As one of the key professionals in LTC, the LPN performs important duties while serving as a mentor/role model for the CNAs and other staff providing direct care to persons with Alzheimer's disease and related disorders, which we designated in this document as dementia. Some less-common dementias may differ in their presentation and clinical course from Alzheimer's disease; we have emphasized as core competencies in dementia those pertaining to recognition and management of persons with advancing Alzheimer's disease.
Under the supervision of the registered nurse, the supervising, teaching, and mentoring roles of the LPN, in concert with their central role in providing direct care to persons with dementia, prompted our initial focus on specifying the competencies for this pivotal position in the care continuum. Acknowledging that core competencies will change as knowledge and skills in dementia care advance, the following listing represents the current consensus of the Steering Committee's workgroup and leadership. Our proposed phases of training for LPN competencies is organized to reflect training that might occur in 1- and 3-hour sessions in compliance with the dementia training mandate of SB1202.
Competency 1.1 -- Understanding the characteristics of dementia and the special needs of the person with dementia
Knowledge, skills, attitudes:
Competency 1.2 -- Adapts communication to cognitive/emotional needs of the person with dementia
Knowledge, skills, attitudes:
Competency 2.1 -- Demonstrates a working knowledge of dementia
Knowledge, skills, attitudes:
Competency 2.2 -- Recognizes, prevents, and manages distress behaviors including agitation, pacing, exit-seeking, combativeness, withdrawal, and repetitive vocalizations
Knowledge, skills, attitudes:
Competency 2.3 -- Understands special needs of family and friends of persons with dementia
Knowledge, skills, attitudes:
Competency 2.4 -- Promotes independence in activities of daily living
Knowledge, skills, attitudes:
Competency 2.5 -- Promotes an optimal environment that will support resident autonomy and enhance capabilities
Knowledge, skills, attitudes:
Competency 2.6 -- Recognizes ethical issues that arise in dementia care and incorporates these into care approaches
Knowledge, skills, attitudes:
Advanced Competencies (important, but not to be covered in the 1- and 3-hour initial dementia training sessions)
In order to prevent excess disability, incorporates an approach to remaining capabilities and capitalizes on potential for rehabilitation
STRATEGY
A best practices strategy should be developed, articulated, and incorporated into many of the services managed by organizations. Opportunities for collaboration should be used to help establish such program-level strategies.
IDENTIFYING PRACTICES
Focus on proven sources of best practices. Promote "leading edge" practices. Residents and their families are excellent resources. Also, use innovative methods to help identify new and emerging practices.
SOURCES
Examine practices in programs that have a reputation of excellence, especially those where resources have not been plentiful. Also, focus on Administrators or DONs recognized for special expertise to help identify best practices.
METHODS
Other suggestions for soliciting and identifying practices include having a competition among service functions, information exchange forums, mentors, speakers, soliciting electronic submissions, and old-fashioned bulletin boards.
EVALUATING PRACTICES
The concept is to establish criteria, up front, to benchmark and determine which practices are effective, or best, and have the greatest usefulness for residents and families.
CRITERIA
Use residents and families to help identify pertinent and consistent criteria, up front. Use criteria such as cost effectiveness, time savings, proven performance, satisfactions surveys and ease of implementation.
Please send all Best Practices questions/comments to Best.Practices@dia.state.ia.us
Best Practices Program Disclaimer
Participation in the Best Practices Program is strictly voluntary on the part of Iowa long-term care facilities. The identification of a best practice at an Iowa long-term care facility is not an endorsement or recommendation of the practice by the Iowa Department of Inspections and Appeals or the Health Facilities Division. Nor does the identification of a best practice create a new standard used during the survey process. The identification of a best practice is solely designed to make available to other long-term care facilities in Iowa information about new or innovative methods positively impacting resident care and quality of life.
Participation in Best Practices is voluntary.
The Best Practice designation is neither an endorsement nor the establishment of a standard.
The identification of a Best Practice does not preclude other deficiencies.
Participation in Best Practices does not alter the survey or complaint investigation process.
The Iowa Department of Inspections and Appeals (DIA) reserves the right to remove a facility from Best Practices list for reasons dealing with the quality of services for residents.
DIA will acknowledge in writing when a surveyor confirms a Best Practice.
The DIA Administrator and Bureau Chiefs will assess Best Practices for inclusion on the agency's web page.
Best Practices on the DIA web page will be changed or updated once every six months.
Please send all Best Practices questions/comments to Best.Practices@dia.state.ia.us
Best Practices Program Disclaimer
Participation in the Best Practices Program is strictly voluntary on the part of Iowa long-term care facilities. The identification of a best practice at an Iowa long-term care facility is not an endorsement or recommendation of the practice by the Iowa Department of Inspections and Appeals or the Health Facilities Division. Nor does the identification of a best practice create a new standard used during the survey process. The identification of a best practice is solely designed to make available to other long-term care facilities in Iowa information about new or innovative methods positively impacting resident care and quality of life.
The Office of Health Care Quality has, in recent months, noted an increase in clinical problems related to the use of anticoagulants, especially Warfarin. Undesirable outcomes resulting from inappropriate prescribing, dispensing, administration and monitoring of these drugs are encountered frequently by our surveyors. A common theme in these cases is the systemic failure on the part of certain facilities to anticipate and address well-known complications associated with the use of these potent medications. The following case presentation highlights areas of concern:
Resident #1 was a 78 year-old female with numerous diagnoses including hypertension, diabetes mellitus, osteoporosis and glaucoma. She was living at home independently until March 1, 2001 when she was admitted to the hospital with sudden onset of slurred speech and right-sided weakness. She was diagnosed with an embolic CVA and new onset atrial fibrillation. Treatment included the administration of IV Heparin, then Coumadin and active rehabilitation. She was transferred to a long-term care facility on March 6, 2001 for continued therapy.
