Reducing the use of physical restraints in nursing homes

Colleen J. Cooper, MD

VOL 107 / NO 2 / FEBRUARY 2000 / POSTGRADUATE MEDICINE

You've got a busy day ahead of you, including clinic appointments and hospital rounds, and you'd like to get to your daughter's soccer game by 6 pm. Among the myriad phone calls you need to return is one from a nursing home, asking you to authorize a wheelchair restraint for one of your patients who has fallen twice while attempting to stand without assistance. It makes sense: The patient is confused and doesn't recognize his inability to walk independently. Why not order a physical restraint?

Physical restraint devices (belts, vests, pelvic ties, specialized chairs, bed side rails) have been a mainstay in the care of forgetful and unsteady patients in the United States. Physicians have used these devices almost reflexively, believing that they provided safety for patients. So, the controversy and regulations regarding use of physical restraints may be perplexing to many physicians.

In this age of dazzling high-tech innovations in healthcare, it is difficult to understand how cloth belts and vests can command serious attention. Many physicians may consider restraints to be a nursing intervention. The regulatory mandate to obtain a physician's order before restraints can be used may be viewed as just another bureaucratic tangle, and the definition of physical restraints as "medical treatments" may be regarded as an artificial regulatory directive.

However, current research challenges us to reconsider the inherent safety of physical restraints (1-3). These commonplace, low-tech devices are responsible for serious morbidity, including increased behavioral problems, increased physical debility, pressure sores, incontinence, and direct trauma. Restraints also are underrecognized causes of death, usually by strangulation or entrapment. Miles and associates (4-6) have published compelling data in the medical and lay press detailing the often unrecognized, but nevertheless serious, effects of physical restraints. Notably, there are no corresponding data to support the efficacy of physical restraints. Their use has become a standard based on past practice rather than on research demonstrating clinical benefits.

Federal regulations
The federal restraint regulations have evolved from a combination of the medical research and a trend toward overall improvement in the quality of life and quality of care in nursing homes. Healthcare professionals, advocates, providers, and regulators have collaborated on the development of regulations that reflect current concepts of care and a commitment to an acceptable quality of life for nursing home residents. The regulations are not the product of idealists detached from clinical practice.

In the federal Nursing Home Reform Act of 1987 (also called OBRA '87), physical restraints are defined as:

Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body (7).

The regulation regarding use of restraints for nursing home residents states:

The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms (7).

Before OBRA '87 was implemented in 1990, an estimated 40% of nursing home residents were physically restrained, according to Online Survey Certification and Reporting (OSCAR) data collected by the Health Care Financing Administration (HCFA). From 1992 to 1998, the restraint rate remained relatively unchanged at about 21%. At present, the national average is about 12%. These data are encouraging because they represent an important drop in the national percentage in the past year. Compared with a restraint rate of less than 5% in similar patient populations in several European countries (8,9), however, our national rate remains high.

The federal regulations do not prohibit the use of restraints; rather, they set parameters that must be met for use of a restraint to be considered appropriate. First and foremost, the physical restraint must be used only to treat medical symptoms and only after a comprehensive assessment indicating that the device is the least restrictive intervention and that it promotes the resident's highest level of function. In addition, if the restraint is deemed the most appropriate intervention, its use must be monitored for adverse effects and ongoing attempts must be made to find less restrictive alternatives. Such alternatives include personal strengthening and rehabilitation programs, use of assistive devices (eg, hearing aids, mobility devices), efforts to design a safer physical environment, and use of bed and chair alarms to alert staff when a resident needs assistance.

Last July, HCFA released similar restraint regulations for acute care hospitals and added provisions related to use of restraints for behavioral control (10).

Safety concerns of families
Families of nursing home residents raise many questions about restraint use and related regulation, often beginning with, "Why is a doctor's order necessary? Why can't we decide what's best for our family member?" Families approach the question of restraint use with a legitimate desire for safety but often without current and substantive information about the dangers of restraints. Most of them are open to other interventions if their safety concerns are addressed.

