Use restraint with restraints: Tighter rules call for creative ideas
June 1, 1997 6 minutes read
Use restraint with restraints: Tighter rules call for creative ideas
Risk managers find ways to reduce restraint use
Restraining violent or disoriented patients, once a practice commonly used by harried staff, is becoming more rare in health care facilities a shift applauded by risk managers hoping to reduce injuries, lawsuits, and regulatory violations.
Eliminating or sharply reducing the use of restraints is not easy. In many ways, it is far easier to allow staff to use restraints liberally, even if the restraints are not always justified for safety reasons.
Risk managers admit that until recently, health care staff often used restraints out of desperation when a patient was troublesome and required excessive attention.
A more enlightened approach from health care professionals is now fueling the move to reduce the use of restraints, and regulatory bodies such as the Joint Commission on Accreditation of Healthcare Organizations in Oak- brook Terrace, IL, also are spear-
heading a strong push in that direction. Making restraints a last resort takes a dedicated search for alternatives, but the risk management benefits are plentiful.
Reducing the use of restraints is one of those things you do "because it’s right," and then you also reap the risk management benefits, says Debbie Foshee, RN, director of quality and risk management at Sacred Heart Hospital in Pensacola, FL. "It’s a lot easier sometimes to say, Let’s restrain that patient.’ We had to go through a bit of a culture change, because five or 10 years ago it wasn’t considered a big deal to tie a patient down. Now we consider it a very big deal."
The Joint Commission’s tighter rules for restraint use were released in July 1996, prompting many health care facilities to reassess their policies. Sacred Heart Hospital already had begun revising its policy, both to benefit patients and because it saw regulatory changes coming down the pike. In the hospi- tal’s most recent Joint Commission review in December, it received a special commendation for its restraint policy.
"Restraints are the No. 1 hot topic for Joint Commission surveys," Foshee says. "They liked the fact that our policy deals with all the things they like requiring a physician’s order, limiting the restraint to 24 hours, and constantly reassessing the patient."
Restraint use cut nearly in half
In the year and a half that its revised policy has been in place, Sacred Heart Hospital has reduced the use of restraints by 44%. Foshee says there has been "absolutely no increase in our number of injuries from patient falls." There was some initial resistance from clinicians used to a more liberal restraint policy, and Foshee points out that the revised policy requires increased recordkeeping and other administrative burdens. But the results are worth it, she insists.
That success comes from a combination of efforts throughout the hospital. The revised policy requires that a physician order restraint use, except in unusual emergency situations. The physician order must include a start and end time. (See p. 64 for a sample of the restraint order form.) Staff members also are required to pursue alternatives to physical restraints, such as relieving a patient’s distress with sedation or having a family member stay with the patient.
Sacred Heart Hospital also uses an innovative program that provides teen-age volunteers to sit with patients and entertain them. Providing any sort of diversion to the patient often eliminates the need for restraints. (See story, p. 63.)
One aspect of Sacred Heart’s revised policy that most pleased the Joint Commission inspectors was the way the hospital monitors the use of restraints on a daily basis. "At most hospitals, if you asked them how many patients were restrained today, they wouldn’t know," Foshee says.
Under the new policy, a nursing supervisor checks with each department daily and records the names of all patients who have been restrained. A nurse case manager then visits each of those patients that same day and assesses how well the staff has complied with the hospital’s restraint policy. In addition to checking for the proper documentation and procedure, the nurse physically examines the patient to verify that the restraint has been applied properly and to confirm that the patient is not injured by the restraint. If there is a problem, the nurse case manager works with the unit manager to fix it immediately. (See story, p. 62, for components of nurse case manager’s assessment.)
The data from those daily assessments are compiled and analyzed monthly. That allows Foshee to see whether restraint use is up or down and to compare the figures with those of the hospital’s parent health care system.
The 421-bed hospital restrains an average of eight patients per day, compared with about 15 before the restraint policy was changed.
Foshee says Sacred Heart’s restraint policy works so well in part because the hospital has no psychiatric patients. Regular admission of psychiatric patients would create more of a need for physical restraints, because such patients are more likely to become violent.
Although the number of patient falls has not increased since the stricter restraint policy went into effect, Foshee notes that falls still happen. She points out, however, that patients fall in hospitals with liberal restraint policies as well, and those hospitals also see injuries from restraints.
"Restraints don’t promise that the patient won’t be injured," she says. "You’re going to get into trouble by going too far in either direction. You’ll get sued for a fall, or you’ll get nailed by the Joint Commission. So you might as well do the right thing, and we think that means respecting the patient and avoiding restraints."
Respecting patients’ dignity
Sacred Heart Hospital recently settled a lawsuit in which a restraint was removed from an elderly woman, who then was injured in a fall. The incident took place before the hospital’s stricter restraint policy was initiated, and Foshee says the case illustrates that restraints are not a panacea. (See story, p. 65.)
Ideally, Foshee would like to have a policy that prohibits the use of physical restraints. She admits, however, that eliminating restraints is not possible in most acute care hospitals.
A long-term care facility is a different matter. Haven of Our Lady of Peace, the long-term care facility on the Sacred Heart campus, has successfully eliminated physical restraints altogether. It has been restraint-free for two years, says administrator Brent Watson.
Watson shares Foshee’s philosophy that avoiding restraints is a matter of respecting the dignity of the residents, but he points out that the move to eliminate restraints was prompted by a regulatory violation two years ago. In the state’s licensure survey, the facility was cited for improper use of a wheelchair lap device that the facility considered a safety device and the state considered a restraint. "Now we don’t have to worry about regulatory issues with improper restraint use because we just don’t use restraints," he says. "The state was very complimentary when they saw last year that we had eliminated them."
The elimination of restraints is so complete that the 89-bed facility doesn’t even have them in storage. Watson says he would authorize use of a restraint only in an extremely serious and unusual circumstance, which has never happened, and then the staff would have to scramble to find one at a nearby facility.
Some patients always may need restraints
Complete elimination of restraints is possible, Watson says, because the long-term care facility does not accept residents who are violent or difficult to control. At an acute care hospital or a facility accepting more difficult patients, some physical restraint may always be necessary, he says.
Sedation is still available for residents, and staff members are allowed to use bed rails for residents who are not supposed to get out of bed. The state considers bed rails to be assistive devices for the residents, not restraints.
"We’ve had an increase in falls, but not much, and a lot of our falls would occur even if we used restraints," Watson explains. "We weigh the falls and possible lawsuits against the quality of life for a patient who is able to get up and move on his own. Is the freedom worth risking a fall? We’ve decided that sometimes it is."
(For more information, contact: Sacred Heart Hospital, 5151 N. Ninth Ave., P.O. Box 2700, Pensacola, FL 32513-2700.)
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