When admitted to the LTC facility she remained in atrial fibrillation. Coumadin was continued at a dose of 5 milligrams each evening. One day after admission, an INR was obtained and noted to be 1.44. The physician increased the dose of Coumadin to 7.5 milligrams each evening and ordered a repeat INR obtained in 2 weeks. The nursing staff administered the increased dose of Coumadin but failed to obtain the follow-up INR. As there were no standing orders or facility policy regarding the frequency of laboratory testing of residents on Coumadin, no further INRs were obtained.
On April 12, 2001 (Day 35 in the nursing home), the attending physician examined the resident, noted limited progress in therapy but gave no new orders. On April 16, 2001 (Day 39) the consultant pharmacist reviewed this resident's care and recognized the lack of INR monitoring. However, the pharmacist simply left a written recommendation, in the medical record, for the physician to "consider monthly INRs while the resident is receiving Coumadin". As the facility had no system to promptly inform physicians of pharmacy recommendations, this information remained isolated in the medical record.
On April 22, 2001 (Day 45) the resident complained of dysuria, which prompted the nursing staff to contact the attending physician. By phone, the physician ordered Bactrim to be administered twice daily for ten days. As of April 24, 2001 (Day 47) the resident's dysuria had resolved but gross hematuria had developed. The attending physician was again called and ordered the Bactrim discontinued and Cipro started for a presumed resistant urinary tract infection. The nursing staff despite the development of hematuria, continued to administer 7.5 milligrams of Coumadin nightly to this resident.
On April 25 (Day 48), the resident complained of progressive weakness and "dizziness. The nursing staff told her that she needed to give the new antibiotic "time to work" and that she would eventually feel better. Later that day, in the absence of any trauma, bruising was observed on the resident's chest and left arm. The nursing staff failed to notify the physician of either the resident's complaints or the appearance of bruising. Coumadin was administered as ordered.
Over the next 24 hours the resident remained in bed and became progressively more lethargic. Routine vital signs obtained by a nursing assistant on the morning of April 27, 2001 (Day 50) revealed a blood pressure of 84/48 and a pulse of 114 beats per minutes. The nursing assistant documented these results on the vital signs flow sheet, which was not seen by the nurse until later that afternoon. When the nurse went to evaluate the resident she was found to be obtunded, tachycardia, and hypotensive and found with diffuse bruising over her entire body. She was sent to the emergency room where her prothrombin time, the first one obtained in over six weeks, was found to be greater than 100 seconds. She was profoundly anemic with a hematocrit of 15.8%. A CAT scan revealed a large subdural hematoma and despite aggressive interventions the resident expired on hospital day number 2.
The problems in the management of this case are many; some of the ones we noted include:
The staff didn't know which residents in the facility are on anticoagulants.
The physician apparently did not know the proper way to begin and maintain Coumadin treatment in an elderly patient.
There was no understanding by the physician and nursing staff on when to order INRs and the proper monitoring of Coumadin.
There was failure of communication between nursing staff and the physician.
Failure of nursing staff and physician to recognize side effects of Coumadin.
There was no policy or system to require facility staff to obtain timely INRs before Coumadin can be administered.
The pharmacist failed to intervene aggressively in assuring the proper administration of Coumadin.
You can probably easily add to this list.
Does someone in your facility know who is on anticoagulant medications?
Does your facility have a policy to monitor residents on anti-coagulant therapy?
When was your last in-service on anticoagulant therapy?
Warfarin Therapy: Evolving strategies in anticoagulation. American Family Physician, Feb 1, 1999. www.aafp.org/afp/990201ap/635.html
Questions and/or comments regarding this clinical alert should be directed to:
Joseph I. Berman MD
Medical Director, Office of Health Care Quality
Phone: (410) 402-8016
E-mail: Jberman@dhmh.state.md.us
William Vaughan R.N., B.S.N.
Chief Nurse, Office of Health Care
Quality
Phone: (410) 402-8140
E-mail: Wvaughan@dhmh.state.md.us
"We have no simple problems or easy decisions after
kindergarten."
-- John Turk
The right of a patient to accept or refuse medical intervention is a well-established principle in healthcare. In a setting that involves an alert, oriented and clearly competent individual, the process by which medical decisions are made is relatively straightforward. However, when disease or injury precludes the patient from actively participating in healthcare decisions, the situation becomes increasingly more complex. At these times, advance healthcare decisions are pivotal in preserving a patient's ability to direct his/her own care.
Advance healthcare decisions generally involve choices made by competent individuals concerning their own desired end of life care if they should become terminally ill, have an end-stage condition, or be in a persistent vegetative state. The individual determines, while fully able, whether he/she wishes such interventions as the insertion or continued use of a feeding tube, the initial or continued use of a ventilator, the initiation or continuation of renal dialysis and/or the administration of antibiotics. While occasionally difficult for families and even those healthcare workers caring for patients to accept, these "advance directives" should be followed in the same manner that one would in the case of a competent and communicative patient speaking directly to them.
The Office of Heath Care Quality frequently discovers situations in which healthcare providers do not honor the advance directives of patients in their care. The following deficiencies, which occurred in an area nursing home and hospital during 2001, are examples of such situations.
