Safety Without Restraints: A New Practice Standard for Safe Care

One Daughter's Story

My mother is 88 years old and has dementia. After a severe injury, she moved to a nursing home with a good reputation, one where I felt I could trust the staff to keep Mom safe. The staff did an excellent job of helping Mom continue to be able to walk.

Then it happened. I got a call from the nurse at the nursing home saying Mom had been sent to the emergency room. She had been walking when she became tangled in another resident's walker and fell flat on her face. She had a bad cut on her forehead and her face was badly bruised. I cried when I saw her. She returned to the facility in a wheelchair with a lap tray. I felt a lot better believing the chair and tray would protect her from further falls.

Mom didn't like the chair. She kept asking staff to "take it off." You can imagine my horror when the social worker approached me and said they would like to try to reduce the lap tray to something less restrictive. I agreed but was very worried about her getting out of a lesser restraint and falling again. Mom was still pleading with anyone who would listen to her to "let me out of this chair." I was in constant communication with the staff and knew their plan for Mom was to remove the remaining buckle belt in her wheelchair so she could walk again. I was so scared. I also knew Mom's doctor wanted to keep the buckle belt on her in the wheelchair. He knew the risks of her attempting to walk.

Mom's forehead healed. The staff of the nursing home felt they would like to try some periods of time without the buckle belt and wanted her to try to walk again. I couldn't believe it. What were they thinking? Mom was still complaining about being restrained, but I wasn't so sure she knew what was best for her. I called an Ombudsman to help me get what I felt was best for my mother. To my dismay, the Ombudsman agreed with the nursing home staff that there were no medical symptoms warranting the restraint in Mom's case and Mom's clear dislike of the belt was another indication that we should try something less restrictive. The buckle belt was reduced to a velcro belt which Mom could release. Since the belt could no longer keep her in the wheelchair, she walked all over the place.

I realize now that if we had continued to use restraints to keep her in the chair, Mom probably would not be walking today. She is still agitated, but far less than when she was restrained with the buckle belt. I still worry about her safety, but am thrilled every time I see her walking. I am happy that the staff worked with me to show me the possibilities for Mom without restraints. I know Mom's freedom and independence are important to her.

Introduction

Ensuring the safety of nursing home residents is a high priority for families and health care personnel. But what's the best way to ensure safety? Nursing home residents may sometimes be unsteady or forgetful. Various types of restraints - including belts, vests, bed rails and specialized chairs - have commonly been used in the past to prevent falls and injuries. Care givers and families have used these devices in the belief that they were acting in the best interests of their loved ones. New information, however, indicates that there are more effective safety methods that can be substituted for physical restraints.

Over the last 10-15 years, medical research has produced strong evidence that restraints do not prevent injury, and may in fact represent a safety hazard for the resident. These findings, combined with a heightened concern about the quality of life in nursing homes, have prompted a reexamination of past practices regarding the use of restraints. A national effort is now underway to reduce the use of physical restraints in nursing homes, and care givers have been actively seeking alternatives for ensuring the safety of residents.

Care givers have asked the Minnesota Department of Health to help educate residents and families about the hazards of physical restraints and alternative methods for achieving safety. The Minnesota Department of Health, Nursing Home Associations, Medical Directors and the State Ombudsman's Office have worked together to create an informational pamphlet which addresses a common misconception about safety - that physical restraints are the only effective way to protect a physically and mentally impaired individual - and promotes newer methods for achieving safety.

What is a physical restraint?

Physical restraints are defined as: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.

Restraints are considered a form of medical treatment. As such, they can only be used under the direction of a physician. In ordering the use of restraints, the physician must specify the medical reason for using the device, the circumstances under which it can be used, and the length of time over which it can be used. Because of the potential dangers involved, restraint use must be monitored, and its effectiveness must be continuously evaluated. An effort must always be made to use the least restrictive available method of restraint, and to restore each individual to his or her maximum possible level of independence.

