Problem-Oriented Best Practices5
February 2003 Spotlight on new resources
Long Term Care is a multi-disciplinary endeavor with the care of the resident as its central focus. Because all disciplines must work coherently toward a common goal, each of the following topics addresses multiple aspects of LTC practice including resident evaluation, nursing care, facility administration and medical care. The Overview section in each topic includes findings from DHS Medical Quality Assurance (MQA) studies as well as a statement of performance expectations - a DHS MQA vision of high quality care.
The accompanying bibliographies and resources are representative rather than exhaustive collections of current clinical thinking and research. Similarly, the regulatory tags that may be cited for deficient practices are representative rather than exhaustive. The accompanying Geriatric Symposium presentations represent the expert perspectives of the presenters rather than those of DHS.
Where well-designed clinical trials permit defining evidence-based best practices, these have been used in the problem-oriented best practicesummaries. Where such evidence is lacking, expert consensus statements, clinical practice guidelines, case studies and regulatory requirements all offer some insight into what may constitute best practice. Every best practice framework in QMWeb is submitted to one or more clinical peer reviewers for comment. Where there are unresolved differences between MQA and a reviewer, these are noted in the Reviewers section of the page itself. Where opposing viewpoints each have some support in evidence and literature, the goal of QMWeb is to provide a balanced presentation.
It is important to note that even when there is a sound basis for evidence-based best practice, the specific details of implementation (the more common and less strict meaning of best practice) may vary from one venue to the next simply because resident needs, staff expertise and other resources vary from one venue to the next. Therefore, the following pages serve best as frameworks or toolkits from which to design facility-specific care systems rather than as simple cookbook recipes for deficiency-free (let alone, optimal) care.
This section of QMWeb is a work in progress. Only the topics in bold represent completed frameworks. The remaining pages are either preliminary frameworks that have not yet undergone peer review or simply resource pages whose corresponding best practice frameworks remain to be completed. Expect the number of completed best practice frameworks to grow steadily over the next two years in response to provider needs identified through the Quality Monitoring Program, the Statewide Quality Review Process, and the DHS Geriatrics Symposium Series.
- End-of-Life Care
- Ethics Committees
- Medical Futility
- Gender, Ethnic and Age Group Health Outcomes Disparities
- Advance Care Planning & Palliative Care
- Restraint Reduction
- Tube Feeding
- Congestive Heart Failure
- Toileting for Incontinence
- Indwelling Bladder Catheters
- Constipation, Fecal Impaction and Dual Incontinence
- Neurological Syndromes
- Behavioral and Environmental Interventions
- Pressure Ulcers
- Prediction & Prevention
Organizational & Administrative Practices
- Medical Direction & Medical Staff Bylaws
- Implementing Quality Improvement
- Antibiotic Selection, Use and Resistance
- Medication Regimen Simplification - Medication Review
- Missed Therapeutic Opportunities
- Psychotropic Drug Use
- Environment Injuries
- Immunization Recommendations
- Infection Control
Last updated: May 6, 2003
The DHS Medical Quality Assurance vision for restraint reduction in Texas LTC is
Resident-centered evaluation and care planning for restraint-free environments.
Definitions and Scope
In this framework, the term restraints focuses exclusively on devices applied to a resident's wrists, trunk or waist that limit the resident's normal access to the environment or self and that the resident cannot remove at will without assistance. While the use of other devices that achieve these same ends is also discouraged, the findings described below apply only to these three general classes of devices.
According to MDS Quality Indicator statistics, Texas has ranked among the four states with the highest prevalence of restraint use during 2000-2002. An independent assessment of 1972 Texas nursing facility residents conducted for DHS by the Texas Nurses Foundation during FY2002 showed that 19.5% (n=385) of the residents had spent some time in restraints during the preceding 7 days. The majority of these residents, 368/385 (95.6%), had spent time in restraints each and every day during the last 7 days. Among restrained residents, fewer than 10% (n=34) had a clinical problem that an expert panel deemed unlikely to be properly addressed without the use of restraints.
Based on structured assessment, the prevalence of necessary restraints was 2.3% rather than the observed 19.5%. This is consistent with the results of restraint reduction trials that show restraint prevalence can be decreased to 5% or less.[9, 16, 17]
In the Texas cohort, no resident appeared to be in restraints for punishment or for facility convenience. Rather, the majority was in restraints because caregivers believed that they were appropriately addressing a resident safety issue. The following proportions describe the 351 residents who were restrained without a compelling clinical indication:
- 95.7% - falling or fall risk assessment was a reason considered in the decision to use restraints.
