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Physical Restraint Reduction in the Acute Rehabilitation Setting: A Quality Improvement Study
A prospective, continuous quality improvement study was implemented at a hospital on two rehabilitation units: stroke and brain injury. The purpose of the study was to decrease restraint use by 25% and to maintain fall rates no greater than 10% over baseline. A multi-component restraint reduction program was implemented that focused on administrative support, education, consultation, and feedback. Monthly restraint rates and fall rates were monitored and compared to the previous year’s rates. Both units reduced restraint use. Importantly, this reduction was accomplished at the same time as a decline in fall rates.
Nurses have utilized physical restraints as part of patient care for many years in a variety of settings. For example, acute care nurses use physical restraints to prevent delirious or agitated patients from prematurely disrupting therapy devices (Minnick, Mion, Leipzig, Lamb, & Palmer, 1998). Nurses in acute rehabilitation settings physically restrain patients to prevent falls, to manage agitation, and to manage impulsive behavior (Mion, Frengley, Jakovcic, & Marino, 1989; Schleenbaker, McDowell, Moore, Costich, & Prater, 1994). Many patients in acute rehabilitation suffer from neurological conditions, such as brain injury or stroke, that increase their risk for falls and agitated behavior.
Although they are considered beneficial, physical restraints do not necessarily prevent patient falls. Indeed, up to 34% of rehabilitation patients who fall do so while in physical restraint (Arbesman & Wright, 1999; Mion et al., 1989; Schleenbaker et al., 1994). In addition, physical restraints can have adverse effects and may even cause death (Bromberg & Vogel, 1996; Miles & Irvine, 1992). Given the questionable risk-benefit ratio of physical restraints, federal regulation and accreditation standards have restricted the use of physical restraint in all patient settings (Health Care Financing Administration [HCFA], 1999; Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 2005). As a result, many healthcare organizations have actively pursued reducing their use of physical restraints.
Studies have shown that restraint reduction programs in both acute care and long-term care settings have been effective in reducing restraint use while maintaining patient safety (Evans et al., 1997; Mion et al., 2001; Neufeld, Libow, Foley, & White, 1995). A review of the literature yielded a descriptive report (Weeks, 1997) but found that no studies have systematically examined physical restraint reduction in the rehabilitation setting.
To establish the feasibility and effectiveness of non-restraint strategies in an acute rehabilitation setting, a continuous quality improvement (CQI) study was implemented on two acute rehabilitation units, brain injury, and stroke. The study’s purpose was to determine whether a multi-component intervention strategy, adapted from strategies used in long-term care and acute care settings, could safely reduce the use of physical restraints in acute rehabilitation units.
The Restraint Reduction Program (RRP) was implemented from March 2004 through March 2005 on two acute rehabilitation units at a 732-bed county teaching hospital in the Midwest. The two units involved were the stroke rehabilitation unit (a 16-bed unit) and the brain injury rehabilitation unit (an 18-bed unit.)
Restraint Reduction Program
Interventions in the RRP were adapted from programs successfully implemented in acute and long-term care settings (Evans et al., 1997; Mion et al., 2001). The planning committee for the program consisted of clinical nurse specialists, unit nurse managers, nurse patient-care coordinators, physical therapists, occupational therapists, and staff nurses.
The program consisted of four components: administration, education, consultation, and feedback. The administrative component involved gaining the active support of the director of nursing, nurse managers, patient care coordinators, physician leaders, and therapists prior to implementation of the program. The clinical nurse specialists met with the leadership group to discuss the high use of restraints on both rehabilitation units, the significance of the restraint use issue, and the proposed Restraint Reduction Program. Updates given during regularly scheduled meetings included progress reports on the program, barriers to implementation, and suggestions for facilitating staff adoption of the program.
The education component consisted of both formal and informal information sessions for all levels of nursing staff. These sessions focused on the restraint and seclusion policy as well as the hospital’s philosophy regarding restraint use. A local vendor demonstrated restraint alternatives available for purchase. Staff members chose the devices that they felt would be most effective for their patient population, then tested the devices on a trial basis for effectiveness, after which the selected devices were purchased for the program. The staff received training on proper use of the devices. Staff also received formal education on falls: risk factors, universal precautions, and targeted interventions using the selected physical restraint alternatives. Content for those sessions was drawn from best evidence and practice guidelines (American Geriatrics Society, 2001; Leipzig, Cumming, & Tinetti, 1999a; Leipzig, Cumming & Tinetti, 1999b) and from the hospital’s own Fall Prevention Protocol.
For the consultation component of the program, the clinical nurse specialists went on rounds with staff nurses, initially biweekly and then weekly after the RRP was firmly established. Rounds focused on patients who were restrained, patients who had fallen, or patients judged to be at risk for falling. For example, the clinical nurse specialist and the nurse caring for a restrained patient might discuss issues for that particular patient such as impulsivity, steadiness of gait, and cognition. When a nurse identified that a patient was starting to use the call light appropriately, or if a patient’s gait was improving, a wheelchair and/or bed alarm respectively, would be recommended. The nurse caring for the patient would then make the final decision to remove the restraint based on the nurse’s assessment of the patient. During the next consultation session, the clinical nurse specialist would evaluate whether recommendations had been carried out. For any patient who had experienced a fall, the clinical nurse specialist would explore circumstances leading to the fall and discuss any interventions nurses may have put in place following the fall. Fall prevention strategies found to be most effective in reducing restraint use included using alarms (for the bed or wheelchair), increased surveillance techniques (such as 15-minute checks or moving patients closer to the nurses’ station), and changing patient routines to facilitate surveillance and staff contact.
The feedback component was twofold. First, the nurses’ adherence to the plan of care was monitored and reviewed during the ongoing consultation rounds, at which time individual nurse-to-nurse feedback was provided. Second, the quality management department provided aggregate data in the form of monthly run charts for fall rates and physical restraint use on each unit (see Figure 1).