COMAR 10.07.02.07 A (2)
The administrator shall be responsible for the implementation and enforcement of all provisions of the Resident's Bill of Rights under COMAR 10.07.09
COMAR 10.07.09.08 C (11)
A resident has the right to consent to or refuse treatment, including the right to accept or reject artificially administered sustenance in accordance with State law.
COMAR 10.07.09.08 C (3)
'A resident has the right to a dignified existence, self-determination, and communication with and access to individuals and services inside and outside the nursing facility.
Jane Doe was an 83 year old female when she was admitted to [a local nursing home] on February 26, 1998. Almost a year prior to her admission, while still living in the community, this resident wrote certain instructions related to her healthcare. These instructions were contained in a document entitled "Advance Health Care Directive for [resident's name]". The resident signed this document on March 19, 1997, and two individuals witnessed this signing.
The creation of an advance directive is an important and proactive step in preserving one's autonomy as it relates to health care. An advance directive "speaks" for a resident at a time when she is unable, due to her medical condition, to communicate her wishes. End of life issues, such as withholding or removing life-sustaining interventions, are often the focus of advance directives. The Maryland statute governing advance directives, the Health Care Decisions Act, is found in the Code's Health General Article, §5-601 et seq.
Mrs. Doe's advance directive instructed her healthcare providers to withhold or withdraw life-sustaining procedures if she met any one of the following criteria:
Mrs. Doe, in her advance directive, specifically addressed the issue of artificial nutrition as follows:
"I direct that no nutrition or sustenance be administered to me artificially, such as the insertion of a feeding tube; and, I direct that upon finding that I am as described [as either terminal, in a persistent vegetative state or in an end-stage condition] that any such artificial administration be terminated immediately ...".
Mrs. Doe had been at [a local nursing home] for 18 months when on August 23 and September 20, 1999, two physicians certified that her medical condition was end-stage due to dementia. On July 17, 2000, two physicians again certified that her condition was end-stage secondary to dementia. At that time, the physicians also noted that tube feeding this resident, i.e. providing nutrition via a tube placed into the stomach, would be "medically ineffective".
Mrs. Doe experienced a gradual decline in her overall condition and during the first several months of 2001, it became apparent that her oral intake of food and fluids was becoming inadequate. Her capacity to make medical decisions and her ability to communicate had become severely impaired, and she was no longer able to participate in decisions related to her healthcare due to her dementia. On April 5, 2001, she was admitted to (a local hospital) for the third time in the preceding six months due to dehydration. Despite Mrs. Doe's clear advance directives to the contrary, a feeding tube was surgically placed into her stomach during this hospitalization at the insistence of her son. Fluids and tube feeding formula were then administered to her at the hospital.
She returned to [a local nursing home] on April 13, 2001. The clinical staff at the nursing center, including the attending physician, medical director, numerous members of the nursing staff, the administrator, the social worker and a corporate nurse who was a member of the facility's patient care advisory committee, all agreed that administering tube feeding to this resident would be against her wishes. Therefore, Mrs. Doe received only water and medications through the feeding tube. The facility's decision not to administer nutritional tube feeding per the resident's advance directive was communicated to the resident's family.
On April 14, 2001, the attending physician visited the resident and wrote the following progress note: "... G tube [feeding tube] is placed against living will ..."
The attending physician next visited Mrs. Doe on April 16, 2001, and wrote: "Pt [patient] had PEG [feeding tube] placed for nutritional purposes against the wishes of the patient. I personal [sic] do not recommend G tube [feeding tube] placement, I want to respect patient's wishes à continue G-tube [feeding tube] flushes [water only] no nutrition ..."
Three days later, on April 19, 2001, the attending physician again came to the nursing facility and wrote: "Tried for family discussion with her son and daughter-in-law. Looks like they have contacted the attorney and made the decision if patient is not fed they will sue us ..."
From the time Mrs. Doe was readmitted to the nursing facility on April 13, 2001, until the physician wrote her last note on April 19, 2001, all the resident had received was water and medications through her feeding tube. As she had on two previous occasions been declared in an endstage condition (due to dementia) and her own physician had deemed that providing nutrition via a feeding tube would be "medically ineffective", the decision to withhold nutrition was completely in accordance with her advance directive.
However, after the resident's family made threats of legal action, the physician, on April 20, 2001, ordered the nursing staff to begin administering nutrition via Mrs. Doe's feeding tube. The nursing staff of the facility complied with this order and from April 20, 2001, through May 2, 2001, the resident was administered tube feeding formula daily. On May 2, 2001, the resident became acutely ill, was hospitalized, and did not return to the facility.
In summary, it is clear that the staff at the nursing facility was not responsible for the placement of the feeding tube. That act, in direct contrast to the expressed wishes of the resident, was performed at the hospital. The staff at the nursing facility was, however, required to honor the instructions set forth by Mrs. Doe in her advance directive. Those instructions carried the same weight as if Mrs. Doe had spoken them herself during April and May of 2001. Despite clear misgivings on the part of the nursing and clinical staff, who were personally familiar with Mrs. Doe's wishes, the facility failed to allow this resident to exercise her right to refuse treatment, specifically the right to reject the artificial administration of sustenance. Instead of honoring the very clear and concise directives of Mrs. Doe, the facility inappropriately followed the wishes of the family, which were in absolute contradiction to the expressed wishes of the resident.
