“Overall, the reduction rate was 54%. The majority of nursing homes in the initiative were able to get under a 6% patient restraining rate,” said Dolores Viotti, program manager for Healthcare Quality Strategies Inc., the Medicare-designated quality-improvement organization for New Jersey based in East Brunswick, N.J.
CMS’ Physical Restraint Reduction Project set a goal of a 20% reduction at nursing homes with a rate of 6% rate or more.
A physical restraint is defined as any device a patient cannot remove easily and that restricts his or her freedom of movement or access to his or her own body. Examples include vest restraints, waist belts, geri-chairs, hand mitts, lap trays and side rails on beds.
According to a 2008 report by CMS, the use of restraints can result in accidents that may cause serious injury, bruises, cuts, entrapment, and even death by strangulation and suffocation with the use of side rails.
Other effects from restraints may include poor circulation, constipation, incontinence, weak muscles and bone structure, pressure sores, agitation, depressed appetite and infections. Restrained patients may become depressed and agitated and withdraw from social contact. Restraints also can disrupt sleep.
According to the latest data from CMS, New Jersey nursing homes have a 3.8% restraining average, slightly under the national average of 4%, but not as low as the 1% average of Kansas long-term care facilities.
While the restraint reduction initiative was facility specific, teams from each of the nursing homes would get together via conference calls, the Internet or face-to-face conferences. “The teams would meet on difficult cases and identify best practices on case studies,” Viotti said.
Tool kits available through a Learning and Action Network developed by Healthcare Quality Strategies for web access will continue the process past this initiative and onto the next targeted group of nursing homes, which is being identified, she said.
Interestingly, the New Jersey results showed despite reducing physical restraint, patients did not end up falling more during the three-year project, Viotti said.
“One of the key aspects we were looking at was the fall rate, and it did not go up as a result of the reduction in restraints,” she said. The restraint reducing initiative also showed positive results toward another CMS initiative on reducing pressure ulcers in this population group, she said.
OTs were instrumental in designing the multidisciplinary approach to restraint reduction, which included physical therapists, activity coordinators and nutritionists. OTs provided alternative solutions to nursing staff, Viotti said. “OTs took a very large piece of this project,” she said.
Success story
Seeing no change in the fall rate was important, said Teresa Hubbard, OTR, lead therapist at Christian Health Care Center in Wyckoff, N.J., one of the facilities in the restraint reduction initiative.
“The false idea is if you restrain, then you have less falls,” she said. “That’s not what occurred at all. Some restraints — like long bed rails — can cause greater injury as patients slide through them or try to get over them. As therapists we have been talking about this for years.”
CHCC was able to reduce its use of restraints from 8% to 1.6% by the conclusion of the project.
OTs are involved in restraint reduction of patients from the onset of therapy, said Kimberly Martin, OTR/L, senior clinical specialist at CHCC. “One of the primary responsibilities for OTs in this initiative has been wheelchair seating and positioning,” Martin said. “That starts with a full assessment to determine if we are using restraint, why? And can they be decreased or eliminated?”
Through assessing such issues as a patient’s trunk balance, postural control and weakness on one side, OTs are able to devise a treatment plan that can strengthen a patient so he or she can reposition safely without restraints, Martin said.
Using a variety of modifications for long-term care patients who use wheelchairs also helped decrease restraint use, Martin said. Modifications such as cushions, back rests, foot rests, and upper-extremity supports can increase comfort and compensate for balance issues, Martin said.
Wedges and saddle cushions can help support the patient instead of a belt. In addition, gel and foam cushions can be enlisted to help with sores in the sacrum area. Some cushions have air bladders that can automatically inflate and deflate to shift patients who can’t move themselves.
Lowering the bed to the floor, adding a soft mat beside the bed and using half-bed rails are other strategies used to lower restraint use, Hubbard said. “That makes them safe in bed without the use of a full bed rail,” she said.
Other available equipment in place of restraints include a belt designed like a car seat belt or with Velcro that can be pulled open easily by the patient. Some belts will sound an alarm when opened, which can be used by patients with dementia or Alzheimer’s to notify both the patient and the staff when it has been opened.
Active follow-through
Therapeutic activities play a role in reducing restraint use, Martin said. Activities programs keep patients and residents engaged and active, reducing agitation and pressure ulcers. “If they are not having enough stimuli, patients can get bored and antsy,” she said. “We get them involved in more activity programs, even if they have limitations.”
Another key component of the initiative is position change schedules, Martin said. Patients may stand for short periods, or move from a wheelchair to a table chair in the dining room, or to a lounge chair that will allow them to extend their feet, for example. Wrist bands can identify at-risk patients.
Hubbard said patients often do not mention their wheelchair discomfort, so it’s important for staff to pick up on visual clues. “They may not be able to verbalize their discomfort, but they may be trying to move or get out of the chair,” she said. “We teach the staff to watch for behaviors, and before they put on a restraint, see if there’s another option.”
The restraint reduction initiative will continue at Christian Health Care Center, Hubbard said. “When I first started working, I saw a patient tied with a sheet to a chair at another nursing home,” she said. “That was 18 years ago. We’ve come a long way.”
(Source: TodayInOT.com)
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