Transcript A Systematic Approach to Restraint Reduction

Improving Quality through a
Systematic Approach to Falls
Management for the Elimination
of Physical Restraints
Jo A. Taylor,
RN, MPH
Content
• Background
• Systems approach to falls management
• Self assessment of current falls
management
• Critical thinking and its application to falls
and restraint reduction
Application
 Where are you now?
 Where do you want to be?
 What are your strengths?
 What are the areas for improvement?
Background
Early Activities
• National Citizens Coalition for NH Reform
• Kendal Corporation, 1973 (Untie the Elderly,
1986) http://ute.kendaloutreach.org/
• Institute of Medicine, 1986 Report on quality
• 1987 Federal regulations, “patients have
the right to be free from any physical or
chemical restraint not required to treat
the patient’s medical symptoms”
Regulation 483.13(a)
Building Momentum
• FDA Medical Alert, 1992
• FDA Hospital Bed Safety Workgroup
http://fda.gov/cdrh/beds
• National Quality Forum outcome
• Magnet status for hospitals
Long Term Care
• Public reporting as quality measure
• Focus of 7th, 8th, 9th Scopes of Work
• Goal of Advancing Excellence in
America’s Nursing Homes campaign
http://www.nhqualitycampaign.org/
From a common sense
rationale for protection and
safety
• 200 year history of restraint use in
psychiatric facilities
• Marketing for hospitalized patients and
nursing home residents
• Controlled care versus individualized care
To evidence-based practice
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Physical consequences of immobility
Increase in confusion and agitation
Loss of dignity, social isolation
Increased risk of infection in acute care
Risk of injury and death from positional
asphyxia/strangulation
• Falls and fall related injury
“There is no found evidence to support restraint
use for fall prevention. Restraint usage has
major, serious drawbacks and can contribute
to serious, life-threatening injuries.”
American Geriatrics Society
British Geriatrics Society
American Academy of Orthopedic Surgeons
2001
http://www.americangeriatrics.org/products/positi
onpapers/Falls.pdf
American Geriatrics Society, 2010
AGS/BGS Clinical Practice Guidelines
Prevention of Falls in Older Persons
http://www.americangeriatrics.org/health
_care_professionals/clinical_practice/cl
inical_guidelines_recommendations/20
10/
Restraint Use
• Associated with increased risk of falls among
cognitively impaired, ambulatory residents
• No decreased fall risk in bilateral siderail use
• Removal does not lead to increased falls or
related injuries with individualized care
Evidence
• Capezuti, E., Lawson, W., & Iyer, P. (2007). Legal aspects of
falls. In D. Gray-Miceli, E. Capezuti, W.T. Lawson, & P. Iyer.
Falls handbook: Clinical and medical-legal perspectives of
falls across the lifespan. Flemington, NJ: Med League
Support Services, Inc.
• Capezuti, E., Zwicker, D., Mezey, M., Fulmer, T., Gray-Miceli,
D., & Kluger, M. (Eds.). (2008). Evidence-based geriatric
nursing protocols for best practice (3rd ed.). New York:
Springer Publishing Company.
• Capezuti, E,, Evans, L,, Strumpf, N,, & Maislin, G. (1996).
Physical restraint use and falls in nursing home residents.
Journal of the American Medical Society, 44, 627-633.
Evidence
• Capezuti, E., Strumpf, N.E., Evans, L.K., Grisso, J.A.,
Maislin, G. (1998). The relationship between physical
restraint removal and falls and injuries among nursing
home residents. Journals of Gerontology Series ABiological Sciences & Medical Sciences, 53(1), M47-52.
• Capezuti, E., Strumpf, N., Evans, L., & Maislin, G. (1999).
Outcomes of nighttime physical restraint removal for
severely impaired nursing home residents. American
Journal of Alzheimer’s Disease, 14, 157-164.
• Neufeld, R.R. , Libow, L.S., Foley, W.J., Dunbar, J.M.,
Cohen, C., Breuer, B. (1999). Restraint reduction reduces
serious injuries among nursing home residents. Journal of
the American Geriatrics Society, 47(10),1202-1207.
Evidence
• Miles, S.H. & Irvine, P. (1992). Deaths caused by physical restraints.
The Gerontologist, 32, 762-766.
• Mion, L.C., et al. (1989). A further exploration of the use of physical
restraints in hospitalized patients. Journal of the American Geriatrics
Society, 37, 949-956.
• Tinetti, M.E., Wen-Liang, R.A, & Ginter, S.F. (1992). Mechanical
restraint use and fall-related injuries among residents of skilled
nursing facilities. Annals of Internal Medicine, 116, 369-374.
• Castle, N.G. (1998). Physical restraints in nursing homes: A review
of the literature since the nursing home reform act of 1987. Medical
Care Research and Review, 55(2), 139-170.
