Peer to Peer: Why and How to be Restraint Free

October 10, 2007 Session AE-4 8:00 – 9:00 AM

Room ___ – Convention Center

Moderator: Gloria Bean, RN TMF Health Quality Institute, Austin, Texas

Speakers: Michelle Madkins, Director of Nursing

Greenville Health and Rehabilitation Center, Greenville, Texas Pam Quinn, RN, Director of Nursing

Orchard View Manor, East Providence, Rhode Island

Objectives

Discuss the QIO’s statewide work and lessons learned to reduce restraint use.

Recognize specific strategies used by providers to reduce restraint use, as well as the impact on other restraint outcome measures.

Learn how providers have specifically implemented quality improvement methodologies to reduce restraint use.

National/State QIO Efforts

Build partnerships

Provide evidence based protocols

Educate

Consult

Results Over TimePhysical Restraints in Texas and the Nation

Prepared by TMF Health Quality Institute

Data source: Quality Measure Data from Nursing Home Compare

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Ave

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Nation

Texas

7sow ipg

8sow ipg

Biggest Barriers To Being Restraint Free

“Restraints keep residents safe”

AND

“Without restraints residents will fall and fracture”

FDA SAFETY ALERT

The FDA estimates there may be at least 100 deaths or injuries annually associated with the use of restraints, many deaths occurring when the patient is trying to get out of the restraint or while attempting purposeful behavior such as going to the bathroom.

July 15, 1992

Texas trends for restraints, fractures, and fallsQuality Indicator Data, Oct. 1998 - March 2007

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

Me

an

pro

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rtio

n o

f p

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Restraints

Falls

Fractures

QIO Efforts began*

Texas Trends for Restraints

Michelle Madkins, Director of NursingGreenville Health and Rehabilitation Center

Greenville, Texas

How to Be Restraint Free

The problem

Mindset that residents were safe in restraints

Didn’t know restraints were a problem

Had concerns about chemical restraints

Had 12 restraints or 13% when we started working with the QIO in 2003

Our approach

Goals

Elimination

Removal

Orders

Our most difficult case

History of broken hip

Doctor/family refusal

Resident cried in restraints

Quality of Life issue, staff faced a dilemma

Our solution

Enlisted help

Educated the family

Pursued alternatives

One of our discoveries

Bed and wheelchair alarms can be restraints.

The process we used for handling bed/chair alarms

Determine why the resident is getting up

Staff members walk residents until they are tired

For residents that can’t walk, staff check to see if they are wet or uncomfortable (assessment)

* 0% since Q4 2005

*

How we stay restraint-free

Educate new staff

Problem-solve

Keep restraints out of the building

If a physician orders a restraint, staff are required to call me

Questions?

Contact information:

greenville.don@ltcmail.com

Pam Quinn, RN, Director of NursingOrchard View Manor, East Providence, Rhode Island

ORCHARD VIEW MANORPresents

Maintaining a Restraint-Free Environment

Enthusiasm is Key

YOUR STAFF WILL NOT BELIEVE IT UNLESS YOU DO!!

Decide, as a facility that no restraint is necessary.

1. Reduced restraints equal

2. Reduced incontinence

3. Reduced wounds

4. Reduced depression

5. Reduced behaviors

6. Reduced ADL decline

DATA SHOULD BE DERIVED FROM MDS QUERY – DECIDE

THAT EVEN ONE IS TOO MANY.Include:

1. Physical restraints

2. Bed against the wall

3. GERI chairs with trays

4. LAP buddies

5. Even some interventions can be restraints, if they prevent rising.

LTGDecide to have zero tolerance within six (6)

months.

STGTo evaluate each resident – one per unit, per week for reduction.

(START WITH THE “EASY’ ONES)HAVE A SOLID PLAN

Be a cheerleader:

1. Form your focus group.

2. Meet weekly for twenty (20) minutes.

3. Stay positive with a “can do” attitude.

4. If you don’t care, they wont.

5. Get families involved.

CELEBRATE SUCCESS!