Note: The nursing home appealed the above deficiency and sanction ($10,000.00 fine) to the Maryland Office of Administrative Hearings. A redacted version of the judge's decision in this case is available online at http://www.dhmh.state.md.us/ohcq/download/alj/pdf .
The staff of OHCQ also conducted an investigation into the care Mrs. Doe received at the hospital where the feeding tube was inserted. The hospital was seemingly unaware that a feeding tube had been placed in this patient against her will. The Office of Health Care Quality wrote and forwarded the following deficiency to the hospital.
A76 482.13(b)(3) Exercise of Rights
The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with 489.100 of this part (Definition), 489.102 of this part (Requirements for providers), and 489.104 of this part (Effective dates).
Based on a review of Jane Doe's medical record, the patient's advance directives and the hospital's policies and procedures, it was determined that the hospital failed to comply with the patient's advance directives that clearly indicated her desire to not be fed by artificial means.
Jane Doe was an 83 year old female who had lived at a nursing home for about 4 years. She was diagnosed with advanced dementia, with severe brain atrophy. While still capable of making her own decisions, Jane Doe had executed an advance health care directive in March of 1997. Her son was appointed her health care agent and she also spelled out detailed health care instructions.
Per the patient's instructions in her advance directives, which were to be acted upon when she was "incapable of making an informed decision," two physicians certified (July 17, 2000) that the patient had become "end-stage." The certifications specified that CPR (cardiopulmonary resuscitation) and G-tube feeding would not change patient's deteriorating health or prevent impending death. The patient's advance health care directive instructed "that no nutrition or sustenance be administered to me artificially, such as by the insertion of a feeding tube..." and upon finding that she has an end-stage condition "... that any such artificial administration be terminated immediately." Finally, she had directed, "... that such life-sustaining procedures be withheld or withdrawn, and that I be permitted to die naturally." The patient's son was appointed as health care agent but only to the extent the patient's wishes were unknown or unclear.
On April 4, 2001, Jane Doe was found to be unresponsive at the nursing home and intravenous fluids were started. She was sent from the nursing home to this hospital for dehydration with related abnormal laboratory findings. At the time of admission to the hospital, the patient's medical record indicated that she underwent testing and observation to rule out a heart attack. "Aggressive intravenous hydration" was started to address her dehydration. The patient did not recover sufficiently to take food or liquids by mouth. The attending physician had stated in his admitting history and physical for Jane Doe, dated April 5, 2001, that "The patient is do not resuscitate with no ventilator or tube feedings. Orders are already in place."
On April 7, 2001, the patient's attending physician wrote a progress note in the patient's chart saying, "Discussed with patient's son (who had medical power of attorney) and daughter-in-law about options. They have agreed to placement of a feeding tube. Reiterated patient is DNR/DNI (do not resuscitate/ do not intubate). Will insert NG-tube and start feeds today. Cardiac arrhythmias noted, am hesitant to treat in view of hypotension (low blood pressure); will monitor. Dr. _ _ called for GI (gastroenterology) consult."
On April 9, 2001, the GI surgeon wrote his/her signature on the patient's informed consent, for placement of the G-tube. The son's name is printed, not signed, in the space for (Patient, Nearest Relative, Legal Guardian) signature. The surgeon's signature attests that the physician has explained to the son the surgical procedure, the alternatives, and possible complications and risks.
On April 10, 2001, surgery to insert a feeding tube (G-tube) into Jane Doe's stomach was performed. Fluids and food were administered first through the NG-tube then through the G-tube for approximately a week, until her discharge on April 13, 2001, despite the patient's written directive that she should not be fed by artificial means.
The attending physician stated in Jane Doe's hospital "Transfer Summary -- AMENDED REPORT" dated April 13, 2001, that "However, after discussion with the patient's daughter-in-law, she agreed to a placement at discharge of a feeding tube."
The patient was discharged from this hospital to her previous nursing home placement, then to another acute care hospital and finally to a new nursing home placement. About one month after discharge from this hospital, the patient died with possible aspiration pneumonia, infections in her urinary tract, several decubitus ulcers and hypotension.
The patient's attending physician and her daughter-in-law are the documented decision makers for the patient. The attending and the patient's daughter-in-law chose to institute treatments that would be medically ineffective as previously determined by the two physician certifications, i.e. treatment that would not alter the patient's deteriorating health status nor prevent her impending death.
A review of hospital policies revealed that Hospital Policy Number RI10 was enacted in order to "foster respect for the inherent dignity of each person." This policy defines medically ineffective treatment and end-stage condition and allows a health care provider to withhold or withdraw life-sustaining procedures provided that the patient's attending and a second physician have certified the patient as having a terminal condition. The certifications (noted above) predated this hospital admission by nearly one year and certified that the patient's condition was "severe and permanent deterioration indicated by incompetence and complete physical dependency ... [and] treatment of the irreversible condition would be medically ineffective." Despite this fact, the G-tube was inserted.
A review of Hospital Policy Number RI8 revealed that this hospital policy states to "Avoid conflicts of interest and/or the appearance of conflict." This policy stated that the hospital "assure that the care provided each patient is appropriate" and "ensure the integrity of clinical decision-making..." This policy states that it is in place to "promote employee and medical staff sensitivity to the full range of such needs and practices [physical, psychological, social and spiritual needs and cultural beliefs and practices]." There was no documentation to indicate that the physician, surgeon, anesthe-siologist or other healthcare providers or administrative staff voiced the conflict between the patient's advance directive and the insertion of a feeding tube by invoking the hospital's "specific mechanisms or procedures to resolve conflicting values and ethical dilemmas among patients, their families, medical staff, employees, the institution and the community" as identified in Policy RI8.
