Sweet Freedom
Monday October 17, 2011
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Physical therapists at 20 nursing homes across New Jersey helped develop strategies to reduce significantly the use of restraints on patients over the past three years as part of a nationwide initiative launched by the Centers for Medicare and Medicaid Services.
“Overall, the reduction rate was 54%,” said Dolores Viotti, RN-BC, C-NE, program manager for Healthcare Quality Strategies, Inc., the Medicare-designated quality improvement organization for the state. “The majority of nursing homes in the initiative were able to get under a 6% patient restraining rate.”
CMS’ Physical Restraint Reduction Project set a goal of a 20% reduction at nursing homes with a 6% rate or higher.
A physical restraint is defined as any device that a patient cannot remove easily and 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, including 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.
PTs increased communication with the nursing department and provided education for families when residents go home, Viotti said. While the restraint reduction initiative was facility specific, teams from each of the nursing homes would get together via conference calls, the Internet or in face-to-face conferences to discuss cases and identify best practices, 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.
Strategy development
PTs were instrumental in developing the multidisciplinary approach to restraint reduction, which included occupational therapists, activity coordinators and nutritionists, Viotti said. PTs provided the alternative solutions to nursing staff. “PTs took a very large piece of this project,” she said.
Christian Health Care Center in Wyckoff, which has a 292-bed long-term care facility, reduced its use of restraints from 8% to 1.6%. PTs are involved in the effort from the moment a patient arrives for therapy, said Maricel Bowe, PT, rehabilitation services director for CHCC. “When a patient comes for therapy, we can establish if there is a positioning issue. We may determine that the patient needs a more appropriate wheelchair and positioning devices, such as cushions that will tilt the resident back in the chair.”
PTs can help design a tilt schedule for the patient when using the wheelchair. By tilting the wheelchair back, a patient is able to observe his or her surroundings better, enabling the patient to be more engaged with surroundings.
Bowe said after a couple of hours in a wheelchair, a patient starts to slouch and slowly slides out. “Wheelchairs are not made to be sat on all day, but aging people become dependent on them,” she said.
Wedges and saddle cushions can help support the patient instead of a belt, she said. Gel and foam cushions also can be used to help with sores in the sacrum area, said Christian Victoria, PT, physical therapy team leader at CHCC. Some cushions have air bladders that can inflate and deflate automatically to shift a patient if he or she can’t move him- or herself.
Instead of restraints, patients can wear a belt with buckles or Velcro that can be pulled open easily by the patient, Bowe said. Some belts will sound an alarm when opened, which can be used for patients with dementia or Alzheimer’s to notify the patient and the staff when it has been opened.
Bed alarms also can work as alternatives to side rails and restraints. Low beds and mattresses on the floor, treaded socks and padded underwear can help reduce risk of injury from falls.
One way to reduce the need for restraints is to establish transfer schedules for patients, Victoria said. “Instead of changing the patient from just the wheelchair to a more dependent chair, we established a schedule with which their nurse at certain times of day would help them move from a regular chair and go back to a wheelchair and then go to bed for a nap,” he said. “We found patients were falling out of their chairs not because of frailty, but because they get tired of being in that chair for the whole day.”
Victoria said he worked closely with the wound care nurses of one 85-year-old female patient by establishing a transfer and tilt schedule and putting a gel overlay on her cushion to improve pressure release. “This combination helped her wound improve,” he said.
PTs conduct patient risk assessments under a sitting-and-positioning core program, Victoria said. “We screen patients for tightness in the hamstrings and oblique trunk control,” he said. “We look for causes of discomfort and other factors that would increase the risk of falling.”
Active follow-through
After the initial screening, PTs reassess patients quarterly or within 24 hours if nurses spot changes in the patient’s mobility or their mood, Victoria said. “The [restraint reduction] program introduced a change in culture of how the staff in general cares for the patients in long-term care,” he said.
The program has brought other patients who were in hospice back into a rehab program, Victoria said. “It’s a good positive change for the patients,” he said.
PTs also work with long-term care patients on ambulation techniques and balance, and they develop individualized plans of care, Bowe said. “When they become aggressive, we get them up and walking because they want to move,” Bowe said. “It could be a bowel and bladder issue. We could get them on a bowel and bladder routine.”
Therapeutic activities staff also play a role in reducing the use of restraints. A well-rounded program keeps patients and residents engaged and active, reducing agitation and pressure ulcers.
Wrist bands can identify at-risk patients for extra vigilance from staff.
The restraint reduction initiative will continue at Christian Health Care Center, Bowe said. “Gone are the days when anyone straps a patient in with the belt because they’re not behaving. That was just cruel,” Bowe said. “Now it’s about protecting patients’ rights and dignity.”
