Transcript Peer to Peer - Why and How to be Restraint-Free

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 Time
Physical Restraints in Texas and the Nation
Prepared by TMF Health Quality Institute
Data source: Quality Measure Data from Nursing Hom e Com pare
25
15
Nation
Texas
7sow ipg
10
5
0
20
02
Q
2
20
02
Q
3
20
02
Q
4
20
03
Q
1
20
03
Q
2
20
03
Q
3
20
03
Q
4
20
04
Q
1
20
04
Q
2
20
04
Q
3
20
04
Q
4
20
05
Q
1
20
05
Q
2
20
05
Q
3
20
05
Q
4
20
06
Q
1
20
06
Q
2
20
06
Q
3
20
06
Q
4
20
07
Q
1
Average Restraint Score (%)
20
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
Te xas tre nds for re straints, fracture s, and falls
Quality Indicator Data, Oct. 1998 - M arch 2007
20.0%
18.0%
16.0%
QIO Efforts began*
12.0%
Res traints
10.0%
Falls
Fractures
8.0%
6.0%
4.0%
2.0%
20
0
6
Q
2,
20
0
6
Q
4,
20
0
5
Q
2,
20
0
5
Q
4,
20
0
4
Q
2,
20
0
4
Q
4,
20
0
3
Q
2,
20
0
3
Q
4,
20
0
2
Q
2,
20
0
2
Q
4,
20
0
1
Q
2,
20
0
1
Q
4,
20
0
20
0
0
Q
2,
0
Q
4,
20
0
9
Q
2,
19
9
9
Q
4,
19
9
8
Q
2,
19
9
7
0.0%
Q
4,
Mean proportion of population
14.0%
How to Be Restraint Free
Michelle Madkins, Director of Nursing
Greenville Health and Rehabilitation Center
Greenville, Texas
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:
[email protected]
ORCHARD VIEW MANOR
Presents
Maintaining a Restraint-Free Environment
Enthusiasm is Key
Pam Quinn, RN, Director of Nursing
Orchard View Manor, East Providence, Rhode Island
YOUR STAFF WILL NOT
BELIEVE IT UNLESS YOU DO!!
Decide, as a facility that no restraint is
necessary.
1.
2.
3.
4.
5.
6.
Reduced restraints equal
Reduced incontinence
Reduced wounds
Reduced depression
Reduced behaviors
Reduced ADL decline
DATA SHOULD BE DERIVED
FROM MDS QUERY – DECIDE
THAT EVEN ONE IS TOO MANY.
Include:
1.
2.
3.
4.
5.
Physical restraints
Bed against the wall
GERI chairs with trays
LAP buddies
Even some interventions can be restraints, if
they prevent rising.
LTG
Decide to have zero tolerance within six (6)
months.
STG
To 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!
Lots of positive feedback to staff and
residents.
2. Post the data.
3. Advertise yourself as a “restraint-free”
facility.
1.
A GREAT FALLS PROGRAM
IS ESSENTIAL
1.
2.
3.
4.
5.
Become an expert at intervention.
Begin a Restorative Program with weight
training.
Vitamin D prevents falls! New study.
Use the “Thirty-Nine (39) alternatives”.
Review every fall every day with front line
staff and the resident.
HOW DID WE
SUSTAIN IT?
1.
2.
3.
By the time we were done, it was
part of our culture.
Referring Agencies are notified.
Families are re-educated.
ORCHARD VIEW MANOR
QUALITY IMPROVEMENT WORKSHEET
GOAL: To Become a Restraint-Free Facility
DATE: July 2003
PLAN
DO
CHECK
ACT
1.To achieve restraintfree status by January
14, 2004
1.Form a focus group
including:
DNS
ADNS
CNA Q-unit
PT
SS
AT
6.Change
intervention to less
restrictive
7.Audit and
discuss progress
weekly.
8.Celebrate on
each unit as they
become restraintfree
9.Provide family
education for each
resident
- at family
council
- at resident
council
7/2003 = 28
Currently 34 restraints
-3 physical restraints
2 waist
1 pelvic
-18 full siderails
-7 Geri chairs with
tables
2.Invite to meet
3.Provide list to team.
4.Begin with easiest
5.Reduce 1 or 2 per
week
Include staff in all
aspects to re-educate
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)
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.
1.
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)
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
13.
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 board
2. Educate everyone
3. Create a multidisciplinary team
4. Start with a small number of the easiest
residents to reduce first
5. 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 daily
8. Trial least restrictive interventions first
9. Use increased intervals of Restraint Free time
with more difficult cases
10.Document, Communicate and Celebrate
Any additional questions for our speakers?
Thank you for your attendance and participation!