A review of the hospital's Ethics Committee meeting minutes revealed that the hospital has a functioning system for the review of cases where there are conflicts regarding a patient's treatment, family wishes or advance directives. However, there was no documented evidence that the conflict between this family, the provider and the patient's advance directives had been referred to the hospital's Ethics Committee or for an ethics consult. Hospital staff interviewed on October 10, 2001, indicated that neither the physician nor the family referred this patient's case for an Ethics Consult.
In response, the hospital revised its policies and implemented staff training to ensure that advance directives are followed.
Discussion:
Researchers Morrison and Sin compared the treatment of patients with acute illness and end-stage dementia to another group with acute illness and without end-stage dementia. They found that patients with end-stage dementia received as many burdensome procedures as cognitively intact patients and that only 7% had a documented decision made to forego a life-sustaining treatment other than cardiopulmonary resuscitation. In the case of patient #1, even though she had clearly indicated her desires through advance directives to forego life-sustaining treatment, she was unable to avoid the imposition of unwanted and medically ineffective therapy.
The Office of Health Care Quality considers the rights of patients to be paramount in any healthcare institution and will continue to monitor the response of facilities to this issue.
For additional information, please read:
Summary of Maryland Healthcare Decisions Act: http://www.oag.state.md.us/Healthpol/HCDA.pdf
Morrison, R and Sin, A. "Survival in End-Stage Dementia Following Acute Illness." JAMA. 2000; 47-52.
Administrative Law Judge's decision on the facility's appeal of this deficiency and civil money penalty: http://www.dhmh.state.md.us/ohcq/download/alj.pdf
Questions or comments regarding this Clinical Alert should be directed to:
Joseph I. Berman MD
Medical Director, Office of Health Care Quality
Phone: (410) 402-8016
E-mail: Jberman@dhmh.state.md.us
William Vaughan R.N., B.S.N.
Chief Nurse, Office of Health Care
Quality
Phone: (410) 402-8140
E-mail: Wvaughan@dhmh.state.md.us
Wendy A. Kronmiller
Assistant Attorney General
Phone: (410)
767-5469
E-mail: wkronmiller@dhmh.state.md.us
February 2003 Spotlight on new resources
Long Term Care is a multi-disciplinary endeavor with the care of the resident as its central focus. Because all disciplines must work coherently toward a common goal, each of the following topics addresses multiple aspects of LTC practice including resident evaluation, nursing care, facility administration and medical care. The Overview section in each topic includes findings from DHS Medical Quality Assurance (MQA) studies as well as a statement of performance expectations - a DHS MQA vision of high quality care.
The accompanying bibliographies and resources are representative rather than exhaustive collections of current clinical thinking and research. Similarly, the regulatory tags that may be cited for deficient practices are representative rather than exhaustive. The accompanying Geriatric Symposium presentations represent the expert perspectives of the presenters rather than those of DHS.
Where well-designed clinical trials permit defining evidence-based best practices, these have been used in the problem-oriented best practice summaries. Where such evidence is lacking, expert consensus statements, clinical practice guidelines, case studies and regulatory requirements all offer some insight into what may constitute best practice. Every best practice framework in QMWeb is submitted to one or more clinical peer reviewers for comment. Where there are unresolved differences between MQA and a reviewer, these are noted in the Reviewers section of the page itself. Where opposing viewpoints each have some support in evidence and literature, the goal of QMWeb is to provide a balanced presentation.
It is important to note that even when there is a sound basis for evidence-based best practice, the specific details of implementation (the more common and less strict meaning of best practice) may vary from one venue to the next simply because resident needs, staff expertise and other resources vary from one venue to the next. Therefore, the following pages serve best as frameworks or toolkits from which to design facility-specific care systems rather than as simple cookbook recipes for deficiency-free (let alone, optimal) care.
This section of QMWeb is a work in progress. Only the topics in bold represent completed frameworks. The remaining pages are either preliminary frameworks that have not yet undergone peer review or simply resource pages whose corresponding best practice frameworks remain to be completed. Expect the number of completed best practice frameworks to grow steadily over the next two years in response to provider needs identified through the Quality Monitoring Program, the Statewide Quality Review Process, and the DHS Geriatrics Symposium Series.
Last updated: May 6, 2003
The DHS Medical Quality Assurance vision for restraint reduction in Texas LTC is
Resident-centered evaluation and care planning for restraint-free environments.
Definitions and Scope
In this framework, the term restraints focuses exclusively on devices applied to a resident's wrists, trunk or waist that limit the resident's normal access to the environment or self and that the resident cannot remove at will without assistance. While the use of other devices that achieve these same ends is also discouraged, the findings described below apply only to these three general classes of devices.
According to MDS Quality Indicator statistics, Texas has ranked among the four states with the highest prevalence of restraint use during 2000-2002.[1] An independent assessment of 1972 Texas nursing facility residents conducted for DHS by the Texas Nurses Foundation during FY2002 showed that 19.5% (n=385) of the residents had spent some time in restraints during the preceding 7 days.[2] The majority of these residents, 368/385 (95.6%), had spent time in restraints each and every day during the last 7 days. Among restrained residents, fewer than 10% (n=34) had a clinical problem that an expert panel deemed unlikely to be properly addressed without the use of restraints.
