Removal of bedrails on a short-term nursing home rehabilitation unit.

Our goal was to determine whether bedrails could be removed safely on a geriatric rehabilitation unit. Staff attended in-services about bedrails, assessment, and possible alternatives. Residents in the study group were assessed by an interdisciplinary team, following which a determination was made about the use of bedrails or alternatives. Eighty percent of residents in the study group were free of bedrails, which suggests that bedrails can be safely removed from most short-stay nursing home rehabilitation residents.

Restraint reduction reduces serious injuries among nursing home residents.

OBJECTIVES: To describe how removing physical restraints affected injuries in nursing home settings. DESIGN: A 2-year prospective study of an educational intervention for physical restraint reduction. SETTING: Sixteen diverse nursing homes with 2075 beds in California, Michigan, New York, and North Carolina. PARTICIPANTS: Study A: 859 residents who were physically restrained at the onset of the intervention on October 1, 1991. Study B: all residents who occupied the 2075 beds in the 16 facilities 3 months before the intervention and 3 months after its completion. INTERVENTION: Educational program for nursing home staff followed by quarterly site consultations to participating nursing homes. MAIN OUTCOME MEASURES: Rate of physical restraint use and injuries. RESULTS: Study A: Serious injuries declined significantly among the 859 residents restrained initially when restraint orders were discontinued (X2 = 6.2, P = .013). Study B: During the intervention period, physical restraint use among the 2075 residents decreased from 41% to 4%, a 90% reduction. The decrease in the percentage of injuries of moderate to serious severity was significant (i.e., 7.5% vs 4.4%, P2-tail = .0004) as was the rate of moderate and serious injuries combined (Rate Ratio = 1.580, P2-tail = .0033). CONCLUSIONS: A substantial decrease in restraint use occurred without an increase in serious injuries. Although minor injuries and falls increased, restraint-free care is safe when a comprehensive assessment is done and restraint alternatives are used.

Taking charge. The role of nursing administrators in removing restraints.

The leadership and commitment of nursing administrators play a pivotal role in minimizing the use of restraints and maintaining a restraint-free environment. This article describes the role of nursing administrators in reducing the use of physical restraints as part of a 2-year, national nursing home restraint-reduction project. It reviews important information about restraint-free care the benefits of restraint-free care, and strategies to reduce the use of restraints in nursing homes, much of which is applicable to settings other than nursing homes.

Sequential outbreak of influenza A and B in a nursing home: efficacy of vaccine and amantadine.

OBJECTIVE: To describe the sequential occurrence of influenza A and B in a nursing home, and to determine the efficacy of influenza vaccine and/or amantadine treatment with respect to incidence and sequelae. SETTING: The Jewish Home and Hospital for Aged, a skilled-care nursing facility. PARTICIPANTS: Of 499 frail older nursing home residents, 139 contracted influenza during the study period (mean age 87.5 years; SD = 6.7). The residents were followed from February through April 1988. INTERVENTION: Influenza vaccine and/or amantadine. MEASUREMENTS: Episodes of influenza and their sequelae, i.e., pneumonia, hospitalization, and death. RESULTS: The vaccine had no effect on the incidence of influenza-like illness, length of illness, or the associated death rate. It reduced the rate of pneumonia secondary to influenza A and B (relative risk = .57; 95% CI: .37 to .89; P = .023). Amantadine did not affect the attack rate of influenza nor the rate of pneumonia secondary to influenza. It was associated with decreased mortality (relative risk = 0; P = .001), and shorter length of influenza A illness (PWilcoxon = .082). Although the combination of amantadine and vaccine did not affect length of influenza (A or B) illness, it was associated with a significantly lower rate of sequelae (relative risk = .58; 95% CI: .36 to .95; P = .024). CONCLUSION: In this epidemic, the combination of amantadine and vaccine was most effective in reducing the rate of influenza-associated sequelae. The possibility of a "biphasic" epidemic prompts consideration of vaccinating nonimmunized nursing home residents, even though it may be late in the influenza season.

Retrain, don't restrain: the educational intervention of the National Nursing Home Restraint Removal Project.