Teresa McUsic is a freelance writer.
“Overall, the reduction rate was 54%,” said Dolores Viotti, RN-BC, C-NE, program manager for Healthcare Quality Strategies, Inc., the Medicare-designated quality improvement organization for the state. “The majority of nursing homes in the initiative were able to get under a 6% patient restraining rate.”
CMS’ Physical Restraint Reduction Project set a goal of a 20% reduction at nursing homes with a 6% rate or higher.
A physical restraint is defined as any device that a patient cannot remove easily and 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, including 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.
PTs increased communication with the nursing department and provided education for families when residents go home, Viotti said. While the restraint reduction initiative was facility specific, teams from each of the nursing homes would get together via conference calls, the Internet or in face-to-face conferences to discuss cases and identify best practices, 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.
Strategy development
PTs were instrumental in developing the multidisciplinary approach to restraint reduction, which included occupational therapists, activity coordinators and nutritionists, Viotti said. PTs provided the alternative solutions to nursing staff. “PTs took a very large piece of this project,” she said.
Christian Health Care Center in Wyckoff, which has a 292-bed long-term care facility, reduced its use of restraints from 8% to 1.6%. PTs are involved in the effort from the moment a patient arrives for therapy, said Maricel Bowe, PT, rehabilitation services director for CHCC. “When a patient comes for therapy, we can establish if there is a positioning issue. We may determine that the patient needs a more appropriate wheelchair and positioning devices, such as cushions that will tilt the resident back in the chair.”
PTs can help design a tilt schedule for the patient when using the wheelchair. By tilting the wheelchair back, a patient is able to observe his or her surroundings better, enabling the patient to be more engaged with surroundings.
Bowe said after a couple of hours in a wheelchair, a patient starts to slouch and slowly slides out. “Wheelchairs are not made to be sat on all day, but aging people become dependent on them,” she said.
Wedges and saddle cushions can help support the patient instead of a belt, she said. Gel and foam cushions also can be used to help with sores in the sacrum area, said Christian Victoria, PT, physical therapy team leader at CHCC. Some cushions have air bladders that can inflate and deflate automatically to shift a patient if he or she can’t move him- or herself.
Instead of restraints, patients can wear a belt with buckles or Velcro that can be pulled open easily by the patient, Bowe said. Some belts will sound an alarm when opened, which can be used for patients with dementia or Alzheimer’s to notify the patient and the staff when it has been opened.
Bed alarms also can work as alternatives to side rails and restraints. Low beds and mattresses on the floor, treaded socks and padded underwear can help reduce risk of injury from falls.
One way to reduce the need for restraints is to establish transfer schedules for patients, Victoria said. “Instead of changing the patient from just the wheelchair to a more dependent chair, we established a schedule with which their nurse at certain times of day would help them move from a regular chair and go back to a wheelchair and then go to bed for a nap,” he said. “We found patients were falling out of their chairs not because of frailty, but because they get tired of being in that chair for the whole day.”
Victoria said he worked closely with the wound care nurses of one 85-year-old female patient by establishing a transfer and tilt schedule and putting a gel overlay on her cushion to improve pressure release. “This combination helped her wound improve,” he said.
PTs conduct patient risk assessments under a sitting-and-positioning core program, Victoria said. “We screen patients for tightness in the hamstrings and oblique trunk control,” he said. “We look for causes of discomfort and other factors that would increase the risk of falling.”
Active follow-through
After the initial screening, PTs reassess patients quarterly or within 24 hours if nurses spot changes in the patient’s mobility or their mood, Victoria said. “The [restraint reduction] program introduced a change in culture of how the staff in general cares for the patients in long-term care,” he said.
The program has brought other patients who were in hospice back into a rehab program, Victoria said. “It’s a good positive change for the patients,” he said.
PTs also work with long-term care patients on ambulation techniques and balance, and they develop individualized plans of care, Bowe said. “When they become aggressive, we get them up and walking because they want to move,” Bowe said. “It could be a bowel and bladder issue. We could get them on a bowel and bladder routine.”
Therapeutic activities staff also play a role in reducing the use of restraints. A well-rounded program keeps patients and residents engaged and active, reducing agitation and pressure ulcers.
Wrist bands can identify at-risk patients for extra vigilance from staff.
The restraint reduction initiative will continue at Christian Health Care Center, Bowe said. “Gone are the days when anyone straps a patient in with the belt because they’re not behaving. That was just cruel,” Bowe said. “Now it’s about protecting patients’ rights and dignity.”
Teresa McUsic is a freelance writer.
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Monday October 17, 2011