Based on structured assessment, the prevalence of necessary restraints was 2.3% rather than the observed 19.5%. This is consistent with the results of restraint reduction trials that show restraint prevalence can be decreased to 5% or less.[9, 16, 17]
In the Texas cohort, no resident appeared to be in restraints for punishment or for facility convenience. Rather, the majority was in restraints because caregivers believed that they were appropriately addressing a resident safety issue. The following proportions describe the 351 residents who were restrained without a compelling clinical indication:
Thus, the dominant reasons for using restraints in Texas nursing homes appear to be concern for two common geriatric syndromes - falling and wandering.[2] In the Texas cohort, more severe resident ADL and cognitive impairment are associated with the application of restraints. These findings are consistent with findings of multiple research studies [3, 4, 5, 6] It also appears that families, concerned for resident safety and not knowing what best to do, ask for the use of restraints in a significant number of instances where they are inappropriate.
Considerations for Avoiding and Reducing Restraint Use
Beyond the ethical issues of resident's rights (the principles of individual dignity and self-determination) and quality of life issues, there are compelling clinical reasons to use the least restrictive intervention to deal with the problems that are commonly given as reasons for using restraints. The first clinical reason is to preserve resident function - to prevent loss of independence and ADL capacity and thus avert greater care-giving burden.
The restraint reduction literature identifies the adverse effects of restraint use including the following:[19, 24]
The second clinical reason is to ensure resident safety. Although commonly viewed as an intervention to promote resident safety, restraints actually compromise safety. The complications of restraints can be serious and include injuries and death.[7, 8]
Common reasons for restraints include assisting resident posture, keeping residents from dislodging feeding tubes or other medical devices, limiting resident access to wounds, preventing scratching injuries, and preventing inappropriate disrobing among others. All of these hypothetical scenarios can be managed with less restrictive interventions. Cushions, bolsters and other physical therapy devices can be used to support posture. Various binders and dressings can be used to limit resident access to tubes, devices and wounds. Proper nail care can minimize or eliminate scratching injuries. And, special clothing adaptations can make disrobing very difficult without resorting to restraints. However, every one of these interventions requires individualized care planning, and no one intervention will meet the needs of every resident that has a particular problem. That is, restraint reduction often requires an individualized, resident-centered approach rather than a generic, problem-centered approach.[9, 10]
Myths and Misconceptions
MYTH: Restraints Protect Residents from Falls and Injuries. Some restraint reduction studies show an increase in falls but to levels no greater than seen in control groups; other studies show that with appropriate care planning this increase is minimal to negligible.[11, 12, 13, 14] All of the studies show no increase in serious injuries as a result of restraint reduction; and, other studies show an increase in serious injuries when restraints are used.[7, 8]
MYTH: Restraints Decrease Staff Time. Restraint reduction research shows that there is no increase in the staff time needed to meet the needs of residents in whom restraint use is discontinued.[13, 15]
MYTH: Restraint Use Decreases Cost of Care. Restraint reduction research shows that there is little or no increase in costs required to meet the needs of residents in whom restraint use is discontinued. The increased cost attributable to special devices needed to accomplish restraint removal has been measured at 3 cents per day per resident released from restraints, and this is comparable to the cost of restraint devices themselves.[14, 17]
MYTH: Restraint Reduction Requires Increased Psychoactive Medication Use. Research shows that this belief is common and erroneous.[13, 16]
MYTH: Restraint Use Decreases Facility Liability. There is no evidence that facility liability cases have ever been lost solely on the basis that the facility had failed to apply restraints.[17, 18] There is no literature that shows that the application of restraints constitutes best practice for managing fall risk or wandering. In fact, the lost liability cases due to injuries related to restraint use serve as a reservoir of evidence against the argument that restraints constitute best practice.
The Texas Department of Insurance recognizes restraint use as a key facility liability risk-management issue because of liability claims arising from the use of restraints.
The minimum evaluation prior to using restraints consists of the following:
Clear Identification and Understanding of the Clinical Problems, Goals and Risks
Why are restraints being considered? What are the clinical problems that restraints are supposed to address? Is there an evidence basis that supports restraints as best practice in addressing these problems? What clinical outcome or end-point is desired? Are the potential untoward outcomes associated with restraint use acceptable to the resident and family? Some successful restraint reduction programs use a formal physician's order form that includes these and other elements such as informed consent.[16]
Trial and Evaluation of Less Restrictive Alternatives
With the possible exception of the circumstances described in the DHS structured assessment for restraint use, every other clinical problem can and probably should be addressed with less restrictive interventions.
To proceed directly from problem identification to the use of restraints without a trial of individualized and less restrictive alternatives does not constitute best clinical practice. Yet, in 28.5% of the cases of inappropriate restraint use in the Texas cohort, there was no evidence that less restrictive alternatives had been tried.[2] Since this figure was based on record reviews requiring minimal documentation that alternatives were tried, the 28.5% rate is a conservative.
Structured Resident Assessment and Care Planning
DHS recognizes that there are occasional clinical situations in which the use of restraints may simply be unavoidable because there is no alternative that has an acceptable risk-to-benefit ratio for the resident or others. These rare circumstances include the following:
While there may be other circumstances that are compelling reasons for restraint use in nursing facilities; they are expected to be variations of these four indications, and they appear to be rare.
The DHS Quality Monitoring Program uses this structured resident assessment to evaluate the appropriateness of resident assessment, care planning and care for residents who are restrained.