- 76.4% - falling or fall risk assessment was the only reason that led to the use of restraints.
- 17.9% - wandering was a reason considered in the decision to use restraints, and in the majority falling was also a consideration.
- 19.1% - the family had initiated the request for restraint use.
- ~1% - the presence of a non-critical medical device such as a peripheral IV or the presence of symptoms of inappropriate sexual behavior were factors in the decision to use restraints.
Thus, the dominant reasons for using restraints in Texas nursing homes appear to be concern for two common geriatric syndromes - falling and wandering. In the Texas cohort, more severe resident ADL and cognitive impairment are associated with the application of restraints. These findings are consistent with findings of multiple research studies [3, 4, 5, 6] It also appears that families, concerned for resident safety and not knowing what best to do, ask for the use of restraints in a significant number of instances where they are inappropriate.
Considerations for Avoiding and Reducing Restraint Use
Beyond the ethical issues of resident's rights (the principles of individual dignity and self-determination) and quality of life issues, there are compelling clinical reasons to use the least restrictive intervention to deal with the problems that are commonly given as reasons for using restraints. The first clinical reason is to preserve resident function - to prevent loss of independence and ADL capacity and thus avert greater care-giving burden.
The restraint reduction literature identifies the adverse effects of restraint use including the following:[19, 24]
- Loss of physical independence
- Loss of cardiovascular tone
- Decreased respiratory efficiency
- Loss of muscle tone and strength
- Increased risk of falls and injuries
- Depression and aggressive behaviors
- New-onset cognitive impairment
- Urinary incontinence
- Pressure sores
The second clinical reason is to ensure resident safety. Although commonly viewed as an intervention to promote resident safety, restraints actually compromise safety. The complications of restraints can be serious and include injuries and death.[7, 8]
Common reasons for restraints include assisting resident posture, keeping residents from dislodging feeding tubes or other medical devices, limiting resident access to wounds, preventing scratching injuries, and preventing inappropriate disrobing among others. All of these hypothetical scenarios can be managed with less restrictive interventions. Cushions, bolsters and other physical therapy devices can be used to support posture. Various binders and dressings can be used to limit resident access to tubes, devices and wounds. Proper nail care can minimize or eliminate scratching injuries. And, special clothing adaptations can make disrobing very difficult without resorting to restraints. However, every one of these interventions requires individualized care planning, and no one intervention will meet the needs of every resident that has a particular problem. That is, restraint reduction often requires an individualized, resident-centered approach rather than a generic, problem-centered approach.[9, 10]
Myths and Misconceptions
MYTH: Restraints Protect Residents from Falls and Injuries. Some restraint reduction studies show an increase in falls but to levels no greater than seen in control groups; other studies show that with appropriate care planning this increase is minimal to negligible.[11, 12, 13, 14] All of the studies show no increase in serious injuries as a result of restraint reduction; and, other studies show an increase in serious injuries when restraints are used.[7, 8]
MYTH: Restraints Decrease Staff Time. Restraint reduction research shows that there is no increase in the staff time needed to meet the needs of residents in whom restraint use is discontinued.[13, 15]
MYTH: Restraint Use Decreases Cost of Care. Restraint reduction research shows that there is little or no increase in costs required to meet the needs of residents in whom restraint use is discontinued. The increased cost attributable to special devices needed to accomplish restraint removal has been measured at 3 cents per day per resident released from restraints, and this is comparable to the cost of restraint devices themselves.[14, 17]
MYTH: Restraint Reduction Requires Increased Psychoactive Medication Use. Research shows that this belief is common and erroneous.[13,16]
MYTH: Restraint Use Decreases Facility Liability. There is no evidence that facility liability cases have ever been lost solely on the basis that the facility had failed to apply restraints.[17, 18] There is no literature that shows that the application of restraints constitutes best practice for managing fall risk or wandering. In fact, the lost liability cases due to injuries related to restraint use serve as a reservoir of evidence against the argument that restraints constitute best practice.
