Elizabeth Capezuti

A Clinical Trial to Reduce Restraints in Nursing Homes

OBJECTIVE: To investigate the relative effects of two experimental interventions on the use of physical restraints.

Physical restraint use and falls in nursing home residents

OBJECTIVE: To examine the relationship between restraint use and falls while controlling for the effect of psychoactive drug use among nursing home residents, including subgroups of nursing home residents with high rates of restraint use and/or falls.

Advance care planning and end-of-life care for hospitalized nursing home residents

OBJECTIVES: To describe advance care planning (ACP) and end‐of‐life care for nursing home residents who are hospitalized in the last 6 weeks of life.

Side rail use and bed-related fall outcomes among nursing home residents

OBJECTIVESnTo analyze the effect of physical restraint reduction on nighttime side rail use and to examine the relationship between bilateral side rail use and bed-related falls/injuries among nursing home residents.nnnDESIGNnSecondary analysis of data collected in a longitudinal, prospective clinical trial designed to reduce restraint use.nnnSETTINGnThree nonprofit nursing homes.nnnPARTICIPANTSnTo examine the first question regarding the effect of physical restraint reduction on side rail usage, we included all nursing home residents who survived a 1-year data collection period (n = 463). To answer the second research question concerning the relationship between side rail status and bed-related falls, subjects side rail status for each of the four data collection periods was compared. The sample for this analysis includes only those with consistent side rail status (n = 319) for the four observations periods: either 0/1 side rail (n = 188) or 2 (bilateral) side rails (n = 131).nnnMEASUREMENTSnSide rail and restraint status was directly observed by two research assistants, twice each night shift (10 p.m.-6 a.m.) for three nights at each of four data collection points. Nighttime fall-related outcome data were obtained from a review of nursing home incident reports during the entire 1-year data collection period (T1 through T4). Cognitive status was measured using the Folstein Mini-Mental State Examination. Functional and behavioral status was obtained using subscales of the Psychogeriatric Dependency Rating Scale.nnnRESULTSnOver a 1-year period, there was an increase in the proportion of bilateral side rail use for all three nursing homes. Based on the multiple logistic regression analysis, there was no indication of a decreased risk of falls or recurrent falls with bilateral side rail use, controlling for cognition and functional and behavioral status (adjusted odds ratio (AOR) = 1.13, 95% confidence interval (CI) = 0.45,2.03). Similarly, bilateral side rail use did not reduce the risk of recurrent falls, controlling for cognition and functional status (AOR = 1.25, 95% CI = 0.33,4.67).nnnCONCLUSIONnDespite high usage of bilateral side rails, they do not appear to significantly reduce the likelihood of falls, recurrent falls, or serious injuries. Bed-related falls remain clinically challenging. The data from this study, coupled with increasing reports of side rail-related injuries and deaths, compel us to seek and empirically test alternative interventions to prevent bed-related falls.

Effects of a restraint reduction intervention and OBRA '87 regulations on psychoactive drug use in nursing homes.

OBJECTIVES: To describe the changes in psychoactive drug use in nursing homes after implementation of physical restraint reduction interventions and mandates of the Omnibus Budget Reconciliation Act of 1987 (OBRA 87).

Bed-exit alarm effectiveness

This study describes the accuracy of two types of bed-exit alarms to detect bed-exiting body movements: pressure-sensitive and a pressure-sensitive combined with infrared (IR) beam detectors (dual sensor system). We also evaluated the occurrence of nuisance alarms, or alarms that are activated when a participant does not attempt to get out of bed. Fourteen nursing home residents were directly observed for a total of 256 nights or 1636.5h; an average of 18.3+/-22.3 (+/-S.D.) nights/participant for an average of 6.4+/-1.2 h/night. After adjusting for body movements via repeated measures, Poisson regression modeling, the least squares adjusted means (LSM) show a marginally significant difference between the type of alarm groups on the number of true positives (NTP) (mean/S.E.M.=0.086/1.617) for pressure-sensitive versus dual sensor alarm (0.593/1.238; p=0.0599) indicating that the dual sensor alarm may have a higher NTP. While the dual sensor bed-exit alarm was more accurate than the pressure-sensitive alarm in identifying bed-exiting body movements and reducing the incidence of false alarms, false alarms were not eliminated altogether. Alarms are not a substitute for staff; adequate staff availability is still necessary when residents need or wish to exit bed.

Falls as Risk Factors for Fractures

Publisher Summary Several types of fractures among the elderly are usually due to a fall. Fall-related injuries are the leading cause of mortality by unintentional injuries among adults aged 65 years and older in the United States. Falls are also the leading cause of non-fatal injuries among the elderly. An estimated 5–10% of those over age 75 visit a hospital emergency department each year for treatment of a fall-related injury; about one-third are subsequently hospitalized. Most falls in the elderly are probably due to both intrinsic (host) and extrinsic (environmental) factors. Although there has been a great deal of progress in the identification of intrinsic risk factors, investigation of extrinsic factors remains more limited. Environmental factors are thought to be particularly important in falls among the more active elderly, whereas intrinsic factors may play more of a role among the frail elderly. In studies of risk factors for falls, a fall is usually defined as “an event that results in a person coming to rest inadvertently on the ground or other lower level.” Falls due to an overwhelming force or event, such as a motor vehicle accident or loss of consciousness, are usually excluded. Early research on the identification of fall risk factors has been focused on all falls, despite the fact that the majority of falls do not result in injury. Some researchers suggest that fall-related serious injury, not falls per se, is the significant outcome measure and, thus, research and preventive actions should focus on risk factors for injurious falls. However, it is plausible that efforts to reduce falls in general would also reduce injuries. The most effective approach remains to be clearly established.

Reporting elder mistreatment

Elder mistreatment, defined as the abuse and neglect of older persons, includes physical, psychological, and sexual abuse, caregiver and self-neglect, and financial exploitation. Fifty states and the District of Columbia have passed legislation to establish adult protective service (APS) programs. State APS statutes authorize APS agencies to investigate cases of elder mistreatment. Some status fund services to alleviate the abusive or neglectful situation. This article analyzes the critical aspects of state-specific APS legislation affecting nursing practice with older adults and the nurses role in reporting cases of elder mistreatment.

Outcomes of nighttime physical restraint removal for severely impaired nursing home residents

There is ample evidence that physical restraint reduction does not lead to increased falls or injuries. This study tests the effect of removing nighttime restraints by comparing two groups: Restrained in bed at pre- but not postintervention (n = 51), or restrained in bed at both pre- and post-intervention (n = 11). No differences in nighttime fall rates between the two groups were detected. Nighttime physical restraint removal does not lead to increases in falls from bed in older nursing home residents. Although markedly reduced in nursing homes, restraint use remains a common practice among hospitalized older adults. We should continue to focus efforts on developing new, individualized approaches to reduce risk of falling from bed among frail elders.

Individualized assessment and intervention in bilateral siderail use

The use of bilateral siderails, similar to physical restraints, can be safely reduced by a comprehensive assessment process. This article presents an individualized assessment for evaluating siderail use to guide nurses in managing resident characteristics for falling out of bed and intervening for high-risk residents. The individualized assessment is consistent with federal resident assessment instrument requirements and includes risk factors specific to falls from bed.