Contrary to popular belief, reducing the use of restraints on residents in long-term care can improve care delivery while shielding facilities from liability.

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he case against using restraints on residents in long-term care is clear. They often create serious problems, including incontinence, pressure sores, emotional problems, isolation, and loss of ability to walk or perform other activities. Residents may also be harmed trying to escape from restraints, or they may be harmed by improperly applied restraints. What is unclear is why the numbers show that restraints are still so widely used. Nationally, more than 80,000 nursing home residents are in restraints, according to data from the Centers for Medicare & Medicaid Services (CMS) Quality Improvement Organization Standard Analytical Report. Why is there a disconnect between what is generally recognized as good medical care and what is actually being put into practice?

One Facility’s Journey

       Donna Davis, RN, the former Director of Nursing (DON) at Sheridan on Anderson (College Station, Tex), knew her facility was struggling with its restraint rate. In July 2002, 51.9% of residents were in restraints. Fifty-two residents were wearing some type of body or bed restraint, not including side rails. After discovering that it lacked the appropriate assessment for this problem and a care plan that addressed the restraints, the facility attempted to remedy the problem on its own—without success.
       A second attempt prompted the facility to use a pre-restraint assessment form for new admissions, residents with sudden changes in condition, and any resident with a sudden onset of falls who had not previously used a restraint. Staff members also evaluated every resident then using any type of device. This assessment included:
• Risk factors/complications, recent fractures, medications, and cognitive status
• Positioning issues (eg, wheelchair versus geri-chair, bed versus chair)
• Restraint alternatives/restraint issues
• Options available to maintain or improve level of function while avoiding risk factors (eg, physical therapy/occupational therapy referrals).
       By October 2002, the facility completed all of the assessments. Its restraint rate was still at 46.9% with 53 residents wearing physical restraints every day. The assessments were not tailored to meet specific needs and required further modifications.

A Problem the Size of Texas

       At the same time Sheridan on Anderson was struggling to get a handle on its restraint rate, TMF Health Quality Institute (TMF) in Austin, Tex, had the worst restraint rates in the nation. In November 2002, 13,384 nursing home residents in Texas were being restrained daily, according to data from the aforementioned CMS report. At the time, CMS’ Government Performance and Results Act (GPRA) goal for restraints was 7.8% with plans to reduce that number to 6.6% by 2005.
       A nonprofit organization contracted by CMS to work with long-term care facilities in Texas to use quality improvement (QI) methods to achieve sustained improvement on the Quality Measures (QM) data reported to the agency, TMF convened a coalition of long-term care trade associations, providers, senior groups, surveyors, and government agencies. The first mission was to consistently communicate the definition of a restraint to the long-term care industry in Texas. The second was to send a unified message to providers, families, and the industry that restraints would only be tolerated if medically necessary.

Calling a Spade a Spade

       If it restrains, it is a restraint. Physical restraints are any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident’s body that the individual cannot remove easily; they restrict freedom of movement or normal access to one’s body. Some devices that can be restraints include seat belts, vests, “lap buddies,” walkers, bed side rails, and special chairs. Whether a particular device is considered a physical restraint depends on its effect on the individual resident.
       If a resident cannot remove a device when asked and the device restricts purposeful movement, it is a restraint. The same item may not be considered a restraint for an individual if it assists in his or her quality of life, does not restrict any purposeful movement, and does not prevent the resident from doing something he or she could without it. For example, a bed rail could be used to keep someone from getting out of bed or could be used to help a resident turn over in bed. Actor Christopher Reeve provided a good example of this distinction. The devices used for him did not inhibit his movement; rather, they kept him secure in his wheelchair. In some extreme cases, the use of chair and bed alarms can be considered a restraint if the reaction of the staff to the alarm is always to return the resident to the lying or sitting position. Staff must be appropriately trained prior to applying and/or monitoring any device.
       All long-term care facilities must carefully assess the needs of each resident. Restraints should only be used as a last resort, after less-restrictive alternatives are tried. If restraints are used, they must be based on a physician’s order for a specified and limited time. Restraints must never be used:
• As permanent means of control
• As a form of punishment
• For the convenience of the facility staff
• As a substitute for activities or treatment.
       After building understanding and consensus around this definition, the coalition moved forward by providing joint training for restraint reduction for the more than 500 providers in Texas. TMF also began one-on-one consultative services with the staff at Sheridan on Anderson in March 2003, in addition to initiating similar partnerships with other Texas facilities on QI techniques and the benefits of establishing cross-functional teams.

First Steps

       With the support of TMF, Sheridan on Anderson began to see some immediate success by:
• Disseminating letters to physicians and families about its commitment to be restraint-free
• Developing a new admission policy and acknowledgement statement
• Conducting in-service sessions for all staff
• Hosting the ombudsman to present a restraint-reduction program at a family council meeting
• Setting a goal of being restraint-free at all facilities owned by Sulik Healthcare (eg, Sheridan on Anderson) by November 1, 2004.
       In one month, its restraint rate dropped to 38%, a significant difference but still far higher than the state average. The facility began to dig deeper into its processes and the deeply rooted beliefs about the use of restraints circulating in the facility.