Staff Time
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Frequent checking intervals for restraints
Repositioning and reapplication
Reassessment and monitoring process
Fall incident reports
Staff meetings
Documentation
Data analysis
Litigation
% of NH Residents in Daily
Restraints
2008
• 27 states had statewide averages
below 3%
• 17 states had averages above 10%
2010
• National average 3.3%
The Finish Line
• Is restraint elimination fundamental to
culture change?
• Are falls management and restraint
elimination the results of individualized
care?
Where are you now and where do
you want to be?
Why Do We Still Use Restraints?
• Falls
• Therapy disruption
Factors Associated With Use
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Wandering
• Fall history
Advanced age
• Fall risk
Altered elimination
Physical
dependence
• Altered mental status
Factors Associated With Use
• Interference with • Lack of knowledge &
treatment
skills
• Presence of
• Insufficient
monitoring or
interdisciplinary
treatment devices
collaboration
Systems Approach
Hybrid Model
• TN QIO
collaboratives in 8th
and 9th SOW’s
• Vanderbilt/Emory
falls research and
quality improvement
model
Collaborative Process
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Regional learning sessions
Monthly teleconferences
Listserv
Newsletters
OT/PT participation
State MDS coordinator participation
Data submission, analysis and benchmarking
Vanderbilt/Emory FMP
• Intervention homes: 19 facilities implemented the Falls
Management Program (FMP) while reducing restraints
by 44%
– Fall rate decreased slightly
• Nonintervention homes: 23 facilities reduced restraints
by 30% and did not implement the FMP
– Fall rate increased by 26%
Rask, K., Parmelee, P., Taylor, J.A., Green, D., Brown, H., Hawley, J.,
et al. (2007). Implementation and evaluation of a nursing home fall
management program. Journal of the American Geriatrics Society,
55(3), 342-349.
http://www.innovations.ahrq.gov/content.aspx?id=1835
Core Elements for Success
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Staff knowledge and cooperation
Critical thinking skills
Interdisciplinary teamwork
Systematic assessment and care
planning
• Ongoing monitoring and evaluation
Core Processes
• Multifaceted, interdisciplinary team
approach
• Individualized care strategies based on
comprehensive patient assessment
• Continual monitoring and follow-up
Multifaceted means…
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Cognition
Medications
Unsafe behaviors
Underlying conditions
Age related changes
Functional status
Resident choice and independence
Address Underlying Acute and
Chronic Conditions
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Gait problems, lower extremity weakness
Delirium, dementia, depression
Cardiovascular status
Infections
Hyperglycemia/hypoglycemia
Elimination
Sleep
Nutritional status
Pain
Interdisciplinary means…
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CNA, CNA, CNA
Nurses
Primary care provider
OT/PT
Social work
Restorative staff
Activities staff
Engineer/maintenance staff
Individualized means…
• Knowing the person
• Viewing the world through their eyes
• Careful assessment of person and environment
“To individualize care requires learning about the
individual’s life history, assessing the individual’s current
strengths and needs, developing plans with resident
and/or family input, and designing care around the
resident’s wishes and needs-not facility, staff, or family
needs. “
Rader, J. (1995). Individualized Dementia Care: Creative, Compassionate
Approaches. New York: Springer Publishing Company, Inc., p. 8.
Complex, changing needs of frail residents with
multiple chronic conditions and medications
require:
– Systematic approach
– Multifaceted assessment
– Interdisciplinary teamwork
– Critical thinking skills
– Creative responses
– Continual reassessment
– Expert help
– Equipment and resources
http://www.joataylor.com
http://www.qualitynet.org/dcs/ContentServer?cid=1136495771104&
pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools
Program Requirements
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Initial buy in and contract
Interdisciplinary team
Clinical champion
Staff education and training
Resident and family education
Information for PCP
Monthly conference calls
APN nurse consultation
Regional nurse support
Monthly data collection and analysis
FMP Components
• Fall risk screening and assessment
• Development & ongoing monitoring of
individualized care plans
• Post fall investigation and structured
response
• Environment and equipment safety
• Staff education
Taylor, J.A., Parmelee, P., Brown, H., Strothers, H., Capezuti, E., &
Ouslander, J.G. (2007). A model quality improvement program for
the management of falls in nursing homes. Journal of the American
Medical Directors Association, 8(3), S26-S36.
