Intervention to reduce use of restraints in nursing homes

Intervention to reduce use of restraints in nursing homes – Tips from Other Journals

Grace Brook Huffman

Use of physical restraints in nursing homes is

often rationalized as necessary to prevent falls,

to prevent resistance to treatment and to manage

uncontrollable behavior. However, research

clearly shows that prolonged use of

restraints is associated with adverse events,

such as fall-related injuries and decreased

physical and psychologic function. Evans and

colleagues prospectively studied whether an

educational and interventional program in

nursing homes would have an effect on the

use of physical restraints.

Three nursing homes were included in the

study. Staff in one nursing home received no

intervention, staff in the second nursing home

received restraint education and staff in the

third nursing home received restraint education

and were provided with interventional

consultation that was customized for patients

who were particularly problematic.

The six-month, 10-session restraint education

program was taught by a gerontologic

nurse specialist. The 30- to 40-minute sessions

focused on the effects of physical restraints,

the behavior of residents, ways to minimize

the risk of falls and ways to cope with problem

behaviors such as wandering and agitation.

Interventional consultation was provided for

12 hours each week. The consultations focused

on residents who posed a challenge

because of their behavior.

The greatest reduction in restraint use

occurred in the nursing home in which the

staff received education and consultation.

The average absolute decline in restraint use

at this nursing home was 18 percent, and

this reduction was maintained during the

follow-up period. Use of vest restraints

decreased by 41 percent in the nursing

home that provided education sessions and

by 77 percent in the nursing home that provided

education and consultation. Geriatric

chair use was not significantly affected by

any of the interventions.

No change occurred in the number of staff

hours per resident, and no increase was seen

in psychoactive drug use in the two nursing

homes that underwent intervention. The

baseline rate of falls was lowest in the control

nursing home but, after the interventions, this

nursing home had a higher rate of falls than

the other two nursing homes. The rate of falls

in the control nursing home was 53.3 percent

in the three to six months after the intervention

period, compared with rates of 32.2 percent

in the nursing home that provided

restraint education and 37.8 percent in the

nursing home that provided restraint education

and consultation.

The authors conclude that a combination of

staff education and consultation leads to a

decrease in the use of physical restraints in

nursing homes, without a concomitant increase

in staff time, use of psychoactive drugs

or injuries related to falls. In an accompanying

editorial, Williams and Finch discuss the

effects of “restraint stress”: functional decline,

psychologic distress, agitation, impaired

circulation, incontinence, immobility and serious

accidents. Evidence also suggests that

restraint stress can heighten memory impairment.

They emphasize that the fairly widespread

goal of “restraint reduction” or

“restraint alternatives” will not, in fact, come

near to achieving what should be the true

goal: a restraint-free facility. They state that

restraint-free care is most likely to be achieved

if the director of nursing and the facility

administrator are committed to it. The medical

director and attending physicians must

support the leaders of the nursing home in

this endeavor.

Evans LK, et al. A clinical trial to reduce restraints in

nursing homes. J Am Geriatr Soc 1997;45:675-81, and

Williams CC, Finch CE. Physical restraints: not fit for

women, man or beast [Editorial]. J Am Geriatr Soc

1997;45:773-5.

COPYRIGHT 1998 American Academy of Family Physicians

COPYRIGHT 2000 Gale Group