Progress toward a restraint-free environment in a large academic nursing facility.

OBJECTIVE: To review the implementation and evolution of a successful physical restraint reduction program in a large nursing facility. INTERVENTION AND MEASUREMENTS: An initiative to reduce physical restraint began in March of 1990 with formation of a Restraint Review Committee (RRC), which developed and guided a program of inservice education, policy change, and procedural innovation. Progress was measured by monthly prevalence surveys of restraint use, both unit-specific and facility-wide. PATIENTS AND SETTING: The study took place in an 816-bed not-for-profit nursing facility with academic affiliation and closed medical staff. Mean age of residents was 85.5; 74% were female and 26% male. RESULTS: Physical restraint prevalence in our facility was reduced from 39% to 4% over 3 years, with marked decrease in variation among nursing units. Prevalence initially decreased to 20% after policy modifications and inservice education programs. Further innovations in procedure and policy resulted in continued reduction of physical restraint to 4%. The facility-wide rate of falls and accident-related injuries did not change over the 3-year period. Decrease in physical restraint was not accompanied by a change in the percentage of residents prescribed psychotropic medications such as benzodiazepines and neuroleptics. CONCLUSIONS: In response to the mandate to provide a least-restrictive environment, our institution has developed a successful system resulting in a dramatic reduction in physical restraint use. Changes in institutional culture and barriers to change are discussed, as well as issues of cost and generalizability.

Progressive dementia: strategies to manage new problem behaviors.

The primary care physician plays a key role in the diagnosis and treatment of progressive dementia and in coordinating supportive care with the patient's caregivers. When a patient exhibits a new symptom such as wandering or verbal abuse, your initial workup should eliminate acute medical illness, psychiatric disorders, and drug reactions that may present as behavioral symptoms. In the home, the main focus of care is to provide a safe and secure environment, using preventive measures to minimize the risk of injuries. When caregivers become exhausted from dealing with nocturnal wakenings, a short course of sleep medication for the dementia patient is often necessary. To improve communication, avoid stressful and confusing situations that compound the patient's difficulty in understanding messages or expressing thoughts.

Changes in bedrail prevalence during a bedrails-reduction initiative.

OBJECTIVE: To examine the prevalence of bedrails and observe whether use of bedrails can be decreased during a bedrails-reduction initiative. DESIGN: A serial, cross-sectional, observational study of bedrail use. PATIENTS AND SETTING: An 816-bed not-for-profit nursing facility with academic affiliation and closed medical staff. Median age of residents was 88.1 (range 62-108); 74% were women and 26% were men. MEASUREMENTS: Observed use of bedrails with classification of bedrail configurations into Enclosure Levels based on percentage of bedsides enclosed; serial census of bedrail use during a restraint-reduction effort. RESULTS: Bedrail configurations fell into five Enclosure Levels based on percentage of the bed enclosed. Over 9 months, total bedrail prevalence increased from 50 to 56%; however, the highest Enclosure Levels decreased from 7.7 to 3.9%. CONCLUSIONS: Bedrail configurations can be placed on a continuum of enclosure, and highest Enclosure Levels can be decreased during a bedrails-reduction program.

A study of the effects of tamoxifen in the frail elderly: difficulties encountered in nursing home research.

OBJECTIVE: This study was conducted in order to determine whether the effects of tamoxifen in elderly, frail nursing home residents are similar to those that have been previously reported for younger postmenopausal women. DESIGN: A chart review study. SETTING: The Jewish Home and Hospital for Aged (JHHA), a subacute long-term care facility. PARTICIPANTS: One hundred fifty-eight women who had been at the JHHA at any time since 1986. One hundred ten had a history of breast cancer; 43 of these had been treated with tamoxifen while at the JHHA (Group I), and 66 had not (Group II). The remaining 49 women had no history of breast cancer (Group III). MEASUREMENTS: Data were collected from the time of admission to the JHHA through August, 1994 on: chemistry profiles, bone fractures apparently not a consequence of metastasis, gynecological parameters, and thromboemboli. RESULTS: The lack of pre-admission clinical information presented problems regarding research design and the interpretation of our findings. Nevertheless, compared to women who had not been treated with tamoxifen, treated women had a significantly elevated incidence of vaginal discharge (P = 0.01) and a lower prevalence of elevated total cholesterol (P = 0.04). Although not statistically significant, they also had decreased levels of low density lipoprotein cholesterol and an increased incidence of thromboemboli and bone fractures. CONCLUSIONS: While some of the effects of tamoxifen in elderly, frail women are similar to those observed in younger, postmenopausal women, others may be different. Our results suggest a need for further innovative studies that focus on the consequences of tamoxifen treatment in the elderly, frail population.