Nationwide, less then one out of every ten (approximately 9%) nursing home residents is currently restrained (7/2001). This represents a significant improvement over past practice. Before 1990, approximately one out of every two or three (30-40%) nursing home residents in the US was restrained. In a number of European countries, however, the rate is as low as one of every 20 or 30 (under 5%) residents. This striking difference is almost exclusively due to a difference in practice standards - not a difference in severity of illness or disability. The real issue, however, is the level of risk involved. The U.S. Food and Drug Administration (FDA Alert, 1992) has estimated that over 100 deaths occur annually in the U. S. as a result of restraint use.

Bed rails

Care givers are beginning to recognize the hazards associated with bed rails, and to raise question about their routine use. Bed rails can be used to enhance the mobility of residents by assisting with movement in bed, sitting up or getting out of bed. However, when bed rails prevent a resident from leaving the bed, they are considered to be a form of physical restraint. The increased recognition of serious injuries and deaths associated with bed rail use prompted the FDA to issue an alert about the issue in 1995. They can be especially hazardous for demented or agitated individuals, who may be harmed by sliding between the rails or attempting to climb over them.

What's the key to providing safe care?

Care givers agree that the key to providing safety is individualized care. Care plans are designed to tailor care to the specific needs of each individual. The care planning process begins with an assessment by a team of health care professionals: physicians, nurses, physical and occupational therapists and others with specialized training. The assessment team will look at the effects of illness, pain issues, use of medications and psychological factors - including difficult behaviors.

Safe care also requires the design of living spaces that minimize the risk of injury, and continued efforts to improve comfort and safety.

What is the role of physical restraints and providing safe care?

Risks with restraints:

• Falls
• Strangulation
• Loss of Muscle Tone
• Pressure Sores
• Decreased Mobility
• Agitation
• Reduced Bone Mass
• Stiffness
• Frustration
• Loss of Dignity
• Incontinence
• Constipation

Risks without restraints

• Falls

Physical restraints have been used to remind individuals not to get up without assistance. However, there are often newer and safer techniques available. Restraints are sometimes useful as a temporary measure in providing needed medical treatment - such as intravenous medications, specialized feedings or wound care - during the assessment period, or when other less restrictive measures have failed to provide adequate safety. Applying physical restraints routinely or for prolonged periods should be avoided whenever possible. Restraint use often leads down a slippery slope of increased dependence and disability.

Research conducted from the 1980's onward suggests that restraints are more likely to cause harm than prevent it. Restraints may cause strangulation, and lead to muscle loss and bone weakness. Restrained individuals often feel humiliated. They may become depressed, withdrawn or agitated when freedom of movement is taken away from them. Restraints pose special risks for people who are agitated, or who may fall while attempting to escape their restraints.

One recent study documented an increase in falls - and an increase in serious fall-related injuries - when restraints were used. Studies have repeatedly demonstrated that there is no increase in serious injuries when physical restraints are replaced with other less restrictive safety measures based on the individual's specific needs. Studies have also demonstrated a dramatic decrease in behavior problems when restraints are removed.

What approach does the nursing home take when considering the use of physical restraints?

If the assessment team recommends the use of restraints, a physician's order will be needed - and informed consent. The team will explain why the restraint is being used and how the restraint will be effective in treating the specific medical symptom(s) noted in the physician's order. Potential risks posed by the restraint will also be described.

The restrained individual will be under regular observation, and will have adequate opportunities for movement and toileting. A plan will be in place for eventually phasing out the use of restraints completely - or at least finding the least restrictive form of care that will meet the needs of that particular individual.

The staff will monitor the resident for common side effects of restraint use, such as increasing weakness, other physical effects, fear, agitation and depression. Staff will be prepared to address these problems if they occur.

Minnesota passed a law in 1999 (Minnesota Statute 144.651, subdivision 33) which established explicitly the right of residents or residents' decision makers to request physical restraints. It also specified that legitimate medical reasons for using a physical restraint include: "1) a concern for the physical safety of the resident; and 2) physical or psychological needs expressed by a resident. A resident's fear of falling may be the basis of a medical symptom."