1. Lots of positive feedback to staff and residents.

2. Post the data.

3. Advertise yourself as a “restraint-free” facility.

A GREAT FALLS PROGRAM IS ESSENTIAL

1. Become an expert at intervention.

2. Begin a Restorative Program with weight training.

3. Vitamin D prevents falls! New study.

4. Use the “Thirty-Nine (39) alternatives”.

5. Review every fall every day with front line staff and the resident.

HOW DID WE SUSTAIN IT?

1. By the time we were done, it was part of our culture.

2. Referring Agencies are notified.

3. Families are re-educated.

ORCHARD VIEW MANORQUALITY IMPROVEMENT WORKSHEET

GOAL: To Become a Restraint-Free Facility

DATE: July 2003

PLAN

1.To achieve restraint-free status by January 14, 2004

Currently 34 restraints

-3 physical restraints 2 waist 1 pelvic-18 full siderails-7 Geri chairs with tables

DO

1.Form a focus group including:

DNSADNSCNA Q-unitPTSSAT

2.Invite to meet3.Provide list to team.4.Begin with easiest 5.Reduce 1 or 2 per weekInclude staff in all aspects to re-educate

CHECK

6.Change intervention to less restrictive7.Audit and discuss progress weekly.8.Celebrate on each unit as they become restraint-free9.Provide family education for each resident - at family council - at resident council

ACT

7/2003 = 28

8/2003 = 20 left

9/2003 = 12 left

10/2003 = 4 left

11/2003 = Restraint-free

All 2004 = Restraint-free

All 2005 = Restraint-free

All 2006 = Restraint-free

Up to 8/2007

TIPS FOR SUCCESSFULLY AFFECTING A CHANGE

(NO MATTER HOW BIG OR HOW SMALL) 1. Form a focus group to discuss the pros & cons.

2. Keep your meeting to 20 minutes or less.

3. Let everyone have a say-there are no wrong opinions.

4. Write down the steps needed to achieve the goal or complete the project.

5. Assign tasks.

6. EDUCATE ALL WHO WILL BE AFFECTED.

7. Institute the change.

8. Audit the process for success or failure.

9. Re-assemble the focus group and revise the plan, if needed.

10. Celebrate success.

FALLS AVOIDANCE INTERVENTIONS

The following list is for alternatives to try to reduce falls:

1. PT

2. OT

3. RNA

4. Ambulation program

5. B&B program

6. Increase activities

7. Slip grip in chair

8. Slip strips on floor

9. Slipper socks

10.½ side rails for support

11.Medical work-up

12.Bladder scan

FALLS AVOIDANCE INTERVENTIONS

(CONTINUED 2)13. Monitoring of bowel status

14. Q15min checks

15. Keep in plain view of staff when OOB

16. Psych to reduce meds

17. Orthostatic signs

18. Low bed with mattress beside it

19. Caution tape @ door to room

20. Stop signs

21. Anti-tippers for the w/c

22. Extra snacks

23. Reminder ribbons for the wheelchair

24. Written instructions to the resident

FALLS AVOIDANCE INTERVENTIONS

(CONTINUED 3)25. Afternoon naps

26. Pain management

27. Encourage family to visit

28. Soothing music

29. Quiet areas on the unit

30. Take the resident outdoors

31. One-on-one

32. Avoid sleeping pills

33. Decrease caffeine intake

34. Decrease fluids after supper

35. Exercise programs

36. Raised toilet seat

37. Safe-hips

Questions?

In Summary:

10 Keys to Success

1. Make sure Administration is on board2. Educate everyone3. Create a multidisciplinary team4. Start with a small number of the easiest

residents to reduce first5. Identify medical and care issues that led to

restraint use for each individual

10 Keys to Success Cont.

6. Use comprehensive assessment to determine residents capabilities and needs

7. Review all falls daily8. Trial least restrictive interventions first9. Use increased intervals of Restraint Free time

with more difficult cases10.Document, Communicate and Celebrate

Any additional questions for our speakers?

Thank you for your attendance and participation!