Effective Fall Prevention Strategies Without Physical Restraints or Personal Alarms

Presented by:Sue Ann Guildermann RN, BA, MA

Director of Education, Empira

April 24, 2012

Effective Fall Prevention Strategies Effective Fall Prevention Strategies Without Physical Restraints or Without Physical Restraints or

Personal AlarmsPersonal Alarms

Sue Ann GuildermannSue Ann Guildermann RN, BA, MARN, BA, MA

sguilder@empira.orgsguilder@empira.org952-259-4477952-259-4477

Objectives:Objectives: Discuss the inappropriateness of using restraints Discuss the inappropriateness of using restraints

and personal alarms and their impact on the safety and personal alarms and their impact on the safety and well-being of residentsand well-being of residents

Identify alternate interventions for keeping residents Identify alternate interventions for keeping residents safe other than the use of restraints and alarmssafe other than the use of restraints and alarms

Explore evidence that indicates the elimination of Explore evidence that indicates the elimination of restraints and alarms can lead to a decrease in falls, restraints and alarms can lead to a decrease in falls, incontinence and skin breakdown and can create a incontinence and skin breakdown and can create a more tranquil, homelike environmentmore tranquil, homelike environment

Identify the operational procedures for removing Identify the operational procedures for removing restraints and personal alarms and for preventing therestraints and personal alarms and for preventing the use of future restraints and personal alarmsuse of future restraints and personal alarms

““I did then what I knew then, I did then what I knew then, when I knew better, I did better.”when I knew better, I did better.”

~ Maya Angelou~ Maya Angelou

Change = ProgressChange = Progress In 1991, 59% of residents in nursing homes in the In 1991, 59% of residents in nursing homes in the

USA, were restrainedUSA, were restrained

In 2011 the national average was 3%In 2011 the national average was 3%

Target for 2012 is < 1%Target for 2012 is < 1%

Minnesota Department of Health, Minnesota Department of Health, “Safety Without Restraints”:“Safety Without Restraints”: http://www.health.state.mn.us/divs/fpc/safety.htmhttp://www.health.state.mn.us/divs/fpc/safety.htm

Over 100 Deaths Occur Every Year in Over 100 Deaths Occur Every Year in Nursing Homes from Restraint Use*Nursing Homes from Restraint Use*

Risks With Restraints:Risks With Restraints: FallsFalls StrangulationStrangulation Loss of Muscle ToneLoss of Muscle Tone Pressure SoresPressure Sores Decreased MobilityDecreased Mobility AgitationAgitation Reduced Bone MassReduced Bone Mass StiffnessStiffness FrustrationFrustration Loss of DignityLoss of Dignity IncontinenceIncontinence Constipation Constipation

* From Minnesota Department of Health website: * From Minnesota Department of Health website: http://www.health.state.mn.us/divs/fpc/safety.htmhttp://www.health.state.mn.us/divs/fpc/safety.htm

Virginia Department of Health: Consumer Guide to Restraint UseVirginia Department of Health: Consumer Guide to Restraint Use

Restraint and Alarm Use? Restraint and Alarm Use? Why?Why?

Why would you place a restraint or an Why would you place a restraint or an alarm on a resident? What are your alarm on a resident? What are your reasons for the restraint or an alarm that is reasons for the restraint or an alarm that is currently in use on one of your residents?currently in use on one of your residents?

In each of the situations you just listed, In each of the situations you just listed, if you couldn’t use a restraint or an if you couldn’t use a restraint or an alarm, what would you do instead?alarm, what would you do instead?

Falling Risk Assessment:Falling Risk Assessment:Levels of Risk vs. Specific RiskLevels of Risk vs. Specific Risk

Do you know which of your residents are Do you know which of your residents are at risk for falling?at risk for falling?

What have you identified as the cause(s) What have you identified as the cause(s) contributing to their risks for falling?contributing to their risks for falling?

Do you have interventions tailored to their Do you have interventions tailored to their specific ‘risk level’? specific ‘risk level’?