Fall Risk Screening
• Triggering Falls RAP
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Hx of falls in last 180 days
Wandering
Dizziness
Trunk restraint
Antianxiety or antidepressant medications
Antipsychotic medication
Parkinson’s disease
Dementia
Any restraint
Other reasons (e.g., unsteady gait, poor
judgment)
Fall Risk Assessment
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High risk medications
Orthostatic hypotension
Vision
Mobility
Unsafe behaviors
Development and Monitoring of
Individualized Care Plan
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Medications
Orthostatic hypotension
Vision
Mobility
Unsafe behaviors
PCP - Fax alerts, Fall Assessment Report,
Fax Back Orders
Post Fall Investigation
Tracking Record for Improving Patient Safety: TRIPS
• Date, time, day of
week, location
• Severity level
• Treatment
• Notifications
• Type
• Cause
• Activity
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Staff response
Footwear
Aid
Restraint
Side rails
Mental status
BS, HR, BP, temp
Injury
Structured Response
• Conduct immediate evaluation of resident with
72 hour monitoring
• Complete comprehensive evaluation
• Record circumstances
• Alert PCP
• Implement immediate intervention
• Complete falls assessment
• Develop plan of care
• Monitor implementation and resident response
Environment and Equipment
Safety
Living Space Inspection
– Paths
– Stable furniture
– Easy access
– Lighting
– Floor
– Equipment
– Foot care and footwear
Staff Education
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Inservice content
Video
Handouts
Pre and post tests
Case examples
Program examples
Barriers
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Turnover
Resistance to change
Myths
Patient load
Time management
Lack of knowledge and critical thinking skills
No leadership
Low administrative support
Absence of physician support
Barriers
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Independent facilities without resources
Lack of seating expertise
Family resistance
Negative culture
Absence of teamwork, communication
Fear of litigation
Poor or conflicting surveys
Systems Approach
1. Culture, organizational commitment and
teamwork
2. Staff education and training
Evidence-based practice
3. Resident/family involvement
4. Environment and equipment
5. Documentation, data collection & analysis
1. Culture
Safety
Quality
Individualized care
Components
• Philosophy and values
• Supportive relationships
• Teamwork
• Communication
Blame-free Environment
• Creating atmosphere for reporting errors
without punishment
• Making it easier for personnel to admit
they made a mistake
• Focusing on the system, not individual
Paradigm Shift
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Full investigation of incident
Comprehensive analysis
Regular evaluation of environment
Communication across disciplines
Adequate documentation
Data based decisions
Organizational Commitment and
Leadership
• Medical director
• DON – leader, clinical champion
• Administrator – support and funding
Proactive Administrative Support
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Upfront purchase of equipment
Upgrade of wheelchair fleet
Staff time for meetings
Staff time for supervision
Staff time for individualized care
Staff time for education
Standardized tools
Primary Care Providers
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Medical director leadership and support
Information about initiative
Timely and clear communication from staff
Response to nursing risk assessment
http://www.qualitynet.org/dcs/ContentServer?c=MQT
ools&pagename=Medqic%2FMQTools%2FToolTe
mplate&cid=1150897183247&parentName=Catego
ry
Interdisciplinary Teamwork
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OT/PT
Frontline staff
Activity staff
Social work
Restorative staff
Engineer/maintenance staff
Nursing administration and
management
Interdisciplinary Teamwork
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Regular meetings
Leadership
QI principles
Creativity
Clinical expertise
2. Staff Education and Training
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Assessment of attitudes and beliefs
Dispelling myths
Knowledge of evidence-based care
Knowledge of QI process
Critical thinking skills
Culture of safety and quality
Content
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History and background
Regulations
Risk factors
Negative consequences
Least restraint alternatives
Best practice for falls management
Behavior management
Staff Application
• Equipment & resources
• Information - benchmarking
• Clear role expectations and
performance evaluations
Expertise
Regional
nurse
APN
QIO
Listserv
Corporate
Conferences
Internet
Evidence-Based Practice (EBP)
• Treatment of underlying medical
conditions
• Management of chronic disease
symptoms
• Management of age related changes
Safety When Using the Toilet
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Clear, easy path to bathroom
Height of toilet seat
Grab bars for support
Lighting
Non-skid shoes, socks, slippers
Non-skid flooring
Toileting schedules, assistance
Medications
Toileting rounds
Prompted voiding
Safety When Exiting the Bed
• Bed height
• Lighting (day and night)
• Skid-proof floor or socks,
well fitting shoes with
non-slip soles
• Provide short rail, grab
bar
• Clear pathways
• Mats
Promoting Function
• Maximum functional level
• Balance
– Gait and transfer training
– Muscle strengthening
Safety When Using a Wheelchair
Individualized wheelchair seating
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Pressure relieving seat cushion
Specialized seat cushions
Lateral supports or cushions
Leg panel
Head extension
Tilting back
Drop seats
Rader, J., Jones, D., and Miller, L. (2000). The importance of
individualized wheelchair seating for frail older adults. Journal of
Gerontological Nursing, 26, 24-32.
http://www.nccnhr.org/uploads/T8IndividualizedWheelchairSeatingForOl
derAdults.pdf
http://www.providence.org/Oregon/Programs_and_Services/Center_on
_Aging/wheelChairVideos.htm
Wheelchair Seating
• http://www.cfmc.org/files/nh/wheelchair%20positi
oning.pdf
Lateral Support
Rader, J., Jones, D., & Miller, L. (1998). Individualized wheelchair seating:
For older adults, Part I: A guide for caregivers. Benedictine Institute for Long
Term Care, Mt. Angel, Oregon.