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A clinical trial to reduce restraints in nursing homes
L K Evans1, N E Strumpf, S L Allen-Taylor
1School of Nursing, University of Pennsylvania, Philadelphia 19104-2676, USA.
Objective:
To investigate the relative effects of two experimental interventions on the use of physical restraints.
Design:
Prospective 12-month clinical trial in which three nursing homes were randomly assigned to restraint education (RE), restraint education-with-consultation (REC), or control (C).
Setting:
Three voluntary nursing homes in the Philadelphia area providing both skilled and intermediate care.
Participants:
A total of 643 nursing home residents over the age of 60 were enrolled at baseline, and 463 remained to completion (1 year).
Interventions:
Both RE and REC homes received intensive education by a masters-prepared gerontologic nurse to increase staff awareness of restraint hazards and knowledge about assessing and managing resident behaviors likely to lead to use of restraints. In addition, the REC home received 12 hours per week of unit-based nursing consultation to facilitate restraint reduction in residents with more complex conditions.
Measurements:
Restraint status was observed systematically at baseline, immediately after the 6-month intervention, and again at 9 and 12 months. Staff levels, psychoactive drug use, and injuries were also determined.
Results:
Compared with baseline, the REC home had a statistically significant reduction in restraint prevalence, whereas RE and C homes did not. At 9 months (3 months post-intervention), absolute decline in the percents restrained were 7% RE, 7% C, and 20% REC; at 12 months (6 months post-intervention) declines were 4% RE, 6% C, and 18% REC. However, relative to baseline, these declines represent an average reduction in restraint use of 23% RE, 11% C, and 56% REC. The differences in changes over time were consistently significant (P = .01), whether considering survivors or those present at each time point, and also when controlling for differences between groups at baseline. Further, given any change in restraint use, REC-residents were between 25% and 40% more likely than either RE or C residents to experience decreased restraint use. Results were achieved without increased staff, psychoactive drugs, or serious fall-related injuries.
Conclusion:
A 6-month-long educational program combined with unit-based, resident-centered consultation can reduce use of physical restraints in nursing homes effectively and safely. Whether extending the intervention will achieve greater reduction is not known from these results.