What are some alternatives to restraint use?

The following measures may make restraint use unnecessary:

• Personal strengthening and rehabilitation program;
• Use of "personal assistance" devices such as hearing aids, visual aids and mobility device;
• Use of positioning devices such as body and seat cushions, and padded furniture;
• Efforts to design a safer physical environment, including the removal of obstacles that impede movement, placement of objects and furniture in familiar places, lower beds and adequate lighting;
• Regular attention to toileting and other physical and personal needs, including thirst, hunger, the need for socialization, and the need for activities adapted to current abilities and past interests;
• Design of the physical environment to allow for close observation by staff;
• Efforts to increase staff awareness of residents' individual needs - possibly including assignment of staff to specific residents, in an effort to improve function and decrease difficult behaviors that might otherwise require the use of restraints;
• Design of resident living environments that are relaxing and comfortable, minimize noise, offer soothing music and appropriate lighting, and include massage, art or movement activities;
• Use of bed and chair alarms to alert staff when a resident needs assistance;
• Use of door alarms for residents who may wander away.

What if a family member is already been treated with a restraint?

If a restraint device is already being used as part of the care provided, there are a number of ways to become involved. Ask for a thorough assessment of possible causes for the medical symptom that made use of the restraint device necessary. Ask for information about alternatives to the use of restraints. Participate, as much as possible, in the assessment of needs and development of care plans for your family member. You can help develop an effective care plan, and you will gain a better understanding of the care plan itself and the safeguards that will be used in caring for your family member. You are in a unique position to provide care givers with details about your family member's condition, likes, dislikes, lifestyle and habits. Your experience and knowledge are instrumental in developing an individualized care plan.

Expect a plan that calls for the gradual replacement of restraints with alternative safety measures - measures that are less restrictive and allow the individual to function at the highest possible level. Restraints should not be removed abruptly, without planning for alternative safety measures. Expect a plan that calls for on-going monitoring and reassessment of alternative safety measures, as they are introduced.

Family or close friends can often detect subtle changes in a resident's condition before staff are able to observe any signs or symptoms. Notify staff of changes in behavior or function that may signal a developing or progressing medical problem.

As a concerned family member or other surrogate decision maker, you have a responsibility to act in the best interests of the affected individual. You can provide invaluable information to the health care team. You have the right to approve or refuse health care for your family member, in accord with previously expressed wishes or advance directives. Be aware that - as with any form of medical care - you may not demand care that is potentially harmful or medically unnecessary.

Is safety compatible with high quality of life?

Providing safe care for individuals with physical and mental limitations is a universal concern. There is now convincing evidence that safe care can be provided without applying physical restraints which unduly restrict freedom and create other serious risks. Safe care can be ensured through the use of alternative safety measures, which can be tailored to meet an individual's specific needs, ensuring the best possible quality of life.

Nursing home residents are particularly susceptible to falls, but they may be placed at even greater risk as a result of restricted physical activity. There is no effective and humane way to prevent all falls. Facilities that have dramatically reduced physical restraint use have not experienced an increase in serious injuries and have seen marked decreases in the incidence of agitated behavior among residents.

Reducing the use of physical restraints is a national goal which is being promoted by care givers from all segments of the health care team. The motive behind the goal is enhancing the quality of life of nursing home residents while assuring safety. The payoff will be better and more appropriate health care for individual nursing home residents who will be spared the indignities and harmful effects of unnecessary physical restraints.

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For More Information Please Refer To:

• "Everyone Wins: Quality Care Without Restraints."
  Independent Production: 800-727-2470.
• "Innovation in Restraint Reduction." Video.
  The American Health Care Association: 800-321-0343
• Untie the Elderly."
  The Kendal Corporation: 610-388-7001.
• "Retrain, Don't Restrain, National Nursing Home Restraint Minimization Program." The Jewish Home and Hospital for the Aged: 212-870-5000.

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