This article describes an educational program that contributed to a 90% reduction in the use of physical restraints in 16 randomly selected nursing homes over a two-year period. The educational program advocated assessments by a multidisciplinary team to generate individualized, restraint-free interventions. The program consisted of a workshop, telephone and quarterly on-site consultations, regional meetings, a newsletter, and written and audio-visual materials. The workshop and site visits were powerful motivators, and participants also found the video very useful. Most nursing homes can easily adapt components of this project to create their own restraint-removal programs.

Can physically restrained nursing-home residents be untied safely? Intervention and evaluation design.

OBJECTIVE: To develop an intervention that will enable nursing home personnel to remove physical restraints from nursing-home residents safely and cost effectively. DESIGN: A multicenter prospective pre-post study. SETTING: Sixteen high-restraint-use nursing homes, four each from California, Michigan, New York, and North Carolina. The 16 facilities have 2075 beds. INTERVENTION: A 2-year educational demonstration study, including a 2-day workshop, specially prepared written and video materials, and telephone and on-site clinical consultations. Each nursing home designated a nurse to be the clinical coordinator and to lead a multidisciplinary team in conducting a restraint assessment and devising interventions for removal. OUTCOME MEASURES: We compared pre- and post-study aggregate and individual facility rates of restraint use, incidents and accidents, family attitudes, financial impact, serious injuries, and staff attitudes and work patterns. CONCLUSION: Preliminary data suggest that this intervention was well received and appears to be effective in achieving restraint-free care.

Nursing staff attitudes on the use of physical restraints in a teaching nursing home.

This study supports the importance of assessing the intrinsic and extrinsic attitudes and perceptions of staff on physical restraints. Any program developed to remove physical restraints in nursing homes should focus on safety issues and behavioral interventions that prevent injury to staff and resident. Environmental adaptations that would enhance residents' safety, such as alarms and wedge cushions, would be useful in a restraint reduction program. Educating staff about the risks of physical restraints and about safe alternative interventions might change their attitudes. By developing an educational program that focuses on a few residents at a time and by involving a multidisciplinary team, a truly individualized approach to restraint-free care for residents might be developed.

A center on ethics in long-term care.

Long-term care institutions are beginning to grapple with ethical issues on a regular basis. This has encouraged facilities to develop new mechanisms to deal with these issues. Described is a tripartite program that incorporates direct service, education, and research in ethics.

Tuberculosis surveillance in a long-term care facility.

The prevalence of tuberculous infection in residents of a large nursing facility in New York City was assessed. The population was predominantly female (80%) and white (86%), with almost one-half (49%) being foreign born. The mean age of the group was 86.1 years. Four hundred and fifty-five residents were given tuberculin skin tests using the two-step Mantoux test procedure. The prevalence of tuberculous infection was 27.5% with only slight differences being noted between the native-born (28.8%) and foreign-born (26.1%) residents. A 10% booster effect was noted. Tuberculous infection rates were higher in non-white than white residents. A progressive decline in the prevalence of tuberculous infection was noted with increasing age. No cases of tuberculosis were detected. Our study provides a model for collecting and evaluating epidemiologic data to assess infection prevalence and tuberculosis transmission in a long-term care facility.

Orthostatic change in blood pressure in non-demented, ambulatory nursing home patients.

While postural hypotension was present in almost 20% of ambulatory patients of this long-term institution, associated symptoms were infrequent. A comparison of the groups with and without a history of falls in the prior year revealed no relationship to the presence of postural hypotension and no relationship to a number of medications which have been reported to be associated with orthostatic hypotension. Blood pressure readings should be obtained at 1,3 and 5 min after assuming the erect position as significant falls in blood pressure were found at each interval.

Acute myocardial infarction in a long-term care institution for the aged.

We reviewed the clinical characteristics and outcome of cases of acute myocardial infarction occurring from January 1, 1985, through December 31, 1987, in the population of a long-term care institution for the elderly. The total number of patients in the series was 43. Comparisons were made between those patients transferred to a general acute-care hospital and those who remained at the facility. The most common initial symptoms of acute myocardial infarction in 32 of 48 patients were, in order, dyspnea, dizziness or syncope, precordial pain, and abdominal pain. Nine (of 43) patients were asymptomatic. In the 14 (of 43) patients transferred to an acute-care hospital, cardiac failure, arrhythmias, and cardiogenic shock were much more frequent than among those retained in the long-term care facility. We concluded that a high index of suspicion for the diagnosis of acute myocardial infarction in the institutionalized elderly is indicated. Patients with mild infarction can be retained in long-term care institutions; resulting mortality from cardiac disorders should be low in adequately staffed and equipped long-term care institutions.