Key Components of Successful Restraint Reductions Programs
Successful restraint reduction initiatives require changes in facility policy, staff and family attitudes, beliefs and care practices.[25] The following structural and process elements contribute to success:[9, 10, 13, 14, 19, 20, 21, 22, 23]
Part I. Prepare to Succeed (education)
Part II. Implement Restraint Reduction - Eliminate Inappropriate Restraints (routine process)
Appropriate care planning for restraint reduction is only the beginning of the elimination of inappropriate restraints.
Part III. Implement Restraint Prevention - Eliminate the Initiation of Inappropriate Restraints (event-driven process)
There are a variety of technologies related to restraint reduction. These technologies afford solutions to the clinical problems that lead to restraint use - falls, wandering, self-removal of medical devices, among others. These include various types of alarms, beds, devices to assist ambulation, positioning devices, wheelchair modifications, special clothing, dressings and environmental modifications. The presentations and resources sections in this framework provide examples of such technologies.
The following deficiencies may be cited for the inappropriate use of restraints. Tags that might be cited as evidence that restraints were used inappropriately are also listed. The deficiency list is representative rather than exhaustive.
| Program | Licensure Tags (State) | Certification Tags (Federal) |
|---|---|---|
| Nursing Facilities | 19.402(c)
19.403(g)(1) 19.403(k) 19.601(a) 19.701(1) 19.701(2) 19.801(2)(A)(B) 19.801(2)(C) 19.802(a)(1)(2) 19.802(b) 19.901(1)(A)(B)(C) 19.901(3)(A)(B) 19.901(5(A) 19.901(6)(A) 19.901(10) 19.901(8)(A) 19.901(8)(B) |
F152 Resident competency
F155 Right to refuse treatment F157 Notification of changes F221 Physical restraints F241 Dignity F242 Self Determination/participation F272 Assessment F274 Assessment F279 Care plan F280 Participate in/revise care plan F310 ADLs F314 Pressure sores F317 Range of Motion F319 Mental and Psychosocial adjustment F327 Hydration F323 Accidents F324 Supervision |
| ICFs/MR | M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0022 90.42 (e)(3) M0022 90.42 (e)(3) M0015 90.42 (c) M0023 90.(e)(4) (A) M0023 90.(e)(4) (B) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) M0022 90.42 (e) (3) M0022 90.42 (e) (3) M0015 90.42 (c) M0015 90.42 (c) M0015 90.42 (c) |
W124 Right to refuse treatment
W128 Unnecessary drugs and physical restraints W191 Behavioral management training W193 Behavioral management skills W194 Skills to implement program plans W186 Adequate staffing W214 Identify behavioral management needs W238 Identify inappropriate behavior W239 Replacement of inappropriate behavior W263 Informed consent to program W263 Informed consent to program W264 Monitor drug and physical restraints in behavior programs W276 Behavioral interventions W277 Hierarchy of intervention W278 Documentation of less intrusive methods W279 Use of time out rooms W280 Use of physical restraints W283 Staff who may authorize interventions W284 Monitor and control interventions W285 Safeguards for interventions W286 Protection from punishment W287 Interventions not for staff convenience W288 Interventions are not a substitute for programming W289 Interventions must be part of the program plan W290 No PRN behavior programs W292 Duration of time out W293 Protections in time out W294 Recording time out W295 Use of restraints in behavior plan W296 Emergency use of restraints W297 Restraints for health protection W298 Duration of emergency restraint use W299 Authorization for restraints W300 No PRN restraint use W301 Periodic checks on restraints W302 Release from restraints W303 Restraint records W304 Protection from restraint injuries W305 Comfort of restrained person W306 Opportunity for motion and exercise W307 Activity record W308 Dimensions of cribs W309 Characteristics of cribs W322 Preventive and general care W329 Physician participation in care planning W330 Physician review and revision of care plan |
| Assisted Living | 92.125(a)(3)(A) Right to be free
from physical restraints 92.125(a)(3)(E) Dignity 92.125(a)(3)(O) Participation in service plan development 92.125(a)(3)(P) Right to refuse treatment or services |
All presentations on the Quality Matters web can only be viewed with Microsoft Internet Explorer 5.0 or later. No other browser is currently supported. However, you can follow this link to obtain the same presentations on CDROM for offline use with other browsers. Note that optimal viewing requires broadband internet access such as DSL line or cable modem. Although slow modem connections (down to 28.8 KB) are also supported, download times are much longer and the audio quality is phone-like rather than CD-quality.
| Presentation | View |
|---|---|
| Restraint Literature Review; DHS Joint Training 2002; Leslie L. Cortés, MD | |
| Restraint Reduction; DHS Texas Geriatrics Symposium 2001; Debbie Wiegand, LNFA; Lynne Smith, LMSW; Drew Hofstad, PT | |
Online
A Values-Based Approach to Restraint Reduction (Journal for Healthcare Quality, 2001)
Colorado Foundation for Medical Care (Resident Assessment Guide and Tools)
HCFA Restraint Reduction Newsletters
Untie the Elderly (Restraint Reduction Training Program)
A Restraint Reduction Letter to Families (This sample was graciously provided by Mr. Kinny Pack of Azle Manor. This is not a mandated form; it is simply a resource.)
In Print
Toward a Restraint-Free Environment Book. Edited by Judith V. Braun, Ph.D., Associate Administrator of the Hebrew Home of Greater Washington, Rockville, Maryland, and Steven Lipson, M.D., M.P.H., Medical Director of the Hebrew Home of Greater Washington and Associate Professor at the Georgetown University School of Medicine, Washington, DC.
