Physical Restraints…

1. Physical Restraints… “A national safety priority” Presented by: Carol Compas, BSN, RN, CPHQ Patient Safety Quality Manager Arkansas Foundation for Medical Care November 4, 2009

2. Learning Objectives • Review national physical restraint initiatives • Review the national and California physical restraints quality measures rates • Explore the Arkansas success strategies for stakeholder collaboration • Identify “best practice” steps for restraint management • Review MDS coding

3. Nursing Home Quality Initiative • NHQI launched in November 2002 • Federal initiative that began publicly reporting risk adjusted Quality Measures (QMS) for nursing homes on www.medicare.gov/NHCompare.home.asp • Sponsored by the Centers for Medicare & Medicaid Services • QMs are intended for consumer awareness and to guide quality improvement efforts for providers

4. NHQI 2002-2005 • Originally there were 14 QMs publicly reported that replaced the quality indicators • Each state under QIO contract was ask to select three QM projects

5. NHQI: 2005-2008 Focus • High Risk Pressure Ulcers • Physical Restraints • Management of Depressive Symptoms • Management of Chronic Pain • Person Directed Care • Workforce Retention • Target Setting • The Advancing Excellence in America’s Nursing Homes campaign was launched fall 2006 and selected the same NHQI goals

6. The national NHQI contract ended July 31, 2008 • The nursing home quality work was enfolded under the National Patient Safety Theme umbrella • The Advancing Excellence campaign elected to continue with the original NHQI goals; however, these goals were recently revised but physical restraints remains a clinical goal

7. National Patient Safety Theme • There are 6 total projects: • Surgical infection and heart failure • Cross-setting pressure ulcers • Reducing physical restraints • Improving drug safety • Reducing MRSA rates • Nursing Homes in Need

8. 3 Nursing Home Projects 1. Pressure Ulcer (cross setting work with hospitals) 2. Physical Restraints 3. Nursing Home in Need (Special Focus Facilities) • All patient safety information will be available to nursing homes for ex. MRSA

9. QI Opportunities for Providers • CMS released “the list” of targeted providers this past February • The list was generated based on three quarters of QM review (see NPSI Trend Table): • Qtr 4, 2006 • Qtr 1, 2007 • Qtr 2, 2007

10. CMS Criteria • Pressure Ulcers • Facilities > 20% (2 of 3 Quarters) • Restraints • Facilities > 11% (2 of 3 Quarters) • Nursing Home in Need • Select from the current SFF list

11. NPSI Data Review • Due to risk adjustment calculations, MDS corrections & late submissions, the publicly reported Quality Measures are approximately four months behind the current Quality Measure/Indicator Reports accessible by your facility. *Tip: The Quality Measure/Indicator Report should be monitored monthly for accuracy and to look for QI opportunities

14. National Goals • National Patient Safety Initiative • 18 month 10% relative improvement • 28 month 20% relative improvement • These are contract goals for the NPSI participating providers • Advancing Excellence in America’s Nursing Homes campaign: • Goal is that all nursing homes will strive toward a completely restraint free environment • The national average will be <2% • 50% of nursing homes will report restraint rates less than 1% • What is your current rate and goal?

15. The Arkansas Story

16. Stakeholder Driven Quality • AFMC • Arkansas Health Care Association • Arkansas Medical Director’s Association • Long Term Care Ombudsman • Office of Long Term Care (SSA) • Medicare beneficiaries and consumers • Misc….content experts such as Medical Directors, Physical Therapy and Occupational therapy

17. Stakeholder Commitment • All representatives agreed a uniformed and consistent message was essential • Stakeholder committee formed to review perceptions and barriers for restraint management • Identified variances among standards of practice, regulatory interpretation and MDS coding • Developed the Arkansas Process Indicator • Conducted regional trainings • Identified content experts for referral (i.e. QIO for QI assistance, RAI Coordinator for MDS, Ombudsman for family issues and SSA for documentation, etc…)

18. Address Restraint Myths… • They prevent falls & prevent injury • It is our moral responsibility to safeguard residents from harm by using restraints • Failure to restrain increases legal risk • Residents do not mind being restrained, it makes them feel secure • Restraints must be used because of inadequate staffing • Don’t know what else to do • Important to ask staff and family about their beliefs

19. Acknowledge Restraint Risks • Death • Strangulation, suffocation • Pneumonia, sepsis • ADL decline, loss of muscle tone • Decreased mobility, stiffness, inability to stand, walk, turn • Pressure ulcers • Incontinence….etc. • Read the manufacturer’s guidelines and current research

20. Psychological Risk • Depression • Agitation • Frustration • Loss of dignity • Loss of confidence • Thought of suicide • Increased boredom, loneliness, helplessness • Feelings of being punished, scared • Remember to honor quality of life

21. Restraint Process Indicator • Assessment & Recognition • Diagnosis/Cause Identification • Treatment & Problem Management • Monitoring • Also developed Process Indicators apply to falls and behaviors • Same process as the AEC resource material

23. Assessment/Recognition • All symptoms have underlying causes • More than one underlying cause may need evaluation • Evaluate any symptom or condition for which a restraint might be used • Critical Question: • Is problem acute and reversible or chronic and irreversible?