The Texas Department of Insurance recognizes restraint use as a key facility liability risk-management issue because of liability claims arising from the use of restraints.
The minimum evaluation prior to using restraints consists of the following:
Clear Identification and Understanding of the Clinical Problems, Goals and Risks
Why are restraints being considered? What are the clinical problems that restraints are supposed to address? Is there an evidence basis that supports restraints as best practice in addressing these problems? What clinical outcome or end-point is desired? Are the potential untoward outcomes associated with restraint use acceptable to the resident and family? Some successful restraint reduction programs use a formal physician's order form that includes these and other elements such as informed consent.
Trial and Evaluation of Less Restrictive Alternatives
With the possible exception of the circumstances described in the DHS structured assessment for restraint use, every other clinical problem can and probably should be addressed with less restrictive interventions.
To proceed directly from problem identification to the use of restraints without a trial of individualized and less restrictive alternatives does not constitute best clinical practice. Yet, in 28.5% of the cases of inappropriate restraint use in the Texas cohort, there was no evidence that less restrictive alternatives had been tried. Since this figure was based on record reviews requiring minimal documentation that alternatives were tried, the 28.5% rate is a conservative.
Structured Resident Assessment and Care Planning
DHS recognizes that there are occasional clinical situations in which the use of restraints may simply be unavoidable because there is no alternative that has an acceptable risk-to-benefit ratio for the resident or others. These rare circumstances include the following:
- The presence of a medical device that if disrupted would create an immediate jeopardy to the resident's health - specifically in a resident who is at high risk for unintentionally disrupting that device (examples: endotracheal tube, central venous line, or an interruptible arterio-venous shunt in a delirious resident).
- Unprovoked or uncontrollable physically violent/injurious behavior toward self or others. Note: resisting care is not considered an instance of this type of behavior; patient-to-patient assault or intentional self-injury is. Restraint use in this context must be a temporary measure rather than a permanent strategy.
- Hip fracture with either no repair or an ORIF procedure in the preceding six weeks - specifically in a resident that cannot otherwise be kept from arising without assistance.
- Traumatic self-removal of an indwelling catheter in a resident who has performed it and who continues to demonstrate a tendency to repeat it.
While there may be other circumstances that are compelling reasons for restraint use in nursing facilities; they are expected to be variations of these four indications, and they appear to be rare.
The DHS Quality Monitoring Program uses this structured resident assessment to evaluate the appropriateness of resident assessment, care planning and care for residents who are restrained.
Practical Guide to Quality Improvement
Key Components of Successful Restraint Reductions Programs
Successful restraint reduction initiatives require changes in facility policy, staff and family attitudes, beliefs and care practices. The following structural and process elements contribute to success:[9, 10, 13, 14, 19, 20, 21, 22, 23]
- Unequivocal support from facility owners and administrators
- Restraint reduction education for all levels of direct care staff on every shift
- Restraint reduction education for medical staff and family members
- Use of a multidisciplinary restraint reduction team (a Restraint Review Committee that includes a physician, nurse, CNA staff, Administrator, housekeeping, others)
- Use of a consultative, resident-centered, problem-solving approach
- Allocation of staff time specifically for restraint reduction
- Implementation of restraint reduction one unit or floor at a time
- Restraint reduction in the easiest residents first
- Use of restraint-free intervals to gradually reduce restraints in the most difficult residents
- Use of multiple interventions to solve individual clinical problems (average of three interventions per resident)
- Long-term commitment to achieving a restraint-free environment (6-12 months to succeed)
- On-going, scheduled reevaluation of all residents who remain restrained
Part I. Prepare to Succeed (education)
- Identify any staff and family concerns or misconceptions about restraint use and restraint reduction.
- Develop and distribute a restraint reduction education handout for family and staff to address concerns and false beliefs.
- Use DHS Joint Trainings, handouts and QMWeb presentations and resources to provide in-service and family education on restraint reduction.
- Develop a plan for methodical restraint reduction, and present it to staff, family and resident council.
- Work with DHS Quality Monitors to test, evaluate and refine your restraint reduction program.
- Create a Restraint Review Committee to evaluate all residents in restraints and all new orders for restraints.
Part II. Implement Restraint Reduction - Eliminate Inappropriate Restraints (routine process)
Appropriate care planning for restraint reduction is only the beginning of the elimination of inappropriate restraints.
