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August 10, 1999
Illinois Nursing Homes Lead the Nation in Reducing Physical Restraints
(Chicago) -- Being able to get up
and walk out of his wheelchair signifies a major accomplishment
for Phil Mines, a resident of Glenview Terrace Nursing
Center. After suffering a stroke, Phil came to the facility
with the left side of his body paralyzed. Not only couldn’t
he walk, he was afraid of falling out of his wheelchair
due to body weakness.
“I was frightened of hurting
myself,” Mr. Mines notes. To help him feel safer,
nursing staff had Mr. Mines temporarily wear a waist
belt restraint, which proved to be uncomfortable and
constricting.
The facility staff recommended intensive physical
and occupational therapy sessions to help his body become
stronger and more flexible, so he would not need the
waist restraint.
“After my stroke, I felt like
my whole life was over,” Mr. Mines points out.
“Now I am more confident and optimistic.”
Through his therapy sessions, Mr. Mines gained the ability
to stand up and ambulate. In addition, he is strong
enough that he no longer feels the need to wear a waist
belt.
“The staff at our facility has
worked very hard to avoid the use of restraints,”
states Mariamma Pillai, director of nursing at Glenview
Terrace Nursing Center. “We have decreased our
restraint use substantially over the past few years,
now using them only when absolutely necessary. By finding
alternatives to restraints, we have greatly contributed
to our residents’ quality of life.”
Restraint Reduction: An Illinois Success Story
Mr. Mines’s success story is
one of many at Illinois nursing facilities, which have
dramatically reduced their use of restraints in managing
unsafe mobility, postural instability, and agitated
behavior. Instead of relying on restraints, these facilities
have found creative alternatives to restraint usage
that have helped to enhance residents’ safety,
independence, and well-being.
The Health Care Financing Administration
(HCFA) reports that during the year 1988, physical restraints
were used with 41% of residents in skilled nursing facilities
nationwide. According to data from 1999, the latest
statistics released by HCFA, the physical restraint
rate for nursing homes in the United States has decreased
to 12.09%.
Nursing homes in the state of Illinois
have done far better than the national average: Illinois’
December 1999 restraint rate is 6.9%, the lowest restraint
rate of any state with 70,000 or more nursing home residents.
One of the reasons for the success
in Illinois nursing homes in reducing restraints was
a combined initiative between the nursing homes and
the Illinois state survey agencies in the late 1980’s
to increase rehabilitative therapy and restorative nursing
to get elderly residents up and moving. The State of
Illinois established a special 60-hour course in rehabilitation
for nurses, and another rehabilitation certificate for
nursing assistants to help nursing home residents keep
muscles strong and flexible to maintain their mobility
and independence.
The Illinois Council on Long Term
Care, a state nursing home trade association, developed
a “state-of-the-art” restraint reduction program
to assist nursing facilities in complying with federal
and state regulations. The goal of the Illinois Council
was to assist its members in establishing a consistent,
innovative and standardized approach to reducing the
use of restraints. The Council also conducted ten training
seminars for over 2,000 nursing home staff in how to
reduce restraint usage.
When the federal government established
new stringent regulations regarding restraint reduction
in 1990, Illinois nursing facilities were already ahead
of the nation, and continued that lead. The new federal
regulations, designed to improve the quality of care
in nursing homes, mandated that residents have “the
right to be free” from physical restraints not
required to treat their medical symptoms. Restraints
may only be used to ensure the physical safety of a
resident, upon written order of a physician, and with
the written informed consent of the resident or their
families.
Because of the initial success of
Illinois nursing homes reducing restraints faster than
the national average, the Health Care Financing Administration
selected Illinois in 1996 for an intensive restraint
reduction effort, called “Partnership Beyond Restraints”.
The goal of Partnership Beyond Restraints was to reduce
restraint usage in Illinois nursing homes below 10%,
considered the lowest practical restraint use target.
HCFA worked with Illinois nursing
home associations, the American Association of Retired
Persons (AARP), and the Illinois Department of Public
Health in conducting training programs in restraint
reduction techniques. Some of the training programs
were directed toward training nursing home staff; others
were directed toward family members in helping them
understand the purpose of restraint reduction.
During the same year, the Illinois
Department of Public Health published licensure rules
regarding the use of physical restraints which were
essentially modeled on the federal OBRA standards for
restraint reduction, but exceeded federal standards
in several important areas that added additional assessments,
notifications, and reviews to assure that as few restraints
as possible were used.
The combined efforts of regulatory
agencies, state provider associations, and staff members
at Illinois nursing homes have resulted in the restraint
rate in Illinois to decrease to its current level of
6.9%. “The success of Illinois’ restraint
reduction initiative symbolizes how progress can be
made in improving resident health and quality of life
when nursing home providers and government agencies
work together in addressing resident caregiving needs,”
says Martin Weiss, President of the Illinois Council
on Long Term Care.