24. Alternatives… • First identify the real underlying reason for consideration and think how the device being proposed will help “treat” the symptom • Do you have a list of “alternatives” ? • Use team work! Refer to the appropriate discipline/person for alternative interventions (therapy, social/activities, family, care givers, professional associations, etc.….) for alternative ideas • Adopt Person Directed Care principles

25. Diagnosis/Cause Identification • Diagnosis and treatment could avoid or reduce restraint use quicker • Examples: • Delirium could be caused by infection or fluid & electrolyte imbalance • Agitation could be reduced by addressing physical discomfort, better toileting or repositioning • Nonspecific or agitated behaviors could respond to better assessment and treatment of pain

26. Did you consider all the categories of causes for the “problem”? • Physical • Environmental • Psychosocial, including family dynamics • Staff interactions with residents • Did we cause the “problem” or make it worse with immobility, boredom, sleep deprivation, not honoring normal routines…?

27. Consider Polypharmacy Effect • Combination of medications can result in adverse drug reactions associated with falls, problematic behavior, or other symptoms: -Antihypertensives/cardiac medications -Antidepressants -Cholinesterase inhibitors -Antipsychotics -Anti-Parkinson meds

28. Treatment/Problem Management • Often risk factors & underlying causes can be addressed, at least partially • Addressing risks & causes can influence frequency or severity of problem, thereby making restraint use unnecessary or less restrictive • Does the treatment plan cover the frequency of use (the what, when, how, where….) • Are appropriate disciplines aware of the plan &/or were they involved with treatment plan?

29. Rationale • Example: Changing or stopping medications associated with adverse drug reactions such as dizziness, lethargy, or confusion often alleviates falling, problematic behaviors, or other symptoms that might lead to restraint usage

30. If justified..Appropriate Selection • Choose a device systematically, based on risks & benefits relative to that individual • Does device maintain or enhance functional capacity and/or socialization that cannot be readily achieved by a less restrictive or safer alternative? • What is appropriate for one individual may be hazardous to another • Potential benefits and risks of device itself • Should be able to show the rationale for how the device was selected and explain unsuccessful attempts to manage underlying symptoms or problems without a device

31. Appropriate Use • If justified, devices must be used correctly in order to minimize risks of adverse consequences or complications • Education and Quality Assurance is critical to ensure correct usage • Need to compare actual performance to expected outcome • Have a system that follows professional standards and manufacturer’s guidelines

32. Monitoring • A restraint is an intervention, not a problem • Your intervention can only be as good as the identification of the cause • How often are you monitoring the medical symptom and effect of the device for treating the underlying cause • What is the “standard of care” for monitoring? A device, side rail, enabler?

33. Monitoring • Relate care planning and monitoring to the problem or situation for which the device is being used, and secondarily to interventions • Examples: care plan fall risk, problematic behavior, etc. • Address rationale for continued use of a restraint as an intervention option • Don’t care plan the restraint itself

34. Monitoring • When will you re-assess for the continued use? • Problem or condition for which device is used may resolve or decrease with time or treatment of the underlying cause • Sometimes, the only way to know if the intervention (restraints) is no longer needed, is a trial period without it

35. Rationale • As with medication reduction, reducing or stopping use of device could result in complication or return of symptoms • However, judicious restraint reduction should be beneficial more often than not • Attempted reduction must be part of plan that includes monitoring for recurrence or progression of symptoms

36. Complications • Monitor for complications related to use of device • Document monitoring and how complications are being addressed • Explain how you try to minimize restraint complication • Examples: checking bed rails for proper size or proper application of devices on a resident

37. Complications • Stop or adjust use of device if complication occurs, or explain why benefits outweigh risks in continuing to use device • Identify how device is helping resident’s functional status and/or socialization

38. Bed rails and Side Rails *Although not included in the QM calculation, you should be aware of entrapment zones

39. WG 1: Regulatory Consistency

40. WG 1: Regulatory Consistency

41. MDS Coding

43. MDS Coding • Physical restraints- 7 day look back • Code for the frequency with which the resident was restrained by any devices at any time day or night • Intent is to evaluate whether the device meets the definition of a physical restraint • Such as: full/partial bed rails, trunk, limb or chair preventing rising

44. MDS Coding P4 • P4c- Trunk restraint • P4d- Limb restraint • P4e- Chair prevents rising

45. MDS Coding • The assessor should not focus on the intent or reason behind the use but the effect of the device • For each device, code as: Code 0- not used in last 7 days Code 1- Used less than daily in last 7 days Code 2- Used on a daily basis in last 7 days

46. Quality Measures Calculation • Numerator: Residents who were physically restrained (P4c or P4d or P4e=2) • Denominator: All residents with a valid target assessment • Exclusions: Residents satisfying any of the following conditions: • Target assessment is an admission assessment • QM did not trigger and the value of P4c or P4d or P4e is missing on the target assessment

47. How to get started… • First, adopt Consistent Assignment • De-schedule your facility as much as possible • Start with one resident at a time, one unit at a time • Create a “person directed care” team… • Learn from your peers in state and across the nation • Arkansas has reduced from the highest @ 23% restraint use to 4% since 2009 • We now have several restraint-free homes in Arkansas  • Collaborate with stakeholders and the QIO

48. Questions? • Jennifer Wieckowski, MSG • Manager, Nursing Homes • Health Services Advisory Group • The QIO for California • (818) 409-9229 • jwieckowski@hsag.com • www.hsag.com • www.nhqualitycampaign.org