Do you have interventions tailored to their Do you have interventions tailored to their specific risks? specific risks?

Inaccurate assessmentInaccurate assessment

More accurate assessmentMore accurate assessment

What is root cause analysis?What is root cause analysis?

RCA is a process to find out what happened, RCA is a process to find out what happened,

why it happened, and to determine what can be why it happened, and to determine what can be

done to prevent it from happening again.done to prevent it from happening again.

Determining Causation of FallsDetermining Causation of Falls

Why did the resident fall down?Why did the resident fall down? Internal, External Systemic reasons for fall?Internal, External Systemic reasons for fall?

What was the resident doing just before What was the resident doing just before they fell?they fell?

What did the resident need What did the resident need that set them into motion? that set them into motion? The “4 Ps” ?The “4 Ps” ?

Need for the “4 Ps”Need for the “4 Ps” Position:Position:

Does the resident look comfortable? Does the resident look comfortable? Does the resident look bored, restless and/or agitated?Does the resident look bored, restless and/or agitated? Ask the resident, “Would you like to move or be repositioned?”Ask the resident, “Would you like to move or be repositioned?” Ask the resident, “Are you where you want to be?” Report to the nurse.Ask the resident, “Are you where you want to be?” Report to the nurse.

Personal Personal (Potty)(Potty) Needs: Needs:

Ask the resident, “Do you need to use the bathroom?” Ask the resident, “Do you need to use the bathroom?” Ask if they’d like help to the toilet or commode. Report to the nurse.Ask if they’d like help to the toilet or commode. Report to the nurse.

Pain:Pain: Does the resident appear in to be uncomfortable or in pain? Does the resident appear in to be uncomfortable or in pain? Ask the resident, “Are you uncomfortable, ache or are in pain?”Ask the resident, “Are you uncomfortable, ache or are in pain?” Ask them what you can do to make them comfortable. Ask them what you can do to make them comfortable. Report to the nurse.Report to the nurse.

Placement:Placement: Is the bed at the correct height? Is the bed at the correct height? Is the phone, call light, remote, walker, trash can, water, urinal, tissues, Is the phone, call light, remote, walker, trash can, water, urinal, tissues,

all near the resident? all near the resident? Place them all within easy reach.Place them all within easy reach.

Federal Guideline: definition Federal Guideline: definition of physical restraintof physical restraint

““Physical Restraints are defined as any Physical Restraints are defined as any manual or physical or mechanical manual or physical or mechanical device, material, or equipment attached device, material, or equipment attached or adjacent to the resident’s body that or adjacent to the resident’s body that the individual cannot remove easily the individual cannot remove easily which restricts freedom of movement which restricts freedom of movement or normal access to one’s body.”or normal access to one’s body.”

Personal Alarms: definitionPersonal Alarms: definition Personal alarms are alerting devices designed to Personal alarms are alerting devices designed to

emit a loud warning signal when a person emit a loud warning signal when a person moves. moves. Architectural or building alarms are not an Architectural or building alarms are not an issue.issue.

Most common types of personal alarms are:Most common types of personal alarms are: Pressure sensitive pads placed under the resident Pressure sensitive pads placed under the resident

when they are sitting on chairs, in wheelchairs or when they are sitting on chairs, in wheelchairs or when sleeping in bedwhen sleeping in bed

A cord attached directly on the person’s clothing with A cord attached directly on the person’s clothing with a pull-pin or magnet adhered to the alerting device a pull-pin or magnet adhered to the alerting device

Pressure sensitive mats on the floorPressure sensitive mats on the floor

Devices that emit light beams across a bed, chair, doorwayDevices that emit light beams across a bed, chair, doorway

Our Journey to Eliminate AlarmsOur Journey to Eliminate Alarms Empira, a group of 16 SNFs, applied for and received Empira, a group of 16 SNFs, applied for and received

a MN PIPP 3-year grant to prevent resident falls in a MN PIPP 3-year grant to prevent resident falls in October 2008October 2008

All nursing homes began to collect information All nursing homes began to collect information immediately after the resident fell to identify the immediately after the resident fell to identify the causes of the fall: time, day, date, place, etc.causes of the fall: time, day, date, place, etc.

