Saturday, January 17, 2009

A Restraint Free Nursing Home

We heard from Donna, our instructor for the nursing section of hospital orientation, that there was an initiative to end use of restraints within the hospital. Out of necessity, ICUs were exempt, but the rest of the hospital was currently restraint free. The nursing home that was operated by the hospital had not used restraints for more than a year.

My interest was piqued. As I have mentioned before, I am not very fond of restraints, but they have always seemed an unavoidable feature of the work environment. When things like breathing tubes and feeding tubes are inserted into the body, it is the natural tendency of the patient to want to remove them. Combine this tendency with any kind of dementia, disorientation, or plain disagreement and the situation is intractable. It often boils down to choosing between restraining the patient or letting him starve. You cannot let him starve, so you have to tie him down.

Thinkers who have taken on this riddle tend to recommend sitters. If you can place a person next to the patient for one-on-one observation and guidance, that person should be able to accomplish as much if not more than the restraints achieve. Unfortunately, these thinkers are not nurses, or if they are it has been a long time since they actually dealt with patients. A sitter can really only be effective if the patient is willing to listen. It is not the sitter’s job to watch a patient and grab his hand just as he is about to pull the feeding tube from his nose. Such actions cause immediate escalation and are counter productive anyways. It is a very small percentage of restrained patients that can actually be helped by sitters – those who are forgetful but docile. Even then, to have the expectation that the patient will be watched 24/7 just to stop them from pulling on things is asking quite a lot of an underpaid and unenthusiastic sitter. I challenge my readers to spend just ten minutes in such service. Ask yourself if you could do it for eight or twelve hours at a time.

So how does the hospital manage it? Nursing home patients will be having less technology hanging from their bodies, but they must still have the occasional feeding tube and they will be more mobile as well. You may not have considered this, but people with dementia are not always the most cooperative and if a few nurses and nursing assistants are going to take care of a bunch of residents there needs to be a certain level of routine and order. Residents also need to be protected from each other. “But if they have figured out a way to avoid using restraints, maybe I should look in to working there,” I thought to myself as I wondered what their tricks could possibly be.

The answer came in the next section of orientation when we discussed the use of restraints. Did you know that padded mittens, fastened around the wrist with Velcro, are not restraints because they don’t restrict movement, they only stop a patient from grabbing things? Donna told us that she did not recommend these because they tend to remind the patients of boxing gloves.

If you fasten a Velcro lap belt at the back of the resident’s chair or wheelchair it is a restraint, but if you keep the Velcro in the front where a reasonably able person could release it on their own…it is not a restraint.

Rigid sleeves filled with Styrofoam pellets keep a patient’s arm from bending and thus prevent them from reaching, say, their noses and pulling their feeding tubes. Once called elbow immobilizers, these are now known as ‘Freedom Splints’ (I think they are French) and they are not restraints.

A tray snapped across the front of a wheelchair, which cannot be easily removed by the resident, is also not a restraint provided it is being used for some other purpose. “So make sure you always leave a glass of water on the trays so that you don’t have to count it as a restraint,” says Donna cheerfully. With all sincerity she seems to feel that all of this somehow represents progress.

“Ah…,” I think to myself, a little disappointed but not surprised, “so that is how….you document…. a restraint free facility.”

Oh, and by the way; all of those complications that Medicare will no longer be paying for – you know UTI’s and Decubes etc. – we have almost eradicated them all already.


Conciergedoc said...

I am amazed to discover that this is still happening. When I finished my Geriatrics Fellowship just 3 years ago, Boston University Med Ctr became a 100% restraint free institution (except ICU). Velcro regardless of how used is a restraint. Anything that prohibits a patient from following out on his/her impulses is a restraint - to his harm or not. and to my understanding, BUMC honors this restraint free policy to this very day. And from a practical standpoint, this is a 626 bed institution. I am now the medical director of a medium size nursing home. We have NEVER used a restraint of any kind.

This policy works for our dementia filled nursing home, and a 626 bed hospital. So why it does not work anyone else is more a issue of complacency. A demented patient who pulls his tube - let him. If he does it often enough, families usually accept that the tube is a bad idea and they stop it. IVs - please, cover with lots of cloth and tape it. There is never a reason for restraint. the obly exceptions being outside of ICU where they are recieving acute lifesaving interventions or violence that cannot be controlled by other means.

The hardest thing I've had to do is teach my current institution to institute a similar 100% restraint free policy.

Leo Levy said...

Conciergedoc has written words I have been hankering for. Are the consequences of pulling a feeding tube etc. worse than the consequences of restraining the patient? I think the answer is often 'no,' but for the sake of appearances we are often forced to do what we do not want to.