[1] Centers for Medicare and Medicaid Services; MDS Quality Indicator Report. (2000-2001). online.
[2] Cortes, L. Restraint Use in Texas Nursing Facilities - Preliminary Findings of the 2002 Statewide Review of Quality of Care in Texas Nursing Facilities.
[3] Burton,LC., German, PS., Rovner, BW., Brant, L; & Clark, R. Mental illness and the use of restraints in nursing homes. The Gerontologists 1992;32(2):164-70.
[4] Karlsson S, Bucht G, Eriksson S et al. Physical restraint in geriatric care in Sweden: Prevalence and patient characteristics. Journal of American Geriatrics Society 1996;4411:1348-54.
[5] Phillips CD, Hawes C, Mor V et al. Facility and area variation affecting the use of physical restraints in nursing homes. Medical Care 1996;3411:1149-62.
[6] Karlsson S, Bucht G, Eriksson S et al. Factors related to the use of physical restraints in geriatric care settings. Journal of American Geriatric Society 2001;49:1722-8.
[7] Miles S, Irvine P. Deaths caused by physical restraints. The Gerontologist 1992;32(6):762-6.
[8] Tinetti M, LieW, and Ginter S. Mechanical restraint use and fall related injuries among patients of skilled nursing facilities. Annals of Internal Medicine 1992;16:369-74.
[9] Cohen C, Neufeld R, Dunbar J, et al. Old problem, different approach: alternatives to physical restraints. Journal of Gerontological Nursing 1996;22(2):23-9.
[10] Werner P, Koroknay V, Braun J et al. Individualized care alternatives used in the process of removing physical restraints in the nursing home. Journal of American Geriatrics Society 1994;42:321-5.
[11] Ejaz FK, Jones JA, Rose MS. Falls among nursing home residents: An examination of incident reports before and after restraint reduction programs. Journal of American Geriatrics Society 1994;42:960-4.
[12] Capezuti E, Evans L, Strumpf N et al. Physical restraint use and falls in nursing home residents. Journal of the American Geriatric Society, 1996; 44:627-33.
[13] Evans LK, Stumpf NE, Allen-Taylor SL et al. A clinical trial to reduce restraints in nursing homes. Journal of the American Geriatric Society 1997;45:675-81.
[14] Stratmann D, Vinson MH, Magee R, Hardin SB. The effects of research on clinical practice: The use of restraints. Applied Nursing Research 1997;10(1):39-43.
[15] Phillips CD, Hawes C, Fries BE. Reducing the use of physical restraints in nursing homes: Will it increase the costs? American Journal of Public Health 1993;83(3):342-8.
[16] Levine, JM, Marcello, V, Totolos, E. Progress Toward a Restraint-Free Environment in a Large Academic Nursing Facility. Journal of the American Geriatric Society 1995, 43(8):914-8.
[17] Dunbar JM et al. Taking charge: The role of nursing administrators in removing restraints. Journal of Nursing Administration 1997;27(3):42-8.
[18] Kapp MB. Restraint reduction and legal risk management. Journal of the American Geriatric Society 1999, 47(3):375-6
[19] Terpstra T, Terpstra T,L., Elaine VD., Reducing restraints: Where to start. The Journal of Continuing Education in Nursing 1998;29(1):10-16.
[20] Stilwell, EM. Nurses' education related to the use of restraints. Journal of Gerontological Nursing 1991;17(2):23-6.
[21] Neary, MA et. al. Restraints as Nurse's Aides See Them: What do the people who most often apply restraints know about the alternatives? Geriatric Nursing 1991;12(4):191-2
[22] Strumpf NE, Evans LK, Wagner J et al. Reducing physical restraints: Developing an education program. Journal of Gerontological Nursing 1992;18:21-7.
[23] Bradley L, Siddique CM, Dufton B. Reducing the use of physical restraints in long-term care facilities. Journal of Gerontological Nursing 1995;21(9):21-34.
[24] Morse, JM, McHutchion, E. Releasing Restraints: Providing Safe Care for the Elderly. Research in Nursing & Health 1991, 14:187-96.
[25] Janelli LM, Kanski, GW, Neary MA. Physical restraints: Has OBRA made a difference? Journal of Gerontological Nursing 1994;20:17-21.
Literature Review Evidence Table
Table of Additional References
Peer Reviewer: David A. Smith, MD, CMD
Review Date: June 7, 2002
Dr. Smith practices Long Term Care Geriatrics in his private practice in Brownwood, Texas. He is a Professor in Family Medicine at the Texas A&M School of Medicine and is also currently President of the Texas Medical Director's Association.
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Last updated: September 19, 2002
Source: http://www.dia-hfd.state.ia.us/bestpractices/Principles.asp, 4/1/2003.
Source: http://www.dia-hfd.state.ia.us/bestpractices/procedures.asp, 4/1/2003.
Source: Clinical Alert, Volume 1, Number 1, 2001. (Published periodically by the Office of Health Care Quality, Maryland Department of Health and Mental Hygiene.)
Source: Clinical Alert, Volume 1, Number 1, Summer 2002. (Published periodically by the Office of Health Care Quality, Maryland Department of Health and Mental Hygiene.)
Source: http://mqa.dhs.state.tx.us/QMWeb/POR.htm, 5/14/2003.
Source: http://mqa.dhs.state.tx.us/QMWeb/RestraintReduction.htm, 2/20/2003.
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