Early in the program, all nursing homes identify – Early in the program, all nursing homes identify – most falls occur during the noisiest times of the day; most falls occur during the noisiest times of the day; shift change, meals service, alarms sounding shift change, meals service, alarms sounding

Noise is identified as the major environmental factor Noise is identified as the major environmental factor contributing to fallscontributing to falls

Staff conversation, alarms and TV's are identified as Staff conversation, alarms and TV's are identified as some of the noisiest elements in our SNFssome of the noisiest elements in our SNFs

Alarm elimination is begun in May 2010Alarm elimination is begun in May 2010

Noise Contribution to FallsNoise Contribution to Falls

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6-6:59

AM7-7:

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9PM1-1:

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9AM1-1:

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59

TCU, FALL TIMES, JUNE - NOVEMBER 2010TCU, FALL TIMES, JUNE - NOVEMBER 2010

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TEAM 2, Fall Times, January - March 2010TEAM 2, Fall Times, January - March 2010

Care Center #2: Time of Falls April-June 2010Care Center #2: Time of Falls April-June 2010

Care Center #2: Time of Falls April-June 2010Care Center #2: Time of Falls April-June 2010

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10022

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3023

:55:

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04:3

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0

Noise level in decibels in an Empira member SNF Noise level in decibels in an Empira member SNF from 10:52 PM to 6:22 AM.from 10:52 PM to 6:22 AM.

Lesson learned:Lesson learned:if we can stop the noise,if we can stop the noise,

then we can reduce the falls.then we can reduce the falls.

Why alarms? Historical Context:Why alarms? Historical Context: Prior to alarms, nursing homes used both physical and Prior to alarms, nursing homes used both physical and

chemical restraints chemical restraints (and some continue to do so!)(and some continue to do so!)

1980s: Joanne Rader, RN, PMNNP, began her campaign to 1980s: Joanne Rader, RN, PMNNP, began her campaign to eliminate restraints in SNFs. She is co-founder of Pioneer eliminate restraints in SNFs. She is co-founder of Pioneer Network, and wrote the book, “Bathing Without a Battle.”Network, and wrote the book, “Bathing Without a Battle.”

1992: Mary Tinetti MD, Annals of Intern Med, “Restraints in 1992: Mary Tinetti MD, Annals of Intern Med, “Restraints in nursing homes were associated with continued, and nursing homes were associated with continued, and increased, occurrence of serious fall-related injuries.”increased, occurrence of serious fall-related injuries.”

1994: Laurence Rubenstein MD, JAMA, “Strategies that reduce 1994: Laurence Rubenstein MD, JAMA, “Strategies that reduce mobility through use of restraints have been shown to be more mobility through use of restraints have been shown to be more harmful than beneficial and should be avoided at all costs.”harmful than beneficial and should be avoided at all costs.”

1990’s: CMS heads up a national movement in nursing 1990’s: CMS heads up a national movement in nursing homes to reduce and eliminate restraints, if not used “for homes to reduce and eliminate restraints, if not used “for medical purposes.”medical purposes.”

2000’s: Restraints are replaced by personal alarms attached 2000’s: Restraints are replaced by personal alarms attached to or against the resident.to or against the resident.

Alarms Elimination: Alarms Elimination: Historical ContextHistorical Context

(See handout)(See handout) 2006: MASSPRO, Quality Improvement Organization for Mass., 2006: MASSPRO, Quality Improvement Organization for Mass.,

publishes study called “Nursing Home Alarm Elimination publishes study called “Nursing Home Alarm Elimination Program: It’s Possible to Reduce Falls by Eliminating Resident Program: It’s Possible to Reduce Falls by Eliminating Resident Alarms.” Alarms.”

2007: CMS webinar, “From Institutionalized to Individualized Care” 2007: CMS webinar, “From Institutionalized to Individualized Care” mentions the “detriments of alarms and their effects on mentions the “detriments of alarms and their effects on residents.” CMS sites MASSPRO alarm reduction project.residents.” CMS sites MASSPRO alarm reduction project.