- Begin with the MDS Resident-Level QI Report to identify residents who are in restraints.
- Visually identify additional residents that not identified as being restrained by the MDS report.
- Evaluate every one of these residents for appropriateness of restraints using the accompanying structured assessment instrument or a comparable instrument to evaluate each resident. Leave the completed assessment on the chart for future reference.
- Use the results of structured assessment to identify residents who are not candidates for restraint reduction. Note the reason(s) in the resident's care plan. Ensure that in every instance there is a specific physician order for restraints and that the care plan addresses how the use of restraints will be monitored as well as when and how restraint reduction will be attempted.
- In every instance where restraint use is medically justifiable, schedule each such resident for periodic restraint use reevaluation. Evaluate the need for restraints justified as a temporary intervention for behavioral symptoms within a short time such as 24-48 hours that allows time for evaluation of causes and alternative interventions without permitting temporary restraint use to become on-going restraint use.
- For every remaining resident, identify the clinical problems for which restraints are currently being used.
- Engage PT/OT in the evaluation of the resident for restraint alternatives.
- Develop a resident-specific care plan that addresses each problem with the least restrictive intervention(s) possible.
- Involve the resident's family in the design of the plan.
- Provide family education on the risks of restraint use, the expected negative effects of continued restraint use and anticipated benefits of restraint elimination.
- Repeat this process monthly as part of your facility's Quality Improvement Plan.
- Review each chart to identify instances in which care plans and actual care giving are not congruent.
Part III. Implement Restraint Prevention - Eliminate the Initiation of Inappropriate Restraints (event-driven process)
- Require the use of structured assessment for restraint use before restraints can be ordered.
- Create a Restraint Review Committee that includes the facility Medical Director, an RN, physical therapist, other direct care staff and housekeeping.
- Engage PT/OT in the evaluation of the resident for restraint alternatives.
- Require that your Restraint Review Committee approve all orders for restraints within 24 hours of the order.
- Use the Restraint Review Committee to develop care plan alternatives when structured assessment shows that there is no valid indication for the use of restraints.
There are a variety of technologies related to restraint reduction. These technologies afford solutions to the clinical problems that lead to restraint use - falls, wandering, self-removal of medical devices, among others. These include various types of alarms, beds, devices to assist ambulation, positioning devices, wheelchair modifications, special clothing, dressings and environmental modifications. The presentations and resources sections in this framework provide examples of such technologies.
Related Licensure and Certification Tags
The following deficiencies may be cited for the inappropriate use of restraints. Tags that might be cited as evidence that restraints were used inappropriately are also listed. The deficiency list is representative rather than exhaustive.
Related DHS Presentations
All presentations on the Quality Matters web can only be viewed with Microsoft Internet Explorer 5.0 or later. No other browser is currently supported. However, you can follow this link to obtain the same presentations on CDROM for offline use with other browsers. Note that optimal viewing requires broadband internet access such as DSL line or cable modem. Although slow modem connections (down to 28.8 KB) are also supported, download times are much longer and the audio quality is phone-like rather than CD-quality.
Additional Resources (including online resources)
A Values-Based Approach to Restraint Reduction (Journal for Healthcare Quality, 2001)
Colorado Foundation for Medical Care (Resident Assessment Guide and Tools)
HCFA Restraint Reduction Newsletters
Untie the Elderly (Restraint Reduction Training Program)
A Restraint Reduction Letter to Families (This sample was graciously provided by Mr. Kinny Pack of Azle Manor. This is not a mandated form; it is simply a resource.)
Toward a Restraint-Free Environment Book. Edited by Judith V. Braun, Ph.D., Associate Administrator of the Hebrew Home of Greater Washington, Rockville, Maryland, and Steven Lipson, M.D., M.P.H., Medical Director of the Hebrew Home of Greater Washington and Associate Professor at the Georgetown University School of Medicine, Washington, DC.
 Centers for Medicare and Medicaid Services; MDS Quality Indicator Report. (2000-2001). online.
 Cortes, L. Restraint Use in Texas Nursing Facilities - Preliminary Findings of the 2002 Statewide Review of Quality of Care in Texas Nursing Facilities.
 Burton,LC., German, PS., Rovner, BW., Brant, L; & Clark, R. Mental illness and the use of restraints in nursing homes. The Gerontologists 1992;32(2):164-70.
