Facilities across the country, whether they are ANCC Magnet Recognition Program® (MRP) designated hospitals, designation hopefuls, or just seeking to improve their quality of care, struggle daily with the challenges inherent to the use of restraints. For Cancer Treatment Centers of America (CTCA) at Midwestern Regional Medical Center, the decision was made in 2005 to deal with restraints by simply going restraint-free.
"It was just a natural step under the Mother Standard® of care," says Kimberly Bertini, RN, MRP coordinator with CTCA at Midwestern. The Mother Standard of care is the organization's philosophy to treat every patient and caregiver "as if they are our own mother," says Bertini.
CTCA knew from the start that this needed to be a grassroots initiative with senior-level support because the plan to go restraint-free would involve increased hospital costs and an investment in "patient sitters"—which program organizers believed would be necessary to go restraint-free.
"At first it might have seemed taxing, but as we increased staff, we found having extra patient care techs able to sit with our patients rather than restraining them was not only easier for staff, but also for the patients and the patients' families," says Bertini.
Much of the work toward improvement could not have happened without the total support of leadership.
"Support from leadership naturally made this a very easy process," says Bertini.
Although the restraint-free concept can be implemented in this form at other types of healthcare facilities, at a cancer specialty hospital, there is a palpable difference based on what the patients are going through.
"Really, it's best practice," says Bertini. "We're at a cancer specialty hospital, and we were looking at the harm restraints can cause the patient—increasing confusion, bedsores, and falls."
The first step was to identify nursing staff to lead the program development.
"With every one of our nursing stakeholders delivering Patient Empowerment Medicine®, this was no problem," says Bertini. The organization strives to provide autonomy and empowerment for the nursing team to bring evidence-based practice to the bedside in their day-to-day delivery of care.
Leading the team was Carol Labanco, RN, of the ICU, Sue Wolf, RN, and Josephine Mezger, RN, of the oncology unit. They provided the literature review, wrote the practice guidelines, and created the educational plan to roll out the program to the nursing team. Carmelita Zeta-Sanchez, director of nursing, was the program champion, serving as the patient and nursing voice to the hospital CEO, Anne Meisner, MSN. Zeta-Sanchez encouraged the team to leverage nonproductive hours to develop the program. Sharon Dimitrijevich, manager of the ICU and ED, gave the team guidance, support, and structure.
"The staff nurses who implemented the evidence-based practice conducted a lot of research when they wrote the policy. There was a mass education effort for nurses. Patient safety and satisfaction is our goal at all times," says Dimitrijevich. "We not only reviewed the policy, but also implemented mock scenarios on how the program would work for the patient experiencing simple confusion to the emergency department patient who is striking out and endangering staff." This education took examples from one extreme to the other to prepare staff for a live environment.
"Our goal at the time for the nursing education effort was an ability to implement an immediate stop of restraint use when we went live," says Bertini. "This was a natural evolution of the Mother Standard of care and a living example of delivering Patient Empowerment Medicine."
This means putting the power to make change in the right hands.
"When looking at best practices, we empower the nurses—give them the ball and let them run with it," says Bertini.
CTCA achieved its goal of becoming restraint-free in 2005 and has maintained the program at a 100% accuracy rate to date.
"We report this benchmark indicator nationally to the National Database of Nursing Quality Indicators quarterly and monthly to the hospital board of directors," says Bertini. "Both reports are disseminated to our nursing team."
By delivering Patient Empowerment medicine, CTCA empowers patients and family members to be at the core and center of their own treatment.
Because the hospital is a cancer center, "we explain to them that they might be at higher risk of confusion—this could be cancer tumor–related; chemotherapy can increase confusion—and also our patients can become very sick really quick at times during treatment, so they're more at risk of falling," says Bertini. "Empowering patients and family members from the get-go that they might become more confused and explaining the plan on how we'll work together as a team to address it immediately decreases anxiety of both the patient and their family members."
New initiatives
The program brought about some upgrades and continuous improvement plans to continue to achieve 100% accuracy. The facility replaced every bed in the hospital with new ones that have bed alarms. The beds now ring to the nurses' station so nursing staff will know right away if a patient is out of bed.
"We also educate the patient and family members so they know what those alarms are for—any alarm without explanation causes anxiety," says Bertini.
Every patient gets checked in on at least every hour and more often if they are at a higher risk.
Although the process ties into MRP initiatives, all of those involved with the restraint-free program at CTCA agree that going restraint-free is far more universal than that.
"As the [MRP] coordinator, I'd love to say we did it for MRP, but we did it more than five years ago because it's best for our patients," says Bertini. The organization has been on the MRP journey to excellence for two years, but the restraint-free policy has been working much longer than that.
Buy-in from nurses was no trouble. "As a matter of fact, some of our staff wondered why it took us until 2005 to become restraint-free," says Bertini. "As soon as we started the program, we had a successful immediate stop. Nurses were very proud and happy to have permission to go restraint-free."
The bottom line: It worked. CTCA at Midwestern has seen a dramatic decrease in fall injury rates, which it ties directly to the no-restraint program.
"We also see increased patient satisfaction," Bertini says. "Considering how sick our patients might be at any given time, our goal is to make it as safe and comfortable as possible. We continue quality checks with the restraint-free program and report back on quality to the board."
The program also benefited CTCA at Midwestern on a recent Joint Commission survey.
"We had Joint Commission review not long ago, and the surveyors were impressed that we don't restrain our ventilated patients. They had not seen an initiative like this," says Bertini. "They were very impressed with our process improvement."
Zeta-Sanchez summarizes the success of the program in four steps.
- Support from leadership—both of the practice and financial development
- Sound clinical practice and guidelines, which includes leadership and nursing staff participating in program development
- Training and education at all nursing levels
- Training and education of the patient and family
"We are very fortunate at CTCA at Midwestern that we've got a very active hospital board," says Bertini. "The nurses know all of the hospital board members. We're very comfortable reporting back our numbers. Every month, we are able to report back great success in maintaining the restraint-free environment. There is a lot of accountability in the CTCA environment."
Tips for success
- Keep your program simple. Every encounter at the Cancer Treatment Centers of America (CTCA) is delivered through the Mother Standard® of care. If your mother had cancer, how would you want her treated? Would you want her to be restrained?
- Provide a patient care technician at no cost to patients to sit with them when needed. Using your own nursing and patient care technicians delivers a higher quality of care than using outside sitting services. The connection CTCA nurses have with patients and their family members promotes empowerment and accountability.
- Round every hour on every patient, which decreases the patient's level of stress and fear. Patients become less confused and have a lower fall risk if they feel well cared for. Increase the rounding intervals for patients who are at risk for confusion, falls, and anxiety.
- Maintain a natural-looking environment in patients' rooms, hallways, nursing stations, and lounges. Make sure to have natural light, pleasing colors, and minimal noise levels in every room.
- Educate patients and family members on how to stay in their normal circadian rhythm. Sleep deprivation may lead to a host of problems, including confusion and falls.
This article was adapted from one that originally appeared in the June 2010 issue of HCPro's Advisor to the ANCC Magnet Recognition Program®, an HCPro publication.