Transforming the Culture

       Many long-term care facilities have an easy time identifying areas in which they would like to improve, and they can usually determine how to make changes. But what usually happens is that those changes, no matter how exceptional, will not stay the course without a foolproof system to keep them there.
       Quality improvement is a way of thinking. Encouraging organizations to use small-scale, rapid cycle tests of change will assist in transforming the culture from one that is static to one that actively searches and tests new ideas for improvement. A framework for this trial and learning method is the PDSA (Plan, Do, Study, Act) cycle. The PDSA cycle (see Table 1) begins by asking a few questions. What are you trying to accomplish (eg, a simple goal that identifies a desired outcome)? How will you know if a change is an improvement? What change will result in an improvement?

Table 1

       PDSA cycles encourage small tests of change that can be evaluated before implementation occurs on a larger scale. This method can be accomplished by testing in a rapid cycle, starting with a minimal change and increasing incrementally to minimize the negative impact of unsuccessful changes on the whole system.

Broken Processes Need a Strong Foundation

       A recent television commercial for an automobile features engineers and designers in a room, racking their brains about how to improve next year’s model. They are struggling for ideas when the mail clerk walks in to deliver the mail and says, “Why not make it smaller?” Good ideas come from people at all levels in an organization—but if they are not elicited or welcomed, the ideas may never surface.
       A successful QI approach requires that solutions to problems come not only from management but also from every person who interacts with the residents through the development of cross-functional teams. Teamwork is essential for high-quality performance in many industries, including healthcare. Rigid hierarchies within healthcare and turnover among employees make poor teamwork a widespread problem. Using team-training and team-building strategies can help team members understand their roles and the need to rely on each other to provide the best care for their residents. Cross-functional teams represent a method for achieving better quality in healthcare organizations because they can foster better coordination of care among the many different roles in the facility and other healthcare settings.
       To be highly successful, each team member must be empowered to question decisions, identify problems, and propose solutions. Empowerment promotes decisions based on knowledge rather than status within the group. Training team members to avoid hierarchy and reward each team member for taking the initiative to assure residents receive the best care possible is essential.

Debunking Myths

       The most common reason given for using restraints is to prevent injuries to persons who are at risk of accidental falls due to physical or mental illness, though the CMS report data demonstrate that removing the restraint does not leave a person at an increased risk of falling. Countering this myth through staff education is instrumental. In addition, providing research to families demonstrating that the same number of falls can occur regardless of whether restraints are used can counter this misconception.
       As facilities work to become restraint-free, another challenging myth they face is the belief that residents will not fall once they are in a facility. This myth is often reinforced from the time the resident enters the facility. Perhaps the admissions director wants to reassure a family that their family member will be safe and will not fall again.
       Facilities should be realistic with staff and family members that there is always a risk of a resident falling. Access to the best care in the world does not remove this risk. When Ronald Reagan fell at home in 2001 and broke his hip, he was probably surrounded by his wife, other family members, personnel service, and aides. Restraint reduction must happen only in conjunction with fall-risk assessment and prevention. Residents cannot always be prevented from falling, but they can always be assessed for potential risks to prevent them from injury.

A New Day

       By the end of June 2003, in less than a year’s time, Sheridan on Anderson became a restraint-free facility, reducing its rate from 51.9% to zero. To promote its mission, the facility worked hard to keep restraint myths from resurfacing. The following 10 points highlight what worked for them:
1. Be positive
2. Be familiar with research regarding restraint reduction
3. Know what devices are least-to-most restrictive
4. Put it in terms everyone can understand
5. Keep forms in one place and ready to use
6. Have a weekly restraint committee meeting
7. Get everyone involved
8. Do not take “No” for an answer
9. Put a fall prevention program into place
10. Set your goals and follow-through.

Conclusion

       Since the success at Sheridan on Anderson, Donna Davis moved on to open a sister facility, Sheridan of Bryan, that has never had a restraint in the building. The facility is so committed to this mission that, as a corporation, it has agreed not to accept residents with restraints from physicians or other facilities.
       Part of its motivation stems from the realization that if it were to use restraints, its liability risk would rise significantly. Do the math. For a facility that has 10 residents restrained daily, releasing the restraint every 2 hours for 10 minutes (ie, 6 times a day) would require 600 minutes of staff time or 10 person-hours per day. Facilities need to question whether they are adequately staffed to properly care for restrained residents. The answer is usually no.
       Like Sheridan on Anderson, Texas has seen its share of success as well. Between April 2002 and March 2005, there have been more than 8,200 residents living in nursing homes in Texas who had their restraints removed, according to the CMS data report. The work of the coalition will move forward, as CMS continues to support and promote restraint reduction and other QI activities in long-term settings across the nation.

       Editor’s note: This article was prepared by TMF Health Quality Institute, the Medicare quality improvement (QI) organization for Texas, under contract with CMS, an agency of the Department of Health and Human Services. The content presented does not necessarily reflect CMS policy.