a few even requiring one-to-one or private-duty–type monitoring. This level of care is uncommon in skilled nursing, but Edgemoor is a “distinct part A” facility specialized in the care and treatment of chronically ill, high-acuity patients. One-to-one monitoring has occurred in the past when our facility had a high level of restraint use, but the level did increase when our facility became restraint-free.

The increase in these intensive interventions placed a significant strain on staffing resources. However, one benefit of one-to-one monitoring was the improvement of the staff’s familiarity with the patient’s patterns and tendencies. The one-to-one intervention eventually can be discontinued when staff has developed facility in managing difficult patients with creative approaches.

Our facility is now a 220-bed, distinct part A restraint-free healthcare facility where the average patient age is 55 years, and the population is predominantly male, with almost half of our patients exhibiting behavioral symptoms affecting others. We have been restraint-free since January 2007.