Quality Partners of Road Island, Positional Paper, “Rethinking Quality Partners of Road Island, Positional Paper, “Rethinking the Use of Position Change Alarms” January 4, 2107. the Use of Position Change Alarms” January 4, 2107.

““Individualized Care Pilot Project, Noise Reduction” June 2008, Individualized Care Pilot Project, Noise Reduction” June 2008, Oak Hill Nursing Center, RI.Oak Hill Nursing Center, RI.

CMS, Guidance to Surveyors of Long Term Care Facilities, March CMS, Guidance to Surveyors of Long Term Care Facilities, March 2009, F252 Environment, Interpretive Guidelines,483.15(h)(1). 2009, F252 Environment, Interpretive Guidelines,483.15(h)(1).

Wisconsin Coalition for Person Directed Care. Web conference: Wisconsin Coalition for Person Directed Care. Web conference: “Wisconsin Success Stories in Restraint and Alarm Reduction,” “Wisconsin Success Stories in Restraint and Alarm Reduction,” June 18, 2009.June 18, 2009.

Alarms Elimination:Alarms Elimination:Historical ContextHistorical Context

(See handout)(See handout)

““The Impact of Alarms on Patient Falls at a VA Community The Impact of Alarms on Patient Falls at a VA Community Center Living” Poster session at 2010 Transforming Fall Center Living” Poster session at 2010 Transforming Fall Management Practices Conference, Dept. of Vets Affairs.Management Practices Conference, Dept. of Vets Affairs.

Dr. Steven Levenson, “Strategic Approaches to Improving Dr. Steven Levenson, “Strategic Approaches to Improving the Care Delivery Process – Falls and Fall Risk” May 2010, the Care Delivery Process – Falls and Fall Risk” May 2010, Joint MN Statewide Training. Joint MN Statewide Training.

Pioneer Network’s Annual Convention, Indianapolis, IN. Pioneer Network’s Annual Convention, Indianapolis, IN. Preconference Intensive “Eliminating Restraints Including Preconference Intensive “Eliminating Restraints Including Alarms” August 9, 2010.Alarms” August 9, 2010.

Action Pact’s Culture Change Now – Teleconference, Action Pact’s Culture Change Now – Teleconference, August 20, 2010, “Eliminating Restraints and Alarms by August 20, 2010, “Eliminating Restraints and Alarms by Engaging the Whole Person.”Engaging the Whole Person.”

June 2010 Article in Care Providers of Minnesota Quality in June 2010 Article in Care Providers of Minnesota Quality in Action Newsletter, Action Newsletter, “What’s That Noise? An Account of the “What’s That Noise? An Account of the Journey to an Alarm Free Culture” Journey to an Alarm Free Culture” By Morgan Hinkley, By Morgan Hinkley, Administrator of Mala Strana Health Care Center.Administrator of Mala Strana Health Care Center.

Challenges to Alarm Reduction:Challenges to Alarm Reduction:Myth versus EvidenceMyth versus Evidence

More comfortable in holding onto the knownMore comfortable in holding onto the known

Suspicious of the unknownSuspicious of the unknown

NewNew

FactsFacts

F Tag 222: “Convenience” of staffF Tag 222: “Convenience” of staff

““Convenience is defined as any action Convenience is defined as any action taken by the facility to control a resident’s taken by the facility to control a resident’s behavior or manage a resident’s behavior behavior or manage a resident’s behavior with a lesser amount of effort by the facility with a lesser amount of effort by the facility and not in the resident’s best interest.”and not in the resident’s best interest.”

““Restraints may not be used for staff Restraints may not be used for staff convenience. However, if the resident convenience. However, if the resident needs emergency care, restraints may be needs emergency care, restraints may be used for brief periods to permit medical used for brief periods to permit medical treatment . . .”treatment . . .”