Under current regulations, family members or others designated as surrogate decision makers for a resident can consent to or refuse medical treatments on the basis of an understanding of the risks and benefits of the intervention. Physical restraints, like other medical treatments associated with adverse effects, must only be used to treat specific medical symptoms. (A Minnesota state law passed in 1999 allows "fear of falling" to be considered a medical symptom.) Full disclosure of possible adverse effects and uncertain efficacy must be made. Physical restraints may not be applied to a resident upon the demand of an authorized decision maker in the absence of a medical indication. A successful approach in such situations is to involve authorized decision makers in the assessment and care-planning process, to assure them that their concerns about safety will be met with other, safer interventions.

To the extent possible, family members or surrogate decision makers should contribute to the assessment process, especially when management of safe care or restraint reduction is considered. They may be able to provide critical information about the resident's habits, likes and dislikes, patterns of behavior, and overall condition. Knowledge of such factors can aid in construction of an individualized care plan to minimize behaviors that lead to unnecessary use of physical restraints. In addition, families are much more likely to support a restraint avoidance or reduction program if they are engaged in the process and reassured about alternative safety measures. They need to know that there will not be sudden, unplanned changes in care that place the resident at risk for injury.

Why not order a physical restraint?
There are compelling reasons not to order one. Physical restraints are rarely clinically indicated. More specific and effective interventions are available for treating medical symptoms in cognitively impaired patients. The risks of direct physical injury, psychological harm, and accelerated decline outweigh largely unsupported claims of safety conferred by physical restraints.

Rather than reflexively ordering a physical restraint, it is imperative to perform a thorough assessment of the resident's condition. In the scenario presented at the beginning of this editorial, it is necessary to evaluate why the resident is falling. Is there discomfort? Is he attempting to do something that he cannot express verbally? Is something in the environment disturbing to him? Is toileting needed? Is there a pattern to the falls? Are staff members requesting the least restrictive measure for preventing falls? In most cases, the resident is more likely to be seriously injured if a physical restraint is applied.

Practical approach to restraint reduction
If you find it necessary to order a restraint, work with nursing home staff members to craft a plan of care that will eliminate use of the restraint as quickly as possible. Guide them through an assessment of underlying physical, mental, environmental, care-related, and behavioral factors that may contribute to falls.

Restraint reduction should be done in a planned, methodical way. The restraint reduction plan should include a staged substitution of alternative, less restrictive measures to treat the specific medical symptom, with ongoing monitoring and revision as the plan is implemented. The ultimate goal is to eliminate use of a restrictive device or gradually replace it with the least restrictive intervention necessary.

Successful restraint avoidance or reduction programs require the involvement of the entire nursing home staff. Physicians are charged with overseeing the comprehensive care of the residents. Because they generally have a sophisticated understanding of the physical and psychiatric effects of immobilization, dementia, and aging, they are ideal leaders of restraint reduction efforts. Physicians should promote restraint avoidance or reduction because it is good medicine, which coincides with regulatory compliance.

References

1. Capezuti E, Evans L, Strumpf N, et al. Physical restraint use and falls in nursing home residents. J Am Geriatr Soc 1996;44(6):627-33
2. Frank C, Hodgetts G, Puxty J. Safety and efficacy of physical restraints for the elderly: review of the evidence. Can Fam Physician 1996;42:2402-9
3. Neufeld RR, Dunbar JM. Restraint reduction: where are we now? Nurs Home Economics 1997;4(3):11-5
4. Miles SH, Irvine P. Deaths caused by physical restraints. Gerontologist 1992;32(6):762-6
5. Miles SH. A case of death by physical restraint: new lessons from a photograph. J Am Geriatr Soc 1996;44(3):291-2
6. Parker K, Miles SH. Deaths caused by bedrails. J Am Geriatr Soc 1997;45(7):797-802
7. Survey protocol for long term care facilities. In: State Operations Manual, Appendix P. Bethesda: Dept of Health and Human Services, 1999 Aug:44
8. Evans LK, Strumpf NE. Myths about elder restraint. Image J Nurs Sch 1990;22(2):124-8
9. Kane RL, Williams CC, Williams TF, et al. Restraining restraints: changes in a standard of care. Annu Rev Public Health 1993;14:545-84
10. Medicare and Medicaid programs. Hospital conditions of participation: patients' rights (42 CFR 482). Federal Register, 1999 July 2;64(127):36069-89

