In 1999, some 38% of residents were bound by physical restraints at Windy Hill Village of the Presbyterian Homes, a 120-bed long-term-care facility in Philipsburg, Pa. Given that such restraints are often misused and can lead to physical and mental decline, the facility aimed to change a culture that had been oriented around staff and their tasks rather than residents and their needs.
"We always said we were doing it for safety. We thought we were doing it so the resident wouldn't fall," Administrator Anne Ferguson says of the facility's elderly patients, who have a variety of physical disabilities. She adds that restraints, though used for patient safety, were never used to control patients. "That's the wrong answer," she says.
The hospital formed an interdisciplinary Vision Team, which helped achieve a restraint-free environment by 2001. Called the Kaleidoscope Initiative, this sea change earned Windy Hill the Spirit of Excellence Award for Quality.
"I was particularly impressed with the restraint-free environment project submitted by Windy Hill Village," says awards judge Dennis Vonderfecht, president and chief executive officer of Mountain States Health Alliance, Johnson City, Tenn. "This project was the impetus for an enhanced resident-centered-care philosophy for this organization."
In creating a restraint-free environment, the Kaleidoscope Initiative goes beyond even the tough federal government standards for healthcare facilities to be deemed in compliance for Medicare participation. Those regulations by the Centers for Medicaid and Medicare Services, which say a licensed practitioner must evaluate a patient within an hour of the patient's being placed in restraints, drew criticism from the hospital industry when they were imposed in January 2001. The American Hospital Association says the standard by the Joint Commission on Accreditation of Healthcare Organizations-that an evaluation takes place within four hours of being placed in restraints-was sufficient.
The new environment at Windy Hill also surpasses the Pennsylvania Restraint Reduction Initiative's baseline goal of keeping no more than 10% of residents in restraints. A statewide training and support organization, PARRI conducted a seminar for Windy Hill staff, who at first resisted the idea of not using restraints. But resistance melted away after the organization showed artistic depictions of incidents in which residents had been killed or seriously injured because of restraint use.
Windy Hill methodically reduced the use of restraints, asking each nursing unit to do so one at a time, using a variety of cushions and other positioners to keep residents in place in their wheelchairs. During facility in-services, staff members re-enacted some of the horrific drawings they had seen using nursing mannequins, and some were put in restraints for the entire hour to experience what it felt like.
Among the results of the initiative: The severity of injuries from falls has declined dramatically in large part because residents are no longer bound to heavy equipment such as wheelchairs, which can topple onto them.
Ferguson says Windy Hill spent $260,000 on additional equipment but has seen savings because of no longer purchasing restraints and lower liability insurance premiums.
A side benefit: The increased patient focus has led care planning to be done with the resident and his or her family, in the resident's room.
"They've been given a voice. If they didn't know how to speak up or say something, we are very strongly their advocate now," Ferguson says. "A lot of the culture change has happened. But we're still on the road. We're never done."
That theme has resounded elsewhere through the facility, administrators say, resulting in a variety of patient-focused systems changes: numerous dining times, select menus, more than 400 restorative programs per day and an around-the-clock activities program.