The institutional review board (IRB) approved the study in late 2003. The administrative and education components began on both units in early 2004, with the consultation component starting in March 2004 and the feedback component in April of that year.
The outcome variables for this study were the rates of physical restraint use and patient falls. Physical restraint was defined as “any device, material, or equipment attached or adjacent to the patient’s body that the patient cannot remove easily, that restricts freedom of movement, and that is not intended as part of the standard practice of care” (HCFA, 1999). Restraints included mitt(s), wrist restraints, waist restraints, pelvic restraints, and full side rails. Monthly restraint rates were calculated as the total number of restraint hours per 100 patient days. Patient falls were defined as any witnessed or unwitnessed event in which the patient was found on the ground secondary to an unplanned event. Fall rates were calculated as the number of patient falls per 1,000 patient days.
Data Collection Procedures
Physical restraint data were collected from nursing documentation. Unit secretaries input the information into a computer database. At this hospital, quality management department personnel conduct ongoing audits to ensure data collection consistency; any noted deviations are addressed at the time of the audit. Falls data were collected using the incident reports that nurses completed following any patient fall.
Monthly prevalence rates for both restraint use and falls were calculated for the year prior to implementation of the study (baseline: March 2003 through February 2004) and compared with the rates observed during the RRP (post: March 2004 through February 2005). Physical restraint benchmarks were established for both units using a 25% reduction rate from baseline. Relative reduction rates were calculated using the mean yearly rates with the following equation: [(baseline-post)/baseline] x 100. An upper safety limit for fall rates was established as a 10% relative increase over baseline. The quality management office aggregated the data and reported it to the units.
Both the stroke rehabilitation unit and the brain injury rehabilitation unit reduced their overall restraint rates (Figures 2 and 3). The stroke rehabilitation unit reduced restraint use from 216.6 hours per 100 patient days to 153.3 hours per 100 patient days, representing a 29.2% relative reduction in overall restraint use. The brain injury unit reduced restraint use from 1054.3 hours per 100 patient days to 883.3 hours per 100 patient days—a 16.2% relative reduction.
Fall rates also decreased on both units (Figures 4 and 5). Stroke rehabilitation patients’ fall rates declined from 11.4 to 6.1 falls per 1,000 patient days, a 45.5% relative reduction. Fall rates on the brain injury rehabilitation unit declined from 9.1 to 3.3 falls per 1,000 patient days, a 64.2% relative reduction.
Federal regulations mandate the restriction of physical restraints in all patient settings, including rehabilitation (HCFA, 1999). Thus, rehabilitation nurses must examine other ways to prevent falls among these high-risk patients. A restraint reduction program, focusing on fall risk and impulsive or agitated behavior in stroke and brain injury rehabilitation patients, proved safe as well as effective. Our aim was to reduce restraints while maintaining fall rates within 10% of baseline. Our achievement of both objectives demonstrates the feasibility and effectiveness of this systematic approach.
We found that the RRP program was more successful on the stroke unit than on the brain injury unit. Several factors may account for this. First, the units are shaped differently. The stroke unit is circular, while the brain injury unit is a rectangular space with only a few beds visible from the nurses’ station. Indeed, the two most common strategies on the brain injury unit involved surveillance: moving a patient to a room closer to the nurses’ station and/or instituting 15-minute surveillance checks. Another published report of a restraint reduction program also emphasized surveillance strategies (Weeks, 1997). The nature of patients’ medical conditions may also explain the differences in reduction rates. Although stroke patients may have cognitive deficits, such as poor judgement or lack of insight, brain injury patients tend to have greater impulsivity and agitation.
Of note, both units had spikes in restraint use upon the initiation of the RRP as well as at later points in the program. These occasional increases were not associated with falls, and the rates were within the upper control limits of the mean (see Figure 1 for explanation). The initial spikes may reflect staff resistance toward implementing a new program, but the initial and later occasional spikes may simply reflect normal variations in restraint use over time. Given the successful results in restraint reduction, future plans for the stroke unit are to continue monitoring restraint use and fall rates and to ensure that restraint reduction strategies continue to be implemented in a safe manner.
Although restraint reduction was also successful on the brain injury unit, the outcome difference was not as great as that seen on the stroke unit. The brain injury unit staff will implement a unit-based restraint committee, which will be led by the clinical nurse specialist and will meet monthly. Membership will include all nursing staff as well as the nurse manager. The committee will focus on restraint reduction, examination of the causes of falls, and restraint documentation. In response to the challenge of reducing restraints while maintaining safety in the high-risk brain injury population, a “day room” has been designated and is under current remodeling on the brain injury unit. The room, which is to be staffed by a patient care provider, will provide a place where high-risk patients can be monitored closely during the daytime hours that they are not in therapy.
In summary, in an acute rehabilitation setting, a restraint reduction program that emphasizes restraint alternatives can provide safe care that is effective in preventing falls while preserving patients’ rights and dignity.
The authors wish to acknowledge the staff nurses on the stroke and brain injury rehabilitation units for implementing the Restraint Reduction Program, Kathleen McCarthy for the data analysis portion of this study, and the MetroHealth Foundation (grant no. 57-2003) for the funding to purchase restraint alternatives for this study.
About the Authors
Shelly Amato, MSN RN CNS CRRN, is a clinical nurse specialist for the brain injury and stroke rehabilitation units at MetroHealth Medical Center. Address correspondence to her at MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109 or firstname.lastname@example.org.
Judy P. Salter, MSN RN CNS CRRN, clinical instructor Lorain County Community College.
Lorraine C. Mion, PhD RN FAAN, is director of research at MetroHealth Medical Center.
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