Restraint reduction - in nursing homes - Optima '98/First Runner-Up

Nursing Homes, Sept, 1998

Springfield Health & Rehab Center undertook the initiative of becoming a restraint-free facility, or as close to it as possible, as a way of allowing residents to achieve their highest practicable level of independence. Our goal was to eliminate restraint or reduce its use to the least restrictive device for each individual resident. We felt this initiative was very relevant, as many of our residents are admitted with some type of restraint.

When we began our restraint reduction initiative January 1995, 50% of our residents were in some type of restraint. Today, only 2.5% of our residents are restrained. In the same time period, 100% of our residents were evaluated for side rail use, and 82% of them have had a reduction in side raft usage, either by using only one raft, going to half-rails or eliminating side rails entirely.

Besides reducing the use of restraints, the initiative also was aimed at educating the public, residents, family members, physicians and staff about what restraints are and the positive and negative outcomes of using them. Restraints potentially can cause a negative outcome, such as skin breakdown, agitation, weakness, incontinence, depression, social isolation, stiffness and a decrease in self-esteem.

Because these potential side effects affect the total resident, the restraint reduction initiative became an interdisciplinary issue. The restraint reduction committee consists of the administrator, physical therapist, occupational therapist, recreational therapist, social services, environmental services, director of nursing and assistant director of nursing, other nurses, licensed nursing assistants, physicians, a psychiatrist, and the patient/family and staff in-service educator.

Our first step toward restraint reduction was to develop policies and procedures for restraint and side rail use. We evaluated restraint devices, such as side rails; pelvic, vest and belt restraints; cardiac chairs with trays; Omni belts; and Merry Walkers.

We had to assess every resident inhouse as to the need for side rail or other restraint use. For instance, we asked whether the restraint was actually used as a restraint or to assist the resident with sitting balance. Physician orders were checked regarding when the restraint was to be used and under what particular circumstances. Restraints used as enablers for sitting balance or positioning were not included in the reduction initiative. Once we determined which restraints were used to restrain and not enable, the quality improvement initiative began.

Reducing the use of side rails was an especially time-consuming venture. It has always seemed to be an inborn "instinct" for healthcare staff to protect the resident. After all, the last thing they are taught to do is pull up the side rails on the resident's bed before leaving the room. We finally decided that under the new initiative, residents who do not move voluntarily or purposefully by themselves should have the rails left down.

We started the reduction of side rails on the night shift, whose staff monitored the residents and did checklists every half-hour, or more often if needed, to determine whether the resident moved independently in bed. When we determined that it was safe for the resident, the side rails were discontinued or reduced to half-rails or one rail. We even purchased special beds to allow residents to be restraint- and side-rail-free.

Side rail reduction assessments continued for several days, as did the other restraint reduction or elimination assessments. These included mental status evaluations, ambulation, vision and other considerations, such as histories of falls and the resident's own safety awareness. Sources used for assessments included interviews with residents and family members, medical record reviews, physician interviews, physical therapy and nursing assessments, social service and recreational therapy assessments, assessments regarding past life experiences and history, resident and family psychosocial assessments and spiritual needs assessments. After analyzing the potential benefits and consequences of restraint reduction, we determined whether to reduce, eliminate or to make no changes in the type of restraint or side rail utilization.

All departments had to get involved in making the restraint reduction successful. Social Services and Recreational Therapy got involved by working to increase awareness and activities for those residents who had had restraint reductions or elimination. We realized that we needed to budget for more recreational therapy and activities assistants to provide enhanced activities for those residents who were no longer restrained or who were in a reduced restraint. Maintenance and Housekeeping had to make changes in the physical environment to ensure a safe environment for those residents who were no longer restrained. Organizational leaders played a large role in this initiative, first by supporting it, then by providing the tools and resources necessary to make it a success.