Facility finds creative alternatives to restraints
Facility finds creative alternatives to restraints
Many health care providers say they want to be restraint-free, especially since regulators like hearing that, but many find they are only able to reduce the use of restraints. Some patients and some situations just require restraints, they say.
That excuse is not accepted at Susquehanna Lutheran Village, a 203-bed nursing home in Millersburg, PA. Susquehanna began reducing the use of restraints in 1995 and soon after became a restraint-free facility. The facility now serves as a training site for restraint-free care for the entire state of Pennsylvania, and it recently was one of two recipients of the 1998 Codman Award from the Joint Commission on the Accreditation of Healthcare Organizations. The award recognizes innovative efforts to improve health care.
The Joint Commission and the facility’s administrators point to the program’s success as an endorsement of the restraint-free concept, pointing out that the elimination of restraints has not led to an increase in claims or injuries. In fact, the severity of fall-related injuries actually decreased when restraints were eliminated.
High level of restraint use prompted concern
The facility’s efforts began after the Pennsylvania Department of Health sent a letter noting that 65% of the patients were restrained in some way and asking for a plan of action, says Joseph Mraz, MS, executive director of Suquehanna. It took about two years to eliminate restraints altogether, but now families are told on admission that the facility does not use restraints in any circumstances. If the family insists that restraints are necessary for a patient’s safety, staff suggest they look elsewhere for accommodations.
The families’ reluctance to forgo restraints was one of the biggest hurdles, Mraz says. Though families dislike seeing their loved ones restrained, they also greatly fear the consequences of allowing patients to fall or wander. "Families are just more confident when their loved ones are restrained," he explains. "They would go to the attending physician and say they wanted Mom or Dad restrained. That in turn led to difficulties with physicians who didn’t want to get 10 calls a day from the family, so sometimes the physicians would just say, Let’s do the restraints.’"
Changes in daily routine implemented
Mraz and his colleagues persevered with the plan, insisting that there was no need to restrain patients. By implementing a series of changes in the daily routine, they were able to keep patients safe without the use of restraints. (See p. 33 for details on the changes.) The staff and physicians had to change some of their attitudes about how to protect patients, but time proved that the goal could be achieved, Mraz says.
A "restraint reduction team" was developed, including nurses, nursing assistants, physicians, and administrators. Together, the team brainstormed new ideas to keep patients safe without restraints. The original goal was reducing the use of restraints, but the Susquehanna team decided to eliminate restraints altogether once they saw the initial good results. The nursing home now has no restraints in the building.
"Of course, we looked at the easiest cases first and were able to remove their restraints quickly," Mraz says. "We saw that they were happy to have the restraints removed. If they were cognitive, they would say thanks. If they were less cognitive, we would see that they were less agitated."
One of the first concerns was that the restraint-free policy would require the addition of more staff at the nursing home. Mraz found that was not the case. "It takes more staff to put them in restraints, monitor them, take them out of the restraints, exercise them, and so on," he says. "There’s less work involved in being restraint-free, but we did have to make sure we included the office staff in the program. We wanted the office staff to be able to help if they see a patient wandering or leaving the center. We encourage them to retrieve the patient, or if they have a few minutes, to take the patient for a short walk outside."
The team also anticipated an increase in falls because all the literature concerning the removal of restraints suggested such an increase was inevitable. There was indeed an increase in falls, but there was a significant reduction in the severity of injuries from falls, Mraz says. Because of changes in the care plan that improve the patients’ muscle tone and overall health, for instance, a fall is more likely to result in just a bruise than a serious injury, he says.
Every single fall, no matter how minor, is reported to the patient’s family, he says. That creates a good pattern of accountability and shows how the facility responded to each incident in case the patient is ever involved in a more serious fall. There has been no increase in lawsuits or liability since the facility went restraint-free, Mraz says. Although he cautions that the transition will take some time, he says other facilities should be able to achieve the same elimination of restraints.
"Everyone is on board with this program now," he says. "Patients often come back from the hospital restrained, and the staff runs to us, saying, Get those restraints off! We don’t want any restraints here!’"
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