The “Grumpy elder alarm”

proprietary artwork could not be included in proprietary artwork could not be included in publicly available presentationpublicly available presentation

Alarm sound should be:Alarm sound should be:

““Hello, I have a need that you missed.”Hello, I have a need that you missed.”

Do a Root Cause Analysis: Do a Root Cause Analysis: Why did the alarm go off?Why did the alarm go off?

RCA: Why did the alarm go off? RCA: Why did the alarm go off? “Because the person was moving.” – No!“Because the person was moving.” – No!

RCA: What does the resident need, that set the RCA: What does the resident need, that set the alarm off? alarm off?

RCA: What was the resident doing just before the RCA: What was the resident doing just before the alarm went off? alarm went off?

Alarm goes off: Alarm goes off: Staff reaction is counterintuitiveStaff reaction is counterintuitive

Staff reaction is counterintuitive to everything Staff reaction is counterintuitive to everything we have ever learned or have been taught since we have ever learned or have been taught since childhood regarding alarms: “drop, roll, get out!”childhood regarding alarms: “drop, roll, get out!”

When an alarm goes off, usual staff reaction is to When an alarm goes off, usual staff reaction is to tell the resident to, “Sit down.”tell the resident to, “Sit down.”

This is opposite to what the resident has learned This is opposite to what the resident has learned and confuses them!and confuses them!

““A counterintuitive proposition is one that does A counterintuitive proposition is one that does not seem likely to be true when assessed using not seem likely to be true when assessed using intuition or gut feelings.”intuition or gut feelings.” – Merriam Webster Dictionary – Merriam Webster Dictionary

““Alarms Cause Reactionary Alarms Cause Reactionary Rather than Anticipatory Nursing”Rather than Anticipatory Nursing”

““Sit down.” versus “What do you need.”Sit down.” versus “What do you need.” ~ ~ Theresa Laufmann, BSNTheresa Laufmann, BSN

DON Oakview Terrace Nursing DON Oakview Terrace Nursing Home, Home, Freeman, SD Freeman, SD

Alarms Annul Our AttentionAlarms Annul Our Attention

After you put something in the oven or microwave After you put something in the oven or microwave or clothes dryer, why do you set an alarm on (or the or clothes dryer, why do you set an alarm on (or the machine has an alarm) that goes off?machine has an alarm) that goes off?

proprietary artwork could not be included in proprietary artwork could not be included in publicly available presentationpublicly available presentation

Alarm As a Diagnostic ToolAlarm As a Diagnostic Tool

““The only effective use for a personal The only effective use for a personal alarm on a nursing home resident would alarm on a nursing home resident would be as a temporary diagnostic tool.”be as a temporary diagnostic tool.”

~ ~ Mary Tinetti, MD, Mary Tinetti, MD, Dept of Veterans Affairs; Dept of Veterans Affairs; Transforming Fall Management Transforming Fall Management

Practices, Practices, 2009 Conference 2009 Conference

See: Alarm Tracking ToolSee: Alarm Tracking Tool

How to Reduce Restraints & AlarmsHow to Reduce Restraints & AlarmsMultiple procedures & protocols to remove alarms. Multiple procedures & protocols to remove alarms.

Begin by asking staff their preference:Begin by asking staff their preference:

By resident status/triage:By resident status/triage:1. Begin rounding on residents who 1. Begin rounding on residents who

have fallenhave fallen

2. No restraints or alarms on any 2. No restraints or alarms on any new admissionnew admission

3. Do not put a restraint or an alarm 3. Do not put a restraint or an alarm on any resident who does not on any resident who does not currently have one oncurrently have one on

4. If resident has 4. If resident has notnot fallen in ____ fallen in ____ (30) days (30) days

5. If resident has a history of 5. If resident has a history of removing restraint or alarmremoving restraint or alarm

6. If alarm or restraint appears to 6. If alarm or restraint appears to scare, agitate, or confuse residents scare, agitate, or confuse residents

7. If resident has fallen with an alarm 7. If resident has fallen with an alarm on, do not put it back on on, do not put it back on

By unit, shift, specific times:By unit, shift, specific times:1. Begin rounding on residents 1. Begin rounding on residents

who have fallenwho have fallen2. Start on day shift on 1 2. Start on day shift on 1

nursing /household unitnursing /household unit3. Then go to 2 nursing 3. Then go to 2 nursing

/household units on day shift/household units on day shift4. Then go to 2 shifts on 1 4. Then go to 2 shifts on 1

nursing/household unitnursing/household unit5. Then go to 2 shifts on 2 5. Then go to 2 shifts on 2

nursing/ household units, etc.nursing/ household units, etc.