Selected readings

• Annas GJ. The last resort: the use of physical restraints in medical emergencies. N Engl J Med 1999;341(18):1408-12
• Cohen C, Neufeld R, Dunbar J, et al. Old problem, different approach: alternatives to physical restraints. J Gerontol Nurs 1996;22(2):23-9
• Donius M, Rader J. Use of siderails: rethinking a standard of practice. J Gerontol Nurs 1994;20(11):23-7
• Dunbar JM, Neufeld RR, White HC, et al. Retrain, don't restrain: the educational intervention of the National Nursing Home Restraint Removal Project. Gerontologist 1996;36(4):539-42
• Evans LK, Strumpf NE. Tying down the elderly: a review of the literature on physical restraint. J Am Geriatr Soc 1989;37(1):65-74
• Kapp MB. Nursing home restraints and legal liability: myths and reality. Leg Med 1993:299-336
• Lipsitz LA. An 85-year-old woman with a history of falls. JAMA 1996;76(1):59-66
• Miles SH, Meyers R. Untying the elderly: 1989 to 1993 update. Clin Geriatr Med 1994;10(3):513-25
• Province MA, Hadley EC, Hornbrook MC, et al. The effects of exercise on falls in elderly patients: a preplanned meta-analysis of the FICSIT trials. JAMA 1995;273(17):1341-7
• Ray WA, Taylor JA, Meador KG, et al. A randomized trial of a consultation service to reduce falls in nursing homes. JAMA 1997;278(7):557-62
• Tinetti ME. Prevention of falls and fall injuries in elderly persons: a research agenda. Prev Med 1994;23(5):756-62
• Tinetti ME, Inouye SK, Gill TM, et al. Shared risk factors for falls, incontinence, and functional dependence. JAMA 1995;273(17):1348-53
• Tinetti ME, Liu WL, Claus EB. Predictors and prognosis of inability to get up after fall among elderly persons. JAMA 1993;269(1):65-70

The controversy over bed rails

Bed side rails have been a source of confusion and ongoing discussion in the physical-restraint debate. Most healthcare professionals have been trained to automatically raise bed rails in an institutional setting, under the presumption that the rails confer safety. However, research regarding physical restraints has revealed information about the efficacy (1) as well as the potential dangers of bed rails. In August 1995, the US Food and Drug Administration issued a Safety Alert warning of the dangers of injury and death due to entrapment in bed rails (2). Injuries result when residents attempt to climb over rails or they become wedged between the rail and the mattress, between split rails, or within the rail spaces.

Current regulatory guidelines differentiate between the use of bed rails for mobility and their use as restraints. If bed rails are used to assist with movement in and out of bed, they are not considered to be physical restraints and the regulatory criteria for physical restraints do not apply. However, if bed rails are used to prevent movement out of bed, they must be assessed as the most appropriate intervention for a medical symptom, they must be the least restrictive intervention available, and their use must be monitored for adverse effects. If bed rails assist with movement and prevent movement out of bed, they are functioning as restraints and must be evaluated as such.

References

1. Feinsrod FM. Eliminating full-length bed side rails from long-term care facilities. Nurs Home Med 1997;5(8):257-63
2. Food and Drug Administration. Safety alert: entrapment hazards with hospital bed side rails. Bethesda: US Dept of Health and Human Services; Aug 23, 1995

Dr Cooper is medical advisor, Facility and Provider Compliance Division, Minnesota Department of Health, St Paul. Correspondence: Colleen J. Cooper, MD, Facility and Provider Compliance Division, Minnesota Department of Health, 85 E Seventh Pl, #300, St Paul, MN 55101. E-mail: coopec1@mdh-fpc.health.state.mn.us.

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