 Karlsson S, Bucht G, Eriksson S et al. Physical restraint in geriatric care in Sweden: Prevalence and patient characteristics. Journal of American Geriatrics Society 1996;4411:1348-54.
 Phillips CD, Hawes C, Mor V et al. Facility and area variation affecting the use of physical restraints in nursing homes. Medical Care 1996;3411:1149-62.
 Karlsson S, Bucht G, Eriksson S et al. Factors related to the use of physical restraints in geriatric care settings. Journal of American Geriatric Society 2001;49:1722-8.
 Miles S, Irvine P. Deaths caused by physical restraints. The Gerontologist 1992;32(6):762-6.
 Tinetti M, LieW, and Ginter S. Mechanical restraint use and fall related injuries among patients of skilled nursing facilities. Annals of Internal Medicine 1992;16:369-74.
 Cohen C, Neufeld R, Dunbar J, et al. Old problem, different approach: alternatives to physical restraints. Journal of Gerontological Nursing 1996;22(2):23-9.
 Werner P, Koroknay V, Braun J et al. Individualized care alternatives used in the process of removing physical restraints in the nursing home. Journal of American Geriatrics Society 1994;42:321-5.
 Ejaz FK, Jones JA, Rose MS. Falls among nursing home residents: An examination of incident reports before and after restraint reduction programs. Journal of American Geriatrics Society 1994;42:960-4.
 Capezuti E, Evans L, Strumpf N et al. Physical restraint use and falls in nursing home residents. Journal of the American Geriatric Society, 1996; 44:627-33.
 Evans LK, Stumpf NE, Allen-Taylor SL et al. A clinical trial to reduce restraints in nursing homes. Journal of the American Geriatric Society 1997;45:675-81.
 Stratmann D, Vinson MH, Magee R, Hardin SB. The effects of research on clinical practice: The use of restraints. Applied Nursing Research 1997;10(1):39-43.
 Phillips CD, Hawes C, Fries BE. Reducing the use of physical restraints in nursing homes: Will it increase the costs? American Journal of Public Health 1993;83(3):342-8.
 Levine, JM, Marcello, V, Totolos, E. Progress Toward a Restraint-Free Environment in a Large Academic Nursing Facility. Journal of the American Geriatric Society 1995, 43(8):914-8.
 Dunbar JM et al. Taking charge: The role of nursing administrators in removing restraints. Journal of Nursing Administration 1997;27(3):42-8.
 Kapp MB. Restraint reduction and legal risk management. Journal of the American Geriatric Society 1999, 47(3):375-6
 Terpstra T, Terpstra T,L., Elaine VD., Reducing restraints: Where to start. The Journal of Continuing Education in Nursing 1998;29(1):10-16.
 Stilwell, EM. Nurses' education related to the use of restraints. Journal of Gerontological Nursing 1991;17(2):23-6.
 Neary, MA et. al. Restraints as Nurse's Aides See Them: What do the people who most often apply restraints know about the alternatives? Geriatric Nursing 1991;12(4):191-2
 Strumpf NE, Evans LK, Wagner J et al. Reducing physical restraints: Developing an education program. Journal of Gerontological Nursing 1992;18:21-7.
 Bradley L, Siddique CM, Dufton B. Reducing the use of physical restraints in long-term care facilities. Journal of Gerontological Nursing 1995;21(9):21-34.
 Morse, JM, McHutchion, E. Releasing Restraints: Providing Safe Care for the Elderly. Research in Nursing & Health 1991, 14:187-96.
 Janelli LM, Kanski, GW, Neary MA. Physical restraints: Has OBRA made a difference? Journal of Gerontological Nursing 1994;20:17-21.
Literature Review Evidence Table
Table of Additional References
Peer Reviewer: David A. Smith, MD, CMD
Review Date: June 7, 2002
Dr. Smith practices Long Term Care Geriatrics in his private practice in Brownwood, Texas. He is a Professor in Family Medicine at the Texas A&M School of Medicine and is also currently President of the Texas Medical Director's Association.
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Last updated: September 19, 2002
Source: http://mqa.dhs.state.tx.us/QMWeb/POR.htm, 5/14/2003.
Source: http://mqa.dhs.state.tx.us/QMWeb/RestraintReduction.htm, 2/20/2003.