Cold Turkey:Cold Turkey:

1. “All restraints and/or 1. “All restraints and/or alarms will be alarms will be

removed removed by _________ (date.)by _________ (date.)

How to Reduce AlarmsHow to Reduce Alarms MASSPRO the Quality Improvement Organization for MASSPRO the Quality Improvement Organization for

Massachusetts, Nursing Home Initiative: Massachusetts, Nursing Home Initiative: “Nursing Home Alarm “Nursing Home Alarm Elimination Program: It’s Possible to Reduce Falls by Elimination Program: It’s Possible to Reduce Falls by Eliminating Resident Alarms.” Website publication: Eliminating Resident Alarms.” Website publication: http://www.masspro.org/NH/docs/casestudies/Alarm%20Elimhttp://www.masspro.org/NH/docs/casestudies/Alarm%20Elim%20CS%20Sept%2006.pdf%20CS%20Sept%2006.pdf

CMS 2007 satellite broadcast training. For more information about CMS 2007 satellite broadcast training. For more information about the the detriments of alarms in terms of their effects on residentsdetriments of alarms in terms of their effects on residents see the 2007 CMS satellite broadcast trainingsee the 2007 CMS satellite broadcast training, “From , “From Institutionalized to Individualized Care.” For an Institutionalized to Individualized Care.” For an excerpt on alarm excerpt on alarm reductionreduction,, see website: see website: http://www.bandfconsultinginc.com/Site/Free_Resources/Entries/ http://www.bandfconsultinginc.com/Site/Free_Resources/Entries/ 2009/7/2_Eliminating_Alarms_~_Reducing_Falls.html2009/7/2_Eliminating_Alarms_~_Reducing_Falls.html

June 2010 Quality In Action Newsletter article, June 2010 Quality In Action Newsletter article, “What’s That “What’s That Noise? An Account of the Journey to an Alarm Free Noise? An Account of the Journey to an Alarm Free Culture”Culture”  By Morgan Hinkley, Administrator of Mala Strana Health By Morgan Hinkley, Administrator of Mala Strana Health Care Center, an AHCA Bronze Quality Award winning facility, Care Center, an AHCA Bronze Quality Award winning facility, September 2011.September 2011.

Alternatives to:Alternatives to:Restraints & AlarmsRestraints & Alarms

Determine the resident’s needs: why are they Determine the resident’s needs: why are they moving from their current place? Investigate 4Psmoving from their current place? Investigate 4Ps

Restless, bored, agitated Restless, bored, agitated address why address why Distraction, engagement, entertainment, activitiesDistraction, engagement, entertainment, activities Warm blankets, weighted blankets, weighted baby doll, Warm blankets, weighted blankets, weighted baby doll,

purring stuffed kitten, interest activities, reading purring stuffed kitten, interest activities, reading materials, jewelry case, tackle box, head set with materials, jewelry case, tackle box, head set with soothing musicsoothing music

Vision ImpairedVision Impaired Contrast environment; shrink wrap tubing, thresholds, Contrast environment; shrink wrap tubing, thresholds,

toilets, bedspreads, personal items, shoestoilets, bedspreads, personal items, shoes

Resources for restlessnessResources for restlessness Weighted 19” Baby Doll: Weighted 19” Baby Doll:

http://www.toysrus.com/product/index.jsp? http://www.toysrus.com/product/index.jsp? productId=12076777&CAWELAID=1097046507productId=12076777&CAWELAID=1097046507