Developing Alternatives to Restraint Usage
Many Illinois nursing facilities
have taken the lead in developing comprehensive restraint
reduction initiatives. Staff members of several departments
-- nursing, therapy, activities, dietary, and even maintenance
-- have worked cooperatively together to share creative
approaches and create alternatives that have been tailored
to the individual needs of each resident.
Among the alternatives to restraint
use that have proved successful are the use of specially-designed
chairs, recliners, and wedge cushions for persons in
danger of falling; alarm systems for persons who wander;
activity approaches to help keep residents involved
and reduce agitation; and lowering beds or putting mattresses
next to the beds of residents who are at risk of falling.
Staff training has played a crucial role in making these
restraint reduction alternatives a success.
For years, Illinois facilities have
sponsored restorative care programs, in which nursing
and therapy professionals work together in utilizing
therapeutic exercises to make residents’ bodies
stronger and more flexible. These programs have proved
to be invaluable in dealing with residents’ postural
instability and mobility problems -- thus avoiding the
use of restraints.
At Fox River Pavilion in Aurora,
therapists work with nursing home residents using Nautilus
machines to improve their strength, flexibility and
coordination through the facility’s “Restore”
program. Research studies have proven that the elderly
can greatly increase their functional independence through
weight training techniques which have been specifically
designed for use with a senior population.
As Peggy Nelson, Facility Rehab Director
for Fox River Pavilion, states, “The use of Nautilus
machines has helped us tremendously in improving our
residents’ posture, ability to stand, and walking
ability. Resistance training is part of our facility’s
ongoing efforts to maximize resident independence and
reduce the use of restraints.”
Fears and Myths Regarding Restraints
Restraining residents -- tying them
in bed or in a wheelchair -- was considered good standard
medical practice since the 1950’s to prevent people
from falling, wandering or otherwise hurting themselves.
However, numerous research studies and professional
articles in the 1980’s discovered the damaging
physical and psychological effects of using restraints.
With the decreased mobility, residents
who were restrained increasingly developed negative
physical outcomes such as decreased muscle tone, increased
bone fragility, pressure sores, incontinence, urinary
tract infections, pneumonia, and dehydration. It was
also discovered that, psychologically, restraint use
can lead to depression, withdrawal, agitation, confusion,
and frustration.
When a person stops using a
body part, that part no longer works very well. The
old saying “use it or lose it” is true: people
who are restrained become weaker physically. Some families
will ask that residents be restrained because of the
fear that they will fall if they are not restrained.
But research shows that these residents, when they do
fall, have less serious injuries than those who are
restrained. If restraints are removed and residents
are helped to regain their strength, they may fall less
frequently, and the falls will not hurt them as much.
“It has been the unfortunate
opinion throughout the years that restraints help in
reducing falls and can be used positively as a form
of treatment,” states Dr. Steven C. Fox, President
of the Illinois Citizens for Better Care, a nursing
home industry watch group. “The evidence has shown
that the reverse is true -- restraints cause more falls.”
Short-term, emergency use of restraints
may have some benefits for residents. For instance,
the use of restraints may prevent a severely dehydrated
and confused person from pulling out a life-saving IV.
A restraint may also allow a doctor or nurse to examine
a delirious person to find the cause of symptoms.
However, nursing home providers have
recognized that even short-term, emergency use of restraints
may have serious physical and psychological effects.
When restraints are used, staff try to prevent injury
and physical complications by using the least restrictive
restraint, moving the restrained part every two hours,
providing activities and socialization, and removing
the restraint as soon as the emergency is over.
Future Goals with Restraint Reduction
While great progress has been made in reducing the use of restraints
in Illinois, industry experts agree that there is still
more work to be done.
“Although the nursing home industry
has been moving in the right direction, I still see
facilities where restraints are too frequently used,”
Dr. Steven C. Fox comments. “We need to continue
educating our staff members, particularly those working
the night shift, on alternatives to the use of restraints.”
“In addition, hospitals should
seriously examine their use of restraints,” Dr.
Fox adds. “Too
often, patients come to nursing homes from the hospital
in restraints, when the use of these devices is clinically
unwarranted. I think that the nursing home industry has advanced farther
than the hospital industry in addressing the timely
issue of restraint reduction.”
The Health Care Financing Administration
is continuing its efforts to reduce restraint use in
nursing homes on a national level.
“Our goal is that the number
of residents restrained in nursing homes in the US should
be less than 10% by the year 2000,” states Jerry
Arzt, Health Insurance Specialist for the Health Care
Financing Administration and editor of the HCFA’s
Restraint Reduction
National Newsletter. “We are confident that
the commitment reflected by the scope of activities
so far (by health care providers in Illinois) will result
in the successful completion of this goal throughout
the nation.”
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