Ethics rounds at the nursing home: an alternative to an ethics committee.

The increased attention in US medicine to medical ethics reflects in large part the "new" demography of a growing elderly population and the conflict of whether decisions regarding medical care should be based on cost-effectiveness or "human-effectiveness." Currently, about 40 percent of the nation's elderly end up in nursing homes where they confront ethical and legal dilemmas that would not arise in their own homes. In the nursing home, difficult medical-ethical decisions generally rely on two approaches: the often used but frequently invalid concept of informed consent and little used ethics committees. At The Jewish Home and Hospital for Aged in New York City we have developed a program of "ethics rounds" as an alternative to ethics committees. We conduct the rounds in the open style of a forum or clinical conference rather than with the aura of a decision-making group. We encourage the participation of patients and family and seek to educate the staff, any one of whom may choose to attend. The rounds consist of a multidisciplinary case presentation, an interview of patient and/or family, a discussion by the staff, and an overview by an ethicist. Staff response to the educational and interdisciplinary aspects of the rounds has been remarkably positive.

A multidisciplinary falls consultation service in a nursing home.

A Multidisciplinary Falls Consultation Service made possible a novel interdisciplinary approach to the patient as a faller. A team consisting of members from the medical, nursing, rehabilitation, administration, and activities departments reviewed epidemiological data on 323 falls and evaluated 24 patient referrals. Interventions at all clinical levels of staffing are being developed to reduce the risk of falling.

The clinical utility of a comprehensive periodic assessment form for the geriatric rehabilitation patient.

The Comprehensive Periodic Assessment Form is a new format used to document a patient's rehabilitation progress. It is a nonnarrative, semi-graphical form in which is digested on one page many sheets of progress notes from a variety of disciplines. Mobility, ADL, mental, and medical status overtime can be ascertained at a glance. The form has special utility for the aged patient experiencing rehabilitation treatment.

Autopsy study of the elderly institutionalized patient. Review of 234 autopsies.

Autopsies are performed much less frequently in the elderly than in younger patients. Little information exists as to causes of death in the institutionalized elderly. The clinical diagnostic error rate documented by autopsy studies ranges from 6% to 68%. We analyzed the clinical and autopsy records of 234 patients who died during a 14 1/2-year period at our chronic care institution to determine the accuracy of clinical cause of death in addition to the pathologic cause of death. The most common causes of death included bronchopneumonia (33%), congestive heart failure (15%), metastatic carcinoma (14%), pulmonary embolism (8%), myocardial infarction (7%), cerebrovascular accident (6%), unknown cause of death (8%), and a miscellaneous group (9%). The highest diagnostic error rate was in the underdiagnosis of pulmonary embolism (39% antemortem accuracy rate). The most accurately diagnosed condition was cerebrovascular accident (92% antemortem accuracy rate). Pneumonia was correctly diagnosed antemortem in 73% of the patients studied. These data suggest that serious and potentially treatable illnesses are underdiagnosed in the elderly institutionalized patient and that there is valuable information to be learned by performing autopsies in the elderly population.

Pernicious anemia in the demented patient without anemia or macrocytosis. A case for early recognition.

It is well known that the neurologic manifestations of vitamin B12 deficiency can occur in the absence of anemia. The authors recently observed two elderly patients who presented to a chronic care institution with the diagnosis of dementia, and in both individuals low serum B12 levels were found in conjunction with abnormal Schilling tests. In neither of these two patients was there anemia or macrocytosis. After receiving parenteral B12 injections there was improvement noted in cognitive functions as well as in activities of daily living. The authors are reporting these patients to alert clinicians to the fact that pernicious anemia in the elderly can first present with low serum B12 levels and neurologic abnormalities in the absence of anemia or macrocytosis.