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CE article: Illinois hospital stays restraint free for five years*


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Learning objectives:

  • Identify the steps CTC took to go restraint free
  • Discuss the education staff members received when going restraint free

The Cancer Treatment Centers (CTC) of America at Midwestern Regional Medical Center in Zion, IL, believes in the “mother standard of care,” or treating patients as if they are family members or “your own mother,” says Kimberly Bertini, RN, coordinator for the ANCC Magnet Recognition Program® at CTC.

For years, CTC used restraints on patients who became confused because of brain metastasis, chemotherapy brain, or a mixture of pain medications.

However, Bertini says staff members at CTC were uncomfortable using the restraints on patients, and many opted to stay overtime and sit with patients to refrain from using the restraints.

“We noticed the staffs’ reaction to placing patients in restraints,” says Bertini. “We decided it was time to make a change and actually begin treating patients like they are our mother.”

In 2005, CTC quit restraints cold turkey to mirror this belief and culture of the organization. Since then, CTC continues to decrease patients’ length of stay, falls, and has only had one outstanding case in which a patient needed restraints because of the potential for self-endangerment.

Going restraint free

From the beginning, the administrative team at CTC was supportive of the decision to stop using restraints on patients, says Bertini.

“The administrative team saw this as a way to help empower the staff and let them take patient care into their own hands,” she says.

CTC’s first step to becoming restraint free involved increasing the number of staff. If a patient came in and fell under criteria for which a restraint might previously have been necessary, a patient care tech or sitter was assigned to the patient room at all times.

“We decided not to hire sitters from an outside agency because of our culture,” says Bertini. “It is hard bringing in an outside source and then having to teach [him or her] about our culture and beliefs.” By staying within CTC, the patient and family are already familiar with the caregiver, which helps foster a trusting relationship.

In addition to having sitters available, CTC has bed alarms on every patient’s bed. The bed alarm sounds an alert when it detects a certain level of movement in the patient’s bed or if a patient decides to climb out of bed at the foot because of raised side rails. The bed alarm acts as an alert to the nurses if a patient up and moving around. This is particularly useful to patients if they forget to hit the call button.

“At CTC, our age range of patients is from 18 to 100,” says Bertini. “We have patients in their 30s and 40s who are a fall risk and can forget to call a nurse when they attempt to use the bathroom, and this system helps everyone.”

Additional measures

The use of sitters and bed alarms are only two of the strategies CTC used to become restraint free, says Bertini. In addition to these tactics, staff also conducted mandatory hourly rounds. Prior to 2005, CTC staff conducted rounds, but there was no strict time period and they were not mandatory.

“The staff would round every hour to an hour and a half, and we could not guarantee even this,” says Bertini.

Now staff members make rounds at least every hour, and if the patient is at a higher risk level, the staff member will check in more often.

To read additional measures that can be used instead of restraints, click here.

The staff also has a team check-in used in conjunction with the patient rounding that helps the nurse and primary care physician (PCP) review the care plan of each patient for the day. At the beginning of the day, the PCP and the nurse sit down with the patient for five minutes and develop the care plan for the day.

For each patient, the team writes on a whiteboard located in patients’ rooms what the patient deems as important for the day, what the nurse needs to get done, and what the PCP has to accomplish. The plan also outlines any procedures the patient has that day.

“The plan allows everyone to be on the same page and provides a timeline for the day,” says Bertini. “This way, if a patient wants a bath, the doctor can tell the patient it won’t be until 4 p.m., and the patient isn’t waiting around.”

It also helps patients’ family members stay in the loop regarding the kind of treatment their loved ones will be receiving. “By CTC staff being so open and up front about the care the patient will receive, it is a relief for the family who may not know what to expect,” says Bertini.

Restraint-free training and education

As CTC transitioned from using restraints one day to being restraint free the next, the organization also needed to focus on training its current staff members and informing new hires of the process.

Initially, CTC held a mass education for all staff nurses. This included reviewing the policy and creating scenarios and mock-ups that showed how going restraint free would benefit all of the various patient populations at the facility, from patients in the emergency room to those on the other end of the spectrum, who only show slight confusion.

“The education of current staff went smoothly and was a very easy process,” says Bertini.

New hires at CTC go through a program called “Hope, Joy, and Pride,” during which they learn that the facility is restraint free, how and when sitters are used, and that all beds have alarms triggering the nurses’ station.

“This program also gives the new hire a chance to familiarize themselves with CTC’s culture and to understand the responsibility they have to each patient,” says Bertini.

Although CTC has been restraint free for five years, the Illinois Department of Health requires facilities to conduct competency training annually.

“When we pull the restraints out for this training, they are so dusty, and you can see how uncomfortable staff becomes when they are put in them,” says Bertini. “It’s a great feeling knowing that our patients no longer have to know what this feels like.”

To read additional training methods to reduce the use of restraints from another organization's point of view, click here.

Positive results all around

CTC received positive feedback almost immediately after it became restraint free, but it was not without some hesitation at the administration level.

Bertini admits that administration was concerned about increasing the staffing levels when CTC first went restraint free. But ultimately, leadership was able to look past the immediate cost increase and see the long-term results.

“Getting the patient to their optimal health was always our goal,” says Bertini. “And we found that our return on investment—getting patients as healthy as quickly as we can—eventually paid for itself.”

As CTC discontinued the use of restraints, it saw a decrease in patients’ length of stay, risk of injury, and falls.

Read this article to get the family's point of view when it comes to putting the patient in restraints.

In addition to seeing a dramatic decrease in restraint use over the past five years, The Joint Commission recently surveyed the facility and said it was impressed with its process improvement. Specifically, surveyors were struck by CTC’s lack of restraint use on ventilated patients out of the entire patient population.

Another satisfying aspect of going restraint free is seeing how comfortable the family and patients are knowing exactly what is happening, says Bertini.

She notes that families are told exactly what can happen if a bed alarm is triggered, how often rounds occur, how staff sit down with the patient to discuss the daily events, and that they will not have to pay extra for the sitter CTC uses.

“Most of our patients travel more than 500 miles to visit our facility, and by this point, this is the second or third facility they have visited,” says Bertini. “It’s a relief for families to hear [about the sitter coverage] because most insurance companies do not cover private sitters.”

Source: Briefings on Patient Safety, June 2010, HCPro, Inc.

Resources:

  1. "Alternatives to Restraint and Seclusion in Mental Health Settings: Questions and Answers from Psychiatric Nurse Experts" at http://www.medscape.com/viewarticle/555686.
  2. "Patient Restraints and Other Alternatives: What Family Members Need to Know" at http://www.uwhealth.org/healthfacts/B_EXTRANET_HEALTH_INFORMATION-FlexMember-Show_Public_HFFY_1117547779831.html.
  3. “Using Training in Verbal Skills to Reduce the Use of Seclusion and Restraint" at http://www.crisisprevention.com/research/pdf/Witte%20from%2007-JSM-JOU-002.pdf.

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