Fluffy purring cat doll: Fluffy purring cat doll: http://www.amazon.com/FurReal-Friends-http://www.amazon.com/FurReal-Friends-Lulu-Cuddlin-Kitty/dp/B001TMA03ULulu-Cuddlin-Kitty/dp/B001TMA03U

Heated blanket warmers: medical supplierHeated blanket warmers: medical supplier

Meaningful, engaging activitiesMeaningful, engaging activities

Effective AlternativesEffective AlternativesTo Restraints & AlarmsTo Restraints & Alarms

Anti-roll back and self-locking brakesAnti-roll back and self-locking brakes

Auto timer/dimmerAuto timer/dimmer

Personal items within easy reachPersonal items within easy reach

Contrast black toilet seatContrast black toilet seat Contrast thresholdsContrast thresholds

Heat Shrink TubingHeat Shrink Tubing

Contrast TubingContrast Tubing

““Heat Shrink Tubing” is made by 3MHeat Shrink Tubing” is made by 3M

Du-bro 441, “Heat Shrink Tube Assorted”  Du-bro 441, “Heat Shrink Tube Assorted”  

Both can be purchased on amazon.comBoth can be purchased on amazon.com

Personal items: Which is easier to see?Personal items: Which is easier to see?

Strong Interventions to Prevent FallsStrong Interventions to Prevent Falls Root Cause AnalysisRoot Cause Analysis Hourly Rounding – 4PsHourly Rounding – 4Ps Reduce Noise:Reduce Noise:

Alarm/Restraint Elimination, Staff talking, TVsAlarm/Restraint Elimination, Staff talking, TVs Correct Beds HeightsCorrect Beds Heights Reduce Floor MatsReduce Floor Mats Fall HuddleFall Huddle Reduce MedicationsReduce Medications Contrast EnvironmentContrast Environment Provide Opportunities to BalanceProvide Opportunities to Balance Consistent Staffing: Know The ResidentConsistent Staffing: Know The Resident

Hurdles & Challenges to Hurdles & Challenges to Restraint & Alarm Reduction Restraint & Alarm Reduction

““The family’s want us to use them.”The family’s want us to use them.”

““It prevents a resident from falling.”It prevents a resident from falling.”

““It warns us that they’re moving and about to fall.”It warns us that they’re moving and about to fall.”

““It gets me to them faster if they’re on the floor.”It gets me to them faster if they’re on the floor.”

““The resident has ataxia and dementia and . . .” The resident has ataxia and dementia and . . .”

““We don’t know what else to do.”We don’t know what else to do.”

““Strategies that reduce mobility through the use of restraints have been shown Strategies that reduce mobility through the use of restraints have been shown to be more harmful than beneficial and should be avoided at all costs.” to be more harmful than beneficial and should be avoided at all costs.”

~ Laurence Rubenstein M.D.~ Laurence Rubenstein M.D.

Action StepsAction Steps Don’t be an advocate for restraints and alarmsDon’t be an advocate for restraints and alarms Encourage reducing and discontinuing restraints and alarmsEncourage reducing and discontinuing restraints and alarms Did the facility determine RCA for why the alarm went off: Did the facility determine RCA for why the alarm went off:

What was the resident trying to do just before the alarm went What was the resident trying to do just before the alarm went off? What was the need the resident had, that set the alarm off?off? What was the need the resident had, that set the alarm off?

If a resident falls with an alarm on, did the SNF put it back on? If a resident falls with an alarm on, did the SNF put it back on? If it didn’t prevent the fall the first time, why continue to use it? If it didn’t prevent the fall the first time, why continue to use it?

Did the facility consider that the restraint or alarm might have Did the facility consider that the restraint or alarm might have contributed to the resident’s immobility, discomfort, agitation, contributed to the resident’s immobility, discomfort, agitation, restlessness, sleep disturbance and/or incontinence?restlessness, sleep disturbance and/or incontinence?

If a resident falls with an alarm on, did it sound? Was the alarm If a resident falls with an alarm on, did it sound? Was the alarm applied correctly? What was response time of staff to the alarm? applied correctly? What was response time of staff to the alarm?

