Avoiding Physical Restraints in Long-Term Care Facilities

Despite evidence that physical restraints and full-length bed rails do not prevent falls and injuries in nursing home residents, their use is still widespread in many facilities. Although physical restraints use in nursing homes has significantly decreased since the implementation of the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87) in 1990, the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) Online Survey Certification and Reporting (OSCAR) data show that as of March 1999, 12.7% of nursing home residents were physically restrained (physical restraints as defined by CMS) ranging as high as 23.1% in Louisiana and as low as 2.5% in Iowa. Prevention of falls and related injuries in nursing homes remains a significant clinical challenge to the nursing home care team. There is evidence that alternatives to physical restraints and full-length bed rails can be applied safely, without increasing, and probably decreasing, negative outcomes such as falls and injuries. To consistently apply care principles rooted in evidence, the care team must adhere to a care process, which includes symptom identification, assessment and cause finding, care planning (with ethical considerations, considerations of risks and benefits, principles of risk prevention and evidence-based interventions), application of interventions, monitoring (for efficacy and complications), and revisions of the care plan based on the monitoring. This must be done while maintaining regulatory compliance but without compromising the appropriate individualized care for each resident. Because federal regulations define physical restraints and essentially require adherence to the care process in a detailed fashion, regulatory requirements can be integrated into the care process without compromising appropriate care. The wide geographical variation in the rate of restraint use suggests the presence of a pervasive system problem in the care process related to the use or avoidance of restraints. This problem is in part related to societal attitudes toward the care of the elderly, in which protection and safety receive undue emphasis at the expense of individual choices, freedom, control, and individuality. Confusion as to the definition of physical restraints adds to the problem. But to achieve and enhance the quality of care, standards defining the performance expectations, structures, or processes must be substantially in place in the facility. Organizing the process of care efficiently is an important determinant of quality of care. When processes of care and teamwork related to restraints are efficient and well organized, the use of physical restraints can be avoided. To successfully avoid the use of physical restraints, a facility must educate caregivers to consider resident preferences first in any care planning process and must have in place a care process that would assure the avoidance of unnecessary restraints. However, in some instances, the continuous recording of use or physical restraints in a facility is related not to outdated or inappropriate practice, but to the way the CMS defines physical restraints (as discussed below). Many interventions (which were first used as alternatives to physical restraints) must be considered as physical restraints based on CMS functional definition. Many of these interventions are indeed appropriate and necessary as part of the individualized care planning of specific residents. These treatments may include certain special seating devices, orthotic devices, devices such as Velcro belts or lap trays on chairs, and even the use of constraint therapy for poststroke rehabilitation. Frequently, such treatments or interventions are not intended to be used as restraints but rather as functional enablers for various purposes such as positioning or comfort. But because they have the effect of restricting movement, they must be defined as restraints. This is not necessarily negative because defining such devices as restraints assures that the team provides risk assessment and preventive interventions for potentially negative outcomes related to restricting mobility. The desire to create a “restraint free” environment, or remain in regulatory compliance, should not prevent the care team from providing appropriate interventions for specific residents who need them The purpose of this article is to describe the principles of a process of care that would help providers avoid use of restraints and institute other appropriate treatments and intervention to address resident risks or symptoms. It is likely that following the appropriate process of care in assessment, care planning, intervention, and monitoring of patients’ symptoms would cause the care team to plan for appropriate treatments Lutheran Augustana Center for Extended Care and Rehabilitation and Lutheran Medical Center, Brooklyn, New York.