Was the alarm used as a substitute for something else? Was the alarm used as a substitute for something else? Lack of staff? Busy staff? Poor supervision? Poor monitoring? Lack of staff? Busy staff? Poor supervision? Poor monitoring? Lack of or incorrect assessment of resident’s needs?Lack of or incorrect assessment of resident’s needs?

Family & Visitor BrochureFamily & Visitor Brochure

See Empira brochure:See Empira brochure:

Maryland Patient Safety Council, “Side Rails and Maryland Patient Safety Council, “Side Rails and Restraints: Improve Safety by Involving Residents Restraints: Improve Safety by Involving Residents and Families”and Families”

http://www.marylandpatientsafety.org/html/http://www.marylandpatientsafety.org/html/education /031910/handouts/documents/200-Rm331-education /031910/handouts/documents/200-Rm331-332.pdf332.pdf

True Story:True Story:

An 86 y.o. woman in advanced stages of An 86 y.o. woman in advanced stages of Alzheimer’s was found on the floor of her Alzheimer’s was found on the floor of her room in front of her night stand. When asked room in front of her night stand. When asked what she was trying to do just before she fell, what she was trying to do just before she fell, she explained that the “rug” in front of her she explained that the “rug” in front of her bed makes a loud noise when you step on it bed makes a loud noise when you step on it and that makes her roommate “get mad” at and that makes her roommate “get mad” at her. So she crawled to the edge of her bed, her. So she crawled to the edge of her bed, climbed up onto her nightstand, and fell off climbed up onto her nightstand, and fell off the nightstand. She was trying to avoid the nightstand. She was trying to avoid stepping on the pressure sensitive alarm stepping on the pressure sensitive alarm floor mat when getting out of bed.floor mat when getting out of bed.

True Story:True Story:

At a recent educational workshop with nearly At a recent educational workshop with nearly 80 nursing assistants attending, I asked for a 80 nursing assistants attending, I asked for a volunteer from the audiencevolunteer from the audience to share what it to share what it was like to be working in a SNF that had become was like to be working in a SNF that had become “alarm free” (because some of the NARs were “alarm free” (because some of the NARs were from facilities that had not as yet started to from facilities that had not as yet started to reduce alarms.) reduce alarms.)

One young man stood up and told the others, One young man stood up and told the others, “When we used to use alarms on residents I told “When we used to use alarms on residents I told people, ‘it was like working in a prison’ and now people, ‘it was like working in a prison’ and now that we don’t use alarms any more, I tell people, that we don’t use alarms any more, I tell people, ‘it’s like working in a country club’.”‘it’s like working in a country club’.”

Results from Last Collection DateResults from Last Collection Date Prevalence of Falls (number of residents who have Prevalence of Falls (number of residents who have

fallen) – decreased by 31%fallen) – decreased by 31% (CMS QI 10/10)(CMS QI 10/10)

Incidence of Depression – decreased 20%Incidence of Depression – decreased 20% (CMS QI 10/10)(CMS QI 10/10)

Worsening ADLs – decreased 17%Worsening ADLs – decreased 17% (CMS QI (CMS QI 10/10) 10/10)

Worsening Room Movement – decreased 12%Worsening Room Movement – decreased 12% (CMS QI 10/10)(CMS QI 10/10)

Falls per 1000 resident days (number of falls that Falls per 1000 resident days (number of falls that occurred) – decreased by 14%occurred) – decreased by 14%

Recurrent Falls – double digits to single digitRecurrent Falls – double digits to single digit

* Compared to a baseline from July 1, 2006 to June 30, 2007* Compared to a baseline from July 1, 2006 to June 30, 2007

An Acceptable An Acceptable Alarm!Alarm!

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Thanks for your participation!!!

Questions?

Kristi Wergin, RN, BSN

Program Manager

952-853-8561

Kwergin@stratishealth.org

www.stratishealth.org

This material was prepared by Stratis Health, the Minnesota Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 10SOW-MN-C7-12-67 041612